THIEME Atlas of Anatomy General Anatomy and Musculosl<eletal System
Michael Schuenke Erik Schulte Udo Schumacher Consulting f.clitor~
Lawrence M. Ross Edward D. l ampert i 11lus£rc11ions by
Markus Voll l<arJWesker
I
Thieme
@!) Thieme
General Anatomy and Musculoskeletal System
THIEME Atlas of Anatomy Consulting Editors
Lawrence M. Ross, M.D., Ph.D., Department of Neurobiology and Anatomy University ofTexas Medical School at Houston
Edward D. Lamperti, Ph.D., Immune Disease Institute and Harvard Medical School
Authors
Michael Schuenke, M.D., Ph.D., Institute of Anatomy Christian Albrecht University Kiel
Erik Schulte, M.D., Department of Anatomy and Cell Biology johannes Gutenberg University
Udo Schumacher, M.D., FRCPath, CBiol, FIBiol, DSc, Institute of Anatomy II: Experimental Morphology Center for Experimental Medicine University Medical Center Hamburg-Eppendorf
In collaboration with jurgen Rude Illustrations by
Markus Voll Karl Wesker 1694 Illustrations 100Tables
Thieme Stuttgart· New York
l.ibroryof Congress Carologing-in-Publication Daro is available from the publisher. This book is an authorized and revised translation of the German edition published and copyrighted 2005 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Schuenke et al.: Allgemeine Anatomie und Bewegungssystem: Prometheus Lernatlas der Anatomie. Illustrators Markus Voll, Fiirstenfeldbnuck, GeiTilany; Karl Wesker, Berlin, Germany (homepage: www.karlwesker.de) Translator TerryTelger, Fort Worth, Texas, USA
Important note: Medicine is an ever-changing science undergoing
continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user Is requestl!d to eumlne carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage smedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or Inaccuracies noticed. If errors In this work are found after publication, errata will be posted at www.thleme.com on the product description page.
e corrected reprint 2010 Georg Thieme Verlag Riidigerstra8e 14 D-70469 Stuttgart Germany http:l/www. thieme.de Thieme New York. 333 Seventh Avenue, New York, NY 10001 USA http:ffwww.thieme.com
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Foreword
Preface
Our errthusiasm fur the THIEME Atlas of Anatomy began when each of us, Independently, saw preliminary material from this Atlas. Both of us were Immediately captivated by the new approach, the conceptual organization, and by the stunning quality and detail of the Images of the Atlas. We were delighted when the editors at Thieme offered us the opportunity to cooperate with them In making this outstanding resource available to our students and colleagues In North America.
As it started planning this Atlas, the publisher sought out the opinions and needs of students and lecturers In both the United States and Europe. The goal was to find out what the "Ideal" atlas of anatomy should be-Ideal for students wanting to learn from the atlas, master the extensive amourrts of Information while on a busy class schedule, and, In the process, acquire sound, up-to-date knowledge. The result of this work Is this Atlas. The THIEME Atlas of Anatomy, unlike most other atlases, Is a comprehensive educational tool that combines Illustrations with explanatory text and summarizing tables, introducing clinical applications throughout, and presenting anatomica I concepts in a step-by-step sequence that allows for the integration of both systemby-system and topographical views.
As consulting editors we were asked to review, fur accuracy, the English edition of the THIEME Atlas of Anatomy. Our work involved a conversion of nomenclature to terms in common usage and some organizational changes to reflect pedagogical approaches in anatomy programs in North America. This task was eased greatly by the clear organization of the original text. In all of this, we have tried diligently to remain faithful to the irrtentions and insights of the original authors. We would like to thank the team at Thieme Medical Publishers who worked with us. Heartfelt thanks go first to Cathrin E. Schulz, M.D.• Senior Editor, fur her assistance and constant encouragemerrt and availability. We would also like to extend our thanks to Stefanie Langner, Production Manager, and Annie Hollins, Assistant Editor, fur checking and correcting our work and preparing this volume with care and speed. Lawrence M. Ross, Edward D. Lamperti
Since the THIEME Atlas of Anatomy is based on a fresh approach to the underlying subject matter itself, it was necessary to create for it an entirely new set of illustrationr-a task that took eight years. Our goal was to provide illustrations that would compellingly demonstrate anatomical relations and concepts, revealing the underlying simplicity of the logic and order of human anatomy without sacrificing detail or aesthetics. With the THIEME Atlas of Anatomy, it was our intention to create an atlas that would guide students in their initial study of anatomy, stimulate their errthusiasm for this intriguing and vitally important subject. and provide a reliable reference for experienced students and professionals alike.
"Ifyou want ID attain the possible, you must attempt the impossible" (Rablndranath Tagore). Michael Schiinke, Erik Schulte, Udo Schumacher, Markus Vall, and Karl Wesker
Acknowledgments
First we wish tD thank our families. This atlas is dedicab!d to them. We also thank Prof. Reinhard Gossrau, M.D., for his critical comments and suggestions. We are grab!ful tD several colleagues who rendered valuable help In proofreading: Mrs. Gabriele Schunke, Jakob Fay, M.D., Ms. Claudia Ducker, Ms. Slmln Rassoull, Ms. Heinke Teichmann, and Ms. Sylvia Zllles. We are also grateful to Dr. julia jOrns-Kuhnke for helping with the figure labels. We extend spedal thanks to Stephanie Gay and Bert Sender, who composed the layouts. Their ability to arrange the text and illustrations on facing pages for maximum clarity has contributed greatly to the quality of the Atlas. We particularly acknowledge the efforts of those who handled this project on the publishing side: JGrgen Luthje, M.D.• Ph.D., executive editor at Thieme Medical Publishers, has "made the impossible possible.• He not only reconciled the wishes of the authors and artists with the demands of reality but also managed to keep a team of frve people working together for years on a project whose goal was known to us from the beginning but whose full dimensions we came to appreciate only over time. He is deserving of our most sincere and heartfelt thanks. Sabine Bartl, developmental editor, became a touchstone for the authors in the best sense of the word. She was able to deb!rmine whether a beginning student, and thus one who is not (yet) a professional, could clearly appreciate the logic of the presentation. The authors are Indebted tD her.
We are grateful toAntje Buhl, who was there from the beginning as proj-
ect assistant. working "behind the scenes• on numerous tasks such as repeated proofreading and helping to arrange the figure labels. We owe a great dept of thanks to Martin Spencker, Managing Director
of Educational Publications at Thieme, especially tD his ability tD make quick and unconventional decisions when dealing with problems and uncertainties. His openness to all the concerns of the authors and artists established conditions for a cooperative partnership. Without exception, our collaboration with the entire staff at Thieme Medical Publishers was consistently pleasant and cordial. Unfortunately we do not have room to list everyone who helped in the publication of this atlas, and we must limit our acknowledgments to a few colleagues who made a particularly notable contribution: Rainer Zepf and Martin Waletzko for support in all technical matters; Susanne TochterrnannWenzel and Manfred Lehnert, representing all those who were involved in the production of the book; Almut Leopold for the Index; Marie-Luise Kurschner and her team for creating the cover design; to Birgit Carlsen and Anne Dobler, representing all those who handled marketing, sales, and promotion. The Authors
Table of Contents
General Anatomy
Human Phylogeny and Ontogeny
5
The Musc:les
5.1 5.2
The Skeletal Muscles ................................. 40 The Tendons and Mechanisms That Assist Muscle Function .......................... 42
1.8 1.9
Human Phylogeny .................................... 2 Human Ontogeny: Overview, Fertilization, and Earliest Developmental Stages .............................. 4 Gastrulation, Neurulation, and Somite Formation ••••••• 6 Development of the Fetal Membranes and Placenta ..... 8 Development of the Pharyngeal (Branchial) Arches in Humans ......................................... 10 Early Embryonic Circulation and the Development of Major Blood Vessels .. • . .. . • . • .. • . • .. • . • . • .. • . • .. • . 12 Bone Development and Remodeling •.•.••.•.•.••.•.••. 14 Ossification of the Umbs ............................. 16 DevelopmentandPositionofthelimbs ................ 18
2
Overview of the Human Body
2.1
The Human Body (Proportions, Surface Areas, and Body Weights)•.••.•.••. 20 The Structural Design of the Human Body •.•.•.••.•.••. 22
1.1 1.2
1.3 1.4 1.5
1.6 1.7
2.2
3
Surface Anatomy of the Body, Landmarks and Reference Lines
3.1
Terms of Location and Direction, Cardinal Planes andAxes ........................................... 24 Body Surface Anatomy ................. . ... . ......... 26 Body Surface Contours and Palpable Bony Prominences • • 28 Landmarks and Reference Lines on the Human Body • ••• • 30 Body Regions (Regional Anatomy) •• • •• ••• •• •• •• • •• •• • • 32
3.2 3.3 3.4 3.5
4
The Bones and Joints
4.1
The Bony Skeleton and the Structure of Tubular Bones . •. . 34 Continuous and Discontinuous joints: Synarthroses and Diarthroses . . . . .. . . . .. . . . .. .. . . . .. . . 36 Basic Principles of joint Mechanics .• . . . .• . . . . .. •. . .. •. . 38
4.2
4 .3
6
The Vessels
6.1
Overview of the Human Cardiovascular System ••.•.••.•. 44 The Structure of Arteries and Veins .................... 46 The Terminal Vascular Bed ............................ 48
6.2 6.3
7
The Lymphatic System and Glands
7.1 7.2
The Human Lymphatic System ........................ 50 Exocrine and Endocrine Glands ........................ 52
8
General Neuroanatomy
Development of the Central Nervous System (CNS) .••.•. 54 Neural Crest Derivatives and the Development of the Peripheral Nervous System (PNS) •.•.•..•.•.••.•. 56 8.3 Topography and Structure of the Nervous System ........ 58 8.4 Cells of the Nervous System .... . .... . ................ 60 8.5 Structure of a Spinal Cord Segment .................... 62 8.6 Sensory Innervation: An Overview ..................................... 64 8.7 Dermatomes and Cutaneous Nerve Territories •.•. •• .•. 66 8.8 Motor Innervation .. . . . .... . . . .. . . . .. . . . .. . . . . .. . . . . 68 8.9 Differences between the Central and Peripheral Nervous Systems .. . . . .. . . . . .. . . . .. . . . . 70 8 .10 The Autonomic Nervous System ...... . .... .. ........ . 72
8.1 8.2
IX
Table ofContents
Trunk Wall
Bones, Ugament:s, and Joints
3.4
The Chest Wall Muscles and Endothoraclc Fascia •••••••• 144
3.5
Thoracoabdominal junction:
1.1
TheSkeletonoftheTrunk .•..........•.....•....•.... 76
1 .2
The Bony Spinal Column ..•....•.....•.....•....•.... 78
1.3
Development of the Spinal Column .....•.....•......... 80
3.6
The Lateral and Anterior Abdominal Wall Muscles ••••••• 148
1.4
The Structure of a Vertebra •.......... •.....•....•.... 82
3.7
Structure of the Abdominal Wall
1.5
The Cervical Spine ..•.....•....•................•.... 84
1 .6
The Thoradc Spine .•.....•....•...........•....•.... 86
1 .7
The Lumbar Spine ..•.....•....•................•.... 88
1 .8
The Sacrum and Coccyx •.••.•.••.•.•.••.•.••.•.••.•.• 90
1 .9
The Intervertebral Disk: Structure and Function .•.••.•.• 92
The Diaphragm .................................... 146
and Rectus Sheath .................................. 150 3.8
Overview of the Perineal Region and Superficial Fasciae............................. 152 3.9
1.10 The Ligaments of the Spinal Column: 1.11 1 .1 2 1 .13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1 .21
Overview and Thoracolumbar Region .•.••.•.••.•.••.•.• 94 Overview of the Ligaments of the Cervical Spine .•.••.•.• 96 The Ligaments of the Upper Cervical Spine (Atlanto·ocdpital and Atlantoaxial joints) •.•.••.•.••.•.• 98 The Intervertebral Facet joints, Motion Segments, and RangeofMotion inDifferent Spinal Regions .•.••.•. 100 The UncovertebraiJoints of the Cervical Spine ••.•.••.•. 102 Degenerative Changes in the Lumbar Spine •.••.•.••.•. 104 TheThoradcSkeleton .•.••.•.••.•.•.••.•.••.•.••.•. 106 The Sternum and Ribs .•.••.•.••.•.•.••.•.••.•.••.•. 108 The Costovertebral Joints and Thoracic Movements • . . • . 110 TheBonyPelvis •.•.••.•.••.•.••.•.•..•.•.••.•.••.•.• 112 The Pelvic Ligaments and Pelvic Measurements • . • . • • . • . 114 The Sacroiliac Joint . • • . • . • • . • . • • . • . • . . • . • . • • . • . • • . • . 116
2
Musculature: Functional Groups
2.1
The Muscles of the Trunk Wall, Their Origin The Intrinsic Back Muscles:
Female versus Male •.••.•.•.••.•.••.•.••.•.•.••.•. 154 3.11 3.12
2.4
4.1
The Arteries ....................................... 162
4.2
The Veins ......................................... 164 The Lymphatic Vessels and Lymph Nodes •.•.••.•.••.•. 166 The Nerves ........................................ 168
4.3 4.4
5
Neurovascular Systems: Topographical Anatomy
5.1
AnteriorTrunkWall: Surface Anatomy and Superficial Nerves and Vessels •.... 170
5.2 5.3
The Short Nuchal and Craniovertebral Joint Muscles
5.5
Anterior and Posterior Muscles .. . . . .• . . . . .. . . . .. • . . 128 The Functions of the Abdominal Wall Muscles • . . .. • . . 130
2.8
2.9
The Muscles of the Thoracic Cage
Nerves and Vessels . .. . . . . .. ... .. . . . .. . . . .... . . . .. 178 5.6
Nerves, Blood Vessels, and Lymphatics
5.7
The Inguinal Canal . .. . • . . . .. • . . .. . . . .. . • . .. . . •.... 182
in the Female Breast . . . •.... . • . .. . • . .. . . . .... •.... 180 5.8
Anterior Abdominal Wall: Anatomy and Weak Spots • . . .. 184
5.9
Inguinal and Femoral Hernias .. . • . .. . • . .... . . . .. • . . .. 186
and Transversus thoracis) • . . . .• . . . . .• . . . . .• . . . .• . . . 132
5.10 Rare External Hernias .. ... . . .. . . . .. . . . .... . . . .. . . . .. 188
The Diaphragm .. . . . ...• . . . .• . . . .. • . . .. . • . . . .. . . . 134 (Pelvic Diaphragm, Urogenital Diaphragm, Sphincter
5.11
3
Musculature: Topographical Anatomy
3.1
The Back Muscles and Thoracolumbar Fascia . . • . .. . • . .. 138
3.2
The Intrinsic Back Muscles: Lateral and Medial Tracts • . .. . • . .... . .... . . . .. . • . .. 140 Short Nuchal Muscles .. . • . ...• . .... •.... . •........ 142
Diagnosis and Treatment of Hernias .. . • . .. . . •.... •.... 190
5.12 Development ofthe External Genitalia • . .. . . •.... • .... 192 5.13 Male External Genitalia: Testicular Descent and the Spermatic Cord . •.... •.... 194
and Erectile Muscles) . . ...• . ...• . .... . . . .. . . . .. . • . . . 136
X
AnteriorTrunkWall:
(lntercostales, Subcostales, Scaleni,
2.10 The Muscles of the Pelvic Floor
3.3
Anterior View . . .• . . . .• . . . .. • . . .... . . . .• . . . .. • . . .. 176 Overview and Location of Clinically Important
The Muscles of the Abdominal Wall:
2.6
Posterior Trunk Wall: Posterior View . .. . . . . .. . . .... . .... . . . .. . . . . .. . . .. 174
5.4
2.7
Posterior Trunk Wall: Surface Anatomy and Superficial Nerves and Vessels •.... 172
Medial Tract ••.•.••.•.••.•.••.•.•. • •.•.•..•.•. • •. 122
Lateral and Oblique Muscles • • •• • • • •• • • • • •• • ••• •• • • 126
The Levator ani .................................. 158 Their Relation to Organs and Vessels in Males and Females ••.•.•.••.•.••.•.••.•.•.••.•. 160
Neurovascular Systems: Forms and Relations
and the Prevertebral Muscle • • •• • • • • •• • • • • •• • • • •• • • 124 2.S
The Pelvic Floor Muscles:
4
Lateral Tract • •.•. • •.•.••.•.••.•.•..•.•.••.•.••.•. 120 2.3
Structure of the Pelvic Floor and Pelvic Spaces:
3.10 The Muscles of the Female Pelvic Floor and Wall. .•.••.•. 156
and Function . • •.•. • •.•. •• .•. •• .•.•..•.•. • •.•. •• .•. 118 2.2
The Pelvic Aoor Muscles:
5.14
The Testis and Epididymis ... •.... . . . .. . • . .... •.... 196
5.15
The Fasciae and Erectile Tissues of the Penis ..... .. ... 198
5.16
NervesandVesselsofthePenis •....•..... •.... •.... 200
5.17 Female External Genitalia: 5.18
Overview and Episiotomy . . . . .. . . . .. . . . . .. . . . .. . . . . 202 Neurovascular Structures, Erectile Tissues, Erectile Muscles, and Vestibule • • • • •• • • • • •• • • • • •• • • • 204
Tobie of Contents
Upper Limb
3
Musc:ulature: Topographical Anatomy
The Upper Limb as a Whole .•..........•......•....•. Integration ofthe Shoulder Girdle irrto the Skeleton of the Trunk .........•....•..........•...........•. The Bones of the Shoulder Girdle ..•....•......•....•. The Bones of the Upper Limb: The Humerus ......•....•..........•...........•. Torsion of the Humerus ...•..........•.....•....•.
208
3.1
210 212
3.2 3.3
214 216
3.4 3.5
The Posterior Muscles of the Shoulder Girdle and Shoulder joint .................................. 284 The Posterior Muscles of the Shoulder joint and Arm •... 286 The Anterior Muscles of the Shoulder Girdle and Shoulder joint .................................. 288 The Anterior Muscles of the Shoulder joint and Arm .•... 290 The Anterior Muscles of the Forearm .................. 292
1.6 The Radius and Ulna .............................. 1.7 The Articular Surfaces of the Radius and Ulna •.••.•.•• 1.8 The Hand ....................................... 1.9 The Carpal Bones ................................. 1.10 Thejoirrts of the Shoulder: Overview, Clavicular joints ......................... 1.11 Ugaments of the Clavicular and Scapulothoracic joints ............................ 1.12 The Capsule and Ligaments of the Glenohumeral joint ............................... 1.13 The Subacromial Space ........................... 1.14 The Subacromial Bursa and Subdeltoid Bursa •.•.••.•.•• 1.15 Movements of the Shoulder Girdle and Shoulder joint ... 1.16 The Elbow Joint as a Whole ...................................... 1.17 Capsule and ligaments ........................... 1.18 The Forearm: Proximal and Distal Radioulnar Joirrts •.•.••.•.•.••.•.•• 1.19 Movements of the Elbow and Radioulnar joints ......... 1.20 The Ligaments of the Hand .......................... 1.21 The Carpal Tunnel .................................. 1.22 The Ligaments of the Fingers ........... . ... . ........ 1.23 The Carpometacarpal Joint of the Thumb • •.•.•. • •.•. • • 1.24 Movements of the Hand and Anger joints • •.•.•. • •.•. • •
218 220 222 224
3.6 3.7 3.8 3.9 3.10
Bones, Ligaments, and joints 1.1 1.2 1.3 1.4 1.5
2
Musculature: Functional Croups
2.1 2.2
Functional Muscle Groups . .. . . . . .. . . .... . . . . .. . . . .. . The Muscles of the Shoulder Girdle: Trapezius, Sternocleidomastoid, and Omohyoid . . .. •. Serratus anterior, Subdavius, Pectoralis minor, Levator scapulae, and Rhomboid major and minor . . .. The Rotator Cuff .. .. ........ . ...... .. ........ .... The Deltoid .... . . . .. . . . .. ... .. ... . . .. . . . .. ... .. .. Latissimus dorsi and Teres major ... . . . .. . . . .. ... .. .. Pectoralis major and Coracobrachialis . .• . . . .. • . . .. •. The Muscles of the Arm: Biceps brachii and Bradhialis . . .. ... .. ... . .... . . .. .. Triceps brachii and Anconeus . .. ... .. ... . . .. . . . .. .. The Muscles of the Forearm: The Superficial and Deep Flexors ... .. ... .. . . .. . . . .. The Radialis Musdes ...... .. ... ... .... . .... .. ... .. The Superficial and Deep Extensors . .. . • . .. . . •.... •. The Intrinsic Muscles of the Hand: The Thenar and Hypothenar Muscles .. •. . .. . . •.. . . •. Lumbricals and Interossei (Metacarpal Muscles} •.... . .
2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14
226 228 230 232 234 236 238 240 242 244 246 248 250 252 254
The Posterior Muscles of the Forearm .••.•.•.••.•.••.• 294 Cross Sections of the Arm and Forearm ••.•.•.••.•.••.• 296 The Tendon Sheaths of the Hand ..................... 298 The Dorsal Digital Expansion ......................... 300 The Intrinsic Muscles of the Hand: Superficial Layer ................................. 302 3.11 Middle layer ..................................... 304 3.12 Deep layer ...................................... 306
4 4.1 4.2 4.3 4.4
The Arteries ....................................... 308 The Veins ......................................... 310 The lymphatic Vessels and lymph Nodes .•.•.••.•.••.• 312 The Brachial Plexus: Structure ....................................... 314 Supraclavicular Part ............................... 316 4.5 Infraclavicular Part-Overview and Short Branches ••.• 318 4.6 Infraclavicular Part-The Musrulocutaneous Nerve 4.7 and Axillary Nerve ................................ 320 4.8 lnfraclavirular Part-The Radial Nerve .••.•.••.•.••.• 322 4.9 lnfraclavirular Part-The Ulnar Nerve •. • •.•. • •.•. •• .• 324 4.10 lnfraclavlrularPart-TheMedlan Nerve .............. 326
5
Neurovasc:ular Systems: Topographical Anatomy
5.1
Surface Anatomy and Superficial Nerves and Vessels: Anterior View . . . .. . . . .... . . . .. . . . . .. . . . .. . . . .. . . . 328 Posterior View . . .. . . . . .. . . . . .. . . . .. . . . .... . . .. . . . 330 The Shoulder Region: Anterior View . . . .• . . . . .. . . . .• . . . 332 The Axilla: Anterior Wall . . . .. . . . . .. . . . .... . . .... . .... . . .. . . . 334 Posterior Wall . . . .. . . . . .. . . . . .. . . . .. . . . .... . . .. . . . 336 The Anterior Bradhial Region . . ...... . . .. . . . .. . . . .. . . . 338 The Shoulder Region: Posterior and Superior Views ..• . . 340 The Posterior Brachial Region . .... . . . .. . . . .. . . . . .. . . . 342 The Elbow (Cubital Region) ... ...... . . .. . . . .. . . . .. . . . 344 The Anterior Forearm Region . . ...... . . .. . . . .. . . . .. . . . 346 The Posterior Forearm Region and the Dorsum of the Hand . . ...... . . .. . . . .. . . . .. . . . 348 The Palm of the Hand: Epifascial Nerves and Vessels .. . ..... .. ... .. . . . .. . . . 350 Vascular Supply ........................ .. .... .. .. 352 The Carpal Tunnel ... . ... .. . . .... . .. . ..... .. . . . .. . . . 354 The Ulnar Tunnel and Anterior Carpal Region .. .. ....... 356
256 258 260 262 264 266 268 270 272 274 276 278 280 282
Neurovasmlar Systems: Forms and Relations
5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15
XI
Table ofContents
Lower Limb
Bones, Ugament:s, and Joints 1.1
The Lower Limb: General Aspects .•....•.....•....•... 360
1.2
The Anatomical and Mechanical Axes of the Lower Limb . 362
1.3
TheBonesofthePelvlcGirdle .........•.....•....•... 364
1.4
The Femur: Importance of the Femoral Neck Angle ..... 366
1.5
The Femoral Head and Deformities of the
1.6
The Patella ...•....•.....•....•...........•....•... 370
Femoral Neck .•....•.....•....•.....•.....•....•... 368 1.7
The Tibia and Fibula ••.•.••.•.•..•.•.••.•.••.•.••.•. 372
1.8
The Bones of the Foot from the Dorsal and Plantar Views •.••.•.••.•.•..•.•.••.•.••.•.••.•. 374
1.9
The Posterior Compartment (Superficial Flexor Group) .....•....•..........•.... 434 The Posterior Compartment 2.9 (Deep Flexor Group) ...•.....•....•..........•.... 436 2.10 The Intrinsic Musdes of the Foot: Dorsum and Medial and Lateral Sole of the Foot .•.... 438 2.11 The Intrinsic Musdes of the foot: Central Sole....•.... 440 2.8
3
Musculature: Topographical Anatomy
3.1
The Muscles of the Thigh
The Bones of the Foot from the Lateral
Hip and Gluteal Region from the Medial and Anterior Views .•.••.•.••.•.•..•.•.••.•. 442
and Medial Views; Accessory Tarsal Bones .•.••.•.••.•. 376 1.10 The Hip joint: Articulating Bones ..•.•.••.•.••.•.••.•. 378 1.11
The ligaments of the Hip joint: Stabilization of the Femoral Head •.•.••.•.••.•.••.•. 380
1.12
3.2
Origins and Insertions .••.•.••.•.••.•.•..•.•.••.•. 444 3.3 3.4
1.14 The Movements and Biomechanics of the Hip joint .•..•. 386 1.15 TheDevelopmentoftheHip]oint .•.•.••.•.••.•.••.•. 388
Hip and Gluteal Region from the Lateral and Posterior Views .•.••.•.••.•.••.•.•..•.•.••.•. 446
Nutrition of the Femoral Head •.••.•.••.•.•.••.•.••. 382
1.13 Cross·SectionaiAnatomyofthe Hip joint •.•.••.•.••.•. 384
Hip and Gluteal Region from the Anterior View;
Hip and Gluteal Region from the Posterior View; Origins and Insertions .••.•.••.•.••.•.•..•.•.••.•. 448
3.5
1.16 TheKneejoint: Articulating Bones ••.•.••.•.•..•.•.••.•.••.•.••.•. 390
The Muscles of the Leg from the Lateral and Anterior Views; Origins and Insertions •.•.•.••.•.••.•.••.•.•.••.•. 450
1.17
The ligaments of the Knee joint An Overview ••.•.••. 392
3.6
from the Posterior View; Origins and Insertions •.••.•. 452
1.18
The Cruciform and Collateral Ligaments .•.•.••.•.••. 394
3.7 3.8
The Tendon Sheaths and Retinacula of the Foot •.•.••.•. 454 The Intrinsic Foot Muscles from the Plantar View;
3.9
The Intrinsic Foot Muscles from the Plantar View .•.••.•. 458
1.19
The Menisci ••.•.••.•.••.•.•..•.•.••.•.•..•.•.••. 396
1.20
The Movements ofthe Knee joint •.•.••.•.•.••.•.••. 398
1.21
Capsule and joint Cavity ••.•.•..•.•.••.•.•.••.•.••. 400
1.22 The joints of the Foot Overview of the Articulating Bones and joints .•.•..•. 402 1.23
Articular Surfaces •• .•.• • .•.•.. • .•. •• .•. • . • •.•. • •. 404
1.24
The Talocrural and Subtalar joints •.•. • •.•.•. • •.•. • •. 406
the Plantar Aponeurosis ••.•.•.••.•.••.•.••.•.•.••.•. 456 3.10
Origins and Insertions •.••.•.••.•.••.•.•..•.•.••.•. 460
3.11
Cross-Sectional Anatomy ofthe Thigh, Leg, and Foot •.•. 462
4
Neurovascular Systems: Forms and Relations
1.26 The Movements of the Foot •.•.•..•.•. • •.•.••.•.••.•. 410
4.1
The Arteries • •.•.••.•.••.•.•. • •.•.••.•.••.•.•..•.•. 464
1.27 Overview of the PlantarVaultandtheTransverseArch .•. 412
4.2
The Veins •. • •.•.••.•.••.•.•. • •.•.••.•.••.•.•..•.•. 466
1.28 The Longitudinal Arch of the Foot •• • • • • •• • • • • •• • • • •• • • 414
4.3
The Lymphatic Vessels and Lymph Nodes • • • •• • • • •• • • • • 468
1 .29 The Sesamoid Bones and Deformities of the Toes • • • •• • • 416
4.4
The Structure of the Lumbosacral Plexus • • • •• • • •• • • • • • 470
1.30 Human Gait .. • . . .. • . . . . .• . . . .• . . . . .• . . . . .• . . . .• . . . 418
4.5
The Nerves of the Lumbar Plexus:
1.25 The Ligaments of the Foot ••.•.•..•.•. • •.•.••.•.••.•. 408
The Iliohypogastric, Ilioinguinal, Genitufemoral,
2
Musculature: Functional Groups
2.1
The Muscles of the Lower Limb: Classification .• . . . .. . . . 420
2.2
The Hip and Gluteal Muscles:
and Lateral Femoral Cutaneous Nerves .... . . . .. • . . .. 472 4.6 4.7
The Superior Gluteal, Inferior Gluteal,
The Inner Hip Muscles ...• . .... • . . .. • . . . . .• . . . .. . . . 422 2.3
The Outer Hip Muscles . .• . . . .. . . . .. • . . . .. . • . . .. • . . 424
2.4
The Adductor Group . . . .• . . . .. . . . .. • . . . .. . • . . .. • . . 426
2.5
The Anterior Thigh Muscles: The Extensor Group . . .. . • . .... . . . .. • . . .. . • . . .. • . . . 428
2.6 2.7
The Aexor Group . . • . .. . • . .... . . . .. • . . .. . . . .. . . •.. 430 The Leg Muscles: The Anterior and Lateral Compartments (Extensor and Fibularis Group) . . .... •.... . • . . •. • . .. 432
XII
The Obturator and Femoral Nerves .• . . . .. . . . . .• . . . . 474 The Nerves of the Sacral Plexus: and Posterior Femoral Cutaneous Nenll!s .. . . . .. • . . . . 476
4.8
The Sciatic Nerve (Overview and Sensory Distribution) • . . . .. . . . .. • . . .. 478
4 .9
The Sciatic Nerve (Course and Motor Distribution) . . .. 480
4.10
The Pudendal and Coccygeal Nerves • . . . .. . . . .. • . . .. 482
Tobie of Contents
5
Neurovascular Systems: TopographiC411 Anatomy
5.1
Surface Anatomy and Superficial Nerves and Vessels: Anterior View ......•....•..........•...........•. 484
5.2 5.3
Posterior View •....•.....•....•...........•....•. 486 The Anterior Femoral Region Including the Femoral Triangle ..•....•..........•...... • ....•. 488
5.4
Arterial Supply to the Thigh .•..........•......•....•. 490
5.5
The Gluteal Region: OVerview of Its Vessels and Nerves ....•......•....•. 492
5.6
The Sciatic Foramen and Sciatic Nerve ..•..... • ....•. 494
5.7
The lschioanal Fossa ..•....•..........•...........•. 496
5.8
The Pudendal Canal and Perineal Region (Urogenital and Anal Region) ..........•......•....•. 498
5.9
The Posterior Thigh Region and Popliteal Region .•....•. 500
5.10 The Posterior Leg Region and the Tarsal Tunnel ..•....•. 502 5.11
The Sole of the Foot ..•....•..........•...........•. 504
5.12 The Anterior Leg Region and Dorsum of the Foot: Cutaneous Innervation •••••••••••••••••••••••••••••• 506 5.13 TheArterlesoftheDorsumoftheFoot •••••••••••••••• 508
Appendix
References ... .. .. ... .. ... .. ... .. ... .. .. ... .. ... .. .. ... 513 Index . .. . . . .. . . . . . .. . . . .. . . . .. . . . . .. . . . . .. . . . . .. . . . . .. 515
XIII
General Anatomy Hum<~n Phylogeny and Ontogeny ••••••••••.•.•.••.• 2
2
Overview of the Human Body ..................... 20
3
Surface Anatomy of the Body, Land maries and Referencr Unes .••.•..••••••••••••.•......••• 24
4
The Bones and joints ............................. 34
5
The Muscles ............•.•...•...•............. 40
6
The Vessels •••••••••••••••••••••••••••••••••••• • 44
7
The Lymphatic System and Glands •••••••••••••••.. 50
8
General Neuroanatomy •••••••••••••••••..•.•.••. 54
Gltnetal Amltomy - - J. Human Phylogeny and Ontogeny
1.1
Human Phylogeny
A lrtl!l-MI!woflun.Jn phylogenl!ttcdewfopmlllllt To better underst.md tile ewlutfon of the human body, It Is helpful to tr~c:e it5 phylogenetic d-laFment. Humans ~nd tfleir daRSt rel~tives belong to tfle pflwtum Cllordm, ~lch lncludn appi'QlChnately 50,000 species. It consists oftwo subphyla:
Amphibian
Altptlle
Bird
Mammal
• Invertebrata: tile tunlcates (Tunlcata) and chordates without a true slaJII (Acr.-anlata or Cephalochordata) • Vertebrata: the verttbr.ilt2S (animals that h:M! a vertebral column) Although some members of the dlordate phylum differ marki!dly from one anotber in appearance. they are distinguished frcm all other ani· m.-als by char.-acterlnk morphological structiJres tflat are present at same t!me during the life of the anlm.-al,lf oolydurlng embi')'Oillc devel· opment (see G). lnvertebr.rtl! chcu1l~ such as the Ceflhaladlordates and their best-Ial~ ~pedes, the lat~telet (Billnc:hlo.!toma lanceolatum) are considered !he modd ofaprlmll:llle ~by virtue of their organization. They proW!e clues to the basic structure of the vertebriltl! body and thus are important in understanding the general arganizatian of vertebrate organisms (seeD}. All the member.s of present-cl;ay wrtl!bratl! cS;mes (lawless fish. c:arti· laglnous fish, bonyftsh, amphibians, repClles, birds, and m.-amm.-als) h;we a numbef'of charactzristic fNtures in com man (see H), induding ~
8 Dlft'en=nhtlge$ln the arfycdlryonlt deftlopmmt of wl'tlf:lm:es
The earty dewlopmental stages (top
oolc componmts that hive been adapted to produce sometimes slmtlar (fltiS ;md limbs) and sometimes radically dllferer~t (gills vs. neck carti'lages) adult structures.
Nwr.albJ~
Ccnnedfng -----'~
stak ('o1th
umblfcal III!SS
C Formatron of tfle br.~rtdllal or phuyngeal an:hes In il ftve..weet-
old humanembryo view. The br~nchi~l or pharynge~l;arches of tfle vertebrate embryo have a ml!fX/mmc arrar~gement (similar to tfle somltes. lhe primitive segments of the embryo tile mesoderm); this means that they are organized into a series of segments tflat haw the s.ame basic struc· ture.Amongthelrotherfunctlons,theyprovldethe rJWmaterlalforlhe spedes-spedflc development ofthevlsaeral skeleton (ITiiDdlla and mandible. middle ear. hyoid bone,laryruc), the as:sodiltl!d facial muscles, and the pharyngeal gut (seep. 11}. ~ft lateral
2
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
Branchial arches, branchial clefts
Intestinal vein
NotDChord
Oral callltywlth buccalcilli
An ray
Neural tube Myomere (musculature)
Neural tube
Aortic root
Foregut
Branchial lleSSel Gonads Hindgut
Atrlopore
Hepatic cecum
Branchial artertes
Hypobranchial
Branchial artery
greave
Spinal card In neural canal Neural arch Artery
Sex organ
Liver
Vein Hemal arch
Notochord
H Characteristic features of vertebrilltes
• Nervi! cells, sensory organs, and oral apparatus con<:l!ntrated In the head (cephalization) • Multipart brain with a pituitary gland • Replacement of tile notocllord by the vertebral column • Generally, two pairs of limbs • Development of branchial arches • Pr!!sence of neural crest eels • Closed circulatory system with a ventral, chambered heart • Labyrinthine organ with semidrcul.ar canals • Stratified epidermis • Liver and pancreas always present • Complex endocrine organs such as the thyroid and pituitary • Complex immune system • Sexes ;~!most alw;JyS separate
Heart
E Bilslc vertebrate anatomy, exemplified by the bony !Ish The vertebrates are the subphylum of chorrlates from which humans evolved. With the evolution of fish, the notochord was transformed into a vertebral column (spinal column). The segmentally arranged bony vertebrae of the spinal column encircle remnants of the notochord and have largely taken its place. Dorsal and ventral arches arise from the ve~bral bodies. The dorsal arches (vertebral or neural arches) in their entirety make up the neural canal, while the ventral arches (hemal arches) form a caudal "hemal canal" that transmits the major blood vessels. The ventral arches in the trunk region are the origins of the ribs.
Gonads
• Development of an axial skeleton (notochord) • Dors;oi neural tube • Segmental arrangement of the body, particularly the muscles • Foregut pierced by slits (branchial gut) • Closed circulatory system • Postanal tall
~l'J"pleural
D Bilsic d!ordm ilniltomy, illustrilb!d for the lancelet (Brancl!iosmma lanceolatum} The ve~brates (including humans) are a subphylum of the chordates (Chordata), of which the lancelet is a typical representative. Its anatomy displays relatively simple terms of strucb.Jres common to all vertebrates. The characteristic features of chordates include the development of an axial skeleton called the notocflord. The human body still has remnants of the notochord, such as the nucleus pulposus of the intervertebral disks. The notochord is present in humans only during embryonic life, however, and is not a fully developed structure. Its remnants may give rise to developmental tumors called chorrlomas. Chordates have a rubular nervous systEm lying dorsal to the notochord. The body and particularly the muscles are composed of multiple segments called myomeres. In humans, this myomeric pattern of organization is most clearly apparent in the trunk. Another distinguishing feature of chordates is the presence of a closed circulatory system.
Rib
G Characteristic features of chordates
Spinal cord In neural canal
Spinous process
Transverse
__,~,.__ .. canal
process
~ Vertebral
4
Vertebral arch
Characteristic features of mammals
• Highly glandul~r skin covered with true hair (tennlnal hair) • Females ~lways h;we m~ITVTl~ryglands for nursing offspring, which are usually born live (viviparous) • Well-
body
Lung with
~!m;:J..,In He..rt
lnterv.rtebral disk
j
Spinous process
Neu111l canal
F Bilslc vertebrate anatomy, the dog
3
Gltnetal Amltomy - - J. Human Phylogeny and Ontogeny
1.2
Human Ontogeny: Overview, Fertilization, and Earliest Developmental Stages
Besides gross and mlcrosooplc anatllmy. the development.11 history of the rndMdual organism (ontogeny) Is of key lmpor1.ilr1Ce In underst.1fld· ing the human body. OntGgeny is CGncerned with the IWm;atiGn of tis· sues (hlstogel'le!ls), organs (01J011ogtY!eSis). and the shilpe of the body (motp/logeiH!sls}.
C nmmble of antl!naul hum;~n development (The Cilmegre stages are shown rn p.;~renthe.ses.} Weells 1~:
brty -...pment
Week 1:
Tubal mlgratton.segment.ltlon, and blastocyst formation (stages 1-3) lmplant.rtlonand bll•mlnarembryonlcdlsk, yolk sac (mges 4-5) Trilaminar embryonic a.sk. start of neurulation
Week2: Stage 17 Stag~14
Greatest length {GL)cr ~-n.mp
lenglll {CRI.)
~
Stage20
Week3:
(stages 6-9)
Weells4-1:
Emblyadcpeliod
Weet4:
I'CIIdrng ofthe embryo, neurulation con dueled.-~~ 0f1i~nS. baste body shape (suges IG-13) Ckg;lnogenesls (fonnatfon of all essential external and lntefnal organs, elongated hmb buds) (stages 14-23)
Weeks 5-8: W..bWI:
l'«
Weeks 9-38:
Ckg;ln growth ;and functional maturation (sex-speclllc dlfferentlatfon ofthe extl!rnal genitalia)
181glhafgemtlan
..
• p.o. -()OStOIWiatory<~gt • p.m. • postmensttllill ;age
266d;,ys-38weeks 280 d;,ys •40weeks
• GL • gre.alll!st length. excluding lower limb • CRL • crown-rump length
simplest, mo.st conslsll!nt ultrasound measure similar to Gl in embryonic period. used In most ducrtptlons of the feCal perfod
A f1H. to elght-k-old hum;~n embi}VI Streeter (1942) and O'Rahllly (1987} classified earty human development and Ule embi')'Dillc penod Into 23 stages biiiSed on specimens frvm the Carnegie Callection. The Q!rnegie Jtages are defined by mor· phologlcal char.ICI:erirtlcs that can be dos:dy CGrrelated with speclflc age (postoi/IJiatory days or weelcs) and slze (measured as the greall!st length, excluding lower limb (GL), or crown-rump length (CRL) (see C).
Embryorlcdlsc:
St.Jge14: AfthWH!c.GLS-7mm.futurecerdmrlheml~pheresbeCGme ldentlllable Stage 17: Sixth week, Gl 11-14 mm, digital rays bemmevisible. St.Jge20; Seventh week. Gl18-22 mm, upper arms bent at the elbow, hands In a pronated posltton. StageD: Elghth week, Gl27-31 mm, eyelids fuse. exll!rnal genitalia begin differentiation. B longitudinal growtflancl weTghtpln cbtng thefmll period Age(WIIIIII)
9-12 13-16 17-20 21-24 25-28 29-32 33-36 37-38
4
,_,.mp
llntllh.CRL(an)
5-8 9-14 15-19 20-23 24-27 28-30 31-34 35-36
Weight (I)
10-45 60-200
250-450 500-820 900-1300 1400-2100 2200-2900 3000-3400
PIICII!Irtll Amliotk c;Mty Fetal pmod (weeks 9-38)
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
Oogonium (44XX)
0
@
•
Polar bodies dMdlng
Spe111011Dgonlum
(44XY)
Mitulis
Primary oocyte
(44XX)
Secondary
1\
0
0/\
oocyte
1\
RmnKrturoDon
©
S«ood
maturation division
Primary spermo!Dcyte
(44XY)
dM»on(~~@ ) I \@ j
Oocyte In the second
Semndary spermatacytes
-/ \ 1\ E;1\ 1\ rm.ou"
Ma!~o (22X)
••• © © ©@ ~rzx~· Polar bodies
(22~
I
I
I
I
22Y 22Y)
((((
f f f f
Phase] Spormato.aa
Oogenesis
E Formation of the ovum and spenn (aftl!r Sadler) During the formation of the gametes (sex cells), two successive cell divisions occur (the first and second meiotic maturation divisions). This results In cells having a chromosome set that Is reduced by one-half (haploid). When fertilization occurs, a diploid (full) chromosome set Is restored. During meiosis, extensive chromosal rearrangement occurs, thus recombining the Internal genetic Information Into new and different subsets. Oogenesis: The Initial oogonla first undergo a mitotic division to form prlmaryoocytes, whldl still have adiploid chromosome number(44XX). Later the primary oocytes undergo a first and second maturation division by meiosis, resulting In four haploid cells (22X): one mature ovum and three polar bodies. Spennatogenesls: Diploid spermatogonia undergo mitosis to form prlmaryspermatocytes (44XY). These cells then divide meiotically to form four haploid spermatlds, two of which have an X dlromosome (22X) and two a Y chromosome (22Y). The spermatids develop into motile spermatozoa (spermatohistogenesis). First
segmentation Zygote
formation
T\W<ellstage (30 hours)
Corpus luteum
Postavulatory ovum
Cell nucleus Fusion (male oftheavum pronucleus) and sperm
Spermato.aon
Morula stage
Blastocyst
(day3)
(day4-5)
F Schematic representation of the ferUilzatlon prvcess (after Sadler) In phase 1, the spermatozoon penetrates the corona radiata cells. In phase 2, the acrosome dissolves, releasing enzymes that digest the zona pelluclda. In phase 3, the cell membranes of the ovum and sperm fuse, and the spermatozoon enters the egg.
Embryoblil
Bla
cavity G
Epithelial cell
Trophoblast (outer cell layer)
Trophoblastic cells
Blastocyst cavity
Implantation of the blastocyst in the uterine mucosa on postovulilt:Ory day 5-6 (after Sadler)
H Developmentll proa!S5es during the first week of development (after Sadler) 1. Ovum immediately after ovulation 2. Fertilized within approximately 12 hours 3. Male and female pronucleus with subsequent zygote formation 4. First segmentation 5. Two-cell stage 6. Morula stage 7. Entry Into the uterine cavity 8. Blastocyst 9. Early Implantation
5
CienmllAnaiDmy - - J. Human Phylogeny and OniDgt!ny
1.3
Human Ontogeny: Ciastrolation. Neurolation. and Somite Formation Con'"(llngst.ll•
llllmtlar ..,bryonk:dsc
Ctiri31
l
NDIDchordol ..........
Oropharyngeol ln81'bnne
.....
Ellnembryonk muodeml
Pllmltlw
Fltmlt.,.wak
(ptllfst
~
c
~-
Fltmi!M~'I'olknc
Hypobl.,t
Plane of
soctlonlntl ¢11'1~+---
!'lone ohoctlan In c
Eldlwnbr)lonlc:
maocletm
•
Fltnoltlw JbHk
..
caudol
A Formttron of the trt..m,....r hu!Nn embr,onlc disk (g..tnJ• don) at the mrt vfthe third pas1Dwlmllywulc:{aftEr Sadler) As a result of gastrulation, the cellla)ws become dll'rl!rentlatecl lntD an «todMn. mdo«rm, and merockrm. from which ill structures of the human body are den~ (e.g., the endoderm gives rise tD the central neNUUJ ~m and tfle .tenrory ~:~rg~ns). Gil5trulation als~:~ ero.blishe.s the prtmary mces of the body (~~entnl~oi"Sil, cranlil-
th.._,
1 conaptu1 d 2 paiiiMI!mxy......_ The embrygnlc disk Is stm blklm/nor and Is slretihed bet'Me! the amnlatic Cilvity and yalk sac. The utr.IM'Ibryanic memderm, whose formation cammenas it the posteslor pole of tfle embryonic disk. alre;~dy coven the entire oonoptus. which Is mached to the chorionic cavityby a C~:~nnecting mlk.
SlgltliiiHdlon
b Dcnll "'- of• hu11111n .....,._.k dl1kiltthe sl:ilrt of g•ltruliltkln. The amnion his been removed. Thecellllyer facing the amnlotfc Cil'r lty, the eplblost. will form the embryo Itself; the other layer, the hypoblast. will generate extr.l-embJlOnlc structures. In the third week. the epiblast sequentially develops a prlmltM strlcJic and a prlmltlve nocle; some epiblast cells dn.e into the streak, detach, and migrab! as indiCilted by the iiii'OWS to generm the embryonic endoderm and mesoderm; a mass of cells expands cranially from the node to the omplloryngeo/ 111611brone to fonn tfle notochordal proem. The remain lng epiblast cells bealme the ectoderm, part of which will glw! rtse to the neumi!CIIlderm in the next development phase, nftlftllcrliott. c S.ltlill sedlon: ernlll}ank llllkalong tMI'ICiblchclrdil , . - . d cr- .alan: emb..,.nlc 111111 8t the level of the prtmltlw 11'011111! (ill'CI'M in c: ;md d: di~ction of gastrul~on mOftments by the mesadam). Ctlrlll Cut.,jge
ofamrlon Pllneof section lnf Oolul'f:of nt~~raltube
C.ud•l
Noural crest re.raltube
~ ••~ .•
Amnion =i:
SurRa!_ , ~
~·
ed:odo!nn
""" /
·, '
.. . 'L
Polrof •
ICIT11tr£
~ -r-:- ombr)ooni: Intra'
Gutllme 'l'olksoc
•
f
I Nanliltlon dlol'lngwrfy human dftll!lapment (after Sidler) ~ Dorsal view lifter removal ofthe amnion. d-f Schan~c cross sections ofthe corresponding stagesitthe planes of section m1rlrlld In lt-C- Age In postiM.IIatoly d~YS- During neu-
rulaian, the neuroectoderm differenti.atl!s from the surface ectoderm due to lnductlYe lnftuences from the notDchord. a,d Embryanlc disk~ 19 d~YS- The neural tube Is d -loplng In the a re11 of the neural pll~.
6
(
u.lom
(rutu... body awrty)
b, e Embryonic disk it 20 dlys. The flm somites hive formed, and the neural grocwe Is beginning tD clo.le to form the neural tube, with
c,f
initial folding ofthe anbrya. Embryo it 22 days. Eight p1lrs of somltes 1re se8'l flanking the partially dosed neural tube, which has sunk IMiaw the ectoderm. 14: the sites where the neural fl:llds fuse to dose the neural tube. cells farm a bilateral neural crestwhldl detaches from the surface and mlgrms Into the mesoderm.
General AnG1Dmy - - 1. Human l'hylogeny 11nd OnbJgeny
lllf\Jr;olc~
- - ---::-::-""".;,.
D Dlfhnntt.U.n vfthe 111111 l.,.n (hr Christ 1nd Wlchtler)
mmrlll Nl!lr.ll tUJ. ---:>'-.:..--\itj
Neur~ltube
-chord -......,;;:,...,:,;--..:: sp.,d!m- _ __.:.__;;,j~....
Noul'llaut
ofllwheld
ploul'l eclodonn
,.!kl---..
cmt
i
So"'*"eon ..---"'(
•
~-....:....--
s..-y811d ~ Plllla. pertphonl • • edrW1III mtclulo. plgolwKals,
~rmol
Antwlor plblbry, Cl'llllil se~ gonalio.
p'-cles
olfldOIY opidl..lum.lnlllr _.,len.
Neonlaat
inlni!Y.Ir.. .,.__
-
surmc.
Mlgrolb:l
sdeiO!Ome cells
El'lllllol orgon of lhe t.elh, epithelium
derm
(wmbrolbody
~n!.ge)
'-----'--,..__- Guttube
Axl;)l
-++-- llodya!VIty
lniiMIUI'IIrw.-. sysbmof the bawol,
ponlalk-all. smoath mnde. ....... mh.arodd body. bane.~ CDI1IIeC1Iw tb-. Mill8lld ClltiMnlun
_..
s.n... - -·
lr.~ln. mlna. spinal card
s-y 1nd pll'lsylllpahtlc~la.
Notochord, prechardol
Extr-.c.c!J" musdes
mHOderm
b
Spln1l wh,mn, CXII1,_ tlllut.
~bs. slcddil musdf,
p.....,
d~rmlsand subcutis ofthe b.cbnd ptrt ofth* head, smooth muscle.
bloodwtMis
J
lnttrmedlm
IOdnl)'l. goNdl, rtnal1nd genlbl ~
ducb Vl:rar~l
Ullnl pia mem-
derm
Hart, blood-Is, smocth mulde, bowel
(spland»pleura)
wal~ blood. ad,.,1l e»rta, IIISCJOI'II.....,..
Pllrletrl (somotDpleura)
lllmum,llmbs without muscles, dermis and JUbaltlrwoustusu. of the lntlrdawal body wall, smooth muscle, e»nnectl,.. tissue, pallmllltOA
I ,5
Eplhdlm Gfthe "-\.l'lllphllorytract. cllgaiM . . . .~ gllnlls, ..-.... tJ.k~-'ty.lrirwy biMder. th,mia. pentlrrrold ai-ls. thrnlld gl..d
(For d11rlty. the surrounding 1mnlon IJ not shown.) The first p;~lrs of som112uppear 1Upproxtmately 20 postowbtory lbys. All34 or 35 of lfle somltes ("primitive segmam-) hiM formed by diy30.
~~e ------------~ de!-..... ~--- Spi~ICXJrd In
spiMal'lll
c 5clrllb lllertwtM~•IIIIItpiUI nerve fllrrutfonlllurtng the
embryvnk perW (-b4-1). shown lnaerndccrau sections(art. Drvws)
• When dlfflrentlatlan begins, each of dies. somlms subdivides Into"' dennatome, ~me, 1nd JCitrotome O.e., i1 cutlneous, musculir, and vert.brll segment). b At the end of 4 -eks. the sderotome czlls mi'lll"iite IDMrd the notochord and fonn the an!age of ttle spln1l column. c The neu ril tube-ttle precursor of ttle spinal cord and bl'ollln-dlfrerentlam to fonn i rudimentary spinal cord with doml ind ventral horns. Cells within the ventr1l horn dltrl!!rentlate Into motor neurons that sprout axons which fonTt the WJ~trlll root. The neural crest hilS muldple derlvillves, Including sensory neurons 'Atllch fonn dors.al root (spinal) ganglia, ..tllch s.nd anlr.ll processes Into the splnil cord vl1 lfle dorsrliiOOt. The myotDmes beaJme 5egregated Into a doml p1rt (epimere • epilldll muscles) 1nd 1 ventral p;11rt (hypomere • hypaxial musde.s). d Each p11lr of dorstl and ventral roots unites to form il splnil nerve. which then diVIdes Into t'MI mo~ln bl'ollnches (a dorsil rimus ind o1 ventral ramus). The ep~xial muselen ruupplied by lflt dorAI ramus. the hypaxial muscle.s by ttle wntrill r~mus. e Cross section at the lew! of the future abdomin:~l musdes. The epaA! muscles become lfle Intrinsic blck muKies. whde lfle hypullll muscles dewlap Into structures tNt lndude the btlnl ibdornlnal muscles (external and Internal oblique, tr.nsversus adomlnls) ~~nd the 11nt211or1bdomlnal musda (rectus abdomlnls).
7
Genenll Anatomy - - 1. Human Phylogeny and Ontogeny
1.4
Human Ontogeny: Development of the Fetal Membranes and Placenta uterine COI])US Cho~onlc cavity
Connecting stalk with embryonic
blood vessels
Malnst..m
Chorionic
lntsvillous
villus
mesoderm
space
DetJII,seeb
in chorionic mesoderm
~~;.c:lZJ~t);~:Q-"t4--~ Outer
Fusing .amnion and morton
cytotropho-
blastic layer Amniotic
cavtty
010rlonlc Chorionic
plote
cavity Decidua apsularls
Cytotropho-
Syncytle>-
blast
trophoblast
b ~--:::>--Chorton
frondosum
~col canol
---++)
-----fo<
'-::r-__.<7----
Extemal reNicalos
Yolk sac Amnion
+--- MUCliS plug In cervical canal
d
8
A Development of the fetal membranes and placenta (after Sadler and Drews) a, c, and d Schematic sections through a pregnant ub!rus at different points In gestation. b Detail from a. a Embryo at 5 Wl!l!ks: After the blastocyst has implanted in the ub!rine mucosa, the embryo initially derives its nutrition through the developing trophoblast and chorionic mesodenm. Chorionic villi are fonmed which surround the entire chorionic sac and embryo. They develop from primary to secondary villi and finally to tertiary villi (see close-up in b). b Detail from a: The mainsb!m villi of the chorionic plab! are attached on the mab!mal side to the basal plab! of the decidua basalis by compact columns of trophoblastic cells. Uke the small villous trees that sprout and branch from them, these malnstem villi have a syncytial covering (syncytial trophoblast), which In turn rests on a continuous layer of trophoblastic cells. Inside the villi, capillaries develop In the chorionic mesodenm and communicate with the vessels In the connecting stalk. Mab!rnal blood flows through spiral arteries Into the Intervillous spaces. c Embryo at 8 Wl!l!ks: While the chorionic villi continue to grow and arborize at the embryonic pole, forming the chorion frondosum, the villi outside of this zone begin to regress, forming the nonvlllous chorion laeve directly below the deddua capsularls. The amniotic cavity has enlarged at the expense of the chorionic cavity, and the amnion fuses with the chorion. d Fetus at 20 weeks: The placenta Is fully formed and mnslsts of two parts: a fetal part fonmed by the chorion frondosum and a mab!rnal part, the decidua basalis.
General AnGtomy - - 1. Humanl'lryfogftry and Onlugeny
UmbiiCilll<ml
,L,
Dedduabmlls Detldual 5e91.t
Mltemal blaodvasels
Chorionic
(spfr.~larter!ennd
~Ill
Decidual "Pbb
1rmrn1ous ~
venous open\'lgl)
8 Sdlll!nliltfccrosssectfonofil mature human pl;imnta
The mature placenta Is shaped like a frying p.an, Ule mil1lerml decidua basalis (basal plate) forming the base ofUie p.an and the fetal choriot'lic plate formlr~g the "lid.• Some 40 arborlzlr~g villous t:n!es containing fetal vessels proJedfrom thechorfonlc plate Into the portions ofUie placenta thilt are fllled With maternal blood (!n!leNtllous spaces). The miltl!INII blood flows through appraximab!ly 80-100 spiral artl!ries into the inter· villous spaces, whldl are dtvlded Into cotyledoru by lnCllmplete dedd· ual sept;r. After Ule blood has bathed the villi, It Is collected by fm!QU· larly dlstributtd venous openings In the bani plate .md retumed to the ~ri;d cirtUiation.
C 11ut postp;num pl
face are separmd from one another by decidu.. I sesm.
18-23 an In diameter
2- 3cm In thickness Weight:
Total placerWII wlume: Volume ~the lntcNIIIous spam: VIllous surface am: Blood dn:u~n on the maternal side: Sync:ytlo-
!rophoblzst
Flbnlblast
450-500g app.-lmmly 500ml ;~pp.-lmiltlely 150ml appiOidmmly 11-13 m2 SOO~mlfmln
Slruclureafthe pleantalbllnter
• Endothelium of the ftial capillaries and basal lamina • Abrous 11111ous stroma • ~cytlolrophoblast and bawl lamina • Continuous trophoblast cellfayer(becomes dlsmntlnuous.tlar 20 weeks of oestatron)
Mk:nMII
Diffusion dlstanm appro~~. s)lm (Initially apptOIC. so )lm)
Pit....., fundlclnl ofth1 m.-.. pl11c.nt.. I. TIVIISilOit of scdlstunm ood elldllltlge ofmellrbolk products ~
Chol!onlt - -\-,1..,.:..._.,:::,__ mesoderm
D Crosu«Uon tfucrugh il tl!nn1nalllt11us from a m
0,. -·electrolytes. c.arbof'¥drates, amino adds and lipids. hormones. anabodles. vitamins and trace elements. but also dNgs. tolcfns. and certain viNses
................ -r.
electrolytes. urea. uric acid, bilirubin, crealfnlne. hormones
CD1 •
2. Homloneptoductiorl (~ • Human cholfonk gonadotropin (HCC) -maintenance ofthe mrpus luteum • Estrogens - grvwth ~the utena and breasts • Progesll!rone -InhibitS utelfne musde conlradlons
alnlail noU: The HCC formed In the syncytiotrophoblast prewnts prwnatunt breakdown of the -pus luteum and sustains the preg· nancy. HCG c.an be cktected In the mmmal ulfne at an ~~~arly sbge. providing the basis for early pregnancy testing.
9
Gltnetal Amltomy - - J. Human Phylogeny and Ontogeny
1.5
Development of the Pharyngeal (Branchial) Arches in Humans Madlary pnxniU!!UZ
Ccnnedlr>g -----,~J~C'
ltllkwttn
Mlanto~
A He.ad and ned: reglon cl a ~week-old human embr,o. demorwitl'lltTng the phlrynge.lll'dtes nd clc:ft5 left laterill ¥lew. The pharynge..l arches are lnstrument.111n the devel· opment of the neck and face. In fim and amphJblons, the br.;mchlal arches develop intD a respiramry argan (gills) for exdlarlging oxygen and carbon dloldde betwHn the blood .;md water. LamHftwlllng veort!b«
8 Crost. tf!dtDn ttl rough a humin embryo It tile lewl oftile
phlryngeilll gut (after Drews) left superior oblique view. Due tn the aanlocaudal curvatiJre of the
embryo, tile cross sectton paS;Ses through the pharyngeal arcllel and pharyngeal gut as well as the prcsenapbaiDn and ipinal co111. The pharynge..l gut Is bounded on both sides by the pharyngeal arches (see also A}. 'Which contain a mesodermal core. They are COYered extl!r· nally by ectoderm and Internally by endoderm. Ectodemnal pharyngeal ck{t$ and endodermal pharyngeal pouches lie dirt!ctly opposite one another. Because the embryo Is curved aanloauclally. tile pharyngeal gut and pharyngeal arches overlie the prominence of the rudlment.1ry heart and llwr.
Tllyrcid gland anlage
ln11tmal ~d
artlery
C Slnlc.tureoftflephiiii'Y"fflliii.Jn:h8 (ifta'Drews) VIew of lfle floor of the pharyngeal gut and the transversely sectioned
pharyngeal arches. The typical components of a pharyngeal arch art! easily Identified: the aortic arch, musculature and assodated nerves. and a cartilaginous skeletal element of each pharyngeal arch. The derlvatllres of these structiJres ire of key 1mport.1nce In the formation of the face. nedc. larynx. and pharynx. Because the developlnC!Iltal tr.lnsfor· matlon of pharyngeal arch structures Is complex. It Is readny disrupted. causing malformations that may lnwolve a cluster of related derlvat!Yes. Defects In pharyngeal arch development result In branchial and lat· eral C1!
D Loc.atfon oftile Hrtk ;u'dl ;md pharynge<~l poudles (after Sadler) The aor1k arches (branchial arch arteries) artse from lfle paired embryonic wnrro/ atlftl'l and run betwel!n the pharyngeal pouches. They O{J6rl
dorJally Into tile domrl oortu. 'Which Is also paiA.ld. The definitive aortic arch develops from the fourth aortic arch on the left side (lfle development of the aor11carch Is described on p.12). The pharyngeal pouches are paired, dilll!rticui;Hike outpoucltings of the endodenn.al pharyngeal gut. Atlltal of four distinct pharyngeal pouches develop on e;rch side; the f1fth Is often absent or rudlmc!lltary. Note lfle pouch protruding from the roc:~f of the oral cavity Is called Rothlt:e's pwch (pre
10
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
0
0
/
~e& ~~cles
Facial nerve (aanlal nerve VII) ~1'-J!j>--/--
Glossopharyngeal nerve(aanial nerve IX)
pharyngeal arch with pharyngeal arch nerve (h)ooid arch)
~nd
D
Third pharyngeal arch with pharyngeal arch nerve
D
Fourth and sixth pharyngeal arches with pharyngeal arch nerve (flfth rudimentary only)
I
•
Mandibular nerve (from trigeminal nerve)
Arst pharyngeal arch with pharyngeal arch nerve (mandibular arch)
)
M~~l's
"" Temporollsmi.ISd~ ~rtllage
Sphenomandibular ligament
/-- ::.-::.~
~
_ _ Ocdpllillls mi.ISde Mosseter mi.ISde ""\-h.fl----- Digastric muscle. posterior belly
Mall.,..
~~t
~=id
\ l . l 9 - - - - Pharyngeal muscles
b l.oryngeal nerve (from vagus nerve)
Digastric muscle, Stylopharyngeus antertor belly mi.ISde
Greater comu
d
of h)ooid bone
lesser cornu of h)oold bone
Cricoid cartilage
Thyroid cartilage
MIIICIIIm.re
Nerw.s
E The system of phar;mgeal or branchial arches (after Sadler and Drews) a Anlage of the embryonic pharyngeal arches with the associated pharyngeal arch nerves.
b Definitive arrangement of the future cranial nerves V, VII, IX, and X. c Muscular derivatives of the pharyngeal arches. d Skeletal derivatives of the pharyngeal arches.
F Derivatives of the phai1'Jigeal (branchial) arches In humans
Muscle First (mandibular arch)
Cranial nerve V (mandibular nerve from the trigeminal)
Masticatory muscles
Second (h}'Oid arch)
Cranial nerve VII (fadal nerve)
Mimetic facial muscles Stylohyoid muscle Digastric muscle (posterior belly)
Slilpes Styloid process of the temporal bone Lesser cornu of hyoid bone Upper part of hyoid body
Third
Cranial nerve IX (gl0550pharyngeal nerve)
Stylopharyngeus muscle
Gremr cornu of h}'Oid bone ~r part of hyoid body
Fourltland sixth
Cranial nerve X (superior and recurrent laryngeal nerve)
Pharyngeal and laryngeal muscles
Laryngeal skeleton (thyroid cartilage, cricoid cartilage, arytenoid cartilage, corniculate and cuneiform cartilages)
- Temporalls -Masseter - Lateral pterygoid -Medial pterygoid Mylohyoid Digastric (anterior belly) Tensor tympani Tensor veli palatini
Malleus and incus Portions of the mandible Meckel's cartilage Sphenomandibular ligament Anterior ligament of malleus
11
Genenll Anatomy - - 1. Human Phylogeny and Ontogeny
1.6
Early Embryonic Circulation and the Development of Major Blood Vessels Aortic ardu!!s
Anb!rior cardinal Vl!in
lnb!mal carotid artery
----!'-----~~~~
Chorionic pial!! of the plaCl!llbl
Ventr.JI aortic root
Vascular pleJws lntheyolksoc
A Cra.llatory sysb!m of a 3· to 4-week-old human embryo (after Drews) Lateral view. The cardiovascular system of a 3- to 4-week-old human embryo consists of a well-functioning two-chambered heart and three distinct circulatory systems:
1. An lntnembryonk systemic drc:ulatlon (ventral and dorsal aorta. branchial arch and aortic arches. anterior and posterior cardinal veins) 2. An extraembryonic vitelline circulation (omphalomesenteric arterIes and veins) 3. A placental drculatlon (umbilical arteries and veins) The vascular pathways still show a largely symmetrical arrangement at this stage.
Dorsal aorta
Aortic arches
First
Second Third Fourth Fifth
Sixth
Ventral aorta
Internal carotid artery Rightsubclavian artery
External carotid artery Right common carotid artely Aortic
Right subclavian artery Brathlo-
arch
arteriosum
trunk b
B Development of the arteries derived from the aortic arch (after Lippert and Pabst) a Initial stage (4-week-old embryo, ventral view). An artery develops in each of the pharyngeal arches. proceeding in the craniocaudal direction. These arteries arise from the paired ventral aortic roots. course through the mesenchyme of the pharyngeal arches. and open into an initially paired dorsal aorta. These vessels give rise to segmental trunk arteries. The six aortic arches are not all present at any one time, however. For example, while the fourth arch is forming, the first two arches are already beginning to regress. The development proceeds In such a waythatthe original symmetry Is lost in favor of a preponderance on the left side. b Stnudu1'1!5 that fe91'1!55 or penlst: The first, second. and fifth aortic arches on both sides regress with continued development. The third
12
External carotid artely Common carotid artery Left subclavlan artery Ugamentum
Ductus ilrter10SU5
cephalic
a
Internal carotid artery
c
Descending aorta
aortic arch gives rise to a common carotid artery on each side and the proximal portion of the internal carotid artery. The left fourth aortic arch later becomes the definitive aortic arch, while the artery on the right side becomes the brachiocephalic trunk and the right suj). clavian artery. The left subclavian artery is derived from the seventh segmental artery. The trunk of the pulmonary arteries and the ductus arteriosus are derived from the sixth aortic arch. c V.rfants In the adult: Besides the typical case pictured here (77%). there are numerous variants of the brachiocephalic trunk that occur with different frequencies. In the second most common pattern (13 %). the left common carotid artery also arises from the brachiacephalic trunk. A right~ided aortic arch and a duplicated aortic arch each occur with a frequency of about 0.1 %.
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
Anterior cardinal vein
Anastomosis of the cranial cardinal vein Oeft brachioceph;JIIcveln)
Cardinal venous: trunk
Superior vena""'" Coronary sinw
Hep;~tic segment of the future
(rightcommonardinal vein) Supracardinal vein
Azygos vein
lnferlor venil cava
-
Subcardinal veins
E---::=:---
-...._ _ Hemiazygosvein
Renal segment of thelnferlorvena c.wa Left gonadal vein
inferior vena cava
1--- f - - Leftgonadal
Posterior\ cardinal vein J
Hepatic segment of the inferior vena CiiVil
Renal segment ofthe future
Rl!nalvelns --+--"fl
cardinal venous trunk Kidney Anterior Supracardlnal Posterior cardinal vein vein cardinal vein
vein
Left common llioc""ln
Sacrocardlnal vein
b
C Development of the cndlnal venous system from weeks 5-7 to bird! (after Sadler)
a At 5-7 weeks (ventral view), b at term (ventral view), c lateral view at 5-7 weeks.
Up until the fourth week of development, three paired venous trunks reb.Jrn the blood to the heart: the vitelline, umbilical, and cardinal veins. The cardinal venous system at this stage consists of the anterior, posterior, and common cardinal veins. The following additional cardinal venous systems are formed between weeks 5 and 7: • Supr.cardlnal veins: These vessels replace the posterior cardinal
veins and receive blood from the intercostal veins (future azygos system: azygos and hemiazygos veins). • Subcardlnal valns: These vessels develop to drain the kidneys-the right subcardinal vein becoming the middle part of the inferior vena
C.rdlna~ /l~ \.__)G" ~ ~~':.us
venoustnmk
'
~
Cutedge ofthe,olk sac
wnosus
Characteristic transverse anastomoses are formed bebveen the individual cardinal venous systems. These connections transfer blood from the right to the left side, channeling it to the irrllow tract of the heart. The transverse anastomosis between the anterior cardinal veins, for example, forms the future left brachiocephalic vein. The fub.Jre superior vena cava develops from the right anterior and common cardinal veins, while the left common cardinal vein contributes to the venous drainage ofthe heart (coronary sinus).
Sinus
Left
venosus
hepatic vein
Inferior ""n• cava
Hep;~tic
Right vitelline vein
slnusolds
Obliterated umbilical
~nos
..,;n
Guttubo
Portal vein oflivl!r
Liver
Anastomotic notwori<
Liver
Ductus venosus
us
venousb"unk
Right vitelline vein
Sacro· cardlnal""ln
cava, and the transverse anastomosis becoming the left renal vein. The distal segment of the left subcardinal vein persists as a gonadal vein (testicular vein or left ovarian vein). • 5acrocardlnal veins: These vessels develop during the formation of the lower limbs, their transverse anastomosis becoming the left common lilac vein.
Ductus
• sr----ifi- Sinus C.rdlnol-
Subcardlnalveln
c
LiYer anlage
, a
Vltelllneveln
Sacrocardlnal segment of the Inferior vena""'"
Guttube Right umblllcal..,ln
b
D Development of the vitelline and umbilical veins (after Sadler) • Fourth week, b fifth week, c second month, d third month (ventral view). Before the vitelline veins (omphalomesenteric veins) open into the venous sinus, they form a venous plexus around the duodenum, perfuse the embryonic liver anlage, and form the first hepatic slnusolds. At this stage the two umbilical veins still course on both sides of the liver anlage. With further development, however, they establish a connection with the hepatic slnusolds. While the right umbilical vein regresses
Leftumblllcal""ln d
completely during the second month, the left umbilical vein assumes the function of transporting all blood back from the placenta to the fetus. The blood flows through a shunt (ductus venosus) into the proximal trunk of the right vitelline vein (the future post-hepatic part of the inferior vena cava) and back to the sinus venosus. The disttJI portion of the right vitelline vein develops Into the future portal vein, by which blood Is conveyed from the unpaired abdominal organs to the liver (superior and Inferior mesenteric veins, splenic vein).
13
Genenll Anatomy - - 1. Human Phylogeny and Ontogeny
Bone Development and Remodeling
1.7
fatigue, repair microinjuries to bone, and provide a rapidly available source of calcium.
Bone development and bone remodeling are closely interrelated. During growth, for instance, bone undergoes a constant remodeling process in which immature woven bone tissue is replaced by "mature" lamellar bone. Continual remodeling also occurs in the mature skeleton, particularly in cancellous bone (called also trabecular or spongy bone, see f). In this way, on average, approximately 10% of the entire adult skeleton is remodeled each year, meaning that the skeleton is completely renewed over about a lQ-year period. This process is basically a functional adaptation of the bones to the dominant stress patterns to which they are exposed (and which vary over time). It also serves to prevent material
Closu~of
Medullary cavity
the proximal epiphyseal plate
Secondary osslflcation center
Proximal epiphysis
(!'~==,,
Primary ossification center
\
~
IJ
;/
II
Epiphyseal plate
·;.,
. yJ Mln~ralllfld
cartilage
Diaphyseal bloodve...l
Dlst..l epiphysis
A Development of a long bone The long bones (humerus, tibia, etc.) are mainly a product of Indirect bone formation, I. e., they form by replacing a preexisting cartilaginous model of the bone (endochondral osteogenesis). But portions of the long bones (the perichondrial bone collar, which allows the bone to grow In thickness) are a product of direct bone formation, I. e., they form from the direct transformation of condensed mesenchyme (membronoos osteogenesis, see E). a Cartilaginous model of a bone in the embryonic skeleton. b Formation of a perichondrial bone collar (directly from mesenchyme). c Differentiationto hypertrophicchondrocytes and mineralization of the car-
Articular cartilage
s~condary ossification centEr In the dlst..leplphysis
dosure of the dlst..l epiphyseal plate
Articular cartilage
tllaginous extracellular matrix, d Ingrowth of a diaphyseal vessel and fonmatlon of a primary ossification center. e Development of the proxImal and distal growth centers (epiphyseal plates). f Appearance of the proximal epiphyseal ossification center (secondary ossification center). g Fonmatlon of the distal epiphyseal ossification center. h Closure of the distal epiphyseal plate. 1 Closure of the proximal epiphyseal plate (occurs at the end of skeletal growth, between about 18 and 23 years of age for most tubular bones). Note: Osteogenesis = the fonmatlon of an Individual bone; ossification = the fonmatlon of bone tissue.
Epiphyseal Epiphyseal ossiplate flcatfon center
Epiphysis
L Epi-and metaphyseal blood vessels
l
Macrophages
Diaphysis
'\\'\g~ft..,--
j •
.-llll.•~.....:r-invaslonofblood
""'sels(openlng
zone)
b
Primary
O.Steoblasts
Osteoid Primary cancellous bone
cancellous bone
B structure of the epiphyseal pl.te a Blood supply, b detail from a: zones of the epiphyseal plate.
14
Multinuclear chondrodasts
C Sdlematlc representation of cellular processes within the epiphyseal pl.te
General AnGtomy - - 1. Humanl'lryfogftry and Onlugeny
TJ'Insfomwtlcn zone
HplncttMtllgt (· endochondr.~l ostecgenesis. Indirect bone formation)
Mes.tnc:f¥nll fibrous tt1111e (• membranous osteogenesis, direct bone formation)
•
!
,.,...,_
EmlodiOitdtol ~
bontfo,rmGiton (•pposltlonal growth
(oml011on
(lnterstllfallongl· ludlnal growth)
In thlelcne$$)
~(. . . ....;;;&r..J:-->If~f--~tt----tt...'¥--11'1'_..,'--
Functional n!modeUng In response to gruter stresses
=:sm:lar
(e.g~ lncreaslr~g body weight)
•
bon~
a
~p11ary
Os1l!o-
loop
~ltlll'aU
Osteobtms
~n bone'l'Ath
Llllllller(mltuN) bone
d!OI\I~osteotYW
D DIM!Iopment of;m osteon (ilfter Hees)
E
The process offunctlonal remodeling (see upper left pi!ge) begins with the lr111a1lon of blood wssels and acccmpi!~ng osteodasts ("bone-eat~r~g ctlfs•) Into ...-en bone. Tiley bUITOYt through the_.. b~ne lilae a drill, cutting a 1/iscul;uized channel (l'\!$0rpticm anal ~r cavity) wflich is equallr1 diameter to the future osteon.
a J.Qngltudlnal section through a resorption anal. b '"'"section at the level of the l'\!$0rption unal.
'!Wei of boiMI diMIIopm~nt {ost.I!Ogenests)
Note: Most borii!S ire formed by flld1recros1Jeo.
genesis (the l1!w exaptioM include the clavi· de and art.1ln bones of lfle alllirla). But portions of these bones still develop from the direct transformation of mesenchyme, I.e., by di~ osteogenesis.
c Transformation zone: osteoprogenltor cells (a ldnd of precursor for bone·fonnlng cells) are transformed Into osteoblasts. d Osteogenic mne (osteoblasts product bony lamellae).
• Newlyformedosteon.
BontmlrTOW
-~~
spaces
I
(uOOJidfled bone mltllx)
I )
/ ( I
IC
the~spaoes)
,-
r
\'
(ails linlr~g die m1m1W~>
............ Ostii!Odastlna
~~ HCIW'IIfplaaln;~ j
; ~
Enclo.sb!um (cells lnlng
""""'7 Endosteum
Ill
I 1 1
•
umellae
Osteoid
Osteoc:ytes
F c:rowth artd l"'!mCCdd!Rrtg processes wttfltn tfle ancelous porUon of a larnelllir bone a Three-dlmenslonal represent.ttlon of cancellous bone tissue. b Detail from a: remodeling of a anCt!llaLJS trabecula.
15
Genenll Anatomy - - 1. Human Phylogeny and Ontogeny
1.8
Ossification of the Limbs reAl Mondls V..Ors manilas 2 4 6 8 10 2 4 6 8 10 12 2 3 4 56 7 8 910 111 1314 1516 171 192( 212J 2312425
Body
Sapulo
CcrOCDid proass lnframromld
=
{Acromion Epiphyses
I•
1•1. 111
Ill
lnferlor:;:'
Body
a.vtde
Praxlrnal { Head iphysls Gn>Jtertubermity op Lessertuberoslty
I• • ~
--------- ----Shott
Distal r•pitEilum Trochlea epiphysis tmnl opicood)llo Medial opimndyte
I• ;
Proxlmoleplphysl Dls131 epiphysis
r"'T"T"
Shalt
~
Ulno
Proximoloplphysi Dls131 epiphysis
C.rpol bonn
Glpit112
Hamm Triquetrum LunatE Tropezlum Trope,gid Scaphoid
a
1::
·:• ~
Shaft: First S
a..,.ls
ProJcimal phalallJ<
{ S
Middle {Third, fourth Second Fifth
phalallJ<
Distal { First phalanx Third, fourth Second, fifth
I
~
-4
~~ .
:~
•
~"'
B Ossification of the skeleton
ofthe upper limb a Location of the epi- and apophyseal ossification centers. b Location of the epl- and apophyseal plates.
16
Fetal months and first}'ellroflife •'-•et off fromthe,.stofthetable.
A and C Timetable of l'l!glon~~l bone growth In the upper limb (A) and lower limb (C) {From Niethard: Kinderorthopadie (Pediatric Orthopedics). Thieme, Stuttgart 1997) The current stage of skeletal development, and thus the individual skeletal age, can be estimated from the times of appearance of the ossification centers. Primaryossifirotioncentl?rs, which generallyappear in the shaft region of bones during tile fetLJI period (diaphyseal ossification), are distinguished from serondary ossification centJ?rs, which form a~r blrtl! within the cartilaginous epiphysis and apophysis (epl- and
1111111
II
•
St!Hmold•
b
le ~
Epiphysis
A
•
Shott
Fl._-.
Jl
1• : .
Pisifonn Mob·
v ~
Sholt RNful
~
Epiphysis
5hoft
H1111111f111
Times of appearance of ossification centers: I Female Period of o..ific:a~on
1 Male
-
Period of synostooi•
apophyseal ossification). Longitudinal growth ceases with the closure of the epiphyseal plate (synostosis). The greater tuberosity of the humerus, for example, begins to ossify at two years of age. A period of synostosis follows from six to eight years of age, and after that the greater tuberosity shows only external, appositional growth. With the cessation of longitudinal growth, the ossification centers disappear and are no longer visible on x-ray films. The relationship between maturation and the appearance of secondary ossification centers Is most clearly demonstrated In the bones of the carpus (see also B). The eight car-
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
-- -Feb!
V.rs
2 4 6 8 10 2 4 6 810 22 3 4 ~Ms
Ilium
Body Epiphysis
Ischium
Body Epiphysis
Pubis
Body Epiphysis
s
6 7 8 910 1112 314 1516 17 8 19~0 212
• •
"'
SynOitosls Pubis+ Ischium T~radlate cartilage
-·
I
ShiJft Hood Gremr1rochon12r
m
"
l.em!rtrochant!r
·-------------Shaft Distol epiphysi>
•
-lla
nblo
Shaft Prax. eplph)'sls Tibial wbo
Abulo
2~
/"'"'"'
• .-
I
. r"'T'T'"I
~"' It
Shaft Prox. opiphy$i5
-------------Shaft Dlstol epiphysis
•
"'"rT"'
l'II'Miboneo
Body C.lant~Js Apophy$1s Talus Cuboid latEral cuneiform (Ill) Medial cuneiform (1) lnb!rmedlm cuneiiDrm (II) Navicular
-.....
•
•• ••
ShiJft Epiphysis
I I
Toes
Prmdmal ShiJft phalanx Epiphysis Middle ShiJft Epiphysis Distal ShiJft phalanx Epiphysis
I I
.,.,....,.
I I
•
SeAmalds
c
Fetal months and ftrstyearofllfe areset off
Times of appea rance of ossification centers: e Female Period of ossification
from the rest of the table.
e
pal bones ossify gradually over a period of approximately nine years. The flrst ossification center Is that of the capitate bone, which appears during the flrst year of life; the last Is that of the pisiform bone, which ossifies at nine years of age. It Is standard practice to use the left or nondomlnant hand for radiographic examinations. The skeletal age reflects the biological maturity of the organism more than chronological age. The estimation of skeletal age, and thus of growth potential, Is of key Importance, for example, In the prognosis and treatment of orthopedic diseases and deformities In children. Also, given the
Male
-
Period of synostosis
relationship that exists between skeletal maturity and body height, the definitive adult height can usually be predicted with reasonable accuracy after six years of age based on the skeletal age and longitudinal measurements.
b
D Ossification of the skeleton ofthelowerllmb
a Locationoftheepi-andapophy· seal ossification centers. b Location of the epl· and apophyseal plates.
17
Genenll Anatomy - - 1. Human Phylogeny and Ontogeny
Development and Position of the Limbs
1.9
D
Humerus (femur)
D
Umbglrdle - ) (shoulder or pelvis)
Ulna(fibula)
lntermedlum
D
Stylopodlum Zygopodlum AutDpodlum
Limb girdle (shoulder or pelvis)
-----\.-+---\~'1..
Radius (tibia) _ _ _,_,
Humerus
Femur
Centlillia (I-IV) ----~~::21J'~k Radiale (tlblale)
Patella
Pre pollex
Tibia
IV Radiu• Ill
Phalange$
A Basic skeletal strucb.lre of a five-ny (pentadactyl) tetrapod limb (after Romer) Both the forelimb and hindlimb of a free-ranging teiTI!strlal vertebrate have tile same basic, three-part structure consisting of a proximal, middle, and distal segment (called the stylopodlum, zygopodium, and autopodium). The elbow or knee joint Is placed between the stylopodlum, which consists of a single bone (humerns or femur), and the zygopodlum, which consists of two bones (the radius and ulna or the tibia and tlbula). The tlve-ray autopodium (hand or foot) Is also made up of proximal, middle, and distal units (called the baslpodium, metapodlum, and acropodium; see C). Additionally, there are some vertebrate classes that depart from this basic structure by showing a reduction or fusion of varIous bony units.
Metot.lrpal bones Phalanges
B Basic: skeletal strocture of the human limbs Anterior view. a Right upper limb, b right lower limb. The skeletal elements of the human upper and lower limbs have been colored to show how they are homologous wltll the tetrapod limb segments shown In A (style-, zygo-, and autopodlum). Congenital malformations such as polydactyly or syndactyly (the presence of supernumerary fingers or toes or their fusion) are not uncommon.
C Bony constituents ofthe pentadactyl tetnpod limb
PMwd hlndlmbs Umbglrdle
Shoulder girdle -Scapula and clavicle
Pelvic girdle -Hlp bone
Free limbs Arm (brachium)
Thigh (femur)
-Humerus
-Femur
Zygopodlum
Foreanm (antebrachium) -Radius -Ulna
Leg (crus) -Tibia -Fibula
Autopodium
Hand
Foot
- Basipodium
Carpus - Proximal row: radiale, intermedium, ulnare - Central group: centralia I-IV - Distal raw: carpals I-V
- Proximal row: tibiale, intenmedium, fibulare - Central group: centralia I-IV - Distal row: tarsals 1-V
- Metapodlum
Metacarpus - Metacarpals 1-V
Metatarsus - Metatarsals 1-V
- Acropodium
Fingers -Digits 1-V (with different numbers of phalanges)
Toes - Digitlii-V (witll diffen!nt numbers of phalanges)
Stylopodium
18
Tarsus
General AncJtomy - - 7. Human Phylogeny ond Ontogeny
Umbgirdle (peM<)
Dors.al, extensors
Ventral, flexors
Stylopodlum (femur)
Autopodlum (foot)
a D Llmb positions In a prtmltlve terrestrial tetl'ilpod (the ll~nl LaattG vfrfdls)
a Dorsal view. b cross section at the level of the hindlimbs. In amphibian and reptilian tetrapods (e.g., salamanders, turtles, and lizards), the trunk is slung between the limbs and frequently touches the ground. The limbs are set almost at right angles to the body, so that the arm and thigh are nearly horizontal and the elbow and knee point outward. The radius and ulna and the tibia and fibula are flexed at right angles at the elbow and knee. The volar surface of the hand and the
plantar surface of the foot are in contact with the ground. The axes of all the joints are directed parallel to the spinal column (see E). NotP: that the extP:nsor muscles are placed dorsally, while the flexor muscles are ventral. Thus, the location of the extensors and flexors relative to the bone does not change with evolution-the bone merely assumes a different alignment (see also F).
Formal dors.al side Femur
with extensors
Heod
........~-=--
F'oiWilrd rotation, causing the knee to point forward
Spinal CDiumn
C•'l'•l bone<
Metacarpal bones E Rotation of the limbs in mammalian noluUon • Before rotation, b after rotation. An important feature of mammalian evolution involved rotation of the tetrapod limb. The limb was reoriented, placed parallel to the body, and moved closer to or beneath the body. This improved locomotion and supported the body more efficiently. The hindlimb rotated {onNfJrcl (with the knee pointing cephalad) while the forelimb rotated baclcword against the body (the elbow pointing caudad). As a result, both sets of limbs assumed a sagittal orientation under or alongside the trunk (see F).
F Skeleton of a cat (.FI!IIs altus) Left lateral view. In order for the volar surfaces of the forelimbs to rest on the ground despite the backward angulation of the elbows, the fore· arm bones must cross to a pronated position. In the hindlimbs, there is no need for pronation of the leg bones because the thigh is rotated forward. This arrangement of the skeletal elements in the various limb segments is essentially preserved in humans. Because the lower limb has been rotated forward, the former dor;al side of this limb faces {onNfJrd in a human standing upright. As a result, the extensors of the thigh and leg (the genetically "dorsal" muscles) are on the anterior side of the limb, placed in front of the corresponding limb bones. This is one reason why the terms "anterior• and "posterior" are preferred over "dorsal" and "ventral" in the human lower limb. By contrast, the extensors and flexors of the arm and forearm have maintained their original dorsal and ventral positions, respectively.
19
Generol Anatomy - - 2. Ollef'vlew ofthe Human Body
2.1
The Human Body (Proportions, Surface Areas, and Body Weights)
®,
= = . .,. .- ----,
- -1+-+- ..l
}·
Upperedgeofthorax
t:~·~-.-~
Pubic!)'mphysis
Two months
2Syears
Newborn
gestation
2years
Flw! months gestation
12years
A Change In body proportions durtng growth While the head height in embryos at two months' gestation is equal to approximately half the total body length, it measures approximately one-fourth of the body length in newborns, one-sixth in a six-year-old child, and one-eighth in an adult. B Nonmal body proportions
In an adult, the midpoint of the total body height lies approximately at the level of the pubic symphysis, I.e., there Is a 1:1 ratio of upper to lower body height at that level. The pelvis accounts for one-fifth of the upper body height, the thorax for two-fifths, and the head and neck for two-fifths. The lower body height Is distributed equally between the thigh and leg (plus heel) at the joint space of the knee.
4
H ) ~
11 12
~
3
4
s 6
7
8
......
~
,..
...
18
Po!raotlllla
5Dih !l5lh
!Jth
.......
5Dih !ISih
1 Forward rH
66.2
72.2
71.7
61.6
69.0
76.2
2 AP boclythk:knoss 3 Owrhead rooch (with both anns)
23.2
27.6
31.8
23.8
28.5
35.7
4 Body height
5 Otulor height I Shoulder height 7 Elt--ll>floorcllstonte
I Hond-ID-floor dist3nao
191.0 205.1 221.0
174.8 187.0 200.0
162.9 173.3 184.1 150.9 161.3 172.1
151.0 161.9 172.5 140.2 150.2 159.6
134.9 144.5 15<4.2
123.4 133.9 143.6
102.1 109.6 117.9
95.7 103.0 110.0
72.3
76.7
12.3
66.4
73.8
80.3
31.0
36.8
31.4
36.7
34.4 39.3
42.3
32.3
35.8 35.5
40.5 38.8
84.9
90.7
96.2
80.5
85.7
91.4
12 Otularheightwhlloslttlng
73.9
79.0
84.4
61.0
73.5
78.5
13 Elbow to sitting surfaco
19.3
23.0
28.0
19.1
23.3
27.8
39.9 32.7
44.2 36.2
48.0
38.9
35.1 29.2
39.5 32.2
43.4 36.4
1& Sitting depth
45.2
50.0
55.2
42.6
41.4
53.2
17 Butl«
55.4 59.9 64.5 96A 103.5 112.5
g
Shoulderwfdth
10 Hlp width• .Undlng
11
Sitting body height (trunk height)
14 Height of leg and loot (height of sitting surfoce)
15 Elbowtogoipplng oxls
11 B..-1<-leg length
53.0 58.7 &3. 1 95.5 104.4 112.6
19 Thigh height
11.7
13.6 15.7
11.8
14.4
21 Wldlh obove the elbow
39.9
45.1
51.2
37.0
45.6
5<4.4
:r1 Hlp width, ~tting
32.5
36.2
39.1
34.0
38.7
45.1
20
17.3
C Span of the out:sl:retl:hed arms The arm span from fingertip to fingertip(- 1 fathom) is slightly g~r than the body height (approximately 103% in women and 106% in men).
D Selected body measurements In the standing and sitting human being (unclothed, 115-60 years of age) The percentile values indicate what percentage in a population group are below the value stated for a particular body measurement. For example, the 95th percentile for body height in males 1 6-60 years of age is 184.1 em, meaning that 95 ll: of this population group are shorter than 184.1 em, and 5% are taller.
Gen«GIAncrfumy - - 2. Ovenliewoft#H!Humanllody
E DlltrtbutSon of body surface I
I'M In adults, dllldren,nd lrlflnts
Aaording to ttl~ "rule of nines• de.scribed by W~llilla (1950). the body surface area of adults om- about 15 years of age (1) can be drvtded Into units thilt are a multiple of 9 X: the heild and each amn acx:ount for 9 X each, the front and back of the trunk and each leg account for 1St: (2x9) e.1ch, and ttl~ external genitalia a~mpriK' 1X. In children (b) ~nd lnf.rnts (c), the rule of nines must be adjumd for age. fllott: The rule of nines c;rn be used In bum llfctlms to provide a quick approximation of the area of $lcln that has been burned.
F H1ncllrea nile
The percentag~ of the body surf.lce affected by buii'U c.;~n be accurately estimated with til~ hand are<~ rule. IM!Ich states that the are9 of the patlenrs hand Is approxfmately 1% of the patient's own toto~! body surface arH. The hand rule .also applies to children, whose hands .and total wrfaoe are.1 are both proporticmately smaller than in adults. Hlllittll1,41
For prograslvdy larger solid bodies. the surface a rei Increases as the sq~~are of the radius. but the volume Increases as the aJbe of the body's radius. Because of this basic geometrical relationship, smallet" animals generally have a larger relative surface area than larger animals. A higher ratio of surface area to volume c.;~ uses smaller animals to radiate relatively more body heat. As a result, small animals like mla and chll· dren tend tD ha1ll! a higher metabolic rab! than larger animals lilae el~ phants and human adults.
,.,
....., ~
1.1111
One )"tar
F'ouryear5 T81years
Adult
3.4 7.5 9.3 1S.S 30.5 70.0
2100 3500 4100 6SOO 10500 18100
617.6 44ie.7 440.9 419.4 344.3 258.6
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41
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D U!nmoly
D ObeM
obae
Newborn Sbcmonths
,...
II ... IIIII • .8 .41 4J' •
MG
-badJwelght
(cm21111)
1.M
m• m• 111 •
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.....,......... .....,_.__ (em')
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G Dependl!ftoe of rellttft body surf- I I'M (skfn surfiloe liN} on agt, 1nd consequences
1.SI
Ul II
H
D
Nonnal
-ht
D lhlor·
Boc:fr miM Index
In anthropometry. the body mass Index (BMI) has bea~me the Intern<~· tiona! stolndard for evaluiltfng body weight because It a~rrela!l!s reb· tlllely well witt! total body f.at. BMI Is defined as the body weight In kilogranru divided byth~ sq~~are of th~ height in m~teiT.
21
2.2
The Structural Design of the Human Body 8
-·{
Reglon;~IIWdMslonsofthe body
Held
Neck
nu'*
~{
• Thcnx(chest)
• Abdomen • I'Wvls !Jiaperllmb • Shoulder girdle • Free upper limb
-;_;_,~---lung -+.:...._-.;,::.,~--
Scapula
Tllorax
a-tolnb • I'1!Mc girdle • FreeiGWOifllmb
t.C~e-l:-~:!J'-4H---
Colon
C
FuncUon;~l subdlwt!lton by organ systl!ms
wmbllrsplne IAIGomotor.,.._(~lllalsyft8m)
• Sloeleton and skl!letal connectlons (passiW part) • Striated skeletal musculatu,. (actlva part)
,..... 'II'":Jo.:-~.;.I....:J+-- Uretl!r 't'::<~.J---
Urtnaryblad6er
''-'..:...,....;;_,;..."'=---Anus ILO:,.,;....--raus
• Cardlonscul.ar ¥~em • Hemolymphiltlc system • Endocrine ¥~em
• Resplr*ry syst1em • Dlgestlw system • Urinary sysmm • Male and female reproductlw system Nerwussptem
• Cenlraland peripheral nervous system • Sensory organs
D Set'oul cmtfes lnd CICII'IMdfve·UIIUt lpiCits ~r
limb
O~ns
and or;;~n syltems are embedded either in $C
• Thoracic cavity (chest cavity) with: -ltle pleural avtty -ltle perlcardlal cavity
A LoclltfGII of the lntlr:rl'lll org~nJ l.ata'alvlew.
22
• AbdomlnapeMcavltywlltl: -ltle perltonal mit)' -ltle pelvic a.rity C.nnedlvMiaue.-.s
• Space between the mldd~ and deep la)<ers of aiYklll fascia • Mecreastinum • Extraperfmneal space with: -ltle relroperltoneil space (relroperltoneum) and -lfle subperiiDnul space • Bursa and synCIIIIIal cavltles
Gen«GIAncrfumy - - 2. OwntlewoftheHumanBody
----- ----- - -... -.
b
Abdominal Cll\llt:y
--- ---
---
E Se4edecl pl•nes ofsedlon tfu•«l!lit the hum•n body Superior view a Mlds.ag!Ual section b Cross section at the level of the head c; Cross section through the thorax
d Cross section through the ~bde~men e Cross section through the lesser peMs (see also C..rdlnar Planes and Axes,p.25)
23
3. Su~ Anotomyo{the Body.I.AJrtdmarb and ~ll!fiQ! Unu
Gltneral Anatomy -
3.1 A
Terms of Location and Direction, Cardinal Planes and Axes
Gen~r.~l term~ of lociltton
n
dln!c\lon
Upper body (had, nedl,ancl tn...)
Cranial Cephalad
C:.udal C:.udad Antelfor Posterlor
Peltalnlng to. or locatJed towald the head) Directed - l d the hue! Petalnlng to. or locatJed towald the tall Directed towald the tall Peltalnlng to. or locatJed towald. the hnt Synonym: Ventral (used for all animals) Petalnlng to. or locatJed toward, the back Synonym: Dorsal (used for all animals)
Superior Inferior MediUs Flb!Or Exte..or
Upper or .-.bGole '--erorbelow IJ)(atN In the middle Pilr1llining to a flb!Or musde or surface Pwtalnlng toiln extensor musc.. orsurfam
LongitUdinal HorlzDntal Ver11al Medial Lateral Median Centnl
PeltalnlngtotheillCfsofa structure Sltwtecl at right angles to the long liXIs of a structure Parallel to the long illCfs of a structure Parallel to the plane of the holfZDn Pwpendlcular to the plane of the holfmn Towald the median plane ~hm the medial plane (towald the side) S'lhlatecl in the mectoan plane or midline Situated ilt the center or lm.tlor of the body
Peripheral Superlicial Deep Extemal lnb!mal Apia I Basal
Situated hm the center S'lhlatecl neer the surface Situated deep beneath the surface Duterorlatltral Inner or medial Pler1lllnlng to the tip or apex Petalnlng to the bollom or base
Ocdpltal
Peltalnlngtothebilckofthehead Pler1lllnlng to the lmral region of the hue! (the temple) Situated parallel to the sagittal suture S'lhlatecl pan1llel to the Qlronal suture (pertllnlngtothecruwnofthehead) Situated toward the nCS~t or brow Peltalnlng to the forehead Pilr1llining to the skull base
Temporal Sagittal Coronal Rostral Frontal Basilar
caudal
jj' Cr.lnlal (aph;olad)
Distil
Palmar
\\
flW"'
-Right
1
1lbl l 1 1 -
FbJlar+-- '
,,
•i6
B Tile .wtumtul body posiUon The gaze is directzd fwward, the hands are supinated. The rigftt half of the body Is shown In light shading to dem11nstrate the skeleton. lilokthatthe dl!$lgBiltlons "left" ind •rtght" always refertothepatlent.
PIG!Idmal Distal Radial
llblal Fibular P.-.lmar(lllllar) Plantar Dorsal
24
Clate to or toward the trunk ~from the trunk (towald the end of the 11mb) Peltalnlng to the radius or the lateral side ofthe forearm Pwtalnlng to the ulna or the medlalslcle ofthe forearm Peltalnlng to the tibia or the medial slcle of the leg Pler1llining to the fibula or the lateral side of the leg Petalnlng to the palm ofthe hand Peltalnlng to the sole of the foot l'lertalnlng to the back of the hand or top of the foot
Genertll Anatomy - - 3. SUrface Anatomy of the Body. t.andmarlcs and Reference Unes
D Coronal and sagittal planes In the skull The coronal plane is named for the fact that it is parallel to the ooronal suture, just as the sagittal plane is parallel to the sagittal suture. The cranial sutures serve as directional indicators, "sagittal" meaning in the direction of the sagittal suture, "coronal" in the direction of the coronal suture.
Tran~rse
plane
Uneof
External
gravity
audltDI)' canal
y •!J:--+- Dens ofaxis (C2)
Transvene iDis
~::---- Cervlco· S.g~loxfs
thoroclc
junction
C cardinal planes and axes In the human body (neutral position,
left anterolateral view) Although any number of planes and axes can be drawn through the human body, It Is standard practice to designate three cardinal planes and axes. They are perpendicular to one another and are based on the three spatial coordinates. The cardinal body planes: • Saglthl plane: Any omtical plane that is parallel to the sagittal suture of the skull, passing through the body from front to back. The midsagittal plane (- median plane) divides the body into equal left and right halves. • Coro1111l plane (fronbll plane): Any plane that is parallel to the (orrhead or to the coronal suture of the skull. In the standing position, it passes vertically through the body from side to side. • Transvene p..ne (11111111 plane): Any horizontal, cross-sectional plane that divides the body into upper and lower portions. It is perpendicular to the longitudinal body axis. The cardinal body ues: • VerUcal or longlb.ldlnal axis: In the standing position, this axis runs through the body croniocauc/o/ly and is perpendicular to the ground. It lies at the intersection of the coronal and sagittal planes. • Saglthl axis: This axis runs onteroposteriorly from the front to back surface of the body (or from back to front) and lies at the intersection of the sagittal and transverse planes. • Tnlnsvene or horizontal axis: This axis runs from side to side and lies at the intersection of the ooronal and transverse planes.
t--+-- Thoracolumbar junction
Whole· body centEr of gravity
b
E The whole-body center of gravity and the line of gravity a Anterior view. The line of gravity is directed vertically along the midsagittal plane, passing through the whole-body center of gravity below the sacral promontory at the level of the seoond sacral vertebra. b Lateral view. The line of gravity passes through the external auditory canal, the dens of the axis (second cervical vertebra), the anatomical and functional junctions within the spinal column, the whole-body center of gravity, and through the hip, knee, and ankle joints (after Kummer).
25
Gltneral Anatomy -
3.2
3. Su~ Anotomyo{the Body.I.AJrtdmarb and ~ll!fiQ! Unu
Body Surface Anatomy
jugllar lima Sterno~I
CliMdt
tne
Do!ltold
An!da NpPie-
MeOla
N\)lie
(1)11'4)11!9<
tlfu!or ll'lljed sapula
Viertebr.ll regon~ ~nal
furrt:JN
Cublt
Brust
~
Unbilm ~ 5~ lht~r.e
Rhombus of Mlc!laells
Styloid pt00!5S
dntd'us
ANI cleft
l'lgulnal c:re;a:e
'lllla---
l.ltml
malleolus Medial m~lleolus
Bodrturfllcunnomyofthe fen\llle Antelforvlew. Body surface anatomy deals wttfl the surf.rce anatomy of A
ttteiMngsubJect.ltplaysan lmpo~t;~ntrolelndowlcmetttodsofexam-
11\rtfon (Inspection, palp.atlon, percussion, auscultation, funcUon tli!St· ing), and $0 it h;Js p~rtiaJiar significana in dinic~l examinati~n cour.ws. To avoid repetltlon. Identical structures such as the oleaanon 1\;JYe not been labeled on both the female and male bodies.
26
a Bodrturfllcunnomyofthe fen\llle Posterlorvlew.
Gluteal n!glon
Scapular jplne
l'eciOI'lllis
~Ill
major musde Linea ;alba
bordl!rd
sapull
Cost.1l
mar9'J> Semilunar
Tend I· no us In· K~ons
llle
lntrtnslc batk
Umb11cw; lliit
musdes
~
Sac:r.ll tn.lgle Styloid
Ptnls
protc$$ duha
Saot11m
Clntrocnemlus .andsoiNS (IJiclepuurae)
C llodysurhcun•tomroftheNie
D BodrsurhcunmmyoftheNie
Antaforvlew.
PostErior view.
27
Gltneral Anatomy -
3.3
3. Su~ Anotomyo{the Body.I.AJrtdmarb and ~ll!fiQ! Unu
Body Surface Contours and Palpable Bony Prominences
Palp.;~ble bony promlr~enc:es 01re lmportilnt lindmarks for aniltomlul ortentatlon In the skl!letor1, .as It Is notilways possible to p.;~lpillte .ilrUCU· fating sb!lml stnu:tures (e.g .. the hip joir~t). lr1 tflue ase.s the ~m· lr~er must rely on p.;~lpable bony prominences as ifllndlrect guldt'totbe locatlor1 of the lnaccesslblt' structure.
+------'T-- - Manubrium sb!ml
+-----r-~-- Bodyofstemum >.:f----=~--=!-- llbs
tnralmalleoh.a
r~ ---1.----'--~-- MeM<JI'IO· ~':; phllinlll!llllo'nb
M;Jnubrium Sterno· ltiL'ml diMcullr.)olnt
A Surfaocuontours 1ncl p1lp1ble ~ promlnenCitS ottfle flee
anclne
28
lnterph.lia ngeal
Jcln1s of tile foot B Surfam -mxn1ncl p1lp1ble ~ promlnenCitS ottfle tn1nk and uppet" and lower limbs In the female Anterior view.
Splr.ous -
.....;.- -4114----£
proatSRS
\ umbdold ----:::---sullft
-+--~--~I bone 1---=~-- Eidltmal~l
Ter"J'90r.albane - - -
protuberance
Martold~ - -Mandibular - - -.,.... angle
l
-Lmnol
mdeolus /\
c Sul'f'llc211:011tocn and palpable bony promlnen.:es oldie trunk and upper and lower limb• In the male Posterior view.
D Surfilce contours and palpable bony promlrten.:es oldie lilce and neck PostErior1/tew.
29
Gltneral Anatomy -
3.4
3. Su~ Anotomyo{the Body.I.AJrtdmarb and ~ll!fiQ! Unu
Landmarks and Reference Lines on the Human Body
Antie
mtdlne
P.Jr.llltm\al
line
~1-+~.----- ~or
Dlllry
rne
H - -+ -Md-
DIIIry
rne
1-+--MicldM-
culllrllne
•
b
!-- _.-Anterior axtlary
rne
c
A Vricall'llhniKIIIIIHISon the trunk a Anterforvfew,b rlghtlilteriii'Ylew,c postelforllfew. Antafor midline Sternal line Parasternal line Mldda'Ylcular line Antafor axlllilry line Mldax!llary line Posterior aldllary line Posterior midline Paravertebral line Scapular line
30
Anterior trunk midline passing ttl rough tile center of the sternum tine along the Jtem;~l margin Une mldw.ly between the stanitlllne ilnd mldda'Yicular line Unettlrough the midpoint of the clalllde (often identical to the nipple line) Une at the lew! of the anterior ildllaryfold (pectorills major muscle) Une midway between the anterior and posteri~r ax~11;ary lines Une at the level of the posterior axlll;aryfold (latiS;S!mus doni muscle) PosteriortnJnlc midline at the level of the spinous processes Une at the le'llel ofttle transvene processes Unettlrough the lnli!rfor angle of the st.'!pula
/Flrrtrb . / - - - - - - ClMde
- - - - - - Sealnd~b - - - - - - - - - - - SUnlal anglt
B •IIJb counUng• for anatomical Cll1efttatScln 'In the tflora: Tbe firstribi$aMred bythedavide. The first palpable rib isthesemnd rib. and thereforethecount begins at that level. The second rlb attiches tD the stemum at the leYel of ttle stemill angle. At. ttle lowe!' end of the rib cage, It Is bert to stiJUtttle twelfth t1b, 'Which Is palpable only In Its poJterior portion.
13splnous
prou:ss S~tlmp~
17splnous pn~a!SS
~~-----*--~-~~~~e ofscapula
L4
' - - - - - - llllcccet
-""------"'• ------- Pl:mltl'larsuper!or lhacsplne ---::....----.;-~-~ft-- ln~lirpla!W
-=---_,...-.;----,..---:..-:-+-
sz
lntmpnal plane
jf#-- --1-- Sl4)ef!orbordl!r ohymphysls
C Sblndard tr.lnswrse planes thro..h tfle abdomll'lill catty (see alsop. 171) Anterior vi eoN. Transpyloric plane
Subcost.ll plane
Supracrestal plane Intertubercular plane
lntcnplnal plane
Transverse plaAe midway betwl!en the superior borden of the symphysis ~nd manubrium PlaAe .rtthe IOINest level of the cost;~l margin (inferior margin of the tenth cost.ll e<~rtili!ge) PlaAe passing through the summits ofthe lilac crests PlaAe .rt the IC!III!I of the iliac tubercles (the lilac tubercle lies appi'Oldmately Scm posterolateral tD !he interior superior lllacspiAe) Plar~e .rtthe leftl of the a~rlor superior lllacspiAeS
D Spii'ICIUS processes thilt provtde useful posterfor lilndmarb Postl!rtorlltew.
o
spinous proce.ss
Vertebra promrnens (!he pro}ectlng spinous process ofCl is de~~rly visible and p,alpable) n spinous proa5S At the level ofthe line connecting thetwll se<~pulilr spinel T7 spinous process At the level ofthe line connecting !he lnfel'for angles of beth scapulae T12 spinous process just bdclwthe twelfth rib L4 spinous process At the level ofthe line connecting !he summits ofthe lllaccrests S2 spinous process At the level of the line connecting the posterior supel'for lilac spines (recognized by small sldn depresslons directly CM!fthe lilac spiAeS)
E Uthotomy position (supine wfth tiM! legs, hips, ilnd ra-s flexed and tflethT!Itlubcb:ted) The position of choice for proctological ex.;~minations. Clgcfc.face not.l· tlon Is used for anatomle<~l Olfent
• 3 o'clock
• Left
• 9o'clodc
•12 o'clgck • 6 o'clgck 6o'dodc Postle~
31
Gltneral Anatomy -
3. Su~ Anotomyo{the Body.I.AJrtdmarb and ~ll!fiQ! Unu
Body Regions (Regional Anatomy)
3.5
I>.Jriet<~l ~on
a-blt<JI region
~on
Tempor.al!!!i~lon
I
1\lnalreglon
Z)'I!Cmlllc region
Tft1'4l0,_ region
I>.JrieUI !!!ilion
lnfr.JCI'blt
Oral !!!ilion
ll'ilmmpor.al region
Mental n!9'on
I>.Jrotld-m;us:eller!c region
Subrnandbular !Jtange Subment
Retnxnandbular region
l J
Anll!rlof
oen1o:al
Cilnlad region !Jtange Mumar (omotr.u:heai)!Jian9e
Bucal region
StAmodeclcmlat.ald
n!!(lon Cftmt SUpnl-
~supnt-
ciiMcularfossa
ciiMculllrfossa
Jugulu fossa
Vetellnl
promlno!IU
Poosterlor aMcllreglon
A lleglons of die he.ild <md neck
B lleglonsoftflehe.ild<md neck
Right an1l!rclmr.al 'VIew.
Right postei'Oiateralllfew.
~I
lnfr~~eiiMculllr
!!!i~lon
fossa
ClaYopectoral !Jtange
Dl!lb:!ldreglcn
()j!ftGidn!fon
~larreglon
Axlll;uyn!!(lon
lntl!r:sapular region
Pectoral region Lmr.ll
~mary
pecblr.al regkln
reglen
lnfr.uapular region
l..m!nl
EpiQIStn:: n!9'on (lpl· 9MttfLm)
lknblllal region Pllblt!!!i~lon
~,_~on
t.um~rltl~ngle
l..m!nl
sacral region
llbdomln.lll reglcn
(lumb.w) hgulllill region
GIUtJealreglcn
~mcnllllgone
Moll n!9'on
C Reglo111 ofd!e d!oru.;md .Jbdomell
D Reglo111 ofdus b.Jdc .1nd buttocks
Antelforvfew.
Pomrlorvlew.
32
+ ---ilnii!
l'osb!tlor - -.....:.::;...--\..
carpal nt9on Dcnum---1:-
~~~--~~~
fcll.'Sol
Aldlto.y mglon
- t---P.rmd
aflheh:lnd
(axllt;Jry~)
the hind
E Rlglonsoftheup!Mrllmb Porterlor view.
F ltegtanuftheupperllrnb Anterior view.
G Reglonnllouttheulllil Antenorlllew.
Alm!r!ort!llgh - -:,.--
n!Pon
Almforgenual mglcn
- ----=--
Utmlnotro· malleolar region ~....----
Cllanealregkln
--~- Soled~efoot H Rl!glonsofthel-rhmb Anteriarview.
J RfQiansoftMiowet'llmb
Ul1l!ll!l'it.ll
ANI
regkln
n!Pon
Fler!netl region
K PertnMI reg1an (lltftotomypo!ll'tlan}
Posterior view.
33
Cimeral Anatomy - - 4. The Bones andjoints
4.1
The Bony Skeleton and the Structure of Tubular Bones
~~~!l-~-- v.rl2lnl mklmn
Arm
1f,:L=::r)o'rt
nblal
ptm.u
FWo
nw.
}-A Hu""n tbleton from the "*"or view The left fore.inn Is pronill2d, and both feet are In pi;Jntu flexion.
I Hu""n tlceleton from the potterlar view The left fore.1nn Is plllllitM, ind both feet 1 re In pi;Jnti rflexion.
c 1'ftlel of IIane • Leng llena. e.g•• tubular bona oflhe limbs
• ShDrt • - e.g.. carpal and tllrsal bones e.g., IQpula, Ilium, •nd bonl!l of lhe alnria
• A.t-..,
• l,....ullr ._.., .... , . . , . , 11nomalous, supernu,...;~ry bones not conslste111!y pno.nt, a. In the skull bue
34
• ..........., ban• (mntaining air-1\11..:1 spaas).I.!Jo. bones ofthe fadal sall!l:on 1 nd par~~nasal slnuoes • S.Umold ban• (bo""lnaJil)orlltld In tendoM), e.!Jo,lhe patelll • AaaiDry......., (anomalous, supomumer~~ry bonl!l), • In tile alnria and foot (ga.erally result from the flllu!'f of fu51on of artaln aciJaant assifiation Clll'lll!rs)
Altladarartllage
l
..-1{
Clna!la111 ~
~
tnbealll
...
0~----------------·
epiphysis
\
Clmabl-~
.
lanyepl-
pllysellllne
Cln
I
•V
~
Cml)llct bane (corUalbone)
+-·-
HM!rJian......,.ln - - - - . . - - - - . . o.,_.lananol
Splril
allllgen ftbeiJ
----=--"""'
~em:
J'oromon 1!:~~--
Vollmllnn anol
Nlldl.llllry c:Mtywllh
tot .........
!ilntllmftb..,...,m--
o.teab!Bbil the amblum Ioyer ~~--~---I
D Strud:unt fill 11 typk:al tllbul•r bane. lllullrllt8d fur the1\tmur Coronal saw arts hiw! been made through the prOIIdmal and distal parts of an adult femur (without sectioning the midshaft region). It Detill from a: The sectioned arNs dlspllly the limellllr architecture ("l~mellar bone") of the ancellaus tr.a beculae. The l~mell~e are iiiTilnged In conttguou:r plltn, slmllir to plywood. Since the cancellous trab«ullle do not haw an actual vasculir $Upply and are nourished by diffusion from the adjacent medullary avity, the trabeculae ilttiln 1 thickness of only about 200-300 JlRI· c Detall from a: Three-dlmensrona I representation of compact bone, whow structural unib consist ofvascul;uized osteons approximately 1
•
Paiostl!um 1 em long ;r nd 2SD-350 J1R1 In diameter. The hn-erslan canorls. which tend to run longltudln
cl Detail from c. demonstraUng the mlaostructure of an M12on. The haveuian anal at the center Is surrounded by approximately 5-20 concen!Jtc limellir systEms composed of osteocytes and extruelll)lar matrix. The osteocytes are intetconnected by numerous fine cyto-
pliSmlc proce:sses. e Detail from c. shOWing the slnlcture ~the pertom!um.
35
Generol Anatomy - - 4. The Bones andJoints
4.2
Continuous and Discontinuous joints: Synarthroses and Diarthroses
A Different types of bone-to-bone connections r.bejalnts
TRII!Jalnts
(-continuous bone connections In which the intervening tissue consists of fibrous connectivl: tissue. cartilage, or bone): • Low to moderate mobility
(-discontinuous connections In which the bones are separated by a joint space): • Mobility is variable. depending on the atbched ligaments
Syndtrosa
• Syndesmoses (fibrous Joints) • Syncllondroses (cartilaginous joints) (If the intervening tissue is mostly fibrocartilage, the joint Is called a symphysis, e.g., the pubic symphysis.) • Synostoses (sites of bony fusion) (lleciluse ~synostosis is immobile, it is no longer classified as a synarthrosis in the strict sense.)
,_ Classified according to varklus criteriiill:
(seep.38) • Shape and arrangement of the ~rticul• surf~ces
• Number of joint axes • Number of degll!es of freedom
Conc:ave joint ---+-H~
d.~"S!;;~!\'i-';;---
"Stiff joints• whose mobility lsgreiitly limited by strong ligaments (e.g., the sacroiliac joint and proximal tibiofibular joint)
he~ ling
~r-t--
• • • • •
joint space Articular surfaces covered by hyaline cartilage joint cavity Closed joint capsule ligaments and muscles acting as primary joint stabilizers
Some joints also contain lntn-artloular st111cblres that help the joint to function: menisci (e.g., In the knee joint), articular disk (e.g., In the temporomandibular joint), articular labrum (e.g., In the shoulder joint), and Intra-articular ligaments (e.g., the cruclate ligaments af the knee).
8 cell$
joint sp;~ce, - joint cavity. synovial fluid --11\-11HfHi-H.~R
Mineralized - -t-\1-1/:ricartllagem;rtrtx Blood....,els, bone marrow
C Sbucblre of artlmlar a~rtllage (after Kristic) Articulating bone surfaces are covered by a layer of /ryD/ine rortilage af variable thickness (exceptions are the temporomandibular and sterno· clavirular joints, which are covered by fibrocartilage). The thickness af the artirular cartilage depends largely on the magnitude af the joint stresses, ranging from 1-2 mm In the phalangeal joints and 2-4 mm In the hlp joint to 5-7mm In thefemoropatellarjolnt.
} Intima )
Subintilllil (subsynovlalls)
--f-i,~,.
Boundary line (tldemartc)
36
]oint ca\lity
B St111cture of a true (synovial) Joint True Joints have the following characteristics:
Direction of the --F~;;:~~~~~v;~ collagen fibers
Chondrocytes
]oint spiKe
W *-'1---- Joint capsule
Amplliarlllnlns
Ankylasls- abnormal bonyflxatlon of a true joint Arthraclesls- surg~l fusion ofajolntfortherapeutlc reasons Pseudarthrosis (nonunion)- "false joint" due to ~bnormal hcture
Extrarellular lllillrlx
._....lJ,....+--- member(socla!t:)
Hyallneartlcular { cartilage
SynOIILll membrane
Fibrou5 memb111ne
Subsynovlal flbrobla$ts Fat cells Blood vessels
Mineralized ~~I'J..i.~ cartllagellliltrlx
D St111cture of the Joint a~psule The joint space is shown greatly widened in the diagram to exhibit its features more clearly. The synovial fluid, produced mainly by type Bsynovlocytes, Is a very viscous Intra-articular fluid with a high content af hyaluronic acid. The synovial fluid performs three main functions: • It nourishes the articular cartilage through diffusion and convection. • It lubricates the articular surfaces to reduce friction. • It cushions shocks by evenly distributing compressive forces.
Allb!rtcr
blbnele
Talus Cmdll -\-L--+-bona Pas11erlllr Wltande
--~;:::~~-?'
•
Hlp bani!
lnbnplnaw
hgamont SUpraspnous ligament
Splna111 process
E ~ (fib..-jofntl) • Interosseous membrane. It Tibiofibularsyndesmosis.
d GomphDSis.
e Ugamentum flavum, lnb!rsplnous ligament and supraspinous ligament.
c Fomnelles.
~urn
Oxbl~~~~~~ artlllge
c
G 5ynGRula (slta ol bonyfllllon) • Sacrum {fused sxral wrtebrae). It Hip bone(fu(IOn of the ilium. ischium.<md pubis).
c F Sylldlal'*-(urtllagiDIIIIIS)IIInt!l) 1
Epiphyseal plate prior to dosure.
It Hlp bone before do.sure ofthe growth
c Cosbl cartilage. d Pubk: symphysis and lnterwrtebr.~l dlsb
c Closedandossmed epiphyseal plates.
(lntr.~ertebral symphysis).
plates.
37
Generol Anatomy - - 4. The Bones andJoints
4.3
Basic Principles of joint Mechanics
A Degrees of freedom, illustrated for the possible movements of a tennis ball In spaCII! a Three degrees of freedom in translation (one each along the x. y, and z axes). b Three degrees offreedom in rototion (one each around the x, y, and z axes). With its similarity to a tennis ball, the spheroidal joint (see 0.) has the greatest freedom of movement.
•p;·;2:~~~~~~~~~~~~~~~~~~ ~:-·~ pl•·· ············ · ···-
•
--- ·~
p4•·············· ........• ,..,
Ps• ----- -----
a Spheroidal Joint This type of joint has three mutually perpendicular axes of motion, resulting in six primary movements (example: hip joint).
b Hinge Joint This joint has one axis of motion, resulting in two primary movements (example: parts of the elbow joint).
(
-----------• Ps,
b B Translation
Translation means that a body Is sliding on a straight or curved path without rotating. As a result, all points on the moving body travel an eqool diswnce in the same direction.
c ElllpsoldJolnt This joint is biaxial and has four primary movements (example: the radiocarpal joint).
d Saddle Joint This is a biaxial joint with four primary movements (example: the carpometacarpal joint of the thumb).
e PlvotJolnt This is a uniaxial joint with two primary movements (example: the proximal radioulnar joint).
f Plane Joint The only movement allowed is a translation (sliding) of one member on the other (example: vertebral facet joint).
a All the points move on parallel lines. b The gliding Ice skater Illustrates movement In translation.
a
C llobltlon
When a body is rotating, different points on the body move on concentric circles and travel different dlstDnO!S. a All the points move on circular arcs.
b The spinning ice skater illustrates movement in rotation.
38
D Tbe classification of Joints by shape The arrows indicate the direction in which the skeletal elements can move around the axis or axes of the joint. Amphiarthroses (not shown here) are •stiff" because their mobility Is greatly restricted by the shape of their articular surfaces and by tight ligaments (examples are the proxImal tibiofibular joint and sacroiliac joint).
Genertll Anatomy - - 4. The Bones andjoints
:::~:n:
Force
Force
a
ann
7'---====<~ r+-+-- Force
limits
hype~nslon
11.1dlus
]
oftheforearm
Ulna
•nn
•
Load
Loodann
Cenll!r of rotrtlon ofelbowjoint
Center of rotrtlon
Load
Hamstrings: limit maximum flexion of the hlp joint
Partial-body center of gr.wity Glull!us medius and mlnlmus Force
.....
Hipbone lllofemol'illllgament limits hype~nsion of the hip joint
Lailclann
Center of rolirtion
b
l.o;ld
Femur
E One- and two-ann Ieven a One-arm lever (elbow joint), b two-arm lever (hlp joint). joint mechanics Is based on the principles of the lever. The amount of force that a muscle can transmit to a joint depends on the length of the associated lever arm. This depends on the perpendicular distance from the musde and Its tendon to the center of rotation (=force ann) and Is opposed by the force of the load ann. In the case of the elbow joint In a, the load arm Is the distance from the joint axis (center of rotation) to the load. The magnitude of each ofthe three ac!:lve {Drees Is determined by multiplying the force by the force arm and the load by the load arm. This product Is called the rorque (= moment of rotational force) because the active forces produce a rotational movement of the associated lever. Ifthe product of the load times the load arm equals the product of the force times the force arm, both torques are Identical and the joint Is at rest. The lever In a Is classified as a Olle-{Jnn le~~er because the muscular force and load act on the same side -In this case to the left of the center of joint rotation. The lever In b Is a two-;:~rm lever because the muscular force acts to the left of the center of joint rotation while the force of the body weight acts to the right of the joint center.
H i-+-- Soft-tissue envelope ofthethlgh: limits maximum flexion of the knee joint
Extension/Flexion 5/0/140' b
Extension/Flexion 0/20/140" c
-~~ d
/ ~ 20'
Extension/Flexion 0/20/20'
140"
G The neutral-zero method
F Constraints to Joint moUon The range of joint motion depends not only on the shape of the bony joint members (see D, left) but also on the muscles, ligaments, and soft-tissue envelope that surround the joint. Accordingly, all of these factors determine the total range of joint motion: a b c d
Bony constraint Muscular constraint Ligamentous constraint Soft-tissue constraint
The "neutral-zero method" is a standardized method for measuring the range of joint motion. a b c d
Zero-degree starting position, viewed from the anterior and lateral aspects. Range of motion of a normal knee joint. Umitation of motion caused by a flexion contracture. Ankylosis of the knee joint in 20" of flexion.
39
5.1
The Skeletal Muscles
l """";7"-;L---- - GM!rocnemlus ~ndsclem
(l!la!)JSUI1l~)
A PoStural musd•indnudesof!Mftmlllt
a Porterola!l!ril view, b ;mterolatefal view (dr
Thevolunuryskl!leul musdes ~re c~ssified functionally into two luwd groups: postiHil muscles (tonic muscles) ;md muscles of movematt (phasic musdes) .
.._...III!Uides(.Wmuldel)
a-IBtslla:
• Phylogenetlcallyolder
• Predominantly slow~ ftbers (type 1 fibers. appiUXimltiely 100 ms) • Function best In endu1111~n
EDmpla:
.._...,_ent(whltlemUid•) • Phylogenetlcally mare l'«
• Pl'edomlnanllyfut-twltcllllbers (type 2 fibers. apprc~~~lmately 30 ms) • Brfef periods~ lntense;~ctMty
• l'allgue siCMiy • Large mator units • Rich In II'I)"'globln • Abundant mitochondria • Energy derflled from Glddat11111 (aerobic) metaboliSm • Utile g¥togen (MS~egaiiW)
• filllgue more rapidly
• Rellllhely highly wsa.olarfmd • Prone to shortenii'Q Oncrased restilg tonus) and req~ rttular stmchlng
• Mud! smaller capillary supply • Prone to atrophy and require regular strengthening
Intercostal muscles. INStlcatory musdes. tr.llpezlus (descending part), hamstrings. diopso~s. adductors. reClus femoris. soleus. Intrinsic back musdll!l (mainly ltle a!Nlal and lumbar part)
Bleeps bracl\11, vastus latera lis .1nd medllllls. tlbllllls anterior, serratus anll!rior. gluteus mlllimus. gastrocn•
• SmallmotDrunlb
• • • •
Scant II'I)"'globln Few mitochondria Energy derflled mainly from <~naeroblc glycolysis
Abundant glycogen (PAS-posiiiW)
mlus
Sludles halla shown ltlat altlleta who engage In sports lrwoMng Intense bums of muscular activity (e.g., sprinters) U. more white (bsHwltdl) flben, willie endura~n athletes (e.g.,ITiilrathon runners) U. more red (sfow.twltell) fibers {PI!ltle and Staron 2001).
40
GenrraiAmrt:omy -
Tendon of lll:ll!ftlen
s. TheMusdu
PM\iry bundle
Musde belles
CA!II nude!
d
Endamysh.rn w'lth
• D strucmr~: of a slaeletalll"llllde Cross section oh skr!lml mil! de. b Deu!l from a {cross section). c Oeto!!l from a (longitudinal section).
1
f
d Structure of a muscle fiber (• muscle all). • Structure oh myofibril.
PhysiiJiodCill CIVSS ~ctlon
oftllemtaele --l"!'~.'~i ;~1-- Anlllomlc.~l
CIVSS ~ctlon
oftllemtaele
• c Morphologtul forms ol muscles • Two heilds • bicipiul (e.g .. the bleeps brachO). b Three heilds • trldplul (e.g., the !Jfceps sur~ e). c: Four heads • quadricipit."ll (e.g .• the quadriceps femorts). d Twobellles·dlgilrtric (e.g., the dl~strlc musde). e Multiple bellies • multigastric (e.g .• the rectus abclomlnls). f R.ildlal (e.g .• the emrnal anal sphlnctl!r). g Flat (e.g., the exb!rnal obfiqLJe).
E Amlngementofmllldeflbenancltfle penllltlon angle Muscle fi~ may havt' a parallel arrangement or may show varying degnees of obliquity, or pennation, at their attachment. a Muscle with p;~rallel fibers (fuslfonn mll!de), b unlpennilte musde. c blpennate muscle, cl multlpennate muscle. In cgntr;~st wp;~rallel mUKiu, whose fibers ;~re approximately p;~r;~llel wthe "line of pull• of the tendon. pa1nate muscles converge tDWard the tendon at a certain angle called the pennatlon aflgle. While !he muscle fl~ are shorter due to their oblique att
41
Generol Anatomy - - 5. The Muscles
5.2
The Tendons and Mechanisms That Assist Muscle Function
a
t.~.B~one~l~L~c= Tensile •tress
Blood
..,...I
=-·
Compress~
stress
Lil)'erof flbrocartlloge
b PresBone
sure tendon
Peritendineum Bony fulcrum
Blood..,..el .'.l::--:'o~""-f=~-- Primary
bundle Epitendineum
A strucblre of a tendon (after Krtstic) a The tendon Is connected to Its surroundings by the loose, richly vascularized paratenon. b Detail from a: The Individual primary bundles are surrounded by peritendineum and are grouped Into the actual tendon by the epitendineum. The function of a tendon Is to transmit force from the musde to the bone.
Blood""'""' In the tendon tissue
B Pressure tendons and traction tendons a Traction tendons are subject to tensile stresses and consist of strong connective tissue with parallel fibers_ b Pressure tendons are strained by pressure and change their direction by running around the bone (unlike traction tendons). They consist of fibrocartilage on the side In contact with the bone, which acts as a fulcrum. c Detail from b: The fibrocartilage layer In the compressed area, unlike the strong connective tissue In a traction tendon, Is not vascularIzed.
lDneoftendon tissue with parallel flbel'5
Nonmlnerollz.od Mlneroll"'d flbrocartlloge flbrocartllogezone
Musde
Vhvy(lox) - - - . . _ collagen fibers
•
Elastic flben (alr..dy taut at rest)
b
Musde
Collagenflben ----..._ on stretch Elastic flben (function as stretch prob!ctars)
Spring (cartilage a!ll)
~ longitudinalstretth
Tronwerse shortening In reoponse ID longitudinal stretch
b C strucblre and function of a periosteal diaphyseal tendon Insertion a Tendon in the lax condition_ b Tendon on stretch.
42
D Structure and function of a dlondral apophyseal tendon Insertion a Tendon in the lax condition (muscle relaxed). b Tendon on stretch (muscle contracted). c The principle of stretch protection: Cartilage cells in the nonmineralized fibrocartilage zone act like taut springs to resist transverse shortening.
GenrraiAmrt:omy - -
s. TheMusdu
n!aps brachll
Meehl
lnunnLSCUiar septum
Humerus
l..llet1il
lntmnUiWiar RPIUm
....,.,_ _ Brxtl'lllts
locMIUill musc:leliacli P.&scla en cbs'ng amusdtgraup
Br
Tendon --+--H~ Pel·
Bane
E Mulldeliud1e
Pn:lxim.al view. Cross section through the middle tflird of the right ann. Musde mdae (fibrous sheaths a1doslng musde) are composed of tough collii!Jenous connective tissue. They help to malntiln the shape and position of muscles <md pennlt adjacent muscles or muscle groups to glide past each otfler with relat:Miy little friction (less friction means !ellS loss of fora).
F Strudllre of ;a tl!ndon sheath {syrtO'If&;ll sheatfl) Tendon sheaths serve to prctect ind facilitate the gliding of b!ndons that run dlrec:tlyon bone. The wall structure of the sheath, consisting of an outerflbrous membrane and an Inner syoovlal membrane. resanbles that of aJoint capsule. The Inner la)'l!l' ofthesynOII!al membrane rs flmnly attached to the tendon, wflile its oub!r layer is attached to the fibrous membrane of the tendon sheath. The spact' between the two k!yers Is filled with synovial fluid. The mesotendlneum (sometimes referred to as vinculo brev1o and IDIIga In different loc.ttrons) trinsmft:s blood wssels to the tendan.
Aaomlon
11!mlr
Sublcnxn'lll bui'Ja Subdeltoid bur'll Deltdd
Pectalllils ma)ar
~Ia
Slbb!ndlnaus bursa of the slbsapulllrls Sub· Kipuliris
~sofma!lan
lnthekMefalnt Joint apsule
Effmlve ICIICI'am
lnfnlpllttlr lilt pad ~lirlljillllent
Ml!nll(lll
Ribs
Thlill wbllrostty 1bla
G SJIIDWHI bursae tnthe shoulder r.glon
Right shoulder viewed from the interior a1pect. with some of the musdes rerncMd. Bunae are pouchlllo! structures ofvirylng siZe,. usually flatb!ned, that cont.ilin synovial fluid. Their wall $tr\lcture is simil;!r to thatofijolntcapsule. The!KJI'Jaemaybecomelnflamed(bur!llfs),ciuslng severe pain.
H FunctlonalslgnffiCilnce of S11Si11110Jd bones Sagittal section through a knee joint. Sesamoid bones ire bones that are l!mbedded In tendons ~nd protect the tendons from excess'llle frlc· tion. Their occurrence i$ \'iriable, so everyone doe$ not 1\;M! an equal number of sesamoid bones. Their main functional role Is to kngthfn the f!{fKt1w! IM!r G1711 ofo mCI:Ide. Increasing Its mechanical efl!dency. The dlagr~m Illustrates this principle for the p.a!J!IIa, IM'IIch Is the largest ses~moid bone in the body. The patell;! signifiCC~ntlyll!llgthens the effective lever amn. tqlnesented by a perpe11dlaJiar line from the joint axis to the tendor1 ofrnsertlofl of the quilldrfceps femoris.
43
6.1
Overview of the Human Cardiovascular System
A Sct.nutlc ...,....~n ClfU. dl'allmlry.,.atn Special cii'DI Ia!Dry org.ilns are needed tD tr3nsport ilnd dlstrlbute the biOCJd, ensuring tNt it is m.de KaSiible tD all the cells in the body. These org;~ns amslst of the heiiirt and vascular syRen1 (blood vessels ilnd lymphatics). The syst~tm at IIIDad -.Is consists of arterles. CiiJ>' dlarfes, 1nd veins. The Clltrr1es c.~ny die blood from die heart ilnd distribute it throughout the body. The Vl!ins retu m die blood Ill the heart. The elldlinge of !Jilses, nutrlents, and wute products tilb!s place In the CDpH/aty region. All blood vessels INdlng 1NR'f from the hr:<~rt are ailed a riB!es ilnd all vessels leading IIIWilnd the heart ilre called veins, regandless oftheir oxygen content (the umbilical vein, for uample, carrtes CBI)'gen-fich blood). The blood flow In this cbed vascular system Is millntalned by the pumpl• Kdon oldie '-rt The IJmphllktylb!m runs parallel Ill the venous system. It originaw with blind·ended vessels In the apllliry region, collects the ~fluid thilt Is deposIted th~. and netums It Ill the venous blood through lymphotJc llf!!Stls. t,ymp/1 nodes o1re lnttrpD!Ied along these ~ays Ill filter the lymph. Functionally, the circulatDry lylb!m is divided into two main circuits:
Pulmonary win
• The pulmonary drculllton: ~
111!11DUS blood from the upper and 1_.- body reglo"' Is returned through tile superior and lnfertorveno1 cava Ill the right o1b1um.ltthen enters the rlghtventrkle, which pumps It through the pulmol'liry utelfes tD the lungs. • The sys~amtc dra~llltlon: Clx)lgen~rid!l!d blood from the lungs returns through the puiiTlOIIilry veins Ill the lrft iltrtum. From the left iltrlum It enters the ll{tventrkle, whldl pumps the blood through the illlrtillniD the syRen11c drcullltlon. A spedo11 pilrt of the systEmk dr· cuit is the Plllrt.l cllw'-don. which ind udes two sucassil!l! capillary beds.lr(tn l!l!nous biOCJd returns Ill the Inferior l!l!na cavo1 from the aplllo1ry beds of the unplllred abdomlnill orgilns (stomildl, bowel, pllncreas, and spleen), It Is carried by the porbl vein tD die capillary bed of the liver. This ensures thilt nutri811-
v.toblo pumphg ICtlon
(canllacwnb1de&)
./
lliUIIc r'llCilll (•orb and athl!l'
large.....,... nurthe hl>llrt)
l-..---J-
l' {
' r-~~1 ''
V.rllbloa~
(wins and l.lng)
Ylrt.lbleroolsbii1CII! (5111i11artorles ••d•r11!rlole)
Right lllfUm ---4~--+l~·i"' ll'ftrlor
ftl1ilavil
--1.--J~-:f'llllllll~
Lymph node ~wins
--·
Lymph Ilk:
8 hllc functlonaldJ.tlnm at the di'CUIItDry.,.tem (no dlstfnctlon Is rl'lide betwea1 the systemic and pulmonary systEms In the diagram; after Kl Inial, Sllbemagl) Blood is transported through the drculatory system along a pressuregro· dlent cremd by the different pressure IMs In the artertalind venous systems. While the average blood pressure In the artflla/ hlgll-prem~re sys«rm Is approximately 1oo mmHg (13.3 N), the prftSUre In the W!IIIIUS kw'f..pressure SJS!IM'I ger~erally does not eoaed 20 mmHg (2.6N). The two systems meet In tile capillary region of tile terminal vasaJI;.r bed, where metibollc exchange tai(es plaat. When the heart expels blood dulfng systole. the orlMes surtOUndlng tilt htcrt (tlastlc-type arteries) can bemporarily expand to accommodate tile ejected blood volume. During the diastole thilt fullows, the vessellu men undergoes an elastic m:ollthattr.J nsforms the lntermltttrnly ejected blood volumes IRID ccnUnuous flow. ~s dlstont from tM htort (musculol'type arteries} an actively expand(~) and CDntrect (wuusllitllon), p
CimmllAnatomy - - 6. 1bt!Veuels
Inter·
n~lllllc
v.
Ulnari.
C OVI!nfew of tfle prfl'ldp.;lli!rb!t'Tes In die sy.ltl!mlc dr'CdMlon
D OW!rwtew of the prfnclp;ll vehls In tfle systemic drcul;rUon Tbevenous 1'J$U!m Is comprised afsuperficial veins, deep veins, ~nd ~I so ~~;~tor ~ins, which interconnect the superfitial and dHP venous
systems. ~lch ames nutrient-rich blood (shown here In purple) from the dlgesti've organs dlrtctly to the li~r (a~mpart'with tne left side ofA).
lllotl! the port;ll drculiltlon (port;ll vein),
45
6.2
The Structure of Arteries and Veins B Org...._..onolthebloiMI-Iq~t~em
Artste(hlgt>-...--,.._-...,., fundlan) •
Ellstlc~ llterles
·~--
~ ........... (rnlaDdrallalfon •llldllnge llnctlan)
.._,..n
h Medi.m-
• ArterlCIIes • Capillaries
• Venules VltM Claw-1>......,. sysmm • Nsenalrfundlan)
c Small
• Small and medlurn-shlewlns (With vaMs) • l;Jrge wnous tnlnlcs
.-.y
1 Small win
dlrtint from the
Tl!rmllllll ........ b..t
heart
W:.l !hide-
e Capllary
..
ness(w) ~
wmlnal
TWmiNI_..rW
I'Oidlus(~)
A 5tnJdul'l! olthe llloiMI - I I In cmr-.t ftGians oltM s,stlemk drculltlon Consistent with changing derNnds, the vessels In different regions of the systmlic circulation (high- and low-p18SUrt: systems. micnx:irculation) show slgnlflant foal stn.tdlJral dlft'erences desplb! a !Nstcsimilarity In the arrangement of their walll~rs. Whereas a relatively high lntJ!.rnal pressure pren llsthroughouttheomltdl~.and the~ vessels hiM co.m sponcllngly thick wds, the wins h~ a consldenbly lower lnlrlvaKUiar pressure. rtit!lltng In thinner walls and lilf!IS luml-
Aartl SINIIII'II!ry Arteriole
Z.5mm
lmm
ZOpm
~·
Veuje
v.ln
II'Maav:a
5pm
O.Smm
l.Smm
00@@00 1Z.5mm
2mm
20pm
lOpm
2.5mm
15mm
na I dlimeten than In the arteries. In the termIna I ViSCUiir bed, on the other hand, the vesselwalll~rs are reduczd to permit the exdlange of gases, fluids, and oCher substanas. a-c Arteria, d-f terminal nsa~lilr bed. g- 1 wins. a Close-up view of the aortic wall (elastic-type artery). b,c urge and small arteries distant from the heart (muscular-type vterles). II Arteriole. • Capillary. f Venule. g.h Smalbnd medium-size wins (some with venous vahiles). I Close1Jpvlewoflflewanoflfle lrhrlorveni an.
C Will structure of a blood -l.llluatnletl hlr 1 muacullf.type il1l!ry
Endothol;.,m Baillimm lntemll elntic membrone
Media
l-
The wall of a blood vessel bnleo~lly consists of thsft laym: the lntlmo, medlu, and adwn111111. The three-!~ s1Jucture Is dearly apparent In the walls of arteries ilnd Is less complcuous In ~ns (see D). • The Inihil consists oh lll)'er of splnd le-shiped endothelial cells that are aligned along lfle vessel axis and rest upon a ba5el11ent membranund a lflln h1yer of subendothelial connective tissue. In museufar-type ~rteries, the intim;~ is con$istently sep;~rated frvm lfle media by an Internal eliStlc membrane. • The media Ulnsim of an approxim;~tely circular an-angement of smooth muscle CElls, elasltc and collagenous flbers. and proteoglycans. Muscular-type artelie.5 may haw an eatemal elastic membr.lne that separates the medii from the adwntltb. • The ..,_ntlllll,lib the intima, Is Ulmposed of longitudinally aligned elements, mostly connectiYe tissue. The adventitia ofvel ns may additionally contain smooth muscle. The adwntltia transmits autonomic ne~ to the muscle of the vessel walland, cspedally In larger vessels, it also transmits lfle vua vilsorum, which supply blood to the outer third of the wsselwall. Specific functtons can be assigned to ill three byers: The Intima Is concernedwith the e:llii:Nnge of gases, fluids. and olfler substince through the wssel waiLThe medii regulates blood 11-. and the llldwntttla Integrates the bl-r vessel Into Its surroundings.
46
CimmllAnatomy - - 6. 1bt!Veuels
AIWy
v.tft AcMnlflla
Mlll!ntltSa
Medii
Med~
Intima
Wine Pmsure(mmHg)
~Pres:sure (mmHg)
-30
+35
-15
+50
-l
+100
Intima --VHsd lumen
• rntnh.mnal clatled blood
Hydrastatlc
Poemr.aolallllr
_,~lf!'IOI!I(O)
alnMedll/eUSS\1~
+20 Med~
ofwin
lllll!mil datlc
membnne
£115!1c:
flben
Emmal elzdlc
+90
+180
m«mlr.lne
b
D Dlffei'I!IICI!S lrt tile Will struc:ture of artl!t'Tes nd wlns wall sections from a muSCIIIar-type arb!ty and an aa:ompanyiAg vein. Comparlsor1 of tissue cross sections treatl!d with different st
Vdns
Contncb!d
Open
siGelealmusde
~nousv.ll••e
E Artert1l and Yl!ftous prasure changes In tfle standing podlan ChaAging from a tecumbent to a standing pDiition radically alters the
pressure relationships In lfle drculatoty system. The hydrostatic effects of this change ca~~Se !he pressure to rfse sharply In the l0111er p;1rts of the body, 'While the pressures lfllhe upperbodydeaease (the pressures remairl unchanged at the "hydrostatic: indilfetenCZ level• just below the dlaphr.tgm). Along wllfllfle hydrortatfc pressure changes. ipproxl· mately 500 mL of blood volume Is shifted Into !he lo!Ner limb veins. This rise of venous pressure greatly Increases the trlln.smur.al pressure In !he lower limb veins, whi1e the pressure in tne head and neclc:veiru may fall so low th
F Venousretumtothei!Nrt The following f<1ctors promote the retum of venous blood to the heart • opening and do5ing of the venou5 ~~;~hies, b arb!ric:lllenoU$ coupling (the pulse wave lr1 the arb!ry Is trin.smltted to the aa:ompanyiAg vdn). and cthe musde pump. Venousretum ls.iiiSO.illded by the "suction effect• ofthehe..rt, I.e .• the neoJ~~tive prenure produad when the valve plane moves toward the cardiac apex during systole. A lack of muscular movement due to prolonged stand lAg or sitting, forex.1mple, an cause the damming b
b
47
Generol Anatomy - - 6. The Vessels
6.3
The Terminal Vascular Bed
Metabolic exdlange
Sldn
c¢)
Cell(lntr.tCl!llulorspaa!)
Ptatmoon
Primonllal sea b
Number of vessels
lnt.Btitium} Extraa!llular space Blood vessels (capillaries)
A The milieu In which a cell lives (after Sllbernagl, Despopoulos} a Protoman: The first single-cell organisms lived in an environment, the primordial sea, which provided a milieu of constant composition. The internal and external milieu were the same, and so neither of them changed during metabolism. b Human: The cells of a multicellular organism are bathed by extracel· lular fluid, whose volume Is substantially smaller than the lntracel· lular volume. The extra- and Intracellular fluids also have a different composition. In this situation the Internal milieu would change very quickly If the Intercellular space (Interstitium) were not linked via the bloodstream to organs such as the lung, kidneys, and digestive tract, which absorb nutrients and excrete metabolic products. Nutrl· ents absorbed from the bowel are distributed to the cells of the varl· ous organs (Interstitium of the capillary beds) via the bloodstream. The blood also transports the metabolic products of the cells to the organs that are responsible for their excretion (e.g., the lungs and kidneys).
Dlamell!r of the Individual vessel (em)
5.3
Total cmss·sect!onalarea {em>)
~I
~
40 30 20 10
0
B Characteristics of different vascular regions (after Silbernagl, Despopoulos) The terminal vascular bed is the site of the microcirculation and there· fore is the site where gases, fluids, and other substances are exchanged. It consists of: • an afferent orterlol limb (precapillary arterioles}, • the cop/1/ory bed Itself, and • an e(ferentvenotJS limb (postcaplllaryvenules). The smallest vessels, the capillaries, consist only of an endothelial layer and a basal lamina to which pericytes may be externally attached (con· trast with the more complex structure of large vessels, p. 46}. Owing to the extensive branching of the vessels in the capillary bed, the total vascular cross section is greatly increased (approximately 800 times) while the flow velodty is corTespondingly reduced (from 50cmfs in the aorta to 0.05 cm/s in the capillaries). With an average capillary length of 0.5 mm, a time of approximately 1 second is available for metabolic exchange. The increased vascular resistance in the arterioles and capil· lanes caused by contact of the blood with the large endothelial surface area (Increased friction) lowers the blood pressure and eliminates pres· sure spikes. Thus the capillaries provide Ideal conditions for exchange processes to occur between the blood and the Interstitial fluid that bathes the body's cells.
48
tl\
z---
Flow velocity {cm/s)
1:~
120
40 20
~~.--
of!W~
Systolic pressure
~~~~~wre ~-~----~~----------------~ ~
0
~-----------~
Intravascular pressure (mmHg)
Pert1!1ltage of total resistance
-----
CimmllAnatomy - - 6. 1bt!Veuels
a
b
Venul~
Arteriole
Artl!rfole
Venule
Pn!aplllary
sphlnc1:2<, coi'Ar.ld:ed
c Bloodflowlntheaplllrybed • Sphincter relillled, b sphincter contricted. Precapillary ~phlncters. with their drcular array of muscle ails. are loc.l1led at the Junction of the metarterloles and capillaries .md regulate blt~ad flowwithiA the capillary network.. Wher\ the sphincten mntract. the branching caplllarles are clond and the capillary bed Is unperfused except for the met.1rterioles (e.g .• only about 25-35 ~of all capillaries are perfused under restfng condltfons). The arterioles <md venules may also be interCDnnected by shur\ts called artl!ficMenous anastDmc:!es.
D Dlft'cmlt fvrms of apftl1ry mdothchll cells (scheme of ultrastruct\lr.II fe.ttures) Capillaries range from 5 to 15 pm In diameter and consist of endothelial czlls, basal lamin<~, .ilrld external pericytes. Pericytes ha1le various properties and functions, Including a role lnvascular development and ang~ genesis. The Individual endothelial cells are mnnec:ted to one another by .ildheslon contacts, tfght {unctions, .ilnd gap Junctfons, largely p~ venting any metabolic euhange between indMdual endothelial ails. The endothelia of different capillaries have varying degrees of perme.il· blllty, <md sever.ill types of endolhellum .ilre distinguished on th.ilt basis: I Oosecl endotilellum without fenestrations and with .il mntlnuous
biiS.ill lamina (e.g., nerwus system) I Oosecl endothelium with pingcytotic activity {e.g., cardi;lc and slcel·
etal muscle) II EncloUtellal cells fenestrated by a diaphragm (e.g., gastrointestinal tr~ct)
IV Endotheli~l cells with interallular gap$ {large fenestr.atiCins) ~nd
without .il continuous b.iiS.illlamlna (e.g .. lrver) ~caplhry
Venule
l~um
(N) 4.0
35
(mmHg)
30
25
3.0
25 2.0
20
15
Flltr.a!lon·~cn+lympha!lcdralnage
E Mechlnllmoffluld4!lldlilnge1nacaplllllry(afterSIIbernagl. De~popoulg:s)
Fluid exchange bd:vo'Hn capillaries and the sui'TOIJndlng tissue (IntEr· stftlum) Is regulated by a changing pressure gr.ildlent bet:wHn the blood pressure in the capilla(.es (hydrastatic pressure) and the intra·
vascular colle~id osmotic pressure. The driving fo~ behind tne fluid exchange Is tile hydromtlc blood pressure. The pressure .ilt the .ilrtt'rlal end Clflhe c.1plllaryls 35mmHg (·4.6N), which Is 10mmHg higher than the colloid osmotic pressure of.ilpproxlmately 25 mmHg (• 3.3 N). This pgslt!ve pressure differential makes It posslble for fluid as well as dissolved p.iirtldes to fllter out Clf the c.ilplllarles .ilnd Into the surround· lng tissue. These relationship$ are revenec:t at the venous end of tile capillary-the~ the hydrostatic blaod pressure falls to apprDXimately 15 mmHg (2.0 N) while the colloid osmotic pressure ranalns essen· tlally unchanged at .ilbout 25 mmHg. As .if result ofthts. the hydrost.iltlc pressure on the - s side of the CDPNiol)' Is 1OmmHg /owtr than !he colloid osmotic pressure (1 S-25 • -1 OmmHg), causing fluid with its solute particles to flow back Into the vessel (reobsosplfon). Of the 201ltl!rs of fluid that leave the capillaries eiiCh day, only .ilbout 18 llten (90") are reabsorbed. Approximately 2 liters {1 OX) of the fll· tered volume are removed by lymph
49
Generol Anatomy - - 7. The tymphtJtlc System and Glands
7.1
The Human Lymphatic System
A Tbe human lymphatic system This system includes the lymphatic vessels and the lymphatic organs (immune organs, see B). The lymphatic: Yi5CIIIarsystem runs parallel to the venous system and perfonms several functions: • Its primary function is to clear the interstitial spaces of tissue fluid and substances that cannot be reabsorbed in the venous capillary bed. The composition of the lymph varies in different regions and is similar to that of the surrounding interstitial fluid. • It carTies away food lipids (chylomicrons) that are absorbed in the bowel.
• It retums lymphocytes from the lymphatic organs to the blood. The lymphatic vascular system consists of: • lymphatic capillaries, which begin peripherally as blind-ended ~~c---1-+~----~
duct
Spleen
Vennlform ---+--""""ir -1 appendix
Bone maii'OW
vessels; • the lymphatic vessels and interposed lymph nodes; and • the major lymphatic trunks (thoradc duct and right lymphatic duct). The lymphatic capillaries collect fluid from the interstitium and transportitvia the lymphatic vessels and lymph nodes to the major lymphatic trunks. The fluid reenters the venous system from these trunks at the junctions of the left and right subclavian and internal jugular veins. The lymph drained from three body quadrants enters the leftjugulo-subclavlan venous junction, while only lymph from the right upper quadrant enters the rlghtjugulo-subclavlan venous junction. The lymphatic organs are part of the specific Immune system and, as such, are situated at likely portals of entry for lnh!ctlous microorganIsms. The spleen Is the only Immune organ that Is dlrecdy Integrated Into the bloodstream.
Tonsils
Primary and secondary lymphatic organs The functions of the lymphatic organs indude mounting a specific immune response. A distinction is drawn between primary and second· ary lymphatic organs. The primary lymphatic organs are concerned with the production, maturation, and selection of immune cells. The second· ary lymphatic organs are subsequently populated by the immunocom· petent lymphocytes and are sites for various processes such as antigen presentation, lymphocyte proliferation, and antibody fonmation.
B
• Primary lymphatic organs: - Thymus (selection ofT-lymphocytes) - Bone marTow (selection of 11-lymphocytes) • Secondary lymphatic organs: - Spleen - Lymph nodes - Mucosa-associated lymphatic tissue (MALT) and the pharyngeal lymphatic (Waldeyer's) ring-the pharyngeal, palatine, and lingual tonsils. - Bronchus-associated lymphatic tissue (BALl) - Gut-associated lymphatic tissue (GALT), such as Peyer plaques and the vermiform appendix
Peyer patches (lymph nodules in the bowel)
/
T-lymphocytes; cell-medr.~ lmrn..~ne response
Primary lymphatic organs
50
. \ .Spleen
B-lymphocytes; antlbodl.. for h1m0ral lmmune response
Genertll Anatomy - - 7. The lymphatic System and Glands
c
Organization of the lymphatic vascular system (after Kubik) Three compartments can be distinguished In the lymphatic vascular system based on topographical and functional crtterla: 1. A superficial system- drains the skin and subcutaneous tissue. 2. A deep system- drains lymph from the muscles, joints, tendon sheaths, and nerves. 3. An organ-5pecific system- drains the organs and shows organspeclflc differences.
A system of perforator - I s Interconnects the superficial and deep systems, conveying lymphatic fluid toward the surf~ce from deeper tissues. The lymphaticv;,scul;,r system can be subdivided into [ourdi/frRnt ~ons based oo the hlstologk •tructure af the wuel-11•: 1. Lymphatic capillaries,
2. Precollectors,
3. Collectors, 4. Lymphatic trunks.
Lymphatic capillaries and precollectors are also known as initial lymphatics. Collector Perforatorvessei Distal valve
Contracted valveless mllector5egment (emptying phase)
Deep ~-+-.......,ll\-'"&--
lymphatic vessel Skin Subcut:aneoust:l5sue Fascia
MuKie
Bone
a
vascular sheath
Proximal valve Laxrollector segment (filling phase)
Phases af lymphatic
Arll!ryand b
iiCCOmpanying vein
D Organization and strudure of the different lymphatic regions (after Kubik) a Lymphatics In the skin and muscles. b Detail from a, showing the structure and function of a collector segment. Both the superficial and deep lymphatics originate with the extremely thin-walled lymphatic c.aplllalies, which are approximately 50 11m In diameter. Their endothelium Is bounded by an Incomplete basal lamIna, and they are attached by collagenous "anchoring filaments" to elastic fibers and collagen fibers In their surroundings. The network of lymphatic capillaries opens Into larger pnecollecton approximately
Cortex
dr.olnap
1OOJlm In diameter. Unlike the lymphatic capillaries, these vessels contain valve cusps and their wallis reinforced by a layer of connective tl~ sue. They open Into collectors, which also contain valves and have a transverse diameter of 150-600 11m. Like the larger lymphatic vessels and the lymphatic trunks, the collectors have a venous-type wall structure dMded Indistinctly Into an Intima (endothelium and basement membrane), a smooth-muscle media, and a Hbrous adventitia. Lymph transport Is effected by series of rhythmic contractile waves (10-12/mln) that are generated In the smooth-muscle, valveless collector segments. The direction of lymph flow Is controlled by closing the distal valves and opening the proximal valves of the precollectors and collectors.
TrabeaJia Paracortex
Serondary follicle Capsule
Eff...,nt
Gaplllary loops around a(serondary) lymph folhde
Medullary sinus Vein
vessel
Arll!ry Hilum
Postraplllaryvenule A1'11!11ole Intermediate sinus
Afferent
......r.
sinus
a
Arrangement of musdefibers
Marginal sinus
E Structure of a lymph node a Lymph circulation, b blood supply to the lymph node. Lymph nodes are small filtering stations located in the course of lymphatic vessels and are components ofthe specific immune response (they contain T- and 8-lymphocytes). Regional lymph nodes are distinguished from the collecting lymph nodes that receive lymph from multiple regional nodes. The lymph enters the lymph node through multiple afferent vessels. As the fluid passes along the various lymph sinuses to the efferent vessels, It comes Into contact with the lymph node tissue over a broad surface area. From outside to Inside, a lymph node con-
Seoondary follicle
b
Gapsule
Marginal sinus
sists of the cortex, paracortex. and medulla. The numerous secondary follicles in the cortl!x fonm the 8-lymphocyte region, and the lymphocyte-rich areas between and below the secondary follicles are the T-lymphocyte regions (parocortv:). Lymphocytes leave the bloodstream in the high-endothelial postc.apillary venules of the T-lymphocyte region; then, after differentiating, they leave the lymph node with the draining lymph via efferent lymph vessels, which often become the afferent vessel of another lymph node of a lymph node group.
51
Generol Anatomy - - 7. The tymphtJtlc System and Glands
7.2
Exocrine and Endocrine Glands
A Development and classification of glands Glands are epithelial aggregations of highly specialized single cells (goblet cells, multicellular intraepithelial glands) or oflarger cell groups that have migrated to deeper levels. Their function is to synthesize and release secretions. Glands fall into two main categories:
• Exoalne glands (e.g., salivary glands, sweat glands): These glands release their secretion emmallytothe skin or mucosa, either directly or through excretory ducts. • Endocrine glands: Their secretions (in this case hormonal messen· gers) are released Internally, i.e., into the bloodstream, lymphatics, or intercellular spaces. Endocrine glands do not have excretory ducts (see F for mechanisms af hormone release). Once released into the bloodstream, the honmones are distributed throughout the body and are transported to their target cells, where they bind to specific receptors and eXl!rt their effect
Multicellular lntr.leplthellal gland Goblet cells
Endocrine gland without a fulllde
Exocrine gland
Afferent blood,.,ssel
Elu:ll!tory duct
Endocrine gland wtthafolllde
Epithelial cells
Afferent blood vessel
Foilide
Pinched-offsecll!tlon
(!j:J
ccl
~ Bulging membronebound secretion
cJ
Membrane-bound secre!Dry"""lcle
Tronsfom1atlon of the glandular cellln!Dthe seaetion
r:r-1 ~•---
Ml • • cQ \~-
.
Golgi apparatus
r)
t
Secll!toryvesicle
a
~
..
•
B Medlanlsms by which exocrine glands release their secretions (light-microscopic scale) • Emcytosls: In this mechanism, the secretion is released without an enclosing membrane (merocrine or e<:crine secretion). The mem· brane-bound vesicles containing the secretion fuse with the api· cal cell membrane and discharge their contents to the outside with no loss af membranous material (the secretory mechanism of most glands, see also C). b Apocytosls: The membrane-bound vesicles form a bulge in the apical cell membrane and are finally pinched off by it (apocrine secretion). The pinched-off secretory products are enclosed within a membrane. This mechanism is necessary in the secretion af fats. The membrane encloses the fats and keeps them emulsified (e.g., scent glands, mammary glands). c Holocy!Dsls: In this mechanism the entire glandular wl disintegrates and becomes the secre!Dty product (holocrine secretion). As a result, the glandular cells must be constantly replaced by a basaln!generative cell layer (e.g., sebaceous glands in the skin).
52
..
Absorption
Rough endoplasmic reticulum
of compounds
from the blood
C Production and release of secretions by exocytosls (electronmicroscopic scale) After the glandular cell has absorbed essential compounds from the blood and synthesized necessary materials such as secretory proteins In the rough endoplasmic reticulum (a), the secretions are transported by the Golgi apparatus (b) to the apical part of the cell, where they are discharged by exocytosis (c).
Genertll Anatomy - - 7. The lymphatic System and Glands
D Principal sites where honnones and hormonellke substances are fonned Hormones are vitally important chemical messengers that enable cells to communicate with one another. Usually, very small amounts of these messengers act on metabolic processes in their target cells. Different hormones can be classified on the basis of their: • • • •
site offonnatlon, site of action, mechanism of action, or chemical structure.
Examples are steroid hormones (e.g., testosterone, aldosterone}, amino add derivatives (e.g., epinephrine, norepinephrine, dopamine, sero· tonin}, peptide hormones (e.g., insulin, glucagon}, and fatty acid derivatives (e.g., prostaglandins).
Prlnci(NIIltes d fvnnlltlon
Pituitary
(ante~orand ----...:~---- Pineal gland
posterior lobes) Parathyroid glands
Adrenal glands
------<(tf---- Thyroid gland
- --7---,
~-"' >'.J;.~:'Ji!'----- Islets of Langemans Y.'
in the panCTI!iU
/J..,---7-- - Ovaries
Hormones1nd hanwn.... ,....._
Oauic encloaine hormon.r glands Pituitary gland (anwior and posterior lobes)
Pineal gland
ACTH (adrenocorticotropic honnone, corticotropin) TSH (thyroid-stimulating hormone, thyrotropin) FSH (follld~stlmulating hormone, follltropl n) I..H (luteinizing honnone, lutropin) ~(somatotropic hormone. somatotro· pin) MSH (melanocyte-5timulating hormone, melanotropin) PRL (prolactin) ADH (antidiuretic hormone or vasopressin) Oxytocin (formed In the hypothalamus and secl@ted bytf1e posterior pituitary)
E Ovenllew of the human endocrine glands The diffuse or disseminated endocrine cell system (Individual endocrine cells dispersed among the cells of the surface epithelium) In the gastrttintestlnal tract Is not shown.
rmonerelease
nto capllla~e•
•
Melatonin
Thyroid gland Thyroxine (T4) and triiodothyronine (T3) C cells oftf1e thyroid gland Calcitonin Parathyroid glands Parathormone Adrenal glands Mlneralocortlcolds and glucocortlcolds Andnogens Epinephrine and norepinephrine Pancreatic Islet cells (Langerh;ms cells)
Insulin, glucagon, somatostatin, and pancreatic polypeptide
Ovary
Estnogens and progestlns
Testis
Andnogens (mainly testosterone)
Placenta
Chononic gonadotropin, progesterone
Hormone-producing tissues and single cells Central and autonomic nervous system
Neuronal transmitters
Parts of the diencephalon (e.g., the hypothalamus) System of gastrointestinal cells in 1he Gl tract cardiac atria
Releasing and Inhibitory hormones (llberlns and statlns) Gastrin, cholecystokinin, secretin
Kidney
Erythropoietin, renin
Atrial natriuretic peptide
Uver
Anglotenslnogen, som01tomedlns
Immune org;ms
Thymus hormones. cytokins, lymphokines
Tissue hormones
Eicosanoids, prostaglandins, histamine, braclykinin
b Hormone releo~se Into the intercellular space
c
d Hormone release as tl'illnsmitters
Released Into
caplllarle••• neuromodulators
F Types of honnone-medlated Information transmission The endocrine system is closely linked to the autonomic nervous system and Immune system In terms of Its biological tasks. It functions as a kind of wireless communication system that coondlnates the functions of target tissues and target organs, which may be located at distant sites. il Pilrilcrlne nd ilutoatne secretion: The hormones are not released into the bloodstream but into the intercellular space. Hence they act only in close proximity to their site of synthesis. b Endocrine seawtlon: The hormones are synthesized and released into the bloodstream (fenestrated capillaries). c Neurocrine secretion: Honnones of the neurocrine system (neu· rutransmitters) act in the form of synaptic transmitter substances and are concerned with local information transmission. d Neurosecretion: Hormones or neuromodulators (neurohormones) are produced in specialized nerve cells and released to blood vessels in neurohemal regions (e.g., the pituitary). This enables them to act on distant organs.
53
8.1
Development of the Central Nervous System (CNS)
_
_.......__ _ _ Tell!ncl!phalon
Mes1!nCII!PhiiiX'I
• Telodlen· -----,. -~
aphallcwlcus
Telenajlhalon
+-- - - Medulla
ablonga!a
d
b
A Dewelopmentoftflelnln ;a
Embryo with a greatest lmgth (GL. see p.4) of 1Omm, ot th! fit<.. g/ootng of the 5f!C01Id month of de\telcpment. Even at !his stage we an see !he differentiation of!he ntllr.alllibe Into segments lhatw111 gmerate various br;in regions (l;ee C): • • • • • •
Medulla oblongata (gr.ty) Pons (gr;ry) Cerebellum (light blue) Mldlmaln (mesencephalon, dark: blue) Interbrain (dienceph~lon, yellow) Forebriln (telencephalon, red)
Nok: The telmcephalon g!Wil over all the other brain structures iS
development pro~s.
B Bratn vesldes and their dertvlttvK The crani~l end of !he neur;l tube exp~nds to form three prlm<~ry brain vesldes: the forebriln (prosencephalon), !he midbrain (mesencephalon), aAd the hindbrain (rhombena!pha· ion). The forebriln (telencephalon) and Inter· briln (diencephalon) develop from the prosencephalon. The mesencephalon gllles rlse to the superior aAd inli!rior colliculi and nelatecl structures. The rhombencephalon different!· ates lnm !he pons, arebellum, ind medulla oblongm. The pons .and arebellum are .also known CQI!ectively .., the rnetmcephalon. Some Important structures of the adult brain are llstecl at far right to Illustrate !he derfva· twes of the brllln vesldes. They can be trued bick in the diagram to their developmmtal precurwrs.
54
b
EmbryowithaGLof27mm,tlf(lrtht:endofthe~montho/c/C'IIel
opment (end of the embryonic period}. The olfactory bulb Is devel· oping from !he telencephalon, Pirt of the pituitary anlage (neuroh)<pophysiS) from !he diencephalon. c Fetus with a GL of 53 mm, in approximal!!ly the thinl month ofc/C'IIelopment. By this time the telencephalor1 has begur1 to overgrow the other briln ireis. The Insula Is still on the SIJrface but will su~ quentiy be CCMn!d by the cerebral hemispheres (camp
General Anatomy - - B. General Neuroanatomy
C Development of the nervous system: cross section through the neural tube, neural crest, and dorsal ectodenn During development, the neural groove folds away from the overlying dorsal ectoderm and closes to form the neural tube. Cells migrate from the lateral portions of the neural groove to form the neural creston each side. The centra/ nervous system (brain and spinal cord) develops from the neural tube while the peripheral nervous system develops from derivatives of the neural crest (seep. 56).
Roof plate
- - - - , f - - Lumen of the neural tube ~---:,.___ _
Neural tube
Roof plate
Alar plate _,__ _ _ White matter
Alar plate
Zone af autonomic
Posterior
neurons
f
Zone of autonomic
r~~::..~:::--t-- Lateral hom
neurons Basal pl;rte ~--=----
-f---'1--- (dorsal) hom Anterior
---,1-+-- (ventr.~l) hom
Basal plate
'--'.?'7'---
Floor plate
'---:;;r'----
Floor plate
Centr.~l canal
b
D Differentiation of the neural tube In the spinal cord region during development Cross section, cranial view.
a Early neural tube, b Intermediate stage, c adult spinal cord. The neurons that form In the basal plate are~ (motor) neurons, while those that form In the alar plate are afferent (sensory) neurons.
Somatosensol)' nudearcolumn
The area between them-the future thoracic. lumbar and sacral cord-Is another zone that gives rise to preganglionic autonomic neurons. The roof plate and Hoor plate do not form neurons. A knowledge of how these neuron populations are distributed Is helpful In understanding the structure of the hindbrain (rhombencephalon, see E).
Somatosensory
Visceromotor
nuclear column
nudec~rmlumn
\
Viscerosensory nudearcolumn VIsceromotor nudearcolumn
SomiltomDIDr
VISC!!rasensory
Somatamotor
nudear column
notochord
noclearcolumn
E Embryonic migratory movements of neuron populations and their effect on the location of the aanlal nerve nudel Cross section, cranial view. (Visual aid: If we compare the spinal cord to a book. it would be closed in a and open in band c.) a In the Initial stage the motor neurons are ventral and the sensory neurons are dorsal. The arrows indicate the directions of migration. b In the early embryonic stage, the neurons of the alar plate migrate laterally and ventrally.
c In the adult brain (medulla oblongata and pons, derivatives of the rhombencephalon) we can distinguish four nudear columns (after His and Herrick) that contain functionally distinct cranial nenre nuclei (from medial to lateral): I . Somatomotor column (lilac) 2. Visceromotor column (orange and green stripes) 3. Viscerosensory column (light blue) 4. Somatosensory column (dark blue)
55
Gltneral Anatomy - - B. Gltnaal NeuroaiHif:Dmy
8.2
Neural Crest Derivatives and the Development of the Peripheral Nervous System (PNS)
A Developmentoftfleneul'illcn!rtc:els At three weeks' development. the notocholll Induce~ surf'lla! ectodenn in the medial embryonic disk to thichn and form the neul'ill pl;ate (neu· roectodenn). The neul'ill platedlffa'entlates to form lfle primordia of the ne!'VOus system. Neur.rl folds are raised on each side of the neur.~l plm, and a median grocwe delll!lop~ between them-the neur.rl groove. Tills grocwe subsequently deepen$ and dos;es to form the neural tube. wnicb slnksbelowlheectodmn. Portlonsofthefoldslhatdonotcontr1buteto neural tube formation dlffi!fen1!m to form the ne4Jrill cl'l!$t. While neurill crest cells in the future he.ad n!gicm start to migrate I!VI!n before the neural tube Is closed, crest migration In the trunk Is delayed until tube dosure. Cells destined to form the neural crest detich from the ectodenn at the fusing margins of the neural tube ;md undergo ;m ft)Jtheflomestndlymol trar!SitiM, diving into underlying mesodenn, where they begln a long and tortuous migration. As the neural tube dlffi!fentlates Into the centr.-all'lef\'OUS system, mlgr.-atlng neur.1l ae~t cells settle In dlf· ferent locations ilnd di!VI!Iop Into sensory and ilutonomlc gilnglla, endocrine gl;ands, melanocytes, cartilage, and other structure$ (see Band C) (ifta' Wolpert).
Epldennls
8 Ml!ln mlgi'MOryprilwi!IYUnd
dertlliltMs of the I'IIUI'ill cl"'llt (ifter Oulst .-and Wachtler) Neurill crestallsorfglnilted Indifferent ll!glons have difl'ell!ntmigr;~tion paths and fates. Thine from aanlilllevels contribute to cartilage and bone In the head and neck, ;md to cranial parasympathetic gilnglia (see C). Those fn:Mn thl)o r.rcolumbar levels do not become skeletal cells, but gesmm perlpher.rl neurons. endoafne ails, melanoc:ytes, .-and Schwann cells. This diagr.am shows the migratior\ of the neu· r.~l crest cells In tM trllnk r:1( lfle earty embryo (four weeks' development. see p. 7). They follow three main mtgmory ~
Thus. the neural crest can develop Into a v~rf· ety of seemingly unrelated nonneuronol cells as well is peri'pher.al ganglion ails. These unusual characteristics of the neural crest-¢J pluripl)o tentlal capacity and wfde·ranglng migrationh.-ave Glllsequences vmen Its dllferernlatlon or mlgr.atlon Is defect!~. Disruption of neur.~l crest development m;ay deprllle organs of their aut:onomk: lnnerv.ttlon (Hirschsprung disease). Tumors clelfved from neur.al crest ails IJ!nd to be highly malignaAt and diffiCUlt to trut. (See D.)
56
Gangloblasts S)mpa1hetlc p>91cn anlaoe '~'r-:.-...~.=-'-----t:--4--+-
Melanoblasts
Adl'l!nllanll!lf
Genenil Anatomy - - 8. General NeuroanciiDmy
D D11- ofna~1111 Cftlt delfnltw1 (teleded eumplel)
'*-
......CNit
..
•
C N. . .l ClWit d•m.tlwlln th• '-d and narwglan Besides the equlwlents oftfle structures named In 1 (such~ melanocyta), otherstnlctu~s in tfle heild and neck ~gion that originate frGm the cranial nam1l aert Include saletil, artllaglnous, and desmal musdH.
era nlal neur.lll crest derhi.Jtlloti In tfle adult slalleton: facia I bones, hyoid bone, portions of the thyroid artllllge. b Mort of the faclal.sldn Is derfVed frGm the neural crest. a
P~vlsceral
~
gongla
(mallgnantchldhood tumar)
~-~
Hlrschsprung . . _ (agan9lonkallon)
Glial mls (sm-.. .....
~
md~mls)
(lleddlnghaustn dlstlst)
MeLanocytes
Malignant mellncma,alblnlsm
Adre111l medulla
Pheothromocytoma (.clren~lgl•nd l!.lmor)
Endoclfne cells of the lung and
Clrdnolds (malrg111nt l!.lmors with 111docl1not actMty)
heart
Par.folllculumlls (C czlls) of the thyroid gLand
~>..!---
DDtulroat (Jplnol)gargllan
Spwllrg lfrlnnt
-··of
the do!YI roat In tile donal roat (splnall!l'•!l.,"
~~---- Spwllllg~
-••ofthe wntnl IOCit
..
Medullary thyroid cardnoma
E Dtwlapment of 11Nfiph1111lnerw Afferent (blue) and ~nt (red) UDns sprout ~ 1\"om the neuron somata during e<~rly dewlopment (1). Primary afferent (.Hilsory) neurons delll!lop In the dorsal root (spinal) gangliOn, and prlrNry motor neurons dewlop from the basal plate of the spinal cord (II). llllfmfWOIIS (blxlc), whldl connect .Yn-
sory gqlion and motor nturOns,
d~lop
Later.
M,ollnud ftbor ~mobr
or sensory)
F Structurw of il pertpheral .,....,.
A periphert I netve (1)11Sirts entirely of axons (also called neurltes) and sheath tissue (Schwann cells, flbrobllrts, blood vessels). The alCOns tn nsmlt Information either from the perlpherytotheCNS (affttents) orin tfle opposite direction from the CNS to the periphery (rfl'mnb). AlulnsrNy be lll)'ellnated or unmyellnmd. The l~r hive a much slower COilduction velocity and 1re usually fibers of the autonomic n«Wus system (see p. 73). Among tfle inwstlng layers of the neM!, the perifleurlum ensh..ths the nerve fasdcles 1nd provides an lmpoi'Unt tissue ban1er (seep. 71)
57
8.3
Topography and Structure of the Nervous System
7
..
<(
,~
fonlmr ..
"'-
Spln;JI!)I"gh
Spinal nerves
~----Wm~l----~~------
plexus
b
A Topog111phyofthe Ml'\llllllsydl!m • Poro!ri~rview, b right l;ater;llliew. The otnttol ni!!Wus S)'5trm (CNS). consisting of the br.1!n (mcephaton) and spin.. I cord. Is shown In pink. The perlpherol nMIOUS sys!l!m {PNS), consisting of ne~WS ind ganglia, Is shown In yellow. The nerves artslng from the spinal cord !~ their bony an.1l through the i~l foramina and are distributed tothetr tuget organs. The sp1mJ1 nt'M'S are
58
formed in the far.amina by the union of their dana! (postzriar) raol3 and ventral (~nterior) raou (5ft p. 63). The small spimllgangfian in the inn!r· vertebral for; men .1ppe.;1rs iS a slight swelling of the donal root (visible only In the posterforvfew; Its function Is desafbed on p. 64}. In the limbs,1heventrat r.1m1 ofthe spin.. Inerves come together to form plexuses. These plexuses then give rise to the peripher.~l nerves that supply the limbs.
General Anatomy - - B. General Neuroanatomy
Ill IV
.~~~±.=~
~~,....,....::...--+-- VII
Front.>IJcronlal/ oral/rostral
Oaipital/ cau~
VIII XII
IX
XI
X
B Spln•l nerves and cranial nerves AntErior view. Thirty-one pairs ofspinal ne~Ws arise from the spinal cord in the PNS, compared with 12 pairs of cranial neM!s that arise from the brain. The cranial nerve pairs are traditionally designated by Roman numerals.
·-
a... lf-trol
Ventral/
Couct.l
D Tenns of location and direction In the CN5
Midsagittal section, right lateral view. Nate two Important axes:
The horizontal axis through the diencephalon and telencephalon.
Keep these reference axes in mind when using directional tErms in the CNSI
Joints, sldn,
5lc*tal
skeletal muscle
muscle
./' Somotosensory
Somotomotor
fliers
fibers
/ CNS
Afferents
Efferents
./' Visa!rDSOI\50ry fobers
/ C Loc~tlon •nd deslgn.tlon of spln•l cord segments In relation to the spln•l c.nal Right lateral view. The longitudinal growth of the spinal cord lags behind that of the spinal column, with the result that the cord extends only about to the level of the first lumbar vertEbra (L 1). NotE that there are seven cervical vertebrae (C1-C7) but eight pairs of cervical nerves (C 1-CS). The highest pair of cervical nerves exit the spinal canal superior to the first cervical vertebra. The remaining pairs of cervical nerves, like all the other spinal nerve pairs, exit Inferior to the cervical vertebral body. The pair of coccygeal nerves (gray) has no dlnlcal Importance.
VIscera, \OI!SSOis
V15aromotor fibers
"-... Glonds, smooth muscle, cardiac musde
E Schem.tlc representation of information flow In the nervous system The information encoded in nerve fibers is transmitted either to the CNS (brain and spinal cord) or from the CNSto the periphery (PNS, including the peripheral parts of the autonomic nervous system, seep. 72). Fibers that carry information to the CNS are called afferent fibers or afferents for short; fibers that carry signals away from the CNS are called efferent fibers or ~Is.
59
Generol Anatomy - - B. Generol NeuroanGtomy
Cells of the Nervous System
8.4
Receptor
Tennlnal
Transmission segment
segment
Dendrite
Nudeus
Nucleolus
Mlto-
segment
~---A----~~----------A---------~~
Soma
Dlr&llon of transmission -
..,_'·-.::::::::~_--,
.
\, \,
',,
'
' ~ o _ : _ j <[~\~W l:'"":_rj~
Membrane
potential
'
~1-H
__-_--__
Exdtatory posbynaptlc
Inhibitory
Potentlalatthe
posbynaptlc
axon hillock
potential (EPSP)
potential (IPSP)
A The nei'VI! Cl!ll (neuron) The neuron Is the smallest functional unit of the nervous system. Neurons communicate with other nerve cells through synapses. The synapses that end at nenll! cells usually do so at dendrites (as seen here). The transmitter substance that Is released at the synapses to act on the dendrite membrane may have an excitatory or Inhibitory action, meaning that the
Action potential
transmitter either Increases or decreases the local action potential at the nerve cell membrane. All of the excitatory and inhibitory potentials of a nerve cell are integrated in the axon hillock. If the excitatory potentials predominate, the stimulus exceeds the excitation threshold of the neuron, causing the axon to fire (transmit an impulse) according to the alior-nothing rule.
C Basic fonns of the neuron and Its
functionally adapted wrlants The horizontal line marks the region of the axon hillock, which represents the initial segment of the axon_(The structure of a peripheral nerve, cansisting only of axons and sheath tissue, is shown on p. 57.) a Multipolar neuron (multiple dendrites) with a long axon (= long transmission path). Examples are projection neurons such as alpha motor neurons In the spinal cord. b Multipolar neuron with a short axon(= short transmission path). Examples are interneurons like those in the gray matter of the brain and spinal cord. c Pyramidal cell: Dendrites are present only at the apex and base of the tridrntall! cell body,
60
Golgiar>paratus
Rough end<>plasmic reticulum
Neurotubules and neurofllaments
B Electron mlaoscopy of the neuron Neurons are rich In rough endoplasmic reticulum (protein synthesis, active metabolism). This endoplasmic reticulum (known also as Nlssl substance) Is easily demonstrated by light microscopy using cationic dyes, which bind to the phosphodlester backbone of the ribosomal RNAs. The distribution pattem of the Nlssl substance Is used In neuropathology to evaluate the functional integrity of neurons. Neurotubules and neurofilaments are referred to callectively as neurofibrils in light microsopy, as they are too fine to be identified as separate structures under a light microscope. Neurofibrils can be demonstrated in light microscopy by impregnating the nerve tissue with silver salts. This is of interest in neuropathology because the clumping of neurofibrils is an important histological feature of Alzheimer disease.
and the axon is long. Examples are efferent neurons of the cerebral motor cortex. d Purkinje cell: An elaborately branched dendritic tree arises from a circumscribed site on the cell body. The Purkinje cell receives many synaptic contacts from afkrents to the cerebellum and is also the efferent cell of the cerebellar cortex. e Bipolar neuron: The dendrite branches in the periphery. Examples are bipolar cells of the retina. Pseudounipolar neuron: The dendrite and axon are not separated by a cell body. An example is the primary afkrent (-first sensory) neuron in the spinal ganglion (see p.63)-
Genenil Anatomy - - 8. General NeuroanciiDmy
Pla)'lllpiiC
membnne Synaptic deft -----l.;ll!!!:!!~ Pasls)'nlpllc membnne
D ~pUc ~nwln a11111llen~up llfMui'CII1I AxDns Ciiln termlnilte It various sltl!s on the target neuron ~nd form synap<~es ~.The synap1k patlem$ •ne described as PUdendritk. ~nnltlc, or uoaxonal. Axlldendrltlc synapses are the most common <-also A).
E Elac:lnln mbwoDpyllfiJillpt•ln dw CNS Synilpses are the functioN I connecl1on between two neurons. They consist of a pnesynaptic membrane, a synaptic deft. and • postsynaptic memb1'1!1ne. In a spiM syrH1fR ( 1), the presyna ptlc knob (bouton) Is In contact With a speclallzl!!d protuberance (spine) of the target neuron. The skle-~de synap<~e of an 1*111 With tile flit sumce of a target neuron Is ailed il p;1 rillel contact or boutoo ffl ~ (2). The vesicles in the presynaptic expa nslon mntain tile neurolr.l nsmittlers that ilre released Into the syN ptlc deft: by exocy!Dsls when the iliOn tlres. From there the neu rolr.lnsmlttJ!rs diffuse to tile postsyniptlc memb1'1!1ne, where their receptors 1re loCited. A variety of drugs and taxIns ilct upon synaptic trilrumlsslon (antidepressants, muscle relilllilnts, toxic gases, botulinum b»dn).
•
Flbrtl•ry •Jirocytlo
G Sum-rr. cells ofthe cws aniiii'NS and theirfundi-' lmporbnce
Impulse fonn.tlon 2. 1mpulse c:onducl1on ). Infonnllllon pnx:aslng
1.
Gill ails b
Astrocyll!5 (eNS only)
1. Maintain 1 constant Internal milieu
lntt.CNS 2.
F Cells Dillie neuroglia In llle CNS Neurogli
CA~ntrfbute to the structure ofthe blood-brain blrrl•r (see p. 71)
l. PhagocyUa dud synapses
-4. Form scar tfs:sue In the (Jj$ (1.g.. In multiple sclerosis or following 1 strolal)
Cell nuclei demonstnted with 1 biiSic min.
It Cell body demonstrated II¥ sllwr Impreg nltlon. Mlclllgllil ails (CN5 only)
Phagocytosis ("maaoph1ges ofthe brlln")
Ollgoclendrocyl2s
~In Jhnth for...-Jon
In t~ CNS
(CNSonly) .sm-nn ails (PNS only) ~Cillls(PNSonly)
M,-lln shnth farrNtlon In t~ PNS ~ SchwiM eels; surruund the
011 body tA MUrons In PN5 gallglli
61
General Anatomy - - B. Genervl Neuroonatomy
8.5
Structure of a Spinal Cord Segment
[)orgj (posterior) mot
(function: sensory)
Vontral (onttrior} root (function:
Spin•lnene
motor)
Sympathetic ganglion
t..tl!ral cutaneous branch - - -it-'
wltfl dorsol brand! (1)
and ventral branch (2)
Anterior cutaneous brand! with lateral brandl (1)
•nd ........ branch (2)
A Sbudlll'l! ola spinal cord segment with Its ipiMinerw
Superior view. The spinal cord is made up of 31 consecutive segments arranged one above the other (see B). A W?ntru/ root (anterior root) and a doisal root (pomrior root) emerge from the sides of each segment. The wntrol root consists of qfermt (motor) fibers, while the doria/ root con· sists of a~rt!nt (sensory) fibers. Both roots from one segment unite in the intervertebral foramen to form the spinal nerw. The afferent (sen· sory) fibers and efferent (motor) fibers intermingle at this junction, so that the branches into which the spinal nerve divides (see below) con· tain motor and sensory elements (except for the meningeal ramus, which Is purely sensory). This division into branches (rami) occurs shortly after the dorsal and ventral roots unite to form the spinal nerve. Consequently, the spinal nerVI! itself is only about 1em long.
62
The prindpal branches of the spinal nerve have the following functions: • The ventral ramus innervates the anterior and lateral body wall and the limbs. • The dorsal ramus Innervates the skin of the back and the intrinsic back musdes. • The meningeal ramus reenters the spinal canal, providing sensory innervation to the spinal membranes and other structures. • The white ramus communicans carries white (• myelinated) fibers 10 the ganglion of the sympathetic trunk. • The gay ramus communicans carries gray (= unrnyeinated) fibers {rom the sympathetic ganglion back to the spinal nerve (the functional significance of this is described on p. 73). The dorsal and ventral rami of the spinal nerves subdivide into further branches.
CieneniiAncrfumy - - S. CiltneniiN«
8 Sph11 cord sesment • An!l!l1or 'Yiew, demonstralfng the st.1cked arrangement of tbe spinal cord segments. The spinal nerves and their root5 are pictured only on tbe left side. b Antel1or W!w, demonstrlltlng the spatial extent of one segm~nt along the spinal cord. The diagram Illustrates the wrlfcal arrangement of !he spinal •roottets• (root filaments), which combine to form Ute wntral and dorsal roots of th~ associated spinal nerve.
~~1-----+--~-
splnal rootlets
•
~I ~~~~.._
__J ___
....-----!--+-
v.1!tb! l'llllliiS axnmunlans
'k .:.e-r--
Cirll'fl'lmUJ axnmunlans
I'oslmor
(donal) hom
C Topogr..phkill ;md fundkln.1l org;~nlziltkln of ;a spln.1l a~rd
Lmral hom
segment • The offennt fibers &om the .slcin, muscles, and joints {somatGslti.IOJY, blue) and from the 'Ylscaa ('Yisai"O.Il'II.IOJ)', grnn) pass through the dorsol root Into the spinal cord ;md tennlnm In !he posterior hom. Both flbti's artse from pseudounlpolaralls 11'1 the donal root {spinal) ganglion. • The f(ffnlm fibers for the skelet.~l musculature (somatomotor, red) and for Ute llfsc:era (lltsc:efomotor, brown) pass Utrough the 11'1!1!1.Tc!l mot tD the mrresponding end organs, which coruist of the sla!letal muscles and the smooth musde ofthe Internal 01gans. Theflben dlf· fer II'IUtdr orfgln: Flbti's for Ute skelet
--=lf-:::3-- Antlel1or
~~
63
Generol Anatomy - - B. Generol NeuroanGtomy
8.6
Sensory Innervation: An Overview Alar plate ,\ l:i'E;o!--
Cutaneous
Sensory dorsal root
Spinal netve In the lnteM!rtl!bral Pl!rlpheral Cutaneous folilmen nerve nerve
Maximum area supplied by a cutaneous nei'VI!!
recepto,..
Skeletal musde Bosolplob!
with motor
OW!rlapplng u.rrttortes of
ondplob!s
two cutaneous nerves
A Embryological origins of the topographlc:.~~l and functional anatomy of a spinal cord segment The afferent fibers (e.g., from cutaneous receptors) pass through the dorsal root into the posterior horn of the spinal cord, which is derived embryologically from the alar plate. The efferent fibers arise from neu· ronslocated in the anterior horn of the spinal cord, which is a derivative of the basal plate. They leave the spinal cord by the ventral root and are distributed to their target organ, such as a skeletal muscle.
C Plexus formation, Illustrated for the brachial plexus The period of embryonic development is characterized by a migration and intermixing of ventral musde primordia in the limbs. As the muscles migrate to the limbs, they take their segmental innervation with them, resulting in a complex intermingling of axons (plexus formation). Since only the ventral musde primordia migrate into the limbs, only the ventral rami of the spinal nerves are intermixed. A prime example of this process is the brachial plexus. The ventral rami from segments C5 through T 1 that form the roots of the plexus are shown in different colors. First the C5 and C6 roots unite to form the upper trunk of the plexus. The fibers from C 7 form the middle trunk, and the fibers from C8 and T 1 unite to form the lower trunk. The anterior branches of the upper and middle trunks then unite to form the lmrol cord, while the anterior branch of the lower trunk forms the medial cord and the posterior branches of all three trunks combine to form the posterior cord. Finally, the cords of the brachial plexus give rise to the major nerves that supply the arm and shoulder.
64
B Course of sensory fibers from the dorsal root to the dermatome Sensory fibers pass from the dorsal root to the intervertebral foramen, where they unite with motor fibers to form the spinal nerve. The sensory fibers are then distributed to the ventral and dorsal rami of the spinal nerve. The simple segmental arrangement of the sensory territories that occurs on the trunk is not found in the limbs (see D). This results from the migratory movements of various muscular and cutaneous anlages (precursors or primordia) during the development of the limbs. Because these anlages carry their segmental Innervation with them, the sensory fibers from different segments become Intermingled In the limbs (plexus formation, see C). After Hbers have been exchanged In the plexus, the Hbers In peripheral nerves are distributed to their destinations, their terminal portions often consisting entirely of sensory cutaneous nerves. The area of skin that Is Innervated by one spinal cord segment Is called a dermatome. The dermatomes of adjacent spinal cord segments are often located so close together that their territories broadly overlap. This explains why the clinically detectable area of sensory loss caused by a segmental nerve lesion may be considerably smaller than the dermatome Itself. The area that receives all of Its sensory supply from one cutaneous nerve Is called the autonomous area of that nerve. When a segmental nerve lesion occurs, the cutaneous nerves from the two adjacent spinal cord segments are still available to supply at least the peripheral part of the affected skin area. This helps in understanding the difference between radicular(- segmentol) and peripheral sensoryinnerwtion. When a nerve root becomes damaged (e.g., due to a herniated intervertebral disk), the resulting sensory loss will follow a radicular innervation pattern (see p. 66). But when a peripheral nerve is damaged (e.g., due to a limb injury), the sensory loss will conform to a peripheral innervation pattern (seep. 67).
CieneniiAncrfumy - - S. CiltneniiN«
D Simplified tdlernefor le.limlng the dermftomes The distribution of dermiltOmes on the human limbs !'HUlts from the sprouting of the limb buds thatocom during embryonic dewloprnent. When !he limbs ~repositioned at right ~ngles tD the body as In a quad· ruped, it is ~$ier to appreciite the pattem of denn;atomit innel'"llition (ilfter Mumernhaler).
65
8.7
Sensory Innervation: Dermatomes and Cutaneous Nerve Territories
a PaUem of nuclear sensory lnnenmlon In tile had region The head recellleslts sensory 1nnervat1or1 from the trigeminal nerve (aanial nervi! V). A lesion of the serJsory nudeus of the trlgennlr~al nerve within the bralr1 (= centt.-alle.slon} a uses .-an onlon·sld'n pilttem of sensory alter.iltlon along the mncentric Sllldl!r lines that em:irde the mouth and nostrils. The pilttem of these llnes coJTesponds to the dlsiJfblltlon of the neurons In the sensory nLJde~.~s of the trigeminal nen~e (somawtopic organization, i.e., c:ert.'!in groups of ne\lrons In the CNS are linked to cer· taln terrltol1es In the periphery). Ten!tory 1 Is supplied by the cranial nuclear columr1, ten!· tory 2 by the middle column, and teninlry 3 by the caudal column. This p;n:rern ofsensory loss Is like that assocla!l!d wfth r;adlcular nel.lropil· thy affecting a pertpheral nerve.
66
CieneniiAncrfumy - - S. CiltneniiN«
c PaUI!m of peripheral sensory I'MerwttDn
lhediilgramshowsthesensoryloss pattems that are associated wllh a p«fpheral nerve lesion. Contrast the area of sensory loss caused by a peripheral nerve lesion wllh the area ilffected by a radicular nerve lesion In D(after Mumenthaler).
OphlhamlcneMe (ftrsttrlgemlnal norvedMIIon)
Ci!'NIIr -~1
neNt(O) ~------~~~------~
Olmmm
I.Ae$~r
-~1
~lli!M!
Tr.answrsenerve ctthene
D Pertphmii'Mei'VItScln oftile held and
neck Right later;al view. The are;as supplied by !he segmental cervlc.ll nerves .md the trlgemln;al nef'YI! (first lhi'GU!lh third divisions) intersect in
thls region.
67
Generol Anatomy - - B. Generol NeuroanGtomy
8.8
Motor Innervation
A Simplified scheme of motor Innervation The simplest common path of motor innervation originates in the primary cerebral motor cortex_ large neurons (dark red) contribute axons to bundles collected into massive corticospinal tracts. Many axons pass uninterrupted to the spinal cord, where they synapse upon motor neurons in the ventral horn (orange). In the brainstem the bundles of corticospinal axons are designated pyramids or pyramidal trocts. In the medulla oblongata, most corticospinal axons cross the midline in the pyramidal decussation and continue on the opposite side. Axons from motor neurons in the ventral horn of the spinal cord exit in Vl!ntralroots (p. 62) and reach their targets, skeletal musdes, via peripheral nerves, where they synapse directly at neuromuscularjunctions. The typical spinal motor neuron receives inputs from multiple sources. The simplest local circuit involves afferent (sensory) synapses from tlbers from dorsal root (spinal) ganglion cells (blue). Although most afferent Information Is relayed to spinal motor neurons through multiple Intermediate lntemeurons, some sensory Input-particularly from tendon stretch receptors-Is transmitted directly via a single synapse, as depleted. This chain of connections Is called a refll!x arc. One such arc produces the knee-jerlc or patellar tendon reflex. This pattern of motor connections Is responsible for two fundamental principles rn the diagnosis of neurological disorders. Because of their positions rn the pathway, the cerebral cortical cells are referred to as uppermotornl!urons, those In the spinal cord as lower motor neurons. Damage to lower motor neurons or their axons leads to denervation of muscles, with ~acrid paralysis and eventual muscle atrophy. In contrast, interruption of corticospinal axons or destruction of the upper motor neurons themselves, resulting, for instance, from a cerebral infarction (stroke), leads to a loss of voluntary control over the lower motor neurons. With sudh an upper motor neuron lesion, the lower motor neuron is controlled solely by local spinal circuits. local reflexes remain or are enhanced, but musdes show sustained contractions and increased tone, with spastic paralysis. The second fundamental correlation between the anatomy of the motor pathway and neurological diagnosis involves the crossing of corticospinal axons in the pyramidal decussation. Upper motor lesions that occur above (cranial to) this decussation will produce spastic paralysis on the contralaternl side of the body; lesions in corticospinal axons below (caudal to) this point will cause spastic paralysis on the same side as (ipsilateral to) the lesion.
68
.AII------''------:7-__;:j;.;-----
Upper motor neuron in the
cerebral motor cortex
V!!nlralroot
General Anatomy - - B. General Neuroanatomy
lntemeuron
Upper;~::.::': ----:;:0~~~~~--- Neuron in the motor cortex
sensory cortex
_.olr'flf--7<-:::=-"';-';-- Third sensory neuron
/ 11----,/!---
Mo!Dr
Interneuron ~r
motor neuron
B Neural clrtult for sensory and motor Innervation Left lateral view. lnfonmatlon processing In the CNS Is actually more complex than shown In A because motor innervation is influenced by
afferents of a kind not illustrated here(= sensorimotor drcuit). Although a great many neurons are active at each step in the drcuit, the diagram shows only one at each level. Sensory infonmation, encoded as electrical impulses, enters the spinal cord through a primary afferent neuron (first sensory neuron) whose cell body is in the spinal ganglion (afferent neurons shown in blue). The information is relayed synaptically to the second and third afferent (sensory) neurons, which transfer it to the sensory cortex (black). Associative neurons (interneurons, black) transmit the information to the upper motor neuron in the cerebral motor cor-
tex, where the information is modified by many associated inputs. The cortical motor neuron (upper motor neuron) redirects the infonnation to the spinal cord, where it reaches the spinal (lower) motor neuron, either directly or via interneurons and additional synaptic relays. Finally, the lower motor neuron in the spinal cord transmits the impulses to the voluntary skeletal muscle. Corticospinal projections are most direct and numerous for lower motor neurons that innervate musdes, like those in the human hand, which are often under fine control and coordinated cognitive direction. Other motor pathways, not depicted here, are more important for controlling posture and balance. Because the axons in some of these other paltlways are not in the corticospinal and pyramidal tracts, they are sometimes referred to as extropyromidal.
C Oberstelner--Redllch zone In • dors.l root
The Obersteiner-Redlich zone marks the morphological junction between the CNS and PNS (arrow). Oligodendrocytes in the CNS form a myelin sheath around the axons only as far as this zone, which is located just past the emergence of the dorsal root from the spinal cord. The myelin sheaths In the PNS are fonmed by Schwann cells (see p. 70 for details). The myelin Is so thin at these sites that the fibers appear almost unmyelinated. This creates a site of predilection for Immunological diseases such as the Immune reactions that occur In the late stages of syphilis.
69
Generol Anatomy - - B. Generol NeuroanGtomy
8.9
Differences between the Central and Peripheral Nervous Systems
CNS
PNS
Oligodendrocyte I I I \
\
\ \
\
\ \ \
A Myelrniltlon differences In the PNS and CNS
The purpose of myellnadon Is to provide the axons with electrlcallnsuladon, which slgnlflcantly Increases the nerve conduction velocity. The very lipid-rich membranes of myellnatlng cells are wrapped around the axons to produce this insulation. Schwann cells (left) nnyelinate the axons in the PNS, while oligodendmcytes (right) form the myelin in the CNS. Nare: In the CNS, one oligodendrocyte alwoys wraps around multiple axons. In the PNS, one Schwann cell may en sheath multiple axons if the peripheral nerve is unmyelinated_ If the peripheral nerve is myelinated, one Schwann cell always wraps around one axon.
70
Owing to this Improved Insulation, the nerve conduction velocity Is higher In myelinated nerves than In unmyelinated nerves. Myelinated flbers occur In areas where fast reaction speeds are needed (muscular contractions), while unmyelinated flbers occur In areas that do not require rapid information transfer, as in the transmission of visceral pain. Because of the different cell types, myelin has a different composition in the CNS and PNS. This difference in myelination is also important clinically. An example is multiple sclerosis, in which the oligodendrocytes are damaged but the Schwann cells are not, so that the central myelin sheaths are disrupted while the peripheral myelin sheaths remain intact.
CieneniiAncrfumy - - S. CiltneniiN«
Sdlw.lnn
«
I St.ructureofil nodlofltlnvterlnthePNS In the PNS, thenodtofRa!Merlstheslll!wlteretwoSc:flwanrlcellscome mgether. That sib! Is marked by a small gap In !he myelin she.irth. 'Which forms !he ITICirphological b;~~~is for S~J/nrroly neorw conduction. allowing Impulses to be transmitted at a hlghervelodty.
Brain milieu
l:olp11ary1011!1
Tlcj!t)lnc:llon~
llght~nc:llon
perineural epilt!ellal a!lls
I
Brain
apllary
Clplllary klmen
llght junction
Astroeytlc: proe~!S5e!
C Stn.Jc.:twe of the blood-b111ln b.lmer In the CNS ~Ides the type of myelination. there Is also a difference In tissue bar· rlers betweer1 the CNS .arid PNS. The CNSis Isolated ftom surrounding tissues by the blood-br;ain barrier. The component$ of the blood-bri!in barrier Include: (1) most lmport.antly, a continuo ~aS capillary endothelial cell layer, se<~led by tight junctions: (2} a continuous bil1allamlr~a surrcundlflg the endothelial cells; arid (3) enveloping astrocytlc precesses MJrrounding !he bri!inc:apillary. This barrier serves to exclude m;acrvmol· ecules. as well as manysmall moleaJies that are not actlvelytransported by!he endothelial cells. th~JS prc!l!c:Ur~g the delicate environment ofthe antral nerw~JS system. The barrier Is wlnerable, howeYer, tD lipid· $01uble molecule$ that un ~rse the endothelial cell membri!nes. The perineurial she<1th ae<~ll!s a similar barrier In tile PNS (seeD}.
D St.ructureoftheperir~~urf;llshNth In the PNS The perlnaJrlal she..th,lllce the blood-bralfl barrier, Is formed by tight junctions betweer1 the epithelium-like flbrcblasts (perlr~aJrlal cells; !he perineurium is described on p. 57). It isolilte$ the milieu of !he axon ftom that of the MJrrcundlng endoneural space (endoneurium). thereby prewntlng harmful subst.mces from Invading tile .w1r1. This Ussue barrier must be surmounted by drugs that are designed ta act on the a:mn, such
71
Generol Anatomy - - B. Generol NeuroanGtomy
8.10
The Autonomic Nervous System
l'ilrasympathetic aanlai!Jilnglla E}'!
Lilcrim.land ,..llvory glands
Cranial vessels
•stellate ganglion •lnfenora!nllcal ganglion andftrst
thoracic sympathetic ganglion Lung
Stomach
Liver
PancrR!Ii
lntetine Super1or mesenteric !Jilngllon Inferior mesenteric ganglion
Piorts of the colon, rectum Bladder
Sacral cord with Genibllil
A Sbuc:ture of the autonomic nervous system The system of motor innervation of skeletal muscle is complemented by the oufDnomic nen/DUS system, with two divisions: sympathetic (red) and parasympathetic (blue}. Both divisions have a two-neuron path between the CNS and their targets: a preganglionic CNS neuron, and a ganglion cell in the PNS that is close to the target. The preganglionic neurons of the sympathetic system are in the lateral horns of the cervical, thoracic, and lumbar spinal cord. Their axons exit the CNS via the ventral roots and synapse In sympathetic ganglia In bilateral poravembrol chains (sympathetic tnmb), or as single midline prwertebrol ganglia (see E). Axons from these ganglion cells course In unmyelinated bundles on blood wssels or In peripheral nerves to their targets. The preganglionic neurons of the parasympathetic system are located In ltle brain-
72
parasympathetic
} nudel (,..cral part)
stem and sacral spinal cord. Their axons exit the CNS via cranial and pelvic splanchnic nerves to synapse with parasympathetic ganglion cells. In the head, these cells are in discrete ganglia assodated with the cranial nerves. In other locations the parasympathetic ganglion cells are In tiny clusters embedded In their target tissues. The sympathetic and parasympathetic systems regulate blood flow, secretions, and organ function; the two divisions often act In antagonistic ways on the same target(see B). Although this basic dichotomy of visceral motor activity was identified early, by Langley (1905) and others, it has been shown more recently that autonomic control of various organs, particularly in the gastrointestinal and urogenital tracts, Is highly sophisticated, dependent upon feedback from local visceral afferents that relay pain and stretch Information, etc., through complex local circuits.
General Anatomy - - B. General Neuroanatomy
B Synopsis of the sympathetic: and parasympathetic nervous systems 1. The sympathetic nervous system can be considered the excitatory
2.
3.
4.
5.
Sym(>ilthet!c nerve cells ln the lirteral hom (- flrst effl!rent neuron)
part of the autonomic nervous system that prepares the body for a "fight or flight" response. The parasympathetic nervous system Is the part of the autonomic nervous system that coordinates the "rest and digest" responses of the body. Although there are separate control centers for the two divisions in the brainstem and spinal cord, they have dose anatomical and functional ties in the periphery. The principal transmitter at the target organ is acetylcholine in the parasympathetic nervous system and norepinephrine in the sympathetic nervous organ. Stimulation of the sympathetic and parasympathetic nervous systems produces the following different effects on specific organs:
Gray ramus communlans
Org~~n
(recurTent br.~nch ID the spinal nerve)
Sympdh.tk nervous system
Pensympii!Miic
Eye
Pupillary dilation
Pupillary constriction and Increased curvature of the lens
Salivary glands
Decreased salivation (sc~nt. viscous)
Increased salivation (copious, w~tery)
Heart
Elevation of the heart rate
Slowing of the heart
Lungs
Decreased bronchial secretions and bronchial dilation
Increased bronchial secretions ~nd bronchioli constriction
Gastrointestl· nal tract
Decreased secretions and motor activity
Increased secretions and motor activity
Pancre;~s
Decreased secretion from the endocrine pilrt of the gland
Increased secretion
Male sex organs
Ejaculation
Erection
Skin
Vasoconstriction, SWNt secretion, piloerection
No effect
nmmus s,sum
rate
Prevertebral ganglion with second effl!rent neuron
D Distribution of sympathetic fibers In the periphery Some sympathetic fibers in the periphery (e.g., in the trunk region) "hitchhike" on spinal nerves to reach their destinations. The synapse of the first with the second efferent neuron (red) may occur at three locations (see E).
Sympathetic - ganglion - - Parasympathetic ganglion neurons
Tilrget organ
Torget organ
C Orcutt diagram of the autonomic nervous system
The synapse of the central, preganglionic neuron uses acetylcholine as a transmitter in both the sympathetic and parasympathetic nervous systems (cholinergic neuron, shown in blue). In the sympathetic nervous system, the transmitter changes to norepinephrine at the synapse of the postganglionic neuron with the target organ (adrenergic neuron, shown in red), while the parasympathetic system continues to use acetylcholine at that level. NotP: various types of receptors for acetylcholine (- neurotransmitter sensors) are located in the membrane of the target cells. As a result, acetylcholine can produce a range of effects depending on the receptor type.
E Location of syn•pses In the •utonomlc nervous system
Acetylcholine is the transmitter for bath the first and second neurons in the parasympathetic system, but the sympathetic system switches to norepinephrine for the second neuron.Synapses of the first, preganglionic cholinergic neuron (blue) with the second neuron (red) may be located in three different sites: CD In discrete bilateral dusters of postganglionic neurons (autonomic ganglia). In the sympathetic system, these synapses are in the paravertebral ganglia on either side of the vertebral column. In the cranial part of the parasympathetic system, the synapses are in paired cranial parasympathetic ganglia (see A).
73
Trunk Wall Bones, Ligament s, and joints ..... •••••••....•••••• 76 2
Musculature: Functional Groups ............ ...... 118
3
Musculature: Topographical Anatomy ....... ..... 138
4
Neurovascular Systems: Forms and Relations . .... . 162
5
Neurovascular Systems: Topographical Anatomy ... 170
Tnrnk
1.1
wan --
J. Bona, Ugoments, ond}olnts
The Skeleton of the Trunk
RJb:s
A Skeleton of the tr\lnlr. •nterlor'llfew The skeleton ofthe !JUnk Is made up ofthe verlll!bral column, r1bs, .and mrnum. Det.alls on the n'bs and stemum are given on p. 106.
76
Tnmk wall - - 1.
Bones. UgamenB. andjoints
C T1le spinous processes 011 unomkill landmlrkll Posterior view. The spinous promm of the vertEbrae appear as variable promlna1ces bene.ntllhe sklr1 ;mel pi'OII!de lmport'lnt Iarid· marks durirlg the phyiical examination. Witb few ex.ceptions. they are easily p;~lpated. • The ~ii'IOUS proa.$$ of the seventh cervi· cal vertebra. loc.rted it the junction of the ceNfcal<md thoradc spine. Usually It Is the mast prominent of the ~inous processes, causing the seventh cervical vertebra tv be known also as the ll!l'!rblll p1001Tnms. • The spinous process of the third thoracic wrtzbra, locat.ed on a hotizont.'!l line am· nectlng the scapular ~pines. • The spinous proc::ess or the sewrnh thoracic vertEbra, loc.rted at the level of the lnfel'for ~ngles of the scapulae. • The spinous proc1e5s of the twelfth thoracic vertEbra, loc.111!d sllghUy below the attich· mentofthe lastrlb. • The spinous p~s of the fourth fum· bar vertdlra, loc.rted on a horlzontil line connecting the highest points or the lilac crests. Note: The spinous processes af the thoracic
vertl!brae are <~ngled downward (see p. 86), and so the spinous process of the fifth thoracic vertEbra. for ex.-~mple. Is at the level of the sixth thoradcvertebral body.
B Skeleton of the trunk, posterlorvtew
77
Tnrnk
wan --
J. Bones, Ugoments, ond}olnts
The Bony Spinal Column
1.2
~ AIIas(CI}
~ D«ruaf;alls (ald's•C)
~ ~~ Ms(C)
Alils(Cl)
"
r
1\'~
p-
LI--U -bra~
l Pl'omcntory
Postsfor sacral fcr.mna
• A 111e bony spiRill column a AntertorVIew, b posterforVIew, c left later.ill VIew.
78
Sacrum
c liloll!th.ilt,. ~enetlally, the transverse processes of!he lumbar vertebrae .ilne rudimentary 11bs.. They ue often known as cost.ll processes then!f'Dne (see alsop. 82).
TrunlciNall -
J. Bones,ligtfments, am/joints
CoaniCKI!IVkill /Unction
} CemC3Ispi1~
(cervlclllardosls)
Centcotllaoadc /Unction Thooadcspn• (thooadr kyphosis)
Uneofgmlty
Tboraa~lumbar
junction
) wmbar'l)lne (lumbar lonlosls)
wmbowrrol junction
},_.,
>iplne
(...,.al kyphosis)
Antor1orsuperkr lllilesplne
S...:...l•nd•
LJJmbosoroal
S...:...l promontooy, Publci)TTiphylls
..mo~body
antler of gmtty
Pelvic lndl""lon ll'lgle B Regions and cui'Yilltures of the spinal mlumn Left latEral vtew.lhe spinal column ofan adult Is divided lniD four regions and presents four ch.a radl!r1stlc curvatures In the sagittal pia ne. These curves are the result af human adaptation ID upright bipedal locomo-
tion, acting ilS springs to cushion axial loads. The following rqjions and curvatures are distinguished In the cranlocaudal direction: • Cervical spine- tft\lic:allurdosis • Thoracic spine - thoradc kyphosis • Lumbar spine- lumbar lordosis • Sacral spine - sacral kyphosis
The cervical, tnoracl~ and lumbar regions of the spinal col urn n are also known collectively as the pr~~SCICrol spirit. The transitional areas between the different regions are of dlnlcallmportai"ID! because they are potentia I sites for spinal disorders (e.g., herniated disks). Occasionally the vertebrae in these transitional areas have an atypical morphology which ldelltlfles them as !ronslllonal vertebrae. lhls Is parlklllarty mmmon at the lu mbosiKJ"ill junction, wllere saaulizrrtion or lumbarizr1rion may be seen, depending on the appeara nee of the atyplca Ivertebra. With Iumbariutfon, the first sacral vertebra Is not fused ID the sacrum and constitutes an rxtra lumbar~rtebra. With sacralization, th~ are only four lumbar vertebrae, the fifth being "saaallzed" by fusion ID the sacnJm. These osslmllatlon dl510rtkrs are often unilatEral (hemllumbarlzatlon, hemlsacraiiZ.ltfon).
C Integration of the splnill mlumn ~the pelwk: girdle Skele!Dn of the trunk with the sbJII and pelvic girdle, left latEral vtew. Normally the spinal column Is curved and IntegratEd lniD the pelvic girdle In such a way that characteristic angles are fonned between certain imaginary lin~s and axes. These angles and lin~s are useful in the rad~ graphic evaluation of positional abnormalities and deformities of the spine and trunk. Lum'*'Glll•ngle: angle formed by the axes of the L5 and S1 vertebrae, awraglng 143". It results fi"om the fact that the sacrum Is a fixed component of the pelvic ring (see p. 112) and thus contributes little ID Waightening the vertebral column. The resu It is a characteristic sharp angle at the junction ofthe presacr.~l part of the spinal column with the sacrum. Secr.ll•ngle: angle between the horlmntill plane and the superior surface ofthe sacrum, averaging appraxlmately 30'. Pelvk lndki.Uon•nglel angle fonned by the ptolvic inlet plane (connectIng the sacral promon!Dry to the upper border of the symphysis) with the horizonta I. It measures approximately 60' in upright stance. The peMc lndlnatlon angle Increases or decreases as the pelvis Is tilted forward or biiCkwa rd (see p. 131). With an IdeaI pelvic position In upright stance. the anterior and posterior superior iliac spines are at the same horizonta I level willie the a nter1or super1or Olac spl11e Is directly above the pubic symphysis. By knowing thIs, the elCilmlner can easily evaluate the posllfon of the pelvis by using palpable bony land marks. Die ol gl"illllty: The line of gravity passes through landmarks that ind ud~ the extema I auditory canal, the d~ns of the axis (C 2), the functional-anatomical transition points In the spinal column (between lordosis and kyphosis), and the whale-body center of gravity just antEr1or to the sacral prornontl:lry.
79
Dunk wan
1.3
--
J. Bones, LJgametrtl. tmd}olnrs
Development of the Spinal Column
f'Qotstor horns
Antlrlor horns
A D-lopmlnl:oflhl! 1pl1111l culutm (-elo 4-1 0)
• Schemnlc CI"'SS sedlon, H sdlem.itlc coronal sections (the plane Gf section In H Is lndl~ In ~II The fonner somltes hn<e differentiated Into the myotome. dermatome, i nd sclero!Dme. The scleromme cells sep<~rate from the other cells it four migrate to\q rd the notuchord, ;and form ; duster of mesendlymiI cells around the nollld!ord (1nlage ofthe future spinal column). c AdjKent cranlil1nd a udal sderotome segments ab~ <md beiiM the lntersegllllllbll vessels join mgether and begin to chondrify In the sixth -ek, cf;,plo~cing the notochord miteri•lsuperiorly and i.nJtoriy (notDchord segments). d The ll'ltltrWrlebra Idisks with thtfr nudeus pu lposus and arrulus ftbrosus d~lop ~en tfle rudlmentlr)' wrtebr•l bodies. Ossification begins it the anter of the vertebral bodies In the eighth week of
•>·
-Ia.
c
N"""""ord
,nth
Ncltochol'l
{noiDchord sogment)
~*=--.:...- hdplentbone fonllillon (OBI·
llallon anRIS)
d~lopment.
e By fusion of the caud1l1 nd cranial scleromme segments, the segmef'ltally arnnged mytomes Interconnect the processes of two adJacent wrtebral anl1~ bridging tfle gap across the lnteNertebr.ll disks. This Is how the motion segmfllts 11re fonned (see p. 100). The segmental spinal nerve mursas ilt the lewl of the future interver12bral foramen, ind the Intersegmental ~ssels become the nllf1fMt wSS!Is of the vertebral bodies (week 10). Clnlcal aspecb: If the neural t1J be or the dorsal portions ofthe vertebral arches fall to close normally durfng embryonic development, tfle result Is splno bifldtJ.; deft spine. In this anomaly the spinal column Is open p05teriorty and the .lf)inous proc:e.tle$ •re ;bsent (the vafiOU5 forms and manlfemtlons are described In textboola of embryology). Usuilly there Is a bllatera Idlf«t In the vertebralardtes (generally.1ffectlng the L4 and L5 region), kncMn as spondylolyJis. This defect rmy be cor.genltal or 1cqulred (e.g., due to trauma). Acquired cases are common in sports that pos:e e rtslc ohertebral •rch fractures (i<MI in throwing, gymnastics, high jumping). If tfle associated Intervertebral disk Is ilso damaged, the verteb.,l body will begin tD slip forward (spondjllu~ sis). In cues uf CWJgmilol1pOIKiylo/ysis (whim are assoc:ilted with varyIng degrees urspondylolisthesis), the slippage progresses slowlyduring growth, ;~nd the condition b!nds to stabili~ after :ZO years of "!J~.
..
ltlrmlnt Ill noiDchord
(noiDchonl segment)
Nudea pulpoous{llmaants ot.-holdJ19'1fllts)
80
Tnmk wall - - 1.
Bones. UgamenB. andjoints
Corpus ----f....:..._,.....,..9==::-'~
c:allost.m
Tongue
--~IT-
Mllndble ----1E-f\1
pn~mlnens
(C7)
a Neonml kyphosb Mlds;rglttal section through a ..-born. left: lilteral view. Owing to the curved lnt:rauter· lne position of the fl!tus. the newbcm has a "kyphotic• spinal cun~ature with no lordotic straightening of the ceme<~l and lumbar spine (.ilfb!r Rohen, Yoklx:hl, Llltjen-Drecoll).
Asa!ndlng - ---::.,--
_...
-r-•
+---.-:r--
Spnal<:onl ln-br.JI anal lhonclc:Sj)(ne
l.lwr
AdultSllhal CIOI~.mn
_...
Abdominal
l
Stomach
Thontdc kyphosis
Lumbll' spine
.,....-G-~~T--- ~I pnMllOI'JIOry
C Stn1ghtl!nlngofthespb!durfng normal development (aftl!r Dl!llrunner) The characteristic curYatures of the adult spine are only partially present In the nmorn (com· pare with IS) and appe.;~ronly during the course of postnatal dewloprnent. First ceme<~llord~ sis develops to balance the head in ~'1!.SJ~Onse to the growing strength of the posterior neck muscles. Lumbir lordosis develops later as the child learns to slt, stand, and walk. The degree of lordosis i~ses until the le!P un ~fully extended at the hips. and It finally becomes stable during puberty. A similar transforma· tron of the spinal column Is obsei'Yed rn the phyloo.ilenetic tr;nsition from quadrupedal to bipedal locomotion.
J
l
Sacrum
S)mphysls - --t--'':.'
J
f'rostirtlo--~~~~
D PhyslologJcal anwturet ofthe adult lplnllalumn
Midsagittal .section through an adult male, left lateral view.
81
Dunk wan
1.4
--
J. Iones, Ugaments, GIKI}olnrs
The Structure of a Vertebra
Spinous PI'OcaJ
Supslor
J
artlcularsulface
-:=~
/.
n:=~= Anllrlor tuberde
Veltl!bral body
l=-
prcca~
UndNIIe procas
Sptlousp,_.
rastalf.lltlltof
trtnswne prcca~
A Stnldunll..MMIIDvi il wm.bna
Left posll!rosupenor view. All wr1l!br~e exapt the ~tbs and axis (see p. 84) co!\list ofthe same INsic structurtl elemtnts; Avertebr~l body Avertebril in:tl Asplnousproce.ss Two trilnsvers:e proc:esses (tailed cost1l prvcesses In the lumiNr vertebrie) • NK!r articular processes
• • • •
b
The pnKesses give llttath ment to musdes and IIIJiments, and the bodIes of the thondc wrtebrae hlw costowrtebril joints. The wrtl!bral bodies and an:tles endose the wrtebral foramen, and all of the .wtebril forilmlna together mnstlbJte tne vertebral (spinaI) anal.
!lh~- rastal process
SUperior veNbrll notdl
----::r-511cnl anal
Mtdlon ucnl cNSt
Vtntbril body
SJ4181or artlcularsulface
I
lu!of - - - - - - - YCNm
•
.. SLpellor artlcularp""""
b B Al:allory rtlls
Superior view. 1 Cervial rib. b lumb1r rib. The presence of1nomalous c:ervltal r1bs an narrow thesulene lntavill, causing comprMSion of the brachial pluus and subclavian artzry (sca-
lenus syndrome orcavlal rib syndrome. seulso p.l17).An iltaSSIIII)' lumbar rfb. on tne otfl..-lund,lus no adwrse d lnlal ef!Kts.
82
'----~~~--~<
•urface
C Coltll elements In different region~ ofthe tplnll c:olumn Superior Ylew. The shlpund conllguriltlon of the wrtebrae ilre dasely relmd ID the di!Wiopment of the r1bs and their rudiments (Indicated here by mlor shading). il Cervical vertebr~e: Here the rudimentlry rib forms il process ailed the a nt:erlor tllberde. It unites with the posterior tubercle to form the transverse fori men. b Thoradc vertebrie: Bea use these vertdl~e glYe ilttilthment to the rtbs, their bodies and transwrse processes bear mrTeSpondlng arlllage-covered artlculu surfaces (mstill ~on the tnnsvene proasses, also superior ilnd Inferior mstill r-ts). o:: lumbtr vertebr;~e: The Clllstlll elements in the lumbar spine tilke the form of "transverse processes; wh lch 1re much l1rger th1n In the mi'Yital spine. B~tcause of their size, they 1re also lcnawn u Clllstlll processes. d Sacrum: Here the rudlmentilry rib farms the 1 nt:erlor portion of the la~l part f# the saoal vertebr•. It is fused to the tr•nsvvse processes.
Tnmk WGII - - f. Bom!s, Ugti~M~~ts, andjoints
D Typkiill w1111ne fnlm cllffen!nt Ng.IDfiS Ill thesplllill clllumn Superior<~nd left lmr~l vtew• ... • Flrst arvlal ~mbril (atlas). c. cl Second cel'1lkiill wr11ebra {Dis).
b
•· f Fourth cervlal ~mbra.
g, h Sixth thoradc wr11!bra. 1. J Fourth lumbar vertebra. t,l S;aaum.
The wr11eb111e in different rtgions of tlte spln11l mlu mn differ nat only in their Jill! but also in their specill features. While the vembral bodll's gradually become larger from supe· r1or to Inferior tD ummmodll:l! tne inCJNSing streS.Se$ Imposed by the gravity and body weight, the _.. ttbr01l forvmina gntdually become smalleriD m.tch the decreasing diameter of the spinal cord. The n· rangement of tne Ya'ttbral ardles and adjaant proteJses tlso varies at different levels In the spine (for details see pp. 85, 87, 'nd 89).
c
f
CosUI tuberde
h
Shift-alrb
•
Vembtal body
83
Dunk wan
1.5
--
J. Bones, LJgametrtl. tmd}olnrs
The Cervical Spine
Anll!rtortubeme
..
/
Tr.,._,. foramen
j
Sulcus frr
•llDI....,..,
-l
-r- ~ r- Deru
artlallorf.lcet
Superior
Pomrlor •rdcullrr-t
artlallor f.lcet
-
Spinous p ........
Body
Trwlliftne p..,.,...
lnfwior
ria~loor lXII:
\llrt.brol 1rdl
C7~rw -
pranlnons)
A Cei'Ykllspln-.lllft 1-..lvllw Of the cervical vertebr1e, which number seven In llll. the ftrst ~sec: lllhl ll!nlluhatar• (Cl 1nd C2,lllbs and illlfs) differ mMt conspicuously from the o;ommon vertebral morphology. They are spedallzed forbsr1ngthewelghtofthe hudand allowing th•hl!lld to mDO'o'l! lull dirKtions. similar to a blll-1nd-10eket joint. Eac:h of thtre11111lnlngllw CI!NDI wrte.,ra• (Cl-C 7) 11m a relatively small body, whld! presents a more or less square shape when viewed from a~ and a large, triilngular'l'ertebral foramen (see Cc). The superior and lnfaforsurfaces of th• wrtebral bodies lire Addle-shaped, tne superior surfaces bearing lat:fral uncinate proc:esses tnat do not appear until about tne tenth ~r of life (see p.102). The transverse proass consists of an antErior and a postelfor bar, whkh tJ!rmlnalle lallerlllly In two sm~ll lllbercles (llntJ!rlor ilnd posterior tubercles). T11ese bars endose the transvene foramen, through whld! th• -ubralllrtely asmnds from the C6 to tne C1 level. The 5Upertar su rfK2 of the transvtrse proceu of the flrst three cerAcal vertebrae beirs a brolld. deep notch (splnill nerve sulcus). In which lies the emerging spinal nt!VI! at that level. The 5Uperlor and Inferior articular processes are broad and flat. T11eir articul.u surfaces are flat and .ue lndlned ilpproxlmltely 45' from the horizontal plllne. The spinous prDC2SSes al the third through sbcth Qlntkal wrtebrlle are short and bifid. The spinous process of the sewnth cerviClll vertebril Is longer and thicker tn1n tile others 01nd Is tne flrst al the spinous processes t11at Is distinctly pilpable through the skin (vertebrll prominens).
Sul111!1far .pnolnerw
lnfwior articular lXII:
lnfa1or
~rtlculoor lXII:
d Seventh cervlal 'l'ertebra (~rtebr11 promlnens} B Cenkill w~.leftl•t.nll wtew
84
- r a r d l - - - - - ...... ;::.,__ _ _ _ Portfrtor
SUpafor articular faatt
tuberde
AnlllriDr
.dl
A 1
nar-,...
lnr.rtor
foramen
ar1fcular focl!t
First cervical ~rteln (ltiiS)
Tra,_.., foramen Anlllrlor artlellar facet
It Second cervical wrll!bra (axis)
.. Second a!I"VVal verll!bra (axis)
nerw
lnr.rtor
Tranovene for.~men
arUa~lar
tacot
Spinous plootSS
c Fourth cervical Yertdl~ Spinous process
Tran_... for~men
Undrlltl!
S~or
process
ricular proces.s
,-:-.1 ~=- ~'-
l
Body
I.
Tta,.,.....,/ foramen
lnft!tor articular pruaoo
lnft!tor rialllrlacot
SplnoLaprocat
Ill Seventh cervical wrteb~ (wrtdl~ promlnens)
Ill Seventh arvtcal wrtdl~ (wrtdl~ promlnens)
c CcfYkll wertcllor•, •upmorwt-
D Cenklll vertellonc, •*r1•rv1-
85
Tnrnk
1.6
wan --
J. Bona, Ugoments, ond}olnts
The Thoracic Spine ~':r-t CDitll faat en tr.on.Mr.se proat:lll
Antlt.oradc
lll!l'tl!bra(Tl)
Tr.~ll!iVefl
_.,;, .•..£ ,;,
proms
l'lferlarartlcular ptDCKS
Spinous
lnferiarc:omll
__;~[~•--"'lr-"'""'r-- S~rlararllcullr
~
fllc:1ot
p-
a Sealnd thoradcvertebra
Inferior artlculllrfllc:lot
b Slxththoraclc'Witebra
lnlerlor wrll!bnl nob:h c;
A 111Dr.ldc: spine, left l;l1;e1111l vtew The thor~dc wrtebral bodies gr.-a dually bealme tiller ~nd bro.ilder from superior to inferior, the lower vertebral bodies i!ISsuming a lr.!nsve<W cw.rl shape like that of the lumbar vertebrae. The vembr.-al foramen Is roughlydrcular .-arid Is smaller than In thecervlCOII<md lumbarwnebr.-ae. The l!rldplates ;are rounded and trtangular. The spiDOUS processes are long arid <Jngled sharply infl!riorly, cre~~ting an over~pping <Jrr.~ngemertt that lnterllnb the thoradc:Yeftebrae. The f.lcets of the tn(fltor articular processes ire directed interforly, while the f.-acets ofUle superior articular proceS$eS face postl!rlor so ti\at they can articulate with the Inferior facets tofonm the zygapos~hy:H;ll orf<Jcetjoints (p.100).Anotherspeci
86
Twelfth thor.! de w.ubr.a
The com! f.-acets ire cartll.-age-covered surf.-aces which .-articulate with the corresponding ribs (see p. 111). The bodies of the flrst through ninth thoracic vel'b!brae (T1-T!l) bear two articular facets on each side -i superior costal facet and an Inferior costal ficet-such that two ad· jacent vertebrae combine to articulate wlt:h the head of ;a rfb. Thus a gillen numbered rtb articulates With Its own numbered vertebra and the vertebra above. Exaptions to this scheme are n'bs1, 11, and 12, which artloulate only with the vertebral body of the same number. The body of the tenth thoracic ve!Ubra has only superior irtlcular f.-acets, and the tenth rib articulates With the ninth and tenth thoradcvertebrae. As mentioned, tfle transverse processeJ of the thoracit vertebrae (exa!Ft for T11 irld T12) also bear artloular f.-acets for tfle ribs.
1
Second thorilclc~nl
1
Sealnd thoriClc wrtebn1
SUperior •~•r pn>CIIII
llody
\ !o\lporlar
costal fact( !o\lportar
wrttlnl nold!
b Sixth thoracic vertebra
b Sixth thoracic vertebra
lmnor.UW•r --;f7::\i:::~.AJ. PIUCIOII
c
Twelfththoradc~ril
c
Twelfththoradc~ril
c TllaiWCkvertebree, supet1Drvtew The limln.e ilnd pedlclesm;lle up the ~rill uch.
87
Tnrnk wan
1.7
--
J. Bona, Ugoments, ond}olnts
The Lumbar Spine
Fhth.mbarwrtlebrli(Ll)
nf~or -,l_~~~~~~~~~
Yeflebr.JI lntl!f· { Wl'tebral for;~ men
notd't
Superior ~,..=:!!!:;:!!1~'7 Vffimnl notd't
• Second lumbar vertebra
lnfufar artla.farfaat
'hl'tebral body
Flftilklmbn-wrtSir.t{l.S)
Inferior
Inferior
artk:UiarprocHs
artk:Uiarfam
A wmbauptM,II!ft llf:lnt vtew The bodies of the lumb;rrvertebrae are large and have a transverse 0'1'<11 shape when viewed from aboYe (see C}. The massive vertebral arches enclose an almost !Jfar~gular vertebral foramen, and !hey unite posten· otly m fonm a thick spiAOU!. ptoa!SS that is flatb!ned on eiM:h side. The
"tr.ln$Vt'IW procellSes" of the lumb;rr vertebrae aHTespond phylogenetlc311yto rudlment.1ry nbs (seep. 82). Thus they are more aa:urately termed costal processes and are not homologous with the tr.lnsvene pro ~:rues of the other vel'tl!brae. The thidc costal ptoa!ss is fused with the actual transvene process. which Is a small. pointed eminence Jo. cated at Ute root of eo~c:h costal process (acce.s5ory process, see Cb). The relatively massive superior and Inferior articular processes bear slightly inclined ;articular facets that have ;a vertial, almoJt$i!llittll orientation. The artfcular f.rcets of the superior articular processes are slightly con· CliVt' and face medially, ¥mile those ofthe Inferior artfcularprocesses are sllghlfy convex and f.lce lmrally. The mamlllary pi\ICeSseson the lateral surfaces of the superior articular processes aos origins and inser· tfonsforthe ln!Jfnslcb;rckmusdes (seelb and <:;a).
b Fourth lumbar vertebra
s...,er~ar
wrtl!br.ll natl:h
c Fifth lumbar vertebra
88
Inferior irtltulolrprocus
nferfar artlcUarfaat
Spnaus ~
orUc>Jw~= ~
~-~
.uaawprocrss -broil f
S14*1or -mbr.ll nall:h
llody,lnta'- ---'1----
-lnl s~
Inferior
Spinous
doJWpiOClUI
proC!D
1 ~d lumbar ""rtebra
lnmtor dadarproaeu
It Fourth lumbar vertebri
Spinous piOQOIS
It Fourth lu mbanertebr~
SUpaior lody
...
,
orlkullrf.laot
artlaJar proasa
Spinous procaa
D LumiNrn~t~e.,_, 1111Btar vf-
89
Tnrnk
1.8
wan --
J. Bones, Ugoments, ond}olnts
The Sacrum and Coccyx ~of
Promontory
HaUm
wnuof
A Sacrum 1nd a.a::yx. antertor (peMc)
HaUm
1::;;7--......;;"'--f--
Trarswr.se lines
vtew The sacrum
a sacrum •ncl COClCJX, pOSUrlor (doFAI)IIfThe fused spinous processes fonn a jagged
Po:st!r1or -....;..~::: saa.al
~~------"lS.f---
Median
~lcrat
foramtn2
~---'--"'=-~~"'""""'~~-
90
Medial
sa:nl crest
bony rtdge 011 the corti/I!X dorul surface of tne S<~crum, tne median soavl Ol'St. This ridge Is flanked on eadh side by the paired trlfdlol sGaal aests. tixmed by fuslor~ of the articular processes. The medial crem atl! mntinuous below -Mth the rudlmentiry Inferior artie· ular proc:esses of the fifth sacral vertebra (!he sacr.al mmull); !heyarecontlnuous .abCM!With ttle two superior artirular proceues which faa posteriorly. Between the sacr.1l comua Is an apefi:IJre. the sacril hiatus. which Is fonmed by the Incomplete vertebral arch of the ftfth sacral verb!!brae and pravides acr.ess to the sacral can<~l (e.g .. for ar~esthesla). Later<~l to the postErtor sacril foramina ire another pair of longltudtn<~l ridges, the lotl!rol socral cmts. fonmed by the fused transvene prvc!L!S$U. The bony union of the transwne processes With the rudimentary rtbs forms the thick lotl!rol parts of the sacral Wing which flank the body of the sacrum. Eadh lateral part bearJ ~n ear· shaped ("auricular") surface that irtlculates With the Ilium (see C).
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
ll.l.leaf
naum
c
SllcnJm, left lltl!nll vrew
-1:-~\----- ~....1
tllbt!!Wty
Medan s.ICI'IItre!
- - - rl----
IJIItrliiPIIrl
ofSICrUm
Wlngaf
D Sla"Um, superklntew
s.IC!\111
Median sacralcre5t
~I
anal
~~~~~~~~~~~~---~or
sa(ralforamlna
E ThiMWrtuedlon tfii'O!Jgh the taa"Um
Superiorvlew(the levelofthesectlor~lss!MMn In A). Fusion of the upper focJr sacril ~ bl'ile aeatts four T-$1\aped bony c.mals at !he level of the intl!rvertebral for;~mina on each slde, pi'O'IIidlng sites of emergence for the first ttl rough fourth saaal nerves. The correspond· lng ventral and dorsal r<~ml of the splr~al nerves exit ttle bony anals thro!J!Ih the antl!rior and
posterior sacral for.-amln<~ (seep. 477).
91
TrunlcWaR - - J. Bona, Ugomenb, and}olnts
1.9
The Intervertebral Disk: Structure and Function
A strudureofanlnterw.....,.lcl* Isolated lumbar intl!rvertebral disk, anterMuperior view. The lntavertEbnll disk consists of an eJCtemil fibrous ring, the on11lus flbrosus, and a gelitlnous core, the IIUclfiiS pulpows. The ;mulus flbrosus consists ahn outer zone lind an Inner zone. The oub!r zone Is a ft. broussheath that passesses high tensile strength and is midt up of con· czntrfc laminae of type I collagen fibers. Its fiber systems crisscross due ID their Vilrylng obliquity and lnb!rconnect the marginal rtdges of two adJacent vertebrae (see B), to whldt they are att.adted. At. the JuncUon with the inner zone of the anulus fibrvsus, the tough fibrous tissue of the outrrzone blends with a fibrocartilaginous tissue whose type II col· lagen fibers are attached to the hyaline cartilage endplates ofthe vertebral bodies (see o. and Ell).
_ . / S._tonrticUar
7.?r
p-
,<'11111~~- c..ul praces5
S._tor....ubnl nab:h lnfMar _..S..,"'4lS"~il"'
---+T-- V..rtmralbody
artlaJiar
..
prDCHS
with hyollne
CMtllage~
I OIIIB' ane of the anulu1 tlbrol111
C Mlln ltrudinl amponl!nb af llllnh!rwriRbraldllll
In!Ervertebral disk betwel!n the thlnd and fvurth lumbar vertebrae. an·
Fourth lumbar ~rtebra with its uaodmd upper disk. superior view.
terlor view.
The mnnectllle-llssue fiber bundles In the outrr mne of the anulus ft. bronl5 OVISS gne another It vt riDus angles. interconnecting the bony mirglnal ridges Df two adj~KZnt vertEbral bodies.
92
lnterverb!bral disk with the anuiU5 fibrosus and nudi!U5 pul pOSI.I'. II Anulus tlbrosuJ (wid! the nudeus pulposus remDYed). c Oub!r zone of the an ulus ftbrasus (wilt! the Inner zone remDYed). d Hyaline cartilage endplate Within the bony margiN I ridge (enure In· tervertebral disk re!T'IIMd).
1
Anuus ftb,_.,
Nude.a
NudNI
pUpcJSIII
pu--111
I
b
Deeall Inc
D Polldon Dfthalnt.wl1illnl clllk In th•motiDn Htnwnt Hyilllne c.utllillge end pliltl, 1nterosuperlor llfew (die antelfor half of th~ disk and ri51ht helf of die er~dplm hM! been ~~d). b Silglttal section through 1 motion segment (see p.l 00), left lil:etoll
1
view.
c Detail from b.
c
Exl:eptforthe outer zone of the ;mulus ftbrosus. the entl~ disk bin contact superiorly and Inferiorly wtltl the hylllne cartilage layer of the ldjot~nt~ral endplaw. The.ubc:hondral, bony portion ofthe end pi~ consists of compact bone (lnt:er.'ertebral surflce) perrneaed by myriad pores (see c) through which the vessels In the bone 11\liiTOW s~ces of the vertebral bodies can supply nutrients to die dlskttSKJe.
v.mbrol
Nudaa
pulpom I
Inferior1rtla.olllr ProeHl
E loold-depelllllent lluld 1hll'b In the lnterwrb!bnl disk 1
The nudeus pul posus functions as a "Willer cushion" t1:1 ab$orb tran· slent iXIalloads on thelnttrverb!bril dlslt. Me!Nnlcilly,ltle disk represents a hydrostatic system thirtls resilient under pressure. ItIs mnr posed of a teruion-t"eSIJtlnt shuth (the anulus flbrosus) and a w.tIRry,lnc:ompresslble core, the nudeus pulposus. This core consists of 80-85 r; w.-.ter, whiCh It an rever$ibly bind in it$ pauciaollular, gelatinous, mucovlsc:ous tissue (owing to Its high c:ontent of glyms;~mlno glyans).lhe nudeus pulposus Is under il wry high hydrostltlc pressure, partlcu lirly when 1md upon by g ravlty and other forces. This pressure can be1bsorbed by the adjacent cartlliglnous endplites and also by the anu Ius flbrosus (which transforms compress~ for«$ into tensile forces). In this WilY the nucleus pu lposus functions u a •water cushion" or hyd rilullc press betwHn two idJilcenl: vertl!bril bodies.. Combined with the anulus flbrmus, It acts u an~ shock absorberthit an dlstr1bute prMSUres uniformly ~r the 1djacent vertebra Ier~dp"tes.
c
b Fluid outflow frorn ltle Intervertebral disk (green ~rTOWS) In response to a sustained preSKJre load (thltk ~ arrows). Whil~ tr1nsient loads are cush loned by the shod!:-1 mrber function of the nucleus pulposus and ;anulus flbf'Dsus (see •). sustllned loads CiiLM a gradual but penna nent outflow of fluid fnJm the disk. The turgor and height of the disk il re reduced, whne the el'ld plms and eventually ltle bony vertebr.ll elements move closer together (see p,1 05 for further details on disk degener1tlon). c Fluid uptake by the lnttrvertebral disk (green arrows) when pressure Is released (thl n ~ arTGWS). The proass described In b Is ~rsed when die pressure on the disk Is reiRSI!CI, and ltle height d the disk increaR$. This increase is caused by fluid upta!Ge from the subchol'ldral blood vessels In the bone milrrow spaces. whldl are lnstrumer.tal In dlsknutrttlon (see De). As 1 resultafpressure-clependentfluld shifts (torwection) in thei~rvertebrill disks, the~ll body height decreases b!mporartly by approldmabtly 11 (l.S-2.0 em) rel~ve to the inili.al body height during the mum ofthecby.
93
Dunk wan
1.10
--
J. Bones, LJgametrtl. tmd}olnrs
The Ligaments of the Spinal Column: Overview and Thoracolumbar Region -
. - - - - - - Supertar ortlahr fleet
A Ttt.llpmentJaftlle ...... eollllllaat tile1M aftll• thGniQIIumllerJundlan {T11-l3)
vi-.
left liJteral The two uppermost tfloracit w:rtebrae hwe been sectioned In the midsagIttal pline.
lnta...ub1111 ( dllk
f.<---=,!_- Pomrklr
:.=---.c.'
langlbldnol
.~~.,...:...--
Nucleus --..,._.:,_.;..,:;;;~
pulpaaJs
llgarMnt v.rubral fth
l
lnll!rwrt.Drol --~~l~!'•'
..............
_ _ Supertar artla.ior
~~__:_
piO~
B Ttt.IJpmentJ aftlle lpfnal eol11111n The ligaments of the spinal column bind the
splnDUS pn>eeiSI!5
w:rtl!brae .securely ID one another .and enabht the $pine to withstand high mech8nic.;oll011ds ;md sheillfng streSJeS. The ligaments .are subdiVIded lniD vertebral /lady ligaments and vet'tebral mrl!llg~ments.
lnt:enplnaLa lgaments
~~~-~~~~*~~~
v.tlllrelllooclrlte-entl
camlpruc:HS
• Anterior longltudlnalllglment • Pomriur longlllldlnalllgam.m:
~__;;~- lntlrtra.-ne
lgaments Focetjo\11: capsule
v.tlllr•l•rch llpm•'*
_ --;.:,_...!4-!- .;.:.::.,:;.;
• Ligamen!Jifll¥1
• lntenplnous llgamanb
• Supraspinous Dgtment • Nuchalllgiment•
r---~-- tnfortanrtlo.Jia"
la
• lnmrtr.uwnellglments
• The SI!JitulyOlfented nuchlllllgament runs betMWI the allmll oa!pbl p!'Ol1lba'lna nl the MWIIIh aMQI wefl2bq; It mrraponcb Ill a supraspinal
~ar
longttudlnalllglment
ligament that Is bro.dened supenorly
I
(-p.97).
Portaiar
langlbldlnal ligament
a
C Schemdc .......,.natiOn of the wrtebl'ill biMiy and wrt.lnlarch llgamlnb VIewed obliquely from the left postellorvlew.
•
Vertebral body llgamfi!U. b-el Vertl!bral arch ll901ments.
94
•'
11I
Nu1111!nt:
Costal
lnti!M!rtl!lnl
far.~mll'll
pn>eess
dill<
Ylrt!bral bady
l'llslerior langltudl'llll
IICJ!mont
•
Antl!llorlongltudnol
ComoI
IICJ!mont
Pnla!S!
D The llg.menb 1urn~~~ndlng the lumbw1plnc • Anterior longitudinal ligament, anterior view. b Pasteriot longitudina I ligament, pGsteriot view after remaval af the vertebral ardies lit the pedle11lar level. c Ligamenta flava and lntertransverse ligaments, anterior view (after rem~m~l afthe L2-L4 wrt.:bral bodies). (The otherwrtebral arch li!l" aments are not visible In this view.)
The antllrtor lon1ttudbill llgiiMnt runs broadly on the anterior side afthe wrtebral bodies, extending from the skull b;ise to the sacrum. Its deep fiberJ bind adjicentwmbral bodies togethervoflile its superficial fibers span multiple seg malts. Its collagenous fibers are llttad!ed firmly to the w1121nl bodies but haw only a loose llttachment to the Intervertebral disks. The thinner posteltor longttudlnal n,_nt descends from the dlvus along the posteffor view of the -ubral bodies, pnslng into the sacral callill. The portion ~rthew!Ubral bodies is namwnnd Is llttad!ed to their superior and Inferior margins. The ligament broadens at the levels of the Intervertebral disks, to wh ld! It Is firmly llttached by tapered lateral extensions. Despite the attamment of the ligament to the anulus ftbrosus of the lnteMrtebral disks (not seen dearly here. being hidden by the po~sterlor longitudinal ligament), a large portion af the lntem!rtl:bral disk has no llgamernous ~nfol't:l!ment, espedally ~lly (predisposing to lateral disk hemllltton, see p.lDS). Both lorr gltudlnalllgaments contribute to maintaining the normal rurvature af the spinal mlumn. The l ..ment. fiiVII mnslst mainly of elastic fibers, which give these ligaments their characteristic ~low color. They are thick. powerful ligaments that connect the h1mlnile of adjiiCent vertebral ard!es and reinforce the wall of the W!rtebral canal pGsteffor to the lnterwrtEbral furamlna (see A). When the spinal column Is erect. the ligamenta flav.1 are under tension and help the bilck musdes to stabilize the spine in the sagittal plane. They also act il$ med
..;:,.,~---
Supellar artkulapraa!SI
Poster1ar -~!--.,...4• langlllldlnal ligament ~ar--~---~-
lonulllldlnal ligomont ~L---
c
1m..r1or•rtlculor facet
SplnaUJpraa!SI
95
Tnrnk
wan --
1.11
J. Bones, Ugoments, ond}olnts
Overview of the Ligaments of the Cervical Spine
A The llglmentl ofthe a!f'lltc.tl splr~e
.. Postertor1/tew. b Anterior llfew afb!r removal of the antl:!ri~r sk\lll b;~<Se (see p. 98 for the ligaments of the upper
cervical spine, especially the cril· nlovertebr.al )olnts).
;.._,.,......_
Vl!flebr.J premlnens(C7)
lnlemlloafpltlll
a lbe cnlnlowembl'lll JoTnts The cranlovertebral jolnu are the articulations
-~111111----~=--~
prOtuberance
between the iltlas (Cl) and occipital bone (atlanto-ocdplt:ll )olnts) and between the atlas and axis (C2. atlantoaxial joints). Whi1e thHe
Joints. which numberslxln ill, ire irlii'IDmlc311y distinct. they are mechanically lnter11nki!d and mmprise a fuACtional unit(see p.101). All•~lbljDTnls
Paired jOints llltlerethtowl, sllghtlyconmoe superior articular faats or the atlas arti~ ID:wtth the IIIIMX ocxfplbl mndyles.
All•nlaol•l jDTnls
• IJJtm11 otltlmooltJoljoint- paired artlcul• lion be--. the im.rior articular faaeu ofthe atlas and the superior artlallar bcetsofthtilllds • MedlarHiflotltDGxlal}dnt • un~lred artlculatlon (comprising an antmor and poslierior compartment) between the dens ofthe nfs. the folia ofthe atlas. and the a1111age
96
~~+-Vl!rllebr.J
premlrms (C7)
b
Sella Aplalllgament lllda afthfd..,.
~1.,..1
TedDrlal
anal
mombr.,...
C lbe lllilf!Mnts flldw antcal lplrM:IIudwlllgii!III!M MldRglttal sed!on,left litenlvlew. The nuchalllgam..nt Is the brCNdenl:d, Ngitully orien~ p;ort of tht supraspinous ligament tNt extends from the vert2bra promlnens (Cl ) to the exll!rnal ocdplul protuberance (ste A; see also p.98 for tile lig•ment:s of the i!tlanto-otcipital 1 nd iltbnlloaxlil joints).
Sphonoldtln~a
-
O:dplbol bm~ bullarport itlonto«dpn.ol
membro111
Fooatjolntapsule - ....:,..'-=---:-:\1-kiil;...--"'-'\~-----,--- 1J91menta ftava
........ .,.,. . __+ -- Verb!bllll ardl . -- - - - Splnaus pnxl!lll
;:..__ ....:..__ _ lntenplnoLAigam..nt Poslllrlor ~dln•l -----.-.-:-~::--'\""
lgam..nt
- - - SUp-aoplnoLAIIgament
l:.en!bellomell;lt.y
Apoo
Cld
Pastztlor tuMid!'
llodyafam
af~
Nuchil ligament Pom!lor longilu-
dlnalllgamont
Vl!rtebrol body 1.-t..br;;ll dlok
Vl!rtebro pn~mlllO!I'Is (C71
SUp-aop'hous llgamont Spll'lll a>rd SUbndlndd I pall!
....
D Plain latet'III111Chogl'llph f/1 the ctnolcal
E ..,gnetk resonance lmege of the eenlbltplne Mldsilqlttal section, left lateral view, T2-welghted TSE sequence•
97
TronlcWfiH - - J. Bona, tlgflmenb, andjoints
1.12
The Ligaments of the Upper Cervical Spine (Atlanto-occipital and Atlantoaxial joints) NU
bont
lr I
)
-~4--
Tectorial mombnne
I.P:I+- - V..rtmnl•rdl )-DIL-.J--
Posterior
lcngltudlnal llgilment I
~llllH
capsule
AJ.r llg•monts
Tect~~rW membt~~nt
TedorW membnrw
LA>nsill>ldhll Aplcalllglmont '-Ida atdtns
Cruciknn llg~mont
} crf.U. Thanownt
OUc:lfann lgamtnt
at ;rtfa
{
IIJIITII!Rt at .U. Longlludln•l fasddes
.. A lhallgamanb aftt. c;nmlovartel11~l Jolnb Skull and upper centbl spine, postl!rlor view.
a The postl!rlor illlanto-Gcc:lpbl membrilne -the "ligamentum fla. vum" b«ween the ill! as and occ:lpltal bone (see p. 94}-stretches frvm the postl!r~ 1 rc;h gf the ill! as to the posterior rim of the fol'\il· men rnagnum. This membrane hill been re~ on the rfght side. II With the vertebral canal opened and the splnill mrd rell'ICM!d. the tKtorla I membrane, il bi"'iidened e~qNnslon of the post2110r longitudinal ligament, is seen to form the a nb!rior boundary of the wrtebr;l canal at the l.ewl of the cranlovertEbral joints.
98
c With the tecturial membrilne removed. the Ollclfurm ligament of the illlas can be seen. The trilnsverse ligament of the atlas forms the thick horiZontal bilr fl the cross, ilnd the longltudlnill filscldes form the thinner ~rtical bar. d The transverse ligament of the illlas and longltudlnill filldcles hwe been partlillly rerncJI\Ied to demonstrate the paired alar ligaments, which extend frDm the lateral su rfaa!s of the dens to the comsponding inner su rfacu of the oa:ipital cgndyles, and the unpaired 1 pial llga malt of the dens, which passes frvm the tfp of the dens tD the anterior rlm of the foramtn magnum.
Tnmk wall - - 1.
BotJes. UgamenB. andjoints
~~~~e--~--~~41~
aflheallas
8 Thellg;lmentsofthe mlldl~n ;atlanto.DI;aljotnt Alias and .axis, supelforvtew. (The fovea, vmlle p.ill't of the median atlanta axial joint, is hi Iiden by the joint capsule.}
~~
membr.me
Te(tl)rlal Aplealllt~ment
memblllle
ofthedens
"" •
~
ligament of..tlas ...,,_.-_:~~-
Tr.IM!M!r.le pniCI!'1S
b
C The llg;lments ofthe aantovertebr;ll Joints (Jatnt apsule I'I!IMWd) • ~m.al cervical spine, ~ntetwuperior view with the joint caf)$ule removed. b Alias and axis, posterosuperior view.
~riot
Nuchalllgament
~~ntxH>afpltil membr.~ne
99
Tnrnk
wan --
J. Bones, Ugoments, ond}olnts
The Intervertebral Facet joints, Motion Segments, and Range of Motion in Different Spinal Regions
1.13
•
SUperior
costal facet
Longltl.ldlnal
fa reeL
lnftrlar mstal facet
4~--lnfel1arartlalar proa!.SS
--1---;
.'/Aflll!·~r-- TanSICntlill forQe St
~~~:...._ Ncnnalfo~Sn
....._...,.....=:...--=:--:;--- lnfel1ar articular proeMS ~....,_--':1_.---
SUJlj!ffar articular proeMS
+-+- LIQ;Imentum flr;um
b
Meni!Olld syn~Malfalds
lnlhe)ottt
Sjllnalnerws
upsu~
d
A Tile lnterwrb!bral f.lcetjatnts {zyg;~pophyse;ll Joints) The diagrams show the posltfofl of the artlaJiar surfaces of the lntl!rvertebral fiC!I!t joir~ts in dilli:!rent regicms d the spinal column. g_, from the left posterosuperior view: a cuvfc;rl splr~e. b thor
100
B Strud:ure and loading of a motton segment.lllulltnted fDr two thoracic vettebr~e l.atef'al Ylew. "Motion segment• Is the tl!rm ;rpplled to the artiCIJiar and muscular confi&ISon bei:VIeen two adjacentvertebrae (a).lt CDnslsts of the Intervertebral dlslc, the paired lntl!rvertebral facet joints (zygapoph· yseal joints), and the
Tnmk WGII - - 1. Boner, Ugarnetts, and joints
--------------------------------------------- ---------
SCI'
C Tml ra. .e of matlan of the mrvlul spiM • ~rtlfle>Cion, b floion/extenslon, c rvbtion. Corol'lll plane through shculdelf pelvis tl noutnl position
~glltill
pl1ne
~7tit~~~~~~-G~ lnldlllnter
D Taal n1n1e of motion of the thor.dc nd IYmw lplne • Ub!ralftexlon, b flolon/IICtenslon, c ratatlon. The dlnlcal ex.i~mln.tion, partkululy function t2stlng. Is of key lmporana lneumiNtlons of tile spine. llecJUsrethetDtalrangeofspinal motion Is comprised of1he mCMments of a total of 25 motion segma!ts. geneBUy the examiner can dl!btct only mOIII!ment disorders that llffect individual ~gions. For oa mple. dinial testing can show dear evidence of ankylosis illfKtlng pa rUcular spinal segments. The examiner makes 1M of st<1ndard reftn!na lines (e.g.. tfle di!Yiallar line or ocdusal plane) In determining whether the range of spinal motion Is normal ordecreill:~ed.
'liDo 1-.ck
l.u•
Cenrbll
blor + tlloNck IPlne IPhle + lumw
CtnkliiiPIN EntiN
!oro
M
cervlc.ill
jalnt
Joint
spin•
Flexion
20
6S
Exlalsian
10 5
40
Later1l ftellfon• IIGUtfan"
35
JS 50
35 25 20 35
50 35 20 5
150 100 75 90
/trojoint• ~ntD•Oc>CipiUijalnt ltrl joint= AllaniDildaljolnt
•To each side
F Musurwment ofthe l'llnge oflhDI"'clc11'111 lumlllrtplnll flexion by the nwthod ofSchllber 1nd Ott 1n the metnocl of Schober and ott, the patient stands erect..tllle the ex· amlner rna rb the S1 5plnous proces! and a semnd point 10 an higher. When the patient bends as far forward as possible, the distance between the two skin markings will lnanse to approxlmmly 15 (1 0 + 5) em (range of maCion of the lumbar spine). The thoradc range of motion Is determined by measuring 30 an down fio'om the spinous proass vi the C7 vertebra (ve.Ubra pramillft'ls) and marking that point on the skin. When the patient balds forward, the dlsbnce between the muldngs may Increase by up to llcm. An alternatiW melttod Is m measure the smallestflnger-tD.floor dlstana (FFD) wltt1 the knees extended.
101
Dunk wan
1.14
- - '. 801H!:f, Uganretra, and}olnrs
The Uncovertebral Joints of the Cervical Spine
v.rulnl body
Antlorior tubordo
nt2r-
Und'latJ.o
- I nI
processes
disk
.....:~=----=~- OuiB' ......
donuus
flbi'IIRIS
It
A Tbe u.-rtebnljolnb t1 a ~1'19 ..tult Cavlal spine ohn 18-yelr-old man, antalor'llew. a The upper endplitl!s ofthe C3 through C7 vertebral bodies have later.d projKtions (undN~ prvcesses) that dMop during childhood. Starting at 1bout 10 ye1rs of age. the undllite proc::esses gridually
came IntO mntlct with the oblique, crescent-shaped nvrgln on the und~urface of lhe next higher vembral body. This results In the formltlon of literal clefts (unl:l)llertebral d~ orjoints, see b) In the outer portions of thto interverta111l disks.
b C4 thi'GII!Ih C7 n rtebrne. The bodies of the C4-C6 nrtebrae han been sectioned In the ooron~l pllne to demonstritl! more de.irly the unmwrtebral joints or clefts. ~ dtfts ~~bounded lmrally by a mnn~tlssuutructu~.aldnd ofjolntc.apsule,whkh causestltem to resemble true Joint sp-. These defts 01 ftssures In the lnterwrtl!lnl disk -re first deMribed by the 1natomist Hubert wn Luschki in 1158, who called them ·~m~u~ MnllonhtDses. "He Interpreted them il5 primary mechanisms designed tD enhance the ftl!ldblllty of the aMcal spine and mnfer il functlontl adv.nt:age (dfi'Mngs based on specimens from lhe Anatomical Collection It ICiel University).
Dens
I
TDpagn~phlc reladanshlp of
the •phil nen~e and ver1lebrll ararytD the und!Ytl! proc:eg
Alln(Cll
C1 splnol
""""'
- 4 L - - Axls(C2)
a Fourth a rvl'-'11 vertebra ...tth
spinal cord. spinal roots. spinal nerves, and vertebroil arteries, superior view,
b Cervlc.a) spine with both vertl!br~l al'tll!rles and the emerg lng spinal nerws, anterior view.
Ventral raot Spl~lnenoe
Undn1ta I
102
proeos&
It
Verttlnl body (0)
NoU the murse of the vertebril artery through 1he transverse furamiN and the tDUI"R of the spin~l nave it the level of the Intervertebral fllramlna. Glwn their close proldmlty, both tltu rteryand nerw IN)' be cornpnessed by osteophyte (bony ~rowth~) aused by uncovembrlllllrthrosls (see D).
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
l.lrb!!'ll Dens
itlll1toalcllljalnt
TranswM foramen
C Degenet'ilttve cN"'JJ!S b the c:ervful
tpbe (urlaM!ftl!bralartflrosfs) Coronal $«tion tftrough tfte cervical spine or a 35-ye;~r-old man, anterior view. Nat!! !he course or the vertebral arteries on botft sides or lfle vertebral bodies. The development of the unawertdlralj11lnts at appi'Oldmately 10 years of age Initiates a process of cleft fonnatlon In lfle Intervertebral disb. This proa!SS spreads tDward the unter of the disk wttft aging, eventually resulting In the fonnatlon of complere transverse deft:s that subdMde the lntl!rvertebral disks Into two ~bs of roughly equal tftidcness. The result is a progressive degenerative process marked by flattening of the disks and consequent lnsta· blllty of the motion segments (dl'a'Mng based on specimens ~ the Anatomical Collection at klel Unlwnlty).
Verttbral body
'-:A~---
lnll!MrtSiral
rw~Ina us
• D AdvaiiCIId uncovert.bl'ill ~11hl'lllll ofdJ• c.rwkoll spine • Fourth aMc:al venebra, SIJperforvfew. b Fourth and ftfth cel'llfcal vertebrae, lateral view (dr.a'WI'ngs based Ol'l specimecu from the An;atomiclal Collection Jt Kiel University). The unarvertl!bral joints undergo degenerative changes comp.arable tD tftose seen In other jolnu, Including the fonnation of omophytes (called spondylophytes when they occur an vertebral bodies). Theie sllles of new bane fonnatlon servem distribute the Imposed forces aver a larger area, lflereby reducing tfte pn!SSure an the joint. Wrth progres·
PI'OCI!SS
sive destabil~tion of tfte corTesponding motion segment. the facet joints undergo osteoarthritic changes leading to osteophyte formation. Osteophyte$ of the uncovertebral joints have major clinical Importance because of their relation tD lhe Intervertebral foramen and vertebral artery (uncovertebral arthrwis). They cawe a gradu;al!y progressive nar· rowing of the Intervertebral foramen, with Increasing compression of the spinal nerve ;md often of the vertebral artery as well (see C). Meanwhile the spinal canal Itself may become srgnlftcantly nai'I'!IIN!!d (spiN I stc!no$is) by the same proce.$5.
103
Tnrnk
wan --
1.15
Po:st81ar longitudinal
J. Bones, Ugoments, ond}olnts
Degenerative Changes in the Lumbar Spine
-----;;.:;.-,~
llglment
"'"""- ' - - - - - Spl'!OUI
proass Caudl
equlna
-----\''---~
- + -:--- lnb!r.spfnous llglment
A Mk!AgltQisedlanthroughthel-rputofthespliiiiGIIumn Left lmr;rl view. Not!!: The a udal end of Ule spinal cord, the conus medullarts, terml· nates at the lew! of the firstot second lumbar w.ttebra. The spinal cord ;rnd spinal anal ;rre appi'Olllmately the same length until the 12th week of prenml development. so tflat e;rch p;rlr of spinal nuves emerges through tfle rntervertebrill foramen at the level ofUie ne!'YI!S. Wltfl furthet" g!VNth, howevet', tfle W!rtl!llral column lengthens more rapidly than tfle spinal cord, resulting In ;rn lncrea5lng cephiilad dlsplacemmt ofUie COni medullilr1s. At blrtfl tile COni medullar1s ha5 alre;rdy re;rched the leW!I of tfle tfllrd lumbar vertebra, and It continues Its gr;rdual upw.~rd shift until ;rbout the 1Oth year of life. ll«ause of tflese diip;arm growth rates, tfle spln;rl roots run obliquely downward from tfldr segmmt of ortgln In tfle cord to re;rch Ulelr corresponding lntervertellral fDr;rmen. The spinal roots that descend from the lower end of the cord are colle«ively termed the atUdcr equlno (•horw's tall"). Because the manbr;rnes tflat mdoseUie spinal cord (tfle meninges) extend Into the sacral canal, a needle can be ufely Introduced Into tfle subilrilchnold space below tfle COl'! us medullaris to sample cen!brospinil fluid without Injuring tfle c:wd (hlmbor puncrure). This site Is also used for lumbar $INn aIanesthesia to block both tfle ilffa'ent nerve roots (for analgesia) and the efl'et"ent nerve roots (for muscular p;rralysls) that supply tfle pelvic region and lgwer limbs.
f.ltlnthe epldlnl space 13
Hemtrn!d
dlslc L4
Cluda
equln.a'l'l CSF-fllled dur.als;ac
B Posterfor clsk heml~ttan In tfle lumiNrsplne Mlds;agltbl T2-welghU!d magnetic resonance Image of the lumb.ilr spine, left lmralview. The im;~ge show$ a corupicuous hem~te
104
Tnmk wall - - 1.
Bones. UgamenB. andjoints
Splnousproczss
..,.,,.....,,,.,~
Splllill
-
dur.~ lllitl!r
~
lltenl
hemlirtfon
Nucleus
~.Jff+t---
Centr.il hemlirtfon
pulpasiiS Anulus
Anulus
flbmus
•
flbrosus
Dural sleeve with pomr'lor root.
-root.and spbal91ngllcn
c
C Lumb.1r disk heml;rt:fon a Posterolmrall~emliltlon, SIJpel'forvlew b Post2ri0f herniation, iuperior view c; Posterolmral hemlilt!on. P<»terfor 1liew (the vertebral arches have be1!tl removed to demonstrate !he lumbar dural s;rc and correspond· lfl!l nerve rooti) With aging, !he lnt:ervertebril dlsli:tlssue undergoes regressive changes in which the water collUnt of the disk decreases and, with it, the tu~or ohhe disk. As a multofthls, the disks become thinner (see p.9J), of· ten leading to a loss of st<Jblllty lr1 the motion segment (see D;a). A:5 the stress reslstifiCe of the anulus flbrosus (!he •outer shealh" of !he disk)
also dedlnes with age, providing less effective conulnment. the tls· sue of the nucleus pulposus may protrude lhrough weak spOti under loading. The rnrual step rn !hrs process rs a disk protrusfon.lfthetlbrous ring of the anulus eventually ruptures completely, the nucleus pulpoSIJS can prolapse through the defect. resulting In a herniated or "ruptured" dlslc. The herniated matelfal may compress the c;ont:ent$ of the Intervertebral foramen (nerve rooti and blood vessels}. AP<»terolateral hemlat!or~generally compresses the subjacent nerve root (c), causing pain and paralyJU that <Jffect caudally <1djacent dermatllmes and corresponding muscles.
Spinous procus
Anulus llbnllw
Nuc:INs pulposus
Spinous process
lnterYI!I'tl!lr.ll foramen
Spcndylophybecn
articular process
!iponcl)lophyte (mqlnalspurt)
..
lnfmcr artlcula rt.u:et
D Spondyiophyta TIWOMnga spl.,.l motton segment a Third and fourth lumbar venebrae, lateral view (lntEJvertebral disk removed). b Fourlh lumbar vertebra, superior view. c; Coronal section through the third and fourth lumbarvetll!br;ae. The degeneration of intervertebral disk material is uwally aoo:~mpanied by reactive manges lr1 the bane (aimed at Increasing the load-bear· lfl!l surf.rce area and redudng stresses an !he joint). The overall effect of these c;hanges rs to sublllze the motion segment. The prfndple of these processes i5 similar to that involved in osteoarthritis of the joint$
c
In the limbs. 'JW~Cally !he changes begin With marginal spumng of !he vetll!bral bodies (osteophyte$ • spondylophytes, a), naiTOWing of the lntEJvertebral disk space (chondrosb, b), and sderosls of the vertebral endplates (osteochondrosis. c:). Similar dlafl!les also take place In the facet jolnti (spond~arlhrosls). Further progression may lead to the formation of •b(tdging osteophytes" as adjacent ma~inal spurs grow together and aeate a bony ankylosis across the motion segment (c). However. the body of !he vertebra may be !he prfndpal focus of deterlor.rtlon In the gerlatlfc spine. ProgrtSilve ostl!oporosls and the assod· ~ted loss of bony rtability may culmina in vertebral bady collapse ~nd deformity.
105
Tnrnk
wan --
J. Bones, Ugoments, ond}olnts
1.16 The Thoracic Skeleton
A TIIDI'IIdt lkeletlln <11
- --:t:==-- ........"""""'-3---Manlb!fl.fl'l st2m
~--~IF~--~r,----sw~l lfllle
--4=~~~~~- Bodyof r-~,__,~~~~-
stemum XIphoid
p1!>.:~=-ey:....__
<:ami artl1age
•
~---=...._......,,...-.:+-
Transwr.se p!'OCHS
~~~~~~~-~ Iran~
!oint
b
106
rwetthrb
Anterior view. b pomrlorvlew.
The lfloridc skeleton (lfloradc age, thorax) consists of the Ye11J!bral column, the twelw ~irs ofribs, and the sternum. These struellltes are mowblylntem~nnected by ligaments. true
Swmum
joints, and synchondroses. Tension Is Imparted to the thorax by the Intercostal muscles. The thoracic cage enclases the chest cavity and has a superior aperture (the !florade Inlet) and an Inferior aperture (the lfloraclc outlet). Its shape Is subject to marlo!d varfatrons relalfng to age and gender. The ribs of an infant h;we very little obliquity and are approximately horIZOOtal. With Increasing age. the rlbs Incline dcwnward while the thoracic cage bealmes flattened antenlposterlorfy. Tills Is associated with a decrease In the size oflflethoriclcoutlet. Generally the female thorax Is narrowef and sh«ter !flaB in the mile. From a func· tlonal rundpolnt. the thoracic skeletlln and Its muscular wall structures fonm a rugged, sbble enclosure whkh penmlts the resplri· tory excursions that are necessary fw norm;al breathing. This Is clearly apparent In patients with severe chest Injuries such as multiple rfb fractures due to blunt trauma, 'Where ln.sbbll· ity of lfle chest wallle..ds to paradoxial respi· r.rtlon: the affected side of tile rib age moves Inward during Inspiration and oui:Wird during explrat!Dn. This results In 01 pende/luft effect (from lfle Genman Pmdel. pendulum, and l.u{t. air): air stre
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
n W
ll'ue~bs
(1-7)
Sb!mum
c
Tweii!Mb
Comlmargn ---'--~ (an:tt)
Ll wrtl!llral body
'l'l'ue, lillse, and ftoatfng rtbs Lateral view. Each of the twelve pairs of ribs Is bilaterally symmetrical. but the shapes of the rfbs v.-ary it different levels. The first seven pairs of ribs, called the !:rUe ribs, .ilre nonnally connected anU!riorfy to the sternum. Of the remaining five. called the {oln rlfls. the eighth, ninth, andtl!nth rfbsirejolnedtothecart1lige of the rib directly above, contributing tD the structure of the coml nn.-arglr1 (arch) (see All). The last two pairs of "false• rfbs. c;rlled the floa!Jng J1hs.. uswlly tennlriO!tl! freely between the musdes of the lateral abdominal wall.
Salllatlc:
Rbhump
GJNit
onllle tonW~~tslde
• D Lltl!f.JI curv.rtu~ ofthe sptnal columll (SODiosls) a, b Posterforlltew. Salllosls mortcnmmonly presentsas a tight Clli'NI!Jt anve of the spin.;~l allumn ;at the level of the T8-T9 vertebrae (b). It Is manifested by a typical postur.-al deformity In upright stance
+ c. d
T
the
d
When a paUent with right convex scnllosls bends forw.m:l, a typical rfb hump appears on the cnnvex side ofthe curve (c). This happens beausethe adjila!nt ribs also occupy an abnorrn.;~l pcnition due to torslor1 of the vertebral bodies (d. superlorlltew).
(a).
107
Tnmlcwall - - J. Bona, Ugmrtenb, and}olnU
1.17
The Sternum and Ribs
4-___;.,__ Sec:und lhraugh IIMnlhCIIIUI noldlu
• A
lhut•m~~m
a Anterforvlew. .. l..at8'lllvlew.
The sternum Is a flittl!ned bone, slightly convex antl!rlorly, with multtple lndenbtlons along Its la!2ral borden (mml notrhes). The adult mmum consists of three bony p;~rts; • 'The manubr'ium • 'The body of the mmum • 'The xiphoid proass
The manubrium , body, and xiphoid procESS In adolescents and young adults are connected to one another by urtllaglnous plal25 (manubft05U!mal synmondrosis and xiphost2rnal synd'londrosis). which gradually oS31fy wtth Increasing age. The fully ossified. mature adult form Is depleted here. The depression In lhe superior border of the manubrium Qugular notch)ls dearly palpable through the sldn and marks the Inferior IT'Iilrgin of thejugularfoJsa. On eech side of the lug ular notch is a depression for articulation wtth the davlde on thatsfde (davlculir notrh). and just below that Is a shallow conavlty (first costal notrh) for the synmond ros1s wtth the first rib. At the Junction of the stBNI manubrium and body Is an artlcularfacetforthe Jea~~~d rib (second com Inotch). At. that sl!2 the ITiillnubrlu m Is usually ilngled sllghtty b.XW..rd In relalion tD the body oftne sternum (stem~ mgfe). The lateral borders of the mmal body bear aclditiana Icostal notches that articulate with the third through seventh costa I nrtflages, the notdles for the sblth ;md seventh cmtaf cartilages being plaoed very dose tDgether. The sometimes bifid and perforated xiphoid process Itself Is deYOid of costal ilttachments and is hig hfy varia bfe in its form. Frequently the xiphoid process is still cartilaginous In adults.
108
r ..:~-=--- R.t~
$11t1110-l
lgaments
.--.;.f-.,.,,.,;;:-..~:-- jlllnt space
a The Miemocoatl joints Anterior view (the right half of the mrnum has been sectioned frontally to show the stzmomstaljolnts). The con nectlons between the costa I ar1!bges for the first U1 rough seventh ribs and the costal notrhes of the mrnum consist partly of synchondroses ;tnd partfy of tJue joints. Generally a joint spacz b found only it the second through fifth ribs, while tne first, sixth. ind sewnth ribs ire ittached to the stam um by synd'londroses. In the tJue joints as well as the synchondroses, ligaments (radiate st2mocmtaf ligaments) radiate from the perichondrium of the emtal cartllage to the <~nl2rfor su rt.lce of the sternum. where they blend wtth the per1ostzum to fDmn adense llbrous membrane (the st2maf membrane).
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
castaI tuberde
Crettcl nedc
•
C V.ntablesfzeilndshilpuftflerfbs a Rrst rib, b second rib, t ftfth rlb, d eleventh rib (~II are right ribs, viewed f'n:lm above).
The neckofther1bextendsfrvmthe head ofthe rlbtothecost~ltuber· de. Except on the first r1b, the neck be~rs a sharp supafor ridge (aest of the neck of the rib). Lilter.ill tD the costall:\lberde Is the shaft (body) of tne rib, which cuMs fo<Wird to form the com Iangle. The sh
D Segments of the rfb ;md muc.ture oh tfundc segment Sixth parr of ribs. superior VIew. Each rtb consists of a bony p.art (co Still bane) and .il artilaginous part (costal carblage). The bany p.art mnsists tne following segments. rtartfng from 11:5 vertebral end:
« • • • •
Head Ned: Costal tuberde Shaft (bady), which includes the costal angle
109
Dunk wan
1.18
--
J. Bones, LJgametrtl. tmd}olnrs
The Costovertebral joints and Thoracic Movements
Spi"""'P""'""'
I
Neck I
drlb
lncn~n~ln
sogltbll dllmeb!r
c
A ,._for.-menuofthe con.wrtebnl Joints 1nd rtbs (~ Klp~ndjl)
SUpellar1/lew. 1 Axis of UPP"' nl> m~rTWJits.
Ill Alds of liMier rib m<M!meflts.
c Direction at rib rnaYBT~ents (see c for the mstovertl!broiil joints}.
The ues of rib mavementnre dire~ p~rallel to the necks of the ribs. The ilCI!5 for the upper ribs are closer tD the coronal p~ne (01), while those for the IDMr lfbs are closer Ill the Soilgltbl pbne <•1. For this,_ son, ,. lfb eJ~Z:urslon In the upper p~rt ol the r1b age mainly lncre.ses the SiiSJIIbl thormc dlamet.r while oiiiDMr rib ea:urslon lncreoilses the tr01nJnrw diameter<- 1).
B Moftments of the r1b ca11e durtn1 CDSbl ar chert lllftthlng (s11emocosUol bredllng) Respiration (ventilation) Is effected through changes In the thoradc volume. The lnaease In thoracic volume that Is neceSYry for Inspiration an be Kcompllshed In two ways; lnlr.lltomol
.ongle
1. By lowering the dlaphr.Jgm (amodliphragmatlc breathing or abdominal breathing, seep.134) 2. Byel~;rting the ribs (stern001$tal bruthing, 3lso known as costal ar dlest breoilthlng) While br&thlng at rest Is almost entirely abdominal, respiration during phy$ical effort is augmented by chest bruthing with the intercostll
f I"'Pimatyposition
110
n.o.-....thoracic d~r
muscles ind the auxiliary musdes of respiration. The driwtngs Illustrate the thoracic volume changes that OCXJJr dulfng CMst or C'll&IJJ/Inatlling. in which the tharacic: wlume decreases and increases in both the mronal ;md s3glttal plines. Panels 1- c sh- the decreoR In the tnmsverse and sagitbl chest diameters at en6-cpir;at;on, and d-f .show the intm~llr at end-ln5plratlon.
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
I~
..
Nucleus
pulpcllUS disk { M.llus /
_/
Abto.sus
C Llg;mwnts of the Cllltovlftebr;ll jotnts Theco.stovertebril jolntsarethejoints by which the ribs ilrticulate 'Nith the 1/ef'tzbrae. They comlst of two types: the joints of the heads of the rtbs and tile co.stotransvenejoints. Though morphologlt;~lly dldlnct.
these different joint
typn are functian.ally interrel~.
.a Articulationohheeighth rib with the eighth thor<~clc vertebra, superior vfew(tbe joint of the head ofthe rtb and cmtotr.-ansver5e Joint
Superior ecltllfaat
Inferior -""""r~=-=-~--. costalfaat
on lfle left side have been transversely sectioned).
lntr.NrUcular
b The flftfllflrough elghlfllflor.rclc vertebrae
fgarnent
and associated rlbs (sevenlfl ind eighth rlbs),left late!'<~ I VIew (lfle joint of the he;ad ohhe $C!IIl!nth rib h;Js been tr;ansverselysettloned).
Crest of rtbhead
jolntofthehNcloflflerfb; Thlsjolntconslsts
of two artlcul;ar SIJrfaces:
1. An;artlcularf;acetonthehe;adofthe rlb 2. Acmtal facetonthewrtl!llral body The articular facets on the he..d of the second through tenth nbs (defined by the crest of the rib head) articulate with the fossa formed by the superior and Inferior colitill facets on two adjacent vertebril bodies and the lntei'Wftebral dislc between them. The intra·articular lig· ament, whlchextendsfromthe crertofthertb head to lfle Intervertebral disk, sep;rr.rtes the joint c;avlty of the second through llenth rtb heatk into two compartments. By contr;Jt. lfle heads of the flm, eleventh, and twelfth ribs eillch irtlculate Vlflfl only one thoracic wr· llebral body (see A, p. 86). In all the joints of the head$ of the rib$, the joint t;~psule is rein· forced by the rodlatt! ltgammt. Coltlltrani!VI!ne )oint: In the c:ortotransver5e joints of the first through tenth rtbs, the artie·
----,:--- ----."""'11..
lntl!rwrtebr.al
disk
- -+-- -=:+=::....!- ~-------=r-- Attlcularfaats on ~b head
- -+ _;_-
ltldlllte --~---'--'"""
fgarnent
ular surf.lce of the cmul tllberde articulates with the cmtal fat1:t on the transverse ~ cess of the corresponding thoradc vutebr;a. The eleYellth ;and twelfth rtbs do not have <1 costotransverse joint because their transverse processes do not have articular f;acets (see A. p. 86). Three ligaments rtabntze tile co.s~ tranSYI!!'Se joint and also strengthen the joint capsule:
1. The latel'
the tip of the transverse process to the cos· till tubercle) 2. The costotransverse llgament(between the neck of the n'b and the transverse process) 3. The $Uperior cmtotranM:!ne lig;~ment (between the neck ofthe rib and the transvene proce.ss of the verllebra above It)
111
Tnrnk wan
1.19
--
J. Bona, Ugoments, ond}olnts
The Bony Pelvis
A Tile male pelvis a Anterior view. b Pomriorvlew. c Superfor11tew.
S~cr
artlcularproc:us
l'osb!tlor superior - - : - - - - - - ,
I lac 'Pine Postl!rfarlrhrior llac'IJin~
- --=.:- -....!!\
b
lnnKiip lilac
ln1mnedlatdne
~ { O~ter
l
\
"' lld'l~l
spine
-~~--l--------+-
Baseof sacnm
- -=:.::i,..----1
~....,---
Antl!rfor superfor Mlacsplne
I Tile peMc gtrdlund peMc "'ss Antel'osupertor VIew. The peMc girdle consists of the twa hip bones (c:ox.al bones). The sacn> Iliac joints ~nd the artflaglfiOUS pubic sym· physls unite the bony ~rt:s of the pelvic girdle With the .s;acrum to form .a st.able ling c.alled the pelvic ring (indic.ated by CQior sh;lding). It ;IIlows very little mobility. because st~blllty throughoutthe pelvic ling Is an Important p~ requlsltl! fortr.an.s.mlttlng the trunk load tD the lower limb$.
Pubic S)mphy.ils
112
Pec:t«< pubis
lliopubk ~mlnence
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
Pllblc: l\lberde
lllacm!st
Saaum
c
Thdemalepelv'll a Anteriorview. b Posteriorvlew.
c Superfor111ew•
•
G:illf:
AntB!or
9utealrne
malepeMs
-~~o::-<;;:\ ~
l'o:sll!norsupe!or -~-----.1
lllac$11ine ~orlnti!tlor
llac'l'll'lt
- + - ---t'-..ll.
s~
publcnunus
Ischial spine D Gender-tpedftcfl!atursoftflepeMs
Pllbls
Inferior P~JJ~cramus
Saaorrac Jo'nt
lilac
s~alt'lalar
tuberoslt:y
proass
~t"~:. "~ lJ,~lin~
I . :;:. __..,.o:-+------=l;-- Pramo~ry .,.
Out«fp/
Anterosuperior view. A male and fl!male pel· vis have been superimposed to lllusttate the gender-spedllcdlfferenCI!s. Compo~rfson reveals that the fl!male pelVIs Is larger and broader than the male pelvis, while the latter is t~ller, narrower. and more miSsive than the female pelllls. The Inlet of the female pelllls ls larger and has an almost cwalshape, while the sacral promontory shows a greater projection In the male pdvls (Cc}. Sex dlfferenc:es are also noted In the .ilngle between the Inferior pcJbk rami, which is acute in men (70') but signifiuntly larger In women (alm~~rt 90-100'). Accord· lngly, this ;rngle Is called the subpubic angle In men and the pcJble arch 1r1 women (see 0. p.11S). The $i!CI\lm also exhibits differences betweal tile seKeS. In women tile $i!CI\lm Is angled ilt the level of the third and fourth Yer· tebrae (see p. 90), while In men It presents a
uniform curv.atune.
Pllblc
c
Pubic: tubercle
l)mphyiiS
113
Tnrnk
wan --
J. Bona, Ugoments, ond}olnts
1.20 The Pelvic Ugaments and Pelvic Measurements
~
Saaotubetaur. llgiiiTMrlt
Antello rlengi!Vd InaI ligamEnt
IIIOI~IIM'f!lilme
- -....;...,:..:,..- --+- -.:-.'
Antmarlnfedcr --~llllcJplne
....,L- +-. g-- - - .:!-- - l'llltttfar
sacrciliacligaments
b
~~--lr.dllal
tubei'OOIII:y
A
Ug;mwntsofthem~leptlvts
• Anterosupenor lllew. b
PDstl!ri~:~rview.
114
C lnll=lnllllnd cnnn.l pelwk II'IHIU..menb.llnn tcnnl11111k. ilnd pelvic: Inlet plilne Theintern;~I and l!lltenal peMC measurements ptl)llide direct or inditKt lnforrn~tlon on the slzle and shlpe of the bony bound4iriesofthe 1.,_ pelvis.. Because the lesser pelvis functions u the birth can01l, the lnb!rnal and utem1l pelvic dimfnsio,.,. h - speciaI practial sig niliana in obstl!tr1cs, detennlnlng whetherthe pelvic avlty Is bi"D.lld enough to • law for a vaginal delivery. A particulally important measurement is the 1n1e conjug~tr of the ~c Inlet (the o.b stetrlc conjugatr), which Is the smallest ilntlropostertor dlmerulon of the lesser ptMs. With p~ try, a method of measuring pelvic dimensions, potentiill obstructions to libor un be ldentlfted prior to the dellwly. Generally the measurements are performed by trlnsv•glnal sonography. Some pelVIc dlmel)o slons. such u the diagonal conjugite, an be accurately determined by
blmanuaii!Xilmlnilion. Promontary
ll*ml!pelvll:-......,..111- (Re .. •nd •1 lntmp.,ous
Co«ylt
• Ttlle 0111]11!1*- 11 em (dlsunce hm the s.c:r1l promontory to the posterior border ri the symphysis) • Dlagon;~l con/ug;IW - 12.5- 13 em (dlmnce from the s.011l promontory to the 1 - border oftiM symphysis) • liP dlimeter ofthe pelVIc GUllet - 9 (+2) em (dlsunce from the 1_. bonder ofthe symphysis to the lfp of the cauyx) • Tr.mswr.se dlimeter otthe pefoltc Inlet pllne • 13 em (grutest ci'IStance ' - - n the linue tlrmlnala) • lnb!rsplnous dlilmeter -11 em (dlstanc~t.m.. thelSchlil splnts) • Right (I) and left (II) abllqu• dl1m.._ • 12 an (distance from lhe s.crolllicJoint ft the lewl of the llnu termlnalls to the llloptdlnul •mlnence on the appmlte sld•)
d~
Rlg1l: oblique
IKhlil
"'"~
II
--1d[~-4~~~~~~--~~---Loftd~ oblique
d~
PIMc lnletplone
PUbic ~·
• lnllmplnous dlltilnce • 2S-l&cm (di-IMM•n lhe .onll!riDr supertor1llicsplnls) • lnllercrlsbl clsance • 21-licm (grwMiat dsana ' * - t the left and right k crests In the ooronal plane) • Externol c:anjugate- 20- 21 an (cllblnm from the upper barder d the symphysis to the spinous proc:IU ofthll5 VlltKn)
................ ,_.,
Boundilry line betwwi the g...ter and le- pelvis. amslsts of the pubic symphysis 1nd aest + peo:t.. publa +the.,.:.-llneand u
B lnten&l ilnd u11H1111I pelwkmellillretneniS
Right half of1 fern1le pelVIs, medial View. lit Female pelvis, superior view. c Male pelVIs, supertor Vli!W.
1
l'l!lwlc ..let,.._ ~Ill ollldlk;l
The linea b!rmlnalls Is m•rbd In red In • · The pelVIc Inlet plane Is color-
Pllne through the pelvic: inletltthelewll ofth•linu terminalis, below which Is the lesser pelvis
shadfd in II and c;,
Alt-....ltl~'<"-7'-- Pubic
~~~~~-- ~c .,...p~~ys~.
.,...ptryD
D l - pullkql• Anurior view.
•
PUbfcarcb (9C..10CI')
..
1 f8nale pelvis: pubic •~h. It Male pelvis: subpubk: angle.
115
Tnrnk
wan --
J. Bona, Ugoments, ond}olnts
The Sacroiliac joint
1.21
l'astl!riouuperlor lilac spine -"roo~--
.,.....- Promontory
lilac tuberosity
- +-- - Ao.rialar sum~of
- .--- - - Alrlcular sumce
sacrum
«Ilium
b ~I
sumce
A Artkullir surf~ of the ucrolll.c Joint ;a Aurlcular surface of the nlum. right hlp bone, medial view (the sa-
crum Is transparent In this view). b Aurlcularsurt.lceoftbesacrum, rfghtlatli!r.alvlew. The two e.ar-5haped artlwlar surf.ac:es ofthe llrum .arid sacrum (aurtcular surfaces) are bA:MJght mgetber at the sacroiliac joint. The auriCI.IIar sur·
l
Antl!t!or superior Ilac spine
116
face of the llrum Is slightly notched .at Its cen1ll!r, and there Is a redprocal ridge on tile articular surfaceoftbe Ilium. The shape and size ofbotll artiCI.IIar surf;aces show considerable lrldMd~aal variation-more so Ulan lfl otherjoints. Thel'r cartilaginous covering Is generally Irregular, the articular c.artllage on the saCI'ill side being appi'!IIC1rn.il1l!!y twice as thldcas on the iliac: side.
a NutltiDnln the sacroiiiK Joint Right half of pelvis, medial vlew. MOYements In the sacroiliac joints ;II· ter the 'Width of the peiYic lfng and thus have pr.-actlcal lmportar~ce In obstetlfcs. The amplitUde of the mOYements Is greatly llmlted by tight ligaments and varies mnsidt!!rabfy in diffi!rent individuals and bebNeen the sexes. Bislcally, very slight ro43tlonal arid trarulat!or~aiiTIOYelllents can be dlstfngulshed lfl the joints. Nutation, as shown here, Is ;a rota· tiona! or •attlng" movement of the sacrum about an axis loe.iltl!d at the attachments of the in1ll!rwseous sacronlac ligament$. Wrth onttriorroWt:lon ofiJir soaum, tile promontory moves foiWilrd and downward while the coccyx moves upward and bickward, thereby rncreil11ng the AP dl· ameterof the pellllc outlet. With postmor rot11tlol'l oftilt soaum, the AP diameter of the pelvic inlet plane increil1es while the AP diameter of the pdllic outlet Is decreased.
Tnmkwall - - 1. BotJes.UgamenB.amljolnts
Saaum ~rsupe!ar
I rae spine
Satr.!l anal
- - - - · ..
C I.Jt;lmantsofthelilcnJIIKjotnt • Oblique section through the pelvis it the level of the pelvic Inlet plane. superior view (pl~ne of S«tion indieited in b). b Right half of peMs, medial view.
a
~ri~.:...._-
----
~sclltk
Anterfar sac:ra11ac
fg;ments
_ _ _--=:..,,£-;f"--=------'~
1\lnmen
Sacrabbefaus ~ment
Planed S«ttonlna
ll
~
i\Jtho'Ugh the S<~croiUac j11lnt Is a true joint. Its movements are greatly restricted by a tight joint capsule and po~Nerfulllgaments (amphl· arthnaiis). The anterior sacn:liliac ligaments st.1bllrze the joint on the anterior side of the pelvis, while the Interosseous ind posterior sacrollrac ligaments and lllolumb.ar ligaments are the m;~in Jti!bilizing elemC!Ilts on the d11r· sal side (see p.114). The powerful Interosseous S<~cromac ligaments are deep b.ands thilt run medially just behind lfle sacrontac Joint frvm lfle mK tllberosity to the tllbenaiity of the S<~crum. They are oxnpletely COYered by the posterior S<~crollrac ligaments. The llga· mC!Ilt mmplex helps to anchor the sacrum iA the pelvk ring during upright stance and keep It from sliding Into the pelvic ca11ft:y. Additionally, the sacrotuberous ligament and sacrospl· no us ligament (see b) stabnize both $0!Croili;lc joints and prevent posteriortiftlng ofthe pelvis about lfle transverse axis. Sacrollloc joint pain may be caused by chlll!llc Inflammatory or degenerative changes (e.g .• anltylosing sp!lnciylltls. osteoarthritis) or by traum;~ (e.g .• sport· relited Injuries). Hypermobllhy of the Siaollrac joint may also develop .as .a result of general ligamentous wt'akness or a pregnancy- or hormor~e-related li!XIty of the ligaments. Sacroiliac dysfunction may Include joint lock· ing (a sudden fora! like that oa:urring in a stralght·legged jump may cause " "wedg· lng• of the Sicrum with Joint locldr~g). This s1JI!tl:hes the joint capsule and can cause I!X· auci~ting pain during moJt body mcwemenu.
117
The Trunk Wall - - 2. Musculature: Functional Groups
2.1
The Muscles of the Trunk Wall. Their Origin and Function
Overview of the Trunk Wall Muscles
The muscles of the trunk wall in the strict sense consist of the intrin· sic back musdes and the musculature of the chest and abdominal wall. In the broad sense, they include the muscles of the pelvic floor (which form the caudal boundary of the abdominal and pelvic cavity) and the diaphragm (which separates the thoracic and abdominal cavities). Be· sides the actual (primary) muscles of the trunk wall, the back and thorax also contain muscles of the shoulder girdle and upper limb whose origins
have migrated eniD the trunk during the course of phylogenetic devel· opment (nonintrinsic back and thoracic muscles). Examples are the tho· rocohumero/ muscles anteriorly, the spinohumerol muscles laterally and posteriorly, and the spinoeostal muscles. Other musdes that have mi· grated to the trunk, such as the trapezius, are derived from the mesen· chyme of the branchial arches (branchial musculature). They are inner· vated by cranial nerves (the trapezius by the accessory nerve) and were incorporated secondarily into the locomotor apparatus (seep. 258ff.).
A Trunk Willi muscles In the strict sense
B Trunk w•ll muscles In the broad sense
lnlrtnllc bKII ,._les
Pelvic: floor muscles
Utenltnlct • ~rospin;,lsystem - Iliocostalis - Longissimus • Splnatransverse system - Splenius • lntertr;,nsverse system - lntertransve~rii - ~aiDres costanum
Pelvkd..ph1111J111 • LevaiDr ani muscle - Puborectalis - Pubococcygeus - lllococcygeus -Coccygeus
Medial tract
• Spinalsystem - Interspinales -Spinalis • Transversosplnal system - Rotiltoll!S breves and longi -Multifidus - Semispinalis Short n•duol....t cranlawnebral Joint muscles (capiU. ....t suboaiplt.JI muscles)' • Rectus capitis posterior major • Rectus capitis posterior minor • Obllquus capitis superior • Obliquus capitis inferior Prewrtebr.! ned< mllldes (belong topographically ID tt.e group of deep neck muscles but act mainly on the cervical spine) • • • •
Longus capitis Longuscolli Rectus capitis latera lis Rectus capitis anterior
Mllldesofthethwadc:cage(c:hatwallmusdes) • • • •
lntermstal musdes Transversus thoracis Subcostal muscles SQ!eni (belong topographically IDthe group of deep neck muscles but are functionally related ID thoracic breatlling)
Mllldes oftheabdominll-1
UrogllnitAI diaphragm • Deep transverse pl!rineal
• Sphincter urethrae Sphlnctersand eractll• muscles ofthll wogenltal and lrastlnal tract
• External anal sphincter • Bulbospongiosus • Ischiocavernosus
• Superficial transverse perineal Dllph1111J111
• Costal part • Lumbar part • Sternal part
c Muscles that migrated secondarily to the tn.lnk wall (described in the chapter on the Upper Umb, p. 208) Splnoc:ostiiii!Kiscles
• Serratus posterior supl!rior • Serr~tus posterior Inferior Splnoh..,enol mllldes betwftn the trunk •nd shoulder girdle • • • • • •
Rhomboid major and minor LevaiDr scapulae Serratus anterior Subclavius Pectoralis minor Trapezius
Splnohumlnll mllldes r.tw.n the trunk and arm
Utenl (obrque) llbclamlnal muKies
• Latissimus dof5i
• External oblique • Internal oblique • Transversus abdomlnis
• Pectoralis m;~jor
Anterior (slralght)llbclamlnal muscles • Rectus abdomlnis • Pyramidalis Posterior (deep) abdominilll,..les • Quadratus lumborum • Psoas major (belongs functionally ID the hlp muscles, seep. 422)
118
• The suboccipital musdes In the strict sense are the short or deep nuchal musdes that are counted among the Intrinsic back muscles (cri· terlon: Innervated by a dorsal ramus). The rectus capitis anterior and lateralls muscles are not classified as Intrinsic back muscles because they are supplied by ventral rami, even though they are also suboccipttalln their location.
The Ttvnk Willi - - 2. MUICt.llature: Functional Gn:Hips
Ortgtnofthe nunkWII Muscles The sttimd muscles of the trunk wall (induding the muscles of the dlaphr~gm ~rid peiYk floor), like the limb musdes, develap embi')V" loglcallyfrom the myotomes ofthe somltEs (see p.6) and are therefore c.1lled the somatic Jl'lllSde:s. In all, approoctmat:ely 42 to 44 pairs of~ mental som~s a reformed in the paraxi;!l mesoderm be~en the 20th and 30th day of development Five ocdpltal, 7 arYlcal, 12 thor.u:lc, 51umbar, 5 sacril, and 8-10 coc::cygeal somltes are formed In a cranloClludal sequence (see D). Some ofthese so mitts regress wth furtherdevelopment. particularly the first occipitA!I somwand most of the coccygeal somltes, so that the number of ortglr~al somltes Is greater than the number of subsequentvenebril segments. The boundary between the he..ad and neck runs through the flftft pair of ocdpltal so mites. At the end of the sixth Wl!ek of d'M!Iopment. the somite ~mes migrm In the dorwmrtral direction and become sep;~rated Into a dorsal part
Oa:lpltll somlles (5} CA!Mt.ll .r.amllts (7) So~
mlliOlilure
so mitts (12}
Elrrudment
I
/
(epimere or epaxial musdes) ilnd a ventril part (hypo mere or hypax· ial muscles) (E). While the 4!pi1Xlal muscles dewlop Into Intrinsic (local) back muscles ~nd ret;~in their origin311c;~cation, the hypomere d'M!ICIII$ Into !he anttrolater.itl muscles of the chest
Spln.al card
Optfcrud'mmt
'~ ~ ~=") ~::.-· =· -d) I
ln!Jfnslc b.adc mwde.s
Ep.mal mllSClllrture
SplnalneMe
mt~~eulmft
D Somltef In • flve..weck.old hurn1n embi}V Right lateralvlew. The so mitEs formed from the paraxlil mesodetm are
dassllled aspn!Ottc(shown In blue <md green) or pOIStortc (shown rn red), meaning that they are locattd cranial or caudal to the earn.~diment. The sotmt!c muscles develop from postot!csomtm. Segmentation Into dlf· ferent somltes Is not observed In the preotlc region. which contains the rudiments for the branchlogenlc pharyngeal arch muscles .ilnd the extraocular muscles. The stJuct:ures in this region are innerYab!d by cranial nerves (after Boyd. Hamilton. and Mossrr~ann. quoted In Starck).
Abdamtn.al Gl\l1l:y
Umb ~O!Ors
'-..,. Cocl;yQeal
somlt:ts(8-10)
r<~mU~>
Abdamln.al wlllmwde.s
Hypulal
Umbbuds
Satllll30mltes(5)
V81tr.JI
V81tr.JI r.~mus
..
Umb flucn
b
E 1\'anwen:e tectlom throulJh allx·week-old humm embi}V a Transverse section at the level of a limb bud. b Transverse section through !he .ilbdomlnal wall.
Musde preaJrsor cells wth replicative Cipaclty located .ilt the lewl of the limb buds migrate from the myotomes Into the limb buds, and !he myotome that retmins in these regions develol'$ into intrinsic back muscles. With further growth of the limb bud. the muscle tissue differentiates Into a dorsal rudiment (blastema) for the extl!n.sor musdes and a ventral rudiment for the &xtw muscles of the up~ and IOW!!r limbs (see p.18). As In the hypomere. the limb muscles are lnnerYated by ventral spinal nave rami (br.ilchlal plexus and lumbosacnl plexus. see pp.314.ilnd470}. Nctethe difl'en!nt innerYation afthe epaxial muscles (dorsal ramus) and hypaldal musdes (ventral r~mus).
F Dllgram ofthe prtnd'pll muscle groups In an eight-week-old hum•n embryo Right lattral ~ew. Red - somatic muscles. blue- br.itndllogenlc (branchlal.ilrdl) musde.s. green- extraoaJiar muscles (after Boyd, Hamllmn, and Mossmann, quotJ!d in St.ilrck).
119
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.2
The Intrinsic Back Muscles: Lateral Tract IIOCIIIIIIIItmusdet (•seep.121.oppolillt.IOMrright) Orllln: I....U•:
CD Iliocostalis lumborum: saaum. Alae crest. dlora
transwne procases of upperlumbarwrtebra • llloaasulls thorads: 1st-6th rtbs • Iliocostalis arvicis: trans-se processes of CA-c6wrtl!brae Acll.: Enll~ muscle: bilateral conlractlon extends the spine, unilateral
A laterel trect: sdlemftlcoftfle Nlnllplrlill ~)'~tam
a IIIOC05talls muscles. b l.alglsslmta muscles.
® longissimus dlorads: saaum. dlac cnst (common tendon of origin with
iliO
Splenlulm..Orllln:
® ~IenlUs cervlds: spinous proCI!SSes of the Tl-T6 Wltebrae (J) 5Pienlus capitis: spinous proCI!SSes of the Cl-T3 Wltebrae
• ~Ienius cervlds: transwrse proomes ofCl and C2 • Splenluscapltls: t.teralsupertornuchal nne, m-Id prouss Acll.: Enllre muscle: bilateralcontJxtlon - c i s the ceNical spine and head, unlla..,.l mntraction ftan and ruutes the hud to die same side lnnerwlfon: Lateral branche$ ot dorsal rami ot spinal nerws C1-C6
I....U•:
lnlieltriln-rall
®
Orlglnand ® ln181Janswrsartl medlales lumborum: course ~n adJacent mamAiary l...tl•: processes of alllumbarwrtl!brae 181n12r1nnswrsani laterales lumborum: (l)urse between adjaant
b B lat.l!faltr.~ct: sd!em;~Uc of tfle
tptnou-neandTntertraMWne
sym:rn a Sple11lus muscles. b lntel1r.an.sw!'1arll and levatores mstarum.
120
Orllln: I....U•:
@ l.eYatore$ (l)starum b..-: transwrse proce$Se$ ofthe C7 and n-Tll vertebra @ l.eYatore$ mstarum IOngl: tranm!rse proce.ssesofthe and T1-T11 Wl12brae • l.eYatore$ mstarum b....: costal angle of the nut lower rib • l.eYatore$ mstarum longl: costal angle of next higher rtb
a
• Bilater~l mntraclion exb!nds die dloracic spine • Unilateral conII'action bends die dloradc spine to die same side. robii!S It to the opposite side 1-'!on: Both dorsal and wntral rami of the splnalnaws Acll.:
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
Sl.pe!10r
nuchalline
,..jj.jofr-.0::.,- - I.GI'Gissfmw anicls
C Lllt-=1'11 trutofthe lntrfnll' INrd: ITIUKiet; the Ncrotplllll sysb!m (llloaMtilllund lo~~t~lssfmll'l mllldes)
• The structures named In the tables at left ane not all labeled In the drawings above, as they may not all be 'Yislble In the perspeciM!s shown. The schematf' diagrams at left, along With the tables, are intended w g~ a $YJtematic overvii!W of the mUKiu and their ac· tlons. The drawings on the right-hand p;~ge ane Intended to display the musdes as they would .ilppe.ar In .il dissection.
D Lillterill t.rutofthe lnt.rfntk baclurud&s; the splnotrar.wFA symm (splenrus muKie) 01nd lntl!rtr.lft5111HS4! symm {TntertraMWnartl and lmrtora costa rum lnllldet)
121
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.3
The Intrinsic Back Muscles: Medial Tract lntenpMales muscles
Clrlllln•d IIINftiGII:
(!) lnt.npln.ales cervlcls:
murw betwMn the spinous procases of the cervical
wr12bl3e C!lln~nales lumbol\lm: aiUIW between the spinous processes of the lumbar
wr12bl3e AciiGR: EXII!ncls the ceNical and lumbar spine 1-clon: Dorsal rami of the spinal nerws SpiMis muscles
®Spinalis thorads: ~al surface ofthesplnous prowsses of the T10-T12 and l1-ll Wrubl3e ® Spinalis cervlc1s: spinous processes ofthen - T2 •nd cs-c7 vertebnle I....U•: • 5Pinalls thorads: ~al surface of the spinous p . . - of the T2-T8 vertebrae • spinalis ceiVlcls: spinous processes of the cz-cs wrtlebrae AciiGR: • Bilateral mntraction exb!ncls the cenrialand thoracic spine • Unilateral CGRtr.actlan bends the cenllcal and thol3dc spine to the same side 1-clon: Dorsal r.aml of the spinal nerws 01111111:
A MedlaltnlctoftherntrtMitblck muMies-: schematic of die tpinlll fY$tem
~"'-<~~~d ..ngll
The lntenplnales and spinalis musdes.
Ortgln and
lnlert'-n:
CJ> Rotatares bmlls: from tl3nswne procasof thol3dc wrtebrae to spinous process of the next higher wrtebr.a ® Rotatares longi: from transwne process of thoracic wrtebrae to spiniOus process of the wrubra two lewis higher
AciiGII: ~nerWion:
• Bilateral CGRtractiOn extends the thoraclc spine • Uni~<JI contraction rotates It to the opposite side Dorsal rami of the spinal nerws
®MultiiiiU Ortgln 1nd
._rt'-n: AdiGII:
~nerWion:
Courses between the transwrw .and spinous pi'OCeSl (skipping 2-4 wr1Jebrae) of all cenllcal wrtebrae (C2 to the sacrum); most fully dewloped In the lumbar spine • Bilateral contraction extends the spine • Uni~<JI contraction f l - to the same side and rotates to the opposite side Dorsal rami of the spinal nerves
Stmllplnals
0> Semispinalis thorads: transwrse processes of the T6-n2 wrtebrae ®Semispinalis cervlcls: tl3nii8H procases of the T1-T6 wrtebrae ~Semispinalis apitis: transwne procases of the Cl-T6 wrtebrae Neraon: • Semispinalis thorads: spinous processes of the C6-T4 wrtebrae • Semispinalis cervlels: spinous processes of the C2-C7 W!rtebrae • Semispinalis capitis: ocdpltal bone betwMn the superior nudl.alline and Inferior nuchal line • Bilateral contraction tlrtends the thor.acic spine. cenriul spine. and head (stabilizes the cranlowrtebral ]Oints) • Unl~al contraction bends the head, ceNICal spine, and thoradc spine to the same side and rotates them to the opposft2slde ~nerWion: Dorsal rami of the spinal nerves
Ortgln:
•
B MedlaltnlctofthetntrtMitblck muMies-: schematic of die
w-FIO!Ipl'nal system • Rotatores breftS and longl. b Muft:ifidUIO.
c Semispinalis.
122
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
~~i!S~- Alias ifi .JIIr- - - Alds
Superior
nudlal rne
Splno~aproces.s ofC7 --~~1~il
(wrtebra prantnens)
C
MedllltrliCtofthelntrfruk~ckmutcles: thesplnll system ~nptnales ;md sptnalls)
D Mldl1l trilct of the lnt.riruk b.Jdt muKies: the t.r'ilnlft..-pin11
symm (robtores llffties itnd long!, multffldus. and semlspiRiht)
123
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.4
The Intrinsic Back Muscles: The Short Nuchal and Craniovertebral joint Muscles and the Prevertebral Muscle
C1wmbta - - - -
A Sdltm.ttlt oftflt dlort nuchll and cranTCIIII!Ittbl'lll )Dint mu&des (subocd~l musdH): rectT qpltb po.stmor m1]or mel m'ilor iind obDquTI c.1pltll supertor iind lnh!rfor
B Sdltmltlc oftflt pn!'l/l!fttbl'lllned: muscles {CDII and cerv'ldl musdes); longl e~pttrsand collland recti qpltlnntertor 1nd Iatifiiis
llecba apllll pasteftDriMJ«
'-II•apllfl
Spinous process dille 4llds Insertion: Middle third or the inferior nuchal line • Bl~.al conlr.ldlan extends ttle head • Unllataralmntraction -~the head tottle same side lni*WIIon: Dorsalramusorcr (subo«lplt.alnerw)
Oltgln:
Oltgln:
AnterfDrtuberde dille transwrse .,._ofthe C3-c6wrtebrae Insertion: Basilar part or the oa:lplt.al bane Adlon: • Unllater.~t Ultund sllghlly rotalla the head to the same side • Bilateral: f l - tile head lni*WIIon: Direct branches from the cenrial plexus (C1 ~)
CJ> llltcba capilli pasteftDrmTnor Oltgln:
long• all (aiYlds)
Insertion: Adlon.:
Oltgln:
Po5ter1Dr tuberde or the atlas InnEr third or the lnferfor nuchllllne • Bilateral conlr.ldlon extends the head • Unilateral contraction 10utes the head to the same side lnnetWIIon: Dorsal ramus ofC1 (suboulplt.alnerw)
• Ver11al (medial) part anterfor sides or the cs -C7 and
n-T3 wrtebral bodies • Superior oblique part anterior tuberde or the transwneprocasesdtheC3-CSwrtebr.~e
•
lnfert~~r oblique part: anterior sides of the T1-Tl
~lboclle$
Q) OllllciUUfapNIJ~...
the atlas Insertion: ~the lnser11on ofttle rectus capitis posterior major Adlon: • Bilateral contr.ldlon extends the head • Unllatel'll contl'lctlon alts the head to the same side and rotates It to the opposite side lni*WIIon: Dorsal ramus of C1 (subouipitlll,_)
Oltgln:
Tr.~n~e piVCIIIS d
@ OllllcluusapNIJlnfwtcw
Spinous process dille 4llds Insertion: lhlnswrse PIVCI!SS d the atlas Adlon: • Bllater•l conlr.ldlan extends the head • Unllataralmntraction - sthe head tottle same side ln...U.: DorsalramusofCl (subo«lplt.alnerw) Oltgln:
• Ver11al part anterfor Sides or the C2 ..C4 vertebrae • Superior oblique part antertortuberde or the atlas • lnfert~~robllque part: anterior tuben:le of the tran• wneprocasesdlheCS.and C6wrtebr.~e Adlon: • Unllater.~l: Ults and-~ the CliNical spine to the same side • Bilateral: f l - the cervical spine lni*WIIon: Direct branches from the cenrial plexus (C2..C6) Insertion:
llecba apllflentert... Insertion: Adlon:
Lateral mass or the atlas Basilar part or the occipital bone • Unllater.~l: lateral ftexlon at the atla-cdpibljolnt • Bilateral: flexion at the atlanto-occlpltal Joint
ln-u-
Ventralr.~musdlheC1nerve
o.tgln:
® lliKbiS apllrs o.tgln:
Insertion: Adlon: lni*WIIon:
124
'*"'If
process« the atlas Basilar part or the occipital bane (lateral to the ocdpltal condyles) • Unilateral: latel'll ftaon at the atla-cdpltalfolnt • Bilatw~l: flexion at the atlanto-occipital joint Tr.~nswne
Ventralr.~musoftheC1nen~e
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
s~
klferior nudlalllne
nuch1llne
R.ettus t.JPiti5 postl!rla rminor
C 111e short nuchal ;md cnniOIII'I!ftebJ';II Obllquus capitis superior M~..-s
• lhanswr~e
Ma!told
proczssd;!tias
proc
Joint musdts: recti upltis postl!rfor and
obllqull capltlt Posterior view, b latel'ill view. In a strict sense. the short nudlal muscles conslst only of the muscles Innervated by the dorsal ramus of the first spinal nerve (suboa:ipi· tal nerve). They Include representatives of the late!"al tnct (obllquus capitis Inferior) and the medial tr.ict{obllquus capltls superior .ind rectus capitis posb!rior major and minor). The an· terior groop of short nuchal muscles (recti C
Emmaloalpltal prolllb«anae
....,.;;;rL- - Obllqws
Allas(C1} -
...
caplllssupe'lor
....."------+~,
AB(C2} -...,...------,,z....fi~•••."IIJ~
~---
RlecMcapllls posb!rior minor
Bail lor p;J rt of acxiplbll bone
R.ettus apltls anll!rlor
b
\Jr-~~---1~~
procesoflllliD
Lang us
col II
D 111• pi'I'VIIItebl';ll mutdes: long111 capitis, longus mill, ..nd rec:tt apiUs antel1or and literal II Anterior 1liew ilfter remcwal of the cervlc<~l vtsan. The longus apllfs musde has been p.irUally rernolled on the left side.
125
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.5
The Muscles of the Abdominal Wall: Lateral and Oblique Muscles
A Sdlenmfc oftfle extll!m;~l obRque {oblquus extll!mus abdomlnls)
1
Sch~coftflel~;~lobnque(obnquuslnternus
abdomlnls)
EXIemeloiiiJque
lnlilnMI oblique
Outer surfxuf the Sth -12th ribs lnser1tan: • Outer lip of the lilac aelt • Antarlorl¥r ttl the reclus sheath, linea alba Adlon: • Unllater;~l: bendsthetrvnktothewmeslde,rotam the trvnkto the opposite side • Bilateral: ~the trunk. stralghtl!ns the pelvis. adift In explrlllion, malniBiara Gf abdominal tone (abclomlnal!ftSS) lnMIWIIon: lntllrtOStal neNeS (TS-n 2),1hohypogastrlc:-
o.tg..:
o.tg..:
Deep layer Gf the thoracolumbar fascia. intermedilt» line ttl the lilac: crest, anterior superior lilac spine. lateral
half Gf the Inguinal ligament • .._r borders ttl the 10th-12th ribs • Antl!l'lor and postl!rlor l~'jers Gfthe rectus sheath, linea alba • junction wlth the cnmaster musde Adlon: • Unilateral: bends thetn.lnk to the wme slcle,rvutu the trvnkto the wme side • Bilateral: fleiCies the trunk. stralghtl!ns the pelvis. actiW In explrlllion, malntl!nanat Gf abdominal tone (abdominalpm;s) lnnerwtlon: • lntercoltal nerws (T 8-T12), dlclhypogastrlc: nen~e.
r-uon:
_,
lllolngulnalnen~e
• O'emaster musde (genital b111nc:h Gf genitofemoral
,__aWomlnls
• Inner surRces Gf the 7th-12th costal artl!iges • Deep l•r ttl the thoracolumbar fascia • Inner lip Gf the iteac:
o.tg..:
126
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
Flft!l~b
Xlptlold
XIphoid
pro ass
~
Antufor h!>dl~S~
Emm.1l oblque Tenthr'b
Llneaalbil
Emma~
Uneulbil
oblqut
ntl!mll oblque liCMXleiJIOSis
liPCil~ls
ntl!mll oblque
umblllcll
Antufor
A!dus sht.tith
~ng
OUII!rllp
$41peilc:lal
llg~~T~ent
Inguinal
Pllblc .l)mphysls
~ng
D E:xtemel obllq~~e Left side. anterior view.
E lntem~~l oblique
left side. anterior view.
TlliMM!'JUS
Aponeuro:slsof -----,A
lnt8nlllobllque
-K
andtr.llnswnus
abdamlnls
abdomlnls
-....,jill-- - Aj)one!JIO$!$ of lnl'lswnus abdomlnls
lnnerfpof llllccn!St Antl!ffcrs141eflot Antl!rforlayerof --~lliilill- re
llllcsplne lngulnalllgamom
F 'n'ai!IW..-abdomlnll Left. side. antertor ~~few. (FGrstruc1lJreaftfte rectus sheath, see p.151.)
127
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.6
The Muscles of the Abdominal Wall: Anterior and Posterior Muscles
Car111ages oftto. fifth ttorough sewenth rlbs, xiphoid
lnlllrllon: Acaon:
process of the stcmum Pllbls (betwMn the publctubertle and svmphysls) Fl- the lumbar spine. straightens the peMs. adlve In expiration, malntenanca of abdomlnalllllne (•bdomlnal press)
ln...,.._ lnte101stal neNK (TS-n2) Q)..,...mldllls OltgM: lnlet'llon: Acaon: ln...U.:
Pllbls (anlllrlorly .It the ln.rtlon of the ..a.. abdornlnls) Unu alba (Nns within ttoe recbls sheath) Tenses the linea alba Subcostal nerw (twelfth lnl!tr
A Sdlenmfc oftfle al'ltl!fforstr.lp mll!ldtsofthe abdomln~l Wolll: l'f!dla abdomlnlt and pynmldalll
Qul*-'slu.-onn OltgM:
lilac crest Twelfth rlb, oostal pi'OCflSe$ ofthe l1-L4wrteb111e Adlon: • Unllatlnl: bendsthetnlnkllllthesameslde • Bilateral: bearing down and explrillfon ln....,.._ Subcostal nerw (twelfth lnl!tr
1-uon:
lllopsoa (Q).-- -Jcw..cl a> lleas)•
• Psoas maJor (superflclall;yer): late111l surfaces of the 112 Wltebral bocly, the l1 ~4 vertebral bodies, and the associated inteMrtebnll disks • Psoas major (deep layer): costal processes of the ll-LS-brae • Iliacus: lilac fo5sa lnMfllon: lnsert)Ointly as the Iliopsoas muscle on the lesser trochanter of the femur Acaon: • Hlp joint ftexlon and ex~BNI rotadon • Lumbar spine: unllate1111111nt111ctlon (with tto. fwmur fbed) bends ttoe trunk laterally, bllalllral cont111ctfon 11111ses the trunk from the supine positiOn lnMIWtlon: Femoralnerw(T12-TI4)and direct branches from the lumbar pleaus
o.tgln:
a Sdlernftlc of the deep pom:rtor muMief ofthubdomlr~~~~l wnll: qu;ull\1tus lumbonlm ;md pso. m.1jor
128
• Of these two muscles. only the psoas maJor belongs topogr;~phleillly llD the postl!l'lor abdominal muscles. It 1s classltled functfonally as a hip muscle (see p.422).
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
C Anlttrfor {rectus ~bclomWs ~nd PJF.... mldalts) ind posterior mll!ldH of the
abdomlnll wall (quldratu11krnbonJm and I lOP IOU) Anterior view. The anterior abdominal wall muscles ire demonstr.rted or1 the left side and the posterior muscles on the right side.
Body of stl!mum ~r.rtus
Uneulba Transwnw abdcmnls
£xll!mal
klmborum Ll'fl!rttbnllbocly Transwn.us ~nl$
oblique
Internal obJque
; L - - - Apontl.rnSe.S of
lntl!mal
latltnl.:lbdombal
Extl!mal
oblique
wollmusdei
oblique
..
b
D Arrangement ofthe abdomln•l wall muldes end rectus 1heeth Anterior view, b transverse section at tile level of L3. The rectus ibdomlnls 01nd lilteril oblique ibdomlr~al Will muscles 01nd thefr aponeuroses comprise 01 functional unit. Fuston of the aponeurosesoftheobliquemuscli!$crutesasheathendosingtherectusmu$Cies which In tum memtheapooeuroslsfromtheopposltesldetoform the Until alba In the .abdomlnil midline. I'«the uppef¥4 ofthe length of the rectus musdes. the aponeurosis of the intl!mal oblique muscle splits, so portions pass both antl!rior and posterior to tile rectus musdes. There-
;a
uns alba
ltectusshslfl
fore,ln the upper A!glon of the rectus, the external oblique aponeurosis passes antufor. and the transverses abdomlnls aponeurosis Pilssei posterior to the rectus muscles. Thus an anterior rectus sheath (exter· nal oblique and a portion of the internal oblique aponetJroses). and a posterior rectus sheith (the rest of the lntemal oblique and transverses aponeuroses) are formed. OVer !he lONer 14 of the rectus musdes, !he aponeuroses of all three abdomlr~al muscles p.ass ,;mtenor 1» the rectus musc:le.s. No p05teriat sheath is prrsent. The inferior edge of the posterior rectus sheith Is called tile arcuate line.
129
The Trunk Wall - - 2. Musculature: Functional Groups
The Functions of the Abdominal Wall Muscles
2.7
Functions of the Abdominal Wall Musdes The different abdominal wall muscles perform numerous functions, which very often are carried out in concert with other muscle groups (e.g., the back and gluteal muscles and the diaphragm). The principal actions of the abdominal wall muscles are as follows: • Maintenance of abdominal tone: tensing the abdominal wall and compressing the abdominal viscera (abdominal press) • Stabilizing the vertebrae and reducing stresses on the spinal column • Moving the trunk and pelvis • Aloslstlng In respiration
•
Abdominal wall muscles
+--+-- Lumbor spine
- -'--...L..-
l'l!lv!c·floor muscles
b
A AbdomiRill press • raising the intl'il-abdominal pressure by tensing the abdomiRill wall and pelvic floor musdes and the diaphragm Schematic coronal section through the abdominal cavity, anterior view. a The walls of the abdominal and pelvic cavity are formed by bony structures (spinal column, thoracic cage, pelvis) and also by muscles (diaphragm, musdes of the abdominal wall and pelvic floor). b When the muscles about the abdomen contract (abdominal press), they reduce the volume of the abdominal cavity, thereby raising the lntra·abdomlnal pressure and actively compressing the abdominal viscera. This action Is Important, for example, In expelling stool from the rectum (defecation), expelling urine from the bladder (mlcturl· tion), and emptying the gastric contents (vomiting). The abdominal press is also an essential part of maternal pushing during the expul· sive phase of labor.
130
B Abdominal press • stabilizing the spinal column by raising the intra-abdomiRill pressure Schematic midsagittal section through the trunk. left lateral view. Simultaneous contraction of the diaphragm and the musdes of the abdominal wall and pelvic floor raises the pressure in the abdominal cavity (abdominal press). The hydrostatic effect of this maneuver stabilizes the trunk, reduces stresses on the spinal column (especially at the lumbar level), and stiffens the trunk wall like the wall of an inflated ball. This action is perfomned automatically during the lifting of heavy loads. The "inflatable space" of the trunk can be employed in this way to lighten the pressure load on the intervertebral disks by up to 50" in the upper lumbar spine and by approximately 30" in the lower lumbar spine. Meanwhile, the forces eXI!rted by the intrinsic back muscles are reduced by more than so,r;. This explains the importance of well·conditioned abdominal muscles in preventing and treating diseases of the spinal column.
The Ttvnk Willi - - 2. MUICt.llature: Functional Gn:Hips
- - - -+---
R.ed:w; ~bela minis
b
d
c;
c Trunk movernenu aided by the ttnoTghhnd oblque mUKIK
c Trunk flexion m the right by ccntraction of the right lateral abliomi· nal muscles (aided by the right lntrir~slc bKk musc;les). d Rotit1ng the trunk m the right side Is effected by the right lateral a~ domlr~al mwdes and the left lntrtnslc back muscles. e Flexion of the trunk is efferted by bi1ater;d contraction of the rectus abdomlnls,lateAI abdominal and psoas musdes.
ofthe~bdomln;IIWilll ~
Course and arrangement of !he straight and oblique abdominal wall muscles. b Trunk flexion w the right with simultaneous I'Qtiltion of the trunk to the left side by conttactlon of the extemal oblique muscle on !he right side ;md the Internal oblique muscle on the left side.
lntt!nslc back
P5oastnljor Abdamhll rnadl!'l
lfti5Cies
Pllmr!or wperlor lltacsf)lne Gluteus
Anter'lor superior
lllacsp'tle ~ctpl
femo!ls
mDI'mUI
"~ Hammfngs
b
D Effect ofthnbclom1nalw~lf IIIU!Ides 011 peMc: mOIVI!fTM!nts: acttw and passtw pD:Sture a Normal active postlJI't', b ;active rigid postui'CI. c; pas5ive slumped posture. An Imbalance betweell the lntr1llslc back mwdes ;md abdominal musdes Is p.artfcularlyevfdent rn the curvature of!he lowerspllle and In the degrt'e of pelvic: tilt. In a nol'lnill active PQJturt', the pelvis i$ tilted for· w.rrd by appi'Oldmately 1r(a). When a rtgld posture Is assumed ("stom· ach lfl, chest out"), !he pelvis Is held In a more upright posllkln so that
c
the anterior superior mac spllle ind the posterior superior lilac spine are at lhe .same leYel (b). The most actiVe mwdes art' the abdominal w.rll muscles, the gluteal muscles, and the hamstrings. When the abdomlr~al musdes ire lax and ire not well conditioned, the result Is i passllle slumped posturt' (c) ~han excessllle degree of interior pelvic tilt. Also. the l«dotic curv.aturt' of the lumb.ar spine~ accentuated due tD progressive shortening of the inttirl'lic; b;lck muscln. This posturt' ~ re· Info reed by the tendency of the Iliopsoas muscles (psoas rr~a)or and lila· cus) to become shortened.
131
l7te nvnt wall - - 2. Musa~ltmJre: Ftlnctlonal Groups
2.8
The Muscles of the Thoracic cage (lntercostales, Subcostales, Scaleni, and Transversus thoracis) SaleM . . . . . ~
(J)Anllerforsc.MM: lr'llnlrtublrdedthtu-rse ~oftheC3-Cfiwn.inl ~Middle sa1ene: poJIItriot tubmle «the mn-w
prooeaa «the o-c7 wrtdne ~ Pastll1or salenr. posllllfortLDerde
•
• Arlterlor salale: •l'llllf1orlltlllene tubercle of first r1b • M'kidle salenc limnb (posterior to the g-fur tlwsubclovl•n 111ary) • ~lor salene: outzrsurt.ce oflht st
Oitgln lind !ftll!l1toft:
® ExtemlllntzrtDJti11'1'411Cies (costel tubercle to chondi'CHISMOus Junction): 1rlsntthe IOIIIIN!r mugln « 1 rib and ln•rt an Ill• upper margin of tlw next 1 -rlb (CDUne obllqlllly farwarcland d_,_rd)
® lnt.mlll~l muscles (costll1ngleto sternum):
• A O..nt.wafdlothor.dc:mwd11 Antel1or lltew.
• Scalene muscles. b lntm:D.ml muscles.
arise at the upp•r margin of1 rib 1nd insert an the 1 -m•rgln ofth• nut hlgh•r rlb (CDUne obliquely forwllrd and upward) "--mostiniJtrcllstel muscles: division« the infilrflll
<-----
lnl>lralobls Kllan) • ExtemlllntertDJtais: raiSe the ,., (In lmplniiOn). support tiM ~sp-. subhlethechtstWil • lr*mlllnllnloatU ._., tht ribs (In apntlan). support the lntzt'cosUl spaca, stlbllre the~ ...... iMido& First llnugh llllwnlh lntercosbl-
Adlen:
rr.--thorKit Ottgln:
Inner surfiCII! ot the CIOttiI artlllge of the st
lniB'dan:
Ill rough siXth ribs Inner surfiCII! dthe sternum 1nd xlphald pnx:ess
~the ribs (In expiration) Inn.,.._: Second through~ lntei'CIOIUI-
Action:
8 O..nt.wafdlo trwww~ dlo!M11 Posb!rlor view.
132
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
c
Antll!rfor, middle, •nd postl!d'arse~lene •nd tfle lntem1l nd II!Xtl!fn.tl tntei'Uidlbl
musdeJ Anterior 11tew wllfl the thor.u:lc age partially removed. Topographlally. !he salenl ire In· duded <~mong the deep neck muscles but functionally tfley play .. n lmpomnt role In thorilclc breillhlng. Subcostal musdes h;we the same orlenutron as lntl!nn<~l lnten:osuls, but skip over one or two ribs to form continu· ous sheets. especially at the angle of the sbdfl through elewnth nbs.
~ I~
EmmaI
mtades
lntercostll
muscles
~ I~
mtades lntm1.11 ~I
Sternum
musdes
Subcostal muscles
lllll!mal
lnt~
ITAISdu
Transwnw
tho radii
D TriiMWJ'S\15 thor.IC1s Piml!rklr surf<~ce of the rib section removed In
C (right half of the tran~us tfloracis mus· de), posterior view.
133
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.9
The Muscles of the Thoracic Cage: The Diaphragm
IJUT!bilrpart, rfghtcna
~~~~~=fi--
Lumbarpart. leftaus
"'=....,,;;;==-- - - Quadratus ll1:old~
Psoar. ma)or AorUc apetuA!
A OWrvtewoftfledllphragm
Ottg~:
• Cosul p;art: lower margin of cmbl an::h
{Inner surfi<e of -nth through twelfth rlbs) • LUmbarp;art(r1ghtanclleftaura): - Medial parts: l1-L3wrtlebral bodies. second and third Intervertebral dlsla, anllertor longitudinal ligament - UWfl parb: lll'lt tendlnousan::h of the abdominal
aorta (median arcuate ligament) at L1 assoela~ w1lh Its anllertor surface: semnd wndlnous an::h of the psoas arude (mediala~Uitl! ligament) from L2 -mbral body tii&SSOCII~ (I)Stl!l pn!CI!SS; third b!ndlnous an::h oft~ quadralllslumborum arade
ln.nlon: Adion:
lnnerwllon:
(lmlralarwate ligament) from the costal process of L2 111 the tlp of11b 12 • Stemal p;art: posterlorsurfaceofthu!phold process Central tendon Pr1ndpal musde of respiration (dlaphr.~gmatlc and thcndc breathing), alck In compressing the abdominal \'lsot111 {abdomlnal~nSSI Phrw~lc nerve from the cervical plexus (C3..C5)
B Posllt1111 afthe dllphragmand rtbs atfulllnlplratlonand upll\1\lon Thoracic cage, <mterforllfew. Noklhe different positions oftfle diaphragm at fulllnsplratfofl (red) and full expiration (blue). During a physical examination, the posterior lung boundarfes can be Identified by percussion (tapping the body surface). The respiratory movement of Ule diaphragm from end-expiration Ill end-<'nsplr.atton should be determined; It Is approxlmately4-6cm.
134
The Ttvnk Woll - - 2. MUJCUiature: Functional Gn:Hips
··""""""'"'-rl-f-- left dome
ofd!Oiph~m
wm~r~rt--~~~~~
XIphoid proc:MS
ofdaphragn ComI part af daphragn Tenth~b
C
11ledl;~ph111111m
• Antenorllfew, b posti!rtorllfN.
~~----:~---Pom11Dr 1Upei1Dr
lilac spine ~~~~~------~m
b
135
TIJe Tn.tnlc Wall - - 2. Musculature: Functional Groups
2.10 The Muscles of the Pelvic Floor (Pelvic Diaphragm, Urogenital Diaphragm, Sphincter and Erectile Muscles) a.v.toranl
OltgM: Pubis (lateral .at cwtgln of the pubo!Kt.alls) ln..nlon: Anococcygeelllgam81t, caccyx ln...U.: Direct branches ofthe s.acral plelcus (S2-S4)
A Schenll'llcofthepelvtcdllphralJm: the lc:Yitoranl (puboi'Kt.1111,. puboau:cygeus. indllloalccygl!lls} ind
ma:ygeus(not!Nwn) Superior view.
0> IIIOCIOOCWOitgM:
Tendinous arch of the lntemal obturator fuda (of the levator ani)
ln..,.._
Anococcygeelllgament,caccyx
Nlctlenof the pelvic ••~~rap Holds the peMc organs In place ln...,..._ Direct branches ofthe s.acral plelcus (S2-S4)
CD Deep~ pai-l OltgM: Inferior pubic ramus, Ischial ramus ln..,.._ \Vall ofvagina or prostate, centraltlendon of dlaphr.~gm In~ Pudendal nerw(S2-S4)
(]) Supedldlll...__pein_. OltgM: ln..,.._
Ischial ramus Central tendon of diaphragm
Ftmctlenof the ...,....r.a1 B
Sdlenll'llc of the urogenltlll dllphl'8gm: deep end s:uperfld•l transverse perineal
••~~rap Holds the peMc organs In place, doses the urethra ln...U.: Pudendal nerw ($2-$4)
lnferlorvlew. Q) rxt8~NIIRII sphlndlr
The extemal anal sphincter runs posteriorly from the central tendon to the anococqogealllgament (encircles the anus) Adlon: Ooses the anus •~ Pudendal nerw(S2-S4) (]) E:aten11l urednl.hlnda' Division of the deep transwrse perineal (encircles the urethra) Adlon: Ooses the urethra In~ Pudendal nerw(S2-S4)
C Schenll'llc of the sphincter and erectile muKies of the peMc floor: extem;ll <mal sphincter, uta mal umflrill sphlncta-, bulbo:!pangtos:us. indlscHoawmos:us Inferior view.
(]) lulbalpclnefOIIB IILins anteriorly fnlm the central tendon to the dltorls In females, to the penile raphe In males Adlon: Narruws the wglnallnlnlltus ln females, surrounds the awpus sponglosum In males •-uon: Pudendal nerw ($2-$4)
OltgM: ln..nlon: Adlon:
Ischial ramus Crus of penis or dltorll
SqueeZII!S blood Into the awpusQVUtlosum ofthe penis or dltorls ln...,.._ Pudendal nerw (S2 -S4)
136
The Ttvnk Willi - - 2. MUICt.llature: Functional Gn:Hips
lnferlarpublc 111mus
Urogerital hiatus
Sph\'u:ll!f
~Is
un!lhr.teoll!mus
} Levalar a1l
~~~--"'---
Qntr.ll
tl!ndan
Bulbo-
!pOngiDius Sphln(ll!f ~nlextenus
~--~:"'o
spllaus ligament
~ -~:-:---.
bctill ~ne
tlberous
ligament
•
c
D The ITIUIIdts of die female peMc:floor • Pelvic: diolphragm, superi~;~r view. b Urogenital diaphragm, Inferior view. c Sphincter ind erectile muscles, Inferior view. The term •urogenital dl;lphrigm• his been e<~lled Into question due to controYersy regallllng the existence of the deep trinsverse perineal muscle in the female pelvis. This is bee! use the deepb'anM!rse perineal bemmes heavily pameated by connective tissue with aging and espedally after y,rglnal deliveries. In older women. the deep pert neal space (see p.155) basle<~lly contains connectiVe !Issue that completely occupies the urogenital hiatus at the openings of the udra and vagina (see also p.160).
lmportilnt hnclfon5 of the Pelvtc noor Mullde5 The pellllc floor perfonns a dual funcaon: • It supports tile abdominal and peMc organs by dosing the ibdoml· nal and peMc Ql/ltses Inferiorly, bealfng the bulk of the lltsceralload. • It co~ the QS~eningJ of tile 11!ctum and urogenital pi1$$ill!le5 (sphincter functions), v.fllch med!anle<~llywe;rken tile pellllc floor by piercing lt. To accomplish these Inherently conflicting functions (sealing off the peMc c.avlty wltlle maintaining seYel'ill apertu11!s), tile peMc floor Is lined by ~rl;lpping sheets of musde and connecti~ tinue. This com· plex structure, however. also makes the pelvic floor highly susceptible to damage, espedally In women. Repetitive, extreme fluctuations In lntr.Nbdomlnal pressure and other stresses, particularly at the end of
pregnancy. can we<~ken the conMCUve tissue apparatus and damage the pelvic floor muscles. Stretching and other Injuries, as during labor and deli~ry (ill multiparae), e<~n elll!!ntually lead to pelvic floor insuffi· dcncy and IU y,rrfous dln!Cill seqUElae: • Descent of tfle pelvic organs (e.g.,llltrinecfesce:nt) • In extreme cases, prolapse of the uterus with eversion of the vagina (utl!rlllf! prok}jR)
Vlscefal descent Is generally associated wtth urinary or fecal rncontl· nence In response m coughing or other ~cts (rnus tnconttnMCe). Mild degl1!eJt~f descent often rwpond well to regular pelvic floor exercises, but more safous cases may require surgical treatment wl!h pfivlc floor repair (surgfe<~l exposure arid approodmatfon of the two levator crurapubarectalls muscle).
137
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
3.1
The Back Muscles and Thoracolumbar Fascia
Tl'llpez.lus, ------:!~~
deJ«ndtlg part
A The thol'llcolumblr 1\uda 111 ,_rtttSon'" ~the lntJtnsk
•nd nonlntrl'nllfc bM:k m!~Mief The trapeziiiS muscle has been completely re!TICMd on the right side of the drawing <md the latlS$ImiiS dorsi has been parttallyremoved to dem· onstra!J! the tharamlumbar fascia. The superficial layet" of the thar.aco-
138
lumbar faSCia $epa rates the lntrtnslc bade m~~Selel from the nonlntrlnslc muKin that have migrated to the back. Not!!: The superl!dal layerafthe thoracolumbar faSCia Is reinforced lnfe.. rtorty by the .aponeuroUcolfgln of the latiS$ImiiS doni.
3. ftfuscuJGf:urr. TopographicalAnatomy
The Dvnk wall -
Q
Vbanl r-Io
v......;;;;~,-----~
lntomol
Jugullrw!n
~~~otr
N!ii"..~lt.---
S..,..tdal
lll'tr
"'-ltlbral
lllotr
}
• Abdorrlnol
lnf'orlor
Porloal pe
aato
...... avo
mn""'"'"'lsfasda
I
~chalbodl
4j.j;il.ol. ....-- lltleril
ibdcmlnol wollmuodoo
- ----IIU.,_,.i-"-- Fllnus apstle >-~-+o/l,fl..,t;H--
hmnolt.
--,~r.l-fi.J..J---- ltenolfadlo,
pas11!rlor lllotr
~~~~--- Santul
posli!riOt Walar
lhor.aaoumbor } floscll
B Thoraoolumberfatd• a Tr;msverse section through the neck K the lew! of the C6 vertebra,
su pelfor view. b Tr01nsverse section through the post2rior trunk wall at the lew! of the l3 vertebra (cauda eq ulna removed), superior vtew. The thorico Iumbil r fudi forms the li!Rral portion of in osseoflbrous Qnal thit ~osa all of the ltttrinsic bockmu.sdes. Besides the thaniCO' lumbarf.sc:la, this una I b also formed bythewrtebral arches and the
spinous and costaI processes of the assocfmd W!Ubrae. The thoramlumbar fascli CUnJists of i1 superfldilla nd I deep ~r, especially In the lumbar region; both layers unite K the lmral m~rgln of the Intrinsic bade: muscles. At the back of the ned<. the superficial layer of the thor.~culumbarfasda blends with the nuchalfuda (deep liyer), becumlng continuous with the prewrtebrall;ryer of the cervical bscla.
139
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
3.2
The Intrinsic Back Muscles: Lateral and Medial Tracts
Rhombokle!Js -
----="i;f'-(
majot~nd n'lnor
Splerius ---1\W'~•\1 apltl5
Splerius - --!-'\ Ul'llldl
Semtur. ~
Spinalis
lnferlar lnll!mal
obl~e
Utl$$lnUS
doni aponeurosis
Exll!ITtll
l'lctemal
oblique
oblk(Ut!
rro-
costalis LDnglsslmw; Extemal oblique
lltacccet
"lhor
A Courseottflethoruoklmbnf.nd~ Postl!rlor\llew. To clemon.stratethethor~cclumb.arf~sela, both shoulder girdles and the extrinsic b.ack musdes hOJllt' been remcwed (exa!pt for the serratus posterior superior and Inferior and the apone\lrotfc or1gln of the latissimus doni on the right side).
a Lateraltl'llctofthe lmrtn.,c"'-dcmusde. Postefor\llew. Portlonsofthesupaildal layerofthethor.rcolumbarfasda have been removed on the left side of the back1» expose the lateral tract muscles (iliamstalis, longissimus, splenii aniicis and apitis). The levamr costai1Jm and lntatransversar1l, also p;~rt of the lateral tract, are covered here by the llloca5tal and longissimus mu5eles (see c and D). Notf! that the thor~cclumbar f~sela an the bade of the neck~ continuous with the deep I~ of tile nuch;!l fastia.
140
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
~~-- ll.ct.ltorH d!oracls~ I~~~~~..--- ll.ct.ltorH
d!oracls breYH
Medl;~l tr.Kt of the lnlrfnsk buk muscles (portions of the lm!rill tndlefttnplaoe) Pom!rioc' view. The longi$$imu' (tx«!pt for longinimu' apiti$) ~nd the splenii cervlcls ;md capitis hive been removed on the left side of the bade, and the entire Iliocostalis has been removed on the right side (see C for rotamr muscles). Milk the deep layer of the thoracolumbar f.rosda, which gives origin to both the lnll!mal oblique and the transversus abdomlnls (see D).
C
lhorac:dumbar
~deepl;ryl!r
Muh~
Quacntus
lumborum
D Medl;~ltrilctofthelnlrflllkbukmu~:cl•(wtththeenUrelilterlll triiCt l'l!fnllftd) Posterior VIew. The enure lateral tract (except for the lntertransversarfl ~nd levatoru co.surum) haJ been removed along with portions ol the medial tr.let to demonstrate the wrfo~JS lndlvld~~al musdes of the medial tract. Nokthe ongln of the transvenus abdornlnls from the deep layer of tile thor~columbilrfaKi
141
1M T1Vnlc wall - - 3. ll.fusallature: TopogtGphloal Anatomy
3.3
The Intrinsic Back Muscles: Short Nuchal Muscles
~~N,,--~7-~~~~~~·v.rJ
capt!' Stl!mocleldo- _ _..;__...,....{::.{
mam:.ld ~-~'----
Transwrseproc65 of atlas
-n;;r---- - - - Obllquuscapllh lnfmlt
A l.oc.1\lon oftheshort nudtal mu~eles (subocdpltll muldes) Nlldral region, posterior view. The suboccfpltoll muscles In the SU'fct sense are the $hort or deep nuchal muscles U\at belong to the Intrinsic b
142
the tii<Jracolumbar f;rsda deep ;rt ttle back of the neck and course between the occiput and the flrsttwo cervfc;rl venebr.ae. They .act mainly on the cranlovertebral jolnU {seep. 96) and support dlffen!nll'md he.ad mcwements (e.g., for fine adjustments of hel\ld position}. The fvll~ng muscles hi!Ve bem p;rrtlally rem DYed to demonstrate their IOCiltlon In the lfght nlldral region: tr.apezlus, sternocleldoma5told, splenius capl· tis, and semispinalis capitis. An Important landmarlc In the deep nuchal region is the spinous proce$$ of the axis.
11Je Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
Su~ nuchal foe
Scmlspln~lls
apltls ~r-+--- RKtusc.lpltls
sumodeldo-
postl!tfor ma)cr
mastdd
,....,;- - Obllquus
SpleniUJapltls
Oblrquus a pillS supertor Lalglsslmus
CIPIUss~ -----'~~
.,..;,.---llliiSIIlidp~
------'-~
apltls
B Courseoftfleshortnuchillmusdes Subocdpltal region, posttrforvlew. The 11!ctus capitis pl:lro!rior major and obliquus capitis su· periormusdesor~tilerfghtsldehavebHnpar
Spnow flC'OCit5Sof0
tlally removed.
-~i:2=:..;_---t
~mlspln.llls
Re
R«tus capitis
a pill's
po.sterlor minor
po.stl!rlot major
C Ortgtn artcUnsert1Dn of tfle IIIU!Ides rn the tuboccTpltal region Pom!rior 1/iew. The colon:!d ar-Ns indic~tt' tile origins (red) and lnseftlons (blue) of the musdes.
143
1M T1Vnlc wall - - 3. ll.fusallature: TopogtGphloal Anatomy
3.4
The Chest Wall Muscles and Endothoracic Fascia
Anterlcr~or¢.~- ----t~t
dnalllgament
-~~. .~~7----
lO)ltlokl --:-~-;---..=~-f-~ pnHZIS
Nuthal
lgaml!ilt
~------ Salenus medW >'-'•~-- Salenlll
partl!rlct
flrrtrb Anterior laf19111r
Costal car1llage
dhal fgament
~~---~~~~~~-~ GliSI:otr.IMWI'S
ligament
A Mu•deuftfu:chatWllll Anterlorvlew, b postzrlor'lltew. Topogr.ilphlt.llly, the lntermstales. tnnsversus thor.u:is (see Ba), and subrostales (see Bb) are lnducled ln the category of chestw.rll musdes. Nair. The scalene mwdes, 'Which belong to the deep neck m~~Sdes topogr.tphic;ally, .toe d
;a
b
144
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
Rlb
Marnb!lo.m
stemI
Vlsatlll
(pulmonary) pleunt Partetol (mst.ll) pleu~
E.ndott.a ra de fasda Pl~r.ll~
CostJI sllcus
Boclyof stl!mum
lnb!<'alltllartery, w'h, ;ond nerw
lr.lniWfSUS
Extemallntt,..
thcr.ar:ls
tOStJIIl'AIS
tOStJIIl'AIS
l'lrietll pleul'll,
OlllphrJgn
tOStJip.wrt
PhredCGpleural fasda Partetol pleu~ (dl:lphr.agma!lc
-
Ad;u
Costochph~
Ante!IIX'Iongllu· -----;:,_..,,.til~ dlnalllgllment
p;~rt)
l'Met
B Endothon1ck~•d• Posterfor surface of the dlest wall segmem removed In b. b Posteriar dle.st w.all, anterior view (endathor~ck:fasda remoftd ontheleftslde). c Coronal section throcJgh the lat:eril chest wall 01nd cosmdlaphrigrnaUc rea.ss.
;a ~~u~l---~~~· ~
rnembr-
(Sib:lon's md1)
.~$l~-
lnttmal
lntf!I'OliSbl nudes
Parletll pl~ra.
dlaphni!J· malic p;~rt E.ndotti!X'IdC
fascia
The thoruk caVIty Is lined by" faselallke layer ol aM'Inecti~ tissue. the endtsthomck {o!iCKI.It lies betweenthed~ musclesofthe ell est will and the cos toll por11on of the parletil pleuri, to which It Is firmly attached, 01nd IS inilogaca to the transvernlis fascia of the abdominal cavIty (a). The endothoriclc fascia Is thickened owr the pleural apex to fonn the suproplf!Ural membrane(SibsM'sjUscla). Thephn!nlaljllf!Ural (osdo is the portion of the endothoracic: fascia that connects the diaphragmatic part of the p;u1etal pie uri to the upper SIJrfice of the dla· phragm (b). The costodlaphragrnatk: recess
(c) betM.len the ell est wall and diaphragm Is a potemlal space that enlarges on lnsplr.ll:lon QO!Nerlng of the diaphragm) to 01ccommodate the expanding lung. The plana! space i5 the potential space located between the parfet;llf costal pleura and the visceral pleura, which dl· rectly ln-ts the lung tissue.
145
1M T1Vnlc wall - - 3. ll.fusallature: TopogtGphloal Anatomy
3.5
Thoracoabdominal junction: The Diaphragm
CCistllpaltd - --f-;-f, daphn~gm
A The dl•phngm,superklntew The diaphragm consists of three
parts: costal, lumbar, ;mel rternal. the mlllde that separates the thoracic and abdominal cavities, the diaphragm hiS characteristic apertures for the piSsage of the As
e.sophi\lgus, infi:!rigr Vl!na av;~, and aCII1a (see Cb and Dd}.
wnbiri);Jrt ofdiphr.~gm,
Intrinsic
backmusclu
left crus
5tl!mocostll triangle (loi!Te)'s deft)
Lumbirpalt ofdlaph~. right crus
Sternum Stlernil~d dl1ph~
Rectus
ibdomhis
Cost.1l part of
Med1n
daphragm
Aortic
Esophageal 1perture
l:xtllmal
obtque
Lumbar part of dlaphr.~gm,
wnbir(l>irtof dliphr.~gm, rlghtaus
left (I\!$ Lumboc:Dst.ll
Intern;~I
tllande
obtque
(llodldilek'$ I!Iande)
lrli'IM!I'SUIJ
utlss'mus
lllxlomlnls
doni
B Thedf;aplngm.lnfertorvtew
146
Vtrtl!tlr.al body
lntrlnslc:
Medlallii'QI~Ifg;mert
bade mlades
(pso;lsan:ade)
The Dvnk wall -
M1oobrlum
lntl!mlllnteR:ostal musd01
1'11nwenus
Venoavol ~ptrt\Jrt
tllo111ds
C'.oltiiJYrt
bo6j
ofd&,ph.-gm Aartlc
Certral ll!ndon
anum ilpment
lptrt\111!
110 wrtebrol
Vtnltw~l aptrU~re
Mtdlln
EIO~I
BodyafJb!mum
ltfU.rcuiGiure: TopographlaJI Anotomy
Esophageal openure
Tlvnebrolbudy
Cen!AI tzndon
3.
Gost.al partol'
daphragm
Lallerilii'CIIIII! ilpment
LLmbarJY!tof daphragm, left crus
~~··· """'"")
T12 wrtebrol body
Modlll•num ligament
~
Coltii..U.
Aorticlpcrt\Jre
(psoas .....do)
T111~
TI'II1MnU!
Quachtus lumbonm
•bdomnls L5'm11!brolbody
abdomlnls Ploalmajor
Psoosmi'lor lbcw
1'111farmls
Sicrosp'hous II~ mont(
llopso&~
Glull!us mu)tua
•
• Tl vesubral body 11o."'i~~~:.._- I~IIOrwna~
lnflr1orwna CiiWI
-~-;;a
Modlin arco.ate IIgamont
. ,•.,_~~--- &oph1gus
T10'm11!bral body ~Mi::::...--
n2 'm11!bral body llor1
• D Posll:lon and shape llf the dlaphl"'gm, anb!l1ar view
Coronal section w1th the dlaph~m In an lntermedllll:e position. a The apertures are located in the region ofthe central tendon (inferiot
b
C PDIIUan and lh~pe crt' the dlllphngm, viewed from 1M left side MldsagltDI section demonstrat:tng the right half of the body. The d~
ph r.agm Is In an lntermedlite position at Md·e~q~lntlon.
a TheapeMllreslnthedliphragmaredepkUdatwrtScalposiiiDnscor~sponding CD the fglfowing landmarks in the ~ thoracic spine: wna cavlllaperture - T 8 wrh!bl'ill body, esophigulapertu re - T10 wrll!~l body, ~artie a.-ture • T 12wrtl!bral body. b The dlaph~matlc apertures and the structures that they tl'il nsmlt.
vena cava) and In lfle lumbar part of the dliphragm (esophageal and aortfc aperturu). b Enlarged view of the diaphragmatic aperture.s, with vessels t.,n-
sected. The vena cavlllaperture Is located to the right ofthe midline. the esophagul and o1or1Sc .apertures to the left In a dlc/phnJgmllfk hfmiD (diaphragmatic rupture), abdomlna11/1S(2r.J prolapse lntD the chest cavity through o1 cungenlt.JI or acquired inea of we~kness In th• diaphragm. By far the most common herni.Jtfon site is the esophagul iper1\lre, accounting for 90X of ca-. Typically the distal t~~d of the esophagus .and the gastric cardia (gastdc lnl«) •slid•• upward through the esophageal aperture into the chest (axial hiatal hernia or sliding hernli; ippraxlmately 85X of ;Ill hlital hernias). Typical symptoms ire o1dd reflux, heartburn, and a fl!ell ng of retrastemal pressure after me.JIJ. More ~~ t.ases may present with na~~~e~~, ~.Vmitlng, and functional cardiac complaints.
147
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
The Lateral and Anterior Abdominal Wall Muscles•
3.6
• The posterfor or deep abdominal w.~ll musdes. most not;~bly ttre pswsrn.ajor, a~ ;Ktu· ally hlp musdes In afunctlonal5a'1Se because they 01ct predominantly on the hlp joint. For this reiiiSon ttrey .ilre desert bed In ttre chapters on tfre Lawer Umb (see p.420).
'-
PtctoraUs major, ----.=!;l!:i!~=:-o
stemoeosul
!)art
PtctoraUs INjor, abdamlnalp.;~rt
>-~····
Emma! ablque
MU~~-----!~~~~---(
shN1!1 (I!IICb!mal obtque apon~IS)
hb!mirl ----,ii,..4;-~w:I:
lnt~
arthlll!
mUK!es
Ex!!mal
lngu'nirl ----f-------r'\,.
lntetcost~l
liljilllt!nt
Superficial
musdei --+----------......;.;..;:..~..,._
IIKturo -+.~--¥!-.~-ffi:'. abdamlrfs
bgulnalrfng
• Spennatlt «o~ ~musde
Fundfonn ligament olthepenls
£xtemrrl oblique
A utl!nll (oblique} abdomlr~~l Will mu~eleslnthem~le
Right side, antertor view. The oblique musdes of the abdominal wall consist ofthe external and internal oblique and the transversus abdomlnb.
• The external oblique aponeurosis borden ttre superficial Inguinal rlng,lts lnferlormargln forming ttre Inguinal ligament. b The external oblique,. pectoralis ma)or, and St'IT.iiM anterior musdes have been ranoved. The Inferior border of the Inter· nal oblique forms the roof of the Inguinal canal (seep. 182) and is wntinued ontD ttre spermatic cord In the male iS tfre cremaster muscle and tasda.
lteclus sh elth (lrrtmlrrl oblique liPO neu rosls)
MUI'IorSJperlor - - \1 Mlacsptre
b
148
__...,....:..._-=-- Costil
'·'
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
B Antertor (stnlght} abdominal wall
musde$ In tile INIIe Right side, anterior view. The straight or strap muscles of the abdominal wall Include the rec-
tus abdomtnts <md pyramidalis.. a The Internal oblique has been removed.
b The uJlller portion of the rectus abdaminis has been removed. Nok: Below the arcuate line, the traruver· sus abdomlnls aponeurosis and !he Internal
oblique aponeurosis lie antelfor to the rectus abdamtnts (see alsop. 151). ~s----~._~~~+.(
abdomlnls
Tr.lnswnus ---~:!:::=:o
abdomlnls
Tr.l~--~------~~~---
abdomlnts <JJ)OOI!II'05is
(-r!or n!ctuntu!lllh}
•
Tr.lns'l'ei$US--~
abdomtnrs
Rectus abdomlnls
---4i·&~~~:;
tngutnalltgament _ Tr.lns'l'ei$USMldon'inls aponeu-osls (passes ;mll!rior to !he ~abdom_,ls
_..;:..--·~'
~-.....,..,..;,__
_ _ Deep
tngumlr!ng
below the lrc\11111! liM)
b
149
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
3.7
Structure of the Abdominal Wall and Rectus Sheath
Manublfum mmr
Bodyofmmum Endotflo r.KIC fascia
TranM!I'SUS thoracls Unlnl tendon
P.Jrtetal pleura, costal part P.Jrtetal pleura, dlllplngmatlc part Dlaphr.agn
Costllpart ofd'aphr.agn ureulba Tr.lnMn.alls fasda
P.Jrtetal per!blne&.m
Em!INI oblique
lntl!mal oblique Post2f!cr
nectuuhealh
Tl;lMIVI!S'SUS
abdomhiJ Tn1nswnw abdcmtlls
Umbrtcus
An:u~llne
l'lanecfsectfon !nCb
lliira6 ltec:lus
llbdcmlnls
A Ow'I!MI!w of the ;~bdomtnalw.Jhnd r.ctuuhNth Posterior view with the vlscen removed. To show how the dlaplmagm separ.atl!l the thor~ ere ~lty tRim the ~bdomrnal Glllllty. the tr~nsver "'lis f'a5ci;1 ;and p;~rieul periton~m havt' been removed from the left obdomlnal while the endothoraclc f.lsda and parlet31 pl~ra have been removed from the left chl!stMII. The l'l!CI:Us slu!Gth (en dosing the
M"
150
rectus abdomlnls m111de) plays a special role In the abdominal wall. because Its structure ch;rnges below the arcuate line to accommodm the Increasing preS$ure of the \llscer~ ~~lnst the body w~ll (see C). The rectus sheath is formed by the aponeUI'O$U of the later;~! ;abdominal muscles (ofwhich only the transYersuslsvlslble here; the othen are hld· den) .md Is dMded Into an ant2rlor and a posterior layer.
l'liUmil oblique
• strueure oftllnWoml"" - 'l
Cross section through tne abdomlnll wd ~.,_tile umbilicus. superior view. The fDIIowlng I~ a~ distinguished In the 1*'<11 ~bdomlnal Mil, from Inside to outside:
llDmll oblique
• Pilfml pei11Dneum
• • • • •
Tn•nsverMiis fascil Trinswrsus ibdomlnls musde lnttlml oblique muscle Extemill oblique musde SUperflclalabdomlnil fuda
• SUbcutaneous tissue • Skin
Extllrral oblique aponeun:tlls
Rectus
Uneuba
abdomlrls
Sldn F«ty
1.,-.suporlldol modo
I .-.rt.ul
T111nnwsolls
perltllneum
f>ocll
ttllmll
•
[Dmal abli
lntorn1l ablkp
abli
r..n-rsta
lpoMU"OSis
ebdomlnls
lniBIIal obllq~a oponeurusls
llettusshMh ont.rtar'-
Unenlba
S..perfklll obckmlnolf.a.
.. c
!il:ftldurR of tile recllls IIIMth
Cross sections through the rectus shuth superior (a) and inferior (b) to the art:Uilte line, superior lllew. The aponeuroses atthe 1*'<11 ibdomlnal wall musdes eRSheath the anti!IW strap musdes tD farm the redulll sheith. This creates a muscular mmpirtment mrulstlng of in anterior la)'l!l' and a postBior 1~. While the ipone~ of tne three fateril
abdominal muscles mntnbute equally to the antl!foor and posterior layen of the sheath above the umbilicus, the tv.v layers blend together approxfmiltl!ly 3-5 em bel-the umblllo&s (at the lewl of the altlliltl! line) to fonn a single (and Cllnsequently more stable) sheet that passes In front of the rectus abdomlnls musde. ~ tM llmllllr liM, the posterior fa)'l!r ofthe rectus shNth Is ibsent
151
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
3.8
The Pelvic Floor Muscles: Overview of the Perineal Region and Superficial Fasciae
S;JcnJm
SUperior
Scrot\lm
Pelts
pubic ramus
lnfi!tlcr publct.lmw
Sacrum
A Perine-al region tn the tem.le (•) •nd m•le (b} Lithotomy position. c:.;rudal (Inferior) view. The perineal region In both sexes consists af Ule urogenlfl11 region intel1orty ind the adjacent CHICII ll!!lfon postl!rtorly. The two regions ~re separlllled by i line ~t runs between tile ischial wberosities. The perinn~m denotu the soft·tissue area between the thighs and the buttocks. In the female, obstetricians refer to the pel'fr~eum.asthereglonfromthe.;mtenormarglnaftheinus
152
to the posterior commiuure of the vagina. It is considerably longer in the male, extending from the anal margin to the root af the scrotum. The perlnNm Is a region containing fibrous ind fatty tissue, ~nd the pefMo/ body (see Ba), a fibromuscular mus also refem!d to .as the centro/Wndon o(tll~ Pfrinn~m. Amore detailed structur;l description of the perlnNm Is glval on p. 156.
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
lsthlcGiwmcKus
Anal deft
Bulbospongosus
lnt.!rior pdvlc dlaphragmltftfasda
a Superfidlll fasciae ofthe ferNie (a) and m~~le pelvkfloor (b} Lithotomy position. caudalvlew. The superildal perine;rl fascli (urogenital region) ;rnd !he Inferior peMc dlaphragmatlcfasda (in
bounded PD$teriorly by the superiitial traMverse perineal and superi· oriy by the perineal membrane. The bulbosponglosus muscle Is loc.rted In the medial pi!rtofthlssuperildal perineil space, the lschloCiYemosus Is loc.rttd laterally. and lhe superficial trllnwerse perineal Is locort:ed posteriorly. The green arrewt in e;rch f'!lure points to the anterior rea:ss of the left lschloanal fosSil (see ;rlso p. 496).
153
~ Dvnk WtJ/1
3.9
- - 3. Mu.tculabue: Topographical Anatomy
Structure of the Pelvic Floor and Pelvic Spaces: Female versus Male Exmm•IIIIK ~~ndwln
Ulll1no raund
llgomut Ulll1no czl'llx
P•-11111
~~~~~~~-- u~ ~"i'--'+-';......,---:1---
Vllun•
i+- - - Pudt!ndol
(Aiaxb) carwl
----lnfaiar.,.Jik: r1mus
~ CnlsafdltDrts, lsctdGCMm·
osu:smusde
C Subdhllllo111 oftiM pelvis and llbllctu,. Dllhe pelvk naor (ln both sexes) SUWM"-flfthe .... The pelviSis the portion of the ilbclamlnal cavity loatacl In thelluer pelvis. It is su,... rounded by the skeleUin of the lesser peMs. which meets the gmtltr pelvis It the linea f1rmillalir (see p. 114). The pelvis iuubdMdld lntD upper, middle, ~nd 1_.1..,..11 by lhl pelftoneum and pelvic ftoor: • Up,... I-': pe1111oneal Cl'ltty ofthe lesser
pelvis • Mid•• ...,.,, subperllxsnul sp;~m
• a - lwll: subfliSCIIIJP~Ce (lschl01nal Veollbule af111gln•
fassa)
Vestlbulor bulb, bulbmpanglos"' muscle
SUbjllanttDthe pelvis are three more opams tNtare mnsldered tD be sep~m. from the peMs Itself: thedetp ~~ tht sup«ffccoopfttl«
A Corvn1hedlon through tlletw-le pelwt1 Anterior Yi~M.
...., .........
<-A.
IW1tonun
Ullnls
~
Superior ...... dlaphrogmallc
,...
~fllfthe
~
Sllwbn. . . . . . . . . . . .
Thllhlee IIIUSC1IIar and Cllllllldlve-Ussue sheets INtconlltlut. tD the 51nlduredthe pelwlcfiDar •ranged In lhlee lewis:
are....,
r-s.
awlty
• Up,... '-1: pllvk claphragm
lemor1nl
.-e
~
• Mid•• ...,.,, deep urogal"bl muscles • a - I...,: sp/llnct.rs 1nd erecUie musda of the u.....,ltaland lnlllltlnal tract
lnforlor ...... dl1phrogmallc
.,....
SlllnKIII
r-s.
lllcHo1rwl l'aul)
u.....,....
.,...,
,..phnlgm:
DeEpperii'U
Fasclaofthe deoplnlnMnl pertnal
SUpridlil pe~n..l sp;IIZ
Deop
tro............, per1rU Pwlne~l
rnombrono
lsddocavom· BUibosponosus glcsu
subcuto....... perineal""'""
!"nctlo muodet
I Pllvtc SJiiiCB, flsdle,1nd IIHIItl-nt Dldle p~~lvkftaor musdMin 1 tw-le pelwt1 Coronal section It the level of the v.~~glna (see srnilll dlagrim above fur theeuct loatfonoftheplane). The 1-lsofthe pehlfure shown lndlffamtcolon.
1.54
The fu nnel-sh1ped pelvic dl1 phr~m Is farmed chlelly by the lev.torani musde ;~nd Its superlar 1nd 1nr.11orflsdae (superficial •nd lnfelfor pelvlcdlaphragiNtk: fasd11). The deep urogenlbl mUKim (.seep. 157) ll"el hollzontll shMt of musde lind omnectlwti-tlllt stNtches "--the lschl•l•nd pubic rami. ItII fanned mainly bythed"P transverst pelfnet ImUKits lind its inferior r.ciH (perineal membrane). The sphlnctllrs 1 nd erectile musdes mnslst of the bulbosponglosus, lschiOCliVemosus, 1nd the extima Iureth111l 1nd exte~mla nal sphlnct.rs with their associm!d muscul•r f1sdae p. 136).
<-
11Je Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
Uillary
bl;ulder
Planeof!illdlon
" "" "-""'--
lnDandE
Glu!ais mlnmus
Urethra, membrana~&
~~~~~~~~~~--Obru~r
p.wt
~~ Qu;tehtus emmus
~~~~~~~~~~
tr.lnswne
fl!mafs
pl!ffneal
lnfenct publc!'
Bub of 1)811s,
Superfiaal f)l!mealfil!lda
c<~rpussponglo:sullV
Slbc:lltlrnow ()l!r!neahp;u:e
(Coles')
bubcl:!pcnglo5us musde
D Coronal sec:Uon through tfl~ mill~ pelv'ls Anterior vi eoN. F Boundirt• ~nd contents ot the deep perfne.JIIpiiiCII and superfldlll pertneal space (ColleS' spaat) In tfl~ male [and female)
.,.,,.._,.pace
Obl:lntor
ln!J!mus
• Boundarlci:
- 1'81neal membrane - lnferiorpelvicdiaphl1gmatic fascia - Supl!l'flclal tr.ln.swne perinul muscle • Cantents In 111e male [ln 111e female): - DeEp transverw perineal muscle
- Membraoous partofltleurelfua - Bulboureltlral glands -Terminal brMnchesohhelnbmal pudendalarll!ryandwln - Terminal branches ofthe pudend;tl neNe Superftcflll pemul.-e
• Boundarlci:
- Superficial perineal fasdll (Colles') - Perineal membrane - SuperfiCial tnmsverse perineal muscle • Cantents tn 111e male [ln 111e female):
- Bulb of penis [vutfbular bulb]
- Cruraofltle(l)ll)usavunosum [crur.t, shaft.andglansoftht lllllbof ()l!nls
E PelvTctp.Kli!S.Iilsdae, and a!TIIr~gementofthe pelwkfiDOr
mu1des In a male peM' Coronal section at the level of the prostate (see small diagram above for the ex
dltol1s) - Bulbospongiosus musdu - lschiOClMI!rnosus musdes
- Termtnat branchesofthelnbmat pudendal arll!ryandveln -Terminal branchesofthepudendalneNe The su~YI perfnNilspKe Is lacated between 111e superficial perineal fasda and skfn and contains mcst:lyfatt.ytfssue.
155
1M T1Vnlc wall - - 3. ll.fusallature: TopogtGphloal Anatomy
3.10 The Muscles of the Female Pelvic Floor and Wall
Anteiorlnll!r!or "'-..._ ibcll)!ne Antl!flcr~141t!f!ot
~
- -----":..
llac41fne A.tlrblbulum
Ischial llbefoslty
~~7-~
SUp«ffccaatr.lnMne pet! neal
Sacrotu~rous ligament
A Mus des oftfle pelllfc floor ilftl!r rei1IO\Iill oftfle hsc:tal!
Female pelllls, lnti!rtor view. The mwwlar lil)'l!rs ~re progresslllely removed from 8 thrvugh D to dl!m~nstratli! the underlying muKies
ftom a consistent persp&t!ve. The lev.rtor ani mil!de Is dt$albed mane fully on subsequent p;tges.
lsdllal --~-+==~
~
Sacrospbow ligament
8 MusdesoftflepeMcfloorwtththetphlriCtersremcwed Female pelllis, inferior view. The sphincter muKies hilllt' ~ nemoved
ftom tile urogentul inc! lnte:stlnil tract(· bulbosponglosus ind extErnal anal sphlnctef), leallfng the external urethral sphincter Intact.
156
Pfr!fonnls
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
=ts}
~--~==~~~--- ~ cocxygeur. ~~4----
~ <ml
Ito·
Cocxygeus
C MU!Ides of tiM! pi!Mc ftoorwttfl the urogenltill mll!ldes remowd Female peMs, Inferior llfew. The u~enlt.tl musdes (• superlldal and d~ tr~mwrse perineal and the lsdllocavernosl) have been ranoved. Not!! the opening of the levitDr hiatus, wfllcflls bounded by the two
rect
aura of the puborectalls muscle (the "levitDrcrura•). Note illsothe pre·
Superior publcl'llmus
---------:-:=-::
'-~-----.i:!~--:!!!!:--l:---- Obll.r.III:Gr ~
D Mllldes of tiM! pi!Mcwall (pertetaiii'IUICies of the lesser peM1) Female pelvis, inferior view. All of the pelvic floor m~~Sdes have been
ranoved. lealng the •partrul• pelvic muscles lnt:3ct (obt:uritor IntEr· nus, ccccygeus, and piriformis}. Along 'With the skeleton af the lesser
pelvis, these muscles ccntl1bute structurally to the peiYicwall and assist in closing the posterigr pelvic CIUtlet. The obturator intemm ~nd its l'a$· da prollfde a tendon of origin for the lllococcygeus, whlcfl Is part of the levmw ani ccmplex (tendinous arch of the levator ilnl, seep. 159}.
157
1M Trvnlc wall - - 3. Musculature TopogtGphlc:alAnatomy
Pelvic Floor Muscles: The Levator ani
3.11
Pubk tube~~
}-lscha.l spin~
T...rllllllll~ --~~~----
~--------~~---~as
af levotior •nl
~~----------~-A~~ lllkcmt
! - - -- - - - -1---
Cocqx
Sac!Oillacjoilt
Sacn.m
I
O~u~r------T~~~~~
lnl2n'w An~ ----.;.....:~------___,:
lgmll!nt Co
b
A hrts of the lev.tor Jnl •nd the JNOrlehol muscles of the peMc -II Female peMs, su perlor view. a The I~IDr ani musde consists of tit ree ~rts: the puborectalls, pubom«ygeus, and llrococeygeus. It artses from the an~
rior and li~l pelvic wall gn a line nunning fTliiT1 the ~of the pubic symphysis ID the lsmlal spine (- tendlnDus ardl of the lewlllr ant). As il contrtbu!Dr ID contlnena, the puboredrll1s muscle iiiSSists the exbrnal arul sphincter (not VIsible here) In eeplng the anus dDSed. It arisa fTliiT1 the superior pubic ram115 gn both $ide$
158
of the symphysis and ext8'ds posteriorly past the organs ID unib! at the midline behind the rectum (anoc:uccygeal raphe). It has the shape of an ardled g~. Its hWI crura (the levii!Dr cnura) forming the boundaries of the levator hiabls. CGntradion of the puborec· tal is driiWS the perineal flexure forward. as if thnoll!lh a sJ in g. b The puborecta Its and pubococcygeus musdes ha~~e been remowd. The coccygeus (muscle ftben on the si11CT05plnous ligament) and the plrtformls complete the pelvic outlet pomr!orly on both sides of the sacnum.
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
B Tendtnounnhoftfleii!Viltonnl Right hemlpehlls, medial view. The tendinous ~rc;h of ttue levator ~ni is a thidaening of the obturatvr lntemus fasda which serves as the ortgln of the lllococcyge~~s muscle.
Mll!rlar S\lptrlar
Olacsplne Mll!rlar s.xro11ac
llpnent5 Arwiteline
- - - --->;=---..JIIII'
r .:.."""-''""St-- (oa:ygeuJ
Olmntor lnlemusfmcil
:""1'r-li--
lsd!lal spine
=---Co«yx
. .____
::=:::::i~~~~~~w
Anoa:lt'C)'Vellli!llrMnt
Pll<der'lar - --+ stJper'lar lllacspne
Sacrum
c.xtygeus ~~---
Acetabuh.m F\lblc l\lbeltle
~~---
C
FunnehMpeoftheleu••ta:~r•nl
Pelvis viewed from tile right side. A portion of the Ischium Is shown transj)irent. Beciusetile muscle Is irranged In a cnne or funnel·shape, contraction of the lev<m~r ~ni ca~~Ses the anus to dfsomd when there Is a concomltint rise of the lntr.t-ibdomlnal press~Jre. Acamllngly. fltw1tfoll of the <~nus results &om relalliltlon rather than contraction ofthele\'itor ani.
159
1M T1Vnlc wall - - 3. ll.tusallature: TopogtGphloal Anatomy
3.12
Pelvic Floor Muscles: Their Relation to Organs and Vessels in Males and Females
R.ectum. ampulla
L--~-t-- ~tg;ment ~-------'-:------:l~-
~~.----~~~~~~~1~~~
·,_..____--:-;:..____,~--
membl;lllOUSp;lrt
Olrpus
-
---iii;.£
R:--'~-.......,~--
I.A!WIO
Ext8nill.ml sphlnch!r
c:Mem~XSum
Uneth~. --~-'!'
penfecupangyp.wt Glanspenls
- -----.- c:·• •
A Mlds.Jglttill sec:tlonthrough il m;ale peMs
Olrpus 'I'Onglonm
Right half oftbe peiYis, VIewed frcm the left side.
RDund ligament ofthe utlel\.5 Ub!rfne c;Mty
------'i---'~~
ltectoLI!o!r'he
paudl
lkharybladcler - - --TPtblci)'mphysls
-.::--=;;iiO
- - - -+ -
~~
L...J.--iL----l~'l- lhler!neamx "'ii--T-c:,---+-
T--
ltb:I!Jm, ampulla
----'':---- - -r.-..:.....'-1 l..r7--~=-----=~-
lntemalanal
'!lhncll!r
B Mlds.Jglttill sectlonthrough il fem;~le peMs Right half oftbe peiYis, VIewed frcm the left side.
160
TIH! Ttvnk WGfl - - 3. Musa.rlature: Topogtvphkal Ancrtomy
Adductor muscles
Urelflra, prost.;ltiC p;l rt Lev.~~~~ rani
1\lbk:
,.,phy.sls ObtuMOr
PrclstR
eW!m~
ObtuMOr
membi\Jne
I'Emtr
Semln.ll
lso:hlal
wsld~
tube1051ty
RKtun
ObtuMOr lnll!mus
Scllllc neM
Gluteus
lso:hiOliNI fosfa
maxmus
Plldendal nenoe, lnll!mal pudendal
aruryandwn
C Crosu«Uon tfuough ;a malt peMs SupertorW!w.
~MY bladd~
1\lblc symphysis
lnftrlor
1
pubkrliT!us
Vadus--~~--~~~•
lalleralls
Sda!kn~
Rectum
LA!\r.ltounl
ntl!mll pudendal
artery and win
D Cross 54!c:Uon through ;a fem.Jit pelvis SupertorW!w.
161
4.1
The Arteries
A OwrW!w oftflnrtertesofthe tnmk wall The ~m~ngemc!llt of ttue neurvv;~:Scular struc· tures lr1 the trunk reflects the segmc!llt
~~ij~-~~~------lnternal
thonldc artery
::=....;::o:r--:iiE<-"'M---- Mrtft ardl
IIIIWJ:
!!!!!!llll~r:r-- Ascl!nd'ngl10113
• The first and s«:ond posll!rior intercos1lll al12rfa,IM11ch are glwn df lit' the superior l~l<mry(- braOOI of the ms!DarY!altrunk,- D•) • The tHrd thi'O\I!tl t!Mnth posterior lnb!R:ostal ~rterles (uch giVIng off~ dorsal, .a colla!J!r.al, and a ~ral cutlneous braOOI, seeD b) • The musculaphrenlcartery (one of the~ llennlnal brllllthes of the lnllemalthor.~dt .arury). wN:ch runs ~indthe
-·
• The subcostll artery (twelfth 1~1 artery), suI • The antl!rfor lnllercostal a112r!es.IM!Ich ariSe from the lnllemalthoradt artery. set I
Mlnyothr"ft901111" arttrtlssupplytht .ntl!rtar,llmnl,•1111 pcllllll!ll!arlnri: Mil. AnatlorIIUI!htd • The perfor.Jtlng branches (from the lntl!mal tharoldc artery, e.g., the med\111 mammary br.anchesthat si.pplythe brsst), -ob • The superior eplg21tr!c .arttry(mnl!nuatton of the lnllemal thor.adt artery, see I and C) • The lnfa1oreplgilSU!c artecy(fromthe allemlliliaurtery.setlandC) • The suptrl!cllll eplgastllc artery, sed • The superficial drn~mftex llac artery, see I • The deq>
l'ritsfftiorlnlnkwoll • Donal branches (fnlm the posterior lnt:2nmt!l.arttry), each with a medal, a latlni(IJtaneouund a spinal branch, set De • The first thnlugh fllurth lumbar arteria (uch wtth • dors.Jilllld l!plnal braOOI), see I • Themedlans.xralartecy,seel 1.-oSIIUI!tWillS • The superior thcndcartecy, see I • The thor.amac:nxnlal artery, set' I • The lmnlthoraclcartery. see 1 • The lmni(IJtaneous branches (from the 1~1 aury), which dlstt1bute br.~nche:s mainly to the brust (la11!ral mammary branches,Jte Db) • The Ololumbar artery (from the lntll!nlal mac <mry), which gl¥es df an II lie. alumbar, .~ndaspttalbranch. set I
162
l...titU
artery
Anll!rlor ----'-~ ln-1.11 amrles
SUpEI!oreplgamstlll'ttry
--~.-'-';;;,..=:::.....,.,....,~
Misc:ulo- ---~5"' phrenic artery
~~n--~~----~~
,. D'll.artery
"lli!l=-~!:-.,f----
SUbalst.al.artery (twdl'th tnll!nmtal artery)
'~7--------
Arst through fourth lumbar 1rter!es
~"''---'---~"r-~.,------,H---
lnfulorepl- ----~..;;---h gamst .artery Extl!mll _ _ I lac .artery
___;~---;~
lllclumblrartay lnll!mallllacarte'Y
-~--....,....,..~--- Lllltrlll sacral~rtery >t<-,~-----
DeE!>drwmflex lllacarte'Y SUpllt1!ctalcnurnllex I lac .artery
~..,..._
__............_
~llllll'ttfy
8 Artertesofthe tnmk wall Antenor view. The ;mtenor portions of the r1bs haYe beer1 removed Ofl
the left side.
Tnrnk wall - - 4.. Neui'OIIVSGIIGr Systems: Fomu ami Rt!lattons
vettmral artl!ry
DeepuN'cal artery
Supl!f!arlnt«·
Verut!n~lartery
cmt.11.-tery
Comman CMOUdartery
CD!toci!Mc.al tt\lnk
Bradlloa!)hallc tt\lrk
A«tkaV>
lnt!mal tharaoc army Post!flcr
lntl!rmstal artl!rleS
Dcrs.1l r;mus
Antl!rfar lntl!rmstal artl!rleS
l
lhar.ldc: acrtl
Collatl!ral branch
MU'ICIIIoplftnlc Ute:.alm;mmary br.anchtJ;
artl!ry Superior
Antmlrlntcrto~t~l artl!rles
eplgastllc
artl!ry Abdomln1l
Medlalmammary br.anchtJ;
lnt.zrnal Sub
!flora de artay
Perfw&fng brn:l!e
b
Postmar rad'cularartl!ry
lib~--
Elltlemallllacarl2ry
Postl!ffor lntw· Medal rutacostalarter!~
lr.!nc:h
l
c
C Artl!rfesoftfletnlnkwall Right laterill view.
D Course and bnnches oftfle fnten:ostoll arb!des a Antel'for llfew of the superior lnteral:ltillllrte!'y, which gllles off the flm: two interamal ~rteria. Not!!: The flrrt and second posterior Intercostal ;uteries ire not branches ofthe lhoradc aorta but arise from the supertor ln!J!rcostil artl!I'Y(bl'ilnch ofthe~caltrunk), whlcharebrancheloftile wbdi!llian artery. b Anterior llfew ofthe postaior lnten:ostal arteries that are segmental branches of the thor;aclc aort
163
Tnrnk wall - - 4.. Neui'OIIVSGIIGr Systems: Fomu ami ~attons
e.-- - - I..Umal
~or ~lwim
Jugular win
}
WilSof verll!bnl ooh.mn
1lzlc.+ --r..umal 1fKnclcwln J"'--:--...,.;:;_=---~+- ~riot
lnleral&t.11 Wins
SUperior
eplgastrtc:wn
•
Anb!r!or
I..Umal
I..U~wln~
1fKnclcwln~
~-----~--~~ WNCJNa
E ll'lt.I!K.llltil Vlfns ilnd VlfiOUS pll!lCUW.S oUhe vertl!bl\11 c;m;~l
a
Vertebr~lcolumn ~nd rtbsegment,~nl:l!ro$uperforvfi!W.
b
Lum~rvertebr;~,$uperiorvii!W.
D VtlnsofthetrunkWIIII Right l~teral vii!W.
165
Tnmlc WaR - - 4. Neuruwlscular ~Forms and Rtt!latlons
4.3
The Lymphatic Vessels and Lymph Nodes
ugulor IJulk
Lumlm" !Junk
Conlal lymP,nodes hteiNI )lg.lloarwln
-:::;~~~- IUght
Lumlm" lyn'43h noda
\I
----~~.,.........
'\! ·,
~
'm'IOUiill!lle lradllo-
""phalcwln
)-~~ ..
Exll!mallln ---~<[f"
Comman
------- llllc lymP, nodes
17-------'-- lnl!tmal
rliiclymph nodes
lymph nodes
;;;~""'"-------Deep
"iL
~o;:r
~
nodes
s=:: _ q
lyn'Cih noda
A lleglollilllymph IICIIIft and U.Tr DICida.d lympMtfcs Anterior VIew. • Axillary, pii"IStl!rnal, and arvlCill lymph nodes (rtght thoradc and axillary region with the arm abducb!d). The lymph node levels are desalbed on p.181. II lVJnph nodes of lfle Inguinal region and lesser pelvis.
Rlght)ugut,r tn~nk
I LeftilndrlghtVB~C~U~ang• AntsforVlew. The appnlldmmly 1-<m-blg llglrt.~dudcollects lymph from the right upper quadrant of the body (see C.) and empties Into the rl1ht -•~a •1111• at the junction of the rfght lntmNI jugular win with lfle rlg ht subdllllan .... n. Its major tributaries ilre:
• lfle rfghtjugulirtrunk (rfght half of the held and neck), • lfle rtght subclwlln trunk (right upper 11mb, rlghtJide of the chest and batk-11), and • lfle rfght brond!omedlastlnal trunk (organs of the rfght thoradc cllllty).
The lhoradc duct Is approximately 40 em long and transports lymph from the ernlre lower half of the body and left upper quildrant It empties intD the left we-. angle between lfle left internal jugular win and leftsubclllllan vein. Its main tributaries are; • the left jugular trunk (left hllfoflfle he~~d ;~nd nedt), • the left subclavian trunk (left upper limb, left side of the chest and back-11), • the left bronchomediastinal trunk (organs of the left thoradc cavity), • the Intestinal trunks (abdominal organs),and • the rtght ilnd left lumbar trunks (rtght and left lower limb; pelvic visan; right and left pelvic. abdominal and back wall). The lnb!rcosb I lymphatic vusels transport lymph from the left and right intercosbl spac:a Ill the lymphatic duct.
166
RIQhtlumlm" - - - - - - 1 trunk ~~~-~~---~~ \Wiac.llla
Tnrnk wall - - 4.. Neui'OIIVSGIIGr Systems: Fomu ami Rt!lattons
Do...~~..--
Ce<W:al
lymphnocfK >------"'>- l'a'41Sb!mi11 lymph node
"Wmnhed"
C AI'Ns d111tned bydluuperfidal frmpN1kveuel,ofthe i!ntlriortnlnk'Wllll Anterior llfew. lymphiltfc p.;l1hwiy3 ;md reglorlill lymph nodes of the ;mterlortrunk wall (~m:IWS lnd!ute !he direction of lymph flow). b Superficial network d lymphatic vessels in the f'!lht anterior trunk wall.
01
t:ymph from tile slcin of tile trunk wall is collected mainly by tile ~xil· lary and superflclallngulnallymph nodes, following the genml pilttan
of lll!nous dr;~iflilge in the anterior trunk wall. The "w..te
duct.
167
4.4
The Nerves
A Antl!flor •nd po:ltl!ffor bnnches ofdie •pinal nef'lfa The trunk w.rll recdYeS most of Its smsory nerve supply from lfle interior irld posterfor brllnches oflfle T I-Tl2 spin<~ I cord segments (interCO<Still nCS'Vl!s and dornl rami of the spi· nal nerves}(see alsop. 172).
Sptnll
Anlllltor b..-.
CDnl
«-*•1
~e~~ment
reml*,
I
I'Nieltor bnndles
,...........,..,
BracN'al plexur.
SUbocclplbl nerw
C1
C2
Cei'YIUI
plexus
C3
}
Greater
oa:lpltal nerve Third OC
C4
cs C6
C7
cs
}
-
Bl'illdtlal plexus
lntl!rcDst
11 12 T3
14
TS 16
T7 T8 T9
no
DoI'llI
111 112 L1 L2
u
r.am1•••
LUmbar }
l4 LS
pltllus
Sacr.~l
S1
S2 Sl
}
$4 S5 Co1 Co2
nl!n't'
Obturmr -~~c:----'] neM
pltllus
Coccwtal }
~moral nl!n't'
plexus (seep.4&2)
• ulled also anterior rami •• ulled also postlei'IOr rami ••• The donal ramlofltlel1-L3 spinal nerwsare also known as dle superior duneall'll!n'e:l, Ulose from S1-Sl as Ule mTddltdunealnerves(seeC). Not!: Tilt lll(e'lorcluneal MI'IIII!Hre anteriorbl'llnchts from dle sacral plexus, see.allo p. 476.
168
Genllm!rncnl - - : -t -- : - --1
8 Nlrwsofthetnmkwall Anterior view. The in!l!rior partoflfle left half of 1he thoricle uge his been 1'1!1110\ll!d. The trunk walll'l:!aives most of its motor arid sensory lnnerwtlor1 from the twelve !florade spln<~lnerYeS. Ofill the spin<~ InerYes, these twelve pairs most de-.rty reflect the original segmtal (metameric:) organiz;aticm of the body. The ventral rami run fow.rrd In !he lnten::o:stal
spaces to become the Intercostal nerves, while the dorsal rami are distributed to lfle lntrln· sic bade musdes lind to 1he skin of the back. Portions of dle trunk wall are also supplied by nerYes from the oel'lllcal plexus (supr;ldil\llcular nerYes), brichlal plexus (e.g.,1he long !floride neflle), and lumbar plexus (e.g., the lifo. inguinal nerve).
Tnrnk wall - - 4.. Neui'OIIVSGIIGr Systems: Fomu ami Rt!lattons
-
~---.....----.,,.
bl'lld!lal
mstomOSis - - -;..< wlthmedlil br.Khlil OJI
lntK:tle
D Couneoftflelnte~lnervcs Right slde. antErlor'lltew.
Spinal cord
DorsiI
~
~ \
)
OJI
(tiW!fm
fnti!!W:Stil n~l
lrohypo· giStlk n~
llollgulnal ni!M! :--~:;:;~:::!::=::::;,....---::::,__-- Anterior - - - . . . . . __../\
Cltlni!OUS
bra nell
C Course of tfle nei'W!S on the latl!r.ll trunk w.lll Right lilterlll view. Nott! the segmenul ~rr;ngement of the int!!rcoJt~l nervu (c:ompa~ wllh the segment.11 ;rrrangement of the arterk:s ;rnd veins, pp.162 and 164).
E Br.~nches of ;rr splnaiMrve Fonmed by the unfol'l of the dorsal (sensory) and ventl'ill (motor) roots, the approxim~ely 1-<m·long spin~l nerve ~r- th~gh the interver· tebr.~l foramen and dfllfdes Into five br;rndles after eldtlng the vatebr;rl canal (see f}.
MolrororvllcBomiiCIDrMittioly
(]) Dorsaln~mus
All so~ muscles ~pt for the lntr1nslc ~ck muscles
Skin of the latel'ill and anterior trunkwall;~nd of the upper 1nd I -limbs
Intrinsic bade muscles
Posterior skin of the head and neck, skin of the ~de and buttac:k
Spinal menrnges.lrgaments of the spinal mlumn. capsules of the f«et joints
Q) Meningeal ramus
®Whllar.amus communicans
urrta pregangllonlcftbe~ fnlm the spinal nerw to the sympathetic trunk ("white" beuuse the p~anglronrcftbers are
@G!'IYI'ilmus mmmunialns •
unfes poslgingiiOnk fibErs fAlm the sympathetfcU\rrk~tothe
M)'lllinated)
spinal new rgray• because the fibers are unmyehnated)
• Strictly speaking. the gr~ ramus communicans is not a spinal nerw branch but a branch ptssing from the symptthetic tn.lnk to the spinal,_
169
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.1
Anterior Trunk Wall: Surface Anatomy and Superficial Nerves and Vessels O!jlhallc:wln
(
Extl!maiJugularveln
Medal brach\JI
~--0 C4=r/ --T2
cut
,/.;~,...;¥-~--=-=--
--n
-
Supra-
:: _j~'
d;Mcular
n
b-.~::.r---
--.. medial
Ll
mamm;ry branchH
ca ~ C7
~~·--~---~~
--.. anb!rfar
C\ltlnt
branchH Pl!ri<mblllal Yllm
Ilalftpogaslrfc __ .-.fm!tal
----
s~
I
_j_
l2 ~
lnll!n:ost.1l
Clltlnecus br.lndl
~Ylln
lngllnaltg;ment
Emma~
-T-4
--no -T12 --L1
-s2
4iY ,
l4
a segmental (ract:rculllr) cutan~ lnner¥111ion of the antef'for trw!k Willi I (derm
pudendal win ~t_;~~,----1~
trlc:I'M!nll!. an1Biaraltaneaur.bnnch
lllolnguhll new
I';! men! n~.llni:Mcr cutanea~a brandies
Long
sapllenous Win
A Supl!ri'kt~l cutarteDU5 veuels01nd nei'Vft ofltle ~nt.ll!rklrt111'*Willl Antel1or¥1ew. Superfidlll ~~~; MCIJI: r:l tht- lltWricll supply to the ~nterior trunlc w~ll comes from two sour-as: the Internal thoracic artery and the superiklal epigastric artery. The superfldal wins drain chiefly Into the axillary vein (lila the lhorilcoeplgastllc vein) and Into the fl!moral Win (lila Ule $Uperfici;ll epigastric and wpemci;ll cirtUmflex iliac veins}. The peri· and p;~r.~· umbilical veins provide the ~In communication between the superildal veins ofUletrunli:wall and the portal veins (portoci~Y;II anastomoses). Superfldll nHWS: The SI!IISOIY supply tD the anterior trunlc wall has a l~rgely segmental arrangement (p~ed, for examplto, ~ ~teral and anterior cutaneous branches from the lntercost;!l nerves). The cervl· cal plexus (supradillllcu~r nerves) Is addi!Sonally Involved In Ule thc.racic region, as is the lumbar plexus (e.g., iliohypogastric and ilioinguinal nerves) lr1 the Iowa-abdominal region.
170
c
Pertphen~l sen10ry alta'leous tnneiYIUon of the anterlortnlnk
Willi Rlghthalfafthe tnunkand adj;Ic:errt upper limb. anterior view. The colorcoded ~P af !he peripheral cutafleOW nerve ten1torles follows tbe branching pilttem of the cutaneaus r~erves In the subcutaneous connKtive tinut-. BesidH the cutaneOUJ branches of the int!!rcostal nerves (antafor and liltl!ral cutaneaus branches). 1t I$ chiefly the $Upracli!llfcular nerves and the Iliohypogastric and lllolr~gulrlill nervesUlatsupplythe skin af the anb!tiortrunk wall (after Mumenthaler).
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
Deltoid
Sem1us an181or
Tendl'lous
castllmar9'n _ _ __;__ ____;:,
lntersec:llon
(ardt)
~---- Semllur~;~r
Uneulbe
line
--~:--<
~--- llllccrHt
M H ---Inguloal ligament ~~l------5.1~us
•
b
D Surhceiln;rtomyoftheilntldortn.mkw.lll • Male, b female.
(!) Ejllg;tstrtc:reglon
Ml~
Umblltlll n!!#on
Ql
PUbic reglcn
Ccst.1l
C:!ll.d't hypodlondrlic reglen
mar9'n
l!l Ldtlu~r
------r----;~~--- ~n:tt)
region
® Ldtlngl.fnll
(rneiOlPittfUm) Lower llbdon'MI {hypogllttfum)
Ql
reglen
rille a'eSI
lngu'NI ligament
(!)Right~
dlondrlic region Ill Right lumber region (!)Right Inguinal reglen
b
E Ofterlil fordMclng the i!bdomen Into retlolll a The .abdomen Is dMded Into four quildrants by 1:\W perpendicular lines that intersect at the umbilicus. b Coordinate system composed of 1:\W vertical and two horlzont;rl ltnes. They dMde the abdomen Into nine regions, each loated In
b
c
either tile upper, middle, or lower abdomen. The two vertfc;rlllnes 1'1!present the left and right mldclillllcular lines. The 1:\W horiUint.al line.J p;ru through the klwe5t point ofthe tellth ribs or the summit of the two Iliac crests ($ee p.31).
F Pnl}l!cUoncrftfleaiHiomlnllorg-ontothefOCJrquadrarltlcrf the anterfor aWoml.,.l ,.,.n il Org;rnsofthe;rnterforlayer, b org.ansofthemlddle layer, c organsoftheposterlorlayer. The organs of the on!l!dor layer abut the
171
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.2
SplnalneM'S,
Posterior Trunk Wall: Surface Anatomy and Superficial Nerves and Vessels
-f-=-=~~
do11.111n~ml
Ll ~
(medal
L2-L3--
ClltllriHW
brlii!CIIe)
L4?
C6
LS
ss -l
S4~
S3
SplnalneM"S,
:_..t...::::
S2 I - -·S - -
--~-f
dcn.ll r.ml
Qmral
B Segmentlll (l'illdlcular) aa'liilnecus lnnerwtkln of tfle posterfor tn.lk wall (dermltolnl!s) Right half of the trunk <Jnd adi;!cent upper limb. posterior view (after Mumenthaler).
Clltane«<S
br.anc:hu)
super~or
ciiM151IneNU
- --7--+n
~....;;_....;;;,.;...___
-
GIU!atriallat
l'oste'lor femoral cutiAeoUS nerve
A Superfldal aataneous vessels and ni!I"'H!S oftfle posterklrtrunk Will Posterior view. Except for the lower buttocks and lab!!'al portions of the trunk wall, the po:stel1or trunk wall denves Its sen SO!)' lnnerv.rtfon from dorsal rami of the spinal nerves and from lateral cut:mecus branches cf the intertl:l$t;ll nerves. This is a predominantly segment;~! innervation pattern, analogous to ttl at described lr1 the antertartrunk wall. 8clfl the medial ;md lall!rill cutilnecus nerve branches pi155 wlttl the cutilnecus vessels ttl rough ltle Intrinsic back muscles tD the skin of the back. The slcin of the buttocks is supplied by literal br.lnches fnlm the ltlree cr.~nial lumbar arid s;unl nerves (supel1or and middle clur~eal nerves). Note The lower part of the but:mck Is supplied by the rnti!Jtor clune;al nerve.s, which are branch~ of the sacr~l plexus; thus they are dl!f
172
GlUier------" ~ I.Hs8'ocdpltllnerve ocdplbiiMW
- - - lllohypog;atrlcnerw, laanl a~t.lneous br:lndl
Perfph~r.~~l MIIICryal'tiMous fme!Vil'llon of the pclltlrtortnmk Willi Right half of the trunk and adjacent upper limb, posterfor 'VIew (after Mumenthaler).
C
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
~~------~~--~
promtnms
Supulit, lnferionngle
- --1- - Spinousprogm Pll
----+-----
------l'l~---
Rhomboid oiMfchaejts
tllacspne
>----=!!!--- Anal deft
b
D Sul'filat anatomy ofthe pol'ltt!rfortrunk wall a Male, b female. In both 5eXe$ a Sjlinol {um:ttN runs vertically in the pomrior midline of the trunk below the C7 spinous process. It Is formed by the fbc.ttlon of the SIJbcut
the saaallewl In males, the furTOW Widens to fonn the socro/ t11angle (bounded 11!1' the right and left posterior supertor lilac spinel and tile upper part of the ami cleft. The corresponding di;amond-shaped anea in females Is ailed the rllombold ofMld!aelts (see 1').
PudendaiN~W
----l2
lliolngtillillnem.o4111d --~--
Splnausproci!U ofL4wrtebr.a
--Sl
genitofemoral nerw. gl!!'lbll bnlnch
f'osteolor
fenor.JI
--:----54
---=----
~:---------::--
cublneous n~
~or superior---:---~
llllcsplne S5
~-Col
tniir!or - - -
ckll'fil
I
I"' ""'
----- S2
Supe!or
Mlcldle
~
dune~~! neM!S
dunal neM!S
ni!M!S
E Segmentill ;md perfphH.JI cu'blneous tnnel'VoiUon ofthe rNie pl!l"'neel regiDn
lithotomy po.sition. The segments or dermab:lmes h;M:! been maPSJed on the left side of the body. and the areas supplied by the peripheral eutineous nerws are shown on tile rtght side (after Mumenthaler).
F Aniltumlcal bounclartes ofthe Mldlaells rflombold Female gluteal region, posttrlor llfew. In women the sacral !Jfangle Is expanded to forma diamond-shaped figurewith the following boundar· les: the left and right postertor superior lilac spines, the spinous process of the L4 Wftebra, ;md the UPSJer part of the anal cleft. With a nonnal female pelvis, the vertical and hor!Uint.tl dimensions of the rhomboid are approximately equal. The shape of the Michaelis rbomboid (named for the German gynecologist G. A. Michaelis, 1798-1848) reflec:a tile Width of the female peMs, pi'OIIIdlng an Indirect lndlemlr of !he s~ of the birth anal.
173
Ttunk waR - - S. Neui'OWJICIIIor Sysmns: TopographlcaiAncrtomy
5.3
Posterior Trunk Wall, Posterior View
TWrdocdpltll --~~~j' ni!NI!
Spinal nl!i'VrS, dorulr.~ml (med~l cuuneous branch~)
A Neurii'IIISGIIM' structures of tfle postertDrtn~nkWIII and
nudJ1I regkm PDsterlor ¥few. The segment:311y am~nged ne1.uwascular muctures Df the posterior b'unk w.all (dDnal r;aml of the spinal nerves and porterlor branches of the postertorlnter· CDStlll and lumbar vessels) are dem· onJtrmd on the left ~e of the ttunk (all musde f;asdae hi!Ve been removed except for the superfl· dallayer of the thoracolumb.n f~ da). On the right slde. the trapezius muscle hils been detilched from Its or1glns and reflected laterally to show the alune of the transwne cervical a!Ury In the deep scapular region (a:~mpare with B). lllotl!: On the posterior trunk w.all, only the lateral nuchal region (!Hsef' ocdplt.ll nerve. see C) ;arid the lowe!' gluteal region (Inferior clune;al nerves) recellle their sensory supply from VC!Iltral spinal nc!IV1! rami. The latissimus dorsi muKie has been partially remcM!d on the right side to demon mate the upper al$· tulumbilrtrfangle(ofGrynfeltt}. The flbrouslumbilrtrlangle(boundarles: twelfth rfb, lntrfnslc bilck musdes, and internal oblique) is similarto the lower lllolumbilr triangle (of Petit. bounded by the lilac aest. latlssl· mus dorsi, arid external oblique) rn that it crems a site of predilection for r;are, usually acquired lumbilr hernias (Grynfeltt or Petit hernia, see also p. 139).
174
~d~--~~~~~~~~
duno511nerws
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
Transwrse C8'Vlclll lll'll!l'y.s~dll
(I sanding} bnnc:h Tl\lnswrseterlof~l
artJery,deepbi\Jnc!l
~=~~=!jt~~~~l;:J~~~f3
lthomboldmusc~es ---7~~~Sr-ft~~~\
S~.pWG~pular neM
Alcllarynerw Pos!Jer!or dn:umflex humeral al'tlery Teres minor
B Artertes llf tile deep sapul1r region Right supul~r region, PQm!rior view. The trapezi~JS, splenius apitis.
deltoid, lnfr.rlplnatus, and rhomboid major and minor muscles hive been completely or partlally removed on the rtght side. The deep sapular region is supplied by the tr.anM!ne CA!Nial artery, deep cervical artay (see C). suprasapular artay. drcumflex scapular artery, and posterior draJmflex humeral artefy. All of these vessels arise directly or lndlrec:U)'-1/!a the thyrocenllcal trunk-from the subdavlan artery (nel·
ther are visible here). The suprasapular, citaJmflex scapular and posterior drcumflex humeral arteries form the •scopularomxk" (see p.341 ). Medial to the mastoid process. the occipital artery appears below the tl!lldon ofiMertlon of the rternodeldomastold muscle and runs upward with the SC!rl$0ty gre.>m!r occipital n - to the skin of the occiput. The greater occipital nerw pierces both the trapezius and semispinalis apltls musdes In the area of their flnm tendinous attacllmen13. It may become compressed at these sltes,leilldlng to ocd'pJml neuralgiC!.
C Sulloc:dplt.11 tlf;mgle (vertebral artl!ry
Obllquus a pills
superior
-;J..<~r---....:....-
R.ectur.apltls
OcdpluhrtJery Qellll!r CICdpft3-
postet!armlnor
Ver!J!bnlll'tlery
R.ectur.apltl$ ~liar M;ljor
lhlrdocdplt
Obllquusapltls Inferior
- - --il'\lb
Axlr. spinous~ Del!j)oeMo:
Splenlusapltfs
- - - - '"flR'I'I
- --:::--+
l.onglsslmusaptus
Semlspln~lls
Sembpln~lls
a!Mcls
apltfs
trtangle) Pomrior view. The trapezius. stcmocleido-
mastold, splenius apltls, and semispinalis apltls musdes have been rernOYed to display the suboa:ipital region on the right side. The suboccipital triangle Is b~»unded by the subocdpltal musdes (rectus apltls posterior major. and the obllquus apltls superior and Inferior). Ill the deep partial\ of the biangle, the vertebral artay runs through Its grocwe In the atlas. The suboccipital nerve (C 1). wltlch Is purely motDr, emerges abOYe the posterior arch of the JtlaJ to $Upply the $hort muscles of the head. The greater occipital navt' (C 2) and, at a lower level, the third ocdpltal 11erve (C 3) wlnd postl!lforly as they pass the lower margin d the obliquus apitis inferior. The deep am· al artery, a br;mch of the costocervlcal trunk. runs between the semispinalis apllfs and cerlllclsmusdes.
175
Ttunk WGU - - S. Neui'O!IUCUior Sysmns: TopographlcaiAncrtomy
5.4
Posterior Trunk Wall, Anterior View
A NI!UI'OVIIIIClllarstruc:tures on the arrtl!tfor tTde of the poltltffor trunk Will
Antmorvlew.
Olaptlrasp~,
lumb.lr part Medill1rcu~
Subc:m!llnew
llgl~
("Psoaun:.lde•)
The lumb3r pii!XU5 (see p.470) is fllrmed by the ventral branches of the T12-l4nerves fat· eral to the lumbar spine and Is partially cavertd by the psoas major mlllde. The nerves rur1 lawrally and obliquely d~~W~~w.~rd to the abdominal wall and thigh. except for the obtu· rator nerve (see b) which runs through tbe lat· eral w;all of the IHSef' pelvis and the obturator foramer1 (not visible here) to the medial part of the thigh. Nott: The sites of emergence of the lumbar ~nd iliolum!Hr Vt'$5tls 3te l~1uted below the psoas ma)or mil!de. They rur1 almost hodzontally across the quadratus lumborum ;md lila· cus muscles. Medial to the psoas major (and a~Yered by the infa!or vena c;n~;~) is the lum· !Hr sympathetlctnlnk.
~·~l+lfuil-- S)mp;llhellc tn.nk
llacus llohypoga5tric
nene.litml clltlneous brll!dl
L
a Lumb;lrf\nsa on ttue right side afte.- rem~w.~l of the anterior and lateral trunk w.~ll, the Intra- and retroperlt:one.tl organs. the pe!i· torll!um, and all tbe fasciae of tbe trunk wall. The lnfa!or vena caY<J hilS been par· tlally removed. b Lumbar fossa with tbe lumbar plexus of the right side a~r rtmw.~l of the superficial layer of the J»>iiS ma)or.
ll~neNe.
iillll!rlor wtaneota
br.Jnth
llldii!JIInal nen~e Gl!ntolanonil
- +--
----i------("-
n~
lo!monlll
F
-
Abdominal
br.n:ll
Sibclutll , _
- +-----r-+--1--.....-.. .,. . .1
Gm~~--~~==~
n~.
allll!r'lar
nen~e
Clltlneaur. branclles
lnfe!or
wmbu plexus
Ilioinguinal nerw L
wniClMI
llalumbar
vessels
lnbmill llac
l.atl!flll sa:ral artery
b
176
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
lntrimlc:
Rights~
phA!nlc artery
bldtmllldes
Costll
grolntl!rmstaiWII\
posterior
(6orsll) ramus
SJ)!Ilill
I1III'Ya, a!Urio r
(wntral)raml Pomrtar~l
arterle:undw!ns
peiardiOlphneric arteryandw'n - - - --,-----
P.v!etal ple~~e, - - - - - - "
Pelfc.;ardlum
MuSOJioplnnlc artery (fi'Cim Intimal thor.adcarll!ry)
CDStllp;ut
lntl!mal thoracic arll!ryandw!n ln-.wine~W, ---~
lllenlcu1<1neour. branch
8 Na~nM~IQihii'Stn.JcblrH ofthe postfttor tnmk -ll1tthe tfJOI\Jdc: levl!f Transverse section through the thorax aftef removal of the thoracic orgaru, parietal pleura, and p;~rt of the endothoracicfascia, antetwupe· rlor view. The chest w.~ll receives Its arterial blood supply from the pos·
tafor Intercostal arteries and Is drained by the Intercostal veins. whlch empty Into the azygossy3tem. The lnte!'m5tal vessels run with !he Inter· costal nerves .along the Inferior border of the .assOCiated rib, lodged 1r1
the c:o.stal suiCUJ,
177
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.5
Anterior Trunk Wall: Overview and Location of Clinically Important Nerves and Vessels
Rt
lknblllc:us
ll'allSWISUS
abdomlnls tnfMcr eplgMir'lc: arteryandwb
Superfldll epl~cwln
lngttrwltga-nent Sllpuitdill ctrwmftex thac ~rteryandwb
Superfldalepl~c ~rterya1dwln
Lcing
fliiSdalata
A Neurowna.llill' l\n.Jctur15 on the ;mtartorstde oU:he antllrtor trunkWolll Anterior VIew. The superficial (subcut'lneous) neurovascular structllres ~rt'demonstrJted on the leftside of the trunk and the deep neurovascu· lar struci:IJrt'SOflthe right side. For this purpose the pectoralis major and mtnormusdesha~beenccmpletl!lyrt'move
178
s.!pho!nouswln
external and Internal oblique musdes have beer1 partially removed. Portions of Ute rtght rectus abdomlnls musde have beer1 removed or rendered transp.arentto demonstrate tile Inferior epigastric vesseh. Anally, the intercOJtal spa en hiM! been expo.sed to displ;ay Ute cour.K' of the lrrten:ostal vessds and nerve5.
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.6
Anterior Trunk Wall: Nerves, Blood Vessels, and Lymphatics in the Female Breast
Nlpplt
,
_ _ _ _ __
~.___-'glands
A Shipe and appnranc2 oftflefltmlle br'HIIt Right breast. anrenor view. The female breast Is shaped like a cone that Is more rounded In Its lowe!" halfthan In the upper quadrants. It consists of the glandular tissue (mammary gland) <1nd a tlbrous mom a th
lnter
lnt!n:ostal 'IOe:SSds SUperficial
->-.u,,. .z/.___ lntl!rlobular
abdcmnalfasda
a~nnedii.Oetlr.su~
~
I.Gbulu
f~=: Ac_,l
c
180
Tennlnal duct
Tem~lnal duct labuiN !.flit(TDW)
B Tile ~n~mmllfY ridges The rudiments of tt!e m<~mm<~ry glands fvrm In both sexes along the m<~mm<~ry rfdges. ippe.;~rfng iS of an epidermal rtdge extending from the illdlla to the Inguinal region on eiiCh side. Altttough r01relythe nnamm<~ry ridges m;ay persist in hum<~ns to fonn acassory nipples (polyth~ Ira). normally all the rudiments dlsappar except for tt!e thor<~clc pair. By the end of fetil dewiopment,. lactiferous ducts have sprouted Into the subcutaneous tissue from the two remaining epithelial buds. Aftef menarche, breast d-lopment in fem<~les is m<~rbld by growth of the fibrous stroma and prolifemion of the glandular tree In response to stimulation by sex hormones.
C Gross<~nd mla'OICIIpk anatxnny ofthe brea~t • The b.'lse of the adult female breast extends from the second to the sixth rib along the midd3llicular lirle and directly CMriies the peca.rills m<~)or, serratus interior, and external oblique muscles. It Is loosely itt.1ched to the pectoralis fasda and adjacent fascial planes (nil· lary and supertlclal abdominal fisda) by connective tissue. The b~ art is additianally supported, es(M!(:ially in its upper portion, by per· me.rt!ng bundles of connective tissue (the suspensory ligaments of the breast. or Cooper's ligaments). The glandular tissue Is composed af 10-20 lndMdual lobes, e
the transformation to the lactating MG:It. Tile TOW Is of key Importance In p
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
_..~"": ),.....--- Sl.tldoMin~rtery
andw\1
Millry artery llldwln
- -+-----.,...
uuraltnoradc -~-- artery andwln
- •yl"7r'•7r---
Sl.tld;Mcular
~ lntan~lthonlck:
arteyandw'n
1
-
ln1e'alst.li Mti'+'K, } - medial mammary
brand!K
'-!..__ _ _ _ Mllmrnarybranclles D Blood Rlpply to the breut The breast de!'IVes ItS blood supply ftom perforating br;mches af the
internal thoracic artery (• medial mammary branches from the sea~nd through fourth lnta't:o.Jtal spaces), branches of the lmral thor01· de artery (lilter.ll mam!Tiilry branches), ;md direct branches from the second through fifth Intercostal ~rterfes (!Tiilm!Tiilry branches}. The b~ art is drained by the internal and lateral thoracic veins.
E Nerve supply to ttu~ brent
The sensory Innervation ofthe breast has a segmental ~rr;mgement and is supplied by branches of the second through sixth intercostal nerves (later.al and medial mammarybr01nches). Branches ofthearvical plexus (supradallfcular ne!Vel) also supply the upper portion ofthe breast.
G Dldl1'buUon of mellgnenttumors byqUidr~~ntTn the flmillllu-.;~rt The numbers Indicate the .il'llel'3ge pen:entage location of malignant breast tumors.
F Lymphltkdnrlnl;eofthebn:.t The lymphatic vessels of the breast c.;rn be dMded Into a superficial, subcutaneous. ;md deep systl!m. The deep system begins with lym· phatic capillaries at the acinar IJ!Vel (see Cb and c:} ;and is particularly lmportilnt as a route for tumor metastasis. The main regional filtering stations .are the axJII.ary and parasternal lymph nodes, the appi'QlCTITiil· tely 30-60 axillary lymph nodes receiving most of the lymphatic drai· nage. They are the first nodes to be affected by met
The porommallymph nodes which are distributed along the thori'Cic vessels c:hlefly drain the medial portion of the bre.ilst. From there, tumor
cells nniiY spre01d acnoss the midline to the opposite side. The surviYil rate 11'1 bn!.ilst c.;rncer pi!!Sents correlates most strongly with the number af lnwlved lymph nodes at the varfous tDdllofY nodal levels. The para$temal lymph nodes ane rarely import!nt in this reg;~ rd. Aaording to Henne-Bruns. DQrfg, and Kremer, the 5-year survtv~l rate Is approxl!Tiil· tely 65% with metastatic lnvo!Yement of Ieveii, 31% with lnwolvement af 11!111!111, but approaches 01: in patients with lew! Ill invo!Yement. This elq'lalns the key prognostic Importance of 01 smtirtel fyrnp~Jo«nmomy (removal of the sentinel lymph node). This technique Is b.ilsed on the assumption that every point In the Integument dr.illns vta speclfk: tymphaticpi!lhw.ays to a particularlymph node, r~relydraining to man! than one. Accordlr~gly. the lymph node that Is the first to recdve lymph from the prfm~rytumorwlll be the first node to Gllrtaln tumor cells that have spread ftom the prfnnilry tumor by lymphogenous meta~ls. The specifiC lymphatic drainil!le path, ;and thU$ the Rlltinel node. c.;rn be iden· tilled by sdntlgr.aphlc nni!pplng with r~~dlolabeled colloids (1111 "'TC sulfur micro colloid), 'Which has superseded the older technique of patent blue dye lnjec:tron. The first lymph node tD be llfsual~ Is the sentinel node. That node i$ selec:tively re!n~~Ved and hiSU~Ioo.ilic;ally examined for the presence oftumoralls.lfthe sentinel node does not contain tumor cells, generally the rest of !he axillary nodes will ~!so be negative. This method Is 98" accurate rn predicting !he Jewel of .axillary nodal lnvolllement priorto$urgery.
181
Ttunk WGU - - S. Neui'O!IUCUior Sysmns: TopographlcaiAncrtomy
5.7
Anterior Trunk Wall: The Inguinal Canal
""'::....._--...;.;-- - - -
eutedg~of
antl!rlot I'KILts
shtil1ll
lllopectfnealan:h
- --1---r------- <Jbdomlllill Su~ f.Jsda
lns~~Jin~IIIQ~ment
llopso.H
Emm;alobliqut
apone«RSII
Superftcfal { lns~~Jinal
11ng
!Jrt«alcnu
- --=-- - -
1?-=::------t---=--- lllo~l~~ro~lneM
~~~1---~r--~
~~~~+--:--- Cienltl)fl!mollll
fbt!fS
I'II!IW.9!"Itllbr.lnch ~----jr--'---7--
11!monlll'h!ry -------~~=
and win
Reflected ligament
P'F:III!Hr-,+....;;.- - Spennltltcord •••'--~-..;,...-- LM1Jn~tllglffll!llt
':--rl----- Pubic:tuberde
A Loutfgn of the lnguTnll c~u11l Tn the m1le Right Inguinal region. interior view. Approxlma!l!ly 4-6 an long, tile lngulnil anal passes obliquely forward, downwird, and medially ibOYe the inguinal ligament tJ) pietce the anteriar abdominal w.all. It begins Internally at the d~ Inguinal r1ng (D 01nd E) In the late!"allngulnil fossa (see p.184) ind opens externally at the superffclal Inguinal r1ng, lateral tD the pubic tu~ With tile superffclal abdominal fasda removed, this •external ope~~ing• of the anal an be identified as a slitlib! or1flce In tile aponeurosis of the external oblique muKie (emmal oblique aponeurosis). It Is bounded by the medial CJUS superomedlally and by the la!MJI ous infl!rolatl!rally. 8oth aura are interolnnected by the tntmrurulfi&M. The superflclallngulnal r1ng Is completed Internally by arched flbers from the lngulnilllgament (reflex llgamem}, forming a deep groove. The lngulnil c.1nal In the male provides a pathway for the desa!nt of the testis during fetal life (see p.194).1ts contents in the male (after testicular descent) Include the spermatic cord, and Its con· tents In the fanale Include the round ligament of the uterus (llgamem of head of femur; see C).
Plllneaf Hdan ... lr~;eml
oblique
suP'!ffla<~l -~:-;n\\~l\\:1~'~'-
abdomln<~l
Iii!;~\'.'.~\· ,,\ ,, --~ .llpOM~rosls
B Siglttill sec.tkln through the TnguTnal Ullill Tn the mal~ Medial view. Note the structures thatfonn thew.alls of the inguinal anal
above and bel- the spenmatlc cord and gn the ~ntalor and posterior sides (comparewlth C). The openings andw.all structures of the Inguinal Cllnil be.ar an Important relationship to the pi!tnophyslology of hem las (alb!r Sdlumpelick).
182
5. Neunwascular sy.mnu: TopographlcalAnatomy
Dunk Wtlll -
C Openlngl •nlllwel Ml'uctu'" tlftlle lngulnll caul The lnguiNI tA!Ilil reHmbles 1 flattenedtube with an lntaNI and external opening (see below), a floor, a roof, and antarior and posterior walls. A lumen Is present only ifte' Its mmnts h~ been reiiiiOYed (the ,.,erm~c cord In lllillles. the Utlerlne round llgimenl: and Its lrtery In tern• les, the ilioinguinal nil'...., 1nd lymph~c-"in both R>a). The inguln~l tAIIlil remains pall!nt for Hfe, especldy In rNies. and thus fonns 1 pith for polllnUal hernl~on through the abdomlnal-11 (see p.l86).
=~-----Deep
apaneuroslo
L*l'llci'\A------
- - - - Modlalaus
Intercnnl - - - - - - - - ___...- Superficial
\L- =~
fben
•
Opening In the~~Ctmn•l oblique aponeurosis baund..t by the medial a~a,lmr~l aus, lntlel'tNIIIfbers. and reflex llglment.
Dftp Inguinal ~ng
Inguinal mg
ngulnal - - - - - . .
ligament
lnll!mill _
__;:...J!=i::!o,~
obllqu~
Opening between the l~larllg;lment. lngulnalllgamtnt.and lillnl umblllcil fold: form.! by an autpoudllng of the transwmolls fncla (beclCimltl the ln12rnal spennatfc: faodo) (-p.115)
b
W.llllnldiii'Baft.,.lngulrwl anal (•e 1)
ln11ulnllllpment (den•ly lnt.rwown fibers !It the 1 - tldltrnll oblique iponeurosls 1nd adjlatnt fascia lata of the thigh)
Flaar
TI'IMYfi'SU&
--~~~-:.
obdomlnb
ll'answrsus abclomlnls <~nd lnllmal oblique muscles Anterlor-11
E!lmmal obllqueapa,...nnls
Pasb!riar •II
Transwrsalis fascia and ptritoneum (partially
'l'loo..• . . - - -
Spermollc cord 1Mihlnl2mll
spennatlcfasclo
thldaened 1:1¥ the lnterfoolecllar ligament)
D Conblllullon ofthe altllque •Wamlul rnusde to tlleltnudiJ~
cl tile 1111lelngulnll caul Right lngulrMI reglon,1ntafor view. Progres5Ne removal of the abdominal wall muKies.
•-< lnb!rnal oblque
--.::-~:."11111~
-------~
oblique ...,,...l'lllls
"'"1:!~~~----
llohypogostrtc naw.Interior c:utll'leOUS
o.p--__;~ lnglln~lrii'Q
branch
-
llolngllnal
...........,.;:"rr-- Superfldal
""""'
tlgulnal ~ng
(art open)
Spem~atlc cord w1tt1 cren'la$lcr I
lliolngulllill
~~
musde and mnlistl!rlc hsc:li
E Tlle Inguinal caul, progl'eiiiVely opened to upase the lplltMdC CDrd
a Division of the external oblique aponeurosis revel~ Is the lntl!rnal oblique muscle, .ame or whose fibers are continued onto the spermatic cord as the aemaster muscle. The genltill branch of the genltcrfemor~l nerve runs with It below the aerNsterlcfuda (see p.472}. The ilioinguin~l nerve Nns through the inguirMI aMI on the spermitlc cord. Its senscey flbers pass through the superftdal Inguinal ring to the skin owr the pubic symphysis ~nd ~re distribut2d tD the llte~l part!Gn of the scrotum or l1b~ rrn~jorl, and medlil thigh. It With the Internal oblique muscle diVIded 1nd the crerNster muscle split. the full aJUrse or the spermitlc mrd through the Inguinal
b
canal c;~n be displayed. The spermatk: cord ~ ppears itthe deep InguInal rlng, where the tnn~rsalrs me~ Is lnv1glllilted Into the Inguinal c;~nal (~nd encloses the splllNUc cord on Its way to the testis as the intem~l spermatic fascia).lt runs below the tr~nsversus ibdominls 1long the posterior Will of the Inguinal canlll (tranSY8'Salls f1sd1 and pefltoneum). The wall .at the midpcwtion of tile an~l is formed by the lnterfoveolarllg;~ment and Is relnforad medlilly by the reflex llg;~ment. Medial to the lntl!rfoveo~r llg1ment, below which run the 'Pi!llmiC:: '<'aWls. and a~ the inguinalli511ment is the~ trlvng/t. a we.11kspat In the abdomln•l-11 which Is 1 mmmon sitE for cllrect lng ulnal hernias (ibr SchumjNIIdc. see also p.117).
183
Trunlc WaR -
5.8
5. Neui'OWJlCUiot' Sptems: Topographical Anatomy
Anterior Abdominal Wall: Anatomy and Weak Spots
Rectus sheith,
pootorior' Aiaall!lne
Mod'-' umblltM fold
lllodw abdomlrll
Modlll umbllc:ol fold
lnftttor eptgllltlfc wsals
LDnl umbiliciI fold
IJreep dPOJmftelr
tlkwsals Tt$11wiJri118Yand~ ---.....:.;~
-~4~ill!f"
A lnl2mlllllrilm anftlmy of Ill& ilntl!rfar ilbdomhliiiWilll bthemale Coran~l section through the Jbdamihill ~nd pelvic cavity Jt the level of the hlp joints, post2rtar view. All of the abdomlno~l il nd pelvic organs hoM! been rema..<ed except for the urln;uy blidd&r o1nd prosute. Portl· ans of the perttoneum and tra nsverSillls f.asd.J hOM! also been removed on the left side. The irnrnal surf1ce 1r111tomy of the l~r o~bdomir~~~l Wi Ills milriaed by five peritoneal folds, whld! extEnd towoJrd the umbilicus: • An unp;~lred ~n umbHical fold on the mid line (mntalns the oblltermd ui'Khus) • Paired II!!\ and right medial umbilicAl/ folds (contain the I~ o~nd right obUtented umbilical artery)
184
• Paired left o1nd right latrrul umblllml folds (contilln the left and rtght lnf81or eplgastrtc vessels) lJlated between the peritoneal fOlds on eo~ch side o~re three more or less distinct fossae, whim are sites of potential herniation through the o1 nterlor abdominal Willi:
•
the~(osso.lo~ between the median o~nd medial umbi·
Ual fOlds 1bove the apex of the bl1dder; • the medial Inguinal fOOD (Hesselb~eh trllngle), loated be~ the medial and lateral umbilical folds; and • the laknrl inguino/ (ossa. located lm<~l to the l,ll!r.~l umbilical fold (site of the deep lng ulhill ring).
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
c lntl!t'nallftd external apenlngs far abdamt:nll hemllll the median, medial, ~nd lateral umbilical folds (see A) form tftree sites of we
/IJit;M the Inguinal lfgammt.
Hemtalrfng HemlaiSilt
.......
r.ll!m•l opening
SuprROKiul fossa
Supmeslal hemla
Superfldal Inguinal ring
Mecteal inguinal foal (Hesselbech lri.angle)
Direct inguinal hemla
Superficial Inguinal ring
Latwll inguinal fossa (deep Inguinal rtng)
Indirect inguinal hemla
Superficial Inguinal ring
Femoral hemla
Saphenous hiatus
11111!1111111 opening
Hemlal alllUnts
AIHM* lllgcdnlll /lgamMt
8 Definition, oa:urre.-., ;md structure of ;m ;~bdomtnal heml;a Between the thorax and bony pelVIs Is an extended skelet.11 gap !hat Is
awered by multiple abdominal wall layers ccmposed of broad musc·
les. fasciae. ~poneurwes. ~nd peritoneum. The muscular foundation Is delldent at certain locations, and the ~bdomlnal wall at those sites Is formed enlfrely by connecUve-Ussue s!JIJctiJfl!S. These are the areas of greatestwe~~kness (least l'l!sistancz) in the abdaminalw.all. Occasianally these weak spots cannot withstand a rise of lntra.;~bdomlnal pressure, and openln!JS are created for the herniation of abdominal viscera. The term "hernia" (L lttrnla • "rupture"} refers tD the protrusion of partetal peritoneum through an anatomical opening (e.g., inguinal or h!moral hernia) or a seccndary defect (e.g .• umbilical hernia). An mmral Mr· nfa Is one !hat protrudes from Ule abdominal cavity and Is 11fslble on the body surf.la, while ar\ inb!nlal hf!mif:t protrudes into a peritoneal pauch that Is cont
Below lite inguinal /lgamMt Feman~lrtng
ates. Hernlll SIC Ute pouch, generally lined by pariet.11 peritc:meum, tftat oontalru the herniated YIKus. Its size Is highly variable, depending on Ute extent of the hernia. Hernlll oont:ll!fttl: maybe almost any rntra-.abdomrnallltscus but usually oonsist of g~r omentum or loops of small bowel. CcMtrfngs: the tissue layen surrounding the hernial sac. The composition of Ute coverillgs depe11ds on the location and mechanism of Ute hernia.
Tr;nll/ei'SUS
llopublc
abdomlnls
!net
nferlor ~IQ;J.l1JI<
IIU'Ids la1B'
lngl.fnalfo:aa (def!P lngulnalrtng)
.•lf.-1-tl- - Medial umbllc.wl fold ~~r
D lntl!t'nal hemllll openings Tn the male Inguinal and fernorel regton r.emoral.wtery Detail from A, posterior view. The peritoneum and tr;msversalls fascia have been partially removed to demonstrate the hernial ope111ngs more de.1rly. The internal openings (see Aand C) for indirect and dii'Kt ingui· nal hernias, femoral hernias, and suprapubic(-supraveilcal) hernias are Indicated by oolor shading.
ligament SUpr.r.oeslcal bu
Medial Inguinal fo:aa (H.-ll>achtr!angle)
11!mor.Jirtng
185
Ttunk waR - - S. Neui'OWJICIIIor Sysmns: TopographlcaiAncrtomy
5.9
Inguinal and Femoral Hernias
A Hemlasofthegroln reg1an: lngulnalandfemon~l hemlal•
........
Opm....s•ndaurw
• Dhct (mediBI) lftlulnel hemiB
• lnk!mul opfttlg: Hesselbech triangle. i.e.. allow the inguinal ligament and mecl".al to the inferior epigastric artsy and win • CouJv: s.c: Is perpendicular to the ;~bclomlnal wall
AI~ acquired
•
&Wntll~
superflclallngulnal r1ng
• lndiNct(lltiti'II) ......MiheftM Congenital (patent P"'CitS'SUS wginalis) oracquln!d
• ll'llltmGI opflllllg: deep lngulnal11ng, I.e.. allow the Inguinal ligament and lateral Ill the
·~I'IIIMmll
• ll'llltmGI opflllllg: N!noral rfng and septum, I.e., below the Inguinal ligament • CouJv: sac passeUhrough the femoral canal below the fasda 1m • &liemal openitlg: saphenous hiatus
AI~ acquired
imnor epigastric artery and win • CouJv: uc: passes through the Inguinal anal • &:t.emGI opmlng: superflclallngulnal ring
• 80S of all hernias •re Inguinal hernias (90S of whlc:h occ:ur In malu).and apprGIIdmllll!ly lOS 1re femoral hemlas (more common In females)
(see1lso p.188). Inguinal hemlaure among the most common stNc:tural defects In humans, ac:c:ountlng far some 20S aflll suoglal operations.
~.oc:;;rt~on«
------=:----:--..Jt....ll""r"""':-
lngulnel anal
"""T--7--w~--
I CongeniAl or Kqulred Tndln:« lngul111l heml1 Right male lr~gulr~al region with the .sldn and superficial body fascia remOIII!d, ~ntertor view. The fasda lrta of the thigh Is shown transpa· I'C!Ilt, and the spermatic~ is windi:M'ed. Regardless of the location of the tnt.emal opening, both lnrllm:t (lmrol) ill'ld dlm:t (mrdloQ lr~gul· nal hemlas (see C) emerge from !he superftdallngulnal ring ibOIII! the lr~gulr~alllgament. Indirect Inguinal hemlas may be congeniUI (due to a p~nt processus vaginali$) or acquired and follow a tract parillel to
186
Ptl!tonSJm
ofhemlalsac Trauwnaltsf.ud'a (•lntl!mal spennatft fasCia)
the abdominal w.~ll. The hernial SiK enters the e~epanded deep lr~gul· nal r1fl9 (Internal openlf19), which Is lateral I»the epigastric vessels, and p.a!iies medl~lly ~nd obliquely ~long the lf19Uirlill canal. IIM!5U!d by !he fascia mdoslng the spennatic cord, It flr~ally emerges at the superficial lr~gulr~al ring ind descends Into the scnotum. The CO'Ierings of illlndl· rect Inguinal hernias Include the peritoneum and the ttanswnalls fisda (lnU!rnal sperm~c f~scla).
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
Extemaldllk(ue Inferior
i!p(ll'alrosiS
~pl;&'ltlfcW5Sds
l«<
Inguinal ligament
~b.Mhtr!angle
SUpetfldal lngtillihing
Tr.Jmvenallsfws
Fenor.~l~
Per!1ale<Jm
dhemlals.x
Cnmlst:m:faKia
Cn!miSIJ!rmuscleand
S;~uund
~ccord
ptdiMOSIS muscles.
fasdalat:a
c
Acquired direct lrlfllllnll hemIa Right inguinal regia!\ iA the male with the skin aoo superfiCial bady fas. da removed. anterior view. The fascia lata of the thigh Is lightly shaded. Direct Inguinal hernias are alw.lys acquired and fallow a tractUiat Is per· pendlclllar to the abdominal wall. The hernia wtllleave the abdominal
cavity medial to the Inferior eplgastr1c vessels within Hesselbicll's 111· angle (seep. 185). Such hemias may pass through the superficial ingui· nat ring, and In such Instances the hernial sac Is medial to the ~permatfc cord.
~....__
D Acqulnld 1\Hnonl hlmlil Right female Inguinal region with the skin and superficial body fascia removed, anterior view. Femoral hernias are always acquired ar\d are more common in W~~men (brwder pelvis and la~er~moral ring). They always pass lnferlor to tfle Inguinal ligament. and medial to the femoral vein, extending through the femorallfng to enter the fl!moral canal (not \llstble here). The funnel-shaped canal begins at the femaral11'ng (the internal opening of the hernia, not visible here) and ends approxi·
_ _ _ Inferior tPigl5tllc-sels
mately 2an Inferiorly at the sapheno~JS hiatus, ;md lies anterior to the pec:Uneal f.lsda. The sharp-edged laamar ligament farms the medial boundary of the fernorallfng (11sk of Incarceration). ~lcally the femoral canal is ac:tupied by IOG$e fatty and connectivetiss~~e and deep ingu· lnallynnph nodes. Femoral hernias mayemergeattflenphenous hiatus {extl!rnal opening), which Is cowred by the thin clfblform fascia, and th~&S become subcutaneous.
187
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.10
Rare External Hernias
£plgastrfc hemll lncl!fan~ll
hemla
RKtusdlistilsh RKtusabdomlnls
'n'a11$WISUS
abdomlnls Unbllklls
l.tnbiiiQI
hemla
Uneulba
A loc.IUon ofhemlas 1n thuntl!rtonbclomlnllwall
B Hemlllsofthuntl!ltonbcloml'nll wll" Laallan,-.•nd~r.tura
• UmMiaiiiHmla
• Umbilical n.gion. passing lhrough lhe umbilical ring: -Congenital umbilical hemla: lncamplem regraslan rJ lhe normal fml umbilical hemla due to scanfng ofttle umbilical papilla (hemlal sac: amnion and peritoneum) - Acquired umblllol hernl;l: common .tier multiple pregnanCies. also In aSSOCiation with obesity, hepdc drrhosls. or ascites (secondary Widening of lhe umbilical ring) • Congenbl persistence (1 :6000) of an abdominal wall d~ wllh an lncompleW reduction of abdomhlal vlsoer.~ during fetal I~ unhloe an umbllkll hemla,lhe omphalocele 1s not CIMI'ed b¥ epklenmls but only b¥ perltllneum, mucous connettlw tissue (Wharllln Jelly), and amniotic epithelium (so lhe contents are eaSI1J ..cognimcl) • The hernl;ll openings are gaps hllhe lhlea alba eledudhlg lhe umbilicus (on a continuum wllh rectus diastasis. see below) • The rectus muscles separate ltlhe hnea alba when lhe ;~bdomlnal musdes ;~retightened. CIQtlng a slte for potential for herniation (the hemla n!duces an relaxallan. and oomplalnts are rare)
•lnc~~~otalr..mr.
• Occurs at <1 previous InCISion site (usually In lhe upper abdominal midline)
• Umbilical and epigastric hemlas comprise appniXImately 10S of all hemlas.
188
s.
TIVnk wall - -
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
o
Ant.rlor abdominal Mil betwMn the semHunar line and ~al rect.. shuth, usually at the lewl of the aro.~a~ line
o
Between the twelfth rib and lilac crest - Superior lumbar hemla (superior costolumiNr triangle, CrynRitt's tt'lingle): between the twelfth rlb and iii-Ill lis - lnfwiorlumbar hernia (lnr.rior Iliolumbar triangle, !'«It'striangle): bn-n the ll"c crest. latissimus dorsi, and extemal oblique muscles
oablu---•
o
Through the obturator foramen and then between the pectlne... aclduel!or long... and extemal abtumor musdes
o Sctatlc hemla
o
Through the gl'elter sacniSdatlc foramen: - Supraplrlfonn hernia (a.,_ the plrlfonnls muscle) - lnfr•plrfvnn hemla (bel- the plrlfonnls muscle) - Splnotubero.. hernia (In front of the
o
Through the peMcfloor. - Anterior perineal hernia (In front of the deep trai\M!I'Se perlneaO - Posterior perineal hemia (behind the deep transwne perlnaO - lsdllorectal hemla (through the levator ani Into the rschiOanal fossa)
o
Splgel... ._..•
'---'-----;f---.~- Nell~
ll«tiashealh, latler.alwall
--:-.:..:..;..~~
line
D Splgellln hemla
sacrotubErOus ligament)
s~
lumblrhemll (Grynfeltl:'s hema)
0
Pemellhmlla
• las than 1ll «all hemlas. generally acquired (after Schumpellclc)
E Lumblrhanlll AnUI'Ior
~ tr.lnMne
pertne.al hemla
perineal
I
Suprapfrffonn hemll
Pfrffonnls ~~~~-lr- lmNpfrffonn hemll
hemIa
Sj)lnotubetous hemll
Adductor longus
F ObturatDrhanlll
lschbrertal
Sacrctubwoullg;mt!nt
G Sc1ltk: hanII
H Pertneel hemll
189
nvnk Wan - - 5.
5.11
Neui'D'IIUSallar~: Topogr~~phlcal Analomy
Diagnosis and Treatment of Hernias
DI!Kt lrQumlhlnbo ...)~---.----
Femoral
hlnla
--1----~:---'
lndi!Kt l~umllw1tla
•
lndn.c:t l~uln~l
hnl•
A Tl!chnlquefgrlhe uami!YIIon ufl191fMI iiiNf flmor.Jihl!mlas Hernias of the groin region, like m0$t hernias, are typic.ally prec:ipitatecl by a rise of Intra-abdominal pressure (e.g .. due to coughing. sneezing, or straining) and present .JS a palpable bulge or swelling In the lngutnill ~ron. Usually this ~lling ~res.senpr;mtan-..slywhen the patient lies down. Spontaneous pain Is gene!'illly ibsent with an uncomplicated hernia, and a foreign body sensation Is more common. Penlstl!nt pain accompa nled by a feeling of pressure atthe hemIa site, nausea, and wmltlng are slg ns of Incarceration (see C). In patfllflts v.tth a bulge In the inguinal region or a scrotal mass (see p.197), the diffemrtiill diagn~ sis should Include hydroale, varlcoczle, ectopk testis, lymphoma, and oehertllmol'$ofthe le$1iscwepididymis. Since inguinal and femoral hernias are of the extemill type 1nd are eul1y iltcesslble to Inspection and palpation, the diagnosis Is generally made dlnlcally. 1 PllpiiiOn frclm the tlt1c l(llne (the three-ttng• nile): The "threefinger rule" makes iteasil:f" to app~iate the topographic anatomy of Inguinal ind femor;ll hernias and differentiate among dlrectilnd Indirect inguinal hernias and femoral hernias. When the examiner places the thenar eminence on the anterior superior lllic spine, the Index ftnger pGints tD a direct hernia, the middle ftnger tD an Indirect hernia, and the ring finger to i femor;d hemill. Thus wheu hernia is felt below the Index flnger, for example, this means that the patient his a direct Inguinal hernia. Ill P.Jipatlonfram thucnllllm: This technique b particularly useful for palpating smaller lnguln~ hem lis In the standing patient. By Invaginating the sovtum ...W groin skin, the eqminer palpatu along the spermltlc mrd to ltte superfldal Inguinal r1ng and toudles the posterior wall or the inguinal c.anal with the pad of the finger. When the patient cuughs. an experienced ex.imlner can dbtlngulsh ;m Indirect hernia, which strikes the pad ofltteftnger, fi'om a direct hernia, which s1Ji~s the dim Itip of the finger.
190
B Compllllill ntdudlan oh hamlil When the herniated viscus can ITIIM! freely within the hernial sac and at the hemlil opening, generally the hernia can be reduced spontan-..sly (e.g., by lying down) or by 11\inual manlpulltlon. As a nesult. there Is no risk or uul2 inca rar.rtion.
c lnall'cerlted hem.. IIKilrceraUon Is the ITICMt serious c:ompllcatlon of a hemli. Str;mgulltlon at the neck of the hemla restricts blood flaw to tile herniated bo:r.Nel, with effects r~nglng fi'om Ischemia to necrosis. The patient maydevelop symptoms of a functional or mech;aniClll bowel obstruction with a llfethreate'ling in~ption of intestinal traJuit due to narrowing or obstAJctlon of the bowel lumen. GIYen the risk of bDMI perforation and pentonttls rn these cases, Immediate surgel'f Is tndlcab!d (see D).
TIVnk wall - -
No rnarceratlon
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
lnc:M'CJI!nrted hemll reduced spontaneolllly
Ina ranted.
lm!dudble hemi'a
or l1f a layperson
l are
\
I ltllk
!
!
..,....
1..........
D Hemlltsymptorns•ndtfmlng of the rep.~~lr (~Iter Henne-Brur15,
DO rig, and Kremer) A:s a rule. hernias do not respond definitively to conservative treatment (e.g., tJUsses orblrlden}, .ilrld oil pennanent rediiCt!or~ls .ilchleved only by surgical closure of the hernial opening (see E). The timing of the repair Is based on the cllr~lcal present;rtlofl, I.e.. the preJenee of a redudble, lrredudble. or Incarcerated hemla.
Heml'a defect (Hwelb.xh"s!Nngle)
Tr.l~--~~
abdamlnls
lllo'ngull\ilneM! - --.:-"''-""'i!li
l'lgulnal ligament
• E lflllllhll hemlil np;~lr: tile Sboclldlm tl!chnlque Sagltt;~l sections through the male gro1r1 region:
• Normal anatomy (see p.182). b Acquired direct Inguinal hem Ia. c; The Should lee repair. Wrioll5 surgit;!l methods are avai1able for hernia I'C!S'air. They differ mainly In the t:edtnlque used to reinforce the posterior Willi of the lngu-
c
lnal canal. In all metilods a sldr1 lrldslon Is made appi'Oldmately 2cm above the lr~gulr~al ligament. the hemlal sac Is exposed .arid dissected l'n!e. the conb!nts of thl! sac are mumed tD the abdominal nvity. and the defect Is dosed to restore the stability of the abdomlr~al wall. In lfle Shouldla! f!!PO/r (the most successful arid widely 115ed operation). lfle postenor wallis reinforced by overiapplng the tr.ilnsvenalls f.ilscla and wturing the inb!mal oblique ~nd tr.lnJYC!I'$US abdominis musdes to the lngulr~alllgament lr1 two layers.
191
Trunk Woll - - 5. NeuroWJScular Systems: Topogrophlctll Anatomy
5.12
Development of the External Genitalia
Genltaltuberde Urogenital sinus Anal folds d'
®= ,
c!b
b
B Derivatives of the undifferentiated embryonic genital anlage during development of the external genital organs (after Starck)"
Urogenital fold LabimcrotalsWI!IIIng ~
Unclltllrmlillted .Uge
~
I ~, . ·~ \ ~~:lJ3-Scrotum
Glans of ---1----,/fi ditoris
Labia majora
Petin..l -------\'
l ! - - - - - Anus
Clitoris, glans cWtondls
Gerrilxll folds
Penile raphe
Labia vestibular bulb
~gs
Scrotum
labia majora
Urogenital
Spongiose
sinus
part of the
Vestibule of the vagina
urethra Anal folds
Perine;~ I
raphe
Perineal raphe
• Details on the de\'dopment of the gonads and genital tracts can be found in text· books of embryology.
I
raphe
Glans penis
Labia mlnor.il
Vestibule ------loo:-1::1 ofvagina
Gerriflll tubercles
Gerr/1111
Pll!puce of clitoris Corpora
felule
minoril.
Glilnspenis ~ Penile ,.phe
Mille
Anus
c
A Development of the external genitalia a Rudimentary, undifferentiated external genitalia In a six-week-old embryo. b Differentiation of the eltternal genitalia along male or female lines In a 10-week-old fetus. c Differentiated external genitalia in the newborn. The external genital organs develop from an undifferentiated mesodermal primordium In the doaro and, like the gonads, pass through anInitial Indifferent stage. The anorectal area and urogenital sinus (cloaca) are not yet separated from each other and are closed externally by a common cloacal membrane. The following elevations develop around the cloacal membrane due to Intensive mesodermal cell dMslons: • • • •
Anterior: the genital tubercles lateral: the genital folds (urethral folds) Posterior: the anal folds lateral to the genital folds: the genital swellings (labioscrotal swellings)
Later, between the sixth and seventh weeks of development. the urorectal septum divides the cloaca Into an anterior part (urogenital sinus) and a posterior part (anus and rectum). The cloacal membrane disappears, and the urogenital ostium forms anteriorly. The early perineum forms at the level of the urorectal septum (by fusion of the paired anal folds to the perineal raphe). Differentiation of the genital orvans begins approximately in the eighth to ninth week of fetal development. Sexual differentiation is clearly evident by the 13th week and is fully developed by the 16th week.
192
• In the male fetus, the genital tubercles enlarge under the Influence of testosterone to form the phallus and future penis. The urogenital sinus doses completely by fusion of the genital folds and forms the spongy part of the urethra. The genital (scrotal) swellings unite to form the scrotum. • In the female fetus (absence oftestosterone), the genital tubercles give rise to the clitoris. The urogenital sinus persists as the vestibule of the vagina, and the two genital folds form the labia minora. The genital swellings enlarge to fomn the labia majora. Male seltorgans develop only In the presence of the factors listed below: • A functionally competentSRY(sex-determining region of theY) gene on the Ychromosome (otherwise, ovaries and a female phenotype will develop). The SRY gene ensures thatanti·Miillerian hormone and Leydig cells are produced (see below). • Among its other functions, the anti-miillerian honnooe induces regression of the miillerian ducts. It is formed in the somatic cells of the testicular cards (future Sertoli cells) starting in the eighth week of fetal life. • Leydig c-ells begin to form in the fetal testes by the ninth week and produce large amounts of androgens (testosterone) until birth. They stimulate differentiation of the wo/ffian duct into seminiferous tubules and the development of the male external genitalia. Alteration or interruption of this process of differentiation at any stage can lead to incomplete midline fusion which leaves persistent clefts (hypospadias, epispadias, see C), or to more elttensive external genital anomalies (see E) (after Starck).
Trunk Wall - - 5. Neurowscutar Systems: Topogrophlall Anatomy
E Various forms of Intersexuality" Condition
Abnormal uA!Ihrol openings
• True herm•-
phrodltism""
;f----- Anu•
•
Prost olE
• Pseudohermaphroditism
Pen neal hyp05padios b
Penile
Scrotill
hypospadia•
hypo!5Podios
C Hypospadias: a urethral anomaly In boys
a Cleft anomalies affecting the underside of the penis and scrotum. b Possible sites of emergence of the urethra in hypospadias (penis viewed from the lateral view). If the genital folds do not fuse completely during sexual differentiation (see A), the result is a cleft anomaly of the urethra, which may open on the underside of the penis (hypospadias) or on its dorsal surface (epispadias). Hypospadias is much more common, with an incidence of 1:3000 compared with 1:100,000 for epispadias. It is most common to find an abnormal urethral orifice in the glans region of the penis (glandular hypospadias). Additionally, the shaft of the penis is usually shortened and angled downward by the presence of ventral fibrous bands. Surgical correction is generally performed between the sixth month and second year of life (afterSOkeland, Schulze and Riibben).
- Makpst!udohermophrodilism - Clvonnosomal sex: male (46,XY} - Phenotype: fl!male
-Femolepseudohermophrodilism
- Clvonnosomal sex: female (46,XX) - Phenotype: male
Urethral
D External genitalia of a women with adrenogenltal syndrome Anterior view. The external genitalia show definite signs of masculinization. The clitoris is markedly enlarged. The labia majora and minora are partially fused, and the urogenital sinus forms an undersized vestibule (see E, female pseudohermaphroditism).
• Etiology 111111 pathogent!lll The fl!male phenotype results from a Jack of fetal androgen exposure: 1. Disturb•nee of testosterone synthesis 2. Disturb.nee of testosterone conversion 3. Androgen receptor defect 4, Testlwl;ordysgenesis - 46,XY chromosome complement - Individual h~s ~ female phenotype (estrogen synthesis present) but ~ks pubic~nd ~ll;,ry h;,ir ('h;,irless womin'), The upper v~gina and uterus are also absent. - Ca.- androgen receptor defo!ct or • disturb. nee of androgen metabolism (Sa-reductase-2 defect) - Result absenCI! of spermatogenesis - Trea!ml!nt removal of the testes, which are usually In the Inguinal region (rlskofmallgnanttransform.don) and estrogen replacement for life.
oriflce
Anu•
• The pseudohermaphrodite has a deflnlte chromosomal sex (female: 46,XXor male: 46,XY) but a phenotype of the opposi~ gender. The condition Is termed male pseudohermaphroditism when a testis Is present •nd fem.le pseudoherm•phrodltlsm when an ov•ry Is present.
• Example: ~rfeminizillion (1: 20000 live births):
Oitori>
Yagillil
• Very rare form of hermaphroditism (approximately 70S of cases have a fl!male karyotype: 46,XX). The gonads contain both testicular and ovarian tissue (ottnstis), but with a preponderanCI! of ovarian tissue. Hence the external genitalia tend to have a fl!male appearanCI! with a markedly enlai!Jed clitoris. A uterus Is frequently present. Most hermaphrodites are raised as girls.
• Etiology and pathog-lls The male phenotype results from fetal androgen exposure: 1. Congenil:ill enzyme defect 2. Diaplacental •ndrogen exposure • Example: congenlt.r adrenogenbl syndrome (1: 5000 live births):
- 46,XX chromosome complement - Fem.le Internal genital org;mswlth m•scullnlzed extmKII genitlliil (enlarged clitoris, partial fusion of the labi• mijor;,, sm~ ll urogenital sinus. see D) - CoiJ>f!: adrenocortic.l hyperpl.asi• with impaired steroid synthesis based on a genetic enzyme defect (most mmmonly a 21-hydroxylase defidency). The low hormone lew! Icauses increased ACTH secretion, leading to the overproduction of androgens. - Trea!ml!!lt: hydrocortisone therapy for life, which may be combined with a mineralocorticoid.
'lntersexu• llty refers to • condition malted by contr•dlctlonsln the development of general extern;~ I sexchar;,ctenstlcs, the gonads, and the chromosom;,l sex. "N~med ~fterHermophroditos. theandrogynoussonofHermes~ndAphroditefrom Greek mythology.
193
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.13
Male External Genitalia: Testicular Descent and the Spennatic Cord l'roc:l!ssus
wgt.ars
Urm!f
~
_ ___,__.........,
A~~~~~--u~
BulbcHnlllnll ---?5~~L.-:1' gand
Perilebub
Peris IHJ~~-\1-\\-1--'H--
Ductus deferens Ciubemac&lum
Cilbemlallum
Spnphysls
A OftMI!woftflemillesenltllollilnS The lntl!mal and external mal~ genlt.illla ire dlstfngulshed by their OJ1. gins: The intemal n!productivl! organs originate from the two urogenlt
...........1.....1..,._
• Testis
• Penis •Saotum • c-rings of the ll!slis
• Epididymis • Ductus deferens (vas ciefwwes) • AcassOIY sex glands - P!Oltate - Semlnalwslcles
- Cowper glands (bulbourethral glands) TQ9~ hCJ~~~~~eVer, the testis, epididymiS, and a portion of the ductus deflnns are dassifiecl among the extl!rnal genital OAJins
because they mlgrm from the abdominal av1ty Into the scroblm during fetal dewlopment (tesUcularclescent).
t.gulnal~ertls _ _.......c"-';. '
c Anom•lous posltionofthemtb Abnormal lUes In the descent of the testis occur In approximately 3% of all newborns. The testis may be ret
a Detcentofthetestk Lateral view. a Sealnd month, b third month, c at birth, d after obliteration of the proceSius vaginalis of the pefi1:Dneum. Near the end ofthe second month ofdeYel11pment. the gonads ~nd the rests of the mesonephros lie In a commor1 perltllneal fold (urogenlt
TIVnk wall - -
~mon~l~rtery
and win Te'JUallolrartsy
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
D 111e penis, scrotum, and spenn.1\lc cord Antenor llfew. The skin has been partially removed ~mover the sc:rowm ;rnd spenniltic cord. The tunka dartos and external spennatlc fasda are exposed or1 the left side,. and the $penmiltlc cord on the rfght side has been opened in l.rs. The skin of the ~wm differs In many respects ~m the sldn of the abdoml· nal wan. It Is more plgmentl!
- - - - L;;r-11 ------':..::--"'!!l~~
Pamplnlfonn ------~'--~ plexus
Obllll!ratl!d
processusvagtnalts
--External J
lpenn&IC fascia
F
Comp;ntsonoftllnbdomlnillw.~llliiJ'If'l
.nd tile comt!Spondlng aJWrTngs of tile tMttund spermatic Gll'd
The coverings of the $penmiltlc cord and m· tis are dertved ~m the muscles and f.lsdae of the abdominal wall and from the peritoneum. They represent a continuation of the layers of the antmor abdominal wall and encl0$e the $penmiltlc cord and wlis In a poucfl fonmed by the abdominal slcln (testicular sac or SCR)o tum).
.J."i:~-- 1.mna1 spenTIIII!c flacll
E Contenes of tile spel'lniltk: all'd Cross $ectlon through a $penmiltlc cord. The neui'CYaSCillar stnJctures that supply the tl!s· tis converge at the level of the deep lngulnal ring, fonmlng a bundle the thldcness of the small flngerthilt Is held together by loo.se con· nective tinue;rnd by the Wo/C!ring5 of the ~er· matlc cord and testes. The cv.oerings consist of tile following rtructures:
• Cremasteric f.lsda with the cremaster muscle • Genit;rl brilnch of the gC!Ilitofl!mor;rl nerve • Cremasteric artery and vein • Doctus deferens
• Arte!yandvelnoftheductusdeferens
• • • • •
Tertfcular art4!1'Y Testicularveiru(pampinilWm plexus) Autonomk nerve flbers (testl01lar plexus) cymphiltlc wssels The oblltermd processus vagina lis
The large vein$ of the pamplniform plexus al'l! exceptionally thick-walled. <Mth a three·layered medla, and hence are easily mistaken for arteries. In life the ductus deferens, With Its compact muSCillar wall, h palpable through the skin as a limn cord the thickness of a knlttlng needle. The ease of surgical access to this site Is utilized In wsec!Dmy or ligation of the ductus defefC!Ils to inb!rnJpt the traruport of sperm (mtillratfon).
Sp«k/1 (eatllres:
• Abdominal skin
- Scrotal skin With
• Em!mal abdominal oblique
- External spermiltlc
bJnica dar~~» (m)'Oilbrobluls In the dermis) t.l:sc\a
apo~rosls
• lnbemal oblrqut muscle • Transversalis f.tsda ·~eum
.... Cremasb!r musclt wlt!l~asterlc
faKia -1nremal spermatic
faKia
.... 1\mlcavaglnalls withvisaralllyer
(eplorchlum) and parietal layer (pcnorchTum)
195
Ttunk WGU - - S. Neui'O!IUCUior Sysmns: TopographlcaiAncrtomy
5.14
Male External Genitalia: The Testis and Epididymis (j)ldd)mah\1~
£pklldymls
Ductusdeferens
Testlalar wins
Testlalar artery :~--->~~- Me$or-
dllum Rnetl!slfs ~:;,....----+~--Co!MIIuted
semlllferaus Crem.1Stufc ~7t='H.-
runlawgnals
{~saralllyef
Scro!lllslm ---'r----:...,_!t--~"""!!" v.(thfllnla
·~um)
dar!Ds
a Opened tunica vaglnalls of the left testis,la!l!l'il view. b Cross section through the tl!stls, epididymis, and scrotum, superfor view. The tunica v~ginalis (unobliterated end of the proce~ vaginalis, su p.19S) forms a serous coat surrounding the mtls ;md epididymis. Its vi5«RIIayer Is fused to the tunica ;~lbuglne<~ of the teitls. At. the medl· astinum testis, the meson:h1um (suspensory trgaflll!llt where nerves and
~llllum
Cremastl!r muscle
testis
lnumal
spemurUcfiKIII b
A Tunic.~~ wgtn~~hs of tile testiund perito~l Chlty of the savtum ( • - c;Mtyofthe tal\ls)
tllbule.s
fuda
Tunlavau'nll~s
(v\sc;!ral D)'el1
TUnica
albiJ9nea
Thnkavaglnalls ~rlet;llll)oer)
vessels entl!l' and leave the testis), the tunica v.aglrl.illls Is l1!flected to form the p;~rietall;ryer, which is «Wl!red extennally by the intennal sper· matlc f.l!da. Between the two layers Isa slrtltke mesothelium-lined space (peritoneal C<~Ylty of the saotum) that cont<~lns a se<~nt amount of fluid and Is partially continued between the testis .and epididymis (epididymal sinus). An ~bnonml fluid collection in the serous c;avity of the~ tum Is called a tmlcular hydrrx:M (seen.) (after Rilubef and Kopsch).
Mediastinum - - - - - - -. testis
8 sum-lnltomrofthe testrnnd cpldldJml'f Left b!itls and epididymis. lmr.-al view. The combined weight of the wUs ;md epididymis at sexual maturity Is approxfmmly 20-JOg. The II!litis has an OIICiid shape (<~pproximately 5 an
long and 3cm wide) and an <~Ver.~ge volume of approximately 18ml (12-20ml). The testlOJ· Jar tissue Is en dosed In <1 tough flbroll!i capsule (tunica ;~lbuglnea) and has a rubbery conslmncy. The fPldldYm!S consists of a head, which Is att
196
C Stnlct\lre of the tatlnnd epldkfpll• Section through the testis (epididymis lntict), la!l!r.~l 111ew. Fibrous septa {septula testis) extend r.adlally from the tunica albuginea of the be.stis toward the mediastinum b!stis, subdividing the testicular tissue Into appi"Oldmately 370 wedge-wped lobules. Each lobule cont<~lns one or more convoluted seminiferous tubules, In ~ose epithelium the spermatocytl!s are formed (spennatogen~. see p.4) ~nd which open into the 11!te testis. From thell!. approximately 10-15 elli:!rent ductules p;~ss to the he<~d of the epididymis. where the epididymal duct begins. This single duct Is continuous dlstilly with the ductus deferens, which p;~sses through the Inguinal canal In the spermatic cord to entl!r the abd~minal c;avity and opens into the prwt;atic part of the uretnra via a short lnte!"Yenlng segment, the ejacul.atory duct (see p.199}.
s.
TIVnk wall - -
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
D - -i+- - Te:stlallar ar1!try
M \\....r.t---- Supeffclll 111!(ulnal
(¥mphltftchltll5fe from the tails
andepkll~s
f¥mph01tfc
from the Knllllm
lymph nodes
- - --71
1-1--l+...JI--
l'encnl ar1!try
and~
of1hetesels
E 1¥mph1tlc dr.~ln1gnnd n:slon1l J,mph nodeJ oftfle tatb, the lpfdldymts. the ~19 of the taUs, 01nd the scrotln The lymphatic vessels of the testis and epididymis dr;aln to the lumbilr lymph nodes, ;accompanied by the testicularvessels. The regional nodes that re
D Blood!qlp!yofthetettil a Artl!rfllsupply: The testis, epididymis, and tlleir CCMrings are su~ plied by tllree different arteries, which anastomose with one another (ilfl:er Hundelker and Keller. quoted In Rilubef and KopKh): • Tmlcular artery: arises directly from tile aorta • Artl!!yof tile ductus deferens: from the lnternallllac;uury • Cremasteric artefy:: from the infl!riot epigastric artery The vessels supp~ng !he saotum arise from the Internal pudendal al'l!!ry (5ee p. 496}. b Dlll1!rent venous dl'llln.Jte p;IUI!rns of the rtgl!t 01nd left tl!rtl!s: Venous blood from the testis and epididymis flows Into !he testlcular Vl!in.s in the area of the mediastinum testis. These wins form an elon· gmd veno~JS netwarl:. especially distally. c.1lled the pamplnlform plexus. It surrounds the branches oftile testicular artery and ascends With It through the lnguiBal c.lBal Into !he mroperltoneum. There the right testicularvein empties into the infl!riorvena cav.a, while the I~ testicular vdn opens Into the left rmal vein. This asymmetry af veno~JS dr.~lnage has rBaJor dlnlc.1l relewnc:e: The left testicular vein enU!rs !he left rmal vein at a right angle.. This creates a physlologl· c.1lly signilic.1nt constriction that can obstruct ~no us outflow from tfle left testicular vein and tflusfrom tfle pamplnlform plexus (wrtc:ocele, see Fd). In this case the pamplnlfonn plexus an no longer per· form Its "thennostat•functlon (cooling venous blood returning from the testicular artery}, resulting in a local h~t buildup that may cvm· promise the fertility aftfle left testis.
F Abnclnn;lllflndt11Qson dlnkille1101mllliltfon Clftheextunal genitalII Dbenn tflllt m;Jy pra:ent with sci'Citll ~lng: 11 inguinal her·
11-f
nta. b testlcular hydrocele (Se!'Ous fluid collection In tile Se!'OUS cavity), c sperrBatocele (retention cyst In !he epididymis), d varicocele (p;alnful, varicose dllatatfol'l af the pamplnlfonn plexus), e epididymitis (p;ainful b
always raise suspldol'l of a testloulartumor (afb!rSlllaeland, Schull!!, and Riibben}.
197
Ttunk waR - - S. Neui'OWJ'CIIIor Sysmns: TopographlcaiAncrtomy
5.15
Male External Genitalia: The Fasciae and Erectile Tissues of the Penis
lliolngumlnaw Extl!mal spennatlc:f.tscla P1!1111~~
ligament
Anll!r!or scrollll
L.!l~f--~--;-- ar18yandwh
ll;z-......~-~pj!nllef.tscla S~daldonil
pj!OllewiiU ~dcn.11
pj!nllewin
A Arrngementoftfle penile filllcTae a Anterior view of the penis (sklr1 and fasdae p;~r1!ally removed). b Right lilta'allltew ofthe penis (skin and fa5dae p;~rtlally removed). e Cross section through the shaft of the pet'IIS. The penis rs covered by thin, mobile sklr1 that rs dewkl of fatty lfssue. The slcin oYer the glans penis is duplicated to form the prepuce (foreskin). which rs atUched to the undersurface of the glam by the medlar~ fold of the frenulum (see b). The erectile &sues of the penis are surrounded by a common, strong envelope or collagenous fibers. the !WI lev olbugitleo. The two layers of the penile fascia (superficial and deep) also suiTGund the COIJIUS sponglosum and corpora cavernosa. The erectile lfssues. thelrflbroussheiths.andthewaylr~whlchthevesselsarelncor porated Into these fibrous structures ane of kley ln1lerert In understanding thefuncticm of the pen~ (seep. 201).
Dor5al po!nlle irlft)'iOdnt!M! Superilclal pj!nllefasc'la
S~al po!nfef~
S~l dcrs.alpent~
lldn
Dcn.al !)o!nf~~rtl!ly andnt!noe,brandulth~ deep dina~ po!nfelldn
~
caona gandis Glans penis
Ellt.mal
urethral
en~
fn!ftllum llenlluldn
Deep
Clxpusawmosum
penlefu:la
llld COil' US -vo:sum YAth 1\lnk~ulbugnu
B CoMtlfcUon oftfle prepuce (phimosis) a Crlnstriction of the prepuce in a 3-ye.al'
198
pucesttllcannotslldeovertheglansby3 years of ~ge due to afunctional stenosis (e.g .• persistent epithelial attachments due to an absence of smegma seaetlon). the phimosis should be surgically corrected by drcumdslon. This procedure m1ty be conse~v.~lfve or r~dlcal, resecting ~II the foreslcin (~s ~own h~). depending or1 the severity of the phimosis. Immediate surgical ln1lerventton (before 3 years of ~ge) rs necessary for par.phtmoslr-afl emergency situation irl which the glaru is strar~gu lated by the NITowed foreskin (painful. livid swelling of the glans due to deere<~ sed blood flow, with risk of necrosis) (.after S61Geland, Schulze. and Riibben).
•
TIVnk wall - -
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
Corma!l•ndls - - - - -- iii: Glens penis - -+ii-iir--t-'iii
Corpur.--+..m COMmOSUm
c Tbe~letfuueu.ndereetile~les of the ptnls lnfertor view. The corpus sponglosum Is p.artlally mobiiW!d, and the skin ind filselae have been removed. The isch~sus 01nd bulbosponglosus muscles hiM! bftn removed on the left: side along with the lnfelforfasda of the urogenital dlaphr;agm. b settion through the root of the penis. The root (r.rdl11) of the penis Is firmly atto~chedm the perineal membrane ;and pelviula!leton.lt is distinguished fromtbe freely m11blle shaft (body) ofthe penis, wlth Its dorlil and urethr;ll surfilces, and from the glans penis, which bears the external ureth· till orilicz. The penis contains two types of erectlle lbsue:
;a
'"'s.s
• The paired corpora avem111a • The unpaired corpus sponglosum At the root ofthe penis, e.-~ch of the corpora cavernosa tapers to form a crus penis. Bet· 'M!en the two crura lies the th'lclcl!ll1ed end of the corpus ~~~ngi~~Sum, the bulb of the penis. The glans penis forms the distal end of the corpus sponglosum. Its posterfor m01rgin is br'Dadened to fonn the corona, whk:h lsturnedovertheendsofthecorpora cavernosa. The erectile tissues reallle their blood supply from br.mches of the lntJ!r· nal pudendal artery, which branches in the deq~ perlne
llodyct penis
Obtura=rforamen
Bulbospanglosus
tsclllopublc ramus B~bM~~---~~----~
Oeep!Rnswne - ----"pertu!.;~l
--".,
fasiCia ct lnfetlot ..ogenltll dlllphragm
or perfneal membrane
•
Pubic symphysis
I
Do~l ~lit artery
Corpant ---------+~ aMmOH
Deep!Rnswr.se ---....;..-::,iii perineal
Bulbolperis,
b
OllllUUPOOglosum
Bladder Aectim
Symphysis
lnumal ur«hral
Glens
l'tostlt2
arfflat
Spongy
Prostlltlc PI rt
pwt
Membr.lnous
part t.Rgenlt.al
daptll'iagm
Extl!nlal Lfttllral Clf1ftat
D Courseofthen\llle urethra Mldwglttoll settlon through a m
External &nlhrlll or11lc:e
Coil) US spangrosum
Penleor 'POnliY
partofur«hn1
Nw!culu fossa
E MldsfgHUI M:Ctlon through the diJU~I penis The spongy p;art of the urdftra undergoes an approximately 2-cmlong fuslform dlliltlltlon v.fthln the glans penis. In this ;area, the navicular foss.11, the stratified columnar epithelium of the urethra gives vnry to $tralmed, nonlceratinized K!Uamous epithelium. The upper all I~ of this epithelium are rich In glycogen. which-as In the \'iglnal milieu 1r1 females-provides a culture medium for the lactic add b;u:terla that thtiW! there (acidic pH prab!ct.s against pathogenic organi5ms).
199
Ttunk WGU - - S. Neui'O!IUCUior Sysmns: TopographlcaiAncrtomy
5.16
Male External Genitalia: Nerves and Vessels of the Penis Corpcmt
DHpdonal
c.wemosa
!Mf'llt'Wfn
Ar~ pubic l19tment
Colpus
sponglosum
Exll!m~l
pudendal wssels
Do!ej) donal
Transverse perfnNIIJgament
penile win lllli~~-- Dcn.li1Mf11e
Dorsai!Mf'llt arb!ry
Bubo-
---~11?.--+-fljr.-.
~~---~-,~+-~
saotllnei'YI!S
artery and nerve
Dorsal penlleneM
spongkmlr.
-~~"''~t;}-:;~"""":--=~- Musa.Yrbnnches ~~~~----~---
An~.~~> ----l~~--+.li~
& IW- - Superftd;tldanal
Bulboum!ual giii'K!
penllewtns
l!dllill t\lbenlslty
Inferior --l~_,..,~ recti! neM!S
l '>IR ·- - Deep!Mf'llt
lnumal
flllda
pudl!ndai'YftS!!Is
Eld:l!mal anal __,~5;~"::' sphlndl!r
Pudenditlnl!l"ff! lnfetlclr rectal
Gklt!i.ts
-.d.!
m;!XIm~.~~>
Glinspents
A N~I'IMIJQJIII'~reuftflemele
pertnuii'I!IIDn Llthotomyposltfon wllfl the scrotum re~. lnferforvlew. The superficial perlne..al sp;ace on tne right side hM been opened by 11!moving tne superficial perineal fas:cla. The erectile DctSII
Deep
muscles androotoftnepenls hiM! been removed on t!te left side, and the deep perlne<~l sp;ace Is partially exposed. The penis has been tr.ilnsected aaDSs the shaft. and the spetmatic cords have been dMded.
B Dorul vestdund Mf'Wefofthe pent• The prepuce. skin, and superficial f.lsda hiM! been completely reiTICM!d from t!te penile shaft. The deep penile fasda has also been removed from tne left dot'lum.
Don.JI penlltrwnoe
Flo static wnous plelcul
lnl8nlll
perilurtety !Mf'ilurtery Ihe artery Mlddltrecul arb!ry
lntemll
lnumal
lllac:~~e'n
pudendal ...my D~
lnfetlclr rectiI arb!ry
penile
lil!rfnul.-te~y
Yl!fns
Bulb;rpenlle II~~~~~5=- arb!ry
lntlmlll pudendllw'n lnfmar rectiiYI!fns
l.ftllll'lll.-te!y
un~~~1!!11bl
dlaphl'llgm
1
Sacral ple:xus
·-
Pudendal ~or
rectal nenoes
l"o.m!rlor scnlUI brandies
c Artltrfal supply tiD die penlul.t suotum
D Venous cht111ge oftfle penl's 1nd
E NervesupplytDtflepenlund scl'lltllm
Left later~l Ylew. The penis and scrotum derive t!telr ~rterlal supplyfrom the Internal pudendal al'tl!ry. This vt$$el entl!rs t!te lschloanal foss.a and, after giving off the infl!rior rectal arte
scrotum left lateral Ylew. The veins of !he penis (especially the deep donal penl1e vein and Its tl1butaries the deep penile and bulb.ilt penile veins) open lnltfally Into the Internal pudendal vein and !hen Into t!te prosu!lc venous plexus. Exceptions are the supe!'fldal doiS.ill penile veins (not seen here}, which dl'i!in 'IIi;! the extl!rnal pudendal veins Into tile long saphenous vein. On tts way to t!te promiSe wnous plexus, t!te deep dors.al penile vein passes tnroii!Jh a n~rrow sp;rce jllft bei11N the $YI"" phylls between tne ai'O.Iatl! pubic ligament and the transverse pel1ne..alllgarnent (see ltgamentsii'IA).
Leftlmralllfew.Tbe pudendal nerve entl!rs the lschloanal fossa and, after gMng off t!te lnfe. rtor rectal nerves, courses 1» t!te external anal $1'hincter and to the slcin of the anUJ ;rt tne posterior border of the urogenital diaphragm. There It divides Into Its tl!mllnal branches, the perine..al nerves. The supe!ftclal branchl!l p.ass through tne superflc!al pa!ne<JI space to the skin of the perfneum and posterior saotum (postenor saoul branches}. The ~ bran· mes murse in the ~ perineal space. They lnnerv.ste the en!Ctfle musdes (1/ia mUJcular branches). t!te skin of tbe penis, and t!te erectile bodies (\Ita the dorsal penile nerve). The murse of the aul»nomic fibers is sht:IWn in F.
200
TnmkWall -
5. NeurotlflsallarS)'mms: Topogt'fiJJhlall Anatomy
rvdtndolnsw, plllneol • .,_ (etreNOrrtSOIN!Icfl>eB)
:.....:~,.--
Hf!lldM..u.!K
..
B111nch af deep
TunlculblllJIIIII
Bloodermfng
ttuuugh holldne
po~ftbon)
a111el1a Dlmddeep ponllultay
Dorsal penle .....,. (atrellnt iUNI!c ftbon)
F owm.w fAth•ll'llleiUIRiretThe se~WII refti!USin males are evoked by 11 nri~ of stimuli (e.g., uctil~ visual, olfad:Dry, uoustic, and psychogenic}. SOmatic and auiDnl)o mlc nerve pathw.lys transmit the stlmul us to U!e erection ilnd ejiiKllla· tlon centers In U!e thol'iiCOiumbar ;~nd suril splnil cord. from which It Is rel.tyed to higher c:enters (e.g., the hypothalamus and Umble systEm). For example, lrrelile cutoneous 5timuli to the genitlllla are transmitted to the Siltral cord by af'l'mnt !iOI7IQflc fibers (do11<1l penile nerve from the pudendill nerve, shown In green), and ;~re relayed In the erecdon center (S 2-54) tD effmnt porasympatbel1r: ftbers (peMc splanchnic nerves, shown in blue). These impulses, which stimulata vasodilation of the artrrles supplying the erectlle tmues (see G), ire crltltilly Influenced 11r descending pithways from higher centers. Co.--sely, the exdtl· mry Impulses ewled by rnaeasrng mechanlca Istimulation of the gIa ns penis ascend from the sacral cord to U!e ejaculation center loated at the T12-lllewls. There they ove rei~ to rf(wmt sympod!etlc fibers (hypogasllfc nerves, shown In purple) and stlmulata smooth m~de mntractions in the epididymis, ductus deferens, prostata, and sem1nal vesldes. Simultaneous stimulation of the erectile musdes by efferent .roma!k nerve flbers (perine.1l nerves from the pudendal nerve, shown In red) produces rhythmic contradlons thit expel the efiaJiilte from the urethra (emission). Failure to adli- an erection, despite an active libido (psyc:hologlc311nterest In sexual activity), Is defined as erectile dysfunction. The recent development of successful medltil treatment of er«ttlt dysfimctfon with slldenaftl (Vlagra (l'ftzlll')) Is based on lt:S modu lilt!on of the secund memnger cyclic gua,_ine monophosphate (cGMP). When the primary messenger nitrous GJdde (NO) Is released by neuril stlmu latlon, It .JctiYms the emyme guanylate cydise In penfle erectile tissues. This enzyme generates cGMP ~~ ~ second messenger, whldl In tum Induces vasodilitlon and produces an erection. Sllden11· fll seledlvely Inhibits ~MP br~kdown by i spedflc phospllodlesterase (PDES) that Is prominent In erectile tissue. cGIIII P ~CaJ muliltes, vessels remain dilated, and penile erection is sustained. Sildenafil treatment thus efn!ctlvely amplifies the In it:lal neural stimuli, with the potentia I of prolonging normill erections ;md overmmlng other. Inhibitory physlolaglal problems (~lb!r Kllnlae and Sllbemagl).
CMtywtll
ponllultay
Dit.ted awnlOUS>PillD
PI!Mc splondlnlc nerws (efferent
£mlaorywtns
Clm.unfleltwn
-T~~tit.~ . -. .~~~- CGmpre:ned d111lrlng vein
c
G MIKNnllm vf p111lle -dian (after Lehnert) • Penis In C'OSS section, showing the blood vessels Involved In erection (enlarged VIews In blind c). b Co~J~us ~rnowm in U!e ftiKOd state. c CooJ!us ~rnowm In U!e erect state.
Penile erection Is based essentially on mOJdmum fll90~ and pressure elevitlon In the Civltles (cavernous Spices) of the corpora ciYI!rnosa mmblned with a cans01dton of wnous outflcw. This medlinlsm raile$ the intrauvemous blood prmure to approximately 10 times the normal systolic blood pressure (approximately 1200mmHg In young men). Mlcroscopltilly, the erectile tissue of the pen Is consists of an arborized trabecular meshwork of connective-tissue lind smoothmuscle cells that is mnnected to the tunic:il albuginea. Among the tri· beculile ue lnteranastomoslng cavities that are lined with end.othellum. Branches of the deep penile ilrtery, tilled the hellclne ilr11!rles, open Into these caY~tles. In the fliiiCdd s.tm, the 1\ehdne artllfes are more or less ocduded by •tnttmal pads." When iln erection occurs, die lfferent iii'Urles dilate ilnd the hellclne iii'Urles open under the Influence of dluutonomlc nervous system. The result Is that w1th eadl pulse WolVe, blood is forc;ed into the c.avemous Spices, increasing U!e volume of the erectile tissue, and rihlng the lntracmtlry pressure. The tunica albu· glnea. whldl has a limited ap<~clty for distension, becomes taut and compresses the wins that piSS through 1t. This medlinlsm, aided by the ocdusion of emissary veins. causes a constriction of venous out· flow. en1bllng the penis to remain stiff and hard. Meanwhile the dense venous plexuses In the corpus sponglosum and gIa ns prevent l!llaSSI\11! mmpresslon of the urethra. The ftxcld phase begins with VliSOconstrlctlon of the afferent a112rles. An undesired, prolonged, and painful erection Is tilled psfapkm (from Prf;apus, the Greco-aoman god of procreation) and may oa:ur, for nample, In certain blood diseases or metabolic disorders. The initial treatment of this a>ndition is media I; one option Is the use ofvasoconstr1ctun (etrlefrlne or norepinephrine). Surgical treatment Involves ll'lillifng "pundl ;anastomoses" to promote the outflow of blood.
201
Tronk WfiH - - 5. NevrowJJ~CUIGr Systmls: Topogn~phkaiAnafomy
5.17
Female External Genitalia: Overview and Episiotomy
Mens pubis Prepuce
---:::~iiilli!~~;-.,--:-.;._---1-\ 6(j~-"!l!
of dltoris
~"g of --3==o,.--~
llard>olln
~-----;;-- Po
glindJ l'lrtleal raphe
labial (l)lllmlsiiJre
--=----<
• A OwiYicw lllf th~tfem1l1t gnbl OIJIIW a Internal and some external genltill Orgins. II External genltlllli,lltho!XImy position wid! the labia minora separab!d. As
In males, a distinction Is drawn between d!e development and the
............m,lg...n.l•rgans
t:DpDgraphyofthefemaleintl!rnal and II!Xtemal reprodud:M!organs. The
(wMII
homo~ In
the drvelopment rl the male and feiTiile genltill organs Is reflecb!d chiefly In the CJJmpa rable hlsiDIDglal features of the cat'T& poncllng parts (see textbooks of hlstDiagy). The female external genlta·
• F.alloplln tube
liil (pudendum) is also known in clinical parlance as the """"'.It is sepa·
o
r11ted from the lntRmal genltlll organs by the llymrn (nat sh--. here). The outer boundir1es of the w hli are fanned by the mons pu bls, 1 filt1y-fleshy pramlnena 0111rthe pubic symphysis. ind the~ ma]ara. two pigrnemd ridges of skin that canuin smooth musde ~lis as well as sebiceous glands. sweat glands, and scent glinds. The labia majora are lntlfmnnected antslor1y and posteriorly by a bridge oftissue called the a ntl!riar or posterior labiaI commissure. The area bl!tween the posterior commissure and anus Is the perineal raphe. Specificstructures are listed 1n the tllble at right.
• OWiry Uterus
·~
• Mons pubis • Llbla m.Jjora o Llbtl mlnano 0 v..t!IM*af ......
• \latfbullr bulb • Cllrlrts • v..tlbullrgllnds - Gruter-ibulwgiMds (a.rthonn glondl)
-
'-~bulorglands
1 MldsagltbiiKiton through • female pelvis
Left lateral view. t«b the dose proximity of the external urethral orifice tD the wgl· nal orifice,. whlcll opens lniD the vmibule.
202
Tnmlc wall - - S. Neunwrlscular .symms: TopogtvphlallAmrtctmy
au~··
11.....
r.tdllne eplslaiDmy
Dftp In~
pe-\11111 ~~---- SL.perik:l~l lniiiW<W
b
pe-t,eal OboJI\lll)lfUS lnten'IUi
~r--~--~P
alrllmls~re
t.r.latDr ....
•
Exmmolorwl spNncllr
Glumus maim us
c
C EplllllltaniJ: lndkdo111•nd teclrique • Pelvic floor with crowning ofthe ~I hud. b Types of eplslolxlmy: midline, medlol~ral,l~ral. c Medlobt.era Iepisiotomy perfonmed at the height of a cont~ctlon.
Episiotomy Is a common obstlrtrle procedure utilized to en b rge the birth canal during the es:pulsive stage of bbor (see p.-482). When the fetal hud ~sthrough the pelvic floor, the lefttor ani muscle In partta.llar Is passively stretdled, forced downwilfd, and rotited approximately 90'. The •JevolltDr plollb!" thus helps tD fonm lfle Will of the distal bir1h anal along witfl the urogenital diaphragm and bulbospongiDsus muscle. As such, It comrs under considerable tension at the pertnul body during lfle pushing mge of labor. To protect the perineal muscles from wrtng, the obstlrtrtdan counteracts lflls tension by supporting the perine~m with two fingers (perineal p~n). hi~ IJ often perfonmed to prevent una111trolled lli
that Is at rlslc for hypoxia during the expulslw stage. An Nrly eplslolumy is one that is made before the h~ crowns (the hud is visible with a~n· tractions ind pushing but recedes between contractions). A.tfmrlyql/sfo. tomyls made ilftet'the head has crowned, whert there Is Rlildmum tension on lfle per!nul slcln. Three types al eplslolxlmy .1 re IM!Illable (see D for advanQ~grs and disadvantages): • Mid...• epldilllllmiJ: straight duwn from the vagina tvvnrd the anus • Medlor.bnl eplslcrlllmJ: oblique lndslon from the posterior commissure • a.teral eplsi-IIIJ: lmral incision from the lower third ofthe vu Iva
After the placenta is .W~d. the episiotDmy il. LIISually dosed in at least three layen (vagin~ suture, deep perlneel suture. ~nd cutineous suture). Local il nesthesll Is generally required, espedally when an earty episiotomy h.iis been done. If the eplslolxlmy was made at the height of a contraction ilfu:r crgwning of the hNd, aneJthesii is unneaNllry. Local Infiltration anrsthrsla and the pudendal block (PDB) are described on p.482.
.......... • Midline
• None
• ~~Ill repair
• May lengtflen Ill agrad•lll p•rlnulla...-lon
• Hulswell • Medlo-lrteral
• Bulbosponglosus • Superfidll trii\MISOI peri111111
• Cains more room • Low risk ri laceration
• He.vler bleeding • More diffia.olt ID rep1lr • More dlffla.olt hHIIng
• lata"'''
• 8ulbosponglos.. • Superfldll tro nswrse perlnal • ~r 1ni (pubcnc:talis)
• Goins the mast rvam
• Huvlelt ble.dlng
• Potentlll compilations (e.g.. ilnallncontlnence) • Grutelt paslplrtum 111mplaints
• Very 111rely used
203
Ttunk WGU - - S. Neui'O!IUCUior Sysmns: TopographlcaiAncrtomy
5.18
Female External Cienitalia: Neurovascular Structures, Erectile Tissues, Erectile Muscles, and Vestibule Vestibular bulb
Lympha11c draiAagt of thuntll!rtcrdlb:orts
lntemallhc lyn'9h noclu
~,..-...::.;~;..,...-~or
labial
bnrM:he
lsc:Hal
~ ~-.--~--
klflrlor rectll~s
D~
Pl!m1!111nones
ll'aM"'Itr:se perfnNI
lnfetlor
rertal netW.S
A Nerws and wuek ofh ti!rnlle p~lte!!lon
Utho!Dmy position. The labia majora, sldn. superficial perineal fascia, ;md fatty tissue In the ischioanal fDSsa have been removed to
Deep-.guln.al
l.ev.IUir anl
lyn'9h nodes
demonrtrm the neuFOYaScular structures. The bulbospongio.suJ and isd1iot.111emOSU$ musdes and tile Inferior f.lsda «the urogenl· tal diaphragm have also been dissected away en the leftiide.
B l¥mPhlti'C:dl'lllnage clthe l'l!tnlle extl!malgenttalllt
Female peMs, anterior 1/tew. Lymph frcrn the female ex.ternal genitalia drains to the superfl· cial inguinal lymph ncde.s. Tbe cnly exce¢ions are the anterior pardons of the clitoris (body and glans). which drain to the deep Inguinal and lntl!rnallllac lymph nodes.
,.W,d~--
C Artledilhupplyto the female extl!malgentti!R;a
Perineal region, Inferior lllew. The female external genlt
204
Venous plr!xus of vatbulrrrbub
Vdnof ----i~:..-.lil:..'~'~.......____ Po:s11erlor W>!aiYdi\S
vatbulrrr bulb
J>.rllleilll Ye!OJ
-~'f-J'
Inferior
n!Cil!IYdns D Ven«r$ dnrtn.age of the ferm~le extern.! genitalia Venous drainage Is handled by tile following vessels:
• The deep clitoral vetns, posterior labial veins. and vein ofthevestlbu· lar bulb. which drain Into the lntJ!mol pudmdal vein • The supertldal doml clltorill vel'ns ind antErior labial veins, which drain into the memo/ pudmdol W!in.s (not seen here} • The deep dorsal dltoralveln. v.flldl drains Into the vesla!l venous plexus
TIVnk wall - -
Cttoral p~
s.
NeurotlaSGliGrSym!ms: Topogtvphkrll Amrtomy
Glans dllafdls
~t:F=-:--
Pu6endal
ni!M!
B~bo-
spon~iostA
E Erec:de t1nues end erec:t11e mllldes In tflefemele Perineal region. lithotomy position. The labia majora <1nd minor<~, skin, and superffclal penne~~l f<~scia have been removed, as well as the erectlle muscles on the left side. Erectile tl.aues; The erectlle tissues of the cfi. !Drls <~re dlstrlbu!J!d 01round both of Its crul'il and Its short shaft (body). They correspond to the erectile tissues in the male and are named accordingly; the right and left CQ~Poro CIMT'· nosa o{t!Je clitoris, homologous to the corpora cavemosa of the penis. Tbe SWI!IIing at the end of the clltllral shaft Is called the glans dltllrl·
Vestbullr bulb
Crus
lS
of dttor!s
ClMI'IlO$US
dis, homologous to the glans penis. Its sensory innenr.rtion is like th
Dorsal
dtoral-
Postelor
llblalbr~
Pelfne.i nenou
F Nerve supply to the female extl!mll
genltllllll lesSEr peiYis, left lateral view. The pudendal nerve enters the lschloanal fossa. Aftef giving off Ule Inferior n!Ctill nerves tD the external anal sphincnr and anal skin, it courses to the posterior bordes of the urogenital diaphragm, where It dfllldes Into Its temllnal brioches {perlne~~l nerYeS). The suptrflcta/ bronches pass through tfle superfiCial perineal sp;roce (not seen here) to tfle skin of the perineum and the posterior portions of the labia majora (pas~ rtor labial br.anches). The del!p branches course In the deep pertne~~l space. distributing mus· OJiar branchel to the erectile muscles and the dorsal dltoral ner~~e to the clitoris. The an~ rior portions of the labia majora are supplied by interior labial branches from the tllolngul· nal nerve (not seen here).
BulbospongiOM Vaglnalorfflae
~lor glands
~bul;rbulb
Bilrthdlngland
--~!!J
Oriflaeof
Barthofnglllld
G Thevestbuleendllatlbu.. rgl•nclf Lithotomy position wltfl the labia separated. The vestibule. bounded by the labia minora, cont
(B.artholln glands) each open by a 1-cm-long duct at the posterior border of the vestbular bulb on the inner surfac.e of the labia minora. The lesSEr vestlbular glands are homologous to the uretflril glands In the male, and the greate!'ve1tlbcJiar glands to the bulboureth· r.al glands. TbeVI!$tibular glands produce a mucous secretion th
205
The Upper Limb Bones, Ugaments, and joints .•••••••• • ••••. • .... . 208 2
Muscullture: Functional Groups •••.• .. . .••••• . •• . 256
3
Muscullture: Topographical Anatomy . •. •. . .. •. •• 284
4
Neurovascular Systems: Forms and Relations •. •••• . 308
5
Neurovascular Systems: Topographical AnatDmy . •• 328
Upper Umb - - J. Bonu. UgamrnB. amiJoints
The Upper Limb as a Whole
1.1
-=----
Htrnei\IS
Hunv:nr.adl:ll joint
;~nar
}
llbwtlolnt
Proximal radioulnarjoint
mm~-----,~LY~~ fclntofthe tllumb
,.....r~~;:L-- Clrpcmetlarpal Jclnts
n~m~-~~~~4r.~\
fourlhmea· arpals
l
Sa:ordpi'GICI-
Oiglts
.a
+J f k
ph11irot
Seoard dK.ll ~
phalanx
A Skelelxlnoftflertghtuppl!t'llmb
a Anterforlllew, b postl!rlorW!w.
The skeleton of tne upper limbcvnsim of tne sh~ulder girdle. ~rm. forearm. wrist and hand. The shoulder girdle (divide and scapula) Is joined tD the upper limb at !he shoulder joint, arid It joins the upper limb to
208
F
malpllalanx Sealndm'Oie--
FourlhmlddlepNiar«
-~-+1
FourthdstllpNiar« ----+' b
!he thorax at !he stl!ITIOCiilllfcularjoint (seep. 227}. The limb ItSelf consists of the:
• ann, • fore;~rm, ~nd • hand.
/ ~
Su~ per!aranglt Onlcle. ICtunfllend Acromion
~ =~
Scapular
spine
!oength cfarm
M~i:rl
bonier
Styloldproa!SS-_. ofradlur.
~
-...........r
'nlben:leof ---~ .saptlold
lnfetlor ;r,ge
L - - - Stylald~ I cfuha - - - l'lllfcmlbcn~ ·- - - - Hamuhacf
'nlben:leof
hammebone
trapelfum
,.._- - - . . . . - - - - Met.larpo-
phalange.lfdnb
!oength cfhand
tntet-'--~-+-__,.j~r
phlllw!gul
lalnb
• B PaiJHOble bor1Y prominence• on die lfght upper limb
Anterior view. b posterton!ew. Elapt for the lunate <mel tripezold bones, ill of the bones In the upper lrmb are paiP been defined for use in me.uurfng tile lengths of the segment3 of the dependent limb (with tile P
;a
• Length of tile eptmndyle
<~rm
- distance from the acromion to tile
• Length of the forearm -distance from the lateral epicondyle to tile s~d proct'SS oftheradlus • Length of the hand- distil nee from the styloid process of the radius to the lfp ofthetiltrd finger Tbe segment lengtlts af tlte limb may be me<~sured, for example. to atd in tlte precise eYiluation of isolated pedi~trit giVNth clisturiHncn tltat are C1lnftned to a P
la!l!r<~l
209
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.2
Integration of the Shoulder Girdle into the Skeleton of the Trunk O;Mde
Aaomlo-
ciMc:llarplnt
~~f--- Sapu~
pos1:2!'1arSJrface ")--~~--
Medial border
T12 ll
TMifthrb
A Bones of the rtghtshoulderg~leln tflelr nonnal reiiUon to tfle skeleton oftfle trunk ;a Anterior view. b posterior
view, c lateral
1/few. The two bolll!lofthe shoulderglrdle (theclal/1·
Body of
sll!rnum
Com!I
arttlage
210
de ~nd Kilpula) ~reo::onnected at the acromiodallfcular joint (see p. 227). In Its normal ina· tomlcal p0$ltlon, the sc.1pula extends from the .secc:md tDthe seventh rib. The inferior angle of the scapula Is level with the spinous pro cellS of the seventil thoride vertebra, ind the sapular .spine Is level with the .spinous process of the third thoro1cic wrtebm. When tile sc.1pula oc· OJ pies 01 norm01l position, Its long axis Is angled sllghtiy laterilly and 113 medial border forms a 3-S"<~nglewlth the mldsagltUI plane.
Upper Umb - - 1. ~Jones.UgamenB. andjoints
Densof~s(C2)
S(apular notth Aaomlon Acnlmk>
dniculujont
- + :----1
---:.-~......,,....;,~.,._'7?-7L'----
Mlnubrlum mml
StemodnicularJo'nt B Rlghtthoulder girdle
Superior view. With the tr~mltton w a bipedal mode of locomotion, the human se<~puta ITI01Ied from the more later;l pli!Cement In quad· ruped mammals to a more posfJI!I'tor position, and also a more frontal orientation, on the b.ack of the thorax. Viewed from abcve, the sea~ ula forms a JO" angle with the corvnal plane. The scapula and clav!de
subtefld an angle of apprmimately 60'. Bee<~ use of this arrangement. the two sfloulder joints are angled sltgtrtly forward, shlfdng the r;nge of arm mowments forward Into the field ofvlslor1 and action. This reori· entat1or11n humans creates the opportunltyforvlsual control of manual manipulations (hand-eye coordination).
Shollder gird~
PeMcghlle
C Comp;ntson oftfluhouldKgtrdlt ud peMc girdle tn thelr rellflantothetktletDnottfletrunk Superior Yiew. Unlike the very mobile shoulder girdle. the pelvic girdle,
consisting ofthe paired hlp (lnnomlflate) bones. Is flmnlylntegrated tnto the axial skeleton. As the trunk assumes an upcfght position, the pelvis mcwes rwer the >Neight-beating surfaa! of the fi!et, making it neassary
forthepeMstosupportthetllt
211
UpperUmb
1.3
J. 1JcHJu. Ligaments, andjoints
The Bones of the Shoulder Girdle
Scapular sp'h~
Aaamla-
d;Mcular jdnt
SUpraplnous fossa
- ---;.-::-::--..,..;fill
Impression for ~lirlganent
A PasltiDR ilnll lhil.- vi the rtghtdmde
• Cillllde In Its normal relation ID the sapula, superior view. b lsobted dillllcle, superior view. c: lsobted d
adults, that Is visible and palpable beneath the skin along Its entire length. The medial or s!Jrmal md Df the d~lde bears a saddle-shi ped articular su rfilce, while the latera I or OC1'Dtnla/ md has a fliltter, more ~c:al articuhtr surface. The ci
212
flcatlon). A
Ar:ramlan
Glr
Sapular natm
SUperior border
SUpragll!llafd _ _ _.,...,, 1:\lberde
1..111«111 <Jngle Gll!llald Uf!ty
lnferlaunglt
E 111uapullrl'onmen
111e superior tramverse ligament of the SCCipula (see p. 233) can become ~silled. tramforming the scapcJiar notch rnm an <momalous bany canal refemd to as a SCDpUior r~. 1111s c.orn lead to compression ofthe suprascapular nerve aslt passes through this c.ornal (see p. 340). ActiVe rotational movements of tile shoulder all!lt;lll;!te the nerve pre$Sure, le;IC!· lng to significant symptoms (scopular notch syndrome). A common result Is wealcness and atrophy ofthe musdes-the supr.asplnatm and infr.i!spina~t the supr;.,c.1pular nerve lnner~~ms (seep. 263).
D 111e rtghttapUIL Postertor'llfew
213
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.4
The Bones of the Upper Limb: The Humerus
......_ _ Head of--....,.=... humena
Deltoid tuberwlty
I
'
~
G~for
ractaiMrVe (racial goove)
B Proc:essuuupn~c:onclylllll'b An anom<~lysametlmes found an tile distal humerus above the medial epicondyle Is refem!d ta as a supraa~ndylar proc.!s.s. This bony out· growth Is <1 ~latively rare
Medlal-bordl!r l..mr.ll
Medial eplcandyle
c-forulnar neNt(uhargrool.'e)
b A The l'lght humerus • Anteriorview, b pasteriarview.
214
Olecnnon Troc:hlea fo5H
l..mr.ll eplalnd)1e
C The supr1l'lnlchleilrforiii1MIII The presence of a supr.ttrochlear foramen Is another rare variant rn 'Which !he two oppell· lng olecranon and mronold fossae mmmunl· ate through an opening.
SUperior angle
~&-----:::!----
SUperior border
Artla.farwrfaa! - - -;.:...;.....,....-___,. farthtdMde
Gn!lll!r
--~
tubera:slty
Headof -
--';: - - -"':-- -
htrnen~s
D Position ofthe tntei'Qiberuller fi'IHIIWeof
ln11!rtuberallar - - -1 9roolo't
tfHt rfght humlll'lll wtth the limb hillnSif~ dawnwlrd Anten:lsuperior view. Wrth the upper limb in the neutral (zero-degree) position<- p.237). the greater tuberosity faces later.rlly ;md tile les:ser tubErosity faces anteriorly. The ln1lertll· ben::ular grotwe between them transmits the tendon of the long head of the biceps muscle. The glenoid cavity forms a 30' angle wiUI tile s.agtttal plane.
LHHr tubera:slty
Ccnlt.;le ofhtrneNS
ClpllulotnxhiNr Clplll!llum
\
9,_
I
Ulnar T~lt.a
91110'o'e
I
Oleaananfamot
E The prolllrml right humen1s. Supertorllf-
F The distal right humiii'US.Inferiorllf-
215
Upper Umb - - J. Bonu. UgamrnB. amiJoints
1.5
The Bones of the Upper Limb: Torsion of the Humerus Anllllmlal nedc
He'ldd humerus
Head of humerus
R.;adal
g.-
SNttof-<
hunvrus,
antuomedlal
sutface
I Fl'iiCt\lrwaftheprvxfm.JIIunerw Anterior view. Fractures of lfle proximal humerus comprise approxlmmly 4-5 s of ~II ftacturn. They occur predominantly in older patients wflo sustain a fall onto the out· stn!tthed imn or dlrectfy onto the shoulder. Three main types are distinguished:
• £xtri·artlcularfradllres (a) • lntra-artic:ularfr.actures (b) • Comminuted f'r.lctures (c)
!..mtal
Medial .sup l'aQl n1¥;1t
-....,...-.,11l_
l'ldge
~
ccnt¥;1t l'ldge
Clplb!lum
noc:Nea
ofhLme111S b
A 111e rtght humll!n&S a u.teraiW!w,b medlalllfew.
216
--.:-~
Not infrequently, extra·~rticular ~dlii'C!$ at the level of the SU/f/lcol l!fC1c (site of pnedllectlonfor extri·.ilrtlcularfractures oflfle proximal hurnerus) as well as intra-articular fradllres at the levd of the crnatomlco/ netic are accomp;~· nled by Injuries of lfle blood vessels thilt su~ ply lfle humeral he..d (.anterior and postertor ciraJmflex humeral arteries, see p. 309), with an associated risk of post·traumiltlc avaKu· lar necrosis. Besides proximal humeral fr.actures, other lmportilnt Injuries are fr.ildllres of the humeral shaft and fractures of the dif.· t
Upper Umb - - 1. lloiH!s.UgamenB. and joints
He.lldof hume
C Tonlonoftflehumerus
Right humerus, superior view. The shaft of the adult humerus normally exhibiU some degree of torsion, i.e., the proxim~l end of the humerus Is rotated relative to Its distill end. The degree of this tol'$lon c.an be assessed by supertmposlng the axis of the humeral head (from the antl!r of the greater tubero.sity to the centzr of the humeral head)
HI.I'I'M!nJs---
over the eplcol'ldylar aids of the elbow joint. Thls torsion anglto equals apprOldmately 16*1n .-an adult. compared wlttl .-about 60*1n a nt\Worn. The decrease In the tol'$lon angle with body growtfl correlates IMth the change in the position of the scapulae. Thus, while the glenoid cavity in the newborn still faces anteriorly, It Is directed much more laterally In the .-adult (seep. 21 1). A:s the position of the sc.apula dlanges, there Is a compensatory decrease In the torsion angle t» ensure that hand movements will remain within the visual field of the adult.
Stylcldproas:s of radius Medial eplcD!d.l!e
~~------------~~~----~~---0~~
D Comp~rlson oftfle humenl heed axil aiM! eplcDn!¥nllxll Skeletun of the right arm, viewed from the medial view with the fore.-arm pronated.
217
Upper Umb - - J. Bonu. UgamrnB. amiJoints
1.6
The Bones of the Upper Limb: The Radius and Ulna TrocNNrnatdl
Olecranon
Headofradus, artlallar dra.mtienenae
Head of radius. artlalar dro:umfmi'O!
C~nold
p11X1e$S Radial natdl
Radal~l.y
Medlil--su~
Shaftofr.adlus, anlo!rfarsu~
~o•- $Urf~
.__,:.....----
Head of
HNdd-+.+-:.11 ulna
ulna
S\')lold pro a$$
of ulna A Theradluundulnaoftflertghtforurm
• Anteriorlliew, b poJteriorlliew. The ridlus and ulna are not shown In their nonnal relationship; they have been separ.rted to demonstr.rte the artfa~lar surfaces of the proxl· mal incl distal ridloulnar{ornts.
218
b
Styloldpofuha
Humerus
Humen.ao
U!ml
Hu:::"'jalnt Eljoint bow Humenndljointal Proldmal { radlauhar jOint
Ulna
~HH~:l.....--
Clrpamet;u:;rl!ill )ants
Met.~all'O"
phallngeaiJilints
....:::::;_+-:ri""""'
Praxinal lnte!ph alan geal
(PIP) joints
• 8 Thei\Jdklsartdwn;aoftlleliflrtannrn suplrmfon (a) .nd proniiUon (b)
b
the p.1lm upward or dowiTWilrd (suplnatlon[prcmatlon) takes place at the prcxlmal and distill radioulnarjoints (seep. 242}.
The r:~dim and ulna are p.1ralleJ tD each ather in supination, whereas ir1 pronation the radius crosses f1'm' the ulna. The movement of turning
219
UpperUmb - - J. Bonu. UgamrnB. amiJoints
The Bones of the Upper Limb: The Articular Surfaces of the Radius and Ulna
1.7
Rid Ill notch
lnfetlor 111glt
Olecr~non
In~
border
Hume~o- ----'~;!!S
r.-liilllolnt H151dof r.ad'us
Hand Flrrt d lstal
ph:llarut
Styloid Proc:HS Held of
ofulna
una
~
tubercle A Ther1ghtuppet'llmb uteri! view. The foreirm Is supinated (the radiiiS ind ulrlilire pmllel}.
220
Styloid~
of r.-Uus
a ll.lghtforwnn l.ate!"al view. The r.rdlus .1nd ulna are shown lfl a dl$ilrtlculated position to demonstrate !he articular surfaces of the ulrlil for the proximal and distal radioulrlilr joints (see C}.
Upper Umb - - 1. ~Jones.UgamenB. and joints
Olecranon
f oarsal
Artlalar - -+-foYN He.ldof radius
~=~~.!-~
Coranald pi'OO!SS
- ....:.'=--
He
artlwlar
dn:umfererJCe
Artlt\llr IIM!a
D The prox)m;lliirtkul;n surfaa!s of tile r.ldl• 01rtd ulna of tile right fore.m. Prald'lnllllfew
t Don.11 Shaft of ulna, antlertor su ~'faa!
Ulnar Posterfar Radial Pbsterlar sllf- tm!fa:sseous - I l l sllfaae border
• r .
Plane of
S«!!anlnE
I
Later~
Anlerfar
surface
border
t)\·
border
\\ RadQ
Ant!flcr Sll~
I~ Ill membr.an~
•l
,....,
Ulna
ilnlerfar sllfxe
Medial
st.rfaa!
E Crou HCUon tiii'OlJ!#I tiM! rtght 111dlu1and ulna. Proximal W!w.
Stylald pn1«55 DliUI radioulnar ofradllll Jont
c The r.ldl• 01nd ulna of the rightforfinn
Anterosupenor view. The prolClrnal ind distal radioulnarjoints are functionally lnterilnlaed by the lnten)ssecus membrane between the rlldlus ~nd
ulna. A$" rautt. motion in one joint i$ in~r.~ri;!bly combined with
motion In the other (seep. 244). F Thedlltal attlcularsurf'aceufthe radluund ulna of the right fol'&ll'lll. Dllltll 'Wilw
221
Upper Umb - - J. Bonu. UgamrnB. amiJoints
1.8
The Bones of the Upper Limb: The Hand
Ftrrtdlstllphilanx
Ftrrt p!'Oldmal pNiaM ~~-- Sesamoid banes
A Tbebone.sofdlel'lghthand. hlmarvfew The skdetcm oftfte hand consists of:
• the c~rp;rl bones • the metac3rpal bones • the phalanges.
222
The palm ~fi:!n wthe ~nn!rior (flexor) su~ of the hand, the dorMJm to tfte posterior (extensor) MJrface. The terms of anatomical orfenti· tlon In the hand are palmar or volar (toward the antelforsurface), dorsal (toward the posterior surf.Jce), ulnar (IZIINiard the ulna or small flnger), ~nd rad~l (toward the radius or thumb).
Upper Umb - - 1. lloiH!s.UgamenB. and joints
~---L--~--~~~--~--~--~
lnll!!llhllangell)alnts
~~~~f---~i--f--~~r-~~--~M~~
phalangNI
{olnts
a The bones of the r1ght "-nd· Don•l view The radloca~pal and mldtilpal joints are Indicated by blue lines.
223
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.9
The Bones of the Upper Limb: The Carpal Bones
Tuben:le of trapezium
C..rv;~ltunnel
Pisiform
~11:::----=T-J----'"1---Ciplt
~----- Tr!quet111m
--;-r--.._;~~--- Saphald IJN1J!
St:ylaldp-
ctulna
A C;np;~l bones of the right hind, pFGXtll'lill vt• Af!l!rremov;rl ofttteradlus;rfld ulni, b w!thtttewr1stln flexion. The arp.al bones are arranged In I:'M) rows of four bones e
224
ulnar trlquetnl column (consisting of lfle trlquetrum and hamate). In thisfuncUonal classlftcatlon, the pisiform Is regarded as a Sl!$amold bone embedded in the b!!nclon of the fl~r carpi ulnaris muscle (seep. 356). The bones in each IVN are interconnected by tight joint5, their surfa= emlbltlng a palmar concavity and a donal convexity. This creates the arp.al tunnel on the palmar surt\irce (seep. 248}, which Is bounded by a bony emlnena on the radial and ulnar$ldes.
I
I
I
nm~h~~------------~--~--~--~~~--~, f!flhmm·
"'
CliiJ)IIS
ll'ape:mld Thape.z\Jm ~eot 11'~um
Tube'deof s~hold
Selph old
n!quetrum
I Articular surt..c.s ofthe mldc;nplll jointof the right hllnd The dlsml raw of carpal bolle:S Is shown from the pt'OIIIIJIQ/\Itew. The proi/Jinal row~ shown from the dlstll/vfew.
Triquetrum
'!Uberdeof
saphold
•'r---- Artlcllardlsk (J.fnocarpal disk} . n '----Styloldproass of ulna
Radus. c.a~pal artlallar surface
C Articular surt..c.s ofthe l'iiCiocarpal Joint ofthe rtght harld The proximal row of carpal bones Is shown from the pi'Oidmal vfew. The ~rtlcular surf'aa!l af the r~dlus and ulna and the ~rtlallar disk (uln~IJ)al dille) ~reshown from the disul view. Cllnlc~lly. the r~dloca~l )olnt Is subdivided Into a radial compartment and an ulnar compartment. Th~ ulcl!s lntD account the presence aftne
Artlcllar Glpsjllt
Unar arpal
cal!;moall~ment
ln!ei'posed ulnoca~l disk. which creates a second. ulnar half af the radiocarpal joint In addition ID the r01dlal half. Accordingly. the radius ~rtlculates With the proxl'lnal ,._ af eo~~l bones 1r1 the radial compart· ment while the head af the ulna and ulr~G«!Jilll disk articulate with the proximal rawofca~l bones lr1the ulnar compartment.
225
UpperUmb
1.10
J.
Bonu. Ugammts, andjoints
The joints of the Shoulder: Overview. Clavicular joints
Hudtl humerus
A Tbe fiw )llfntnf thuhauld• Right shoulder, a ntErlor vtew. AIDtal of flve joints contrt~ tD the wide range of a 1111 motions at the shoulder joint. There are three true shaul· der joints and twD functional articulations: •
TrueJa~
1. Stemodavicular joint 2. Acromloclillllcularjoint 3. Glenohumeral joint • FUndlallllll'llaUIIanl:
4. SubiKIVI'IIIal sp;~ce: a sp;~ce lined with bursae (subacromial and subdeltoid bursae) that allows gliding between the acromion and the rotator Cliff (• musculi r aalf of the glenohumera I joint, consistin11 of the supraspi"'Ws, infr;~spin;rtus, subsapullri:s, and teres minor muscles, which press the heilld ofthe humerus Into the glenoid cavtty; seep. 263). 5. Sapulothorac:lc joint loose connectlve tlssue between the subSC;J pull rU and serratus anttrior muscles thirt allows 11lidin11 of the scapuli on the chest wall.
---MaN.Ibr\lm slsnl
Besides the true joints and functional articulations. the two llgamen· tous attachments betweal the davlde and first rib (mstodi!VIcular ligament) and bet\Yeen the clavtde and coracoid process (mracodi!VICJ· lar ligament) contribtrte to the mobility of the upper limb. All of these structures together axnprlse a functional unit. and free mobility In all the joints Is ni!CI!snry tD achii!Ye a full range of motlon. This exp;~nslve mobility Is gained iK the cost of stabdlty, hGWeW!r. Since the shoulder haJ a loose apsule ind weak reinforcing li!taments. it must rely gn the SUblllzlng effect of the rotator cuff tendons. As the upper limb ch;mged In mammalian evoluUon from an organ of support to one of ma nlpulirtlon, the soft Ussues and their pirthology assumed Increasing lmporblnce. 1u a result, a la"!!e percentage of shoulder disorders inwolve the soft tissues.
Upper Umb - - 1. lloiH!s.UgamenB. and joints
Anii!IIDr mmod;Mcular
,.__IS;.;-.&-;;='~-~;:,~_.,. · ·~ '~[ ..
Rad'ms~tmo-
CC511IIIgament
Mar~JiriJm
stern!
B The stemDdiWfculllr JolnUnd lb ligaments Anb!rior vlew. The stemodavlcular joint {ailed also the metllol dilllfcular jolnt) and Ute aaomfodavlcular jolnt (the klttrol dMa.tlar joint,. see below) mgethermake up the b'ue joints within the shouldet"gimle itself. In the figure, a co~al section has bftn made through the stemum ;rnd
Sternocmllll )alnt
~djacent clolvide to ck!monstme the inside of the left stcmoclolvicular joint. A flbroartilaglnous articular disk compensab!s for the mismatch of surfaces between Ute two saddle-shaped articular faces of the clillll· de and manubrium mmi.
Stl!nlal end
--------------------~r----Su~~~ne
sapularllgament
"""----------------------1:--- Scapulm!Ctdl
- - - - - -+--Sopulol.
Medial border
C The uromtocl;wk:ul;n joint ;md Its llg;lment5 Anb!rior llfew. Theacromlodavlcularjoint(the lateralclalllcularjoint) has the form af a t*nejoint. Beca~ the artirulating surfaces are flat, they must be held In plolce by strong ligaments (acromlodilllfcular, cor;reo-
acromial and coracodilllfcular ligaments). This greatly limits Ute mobil· 1ty of the aaomloclalllcular Joint. In some IndiVIduals Ute aaomfocla·
vicular joint has a variably shaped articular disk which gives the joint greater mobility.
227
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.11
The joints of the Shoulder: Ligaments of the Clavicular and Scapulothoracic joints
;..........,,...,.,.,.......:~-Densd
axls(O) Atf21(CI)
c-
tube~W~ty
~---+--:::;
lubeM!ty
A11trfb
Posb!rfar Ant2flar.lt2moStemum mmodoM'allar c:lallk:ular tgament. ligament st>!moclalllc:Uar{alnt
A Ug;mwnts ofthe ltemodmlllln;md ilcromlodm~arjoints
Right side,. superforllfN.
B ln)II'IH ofthe acromiDdm~ll'JoTnt
A f~ll onto the shoulder or oubtretched ~rm frequC!Iltly a uses disl0c.1· tfon of the acromlodavlallar Joint and damage ttl the coracoclavicular ligaments. Ugament Injury allows the lall!fal end of the davldetD mOYe independently of the sc.1pula, causing it to appear upwardly displaa!d. The davldean be pushed down (with significant p;~ln), but will spring back up when pressure Is released ("plano-key sign"). Three grades of iliCJ'OIYllodavlwlar sep.~ra!fon an be dlslfngufshed clinically based on the degree of ligament damage (Tossy dassificatiDn). The aCRIIYlfodavla.Jiar and coracod.Mcular ligaments are stretched but stJ11 inuct. T05110YII The aCRIIYlfodavla.Jiar ligament Is ruptured, with subluxation of the Joint. TOBJIII ligaments are all diiruptJ!d, with mmplete disiDCation of the acromloclaYicular joint TDny-1
Radiographs in different planes will sf,~ widening of t1te spaa in the acromlod.Mcular joint. Comparative-stress r.rdlogr.-aphs with the p;ltlent holding approlClmately 10-kg weights In e.-ach hand will reve.-al the extent of upward displacement of the lateral end of the davlcle on the Jffected side.
228
Tossylll
UpperUmb - - 1. Bones. Ugcrments. and}oiDtl
·~,;;,......_
f P'as1211or
lhombold major
Senma allltl1or
Ribs
Deltoid SublapLialtl
Aldlllry 11'121y. f•dcloscf lncNal plexus ~ds
+Antorior
PKtDrals miA«
I'K!Dnols mojor
C T-ne MCti.Od throuth dMi rltht shoul*rJoint Superior 1/lew. In all movements of the shoulder girdle. the 5Cllpula glides on a 01rwcl surface of loose mnnedlw tissue bet'M!en the sermus anterior and subsc:apularls muKies (see D). This surfa~ c;an be considered a "sc;apulotho.r1clt" Jolntthit allows the sc;apuli not only to
change the position of the shoulder (translational motion), ~ ;~lso to pivot, with the glenohumenl j oint milntilned In relatively stable pas~ llanontheu-ax(rotatlonat mottan)(see p.236).{drawlng ~sed on • speamm fnlm the An.tomic;al Cclllection at the Uniwnity of Kiel).
HNdof-+--hLmiiUI
D l.oatlan ofthe ta~pulllttlorwtc Joint
Right side, wperlorvtew.
229
Upper Umb - - J. Bonu. UgamrnB. amiJoints
The joints of the Shoulder: The Capsule and Ligaments of the Glenohumeral joint
1.12
Inter- - - - : - tubei'Gliar
g.-
• Sapulll' 'IJ(ne
Aaomlon
Glenoid labnJm
230
OIMde
A AltTculatfng bony elements ofdie rtght shoulderjol'llt {glenohumer~l jol'nt) <1 Anterior view. " Postertor lltew. c Coronal section through Ute shoulder Joint, <mtenorvtew.
In the shoulderjoint-the most mobile joint lfl Ute human body butilso Ute most susceptible to Injury-the head ofthe humerus .arlkllla!tsWith tfle glenoid C.iJYity of tfle SC.ilpul;t to form a spheroid;al type of joint. The articular surface of the humeral head Is tflree to four times larger tilirr1 Ute articular surface of the sc.1pula. To help con-ect for tftls dlspartty, Ute glen aid t:allity is slightly deepened and enlarged by a rim of fib11> cartilage. the glenoid labrum (see c). \lAliie ttlis size dlscrep;mcy of the articulating surfaces serves to lr1Creise the r.rnge of shoulder motion, It compromises Ute st.ablllty of the Joint. Slna the jolflt c.1psule .and ligaments are weak. tfle rotator cuff b!ndans are the primary stabilill!rs of the glenohumeral joint (seep. 264). Dlsloc.rtfons of the shoulder joint are notoriously common. Approxlmmly 45 Xof all dlslacatforu lrwollle the shoulder )oint. In typical cases tfle tlead of the humerus dislocates anteriorly or anb!roinll!riorly in response to fordble external rot3tlon of the raised amn. WherNS considerable triluma Is generally needed to c.1use the lnlt:lal dislocation, certain movements of Ute shoulder (e.g .• excessiVe inn rotation during siHP) may be wff!Cient to redisiOC.il!t the humeral head .,_, the glenoid cavity (recun-ent shoulder dlsloc.rtfon).
Almnlod!MC\IIIr Coi1Kll:ld!MC\IIIr ligllmlnt ligament
Sapulllr notxh
SUperior IT.Inswrse scapular ligament
lnlltl"-----'---'-"1• tubtrculor syn~Mal
slleath
Jo'htapsult.
joint
glenolu.meral fgaments
eapule
B Clplu~,ISIIIIMnts.a'ldJolntc:nttyoftflertghtlhouldef a Anterior view. b Pomrlorvlew.
c jolntcavltyfromthe antErtor'lltew. The capsule of the shoulder joint Is broad and Is very thlr1 posteriorly, where It Is not refnforced by ligaments. But It Is strengthened interforly by three ligamentous strudlJres (the supenor, medial. and lnfertor gl~ nohumeral ligi!ments) and superiorly by the COI
subtendlnous bursa of the subscapularis musde and the subcoricold bursa ronsisb!ntly mmmunicate with the jaint cavity. The long bia!ps tEndon sheath also rommunlcates with the joint cavity In Its paSS<~ge through the lntertubefcular groove. c lrmer11Jber~lar
g.-
C\llarsyn~Mal
shea111
231
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.13
The joints of the Shoulder: The Subacromial Space Aaamlan A Subicromlal tpllce,rtghtshoulder Lateral view. The deltoid muscle has been removed to demonnrate the following nruc· tures:
Conaald
Subacromial bl.n'oa
proCHS
, ,._,__ _
• The attuhments ofthe rotator cuff muscles {supraspinatus. Infraspinatus, teres minor, and subSQpularls) to the proximal humerus (s~e also 8) • The tendons of orfgln of the bleeps brachn muscle • The subacromial spaa witb the subacn> mlal bursa. which consistently CDmmunl· cates wl!h the subdeltoid bursa
Su~b\rw
ohtb5apular!5
su~ld ----Pif-~::;._ b~.JSa
Gre.mriiJberuslty
....-ft+- - T!llriMr.seliglml!ft of humerus -.J!'--H- -
~bl!rwlilr
tl!nclon 5headl
The two burne allow frtctfonless gilding between !he humeral head and the rotator cuff tendons (especially the supraspinatus and the upper part of the infraspiBatus) balea!h the coracoaaomlal an:h during abduction and elevation ofthearm(see p.237).
Mlr-41--llk:l!psbr.x:HI,
langhe.ld
Aaoman
Subacromial bur.sa
Subtendl!aw;
bu!S.lof subsupularts
Glen aid c:;Mty Giena'ld labn~m
----,I-T....,\11-4:...._~
- --11--'r t-'L,
'He,-- - Ter.donof blain br.x:HI, long bud
fa\'rtaf'S'llt ---i~~~.---.....:::=::;:-":~~-~- Subsapulalfs
8 Subicromrill buFA <~nd tllnllld COIIIIfty of thertghtshoulderjolnt Lateral view. The humeral h~ has been A!movedand the rotatorcufftendom oflnser· tlon have been drvfded to demonstrate the glenoid callfty of the shocJider joint. The glenoid lobn.tm enlarges and deepens the glenoid anlyvery slightly. just before Inserting Into the humeral head, the muscles of the rotator cuff send undlnoca expansions to the joint capsule that help to pn!$5 the humer.al head into the glenoid cavity. The subicramlal bursa Is located between the C01'30);1Cramlal iln:h and the undons !hat IMert on !he humeral head (seeD).
,........,;t...,__
Alm!ilor (costal)
sumce
CI;Mcular -......;.:..!...--=~~'
GIW1ler
tubero51ty jOint - ---l,.- . . L . . . - -
ap:sule LHJer
tuberosity
- -+--.,"~
1-tlmerus - --4-- -
C 111econCOICI'Omllhsn:h of tfn~ rtvht shaulder Supertor llfew. The ctJI'IJCOfXJ'OI'fllol ardl Is
fvrmedby: • the aaomian,
• the cor~cold process, ~nd • the cor~coi!IO"Omlalllg~ment.
Humetal condyle
Acromial
Sublcnxnlll bun.11
___.;.._.!...,~:..___.,.
- -.f!-__;:!.:..._ ....,
D Posltfon ofthe tubacnmlal burta
between the Qll'.a.Cromlllln:h 1nd 1111pnsplnm. murde Right .shoulder, supenor llfew. See also Ule "sup«npinotus sytJdrotM," p. 234.
233
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.14 The Subacromial Bursa and Subdeltoid Bursa
Subacromial---:-'----~·
bursa ~~~-
Super! artr.aruwrsesc:apLfar
lt9Jment
Glenohumen~l -----:::.:....,+.~---ll:-{
Joint capsule
Tendon!lheilth In Inter· wbeullar
----=,----.....:...:,.:.......,
~
A l.oc:iiUon of bursu In tfle riQht shoulder Antenor view. The pector~l~ major ~nd minor ~nd serr.atus ~ntelfor muscln h;Jve been removed. The loc~tion of the bul"$;;e an be $ftC'I
through the deltoid muscle, which Is lightly shilded. Noll! In particular the amu:oacromlal ardl and the underlying subaao-
mlalbursa.
I Supl'llllpl'nltul (lmpklgemart) syndrome
Asupraspln.atus tendon tflat has beenl:ttlckened byaldllc.ttlon or other degeneratrvechar~ges an be a~~ght underneath the aaomlon, lmplfl!l· ing upon the subacromial bursa, when the arm i5 ~bdurnd. Pain from this suprosplnatlls or Impingement syndrome oa:urs In an arc of motion between 60' and 120" of abduction.
\ /
Supraspinatus \
ttndon
Upper Umb - - 1. llones.UgamenB. and joints
Subdl!ltllld
---E-:;,-:......,r:-+""'ff-1~11
buna
c
Col'llllll sedtDn ttl rough tfl~ rfght shedderjcltl'lt Anterior view. The tendon of lnsmion of the supr<~spiniltus mll!de differs structur;llly from ordinary tJ<~ctlon tendons. Its dlsul course gllles It lfle furlctlon of a gliding tendon, which passes OW!' !he ful· aum of the humeral h~ad (arrows). in that ate~a,I!Kated apprmcirnatl!ly 1-2 em pi'Oldmal to Its Insertion on the greater tubefOslty, !he tendon
tissue in contact with tfle humernl head is composed of fibroC<~rtilil!fe. This flbroC<~rtllage zone Is w.~sallar. representing an <~daptatlon of tile tendon to lfle pressure loilds Imposed by lfle bony fulcrum (drawing based on a spedmen from the Anatomical Collection at lfl~ Unlllerslty ofiCid}.
D Damage to tile tupralplnl1ils tendcln a Calc:lflcatlon (calc:tfying tendinitis) and related degenerative changM. b Rotator cufftear{suprasplniltus tendon avulsion).
The supraspinatus tendon Is tile most frequently damaged component Df the rotator ruff. When it is ruptured, tile subacromial and subdeltoid
bui'Jile ire no longer Isolated from the J~»lnt cavity. becoming one con· tlnuous space. When lfle function of tile supraspinatus musde Is lost after rupture of ItS tendon, the lni!Sal phase of arm .abduction Is spedft· C<~lly impaired. The supr;Jspinatus normally contributes signifiuntly to lfleflrst 100 of abduction (•swterfunctlon": see p.262).
235
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.15
Movements of the Shoulder Girdle and Shoulder joint
..r-..............o..._ AnUro~or
axiS
afmotlan
•
c
A MowmentloftheSGIJMllill The rternod.Mcular and acromloci.Mcular Joints are mec:banlcally linlced in such a w;q that all mcM!ments of the clavicle ~re ~ccompa· nled by movements ofthe sca)XIIa. The scapula moves by gliding on the chest wall In the scapulotttol'illdc joint. Botillts movement ;md Its fix. atlon are effec!led by mu$CIIIar slings. The following types of scapular movement are distinguished:
b Abductlor1 and adduction (during protrictlon and retrictlon of the shoulder girdle): hortzont.ill translation ofUte scapula lfl Ute posteromedial-to-anb!rolateral direction. c; Lateral roeatlon of the Inferior angle (during abduction or ele¥<~tion of Ute arm): rotitlon of the scapula iboc.it .1n anteroporter1or axis through the C4!11ter of the scapula. Wltll an approximately 60" range of rotation, !he inferior angle of the scapula mOI/I!s about 1Oan lab!r· ally whne the superior angle mcMS about 2-3an lnfa'Omedlally.
a Elevation and depresslofl (during elevatlor1 and depression of the shoulder girdle): translation of the scapula In !he cranlocaudal direction.
~«--------~~~~--~~~~- ~ motion 1~
•
b
B M-nt:s (01nd range of motion) In tfte stemKiiw1cular Joint a Elevat1or1 and depresslofl of the shoulder ~bout a para-s;agttUI axis. b Prv~ and retraction of!heshoulder about a longitudinal (verti· cal) axis.
C Rllnge of mothm ofU!e dnk:le Lateral view of the right claYide. VIewing !he range of motion of the daw:le 1r1 Ute rternoclavlcular joint from Ute later.illlllew, we flnd Utat the clavi de mcMS roughly within a conical shell whose apex is directed tDWard the sternum, and with ,. slightly ovil bOise approximately 1013 em In diameter. The davlcle also rotates ibout Its own axis. partlcu· larly during elevatfofl of the shoulder girdle. where Its 5 shape slgfllft· candy increases the r;~nge of shoulder elevation. The range of this rota· tlon Is approxlmitely 45• ind creates,. third degree of freedom which gives the stemoclivfcular joint the /illlC!ton of a spheroidal joint.
UpperUmb -
f. BoMs, Ugammts, andjoints
130-160'
150-170'
Aids of mat!an
..
D M-menb In the ehouWwjoint Al i typiCill spl'leroldilfolnt, the shoulder joint Ius three mutuilly perpendiculir cardinil-s with th1ft degres of ~ecbn and il taUI of six m<~ln directions of mowmtnt. In i wry biSic sense, ill movements In the shoulder girdle can be diiSSified u ftrtiCill, hc:~rizvnbll. or nrtationil. In wrtlml mCMI!IIIlts, the irm Is elevated In Virlaus directions from i neutTII adducted position. In harizvnlllll momnents, the ilnm Is R'IIM!CI forwi.rd or backwilrd while In 90" of abduction. RrltDtJonGI /IXMillents can be perfurmed with the arm In any posltlon. The rNidmum IVIJ9e of tf1ese various I'AIM!ments Ciln be idllewd only by concomitant movement of the shoulder girdle. hOMYI!I".
a Anteversion 1nd retr<J~~~erslon (flexion 1nd exllenslon) aCOJr 1bout i horizonti I axis. II Anteversion ind retroversion of the arm l"'lsed tD 90' 1bductlan ue also dtsCJibecl as horizontal movemenl$.
c Abductic1n and idduction oa:ur ibout il sagittal uis. with move· ments p;1st 90" often reftned tD u elevation. In dlniCill p;~r1ance, h - r. the term "elemion" b genertlly ilpplied to all vertical mOYements. Past 8G-90" of ibductlan, in automitlc extenYI rotation l:lmJI'I which heps the glftter tubmllity fiom impinging an the mrKOacromlal ardl. When the inm Is abducted while lntern~ly rvt~ted. the rilnge ofibductlon Is decmlsed tD ilppradmately 6Q• .
d-f Internal and elltmlll rvtatlon ofthe •rm occurtboutthe longltudl· nill (shift) Dis of the humerus. Whlfl the irm Is 11-d it the elbow during these maftmenl$. the farurm Ciln be used as 1 pointer. When the arm Is lunging it the side, the miiDdmum finge of Internal rCJtitign is limited by the trunk. Placing the inn behind the bilt:* Is equlwlent tD 95' of lnternil rotation (e). When the inn Is abducted 90", the finge of exllemill rot.tlan Is lnaeiiSed while the miXImum range of lntemi I roUtfon Is slightly reduced (f.l.
E Humai'IIIKilpulilr m,thm
The ilmn ilnd SCilpul.a mOYe In a 2:1 rltfo during abduction. This mtilns tlut when the ann Is iibducted 90", far example, 60' oftlut maftment occurs In the glenohumera IJoint while 30" Is 3ccompllshed by concomitant mOYernent of the shoulder girdle. This "humerosc.apular rhythm' Is dependent upon freedom of mowment of the sCipub durtng ~ bductlon. Dlseilses of the shoulder joint Ciln ilter this rhythm, often causIng the SCilpu Ia to begin rts rotation considerably 1Nr11er. This Is best Illustrated by cases Involving ankylosis or arthraclesls of the glcnc:~hu merill joint (pithologlcal or lntentlanill Dl*ltlW! stlf'flnlng or fixation), In whldl movements In the shoulder girdle alone still pennlt the amn tD be abducted 40-60" and still allow rot one-third the normal range of fieldon/extension.
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.16
The Elbow joint as a Whole
llledlal
la1!el;li)
SIJPraGln~r
sup~~~condylar ......____
ridge
ridge
Coronoid
rm..
RadllllfCI:BI ~ la1!el;li)
Medial
eplaond)ie --.....
epicondyle
Qj)lttl~m
HummlboXhlei Coronoid proCI!:I&
H151d of radus
Neck of radl.a
CiplllJ~
Medal suprxondyl;lr---lfdgt
Lllle'lllsupn~-
Olecranon
cond;tlr
Medial eplaond)it
eplaln!¥e
ridge
r-a
Lmr.al
Ulnu
H~dofradlus,
groove
artlaJiar
'nurnfinnce
Ole
!II'OIM!
Radial
R.adus
lube!Wity
una ;a
Una
b Posterior ~ew
llnterlorvlew
Hurnennlnar
Jafnt Olecnnon
c;
Ptudn~;~l
He3d of
radloulnar)olnt
radl.a
una
l..an!r~IYiew
A Tile arttc;ulatfng sla!fetill elements ofthe rtght eiiHM Joint The humerus, radius, and ufM artfcul.rtl! wth one another .tt the elbow (c;ubito!l) joint. The elbow con$iSU of three articulation$;
238
d Medial view • The humeroulnar Joint between the humerus ;md ulna • The humeroradlal jolnt between the humena and radius • The proximal r~dioulnar joint b~ the p~im.al C!lld$ of the ulna and radius
Upper Umb - - 1. llones.UgamenB. and joints
Meehl epicondyle Clpltulotroc:Near g-..e
Extens,or c.wp1 radialis longus
Uhar collatAn!IQ~ment
Rlldal colllter.llllgament ----f.~!. Hlmeroulnar.)olnt
Humeror.td'aiJont
(caplb!llumcfh~.me111s
(humft1lltn~c:hleund
----f~~~'
trochle. notdl)
and
I-I"'T4r'rlf.-T"':¥-Ti:i:ii''F+ - - Proldmal r.tdiol.fnarjolnt
Anul1rlig;Jment
and radial notdl of ulna)
(artlcularctcu~
ofnldlus
4/IIF~~v-::r--- Foncannft~
Heo~dofradlus
l'lane of
Planed
section 1'1 b
section Inc
ArtiC\IIar clr~um·
!\!renee 1- -!!!12::!!=!----t-
Rlldal
notcl\d uln1
b
Uha
B Skelet.Jiiind soft-Uuueefements ofthe rfght elbow Joint a Coronal section VIewed tRim the front (nOll! the planes af sedfol'l shown in band c:). b Sagltt11 section through the humeror.-adlal Joint and pi'Oldm.-al r.-adloulnar Joint. medt.-al vrew. c: Sagitt11 section through the humerDulnar jaint, medial lliew.
c
C«anald praass
Una
(Dra'Wfngs b.ilsed Ofl spedmens from the Anatomical Collection it !he Uniwrsity afKiel).
239
1. Bonu. ligament~, andJalnl:s
Upper Umb -
1.17
The Elbow Joint: Capsule and Ligaments A T11e CiiJIIUI• •nd ll11.n..a of the light •lbowjoint In 90' flulan • Posbl!rtorvlew, lt medlilvfew,c later.JYiew. Both the humen~r~dial and humen~ulnar joinb are stabita ed by~ ful a~llmnlllgimenb that sb'engthm the latenl portions of the joint capsule. These st111ctures, Cilllled tfle ulntlrmllotwo//fgoment 111d rodtol cof1utmll /;go~.,~ ll hon-shllped am~ngemtJttthat an 11~ l~~teral stilblllty ID the joint In any poJitlon. The onnulor llgometJt of tfle radius (see also D) stabili>a. the proximal radioulnarjoint
.....
Oleaanon
----::-::=---;---~
Modill-
eplcondoJie
Anu•rllllll114!nl of radius Ul'llrcollltllnll ll91nwd:
Ul..,.aollllltllll lljpment.
Ol«r3non
ilflllerlorl)ill't
MedW opkondylo
Ul11raolllanol llgoment. paRirlar part Ul'llraollllltllll lljpment. tr.ansut~St
Ulna
J)lrt
.. Oleaanon
c
240
RadiiIcollltllr31 ll~nt
Anular hg• ment of radius
Nod< af radius
LJna
c
B Tlle Hul!tt!r line 1nd Humrbf•nule
• ExU-nsion, posterior view; b flexion,lmr~lview; c flexion, ~rior view. The eplmn~ and tfle olecranon lie on a straight line when lllewed frwn the posterior view inthe atended tlbow. They also lie on a straight line when viewed from the lateral ¥few In the flelCI!d elbow. But when the fle.ed elbow is viewed from behind, the twD epicendyles and the lip of the olea-anon form an equilateral trlilngle. Fractures •md dislocations :o~lterthe shape oftfle triangle.
Upper Umb - - 1. llones.UgamenB. andjoints
Rad'alfoua C41pltulotroc:hletrgi'OCM!
Medal el'l~
Clplbelhm Ratllllclllhrll!llll
lpnent Anular 1\gartlt!nt ofntefus
c¥e
Humml trod!lea
He.id MMlll
AI'AIIarllga-
ment cl rad\ls Sxdfonn recus
c 111e upsule 1nd llglments ofdie light elbaw Joint In extenslon • Anterior view, b Anterior view with the ~ntr~lportions d the upsule removed. The joint apsule of the elbow encloses ill tftree ;u11aJiatlons In Ute elbow joint mmplex. While the capsule is very thin in frant and behind, ltls reinforced on each side by the collateral ligaments (see A). Owrthe
end of Ute radius, the joint capsule is exp;~nded bel- the annular lig· ament to form the saa:lfonn recess-a redundant lluue fold that p~ llfdes a reserve c:ap
H151d of ractus. lunula
Anular
Praxtnal radioulnar
Coronald
Anular
lig;!ment
jelnt
praass
lig;!ment
D Course of thnrdill' l;ament In the right pi'Gldrnal r.tdlou!Nr )ornt • VIew of the pi'OlClrnal artlaJiar surfaces of the r.adl~ and ulna after
remOIIill of the humerus. b Silme view as in • with the l'i'dius also removed. The anular ligament Is of key lmport.ilnce In stabilizing Ute proximal radioulnar joinL It nms from the anterior to the posterior border of the
radial notdl of the ulna (-cartilage
241
Upper Umb - - J. Bonu. UgamrnB. amiJoints
1.18
The Forearm: Proximal and Distal Radioulnar joints Ole
1-- - Tnxhleoar notdl ri=_..~....,....--
Corcncld procus
UNr aataur.al llglment
~-,e.---
Aids ofproMton,l ll!plnatlon
-+- - Shllftofllna
I~
border 14--+--~us membn~ne
llfst.ll
radioulnar )oint
Headdulna
----'~-~.........
Dors.ll l!Jberde
~old ptO<:rSS - - - '{
dulna
b
A Ug•mentund axes for pro~on •nd supt~on In the pi'Gidrnal ;111d dllltill r.tdloulnar Joints Right forearm, antl!rior ~ew.
Supination (the r.-adlus ;md ulna are par.-allel tD each other). b Prona!Son (the r.-adl~ aosses OYer!he ulna).
;a
The proximal r.adlouln;ar joint functions togethtf With the distill r.adJo. ulnar joint to enable pranation and supination movements of the hand.
242
The mtlftments «both joints are functlonilly Interlinked by the Inter· osseo liS membrane. so that the movement of one Is nea:ss.-arfly assod· atedWith mOYementoftheother. The axis forpronatlon.-andsupfn;a!Son ruru obliquely from the center of the humC!r.!l apin!llum (not shown) through the centtf of the r.rdlal articular fovea down tD the styloid process of the ulna.
1. Bones. Ugclmenl'l. andjoints
UpperUmb -
Loatlon d the aols In pronlllon
Meollol sll'faat
Headdl'ldlus Pl'cDdmoll'ldlauln•r )oint
B Cnwi section through the right prmdmill rallloulllilr Joint In pronatlan
Dlsti Iview. Owing to the sllg htly DVlll shape of the r.~dlal head, the pronatlonfsupiiYtlon am ttllt runs through the r1dla Ihead rncJYeS appi'OXJ. miltely 2 mm radially during pronll:lon (the long di<Jmmr of the r<Jdial held Is transvoerse wher~ pronll:lon Is re.ad!ed). This ensures !hit when the hand is pronated, there will be suflldent space for the radial tuber-
oslty within the Interosseous spiCI! (-the space between the radial tubenlsityand oblique mnd; see All, for example). Note the thicker artku lar cartilage of the r.~dlal articular clrcumferer~ce on the pronation side. Tills thldaenlng occurs as an ildaptatlon to the greater articular pressure in the pi'CIIIimal radioulnar joint in the pronated position.
Donal _,___ _;:......,,_"':!:' tubordt
~'------,]~-----'-'---
Artlalw drcumfwnnot
IIMIILB,...,..I •rtlcullrsumce
~·- Cilrpi
DimlradoLinr )oint
Dafllll'ldloulnor
Daflll
llgiiiWlt
llberde
uln~rlsbl!ndon
II
I
Styloid PIO
Heedofulno
Styloid prvcessofradlus
Heodaful,.
l'imamdloulnar
l!liment Dorsi! nodloulllll' l!liment
Styloid
piOCIUS dl'ldlus
•
arpluhirls tltndon
fom~ nm. For clarity. the ulnocarpal disk is not shCIWII.
Suplnll:lon
It Stmlpronltlon
uOirts
~on
/
•
);
~r
C lltatdon of the ral• and ulllil du~ pranilllon and 111plnHIC111 VIew of the distal arUcular sumas of the radius ilncl ulna of the right 1
Exll!nscr - -
arpl
c
styloid proass
d ul1111
Palmor nodlc>-
ulner llg;ment
~ afl"'
artlc:uwsuf.tCJ:
The dorsal and palmar radioulnar ligaments are part of the "ulnocarpal camplex•, which serves to stabilia the distal r:adioulno~rjoint. The mode ofCDntilct between the two distal articular surfues varies wtth the po». t1on of the l'ldlus :md ulna. They are In close appiUitlon only In an Intermediate (semipi'Oiliited or neutral) pc»ition (after Sdunidt and unz).
c Prolliltion
243
UpperUmb - - J. Bonu. UgamrnB. amiJoints
Movements of the Elbow and Radioulnar joints
1.19
L H~n5
~~~~r.r~~--n~
ttu'CU!ft
fifth meta.
arpah
• A Pronlflan nd supl:1111tion oftfle l'lght h1nd Anterior view. a Prona!Son, b supination. Pronatlonfsuplnatlon of !he hand makes It pcmible to r;~ise ;an ob;ect to !he mouth for e<~!lng and to touch <~ny uea of lfle body for protection or de;~nlng. Pron
244
tfol'l ~re ~lso essential for !he working hand In actions such astumlng a screwdriver, saewlng In a light bulb, emptying a bucket. unlocking <1 doer, etc. The r;~nge of hand movements can be further lncl'eiUed by ~ddlng movements of !he shcKJicler girdle and trunk. This m;~y ~ done. for example. to enable a full360" twistIng movement of!he hand.
B NormiiVIIguaoftheelbowjotnt Skeleton of !he right upper limb with lfle forearm supinated. Anterlorvlew. The shape of!he humer;~ltrochlea(see p.238) results In~ norm<~! valgus ~ngulatlon ~tween the humeral shaft and uln<~ (atbibts lo'Cl.fg~~S) [valgus- bend or t\Wt outward, ilW?IY from the body axis)). This applies particularly during extension and supination. This "Olbital angle• equals approximately 1700.
. .~1 ( Aids of
motion
b
C bnge of motion'" tile humeroradllll anclfuneroulnarji)Tnb of
tfleei"The flexion/extension axls of the forearm runs below the eplcondyfes through the capitellum and trochlea of the humerus. Starting from the nemral (zero-deg~) position, both joinU h
c
D ..nge and 111111 of pronatkln/lqii'IIIUon of tfle rtght h1nd The nemr~l (-degree) pcnition oftne hand and forearm in!so called saT~Ipi'OIIiltlon. The illds of pronation/supination extends tnrough the he;ad ofthe radius ;and the styloid process of the ulna.
a Supination (the radius ind uln.. are parillel tD each other). b Pronation {the r.adlus aosses owrthe uln..). c Supination of the Nnd with the elbow fl~. viewed from the front
(the p;~lmar surf.lce of the hand Is up). d Pronadon of the hand with the dbow flexed. viewed from the front (the p;~lmar surface of the hand Is down).
E Dfsplilceml!flt and angulaUon of the l'ildluund ulna durfng pronlt1on
.a Due to the crossed position of the tidim and ulna in pnonation. the
articular fovea oftile radius Is <~ngled approximately s• dlstllly. b Beausethe distil part of tile ulna moves laterally during pronation, the ulna Is ;also angled approximately s• distally rn that position.
..
b
245
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.20 The Ligaments of the Hand
--~-f..!-- I'Rix!ITIIIIIIII!f·
phalangmiJo'nt. alllmtalllgamems
1L-r-f----:i~--
llletaaiJ)OI)IIal;lnljeal
joint, collaterM ligaments
+-----!;~~--l'---~>.......J:---.f--O>.......Jl....,..f-~- flrstltlroughftftttmetaa~Jl;is
L ....t----,-E--4- - - Don.llmmt.illNI r~nts
A The llfllmenb ofthe right hand. Posterlor'lliew. The vartous ligaments In the carpal region form a dense network that strenglhens Ute joint capsule of Ute wrist. Four groups of ligaments can be distinguished based Ol\ their location and arrangement (see alsoti\e palmar view in a):
246
1. The ligaments be~ thefore
Avldmalln!Jel' --.;..,..~-~....J phalangeal
Jclnt capsule
Mlddephalanx - ---:.- ·
Dlltal phalnc
Deep tr.aruwne metaarpallgarnents
---::-~lror-'11
Prvldmal phalnc Mewall'O·
phllllngealjolnt, c:ollmnlllgllmert:s ~-~~~~~~~~--~~~~----Rm
thnlU!#I llftllmea· a.pals
Pamar met:u:arpal -----'=:-~r-+-~:>rL
llg;unen1s ~~::;--:~-:!!---
Palmarcarpametac;rpalllg;~ments
......,,!L~--- 1\lbetdeof
tr.lpe:zlum
a The llpmen1s ofthe right h•nd. Anterior view. Among the ligaments thilt bind the e<~rpal bones together (lnten:.1rpal ligaments). a dlsUnctlon Is ITiilde between lntMiolll!l{lmtnts and surfoa 1/gamtnt:s. The lntemalllgaments lnten:onnect the lndMdual bones at
a deepc!l" level and include the interw.seous interC
247
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.21
The Carpal Tunnel
----;f=~--'--;o.__-
fl-n!tfnaculum (lr.lnswnearpal ligament)
Call)OIIt!.lnnel - -----'.'::="! entr.~nce
A Flexor retfn;uuum (tr.~nmnl! c:;upillllg;lment) 01nd G1111<~1 tunnel,lfght hind Anterior view. The! bony element5 of the wri5t form a con~ grjlove Gn the palmar side (see also C), which Is dosed by the flexor ret!Baculum (referred to dlnlc:311y as the transverse carpal ligament) to form a flbroosseous tunnel called the carpal tunnel or carpal canal. Thl! Barrowest part of this caBal is locatzd appi'Gleima1:21y 1 an beycrld the midline of the distal row of n~pal bCines (see D). The cross-sectional are<~ of tile tunnel at !Ntslte measures only about 1.6cm2, The carpal tunnel Is tra· versed by a total of 11!1! flexor IW!dons (en dosed In tendon she.aths and embedded in connective tissue) and by the lflf(/;(Jn fiiiiYf! (see p.326).
The tight flt of sensltlw neurowsaJiar structures with dosely apposed. frequently mewing tendons In this narrow space often causes prol>leiTU when any e~f the rouctures swell Gr degenerate. le0ding to arrJ~QI tunnl!l syndrome. NaiTOW!ng of the tunnel can entrap or compress !he median nerve. altering Its function both by direct mechanlc:31 action and by rertrfctlr~g !he blood flow Within the neM shmh. With chronic compression. tile medlar! nerve laelf begins to degenmte beyond the site of entrapment. causing progressive pain and paresthesia. aoo. ulti· mately, denervatlon and wasting of the muscles It serves, particularly the abductor poll leis brevis (seep. 326).
Aldll magnttfc resonance lm1ge (T1-Ightitd) of tiN: lfght hind Itthe level of the e~rp.~l tur1nd Proldmal'lltew. The flexor retinaculum (transvene carpal ligament) can be recognized as a band of low slgrNIIntenslty (red .urow). just below it IDwilrd the r.~dial side is the medial\ nerve (small am:.w), whose w.ater and lipid corrtents cause It to dbplay a higher sigrNIIntenslty than the superficial and deep flexor ten doriS. The prfmarydfagnosls ofcarpal tun· nel syndroml! Is based on dlnlcal signs and electrophyslologlcal mea· sunements such as nerve conduction lll!locity. Whilt- convention~! r.u:li~ graphs and CT scans can detect bony causes of !he syndrome, mag· nl!tfc re.sonaoce Imaging can also demonstrate soft-Ussul! causes (e.g .• edema or swelling ofthemedlan nerve, flbro.sh, neiJroma, eCL). B
H • Hamate bone With hook K • C..pitate bon to
T ·Trapezium 11 ·Trapezoid (from V..hfensleckand R.elser: MRT des Bewegungsapparates. 2. eel. Thle~ Stuttgart 20Cl1).
248
Upper Umb - - 1. llones.UgamenB. and joints
~;,;....---+-"7"'"+---1-.,...--f.--Ji....,.--------,. Fi'stthrou~ll flfthml!tle~~ll)lls
Flexor ret!Aaruh.m (lrM\M<'it a ~pal llg~ment)
c Bony boul'ldartes of tiN: urp~l tunnel of tiN: rtght hand Anterior view. The carp;~l bones fonn a convex arch on the dorsal side of the wrist and a concawoe ardl on the palmar side. This ae.tll!s a CO!p(ll lliMt!l on !he p.almar side, which Is boc.mded by bony elevations or1 the radi~l and uln~r sides (ttle radi~l and uln~r carp.al eminenas). The tuber· des of the tr.-apezlum .-and saphold form the palp.able anlnence on the
radial side,. while ttle hook of the hi mate and the pisiform bone farm the emlr~ence on !he ulnar side. Sttetched between them Is the flexor rel1ni10Jium (transwrsecarp;~lllgament), which doses ttle carp;~ltunnel on the p.almar side (the planes of sectlofl marlaed a and b CO!Te$pond to ttle ctoss sectians in Fig. D).
D Cross 5«Uons through the Glrp;ll tunnel a CRiu sectlc:Ml thtough the proximal part of ttle carp.al tunr~el (planuinC). b Cross section thtough the distal p.art ofttte ca!Jlal tunnel (plane bin C).
111otr: The carpal tunnel Is narTOWest OYer tile centef ofttte dlst.11 raw of carp.al bones (b) (a!U!r Schmidt and Lmz).
249
Upper Umb - - J. Bonu. UgamrnB. amiJoints
1.22 The Ligaments of the Fingers
Head of metaurpal
Dlst
plwlangNI
)olnlli.<>OIImnl !lgll'llentt
Cruciform
Olsbl
phalanx
•
!-H;rl::;ooo-- Tendon of flexor dlgltorum ll!pefida!IS
A 1be jornt e~psules. llglmaltl,llnd dlgltll tmdon shelth vfthe rtght m!dcle finger ;~ l
Tendon of ftsor dl!#tonJm superftd'alls Tendonofflextor
b
dgtmrum pnlfllncb
A5 Cl
A4
C2
Al
Cl
A2
•
·v A1
B Llg;lment5 refnfvrdng U!e d!;ltal tl!ndon shNth a l
First anular ligament (A1): at the level of the mebcarpcphalangeal joint Second anular ligament (112): on the shaft of the pi'Oldmal phalanx Third anular ligament (A3}: at the le'Vd ofthe proxlm;allnterph
The crudfonn ligaments are highly variable In their course. b
250
Upper Umb - - 1. llones.UgamenB. and joints
- - - Tmdonofextl!nsor d'IJI!Ortm(~l
d'l!lt31 elqlanslon)
TUbero.slty --=,.....-____;~.;j ofdistal phalanx
Mlddlt phalanx
f>
-=~-=~~~~=,;t---Tmdonof
"'
flelall'dlgi!Orum profundus
C Longltlldlnill sectf1111 dnvugh the distil pilt of"' finger In the met.1e<~rpophalangeal jolnt as well as the proximal and distal Interphalangeal joints, the palmar articular surfaces of the phalanges are enlarged prwamally by a flbrvcartllaglnous plate called the palmar
ligament (volar plate). The palmar ligaments also form the floor of the digital tEll don sheaths it these lowlons (ilfter Schmidt andLanz).
D Tile UJKUie and ligaments of the nM!t.Jc:ilr1Hiphalangeiil Joint a Extl!nslon. b flexion. Lateral view. Note The mllateral ligament is lax in exll!nsion and 11M in fli!Xian. FGr this reason. the finger joints should always be placed In a "functional pasltfon• (e.g .• with the met..e<~rpophalangeal joints flexed ipproxl· rnaU!Iy 50-60", seep. 255) If the hand Is tD be rmmoblliz'!!d (e.g., In a e<~st) for a long period of time. If this is not done and the finger joinU remain extended for " prolonged pertod, the mllateralllgamarts will shorten ind ae<~te in extension deformity after the e<~st Is reiTICI1Ied. The accessory collaural ligament and phalangoglenold ligament are taut in both flexion and extension and act mainly il'l re:straints to limit extension.
E Crosu«tton through the head ofthethtrd m&1r.1rp;1l of the
rtghthand ~mal view. At the level ofthesecondthrough fifth meto!e<~rp;~l heads,
the volar fibrocartilage plata (palmar ligaments) are lnten:Dnnected by trans~~erse binds, the deep tr;mswne mmcarpal ligaments. By bind· rng the palmar ligaments to theA 1anularlrgaments (see B) ofthe flexor tendon sheitbs, they also strC!l'lgthen the distal met
251
UpperUmb - - J. Bonu. UgamrnB. amiJoints
1.23 The Carpometacarpal joint of the Thumb
-+-'t-- Shaftaffton met.ac.;upal
PRIId'lnal phalanx
Head of melltc.p;~l
I Artkul;rdng surt..c.s ofthe carplllllltlc.Jrpil )Dint of the thumb Palmar-ulnar view. The articular surface of the trilpezlum Is COITIH!X In the dorsopalmar direction and awu:ave in the radioulnar direction. This Is oppos!W to the curvatures found In the corre~pondlng articular sur· f.lce of the first met
A Axes of motTon of tfu~ c.trpometllc:arpiiJolnt oftfle thumb Skeleton of the right h~nd, r~dial view. The fim meuc~IJI~I b~ne hn
been moved slightly distally to faclllt.rte ortent.rtlon. The si!ddle-sbaped articular surfilces of the trapezium and ffrrt metacaiJI~I allow ~ ments ilbouttwo cardlr~al.axes: • An ~bductlon/addudfon .tlCls (a} • Aflexfon/emnslon .axis (b)
While the axis for ~bductlon/addudfon runs ilpproxlrnately on a dorsopalmarline,. the axis fDrflexion/extznsion runs tranSYI!!rselythrough the sdlar llmbofthe trapezium. When tfle thumb Is moved toward the small finger (opposition), il rotilry movementuke.s place ilbout a lollglt:udlr~al axis th~h the flrrt mwcarpal bone (third degree of freedom). This oppg:sitior~al m~ment of the thumb-em!nti~l fvr precision gr~sping movements of the hand-Is rr~acle possible by the naturill mismatch of the ilrtlcular surfaces (see F).
252
d
c
~ofgrtp
Normal hand actions un be reduced to fvur prirr~arytypes of grip: a Pinch orpredslongrtp. b power grip, c keygrtp,d hookgrtp. The clinical exilmltlatfon should lrldude function tesUng of the hand, gMng particular ~U!!ntforl to disturbances of flr~e motorsldlls and gross strength. It is impo.Unt. for example. toev.~lllate the pinch grip~nd ~ grtp, the plncfl grlp betwHn the thumb and Index finger hil\llng funda· mentallmport;mce for the function of the hand. This Is why, ln Issues pertaining to workers• compensation, loss of the thumb or Index finger is a'"sidered to Nve ~ more serious impact on O«Upati~n~l capacity than the lg:ss ofthe other long ffngers.
Trlquotnm
H1nwte
Run/
•
-..~an
....
Pisiform
E Relationship vi the ttalmb te the fingers In thenelltnll (DrOdegru) polltlan
c
d
•
f
Right hand, distal vtew. OWing to the concave arch of the carpiI bones. the scaphoid and trapezium hi11Ve a marbdly radlopalnur oltent:atlon. As a result. the metacllrpus of the thumb Is not placed In line with the other fingers but Is rotated approxl1111tely 60" tow.J rd tne palm.
•
I
h
llllpalum
D Moveml!nbln the c.lllpOmltilc.~lpllfolnt vfd. thumb
Right hand. l>.llnu r vtew. • The neutral (zero-degree) position. b Ala!s of motion In the c.~rpometlcarpal Joint of the thumb. c Adductron. d Abduction. e Flexion. f Extension. 1 Opposition. h Axis for opposition of the thumb. M the first mi!Uarpil rol:il2s,lts area of contact wid! the articularsurfaceofthetrapezium is greatly diminished (see F).
Tnpuhm
F RatatiDft-lnduced lnmngrultyofthe arpomelxal pal joint during opposition vi die thumb il Neutral (zero-degree) position, It the tn umb In opposition. M a sellar (.s;addle~luped) )alnt, the carpoml!tilcarpa I joint of tne thumb Is subjected to functional streS5es that may promote osteGarthriUs (afl2r Koebke). The potenllilly harmful stresses ue ci'Nted by rotation of the first metacarpal bone during opposition of the thumb. When the thumb Is maxl~n~lly opposed, this rotiltlon greatly reduces the surface are\ll OIIVallible for streu transfer across tne joint (contrilst this wlth the large area iMillible In •). This toncentr.Jtlon of stresses In a loallzed are~~ predisposes to deg-raU\01! dlanges In the ascending sellar limb of the first metacarpal bone as well as the articular surface of the tr.lpezlum (lint carpometlarpal ostzoarthrltls).
253
Upper Umb - - J. Bonu. Ugamnts, amijoints
------------------------------ ------
1.24
Movements of the Hand and Finger joints
R-'i----f-f--+.~-~k-.,.§-- Pradmal lnterphaiiii!J!III joint
CdlmnoiJUoments _ lntlerphallng011l Jollt
___.,.~......,.....,.~-+.,!,!-.:::.,t'i.
----=-'--"
Meaaorpophllongnl
Joint Gflh•thumb
- - -+
•-'~~~~~1!--:;~;b...~~~-- S«<
Abducllllr dglll mlnml ~.-'i'~~~.?-i~~--
Dorul ~rpol
lgoments
)v..,..,.,?!'-..,..,,.,.....,..,........q,.~~-- Cllrpomm..,.llollt
_;~J-r--- Hlmde
.J..-~~--+--- Ooplt&e ~~-- Pllfiorm
..,.,-l~~---
Tltqudnlm
_ _ _ Urwra>llmnlllgament
~,..._
Unoarpol disk
_.~~~~-·~~
mtmb!'lne
A Tl.._ section tln'OIIQh the rtght hand PostErior view. The hind and forearm are mnnected at the ndlocotrpil and mldarpal)*lb (both lndla!Rd by blue lines In the drawing). Mor· phologkally, the l'lldloc:urJlill }tllllt Is an ovoid or ellipsoidal Joint, while the midaNpcrl joint is an interdigitating hinge joint (with an approxi· m<~tely S-shiped Joint space between the proximal and distal rows of e<~!JNI bones). Exa!pt for the carpometacarpal Joint of the thumb, the Joints between the dlml row of carpal bones and the !Nses afthe metat
254
The finger)olntl are dassilied as folklws; ~lot!g«lljoints between the metac.arpal bones and the proximal pha ~nges (MCP joints. spheroidal type) • Prnxlmallnl&p/la/arrgmfjolnts between the proxlrN Iand middle phalanges (PIP joints, hinge type) • DistDI itJUtphiJJongeal joints between the middle and distal phalanges (DIP joints, hinge type}
•
Since the thumb lada il middle phillilruc, It ha but two joints: a meti· arpophalangealjolnt ;;md an Interphalangeal joint (drilwlng !Nsed on a spedmen fnlm the Anatomlal Collection ilt the UniVersity of Klel).
Ulrw clftlollon 3~
b
8 MCM!mBIII ofthe 111d!ocarp•l•nll mldalrp•l ja-ntl Starting from 1he "neutral (-degree) position." JNimir flalon and dorul wnslon ire performed about a tran~e axis (1), while radial ind uln;r d~ltlon oc01r about i dorsoJNimar iXIs (b). Thot l:nm.IWIR nls runs through the lunlte bone for the nldlocirpal
joint and through the capitate bone fvr the midcarpal joint. The dotsopalrnor axis runs through the capitatE bone. Thus, while palmar flexion and donal exb!nslon can ocmr In both the radionrpal and midc;rpal joi..U, r.ldial and ulnar di!Yiatlon can ocmr only In the r.~dlo· arpaljoint.
C l'\lnctlollill posltton ofthe hilnd For post:Dpemiwl immoMizltion of the hand, the desired position of the wrist and fingers should be coruldered when the cast. splint. or other device is applied. Otherwise the Jig,.. ments m..y shortotn and the hind can no longer assume 4 normal resting position.
PIP
MCP
I
I
Dll'
I
10"
I~ II
D Rillngnf million af thefingll' Jalnb The proacfmal Interphalangeal (PIP) and distal
c Flexion In the metacarpophalangeal joint
interphalangeai(DIP)jointure pure hingejoints with only one degree offreedom (ftulon/extmslon). The metacarpophala ngotal (MCl') Joints of the semnd through fifth fingers are shaped hke spheroidal joints with three thotarttlal degrees of freedom, but rotation is so limited by the collmnlllga ments that only two degrees of freedom exist: flexion/extension and abduction/ adduction. The following 3peeific miM!II'Iellts ofthe finger Joints ire distinguished:
d Extension in the distal interphalangeal joint (DIP). e Extension In the metacarpophalangeal joint
• FluJon In the distal lnt«phlllllngul joint (DIP). Ill Flexion In the prtlldmillnterphlllllngealjoint (PIP).
(Me>).
(Me>). f Abduction and adduction In the metac;r-
pophalangeal joints (spreillding the fin'IJers ;part ;md bringing them tDgether ;bout 1 dorsopalmar a:ois through the hi!Gids of the metuarpals). AbducUon/idductlon movementsilredeKrlbed In relltlon to the middle finger. i ll mCM!ments away from the middle fingl!l' are cbssified as abdudion, ;II movements tuwan:l the middle fingeras illdductlon.
255
Upper Umb - - 2. Musculdhlre: Functional Groups
2.1
Functional Muscle Groups
A Principles used In the dasslflcatlon of muscles The muscles of the upper limb can be classified according to various criteria. An optimum system for classification should be logical and clear. The following criteria are suitable for classifying muscles: • • • •
Origin Topography Function Innervation
While function and topography in the upper limb are often interrelated (musdes with the same action on a joint are often located close IDgether), musdes that have similar actions in the shoulder region (e.g., muscles of the shoulder joint and shoulder girdle) vary considerably in their location_ The following classification (B), then, is a compromise between topographical and functional considerations. In section C, a different muscle classification system, based on innervation, is presented. The grouping of muscles by the pattern of their innervation reveals features oftheir embryological and phylogenetic origin, and provides clinical insights iniD the clusters of consequences from damage ID particular nerves.
B Functional-topographical claullicatlon of the muscles of the upper limb
MUlde fll the shoulder girdle Shoulder girdle IIIUICies tim hiM! mlgr•ted from the hNd • Trapezius
• Stemodeidomas!Did • Omohyoid Postertor muscles of the trunk and should• girdle
• Rhomboid m;ljor • Rhomboid minor • Levator scapulae Anterior muscles of the trunk •nd shoulder glnlle • Subclavius
Mlllcles fllthe forNITII
Posbrior rore.m muscles • Superficial extensors - Extensor dlgitorum - Extensor digiti minlml - Extensor carpi uln;Mis • Deep ~!>!tensors
-
Supinator Abductor pollclslongus Extensor polllcls brevis Extensor polllcls longus Extensor lndic:is
AnCBtor rore.m muscles • Superficial flexors - Pronator teres - Flexordlgltorum superficial Is - Flexor carpi radiab - Flexor carpi ulnaris - Palmaris longus • Deep flexors - Flexor digltorum profundus - Flexor pollicis longus - Pronator quadratus Radial foreann muscles
• Radialis group - Brachioradialls - Extensor carpi radialis longus - Extensor carpi radialis brevis MUlde of the hand MetKarpel muscles • First through fourth lumbricals • First through fourth dorsal interossei
• First through third palmar Interossei
MUlde fll the shoulder Joint
Then..- muscles • AbduciDr polllcls brevis • Adductor polli<:i5 • Flexor pollicis brevis • Opponens pollicis
Postertor muscle group
Hypothenar IIIUKies
• Pectoralis minor
" Serratus anterior
• • • • • • •
Supraspinatus Infraspinatus Teres minor Subscapularis Deltoid l..iltissimus dorsi Teres major
Anterior muscle group • Pectoralis major • Coracobrachialis MUlde fllthe •nn Postertor muscle group
• Triceps brachii • Anconeus
Anterior muscle group • Brachlalls • Biceps brachii
256
• • • •
Abductor digiti minimi Flexor digiti minimi Opponens digiti mlnlml Palmaris brevis
___.___
Uppe-Umb - - 2. Musculature: functional Groups
C Cl..aatTan llfthe muldel of the upper hmb lloy th..r lnwrwtlan Almost 'II th~ muscles d the upper limb ~ ~ lnnervmd by th~ brachial plexus arising fram spinal card ~m.,nts C5-T 1. Eloa!ptions a~ th~ tra· pezlus. stemocleldomiiStold. and omohyoid: orfgiNtfng In vertebrate evolution as musdM ofth~ hHd, they are supplied bycr;mlal nerve XI (aa:essory nerve) and the cervical pii!XUS (ansa cervicalis).
N.rw
..nRWII!d mllld•
AI:IIISIOry nerw
Trapezius sttmodeldomrstold
Anu c:e...Uifs
Omoh,old
Dorsalrqpular nervt
LeYator sapulre Rhomboid mljor llhomtoold "*'or
SujltasapuYriWW!
~us
Long thoracic nerw
SernltUSanterior
lnfr;lspln~s
~to the JUbd...,lus
S...bcloMus
Subsapullr nerw
S4.obsapullris Teres major
Thoraatdon.lnerw
Latissimus dorsi
Arstrt>
Med'llland llter;;ol
~lis major
Medalandlabl!ral
pedDrai~W~WS
~lfsmlnor
MusculoDJI:aneous
Corambrachlalls Bleeps brachl llrachlalls
nltiW
Deltoid T.,.mlnar
111ceps bridlll AnCDniiiUI S...pl~r
Bradlloradla lis &taMOr carpi radialis longuJ EXtensor carpi radialis brwvts EXtensor dlgltorum ElcteMOr digiti mfnlml EXtensor carpi ulnarts EXtensor pollkls langus EXtensor polfkls brwts EXtensor lnclicls
pecloraiUNI'""""' (n the ulnar g..-) Deep branch
---:~--
radlolnenoe
Antafarantmra
-IJn.li'IW!f'ole
Abductor pollds longus ProNtar tens Pral'lltllr qwdrilul
Palmi rts longus Remr carpi radlall• Flel!IOr polllds longus Remr dlgi!Drum prafu ndus (K) FlQOr dlgltorum supe~lfs Abductor pallfds bN!IIls Oppan.,s palllds Flel!IOr polllds brevis (superftdal head) Rmand s~~t~~nd lumbrkals Ull11r ntl'ft
Flel!IOr carpi uln~rls Fl,_r digiiDrum prafu ndus (K) Palma rts brwls Flaor dlglll "*''ml Abductor digiti ....... Opponens dlgttl mlnlml
AdduCIDr pollids Remr polllds bmtll (deep head) Palm~ rand dorsal IMiroutl Third and fourth lumbrtcals
D Oftrvlnr afthl! matDrbl'llndw ofthe bl'llchlal plea~~ thilt ..pply~ II'IUICiel oldie a_.,per limb With the outg rowtll of the limb buds from the trunk during embry!Jnic ~ment. the br•nchrs of the brrchlil plexus follow the gendlully determined podtrdar extensor muscles ilnd ontMor fluor musdM. Thl! netWS for the~ (radial and ulllary nerves) ilr1se from the three pomrior dMsions of the br~chial plexus, while the nei"'Oa for the ~ ors (musculocut;meous nem:. ulnar nerw:. median nerve) a lise from the three onlvlor dlvtslons of the plexus (see p. 346, Neui'OViiiSCulir Systems: Topographical Anill:omy).
257
Upper Umb - - 2. Musct~laturc Functional Groups
2.2
The Muscles of the Shoulder Girdle: Trapezius, Sternocleidomastoid, and Omohyoid ort!lln:
tD DeKendlng part1 1 : • Ocdpltal bone (superior nuchal line and tiCtemal ocdpltal protuberano) • The spinous P"1cesse5 ol all arvical wrtebrae vii the nuchal togament !l>Transvene part: Broad aponeurcslutthe lewl ofthe 1 1-T4 spinous procasses Q) Asandlng part: SplnousprocessesofTS-112 I_,•: • Utel'll third of the davicle (descending part) • Acromion (lnlnswrse part) • Sc:apulllr spine (•andlng part) Adlon~: • DeKendlng part - Draws the scapula obliquely UP'fird and rotates the glenOid cmty Inferiorly (acting wl1h the Inferior part of the serratus anterior) - Tllts the head to the s.ame side and n1t1tu It to the opposite side (with the shoulder girdle tiJCed) • Tn~nsvene part: draws the scapula medllllly • Asandlng part: draws the SC41pula medially clownw.rd (supports the rotating acaon olthedes<endlng part) • Entire muscle: steadies the sapula on the thoru l....wlfon: Cranial nerw XI (acmsscwy nerw) and urvlul plexus (C 2<4)
A Sdlem.IUc ottfle tl'lpezflll
• Sbmal head: manubrium sternl medial third of the dllllde • C~cular Mastoid process and superior nuchal line Action~: • Unilateral: - Tlltstheheadtothesameslde - ~thehudtotheopposlteslde • Bllats"al: - Extends the head - Assists In respiration when the head Is fixed 1-'lon: Ac<essorynerw (cranial nerve XI) and direct branches from the <enllal plelws OrTgln:
""cl:
I_,•:
(C1..C2)
a Sdlem.IUcottfles.temocleTdom~~ltold
ort!lln:
Superior border of the SC41pula Body of the hyoid bone • DepraMs (flxel) the hyoid bone • Mows the larynx and hyoid bone dGWIIWIIrd (for phonation and the final phl!Se of swallowing) • Tmses the cervical Asda w1th Its lntennedlate tmdon and maintains patency ol the lnternal)ugularwln l....wlfon: Ansa anicalis ol the cervical pleaus (C1-CA)
I_,•: Actl-
1
258
Thutructurt$listl!d inthetablesarenotall lllustrmd In tfte drawings at right because they are not necessar11y VIsible In those views. The tables and associated diagr.anu are Intended to give a systematic v.oervlew
of the ~med m111des and their actions. while the drawlr~gs at rlght are Intended to display the musdes as they would appear In a diS$eC·
tion.
Supel'lor -
....::::-:-:--
-:--
nuchallin~
Sapularsplne
~~=--~~----t~~-ll'apezlus,
.asund:ng part
D 111e t.Npt!lllus Po51lerlorvlew.
E 111e stl!modeldorn;utold 01nd omohyold Right side, lateral view.
F 111e omohyoid Right .side, ;mteriorview.
259
Upper Umb - - 2. ltfuKulature: fUnctional GroUPJ
2.3
The Muscles of the Shoulder Girdle: Semtus anterior, Subclavius,
Pectoralis minor, Levator scapulae, and Rhomboid major and minor 01111* -.tt.:
Firstthrough MICh rlls Sapula: ~Superior fNrt(supellar Ingle) ~I~Urmeclliwpart~ ~
allnterb-pirt (lnferb-qle and mtcllll bonlel) .Adlo.l: • Entin! .....de: chwJ the SCAipUII . . . . . fonrad.........the ribs when the shoulder girdle Is flied (41sslsb In resplr.tlon) • lrterlor part: rutilmthe sapuli 1ncl dnws Its Inferior angle !~Willy'--.!. ~glenoid !3VItysuperloriy) • Superior pirt lowers tile r411sed .,., (antagonln ID lhe Inferior part) J.....wl:lgn: Lollg tllonclc nerw (C5-C7)
A Sdll!lllatfc ofthe lm'ltulentlltar 5ulldftlus Oltglln: First rib (~hondro·osseous junction) lnMI'tlen: I nferlorsurfilce of the diVk:le (lmrolllllrd) Adlon: Stll!adies lhe clavicle in lhe stll!rnoci1YicullrJoint ln...,....n: Nerve !Dille subdmus(CS, C6)
Q)
a> .....,,hsmliiOr Oltglln: ~:
.Adlo.l:
Thlrdlllroughflfth ribs Com:old pi'OO!SS of the supuli • Dnws thexapiA dGwnwanl. ausing its infllriot ~to ....postel'lll!ledblly("-rsthe rolled arm). rat1t11s gr.nolcllrfttlorly • Ass1sts In mplritlon
............, Mecillandlateral ~--~l1)
II SdlematlcofthetulldiiiiWI"'I ped11Rll1 rinor
....,_......, ..... 011t11n: 1-u..,:
Trons--.piD
Spinous processes of the c 6 and c 7 wrtllbroe Medial border of the sea pull (1bcM! tilt SCI pul1r spine) • Steadies tile SCilpulil • Drows tile SCipula medially upward (mums tile r1IMd 11111 ID the neutral [zero-clegrH) pMition) ln..,.....n: Dors•lsc•pularneM!(C4-C5)
Spinous processes of the T1-T4 ftrt.bru Medial border of the Klpull (btl-the sapullr splneJ • St&dles tile sapula • Drlws tile 5QPIA medially u pwild (mums tile rllsed ltTT1 to the MUtral C SdlematlcofU. lnRonapulannd
rhvmbol«• mlnw •nd m~w
260
~zero-degree) poskion)
• -........,, Donal sapulilrnerw (C4-C5)
Clmde
Rrstnb
~ -:...._----.!~--~:;:""1:~...
afltlericr
Subdwfus Pectar.ats _ ___:_ ,__ _.,;-...._
minor lhhl -......;~1+---.,C....:.~~~-.-+- thraJgh
ftftMbs
D 1besemtuunlta1or Right sldt.lilta'alvlew.
C2(m)
E l'lle pec:toraDs mTnor.-.nclsubdilllfus Right side, antertorllfew.
llhombold major
F 1be levator sapullle, rflombolcleusm~jor, and rflomboTdeus mlnor Right sidt'. posterior ~ew.
261
Upper Umb - - 2. Musct~laturc Functional Groups
2.4
The Muscles of the Shoulder Girdle: The Rotator Cuff Q') 5upn1Splne1Ua Orfgln: Supraspinous fussa oftM scapula ,......,...: Greatertllberosltyofthe humerus ~ Abducaon 1-a111: Suprascapularnerw(C4-C6) (1) lllfras,.._
lnfr.nous russ. of the scapula Greatertllberoslt)'ofthe humerus ~ Elcb!mal rotldlon 1 - a • : Suprascapularnerw(C4-C6) Orfgln: 1.....,111:
®Tensmlnor
Lateral border of the scapula Greatertllberosltyofthe humerus ~ Extamal rotation, wukadcluctlon lnneiWif111: Axillary nerw (C 5, C6)
Orfgln: ,......,...:
A Sdlem.Jtlc of tfle supr.upllliltus,lnfrnptnnus, 01nd b!fe5 mlrtOr
® 5ubla!U•rf• Subscapular fussa of the scapula Lesser tuberosity of the humerus ~ lm.tnal raallon lnnerwlf111: Subscapular nerw (C 5, C6)
Orfgln: ,......,...:
B Sdlemattc oftfle Sl.lbscapullrTs
262
VpfH!r Umb - - 2. Musallflture: functionGI Groups
LeiMr----,-· -
tu~
lnllertubel-
alargi'OO\Ie Medial border
a
S...,r;a-
Sc.lpl.far
lp(natur.
spbe
Acromion
Aaomlan
Corllalld prvcas "J.la~~-
CIWt!er tuber¢.51ty Sibsa· pularls
c C MUKIK of tiM! rot.1tllralff: 5Upl'ill!lpTr8tlls, trtfr.upll"liltus, ti!I"K
minor, a'ld sublclpul1rTs Right shoulder joint.
• Anterior vfew. b Postl!rlarlltew.
c:
Lilter.~lview.
263
Upper Umb - - 2. Musct~laturc Functional Groups
2.5
The Muscles of the Shoulder Girdle: The Deltoid Origin:
I..UGII: Actl-
1-'lon: AxJI~rynerw(C5,C6)
A Schemlltltofthedeltold
OMculn
part
Acnxnal
part
AbductScn/ - - ---; adductScn as
• I Thewriible;~c\lonsofthedlltold~nts
a Cross section ttl rough !he right shoulder joint. b Right shoulder joint in the neutral (zerDodegl'l!e) positiCin, anterior vlew. c Right shoulderjoint In 60' of abduction. anterior view.
The ac:tlonsofthe three parts ofthe deltoid musde (d.Ma.olar, acromial, and spinal} depend on their relationship to the position of the humerus andlt.uxlsofmotfon.Asa result, the partsofthedeftaldcan actantag· onistically as well
264
b
VpfH!r Umb - - 2. Musallflture: functionGI Groups
Deltoid IU~!OIIty
Shaftof hUmer\$
Aa'Gmlon
- -7.-----
•
Ccraalkl Cln!de
~d.
c
dn!C\1111' put Shaft cf Deltoid h umeNS tubero.sll:y
SCipular -
-P'"WW'II5i!l
Sl)lne
C The deltoid Deltoid tu~1011ty
--+- - Shaft of hLmei'IJS
Right shoulder joint.
a Anterforvtew.
b Pcnterigrview. c Literal view.
265
Upper Limb -
2.6
2. MuscuiGture: Functional Groups
The Muscles of the Shoulder Girdle: Latissimus dorsi and Teres major {I) Uit..._ .....
011111:
• v.rtelnl plft - Sphlus~oftkT7-T12'1eftebrae - n-.a.lumb.t.dl oftkspiiiiiiiS........-af.. lumbilr'lerteblft and the S1CN11 • lllz plft postartordlkd of the l k awst • Cosbl p1rt '1111 through 1Zth ribs • Scilpular p1rt r..r.rlDr ang t. ofthe ~e~~pula
I!Rrtlon:
08t of thei-r tubtroslty (antenor VIeW) ofthe
lldlon1:
humerus 1nternal rot.Uon,addudfon, 1'11:-rslon (m-s the ann blckwllrd), respiration (aplriltlon, •c:augh musde")
lmei'WIIon: Thoro1011dorsal niiMI (C&-CI)
®T-mljor Orltlln: l,..rtlon: Adlon: lmenatlon:
B CIKne afthetl!ndon afl.-rtlon oiiRlsslmus doni In the neutral pollltfon and In tlewtlon
Posterlorvlew. The latissimus dorslnv.Jsde Is mostxtlw! In the abducted or elev.~ted .um. Raising the ann untwists th• muscle fibers In the iii'N ofinsertion, increuing the muscle's stntch and miDiimii:ing the force it an -rt. When the position of the ann Is fured, the latissimus dorsi an pull the body Upwilrds as In the act of dlmblng or an depress the ann against il reslstilna. This mabs the latlsslm us doni an lmporbnt musde fOI' p~rapleglcs, for I!Ai mpll!, who an use that muscle to l"iilse them~ fromwheelchairJ.
266
lnftnorangleofthuapull Ctwst of ltle 1-rtubero.slty of the humerus Internal rot.Uon,addudfon.l'll:-rslon Sub:supullr- (CS, C&)
Hl.mtiiiS
-
---'-..1....:.--IJr!ls:slmusdor.i, 5apular Pll't
- - - - - - SplnouJpi'Oa$1tS
tiTI
- - - - - - uumrmusdanl, wrt!bral part
' - - - - - - l..1tluhn.ada~:~l,
IJacp.art
IL-J---IIIatcn!rt
C Thelllti:Mimu•donlndtll:resiTIIJor Posterior view. He«! of
Commonlftl4!t'tfon ofthe IIUulm111 doni •nd ures ITIIIoron die ere« of die r-rt!Mroslty Antenor lllew.
Acromion
D
!!llr::;_-!-- - lrhr!or •nQie
267
Upper Umb - - 2. Musct~laturc Functional Groups
2.7
The Muscles of the Shoulder Girdle: Pectoralis major and Coracobrachialis
tD,_.,.•m•r Orfgln:
• C!NaJiar part: medial half ttl the c!Nde • ~CIISbl part sternum and the - d through sixth CDStal cartilages • Abdominal part anta1or l•r ttl the rectus sheath 1-aen: Crest of the gmtl!rtuberoslty of the humerus Actlonl: • Adduction and Internal routlon (entire muscle) • Antewnlon (clavicular part and sternocostal part) • A5slsts respiration when the shoulder girdle Is fllced 1-'!en: Medial and lateral pectoralne~W5 (C ~T1)
a>eor-bnchll. Orfgln: Coracoid procas of the tc.~pul.a 1-'!en: Humerus (In line with the crest ofthe lesser tuberosity) Actlonl: Antewrslon, adduction, lnternaiiOQtlon 1-clen: Musculocutaneous ne!W(C6, C7)
A Sdlem.Jtlc of tfle pec:.tol'illls m;~}or ;mel col'ilcobl'ilchl;alls
B 1\vTitlng oftfletendon oflnlf!t'tiDn of pcdorliiiJ miJor Anterlor¥1ew. The three parts of the pectol'illls
major (cla¥Jcular, sternocostal, and abdominal) CDIM!f!le laterally and insert em the al!st of the grearer tuberosity by a broid tendon tflat hasa horseshoe-shapedaosssectlon. The ten· dor1 tlber bundles .are twisted or1 themselvtlln such a~th;rt the d;Jvicular part inM!rts 1_. or1 tfle humerus tflan the stemocost;ll part. which Inserts lower thar1 the abdominal part. As with the latissimus dorsi, the muscle flbers of the pectoralis maj~r become untwisted and stretthed with Increasing elewtlon of the ;nm, lncreaslllg the force that the musde can exert.
268
VpfH!r Umb - - 2. Musallflture: functionGI Groups
=:c-=::----..,;;:=-.:---- Pedllr~ls ma}Cr.
mmomstalp.n
S18'num
Humeti.IS - - - -
C The pec:ton~lls N}or and C0111cobr1ichlalls Right side, anterior1/tew.
269
Upper Umb - - 2. Musct~laturc Functional Groups
2.8
The Muscles of the Arm: Biceps brachii and Brachialis tD BlaSI' lnchll Orfgln:
1-'len:
• long hNd: surnglenold tubercle« the scapula • Short head: e~~racold proau of the sa pula Radial tuberosity
*"-=
• ElbowJOint: - Fieldon, supln.tion (with the elbow flead) • Shoulderjoint:
LDnghead
- Fieldon (forw;~rd motion of humerus) - stabiiiZitiOn of humeral held durfno clellold contraction - AbductiOn and lntJernal (medial) rotation of the humerus Short head
l....wlf•: Musculocutaneous nerw (C5-C6)
®1.-Hiilll Orfaln:
Distal half of tile anb!rlor surface of the humerus. also the medial and lateral
intermuscular septa Uln.artubenlslty
l...tf•: Adbm Flexion .at the elb- Joint 1-'!en: Musculocutaneous ntiW (C5-C6) and racllalnaw (C 7)
A SdlemiiUcottflebfceps bl'lchllancl bradllllls
B supinating actiDn ofthe b'lcltfK bl'lldln wtth the elbow flexed a The forearm Is pr~~nated with the elbow flel(l!d (right arm, medial VIew). b t.rD:ss$C!ICiionatthe leveloftne!'idial tuber· oslty with the foreo~rm pror~ated (proximal
S\lpl..-.1 posltton
Prort;l11td JIO'itton
lltew).
c The fD~rm is iupinated with tfle elbow flexed (right arm, medial VIew). d Cross section at the level ofthe radial tuberoslty with the forearm supinated (proximal view).
Wilen the elbow li flel(ed, the bleeps br.achll ac1$ ;., a powerful supinanlr in addition to itJ role as a fleliOr, because the lever arm In that position Is almost perpendicular to the axis of pronation/supinatian (see p. 242). This is why suplootlon movements ;rre particularly efl'ec:Uve when the elbow Is flexed. When the foreo~rm Is pf'OIKI1:M (a), the llendon of Insertion af bleeps br~cflii is wr.apped ~rDund the r~diLIS. When the mLJScle then cantr.Kts to flex the elbow, the tendon unwraps like a rDpe coiled around acrank(b}.
• ruertlan
R.adha
Ulre
~ b
d
Radius
270
Plane dsectfon
um
VpfH!r Umb - - 2. Musallflture: functionGI Groups
lntl!rtUber·
Supr;a9enold
Coracdd
Scapula,
tubercle
p!'OCHS
an1B'Iarsu~
---""'--!+
cular~
ll.ldlaltllbti'OS!ty. - -...1111 bla:psbr.ICNI
~=----
tl!ndoncf
Ulnarlllberoslty,
bradltlllstltndon ofnHrtlon
Insertion
C 111e bleeps bnlcHI ud br;adllalls Right arm, anU!rlor (ventral) lllew.
D 111e llriKfllillls Right ann, anU!rlor (ventral) lllew.
271
Upper Umb - - 2. Musct~laturc Functional Groups
2.9
The Muscles of the Arm: Triceps brachii and Anconeus Sc
Cor.acold proass
Acromion
Head of hur118'Us
Lmnl had
Cl> '~)bps biWHI o.tg..:
• Longhead:infraglenoidtuberdeofthesapula • Medial head: posterior surbce of the humena, distal tDthe radial groow, and the medlallnterm.-..lar septum
• Lateral head: posterior surbce of the humerus. pi'OIIdmallll the radial g - . and the lateral Intermuscular septum Olecranon ofthe ulna • Elbow joint e~rtenslon • Shoulder joint long head: backw
@AIKDneus Oltg..:
Lateral epicondyle of the humerus (and the posterior
joint capsule In some cases) Insertion: Olecranon of the ulna (raaeal suma) Adlons: Extends the elbaw and dghtens Its joint capsule lnnetWIIon: bdlalnerw(C6-C8)
A Schem.Uc of the triceps In chi Iand ancone111
a Thetrlcep$ brachll and a neonRight upper arm. postErior (dor5il) view.
272
-~--- Shaftof
humena
lllctpS bradll, ten den of crlgln ofth~ lang head
--f.--'-i--1
TrlcepsbrKhll, _ ....,.._ , lang held
......____ _ Trfctpt;bradlf, medLJihead
ll!tepSbradlll,
tl!ndan of Insertion
- ---.J:i>e--
C Thetrkepsbr*Chll•u'ldanconRlght upper arm. posterior (dorsal) view. The lateral he
D Thetr~Q:p$br*Chllandancona~s Right upper arm. posterior (dorsal) 1/lew. The long he..d of triceps brachll has been partially removed.
273
Upper Umb - - 2. Musct~laturc Functional Groups
2.10
The Muscles of the Forearm: The Superficial and Deep Flexors tD Pronnor.._ • Humenl head: medial epicondyle of the humer.. • Ulnar head: e~~ronold procc$$ ofthe ulna 1-'len: Lateral surface oftM radius (distal to the supinator Insertion) *"-= • Elbow]Oint:weakfl-r • Forearm joints: pronation l....wlf•: Medlannerve(C6,C7) Orfgln:
®
n..wdlgllon~m ..perftdlllls
Orfgln:
• Humeral head: medial epicondyle of the humerus • Ulnar head: e~~ronoid procc" of tM ulna • Radial head: dlstaltD the radial tuberosity IIIMI1fon: The sides clthe middle phalanges of the SKDI'Id through fifth digits ~ • ElbowJOint:weakfl-r • Wrlst]Oints and the MCP and PIP Joints of the se
Medial eple~~nclyle of the humerus Base of the - d metacarpal (and sometimes ofthethlrcl metacarpal) Actlonl: Wristjoints: flexion and abduction (radial deviation) of the hand l....wlf•: Medlannerve(C6,C7)
Orf!lln: 1.....,•:
®R.... arpl ....rts • Had of humena: medial eple~~nclyle • Had of ulna: olecranon 1-'len: Pisiform hook of the hamallt, base ofthe fifth metacarpal *"-= Wr1st]Oints: flexion and adductiOn (ulnar devlatfon) of die hand l....wlf•: Ulnarnerw(C7-T1) Orfgln:
®Pelm.tslongu Medial epie~~ndyle of the humerus Palmar aponeurosis • Elbowjolnt:weakfiC!X!Dr • Wrist Joints: palmar flexion, tlghlltns the palmar aponeurosis for gripping l....wlfen: Medlanne.w(C7,C8)
ID R_..g~~onnprafundlls PniiiCimal-thircls ofthefl-r sun- of the ulna and the adjaCI!I'It inte-s membrane 1.....,•: Palmar surbcz ofthe distal phalanges cl the second through tlfth digits *"-= Wflst JOints and the MCP, PIP, and DIP jOints of the second through filth digits: fieldon l....wlfen: • Median ne.w (radial part, second and third digits), C8. T1 • Ulnar nem (ulnar part, fourdl and fifth digits), C7-T1 Orflln:
MlcJ.an~~trlor surface of the radius and the adjacent lnlltrosseous membrane Palmar surbce of the distal phalanx of die thumb • Wristjoints: flexion and radial abdudlon of die hand • Carpometacarpal jointof the thumb: opp01ilion • Metacarpophalangeal and Interphalangeal joints of the thumb: tlelCion IIIINIWII•: Medlannerve(C7, C8)
Q)
Pro..-quachlus
Dlshl on•fourth of the anterior surbce of tM ulna Dlshl on.rourth ofthe anterlorsurbce ofthe radius *"-= Pronates the hand, stablll~ the distal radioulnar ]Oint l....wlfen: Medlanne.w(C7.C8) Orfgln: I....U•:
a Sdlemdt of tile deep fltiiOI'S
274
Humerus,
---Medial~
mechi
common head of
eplalnd)1e
~~~
~nold ~
F'lelalrc.rpi-......;.,:.;...;~LO..
radllfs
•1 /HJ.~I---- Fleancallll ulnarls
Flexorpclllds
long1.11
Fll!liOf -
dl~ltorum
---1~
---:.+-H.
s~Js
*-.......1!!1-11-~4.-.,.-+-~-Second
thiW!#I
tlfthmlddlt
phalanges
C The superficial fle.m:n (pron.torteres. flexor dlgltlll\lm supert'icUIIs. Ruor c;upl Fildlalls. fi_.GII'pl ulnarfs, iind palmarTslongus) Right fDnsJrm, anterior (ventr.al) vi-.
D The deep flexors (flmlr dlgltoc\lm profundus. flexor polld$ longus. iirld prvn;atorqu..driltus) RlghtfDrearm, anterior (ventral) VI-.
275
Upper Umb - - 2. Musct~laturc Functional Groups
2.11
The Muscles of the Forearm: The Radialis Muscles
l*ral surface ofthe distal humerus,laterallntlermuscularseptum Styloid processofthe radius • ElbowJOint: flexion • Forearm joints: semipronation 1......,•: Racllalnerw(CS,C&)
® Exlenlar a.,al I'MIIillslongus l*ral surface of the distal humerus (latl!nll supn1conclylar riclge).llteral lntermUKular septum llllel1f•: Dorsal base of the second metacarpal ~ • ElbowjOint:we;~kflDOr • Wrist jOints: dorsal exll!nslon (assiSts In fist closure). abduction (radial deviatiOn) of the hind 1......,•: Racllalnerw(C6,C7) Orfllln:
® Exlenlara.,aii'MIIelsllfewll l*ral epicondyle of the humerus Dorsal base of the third mebcarpal • ElbowJoint: weakfla~~r • Wristjoints: dorwlexunslon (assiSts In fist closure), abduction (radial devlalon) of the hind 1 - ' 1 • : RacllalneM!(C7, C8)
276
VpfH!r Umb - - 2. Musallflture: functionGI Groups
Olecranon
4-1.11--
l'lttensorUil)l
radtaltsbrel
tnteroueoos --~
ml!lllbr<me
1 -4~--
llasltoflhlrd ITM!tlcap;ll
Styfcldpi'OCI!SS of radius
4-lFio,........;::...,....- - Base ofseax!d metllc.trp~l
+ - --"l!.,.__,___ Second met~~!
Baseoft!llrd rnetl~l
--+--A--1~
14~4-- Baseofseax!d ml!tll~l
:4-- ....r..- +---
Shaftd
secand metaGI~
8 The rM!IIIIIs muKies {bi'IIChTOI'HIIilh, exteRIOrUrpll'lldl•lls longus. ;md exte1110r carpll'iiCialls II"""') Right forearm.
'4--...,?<~-
Headd secand melaa~
;a Lab!!"al (r;uflal} view. b Portl!rlor (dors;al) view.
Z77
Upper Umb - - 2. Musct~laturc Functional Groups
2.12
The Muscles of the Forearm: The Superficial and Deep Extensors
Common head ('-al epicondyle oftto. humerus) Dorwl digital expansleln of the second through fifth dlgll$ • Wrtst]Oints: extension • MCP. PIP. and DIPJOin!$ of the second through fifth digits: extensiOn and abduction of the flnge~ l....wlfGII: Racllalnen~e (C7, C8)
Common head <'-•1 epicondyle of the humenrs) Dorwl digital expansion of the fifth digit • WristjOints: extension, ulnar abduction ofthe hand • MCP. PIP, and DIPj01n15of the tlfth digit: extension and abduction of the tlfth digit 1-'!GII: Racllalnt!W(C7,C8)
® ExleniGr carpi . . .rts Common hucl (latleral epicondyle of the humerus). ulnar hucl (dDrwl surfaat of the ulna) I....,•: Base of the tlfth -carpal ~ Wl1st ]Oin15: extension, <1dductlon (ulnar cle'lllatlon) of the hand 1-cfGII: Racllalnt!W(C7, C8) Orftlln:
IDSup~natar
Ol'ltlln:
I....,•: ~
Olecranon of the ulna, lateral epicondyle of the humerus. radial CDIIateralllgament. annular ligament of the radius Racllus (betwaen the radial tubenlslty and the Insertion of pronator tera) Suplnates tto.farearm j01n15
1-'!en: Racllalnt~W(C6.C7)
® AbMiorpollldslongus Orftlln: Dorwl sumas of the radius and ulna. also the intlnSseDUs membrane I....,•: Base of the flmmetaurpal ~
• Radiocarpal Joint: abduction (racllal cle'lllatlon) of the hand • C..rp~~metaarpal Joint of the thumb: ;~bduction 1-cfGII: Racllalnt!W(C7, C8) Q) ExleniGr polbd5 brevis
Posterior surface of the radius and the i n t e , _ membrane (diSillllliO abductor pallltls longus) I....,•: Base of the piGidmal phalanx of the thumb ~ • Radlelcarpal Joint: abduction (racllal cle'lllatlon) of the hand • C..rpometaarpal and MCP Joint$ of the thumb: extension 1-cfGII: Racllalnt!W(C7, C8) Orftlln:
® ~polbd51GIIIUJ Posterior surface of the ulna and tto. Interosseous membrane Base of the cllstal phalanx ofthe thumb • Wrtst]Oints: extension and abductfon (radial devlatlon) of the hand • C..rpometaarpal Joint of the thumb: adductfon • MCP and lnt.rphalange~~ljoln15 of the thumb: extension l....wlfGII: Racllalnen~e (C7, C8)
Posterior surflla of the ulna, the Interosseous membrane Posterior digital expansiOn of the second digit • Wriltjoint: -nsion • MCP. PIP, and DIPjoln15of the second cllglt: ntenslon l........aGII: Racllalnem!(C7, C8) 8 Sdlemdt of tile deep atll!niDrs
278
~---Latleral
1!7---l.llte'.al eplcand)!~
02pk:llndyle
-.~~~-----a~~
..JR.- - Convncin head«
extmsor d'gi!U'um. exterucrd'gltl mlnlml,<~ndemnsar
arpluhwl$
Elcb!nsar c;rpl
--:;rr-~ 1
ui!Wis
""'\-+--- Abductor
pcilldslongus
£~~.tens« ----7-!::11~
Elcb!nsar digiti - - - i2u.'""il
mlnlml
pollcl$longus
Dorsal tubercle
~ ~d-~~~~~~~
mebt-
I h-+h?'--tr''-r...f.Tt-----"~-+-- Don.1l
arp;~l
~\
== Arstmet..
Grp;ll First
pi'CIIdmal phalanx. btase
dl~ltil
op.wnslon, lntefltn dl-
nousCD>nectfons
C The superficial extensors {exten1or dlgltol\lm, extensor digiti mlnlml. ;md exte1110r carpi uln;nfs) Right forearm, poml1or (doJYI) llfew.
D The deep exte1110rs (suplnnor, abdudor polldllongut, exte1110r pollkls lnvls. IIX.tllnsorpolllds longut, ;md extensor TnclcTs) Right for!! arm, pos!l!rior (doJYI) view.
Z79
Upper Umb - - 2. Musct~laturc Functional Groups
2.13
The Intrinsic Muscles of the Hand: The Thenar and Hypothenar Muscles <» AWuCCIDr polllclf bnvlf Scaphoid bone and trapezium, ftoor retlnaaJium Base ofthe proximal p"'lanx ofthe thumb (Via the 111dlal sesamOid) Adlons Abduction of the thumb ln...,.._ Medlannerw(C8, T1) OltgM:
ln..nlon:
<» AdcluCCIDr polbclf OltgM:
sesamoid
ltadllll
Q)
Ulnar
.....~Jl+--
• Tr<~nswenehead:palmarsurfaceofthethlrclmetaarpal
• Oblique head: apltate bone. base of se(l)nd metaarpal In-"'- Base of the P"lllimal phllanx of the thumb (WI the ulnar sesamoid) Adlons: • Carpometacarpal joint ofthe thumb: apposlllon • Metacarpophalangeal jointof the thumb: ftexlon ln...,.._ Ulnarnerw(CS, T1)
sesamoid
F'-' pellcfs brevis
OltgM:
ln..nlon:
• Superficial had: fluor retinaculum • Deep head: apltate bane, t111pedum Base ofthe proximal p"'lanx ofthe thumb (Via the 111dlal
sesamOid) • carpometacarpal JOint rA the lhun*lluloll. opposlllon • Metacarpophalangeal jointof the thumb: llexion ln...,.._ • Median nerw, C8, T 1 (superfldal head) • Ulnar nen~e, C8, T1 (deep head)
Adlons:
® OppaMns pellets lhlpezlum In-"'- Radial bonier of the first metacarpal Adlon: Cllrpometacarpel joint of the thumb: apposition ln...,..._ Medlannerw(C8, T1)
OltgM:
A Sdlemltlt oftfle then1r((!)-@) 1nd hypGthe111r II'IUides (\tl~)
0 AWuCCIDr llgltl mMimt
flsifonn bone Ulnar base of the pniX!mal phalanx and the dorsal digital expaMion of the fifth digit Adlons: • Metacarpophalangeal jointof the little ftnger: fle21on and abduction of the Attie finger • PIP and DIPJOints of the lltlle linger: exb!nsron ln...,.._ Ulnarnerw(C8, T1) o.tgM: In-"'-
<J> F'-'dleltl mlnlml Hook of the hamate, the ftexor retlnatulum ln..nlon: Base ofthe proximal p"'lanxoftht fifth digit MCP JOint of the lltlle finger: fieldon Adlon: ln...,.._ Ulnarnerw(C8, T1) OltgM:
0 OppaMnsdlelll mlnlml OltgM: Hook of the hamate lnMrllon: Ulnar bonier of the fifth metacarpal Draws the metaarpalln the palmar direction (oppositiOn) Adlon: I n - * - Ulnarnerw(C8, T1) 1'111-rts brevis (not shown)
Ulnar bonier of the palmar aponeun~Sis Skin rA the hypothenar eminence AdiDn: Tightens the palmar aponeunllls (protKif~ function) ln...,..._ UlnarneNe(C8, T1) o.tgM:
I~
280
Opponens ------lr-lr-~-oltr<\. dgl!lmlninl fleliOrd~ --~~~~
mlnlml
Abdi.ICtor--~~'
dlg111 mlnlml
HGGitofhamatl! -----'~~~~
(undertenllon)
~~___;..:..,{..___;..,t,,""';E---
Jldcllctlrpolllcll,
oblique head
/,A77#~~'...J.~-- Flrmrpolllcllbmis. s~dalhad
Thlrdmetac;~~,base
8 The then;n rnurdls (llbductor poll Ids luwts. adductor pol lets. flexor pollIds lnevts. iind opponens polllds) lind the hypotflenn musdes (1bcb:tor dlgTt1 mTnrmf, fte.r dlg'IU mlnTmT, a'ld
opponen$dlgltl mlnTmT) Right hand, antertorlltew
281
Upper Umb - - 2. Musct~laturc Functional Groups
2.14 The Intrinsic Muscles of the Hand: Lumbricals and Interossei (Metacarpal Muscles) Q)
nmthreughfouldl ...-rfal mllld• bdlal sides ofthe tendons of fluor dlgltorum p!Vfundus
o.tgln:
(~~;~rlable)
lnlllrllon:
• Arst lumbrlcat dorsal digital eacpanslon ofthe second digit {lndl!llflngeti • Sea~nd lumbrical: do~l digital apanslon of the thhd digit (mlddr. finger) • Third lumbr1cal: dorsal digital expansion of the fourth digit (ring finger) • Fourth lumbrlcat dorsal dl~l eacpanslon ottht rlfth digit (little finger) Adlons: • Meblurpophalangeal jointsof the second through tlftto digits: flexion • Proximal and distal Interphalangeal Joints of the second through fifth digits: l!llb!nslon l n - u - • Median nem, ca. T1 (flrstandsecondlumbrlcals) • Ulnar nerw. C8, T1 (third and fourth lumbricals) 0 Rmthroughfourth donell.,.._.. Ollgln:
By two heads from ad]acentsldes of the first through
ftfth metacarpals • Do~l dlgltalapanslon of the ~ea~nd through fourth digits, base of the pradmal phalanx • First lrmerosseus: radial side of the second proldmal phalanx (lndl!llflnger) • Second lnteroueus: radial side ofthe third proldmal phalanx (middle finger) • Third Interosseus: ulnar side ofthe third proldmal phalanx (middle finger) • Fourth Interosseus: ulnar side ofthe fourth proldmal phalanx (ring finger) Adlons: • Metacarpophalangeal jointsof the second through fourth digits: flulon • Proximal and distal Interphalangeal Joints of the second through fourth digits: extension and abdudlon of the fingers (abdudlon ofthe lnd•and lfng fingers from the middle finger) l n - u - Ulnarnerw(CI, T1) ln.nlon:
A Sdlemltlt oftfle metaarpal mllldes
0 RmthroughtNnl palnler lnlerauel Ollgln: • First lrmerosseus: ulnar side ofthe se(l)nd metacarpal (lnd• finger) • Second interosseus: radial side of the fourth metacarpal (ring ftnger) • Third lnteroaeus: radlalsldeofthellfthmetacarpal (lrttr. finger) ln.nlon: Donal digital apanslon and base of the proldmal phalanx of the assodillted finger Adlons: • Meblurpophalangeal jointsof the second, fourth, .and tlftto digits: flexion • Proximal .and distal interphalangeal Joints of the second, fourth, and llfth digits: extension and addudlon ofthe fingers (adduction of the second, fourth. and fifth digits lllwlrd the middle finger) l n - u - Ulnarnerw(C8, T1)
282
1/Y:f----
--+-:!--
Sewnd m~UallNI
r - -r-......!-- Fhtl<mlxfal Sewnd lumbrial
FleliO rdlgltorun p 11>fund
~dthi1>Ugh--~~~~--~~~+-~~
fifth p rolCblil phal;ulgef>
Thlrddors.11
---':~~~-...!!~
+-'!7~~!--+.,.,-";!-- ~ddon:al
I~ US
rourthdors.11 I~US
Seoond through ftfltlmetat;lll)als
lntl!ross.ti.IS
------""'\-+
,l;!!!w.!;~--'-;<----
Flrstdorsal lntl!rossws
-----':....:-....J~114.....J~4~
B The muscles of the hand Right hand, anlll!rtorlltew. a FTrstthrough fourth lumbrfcals. b First through third palln.ilr intetwi'C!i. c Arstthrough fourth donallnterossd.
283
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.1
The Posterior Muscles of the Shoulder Girdle and Shoulder joint
Tr.lpe.!lus, _
___:;:,:,.........,..~1
deiandlng p;ut
T111P61us.
-----'----:===----"'==-...,
lnnswn1! PIUt
La1mlmus -~:!i-++1 do lSI
EXternal obtque
A Musdauftheshoulderglrdlund shoulder Joint Right half of lfle body, postl!rlor lllew. Superfici~lli~Yl!r.
284
==!:-Ill!!!!:~-
flexor carpluiAarts
~~~-
ettlen:sot Qrpiulllirts
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
SUperfar--.;.:.......,_.,
,.-.,lllf--
nudlatr.,~
Sternodeldornastald
~~~--
Smllsplnalts capitis
l».~f----
Eredor'!llnae, thoracdumbll'fasda
Splenlusapll!s
--~H~~-
a Musdeuf tile shoulder gt~lund shoulcler Joint Right half of the body, posterior view. Deep layer. Por!Sons of the trapezfUs ~nd lall'sstmus
do!'li muscln have been remcM:!ICI. Tho11101lumbu fa5da
lnta111l
obtque
285
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.2
Rhomboid minor
The Posterior Muscles of the Shoulder joint and Arm lella1llr
S«Jpulill!
S~·
sploatuJ
IJ!v.ltor T~;dus
Rhcmbold
SC<~pUiae
SUprasplnotus
minor
Rhomboid
Rhcmbold
ma)or
mo)or
Bradltoradlds
-~~.-----'-'-f-,
Extensor --~.L
carpi radialis longus
Exlltnsar - -...q.:t._ c.rpl r.ad l•lls bre-.4'
OleaM>Cn -
--';,--.:'L+o
Anconeus - -!---:o-+,...,- '1• Aext~r
c:upl uln.vls
- ---1:-7
Exlltnsar ---!:---..-"""'7i~
carpi uln.vl'
Common held ---":f;-..~. ofoll!nsors Common held ----:.!l~oo. 1 dllmlrs Anc:oneus--"""-~~ Flexor---.....::!~~ carpluh,;a~s
Flexordlgltxlrum
- - - --l
profuoldus
Exlltnsar---!~~~~~~1
dlgl!orum
b A Musda50fthe rfght shedder ;md rfght ;mn from the pDStlrtor view The orfgiM and ln.seltfoM of the muscles are 11\dkated bymlor shading (red • origin, blue• insertion).
286
;a Afta'removal ofthetr.lpezlus.
b Aftfsremovil of the deltoid andforNrmmusdes.
s~
notor
UpperUmb - - 3. MIISallature: Topogrophkrll Amrtomy
IJ!Yato r
Rhcmbold
SGapl.fae
SUprasplnalus
Rhomboid minor
minor
Sup111SI)!Oib.ls
SUpra· splnatus
Infra. sp!nib.ls
lnfnl· splnelus
Tl!f'H
Teres
minor
minor
~t--Trl~
bnchll,
mtdlalhead ~~-Triceps
bradl1, latler.alhe.ad (tutedge) Emnwr«~rpi
radldslong..a
Emnsor ca-p! radialis b!'N's Common held ofectensors
---=.;i!:--~.
ConYncnhead - - -""">ll
Commonhead dflmlrs
-~-11
ConYncnhud - ----,off(_,.
d~
..
llloepsbracNI Analneus
---L'-..31~
• 8 MllldK ofthe rtght si!Oillrf~~r ;mrf rtght arm from the piiStllrior view
The origins and Insertions of the muscles are Indicated by color shading (red • origin, blue • insertion).
a Thesupr.rsplnatus,lnfrasplnatus,;rrldteres minor h;we been removed. The later;rl head of triceps bra chit has been partially removed. b All the muscles hillll! been removed.
287
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.3
The Anterior Muscles of the Shoulder Girdle and Shoulder joint
BadyafC7 verb!br.a
Stlemodeldo· mmnrd
Ddold
Manubrt..m
Pectmils major,
Pectmlls major, stlen\Ocostil PMt
Teresma}or Badyafrumum BICIPS bradll. long head
Blc:q:K bradll, short head
Pectmils major. ~bdomln~l !)Mt
Sem1:us
IJrtlssinLII doni lll!dus shea111
Br'IChlals
Medial eplcond)1e
A Musdesoftfll!rfghtth:dclerancl rfght•nnfromtfleantertor
ww
288
Dttemalobllque
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
Pec:toralls
minor
C.:.racddproc:E.IS
Subclavius
~Ddeld~
ma'llokl Pedllralts ma)or, dlllkular part
Subst.~C~tllrls
Manubrllm
ComI
arttage Teresnwjor
8laps brad!II, longhud 8laps brad!II. shorthud
Bodyafmmum Sen'.atiiS .ant!~!riot
ll'ec1Jonlls m1)or. mrnocmtal Plrt
I.
~Jl")«'$$
BodyafTI2 wrtlbr.l
B MUidK of tile rtght sholllder and rtght ann from tile antelior vk:w The origins ;md Insertions of the muscles ire lndlc3ted by color shid· lllg (red • orfgln, bl~~e •Insertion). The stemodeldornastdd, trapezius, pectorali$ m~jor, clefb:lid, ~nd external oblique muKies h~ been a~m·
pletely removed. The latissimus doni hils been partially removed.
289
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.4
The Anterior Muscles of the Shoulder joint and Arm De!mid
Subd;Mus
Subclavfla
Bla!ps InchII, long
head
Bk:eps blliCNl, ll!ndonof lruertlon
BICIPS bnu:tll~
tl!ndonof Insertion
b
A Musdl5oftherfghtlhcdlfer;md rfght;mnfromthe;mtertor view The orfgiM and ln.sel'tfoM of the muscles are 11\dkated bymlor shading (red • origin, blue• insertion).
290
M.es remCMI of tile titor.rdc skeleton. Latissimus dorsi and serratus antertor have been removed to their Insertions. b Latissimus dorsi and S4!1'1'atus anterior hiM! been completl!ly rem~.
;a
UpperUmb - - 3. MIISallature: Topogrophkrll Amrtomy
Pec:taralts
Supr..~pln.atus
SUI>-
___:~~t.'l.,
scapula~'
w• '---- Common h~d offlelCOI'$
SUplrlab:lr
b
8 MllldKofthertghtshoclllferilnlf rtghtil~mfromthe 01nterlor view
The origins and Insertions of the muscles are lrMIIcated by color shading (red • origin, blue • insertion).
01 M.f!S remw.~l of the thoracic skeletDn ;md the subsc<rpularts and supraspln
291
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.5
The Anterior Muscles of the Forearm
Tr!CI!p! brachl
BICI!p:S bracHl
Brac:hlaUs Medlal~plcandylt.
ammon head
cfllexor:s Bldpltill
ures
Flexor a111lntdalls l'llm.ts longus
FI-r G!llll.frlll'lr.
Flecordlgltorum
superftc:laUs
1/E;l-7""-- Flexor alllfull\lllls ..Jt-\'c'~-'---
l'lllmaris
longus
-*-H--*--'ll-""*"'~~..__-
FII!Ja' dlgltorum
superllclllls, tendons oflri!M!rtfon
U!'-~1-17-+i"'-----" FIMcrdlgltorum pn~fundlll, ll!nclons
•
oflnsl!fllon
Muldtsoftfl~rfghtfore.lnnfromtfl~llltl!rfor{ventral)'llfew
a
The origiru and iMel"tiom of the mu$Cie$ ~re indic:ated bya~lor shi'ding (red- origin. blue •Insertion).
b
A
Th~ iuPfi"lldal flexors and the radial~ group are ihown. Th~ radi
With flexor carpi r.ildlalls, flexor arpl uln.iii1S, abductor pol !leis longus. p.almaris longus, and bia!ps bradlii.
292
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
,....---- llradllillls l'nlna1Jlr tert.'l, h~meral head
Prorwtor~eta.
llledloll eplalndyle.
humenlhead
almmon
h Cild ol flexors
Medalep~.
common he.ldaffteltOI'S
t-- - Flw:ordlglton.m suP8'11cilllls. ulnar held
flemodlgltorum - -H • wpl!rildalls, radlalheild
t+ - - - Flw:ordlglton.m profundus
'JI~i--:::r-- Rtlt« cap!ulnarllo
_,;!-:;.--- Flexar c:arpluln.arl'
b
B Mllldes lllf tile rtght fllreenn from tfu~ 1ntertor (ventral} 'lltew The origins and insertions of the muKies are indic~ted by color shilding
a Pronator teres and ftelUlrdlgltorum superflclalls have been re~.
b All the muscles h;we bftn removed.
(red- orlgln. blue -Insertion).
293
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.6
The Posterior Muscles of the Forearm
£m!nsorGaiJll r.ad lab bn!llll Ananeus
axnmcn headoffte!Ors MCOn&S
Ext!tnsor urpl radlallsb~s
£mnsor dlglton~m
Flexer CIIJlluharts
£mnsor
GIJlll.fn.llfs
Flexor dlgttorun prcli.ndus
Supinator
Flexor urplulnarls
Abductor pol lids longus
£mftsorQIJll
r.adlabbmrts £xtmsor
dglttmlnlml Ext!ensar polllclsbl'e'o4's Ext!ensor lndlds Dorsal
llbt!nl~
Ext!enscrarpl
E:atels«
Intel'· tlendlnous connections
polllds longus
radlallsb~s
tJendon
Ext!ensor urpl radialis~
tlen
tendon
Emnsor d~run
le1dons,
donal dlgltll apanskln
A Mu•desofdlelfghtforurmfromdleposterlor(d-l)'dew The origins and Insertions of the muscles are lrldlc:3ted by color shi!dlng (red • orlgln, blue • Insertion).
294
Ext!tn111r digiti m'rllml
Elditnsor
dlgltorum
• The superfiCial exten50~ ~nd tfle r~dialis group ~reshown.
b Triceps brad! II. anconeus. flex.or c.;npl ulrlilrls. exten50r e<~rpl ulnarls. and extensor dlgrmrum have been removed.
UpperUmb - - 3. MIISallature: Topogrophkrll Amrtomy
common
heldofa!J!nsor.s
~us
IIdgl!DrUm
Anconeus
ne-
S...,natot
proNOOUI
dlgttorum profunckls
Flel!IOC' a111h.frlllfs
(.W1II ulnar!s
FleJaxo
Abductor polldslongus rmnsar polldslangus
Exttnl
rmnsar
Exttnsor
pol lids bre>is
polh:ls brevis
Exttnl
rmnsar rnctds
lndlcls
llltienmeaUI membrane
Extensor
polldslongus Exllensor ctgrtt
£mnsor
dJ911
mrnmr
mlnlml
• 8 MusdK of die lfght fore~~nn from die posterior (dorsal) view The origins and Insertions of the muscles ;rre Indicated by color shading (red • origin, blue •Insertion).
• Abductor pollicis longus. extensor tpollicis longus, and tne radi;alis
group have beal removed. b All the muscles have been removed.
Note tne interossecus membrane, which contrillc.Jtn to tne origin of
several muscles In tne forearm.
295
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.7
Cross Sections of the Arm and Forearm
~Ot
(dornO
t Lolt2f'allntler·
Medlalln12r-
muscular.sepCIJm
muscular Sl!p1Un ofdlearm
ofdlearm
Ulnarnenoe
Humerus
Bractl'lal artl!ry
llk:l!psl:nc:NI,
long head
- ...:.---ill
A Crosue
Posterior (donal)
Abductor
t
pollc'lslo"9US
Floor dlgtton.m profundus
Radius Exb!nlorarpi - -..-.!l..,l;;, rachllslongus
An1B'Ior lnllerosseous
nerve of the forum
Medlann~
a Crou se
296
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
Trkl!ps
Peclor.Jiis
major
br;u:tlll
Bleeps br.H:tln
Bradllalls
Medial eplco nd)1e. axnmonhead offlexcrs
Cora to-
brachlaUs
lllo!9s lndi~
Teres major
tendon of lnserllon
Bia!PS brachll, long heed
Bntdllol'lldlails
Bldpllal apone<Jrosts
Pnnr11o<
BlllllpS brachll, shcrthl!>ld
len!S
Flexor carpi radlab
Pllllllilris longta Humen.tS
~llus
Ulna
~-;---llellilt
Ull)lulnarts ~--- 11-dlgi!Drum
supt!fftdats
Flexor - ---,i-"';M polllcls long LIS
1\bWctor - --Tl poUiclslongLIS
~-.----- 11-retfnaa.lum
(tnnswne
U~palllgament)
C
"WWndowed·d~ndthertght•nn
-,._;,.__ _ Palmaris
Antalor (ventr;rl) view.
Jno;Js ~....:..-~:-\roT--- l>.llm;rr
aponeuro:sfs
D "WWrrdowed• d!Medlon dthe r1flrtforetnn Anterior (ventral) view.
297
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.8
The Tendon Sheaths of the Hand
!l__ \
)
'
poll Ids longt~~
Fntdcn.al lnt~
Adductor poll Ids.
A C.rp.~~l """ clg!UI tendon thHths on the p;~lmusurt.ua of the right hind
ll'llnM!nt' h9d
The palmar iponeurosts (seep. 302) has been 1'1!1Yloved. The tendons of flexor polllds lon· gus, flexor arpi radi~lis, and flexor digitorum superflclalls and profundus rur1 from the distal forearm tftrough a flbro-osseous canal (car· pallllnnel) to tile palm, accomp.anled by !he medlar! ncrw and protecred by !he palmar arp<~l tendon sheaths (see ilso p.248 and p. 354). Thecarp.al tendon sheorth of flexor pol· licis longus is aMlsistently continuous with !he digiti I tendon sheath of tile tllumb, whlle !he dlgltiltendon sheatfts of!he remaining flngers show varfable communrcatlon with tile arpal tl!ndon shealhs (see B).
~~~=---
F~f-!f~+~.P....--
l'nlnamr qllldnrb.ls
+-f-H- - - Flt1e0r pallets longus -!+!--- - Flexo•
al'j)lr11chi!J
B Olmmunfcatfon between thedlgltll and
aol'plll tendon sherils Right hand, interior view (ifter Schmidt and
umz). a rn 71.4% ofcases(Sclleldrup 1951}the dig·
rul tendon sheatll of !he little finger com· municatl!.s directly with the urpal tl!ndon sheath, while tile oCher tendon sheiths of Ute second tllrough focJrtfl digits extend only from tile meucarpophalangeal }oint to the distal interphalangeal joint. b In 17.4~of Cises Ute arp<~l tendon sheitll does not communicate Vlftll tile dlglul ten· donshutbofthelittle linger. c; Besides the tmdor1 sheath of tile little fln· ger. tile Cirpil tendon sheath may occasionally be continuous Wltft !he digital ten· don sheath ofthe index finger(3.5Z} or of tllerfng flnger(3Z}.
298
•
b
c
Mducb:or
pol lids, obltquth9d
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
c
Don11l tl!ndon compartments fortfle extitniOI' tend11n1
Rrstt!lllc!Dn ~mtnl:
Abductorpollldslangus Extl!nsor polllcls brevis
StcDnd_.n Extl!nsorarpl radialis ~ment: longus and brevis
'1111111 tendcln
Extmsor polllcls !angus
oomp;l1menl:
rourtM41K!Dn Extalsor dfgltMim ~ment: Extmsorlndlds nfthtl!ndan
Extmsor dfgltl mlnlml
oomp;l1menl: 5bdh tl!ndan
Extalsor arpl ulnuls
Dorsal
~ment:
dgltill l!!lljHOslOO
The location of the tendon shown in D.
comp;~rtments
Is
.....;:+ifh~h-...,,_+,'---
lnterll!ndlnous connections
D Extensor reUn;u:Uum artd dDrsal urp;~l tl!ftdDn shtlltfllofthe rtghthand '111e extensor retinaculum is part of the antebrachial (forearm) fa5c:ia. Its tr.lnsvene ftben strengthen Ule fibrous layer of the tl!lldon sheaths and fix it to the dorsum of the hand. Deep Ill the extensor retinaculum are mtdon sheath cwnportments wfllch tr.msmlt the long exten.sortlendonsslnglyor In groups. There ~ne a tDtal ofsixofthesecompartments, numben!d 1-6frvm the r<~dlal side to the ulnar skle of the wrist (their contents ane shown InC:}.
£mnsor tufcls
E Schemtlfc ClOSS sec\fon through tfle forMrm at the lll!wl oftfle distal raciCM~In•rJoint. vfewed from the pFGidrnalllf(Loc.rtlon of the sectional plane Is shown In D.) Vertical connectllle Ussue septa extl!nd anb!riorly from the deep surfa~ of the exten· sor retinaculum to the bone or joint capsule and fonn six flbro-osseous canals, the !lendon sheath comp;~rtment.s ofthe extensortendons (extensor tendon compartments}. Nok also the dorsal tuberde. wfllch nedlrects the !lendon of Insertion of extensor pollfcls longus to the thumb (see also D).
E:ateu«arpl roldlallsb~s
Radius
£mnsor
dl9fl mlriml
E:ateu« d~rum
299
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.9
The Dorsal Digital Expansion
Extl!nsor lndlcls
~
dlgltl mlnlml
A Orlgtnund._rUonsofthedon.lmusde.softhei'IQMNnd The origins and Insertions of the muscles are lndlc:3ted by color shi!dlng (red- origin, blue -lnseftlon).
I Extensor tendo.. lind lnitcrtcndlnouJ ~lonl on the dorsum of the right hind The tendons af Insertion af extensor dtgttorum are lntl!rllnlced by varf· able oblique band$ called interut!dino~~Salllnmions. The mo:st proximal of the lntenendlnous conrleCtlons are those extending bet.weal !he Index and middle fingers. Nosoch connection Is presem onU!etendon of extensor lndlcls. The extensor dlgltDrum Inserts by a variable num· bC!r of tendons. Gener.llly, all of the linger$ h;ave ;~t le;ut ~ extellsor tendon elements. In addltlon. !he li!dexflngtr and ltttfe fln!Jff have their own extensor muscles {extensor lndlds and extensor digiti mlnlml) who.se tendons always run on the ulnar side of the tendons of the com· mon extensor digitorum. Beause the index fingl!l' and little linger have thetr own extensors. !hey can more easily be moved Independently of theotherflngers.
300
Second dotAl
lhlrd
In-us
mtac.iiiPil Exb!nsor dlgllcNm
tendon
..
Flomr
Lumbrtal
Second
dlgltDrum lumbrtal
slip
profundls
ttndon Pnlldmol
Interphalangeal Joint
Deeplrl..........
VlncuiLm ion9Jm
mtt.larpol
ligament
Lumbrtal
sip
--J 7
$~
J
7:
lntll!rmuaus .........._
\IIIICIJia breW
c
Fl...,r dlgllorum prafmdus
MoUc:arpo- FlmiDr dlgltDrum pNiangHI JOtlt suporliclolls
lhlrd mtloarpol
----J.:'='
5eaDnd lumbrical
(ftlen~od to
..-tendon)
\;----- lhtrddotAI In""""""
--..:. !Mplrln.......,- . / -.
~~od
~
tobcn~}
r~A: ; Deqllrlnrwne mmarpol
metaarpol ~ 1 '. llg;wnent · ---- 1 / , ~ 5ealnd ILmbrbl ___./ - \
a
d
F1eJoor dlgltDrum suporfldahtondon
Fltl!OI' dgltYJr\m pniundustondon
llgamo:nt Anulor llgoment(Al)
C DoiSill c!Wbtl upans1on
The dorsal digital expansion Is more thin an iponeurosls that lnmrpo-
Oor$al digit~ I expansion of the middle finger of the right hand (ilfter Schmidt and Lanz).
l'iltes slips from the exten!IOI" digitorum,lumbrical, and interOSHGus tendons. It Is a complex systEm of lnterwown flber binds. joined by loose connective tissue to the periosteum ofthe phi~nges.. The dors;al dlglbl
Postertorvlew. b ltilldlaI view.
il
After opening the common tendon sheath of the flexor dlgltorum su perft~lls ind profundus muscles. d CroP section at the 1-1of the metKl!rp.al h~d. c;
expansion consists of a m~tnll slip and lateral bonds, ei!Ch ofwhich has a lateral part and a medial pmt. The llttnl pirt of the expansion receives slips from the tendons of the lumbrical end interosseous muscles (see il). This complell arrangement makes It possible for the long digiti Iflexors and the short hand muscles to act on all three of the finger joints.
301
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.10
The Intrinsic Muscles of the Hand:
Superficial Layer
Ctudfarm --"""';----~+-+-~
IQIITM!nls
-:--1--
Flrstthrou~llflflh
;u111lrligamems
SupcrflcW ---.:l..--i-~---:--= tr~
met.Jai'J)ill
.:;...-~~--F,~----,-.....;lll.=,.--
ligillll8lt
Del!l)tranmne met<~a~I'J)ill
ligament
- .....,..;!___,.__ Fhtdcnal lnt1!roui!W ~z..t:r-.,..........:;--
A.Mlclllrpolllds, tranMne helld
-#~~~,----MdJcblrpollid5.
P.arnarts --..:,.:.,..,.,""'-~II( b<M l'llll'llll' --..:..::;;....,,_...;;;~r-,..,......::..
abUqueheed Rel!M pallets breW, Juperllclalhead - - - - Abctlclllr
pollldsb~s
~---
;!pantUI'OIIs
-~i<----
Opponenspollcls
Flellorrellllilalum
{lnlnS1101r.1et.lll>llligament)
+-....,..,..-...,.----- l'lllnw!slongl.ll.
tendon of lnse<11on
+ 1------ Flellor
arpl radials
+--!-!- - - - - n - r pollcblangus
A The pilrnar ;~poneurosls ;md Dupuytnn's contr.Kture Right hand, an!l!rtor view. The muscular fascia of the palm Is thlckl!lled by finn confii!Cttlte tissue to form the po/mar opoMUIUifs, which $ep;l· ratn the palm from the suba~Uneous fat to protect the soft tilsun. It Is composed mainly of longitudinal fiber bundles (longftudfnal fosc#de:s). wlllch give Ita fan-shaped arrangemem. The longitudinal fa1dcles are held together bytrai\SYI!I'$e fiber bundles (lnlnswrse (ascldes) at the level of the met;rocarpal bonn and by the superfic~ltr.lnsverw meta car· pal ligament at the leYel of the metac3rpophalangeal joints. Two musdn, the palmar1s brevis and palmarts longus, keep the palmar .ilponeurosis tense and pnMnt it from e»ntracting, espec~lly when the hand Is dendted Into a fist. GradU.ill atrophy or contracture of the palmar
302
aponNrosls leads to progressive shortening of the palmar fascia that chiefly affects the llttfe finger and rfng flnger (Dupuytn!n's Cllllf1ocU/re). Over a penod of year$, the contracture may become so $evere that the fin!IC!I'$ auume a fixed flexeocl position with the fingertips touching the palm; this seriously compromises the grasping ability of the hand. The causes of Dupuytren's contr.1cture are poorly understood, but ltls a rei· alfllely common Clllldltlon that Is most prevalent In men_. 4n years of age and is associated with chronic l~diseil5e (e.g .. cinbosis}. Treat· ment generally consists of compl~ surgical removil of the palmar aponNrosls.
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
D~~~----~~--~+-~~~----
f
met.1o:
fl._""""""' 1
longus, tl!ndan Gf lnSI!I'tlan
') • 1
ligamMt
l!--- ---i";....L.,t-1_ _
Flrstdars;~l
tn11enmeus
Opponens
.~<7:!--:-----:----
Adductorpolh:ls, llllnMneheld
~l!z.~..,..,~---
Aclductarpoltd's. oblque head
- --'t---"1:--:T
Flexllr poll Ids b~s. superftdal head
dlgltlmlnlml
~r---~~~,~~' dlgltlmlnlml
•
- - - - Abcluc:tor poltds bmlls
- - - - - - Opponenspolllcls
+.~f----
flex« c.wp1 radialis
k+-1+-~~hh---------
Prollib)r
qul
+~+-----111!:1101' poll Ids len gus
8 Superfid;ll musdl5 of the rf;ht hand ilftar I'IITIO'Ir.JI of the
p;llm;n iiJICIIII!UrosiS Antel'forW!w. The palmar~poneuro.sls,~ntelmachlal (lilreann)f.ascta, and palm~ris brevis and long\.15 muscli!$ have been rem~d al~ng with the palmar ;md e<~rpal tendon sheiltt!s.
303
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.11
The Intrinsic Muscles of the Hand: Middle Layer
Remr pollcls longus. tendon of Insertion Rrstdorsal
Flexordlglton.m
·~
Adduclllr poll ids,
----.-l,.--.,..--¥:...-':!!f.a'~~~H~
tr.msvenehead
profunckls, b!ndonsof Insertion
Adduclllr pol lias, cbl~he<MI
R_. pollc'ls breW, ~uperfklal head ..,. . • .__ _ _ AbctJ(tJ)r pollk!sb~s
~~-- Opponenspollas ~~.........~-#---- Fle~~tt~rpallc'lsbrwls,
superficial head
~'------
Abductor pollclsbrms
...;__ _ _ _ Radus ~~----
Flexo• pdlidslongus
A Musdauftherfghthand Antelfor llfew. The flexor dlgltorum superffclalls mwde has been
rernOIII!d, and Its fourtendonscflnseltfon have been dMded .at!he leYel of the metae.tiJIOpl\;li;lnge;~l joinU. The fil'$1: til rough tilird anular fig;~· menU have been cut open to reveal the flexor tendons on lfle fingers.
304
The flexor retinaculum (transvene carp;rlllg;rment) has been partially removed to open tile carpal tunnel. Of tile thenar muscles, portions of abductor polllcls bl'e'llls and flexor pollicls brevis (superffclal he<~ d) have been rernOIII!d. Part of the abductor digiti minimi hill$ been ~se«ed on the hypothenar side.
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
flel!Ot poltcls tonp.
~on oftnsett~en
Add..ctor polllcls. tr.lnM!nehead Add..ctor poll Ids, cblhpehead
Flel!Ot pollcls breW. Juperflcllllhmd
Abductor - -......i,,\ dlgltlmlntmt
Abell eta' pollldsbre'O!s
~r
dlgltimkllml
~ ·~~'------
Sealndandthtrd _ _.....,~.~....-,
palmartn11erosse1
flel!OtpoltdsbreW. deephm
....,jll-- - - Opponenspollds .n--.-==::::!!~---
Flel!llrpoltdsblwls, superficial he.ad
• '------ Abductor poll(abnMs
lntl!ro.liseous
membrane
- -+----,-,::-:-
8 MllldK of the rtght h;md Anterior llfew. The flex.or dlgltllrum profundus muscle has been remOIII!d, and Its four tl!nclons of Insertion ~IMI the lumbrfc;als arfslng (,_,ttl em have been divided. The flexor pollicislongU$ and flexor digiti
mlnlml mU$Cies have ilso b~ removed.
305
Upper Umb - - J. Musarlaturr. Topogtvphlml Anatomy
3.12
The Intrinsic Muscles of the Hand: Deep Layer
wm~k-----+~~~~~~--~~~-r-+'
Rrst tluQigh fourlh
Adductor polt(k. tnlnswrse head
----......1:---.~;:..........,.--"~l+-lf-+~-----,ll',..
~lln!J!rossel
AbciJcmt
ctglttmtnmt
Adductor polltk.
---....,.1
obllqutheild
Fle!I!Orpolld'blwll; S\lperflcialhl!lld
Fll!xor --~... " dglttmlnml
Abdut!J:)t pol lids bnMs
Opponens - - - - -';ll d'glttmlnmt
rz..- - - Fle!I!Orpollr:Jsbrellls. deephud
Fntthrou~h third -------l~~lfr-.;L.;hl,4----l f);llmar~
~~-------
dlglttmntmt
Fle!I!Orpolld'blwll; S\Jperflcialhl!lld
qp~s------~--~~~~ ~------
qpponeupollkls
'/ ·~r-~----- Abductorpolltkbrellls
A Musde50ftherfghthand Antelforvlew. Thetl!ndons oflnsertfon. tendon sheaths, ;md anular llga· ments ofthe long digital flexors have been completely removed. Nok the elql~ed p~lnnar lig~ments. which combine with the tendon sheaths tD form a kind of trough thilt dlr«13 lfle long flexor tendons (seep. 251).
306
The first dorJallnterosseus and first palmar fnteroneus musdes have been almost completely exposed by removal of the adductor polllds. Both !he opponens pol lids and the opponens dJgiU mlnfml have been
partially removed.
UpperUmb - - 3. Musculature: Topogrophkrll Amrtomy
•
e.--Floor polrclilong~
Adductor pollcls ~.,...---
Floorpdllds bn!W~nd
a~ctor
polrclibre'JIS
. .- --fr-71-- - - Flrrtdarnl ln111!rosseus
_
___,{,;!-. .~-- Floor ClUpl radials
e~----
AbWctJJr poll leis blftls
(!)Arstpalrnar~
12> Seconddcn.ll~ ®TWrddors.ll~ ®Second~hwrl~
(!) Fourtlldanllln!ORS5eiiS ®Tlird~lrnarl-
8 Ortglnrr; ;md Insertions of the p;ilrnar muscl11111 of the right hind The ortglns and Insertions of the muscles ire Indicated by color shading (red • origin, blue •Insertion).
307
4.1
The Arteries I Cherwtew of the •rt>ertet of the sho111der mdThe arteries of the shoulder and inn vary conslderibly In their orf. gins and brinchlng pltlams (tile prfndpal v.ufints ire ~ewed In Olapter 5, Neurovascular 5ystl!ms: Topog raphla I Anammy). The branchn al\' lilted below in the order in which they arise frgm the parent vessels. llnndoft oflhoo.,bdnlm •rmry
• Vertebr•lartery • I ntzm<~l thoracic •rtery (lntzrn;~l mammary artery) • 111yroc»rvlaI trunk - lnflrlor thyroid o1rtery - .5uptnapulw olrt2ry
-
Tra-can~a~.-y
·~trunk
- Deep mWit olrt2ry
- SUpiW!le lntel'aiStllartery lnnciMI DlthealllrylriMy • Superfor thoradc artery
• Thoramoaomlolorll!ry - Acroml•l b,.ndl - OIVtcular b,.ndl - Deltoid br.nch - PedDr•l br.nch • 1.1121111 thorKk lrll!ry • Subsa pular •rtery - Thoramdarul art.ry
- Orcumlu:scipUiar ..-.., • Alnrlor
lnnciMI Dlthe bndiiii•!Wy • Profu~ brachll (d.-p brachial artery)
- Mediol mllota,.lort.ry - lbdlal mllatel'll artery • Superforulno~r mllo...,lart2ry (arterial network af the elbow) • lnrelfor ulnar collateral artery (arterial network ofthe elbow) llriln~
A Couna aftlte dlfhlrartMtm•nts ofthe ~1111r1•1Upplyfng the shoulder md ;nn ~n ar12ry: The light subdllllin ~rtery ~rfses from the lnchloaphalic trunk (n shuwn hell'), ~nd the left arises diredlym.n the ~or tic arch. The vessel runs over the tint rfb ba-en the salenus mt.e11or ~nd seal en us medius ~ntersa lene sp.~ce, salene lnten-~1) ~nd continues as the aillary artery (see below) on rsching the lateral barder of the rib. Un lllae the other artlerles plctu red here. the subc:IIVtan artery supplies blood not only to the upper limb (I. e.. the shoulder girdle and arm) butllso to:
at• ,...1'111 art.ry
• R.tlil recurrent 1rtery (a rll!rlill networlc of the elbow) • Pilm•rarpal branch (palmar carpal networll) • Suprid•l palmor b,. nch ($uperf'oe:ill palmar arch) • Dorul ~ lnndl (dorul carpal netwark) - o.n..l metaarpol~ - o.n..l dlglbl olrll!rla • Pl1ncilps pol leis artery • R.tlalbll'ldlcls 11111ry
• Deep pol m..rorch - P•lm<~rmftlaiJIIII arterl101 - Perforating brandies
• a portion of tile nec:X. • tile cerebral drculatlon. and • thun~orchestwall.
llnndles of the u. . . •rt.ry
Ald..ry art.y; The cuntinuation of the subd.violn, the ~xillary artery runs from the lateral border of the first rib to the lnfafor border of the t2res major musde. llr8d!W ..-ry: The brachial ~rtery ls tile contlnu.Jtlon of the ulllary art2ry. It ends at the elbow joint by dividing into the ~i•d ;~nd ulnar art2rles. -..IW ..-ry: The ndlill ilrtery runs dlsully on tile ndlill side of the fure~nn from the dhllslan of tile brachial artery, p.Jsslng t.et-en the bradhior~dialis and fll!l!GI' urpi radialis muscles on ib my to the wrist. It tErminates In the dHp p.~l mar arch. Ulnar .-ry: This second dMslon of the lnchlill artery runs below pn> nator teru on the ulnar side af the furea nn. under ~of flexor c.arpi ulnarls, to the superficial palmar arch.
• Supricial palma- arch
308
• Ulnar ~n-ent lrmry (;orterfal network of the elbow) • Common lnllenlsseounrt2ry - Posterior Interosseous artery - Aeclln-ent int:arQsseous artery - Antarlor lntarauaous 1 r12ry • l'ilmlr arpal br.nch (palmar e3rp11l networlc) • DorSi Icarpallnndl (dorsi! carpal~ • Deep pal IIIII' branch (detp palmar arch) - Cornman palm•rdlglbl•rterllll - Pruper pol m..r digital arteries
..
acnm':i ar11try
lll!IUtlral artey
aractl,l amry
~ul
ll\lnc
r~--
Common
aralld artily
DeiiDld brand! l'ltdlnl brlrd!
SubciiVIon artily ar.ctio-
apt.lie
ll\lnc
S~or
thoraclcar11try Anllortordrcumfla
Ptctllrals
hLITII!ralartlly
minor
Axillory artily Orcumfla
Profunda brachl .vUry
:~apuaro111try
'ThorliCodcnal artay ut:enl
thoracic artay
•
l.lnar rocumnt ar11ory
-or ....artorlrtor-..sartl!ry
ar11try Donal e<rpel ---4t'i~'}:-- Dan•l network corpal •111try
lniB'o......s
m..,brane
Dorsol --..J~~ml"\- e<rpelbnonch Perforating blll1chK
brlnd!, antalor lllbtl"llllli!OUI
-fF-!~U-<"11
Plinceps poll Ids arbl!ry
n~~~~l,4.- 0cna1 mebcarp.11
arUriel
.. E •rnAI1il=rfll bnlndtalntheright for&1111 (plrfondng IIJ'II1dtK) • From thotradlal artery and ulnar artery(foreann wpinated. ilnlzrior view). b From the poJI2rlor Interosseous artery (formnn pronated, posterfor view).
f;ucloc::utllneow fl1ps with an excellent ViiKU· lar pedicle an be harvKI2d from the thin skin
of the forearm. CDmposed of skin, subartlln~
C Arterleuf thl! right upper IIIIIIt Ante"ior vi~ with the forearm supin;~~. For d;~rlty, JOme of the arteries llst!!d In Bare not Illustrated.
D Alt2rles of the right hllnd
Posterior view.
ous tissue and fascia. these flaps ilre supplied by brindles of major arteries and their iiCCDm· panytng wins.. The sldn flaps carry this VISCUiilr 3Upplywith them when they are trans~d to
the re::lplent site.
309
UpperUmb - - 4. N«!rovaxvlar.s)ste.ms: Fonns and Rc!latlons
4.2
The Veins
Q!phalic win
ll.lllllc:wn
Median Cl!jlh;lkwln
Medan wbltiilwln
O!phakwln Baslttwfn
Blaeps lncNI
Meehl
-
intdl~lal
Qphalcwfn
Deep
median wbltiilwln
Median anttbr.H:tllal win
cuuneous
ll.lllllc:wn
.....,!--Medii eplc:ondyle ~~~"""'"'<=-'f~f-'J!'--- MechncubiUI~n
Utml ----=~rt-t<
~J~~~~~~-~--D~m~~ _ wblt.llwln
antSintehlll
culllleous ni!M!
Medanantl!- -----l!-!i--..-~~+.~:. br.Ktlialw\1
(pl!lfomorwln)
AI-\- - Meclan
~-1-+1~--q....-- Blt~l
wbltllvetl
aponeuro:!ls
Medan ba'llllc:wn
Accusory cephakwin M~lan
~+--+--
Med'an
ba'llllcwln
Cl!jlh;lkwln Q!phallc win b
Q!phalic wn
A Cutaneous ~~etns and CW~neous neMt of the right elbow Antertor 1/few. The subcut.meous veins of the elbow are t!XD!IIent sitl!!s for administl!r· lng Intravenous Injections and drawing blood owing to their size ;md ilccesslblllty ind the rei· atlllely thin skin lt11hat region. But grven their dose l'l!lationship to the cutaneous neM!S, as Illustrated by the pi'Gldmlty of the bislllc vein to the medial antebrachial cutaneous nerve. Injections ltlto these veins may cause severe b'ansient p.1in, as ir1 cases where an accidental "Pir.i'B1aJiar•lnjectlon lrrtt:ates the sumound· lng contii!Cttve tissue. •Rolling veins" refers to a condition In which the subcutatleOilS veins
are exceptionally mobile within the subcuta· neous fat. In approximately 3 ~ of cases the ulr~ar 01rtery nniY p.1ss <M!f the surfice of the fli!Xllr muscles (superficial ulnar artery, .see alsop. 347). An unintended lmra'(lmrlafln)ectlon can have devart.111ng amsequences with cert.illn medlcatfotiS. This complication can be avoided by palpating the vessel and confi~ lng irterial·type pulsations before giving the Injection and always drawing 01 Snnill amount of blood bade Into the syringe (dirk red • venoUJ blood, bright red • arteri;ll blood) before depressing the plunger.
B.lslllc:wn ~---J4--Medlln
arelnct!l;ll w\1
B.lsllic'IOeh
Med'an ba'llllcwln ll.lllllc:wn ~++--Median
arelnchtll wn
B Olbltiil fo5s.J of the rtghUnn: wrtlble CXMJrse of the tuba.rtaneouswfns
•
J.Hhapedvenouspattem~bovethemedian
antebr.IChlal vein. Pre~ence of an accessory cephalic vein from the venous plexuses on the extensor side of the fore.1rm. c Absence of the median cubital vein. b
All ofthe Illustrated variants are common.
310
F Ollerw'lewofthemalntuperfldaland deepvelnsofthe upper limb NumefOUS connections eldst b~ the deep and supertldal veins oftfle arm-the perforator veins. Valves .ue Incorporated Into !he veins at regular i~rvals, in~sing Ute effi· dencydvenousretum (see p.47).
SubdaWnwtn ------.;'~~ Aldllrywln _ _ _ __ , l!lor.lco- ------,A---1 ejllgasb1cw'b
l!lor.lco- - - --lf---1 do
Deepwhffltlleu.,..lmb • Subct.vlan win • Axillary vein • Bracht.l wins • Ulnar veins o Radial wins • Anterior lntefosseo.. wins • Post!erlor tnl!erosseousllelns • Deep palmar wnous arch • Palmar mebcaflNIII'tlns
MI!Gien - --1--+......
abltllwi'l
llledtan bastlcwfn
Superfklelwnffltlleu.,.,lmb o Cephalic win o AcCleSIOry uphallneln • llaslllc vein • Mecllan Cllblt
!J.J+.'z-1-- - lntl!i'tilpltlllar wiM
...,.._,_,___ _ hi!Nt dgltll wins
c
Deepwlnsoftflertghtupperlmb Anterior view.
1C~H""';--
Dorsalwnous networlc
~J¥.f----,b-f---H-- ~~~r
wlnJ
D SUperflcTIIIvelnsofthe rtghtupperhmb A~rior view. The m;~in longitudin;~l trunks of the subcutaneous venous network of the arm
are the median intellr.rchlal vein, the bislllc vein, and the ctphalic lll!in. Ml:dtan illltleb111Chllll 'Wdn: This vein, unlike !he cephalic and bislllc. receives blood m;~lnly from Ute artaneous veins on !he dorsum d the hand,drainingtheJkmrsidtoftllejinorm. The ll!ll'iallk median antebrachial vein opens Into !he corre.spoodlng longltudln<~l veins it the elbow, usuilly by Will'J of the median cephalic vein and medial\ basilic lll!in (seep. 333). lalltne~: This vein begins it the elbow, first ascending In !he f(llfasdal plane In the medial blctpltll groove to the bit!lllc hiatus, where It piel'tl!s the fascia in the middle of tne arm. It tennlnates In a Slibfasclal plane at !he uln<~r brachial vein. Cltpilaltt'IN!In: In the ann the cephalic vein ftrst aSa!ntb on tne lmral side of the bicep$ blachO, then entm a gi'OO'Ie between the deltXJid and pectoralis major mwdes (the deltopectoral gi'OO'Ie). It ftn<~lly opens Into !he axillary vein in the d;svipectoral triangle (seep. 334).
E Superfldill wins of tile dorsum of tile rtghthand
311
4.3
The Lymphatic Vessels and Lymph Nodes
Dorsomedlll onntonttaly
Ulnar bundl~ tlln'lt!)ry
bdbolgi'OUp of~la
.. A ..,._ph-lsoftheupperllmb(ilfterSchmidtandlanz) a Posterior vl~.lt 1 nt£rlor vi~. The lymph vessels (lymphEics) In the upi)O!I' limb are of two types: • Superficial (epihlsd1l) lymphMia • Deep lymphEics
While the deep lymphltics of the upper limb iiCt:Ompany the uteries .1nd deep vans, the superflclilllymphlltlcs lie In the subaJUneous tissue. In the forearm, they are most dosely ttlmd to the cephalic and basillc veins. Numerous lniiSIDmoses eldst between the deep ind superflcla Isystems. The arrows In the diagrams Indicate the main dlrectiDns Df lymphatic drainage. lnlli mmltions and inRctions Gl' the hand generally lndtu painful swttllngofthe lldllarylymph nodH. When the lymph wnels .1re also Involved, they ire visible as red stre.o~lcs benuth the skin (lymphanglds).
L¥mph_,..s asa!ndlngfnm tt. paiiTIII' to dcnll side
-
!Qdiol bundle
tleniiDry
312
1!1 !JmphdcdraiMglt of the thumb. lnda tina•. •nd dorsum of lh~t hand (after Sd'lmldtind Lanz) The thumb, Index flnger,and part of the middle finger are drained by 1 radial gr~~up vf lymph wnels thllt pillS directly til the axillary lymph nodes. The other fingers a~~t drained by in ulnir grDUp of lymphitlcs (nvt shawn here) ~tend it thlt cubitillymph nodes.
~ Umb - - 4. Neui'OWDICIIIGr S)'stems: Forms ami Relations
----------------------------------------------
----~----
Aldllary •r111ry unlni.Jiary lymph nodes
CeNctl~
nodes
Inti! mal Jugular vein
li!~~~~-:== SUbdMin lrb!ry OiMde
~=-==:-:-:::'~--:--- Apical ldlary
lymph node
r-----.~--
Ped:aratts rrlnor
~!!!!!:=--=--~;=--:;:=-;-:-- lntl!rpectorol
Dilllrylymph nodts --'"=~-- Pector'lllf
Cublto11~
nodes
IN) or
>-----~:'-':-'--:--- Pectorol
Dilllrylymph nod ..
C lleglo"'llymph nodes of the right upper nmb
Anterior view. The ~ph nodes of the ullli (axillary lymph nodal are Important mllectlng stations for the arm, shoulder girdle. and anterior chest wall. The lD to 6Diymph nodes afthe axilla are divided into several groups or levels, numbered 1-111 (see E), which are lnterCDilnected by lymph vessels. Taken togelfler, the lymphalk:s In this region fOrm an Gld11arylymphotlc pll!llus lying Mthln lfle fatty Ussue. Lymphatic draInage from the axilla is mlleded in the su bdavia n trunk (ncrt shown here). On the rlghtslde, the lymph Is conveyed by the rtghtjugulartrunk and right bronchomedlastlnal trunk to lfle rfght lymphatic duct. which opens Into the ju nctlon of the rtght subdillllin and Internal jugular wins (see
-#+-1"------ - I..MII - --=-- - I..MIII
p. 166).
D Th• iiiXII;~ry IJmph nod-. grouped bJ '-Is (~ Henn..Bruns,
DDrlg, and Kremer)
Lew!l 1:'-alllrygrou, Qall!r1l to pectonllis minor)
• Pectorolulllory lymph nodes • Subsc:apuLu axillary lymph nodes • ~lltr.JI .xlll1ry lymph nodes • l'lr.Jma mmary lymph nodes Lew!l II: ml. .le axillary group (at the IM r#pedDIW~
• lnterpedllr• l.mdllory l,mph nodes • C...tral alll•ry lymph r.ode:s
E Cl..rfiAtlan ofull.y lymph nodes f~Jievel The axillary lymph nodes have ITiijor dlnlcallmportance In llrHst ancer. Amalignant breast tumor will metutaslze (seed tumor cells) tD the axillary nodes as It grows. As a guide for surgica I rl!miWl'll, the axill;ry lymph nodes an be segregated Into groups ;m-.. nged In three levels. based on their relationship tD the pector;alls minor musde. • Levell: ;all the ~ph nodes lateral to pectoralis minor. • Level II: ~II the lymph nodes lit the level af pectorillls minor. • t..ewllll: an the lymph nodes medial tD pectoralis minor (see p. 260).
Lew!l Ill: uppor,lnfnclnlcullrgroup
(medlill10 pect:Dqlls minor) • Apical alllary lymph nodes
313
UpperUmb - - 4. N«!rovaxvlar.s)ste.ms: Fonns and Rc!latlons
4.4
The Brachial Plexus: Structure Donll root Pomr!or Aml!r!or (5pln~l) (c1Gn.11) ('ferrtrlll) SIIMgllon
root
root
Median neM!, lmral root
MNial------~~~~r
Mtdan n~. medal roct
cord
Aldllary ----::::::~ lleM! (G,C6) IIII.ISCUe>- - -. #. Wblne
{C5.C6) R.adlaln~
(CS.C8}
•
c
b
A Sdlematlt ~n ofthe ttn.Jc:ture of tiN: bl'lldllll plexu1 ll
Names and sequmce of the various elements of the bradllal plexus.
b Relationship of!he lateral, medlill, and posterior cords of the brachial plexus m !he axillary al'tl!ry. c SubdMsion of' the brachial plexus Cllf1h inmtbeir mail\ brandles.
8 Numberandloattonofthe rNinClllmponei!Uofthe bt~~dllllplexus
Components
Nu....,
a-t~on
5
Betwftn sc.alen.. anterior and scalenus medius (lnterscalene space)
z. The primary tnJnks: upper, middle, and IDwer
3
Lateral Ill the lnterscalene space and a.,_ the clavtde
J. The lhnte antelfor and lhree postelfor dMslons
6
Posterior to the dmde
4. The lmral, medial, and posbtrlor mrds
3
In the axilla, posb!rlor Ill pectoralis minor
1. Pluus roots (antl!rlor rami of thuptnal nerws hm cord segments C~T1)
314
C7verb!br.a Cl spinal ntM
n Yl!l1:eln n.....;::!!!!!:!!!!---'--- n
spll\alnen~e
Ccmmon an~tld ~rtery
Subd~an~rtery
llr.lchloaephalc trunk
NeMto lt!esubclavfus Arst~b
Medal - -'7'"=....:;.:..._-.J cord
Aldllary artltry
-----'~--s----1~
AxllllryneM
--~~--<
-+--r.~-~~---~~~--7----l~br~~l n~
Pcster!or --""""Z',...----'-~ draJmflex
'7"""'\'----:;;c- - --?-A:::- - - - - - Med~lbr.lc:Hal
humeral artltry
cutlneous nerve
MllKUio- ---i-:~'-:-. .'f
RlldlalneM --~-:-:-'--'. .-1J'/J Medlanne~~~e ----:'-7--;-;!~~
Uln1r nel'\'e
c
Cour&e oftfle brad!Ill plexul 1nd Itt. relition to the tflorullfter peNing tfl-.gh the li'ltl!f'5GIIene 5p;IOI!
Right skle, an1lertor lltew.
Thon~codor~~l
nenoe
Lmnl pecton~lnerve
D Spin II cord segments and MI'VM ofthe bi'IIChllll pleJU~~ a...w.J plaustNibiiMI auoc!Medsplnll
,__.,.,~pertcltfle
• Uppertnlni::CS + C6 • Middle tNnk C7
lnc:h!al plelall (short and long branches from the plmls CDn:ls) o Latini cord
anseg-
- MuSCIIIocutaneous nen~e
• '--tn1nkC8+11 B...w.lplausanls•dasodatedsp-.11
card s e t •
o
LateraiCDn:IC:S~
• Medial mrd Ol+ 11 • Posterforcord C~T1 Ne.- of die IIUpndevlcullr JMrt of die b...w.l plaus (direct branches from the anterfor rami or piii!Xl.IS trunks)
• Dorsal scapular nerw • Longthcndc:MM! • Suprasc:apularnerw • Nerw to thesubdavius
- Lateral pectoral ne~W - Median nerw Qallnl root) Medial cord - Median nerw (medial root) -Ulnar- Medial pedllraiMM! - Medial brac:hlal cutaneous nerw - Median antebrachial cutaneous nerw
o
l'olb!rior CDn:l - Rlldlalnen~e
- Axlllary nerw - Subsupularne~W - Thoracodonal nerw
315
UpperUmb - - 4. N«
The Brachial Plexus: Supraclavicular Part
4.5
A SupraclaW:ul1r part of the bncHIII plexus Tbe supr~daviwlar part of the br~chial plexus includes all nerves that arbt' directly from the plexus roots (anterior rami of the spinal nerves) or from ttle plexus trunks In ttle li!ta'al cervical triangle between the scalenus <~ntel'for and scalenus medius muscles. The different nerves of the supraclavicular plexus <1te predispo.sed to pir.alysis and/« mmp~ slon 111 wrying degrees based 011 their location and murse (see 11-0). Nerw
Segment
INierwllld mulde
Dors~l KliPUI~r ncNe
Cl-5
• l..eYatorKllpulae • Rhomboid ma.tor • Rhomboid minor
Suprascapular nerve
C4-6
• Supraspinaws
Rhomboid
major
• lnfrnplnatus Long thoracic nerve
CS-7
• Serratunn~or
NcrYe to the subdaYius
C$,6
• SubdiMus
B The dorulsapular IH!t'Vt' Isolated paralysis of the dorSill scapular r~erve Is extremely rare owing to the protected loC
Ve!Ullnt - --s:::=loll
promiMns (C7)
_ ...._ ....
.>:::......~~-
l«lg
tllar.adc n~
5LJH11·
s::r splnatus
_j~~o~
_!~~~~~:;::~~~
$p~~
Infra.
--lf'~.IIE'=.::.._....c;....~_.
splnii!Js
mulde
C 1be long thor;~ etc IIIIW ;~ml nerve to thl subdmus Its long, superficial murseontheserritus anb!rtor alongthelat:er<~l chest wall makes the long thoracic nerve susceptible to mechanl~l InJury. The prolonged wearing of" he..vy badcpick is a mmmon mecmnism forttllstypeofle:slotl.lnlalrogenk:cases, thene~"Vem;aybedam..ged b:Y an .axillary lymphadenectomy performed for~ menstatic breast tumor. Cinic!lly, IDSs of the serratus anteti« musde c.auses the medial scapu· larborderto bemme eleo.>at:edfromtheche:stwall. This "wwnging• of the scapula Is mortOlllsplcuouswhetl the arm Is raised forward, itld generallyttlunncannotbeelevated pist!lO".
316
D Thnupr.ncapular nii'VII
Injuries and thronlc mmpresslon ofthe suprasapular nen'l are unmm· mon conditions tbat lead to .atrophy of ttle supraspinatus and lnfraspf· natus musdes with we;~lme:ss of arm abduction (especi;dly during the Initial phase owing to the •starter• functlor1 of the supr01splnatus) and external rotation of the arm. Besides ar1 Isolated lrljury, the nerve may bea:lme CDmpressed in the fibro-osst!CKJ.S anal between the sc.apular notch and the superior transverse scapular ligament (which Is occasion· ally ossified to form a bony canal}. The resultlng symptoms 01re known mllectiVI!Iy as •scapular notch syndrome• (seep. 213).
E Bnrdllll pii!IWS compression syndrome baled on nal't'OW ..tllmkal pMJ~~gtS Tn the shoclld• n~gton In Its course from the lntei'Yeftl!bril f0101mlna tD the nerves of the upper limb, the brachial pll!liUS mllrt negatiate SCM!r.!l n<~!T'OW passages lfl whldl It may become compressed by surroundlf19 structures. There are ilso extrinsic factors, such iS anylng heavy loads, that nn<~y exert direct pressure on the br.~chial pll!liUS. Severil types of compression syndrome are distinguished: 1.
2.
SaleM syndrome or Olnllal rib syndrome: neu-ular comp...slon In the lntll!rsalene spaot caused by a cervical rib or llgamento.. stNctu,_ (see F) c-lavlaJiarsyndn~me:
namMing of the spaot between the tlrst rlb and clavlde (see G) 3. Hyperabduclion syndrome: mmp..sslon of the brachial pi~DU~ by the pedDr.alls minor mUKie and anmld PIOCII!SS when the upper arm Is raiSed allow the head (see H) 4. Chronk heny load on the shoulder glnlle (e.g.• "bac:lcp«k par•lysls")
a
Costal caralage
Arrt ~b
b
F Sulene syndrome cb! tD nanvwfng of the lntil!t'tallene space by a CII!I"'ITcal rtb In ~PFrvxirn.iltely 1 t; of the popul
ribs mil)' N!T'OW the lnterse<~lme space bounded by the inll!rior irld middle salene m111des and the flrst rtb. In this ccrldltlon the trunks of ttle brachial plexus ttlat pass thrvugh the lnterse<~lene spi!Ce along 'With tile subdotVIan artery are compressed from behind ind below, placing varying degrees of tensian on
Arst~b
the neurovascular bundle. If tilere Is no borry cootact between a short ceN!Cil rtb ind tile first rib (b), that si~ is afb!n occupied by a
ligamentous structure which can ~lso cause neurovascular compression. The nn<~ln dlnl· eil minlfestatlons 01re pain ridlatlng down tile anm, chiefly tD ttle ulnar side of ttle hand, and drCIJiatory Impairment caused by mechanle<~l Irritation ofthe periarterial sympatiletlc plexus of the subclaVIan 01rtery.
t.'lcldle sulene
Aldlt;uy aury Axllaryw'n
PectonltsmiM<
G c.tDdm!Uill'synd.- duetD cm~pn!S!Ion of the neui'CI'II'al>aJiar bundle between the first rtb end dnkle Nartowifl!l of ttle ccstadavia.Jiar space is a rare condition that is mast common In penons 'With drooplf19 shoulden. a flat back. retracted shoulders (from Cinylfl!l he;wy loads), a deformed first rib, or a prevf· o.a claY!aJiar fracture. Arry m~ng of tile costoclaY!CIJiar space an be all!lr;!ll;!ted by l~ng and retracting the shoulder girdle. The com· plaints ire similar to those lr1 se<~lene syndrvme ind may be accompanied by signs of 1H!nOClS stasis e<~used by Impaired return through !he subdilllfafl Yeln.
H Hypenbclldfon syndrome due to a~mprenlon of the neui'O'IIIIIIGIIIIr bundle below the pec:tllnllls mrnor end coracoid process This rire syndrvme Is e<~used by neurovaSOJiar compression beneath tile tendor1 of the pectorills minor under the ccr.~cold process. It Is predpl· tated by nn<~xlmum abduction or elevation of the anm on the
317
UpperUmb - - 4. N«!rovaxvlar.s)ste.ms: Fonns and Rc!latlons
4.6
Infraclavicular Part of the Brachial Plexus: Overview and Short Branches
A lnfr.ldnhUill' p;1rt of the lmacfllal plll!lllll The lnfi'aclilllfculilll' part of the brachial plexus inclucle:s ~II the nerves that leave tne plexus at thelewloflfleplelcuscords-Ute shottbmtdles-
and tnose that continue clown the ;~rm ntumlnal branches of the IndiVIdual plexus c:ords-Ute
long!Kvnd!es.Tbne nervua~ revi~ belclw. beginning wlth the short brandies.
s.gm.nt
~IIIIIICI.
• Sullscapul., n -
CS.C6
• Sullscap"alf• • Temmajer
• lhoracodorsal netW
C6-CI
•IJdlsslmusdcnl
• Medial and lalleral pectoral nenes
CS-Tl
• Pecmrahs maJor • Pecmn1hs minor
• Medial bradllal tull!Aeous nerw
T1
• Medial bradllal tull!Aeous nerw
• Mediillentli!bnldliill culllneous nerw • l~bradllal
CS.Tl
• MediillenwbnKhiill culllneous nerw
Tl,T2
• ..-1 tutaneous brandlet
Nerw
0113-II&IINncfiM
Plrt1:Shert llrancfles
-·
Plrtll: . . . ""'""" • Musmocuwneous nerw (seep.J20)
Medial brachl~l wtiMOUS
nerve and
lntMostl>
brad\lillla'Ye
CS-C7
• Coracdlrachlalls • Bla!K bracNI • Brachlalls
• Lateral antli!bradllal culllneous nerw
• AxlllalyneNe (Mep.320)
CS.C6
• Ddtdd • Temmlnor
• Superlerlmral bradllal cuta.-.s nerw
•Raclelnerw (seep.J22)
C5-T1
• Brachlells (cawlbudon)
•lnferlorlatl!ral bradllal cutaneous nerw • Posterior bnldliill culllneous nerw • Posterior anwbnKhl
·nt~bro11Chn
• AnCGneus
• Supinator • Brachloradlalls • Extensor carplredlalls longus • EXtensor carpi redl;llls breW • Extensor dlgltlanm • Extensor digiti mlnlml • EXtensor carpi ulnarls • Extensor polllds longus • EXtensor polllds brewls • EXtensor lndlds • Abductor polllds longus •Medlannerw (seep.JM)
C6-T1
• P..,natortli!m • P..,..,atorqu.chlus • P~marts longus • Flaor c.pl ntdlllls • Flaor polllels longus • Flaor dlgltoNm profundus~ • Flaor dlgltoNm superfidalls • Abductor polllds bn!olls • Opponens polllcls • Flaor polllcls breW (wpeflclal hetdl • Flnt and seconcllumbrtcals
• Palmar brand! ar mectannerw • Common and p..,,.. palmer dlglbl nerws
• Ulnarnerw (Mep.32A)
C8.11
• Flaor c.pl ulnarts • Flaor dlgltoNm profundus~ • P~m~~rtsbrellls • Flaor digiti mlnlml • Abductor digiti mlnlml • Opponens dlgltl mlnlml • Adductor pollds • Flaor po(llcls breW (deep he.cl) • P~mar and dorsallnlenlsleous muscles • Third M'ld fourth lumblfcals
• Palmar brand! ar ulnernerw • OorYI branch ar ulnarnerw • OoRildglllll nerws • Common and proper palm., digital nerws
• These are the cutaneous branches tdthe 'illercostll netWS Zand 3. which accompany the medial bnKhlalcutil.-.sn-.
318
Medial 1ntli!brlchllll Clllllneous
Common and proper palmard~nef\ti
(UII'/ilrneNt}
B Sen IDlY dlltrt'but'lan of tfle mediiI br~~chTel altllneous nerw and medial
all'llebncH1I cutanCQU5 nerve ol tfle light;~nn
a Antenorlllew. b posterforllfew.
......--Arstrb
.,;;~~a. ~~-
--';;,=--
OIVIcle
1
'1!~~~~~~~::._- Medial pectoral
T12splnous - pnxa~
o n.e medlaliind tml'ill pedorilt neiW'.I Right side, antertorlltew. lbatac:o- lumb.wfasda
-'--
0 vet1ebr.ll body
Saaum - -
C The thor;u:odol'AI nll!l'ft Right side,. posterior view. ~::3ir-,..;::.J,:.---CutedgHof
Se
llor.!ll111mw lnbftllslll nenoes
E Orfgtn 01nd art.JMOUs dlstr111ut1on of tfle lnterc:ostobl'illchhl Mf'VK of the rfght erm J\ntafor view.
sealndnb
J--=...t...- - Subsupullrts
F n.esuiKCilpularnerw Right .side, antl!!riorview. The ribs hall!! '-n p.artially remCM!d.
319
UpperUmb - - 4. N«!rovaxvlar.s)ste.ms: Fonns and Rc!latlons
4.7
Infraclavicular Part of the Brachial Plexus: The Musculocutaneous Nerve and Axillary Nerve An1B'Iar
Aldl arynln'e f1-:
scalen~
=·· lllled~l
b111dial
Radlllnerw - -
t\ltilli!<)US
,_
A Sensory dlltrllutlon oftfle latenl llntd:ncHII a.ttlneocls nerve Anterior view.
-
~ 51¥adoM'cular
D T1u~ musculocutlneous- (C5-C 1) MDIIII'Inndla lncNII Medll l 1 clltlnHus
• Muscular bnu-.ches - Clncabntdllalls
I'll!Me
- 8lcepslnchll - Br;~
Medal i~chl;ll
cut.lneous lli!M!
I S111sory dlltrllutlon of the late rill llntl!bl'lcHIII a.ttlneous nerve
PDstl!riorvii!W.
320
• La!Rr•l•n~chlal cutaneous nerw • Articular bntn
C COuFM of the musa.tloa.ttln- nerve ;~fter ll!flfng the latl!t'.JI cord ofthe brad!Ill plexus Right UPJH!I' limb, anterior 1/iew. The mu'culocut3neous nerve leaves the li!te!"al cord of !he br~chlal plexus as a mlxl!d nerve {one Mth motor and sensory branches) at the level of
the li!te!"al border of the pe<:toralls minor (not shown here) ;md runs a short CDCJrse before
plerdng !he coracobrachialis. It then runs bctwftn the bia!P$ bradlii ;and brachiali' mm· des to tile elbow, wflere Its terminal sensory branch supplies the sklr1 on the r~dlal side of the forearm.
Medial br.achlal Clltll'lO!lOia
llf'fiffH~--
n~
MuKUJo. C111.1neous
nenoe
Plu'tllit "~
,.Y.Bi~-- Antmor
Super!orl;~te111l
sa!me
b111Chlal cvuneous neM(tmnml -rybr.mch of
0 ~
-~~~- Clallldt
S!..;;;:::::~~~-:-- Flrrt rib
E SeniiOI}' dlltrllutlon of the Mlperfor
latl!r.ll br;uHill a.tliln~s nll!l"ft Anterior view.
Ci CourHoftheullllrynervufterlemng
the posterlor Clllrd of the brachllll plexu$ Right upper limb, anterior '~~few. The axillary nerve le-.s the postertor all'd of the brachial p~ as a mixl!d nerve and n.tns badeward thro~~gh the deep part of the axilla, passIng directly below the shoulderjolnt.lt courses thro~~gh the quadrangular space of the aXIlla (with the posterior cin:umflu humeral artl!ry)
and along the surglc:al neck to the portelfor 11ide of the proxim~l humerus. Its termin;~lsen sory branch supplies the skin over the deltoid muscle. Isolated CDdi!Gry tleiYt palsy may occur fallowing an anteroinferior shoulder disk). cation (or a traumatic re
H Thnxfll;~rynerve(C5;mdC6)
,..,.......
• Muscular b111nches -Deltoid
F SeniiOI}' dldrllutlon of the Mlperfor
- Tenes minor
lltcnll bra cHill a.tliln~s nll!l"ft Posterior view. • Superior late111l brachial cutaneous nenoe
321
Upper Umb - - 4. NeurovtJscular Systems: Fonns and Relations
4.8
Infraclavicular Part of the Brachial Plexus: The Radial Nerve
A The l'illdial nerve (C 5-T1) Motor branches
• Muscular br.mmes (from the r.Kiiol nerve) - Brachialis (contribution) - Triceps brachii -Anconeus - Brachloradialls - Extensor carpi radialis longus - Extensor carpi radialis bn!Yis • Deep branch (terminal branch: posterior Interosseous nerve) -Supinator - Extensor digltnrum - Extensor digiti minimi - Extensor carpi ulnaris - Extensor pollicis longus - Extensor pollicis b~s - Extensor indicis - Abductor pollicis longus
• Articul¥ branches (from the radial nerve) - Capsule of the skoulder joint • Articular branches (from the posterior int~ous nerve) - joint capsule of the wrist and the four radial metacarpophalangeal joints
• • • •
Posterior brachial cutaneous nerve Inferior lmral brachial cutan!O!Js nerve Posterior antebrachial cutaneous nerve Superfldal branches - Dorsal digital nerves - Ulnar communicating branch
B Tl'illumatic lesions and compression syndromes involving the radial nerve The radial nerve may be damaged anywhere in its course as a result of injury or chronic compression. The clinical features depend critically on the site of the lrsion. As a general rule, the more proximal the site of the lesion, the greater the number of extensor muscles that are affected. The characteristic feature of a proximal ("high") radial nerve lesion is wrist drop (see C), in whim the patient in unable to extend the wrist or the metacarpophalangeal joints. lesions at some sites may additionally cause sensory disturbances (pain, paresthesia, numbness), particularly in the exclusive sensory territory of the superficial branch on the radial side of the dorsum (first interosseous space between the thumb and index finger).
• Chronic pressure In the axilla (e.g., due to prolonged crutch use). Olnk•l r..tuns: typical dropped wrist with loss of the triceps brachii (and sensory disturbances). • Traumatic lesion due to a numeral shaft fracture at the level of the radial groove (spi-al canal). Clnk•l re-turn: usually a typical dropped wrist without irriiDivPmmtof!M triaps brochii, since the muscular branches that supply the triceps brachii leave the radial nerve just before it enters the radial groove (sensory disturbances are present, however). • Chronic compression of the radial nerve against the bony floor of the radial groove (e.g., during sleep or due to Improper positioning of the patient during general anesthesia, exuberant callus formation after a fracture, or a tendon expansion from the lateral head of triceps brachll). "Park bench palsy" Is a common form caused by draping the arm over the back of a park bench. Olnkal futuns: dropped wrist withoutilwolmnent of the biceps brochii. Sensory disturbances are present. The prognosis is usually favorable, and the palsy should resolve in a few days. Mldlevel r•dllll-leslon
• Chronic compression of the radial nerve in its passage through the lateral intermuscular septum and in the radial tunnel (e.g., by bridging vessels and connedive-ti55ue septa). Olnk•l re-turn: dropped wrist with sensory disturbances. Dorsal digital ne""'s
and anastomoses with median
and ulnar nerves
C Wrtst drop due to proximal and mldlevell'illdlal nerve lesions When the radial ner~~e is damaged, the patient can no longer actively extend the hand at the wrist, and wrist drop (drop hand) is said to be present. Besides the dropped position ofthe wrist, clinical examination ri!VI!als areas of sensory loss on the radial surface of the dorsum and on the extensor surface of the thumb, index finger, and the radial half of the middle finger extending to the proximal interphalangeal joint The sensory defidts are often confined to the area of the hand that receives sensory Innervation exclusively from the radial nerve (the Interosseous space between the thumb and Index finger).
322
• Compression of the deep branc:h of the radial nerve at its entry into the supinatorcanal by a sharp-edged tendon of the superfocial part of the supinator muscle: supinator syndrome or distal r.odial nerve compression syndrome. Clnk•l fHtures: no typical wrist drop and no sensory disturbances Involving the hand (before entering the supinator canal, the deep branch gives off the purely sensory superficial branch and muscular branches for the supinator, brachloradlalls, and extensor carpi radialis longus and brevis). There are palsies lnvoMng the extensor polllcls bn!Yis and longus, abductor polllds longus, extensor dlgltorum, extensor lndlcls, and extensor carpi ulnarls. • Trauma to the deep radial nerve branch caused by a fracture or dislocation of the radius. Clnk•l re-turn: no wristdrop and no sensory disturbances.
I'Gitl!tlorcordcl ---~;-~~*"~~'I'A.. br.Jchlal plexJ~s
MllKUio-
cutlneour. nerw
S...,erftd'al branch of
r.u!lalneM
D sensoryd~tlonofdleraclllllner~~e
Anterior Ylew. ~!"----
lltectHI\s
VAW..- - - - DHpbr.ond!afrad"al
nu"~~elnsuplnatlctc::~n.ol
F Cowse of tile radial ner~~e ilftlt' IN'Wing tM postmen cord oftbe brachTII pleJIUI Right uppeo- limb, anterior view with the fD~ ltldlalls-----q.~ii,-,19]
musdegroup
Abductor _ pel lids len gus ~O!Or
dlglton.m
E sensoryd~tlonofdleracllllner~~e Pom!rior view.
_,""""'~
- ---7'-H!-;
~nn pronated. The radial nerve Is the direct Ollrtlnuiltlon of the posbi!rlor cord of the brachial plexus. It winds around the bade of tile humerus in the r;,dial groove, ac:tQmp;~nied by the profunda br.Khll .-artery. Aftrs plm:lng the latefallnbi!rmu5Cl.llarseptum (not shown here) approximately 10cm pn:»cimal totheradiall!l)i· c:gndyfe of the hurna\.1$, the radial nerve runs dlstilly between the br.-achloradlalls and br.-achlalls muscles (tlldJol tunnel, seep. 344)to tile elbow, where it divides into a deep brandt and a superficial branch. The deep branch passes betweal the supertldal and deep parts of tile supinator muscle (suplnatorconaQ and contln· ues to the wrist as the posterior (antebrach· IaI} lntmmeous nerve. The superficial br~ndt accompanies tile radial artery down !he fDreann along the brachforadlal~. passes to tile extensor side between the radius and br.~chio r.-adlalls In the lower thlnd af the fDreann, and tennfnabi!s as a mall\ sensory branch on tile radial donum of the hal'ld al'ld the donal margins of the radial 2V.. digits (the thumb, il'ldex flngt'f, and radial half ofthe middle finger).
323
Upper Umb - - 4. NeurovtJscular Systems: Fonns and Relations
4.9
Infraclavicular Part of the Brachial Plexus: The Ulnar Nerve
A The ulnar nerve (C8+T1) Motor branches
• Muscul.1r branches (directly from the ulnar Yl) - Fl~xorcarpl ulnarls - Flexordlgitorum profundus (ulnar Yl) • Muscular branch (from the superficial ulnar nerve branch) - Palmaris brevis • Muscular branches (from the deep ulnar nerve branch) - Abductor digiti mlnlml - Flexor digiti mlnlml - Opponens digiti mlnlml - Third and fourth J...,bricals - P;limar and dorsal inteross~us muscles - Adductor pollicis - Flexor pollicis brevis (deep head)
B Tnumatic lesions and compression syndromes involving the ulnar nerve Ulnar nerve palsy is the most common periphmll nerw paralysis. The characteristic feature of an ulnar nerve lesion is a "claw hand" defor· mity (see C), in which Joss ofthe interosseous muscles causes the fingers to be hyperextended at the metacarpophalangeal joints and slightly fleXI!d at the proximal and distal interphalangeal joints. The deformity is least pronounced in the index and middle fingers because the first and second lumbrical muscles, which are innervated by the median nerve, can partially compensate for the clawing of those fingers. The thumb is markedly hyperextended due to the loss of adductor pollicis and the dominance of extensor pollicis longus and abductor pollicis. The interossei muscles become atrophic in 2-3 months: this is most conspicuous in the first interosseous space and is accompanied by hypothenar atrophy. Sensory disturbances affect the ulnar portion ofthe hand, the ulnar half of the ring finger, and the entire little finger.
SllniOI'J branches • ArtlaJI• branches - Capsule of the elbow joint and of the carpal and metacarpo·
phalangeal joints • Do.... l branch of tile ulnar nerve (terminal branciles: dorsal digital
nerves) • Palmar branch of the ulnar nerve • Proper palmar digital nerve (from the superficial branch) • Common palmar digital nerve (from the superficial branch: terminal branch~ proper palmar digital nerves) Clawing of theflngers
Mldlevel ul1111rn- lesion
r----"----,
Autonomous
area of ulnar nerve
Arst Inter-
'T-'19-- Area of sensory
osseous spac:!
• Traumatic lesions, usualy occun1ng at the elbow joint due to the exposed position of tile nerve In tile uln•gi'OO\IIe (e.g., pressure from resting on the arm), displacement of the nerve from Its groove, or articular injuries due to fractures. • Chronic pressune on the nerve in the ulnar groove due to degenera· tive or inflammatory changes in the ~bow joint. or chronic traction on the nerve c.aused by repetitive flexion and extension at the elxJw joint (sulcus ulnaris syndrome). • Possible compression between the tendons of origin of flexor carpi ulnarts (cubital tunn~ syndrom~)Oinical features: claw hand and sensory disturbances.
• Traumatic lesions at the wrist (e.g., lacerations). • Chronic compression of tile nerve in the ulnar tunnel, a fibro-osseous canal between the palmar carpal ligament, pisiform bone, and flexor retinaculum (ulnar tunn~ syndrome, see p.357). Oinical features: claw hand and sensory disturbances that spare the hypothenar 11!9lon (palmar branch Is Intact). Obtai uln.- JWWIIIIIon
lnne!'Wition from
Atrophic
---'t----L-~<::+~1
the ulnar nerve
interossei
• Compression of the deep branch of the ulnar nerve in the palm due to chronic pressure (e.g., from an air hammer or other tools). Olnk•l fHtures: claw hand with no sensory disturbances (superfocial branch is intact).
C a- hand due to an ulnar nerve lesion Besides the typical clawlike appearance of the hand, atrophy of the interossei leads to hollowing of the interosseous spaces in the metacar· pus. Sensory abnormalities are frequently confined to the little finger (exclusive sensory territory of the ulnar nerve). Strong adduction of the thumb in the he;~lthyhand
The thumb Is flexed at the
interphalange;~l joint, signifying
an ulnar nerve lesion D Posldve •Froment slgn•Jn the left hand A positive Froment sign indicates palsy of the adductor pollicis muscle. When the patient is told to hold a piece of paper firmly between the thumb and Index finger, he or she must use the flexor polllds longus, which Is Innervated by the median ni!IW, rather than the paralyzed adductor polllcls, which Is Innervated by the ulnar nerve. Flexing the thumb at the Interphalangeal joint signifies a positive test.
324
Common and
proper palmar
dlglt.ll nei'\'H (ulnarntn~e)
E Sensory dlnrlbuUor\ ofthe uln•r nerve Antaforvlew.
0ors.11 -
d~neNH
"'-fii'H I
(ulnarnenoe)
F Sensory dlnrlbuUon of tfle ulnar nerve Porteri~r view.
G Couneoftfleuln•rnervefromthe brachial pieRight upper limb, .-antel'for view. The ulnar nerve IU~~eS lfle .-aXIlla a.s the contfnuauon of the medial co~ of lfle brichial plexus, initi~lly descending In the medial bldpltal gi'OO'IIe. Halfwlly down the .-amn It crosses tD the exten· sor side, plerdng the medial lnt!!rmuscular septum (seep. 338).1t reiches lfle elbow joint belweallfle septum and the medl.-al head of the t11~ and aosses over lfle joint on Ule medial side below the medial epiamdyle, anbedded In lfle bony ulnar groove. The nerve then p;asses to the fleXIlr side of lfle fore.-amn belweal the two heads of flexor c:arpl ulnarls ;and runs beneath that musde to the wrist. In the hind. the ulnar nerve runs on the flexor rellniiClllum r.-adlal tD lfle pisiform bone, p;asslng lflrough the ulr~art:unnel (seep. 357) to Ule palm~r $Urfice, where it divides into a super· flclal branch .-and a deep motor branch.
325
UpperUmb - - 4. N«!rovaxvlar.s)ste.ms: Fonns and Rc!latlons
4.10
Infraclavicular Part of the Brachial Plexus: The Median Nerve
A Themedlln MJ'Ve(C6-T1) Mallllr lw•ndla
• Muscular branches (directly from the median nerw) - P.onalllr ll!fel - Fluor carpi radialis - Palmaris longus - Fluor dlgrtorum superlldalls • Muscular branches (from the anllel1or antebrachlallnte,_ nerw) - P!Vnalllr quadratus - Fluor polllds longus - Fluor dlgrtorum profundus (radial ~) • Thenar muS
• Articular branches - Capsules of the elbow jOint and wrist Joints • Palmar branch of median nerw (thenar eminence) • Commun1catlng branch Ill ulnar nerw • Commonpalmardlgblnerws • Proper palmar digital nerws (lingers)
\'J:.--.;!J.;i!;:-1-T--j-- ~nsory
lnr>ervatlan frcmtne median nenoe
C "Hartd of benii!ICicUon" following a pi'Gidrnal median MIW lesion Wilen patients try m make a fist, they can flex only the ulnar fingers. This Is the "hand of benediction• defonnlty. There may be associated s:msory disturbances. particularly In the autonomous area of the nerve (tips of lfle r.ildlal3~ digitS).
Ina healthy hand, !he tlu.mb an be abduclltdtoflllly grasp a cylndrlcal object
326
v.l'th a pnlldmal median
nenoe ltsion,lheltlumb an not be fully abcllcttd
B TNumatTc: letlans llld mmpratlon syndi'OII'IeS TIMIMng the median nerve Median nerYe leJions In the anm caused by an aa.Jte Injury or chronic pressure are among the most common peripheral nerve lesions. The dlnlcal manlli!stltlons depend on the stfl! of the lesion. The 1:\W main Gltegories are proximal and distal nerve lesions, ;as ill~~rtr;ted bythep~ noeor tm!s syndrome and the azrpal f1111nf!l syndrome. The hallm;nt of a proximal median nerYe lesion Is lfle "hand o{bertedlctJon: which occurs when the patient tries to denchlfle hand into a fist (lass of the long digi· talflexonu.ceptforthe partofflexordlgltlll'um profundus supplied by lfle ulnar nerYe). This cootrasts v.1th distal median neM lesions. which present select1\lelyVI!Ifl thenar <~trophy .ilnd sensory dls!IJrbances, .iiS In carpal tunnel $yndrome.
• Trauma de Injury caused by a fractur. or dlsloutlon of the elbaw joint. • Ooronrc pressure InJury from •n •nomalous supramndylar p.ooess mnnected to the medial epicondyle by a llgammt ("Struthel's llgammt.•- p.l4S). pressure from a tight bldpltal.ilponeurosrs. or a pron«MII!n!J ~in which the nerw is squeezed between lhe- heeds of p!Vnalllrll!fel. a~ralfelbns: Typlcal"hand of benediction• when fist closure Is attempted. with lne~~mpleW pronatl0n,IO$S of thumb opposition, Impaired grasping ability. atrophY of the thenar muscles. and sensory diStUrbances 6dlng the radial part rl the palm and radial 3~ digits (also aublnomlc lnlphlc disturbances such as decreased swut seaetlon and Increased cutaneous blood ftow). The patient also hn a posltl~ ·~Sign" In whiCh the flng~ and thumb ca~ not fully dose around a
• The supertldalloatlon ofltle nerwln lhe distal forearm malaK It wlnerable to cuts and lacerations (e.g., I" atl!empted suiCide). • Ooronk compression of the median nerw In die carpal tunnel (most e~~mmon e~~mpnesslon syndrome affecting the median nerw: carpal tunnel synd~Vme). Com,..alon or entrapment rJ the nerw within lhe carpal tunnel can !\alia various causes such as fl3ctures and dislocations of the carpal bones,lnflammal!ory changes In the tendon shHths. muscle variants (e.g.,lumbrlcals passing through the carpal tunnel). .ilnd connectlw tissue prollfl!r41tlon due l!o endoatne honnonal changes (diabetes meltltus. rngnancy. mer.opause). d~lalfelbns: O.th hand Is nat pres81l Initial signs CDIISlst of sensory disturbances (pareslheslas and •astheslas), chiefly llffectlng the tips of the Index lind middle fingers and thumb due l!o Increased carpal tunnel pressure resulting from prolonged flexion or emnslon of the wlfst during sleep (•brachialgia paraestheaa noctuma"). Chronic or -re clllmage leeds Ill moblr deficits iiWOiv· lng ltle ltlenar musdes (lhenar
D PoUttve "bottle slgn"ln the rfght hind Wilen pi'Oldmal and distal median nerve lesions are present, the lflumb and flngen cannot completely enclrde .a cyllndrleo~l vessel with the a!fl!cted hand due to we.akness orloss of the abductor pollids briMs.
"'"··-f ) - =lr
Mtdlalconlaf --~-----~~H~~~{ bradllal ple:ws
\.
Mllllryarb!ry ------1
l.atltr.oii'OOtaf
tile mtdl:ln nerw
lt.ldlalne<WJ
Ill eel laii'OOt af tile medlln neMe
!~':~J
"- v branch1 / f Rad'al
neMe
{
Palmu --+-!l
UnarneM
IIf
median netW
·
·
Cammon lW!d
proper pamar
clgltllnerYtS
(median neMe)
E sensoryd~tlonofdlemedllln 111rw. Anterior view.
Pronatarbfts, h urner.~ll>ead
/ ..J'+-- - Flto.lrarpl ~,-.
ntdlllls
- -F-!,..;/jl' \\
Linarhmd
P.Jimarls longus
~....--Fiellllt
Medial bradllal
_l_
neNt
Medial anubrachlal
-
cutlneous
F sensory dlltJtbutTon of tile medlm nerve Pom!r'ior view.
~~~;--~~~~
dlglbarum supe'fldalls
lnte~
G CourM of die medlilln !llrw
Right upper limb, anterior vlew. Distil to tile union of Its brachial plexus roots, the medlar! nerve runs in the medial bicipital gi'OOVI! abtwe
the brachial artery to the elbow allCI pallSes ul'ldef' the bldplul .-aponeunosls and betwHn the two he.-ach (humenl .;md ulnar} of prona· tor teres to the forearm. Aft2r giving off the antErior .-antebr.lld11i111 Interosseous nerve distil to pronator tenes, the median nerve runs betwHn the flexor dlgltorum superflclalls and profundus to the wrist and p;~Mes beneeth the flexor retinaculum (trafiSversecarpalllgament) In the carpal tunnel to the palm of the hand, where It diVIdes Into Its terminal branches (a motor b~nch for the thenar muscles and sen· sory branches for the sklr1 on the palmar side of lhe r.-adlal3!h digits).
327
UpperUmb - - S. NeulVIIUsarlar Systems: Topo9raphk:al Arurtomy
5.1
Surface Anatomy and Superficial Nerves and Vessels: Anterior View Aa'omlcn--
Deltoid -
---ci:Mde
---=-Olstallntw!rpllaLlng lSI! joint O'll!R
---~lis ITII)or
l'lw;i!NIIntw!rpilalingiSII joint
Metu:.rpophaLlngiSII jclntcnme l'lw;i!NI tr11nM!nt'm!'llle
Basile win --4---~lan
wbltllwn
Exbmor-a!lllradlds
Distal----
lorQur. Middle -
-':-- - - -
CI'UIIt
A Surfilao:anltomyofthe rtghtupperlmb Anterior view. The palp.able bony landmarle of the upper limb are
reviewed on p. 209.
And!ortngftlx11sof 1t1e - m basale
Sl:ln~
B Hmd lines and flexlort auses on tfle rtght palm wttflthe wrTit In sllghtflexlort (alter Schmidt and L.anz) The piWdmal wmt
S>Nmgland openngs C Schernatfc stn1cture ofthe rfdgl!d slcb ortthep1lm oftlleh1nd The smoolh, thln skin of the fore<~rm gives Wii'J to !he thlckef, ridged skln on the p.alm of the hand. The p.aplllary ridges are particularly high on the p.almar skin of the fingers and, at 0.1-0.4mm. are distinctly Ylslble. The ridge p.attem (de1111atoglyplls) focJnd on the bulbs of the flngersls unique for e
328
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
--'12
--n
'*",....---- lntl!r·
costobrachlal n~
~!!-'-----
Medial brachial CJI:llneour. nerw Basile N'atm C'1
ce /fit-- - - ksllcwln 1:1-""'b- - - Medial <11'11:2brac:Hal altll'leiOur.nerw
E
setmental, radlarlllr ClU1ane>OU$Innei'VIIUon pattem {denn•·
tames) lr1 the right uppllt' limb Antenor VIew. Wltll the outgrowth of the upper limb durfng devel· opment. the sensory cutan~us segments become elongated in varying degrees to form narrow bands. In the p.-s. segments C5-C7 become separated from the bodywall.
~
/f-
SupraclaWIJillr
nerw-s
lnt«cortll nerws.
; r - <1111:2f1crcutlneous branches lnt«cortll nerws. ial:2ral CUuntOUI brandies .H ! ' - - Medlalbr.achlal altlneour.n~
<~ndl
brachlal nerve
lfr--U~Wn~. PIJI~rbr~~nch
l i,-JI-"'-2...,'!--
Medlannerw,
pelrnarbn~nch
Rad'al nerw, superficial branch
Medlin._ - --JI.:...
l)il(marbr.Jnc:h
Qmmon lind proper -"-;'-;;f,:i)
Com man and proper
palmard~neNe.S
palnwdglt:alnerYe:S (uharneM)
(medllln nenoe)
D Superfid•l Qltaneous veins (subQIUineous veins) •nd cutane>OU$ IMII'VIIS of the rfght upper limb
Anterforvlew. Thearrangementofcutaneousvelnsabouttheelbowcafl v.ary conslder.ably (seep. 31 0). This dlsS4!Ctfon does not show the arta· n~us arteries that perfor~ the ~ntl!brachi~l faKi~ (particularly thol:e arising from the radial artery, see alsop. 309).
F PaUem of pelfphe,_l MniOIY c~us lnnerwnton In the rfght
upper limb Anterior view. The ten1torle.s supplied by the perlpheril cutaneous neM!S(artaneD~abranches)com!spondtotheareasofcutan~usnerve
branchinginthesub~neousconnectillt'tiss~~ethatanedemonstrable
~dissection. The area served elduslvely by a single nerve and thus rendered completely anesthetic by <1 lesion rs much smaller, because the individual sensoryb!rfotories tMJ!ap exten.silll!!ly. Hole: The sensory loss following damage to a plll'ipMrol nMit'shows a complewly different pat· temtothatofadamagednerwroot.
329
UpperUmb - - S. NeulVIIUsarlar Systems: Topo9raphk:al Arurtomy
5.2
Surface Anatomy and Superficial Nerves and Vessels: Posterior View v.
ll'apezlus
Acromion - - - Dolltold
}·-
.:.-- Lateral hmd
Teres major
llledlalhi'Sid
bntd!l
-;--_ Long hmd
1llaps llp«
Olecnnon
--Anltomlc.al
snuflbaot T~ndansof --+~
lnse
A Surt.la!;milltomyofthe lightuppt!l'ltmb Posterior vieW. The palpabl~ bony landmarks of tit~ upper limb .ane reviewed on p. 209.
8 Exte1111Dn Cre;&!14!S on till! dOf'lum ofthl! rfght hartd (aftef Schmidt
;andLilnz) In contrast to the palm, the dorsal iurf.aces of the hand .and fingers be.ar lrldlstinct extension crNses lflat d~en with maximum dorslfleldon of the hand. The most proximal cre.-.se overlies the s~d process of the ulna. whll~tlte mDit distill crease approximately oven res the distill mar· gin of the extensor retinaculum. Unlike the hairless ridged skin of the palm. lfle dorsum of lfle hand Is CDYered by smoolfl. thin. halr-be;ar1ng sldn.
Dimlllnt811hlllln·
gmljolnt(DIP)
Distil phllarutof secondflnger
C l.oc.1\lon of the MCP. PIP, .and DIPjcint sp;ICII5 Right h.and dosed Into .a flst, r;adlalllfew.
330
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
'1\';.,,.,;:....._....,..;._ _
~cr
latnbndllal t.'Jt(jlll----:"""'-:l bnchlll
cutliMG.tSI'M!flle
-
cutllr-.s
E setmental,l'liiCIICIIII!r CUU~neo~~t lnnervaiton pattem {denna· tom•) In the right upp•llmb Posterior lltew. Wltll the ~rowth of tile limb during dewloprnent;.
nerw
the sensory artaneous segments become elor~gil1ll!d In varying degrees w form narrow bands. A:s tills octutl, segments C5...C7 become sepa· rated from the body wall.
lntercilplbJIIIr ---~<J,Hi'fl"ffV1 wins
Dorsal ctgltll - ---bf-L-b' wins
-
Dcr.NIIdlglbll
D Superfichl aat;m_.s veins (subCIIun_.s Vllllns) ;~nal llltln-. IM!fVK of tfle rfght upper limb PosU!rlor view. The eplfasd~l veins of the dorsum of the hand (dorsal
venoll$ network) dispi;Jy a highly variable branching pattern. Generally the eplfa5Cialvelns ~redearlyvlslble beneath the Sldfl, recdllfng trfbut<ar· les that Include perfor.atlflg veins from Ule palmar side of the h~rld. The a!phalic win on the radial side of tile hand pi'DYide!. for most: of the dorSilveno~~Sdr.alnage.wflllethebaslllcvelnprovldesforalmerdegreeon
the ulnar side. This dissection does not show the rnalr1 branches oftfle postertor Interosseous ~rtery that perforate tile anU!brachlal fa5Cia on tile back of the forearm(~ alsop. 309).
--4~ 1
(&.frwrwrve)
F PertphenltensoryaateMOUIInnti'VIUOCI pllttl!m In the right uppll:f'llmb Posterior view. The color-axled areas tllit are supplied by the peripheral cut.;meous nerves (cut.;meous br.anclles) cortespofld to the areilS of artaneous nerve branching In the subcutarii!Oia connective tissue th.at are demonstri!ble by di~on. The areas ofexduslve non·~Weriapping lnnew.atlon of a speclflc nerve Is much smaller. ~th.atthesensorylossfoiiOW!ngdarnagetoa~/1e/111!shows
a Olll'lpleb!ly dilli!rent pattern from that caused by damage to a nt!I'M! root (sed).
331
UpperUmb - - S. NeulVIIUsarlar Systems: Topo9raphk:al Arurtomy
The Shoulder Region: Anterior View
5.3
...;1,~---7--::--- Tr~ni!M!clnedc
.N~~~~---- Externalfugulu'f!ln ~~~~~~-------~n~ w.~~~~~----s~~d~~~
5uprx1Mc:&lar --~~.t....r,:;_;~,.:;....,,....:::.:;;.....l(d
,.-__.-...L
nen'H
lnfrad;Mcularfowl U~~llalk:'f!ln'"'
A
---+or----:r-....,.-;'-1'
Superfld;~l vefns 01nd IM!fVK ofthe rfght shoolder 01nd neck
reg1an
Anteriorview. The skin, plifty$ma, musclef.lsciae, and superfici~IIOJ)'el"of the cervlc
St2moclellb- -----"'--~ IN~~
332
Rldtt ~chiDaph1licwn
ming back d venous blood and may be visible even when the patiC!Ilt Is sitting upright, The apbafk win crosses the shoulder In the groove between tfte pectoralis major and deltoid muscles (delt:opectonalgi'D<M) and empties Into tfte subdillllan vern. This site of entry Into tfte subda· 11ianvdn, and tftuslnto tile deep veins, Is visible and palpable on the skin 015 the lnfradilllfcularfo:ssa.
B lllll!latfonshlp of mil]orS\Ipert'ldilli!nd •ep veins In the ned: to
Exlern1l -------'
Mlulirwin
Subclllllan~~~eb
patient Is lying supine and tfte veins are well filled. When rlgltt-slded htatt (rllfu~ Is preS4!11t, these veins may be engorged due to the dam·
Supet!Or
veoa«M~
the ttemodeTdornatllkl mulde Anterior view. The internal jugular vein runs ~!most straight d~rd from tile jugular foramen and unlres wltll the subclavian vein just lat· eraIto the stemoclilllfcularjoint to form the brachlocepllallc vein. When Its course Is proJected ontD tfte sided the neclc,lt follows a line drawn from the earlobe to the med'o;~l end of the davide. The in~al jugular vein Is crossed obliquely In Its lawer third by tile ~modeldomastold muscle, while the memo/jugular vern runs obliquely downward on the musc:le and opens into the subdavian vein.
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Supmapular utsy
lnt2maiJugularwln Cammana~artay
Scalene musde.s
Phrmlc nerve lnfe!lcr~ld
Tlllnwenearvlcallll'll!l'y
Ext2maiJugulolr\'eln lhy~Cilltrunk
MuKUiocutlnecuan~
Subc!Minwin
- --....,_.1111!!
O;mde
Sullci;N'W
Pector~lls mlnar
Chunllex
Thor.! co-
Subscapular
r..rtl!l'al
Med'al and latl!!'al
sapularlll'll!l'y
dcnoll~
~
thoradcartl!ry
pec:taralnerves
C Course oftfle rtghtsubd;M;~n ;~rtlry In tfle lneral neck region
Antenor VIew. The $Urnodeldomastofd and omohyoid musdes and all li!Yl!rs of the a!111it.<~l fasciiiC! h;ave been removed to demonmte the d~ lareral cervical triangle and !he passage of the subclavian artery and brachial plexus thnaugh the lnte!v.ll between the 01ntelfor;md mid· die scalene muscles (interstollene spaa!). At the lel/1!1 of tbe first rib the subclavian artery becomes the axlllary artery, which artm the aldlla below the tendon of Insertion of pec!Drills minor.
Sc:.alenus postl!riar
Common c.wtrd artery
Supn!melnt21' comlartay
lrtlmll tharack~
D Ortglnind bl'ilnchesofdte rtghtsubdManilllteJY
Antenor VIew.
Br~nches oftfle tubdaWin arttty. nDnnal •naton'PI and vartlnts (after Lippert and Pabst)
E
333
UpperUmb - - S. NeulVIIUsarlfu Systems: Topo9raphk:al Arurtomy
5.4
The Axilla: Anterior Wall
---...::...-------:---MteriorWIIryfold (peaorafloJ rn~jor}
, - - - - - - - - : - - - - Ellttmlllcblique, 3uperfldll abdomilll linda
A TheMIIunclhl•d•eofther1ght.-!lllt Anterlorvlew. With the arm abducted, the axilla (
tnen~l-11: This isn;urowand formed by the intertuberculargrvovt'of the humerus. MeGill Will~ This Is formed by the laterill thoradc wall (Jfbs 1-4 and assoc:iated intei'CI:IStal muscles) .1nd the serratus anb!rior.
An'lll!rtor Willi: The anterior w.rll of the ;ucill;l a~nsists of the pector;rlis major and minor and the clil\llpectoral fasda (the pectoralis minoris not shown here: see C ind D). Pll:lltl!rforwal~ This consists of the subscapul;lris, b!res major(not shown here, seep. 266), and l;ltmlmus dorsi.
Deltoid
Ornclt
_ _ _...:,..,r -:::...:: - - - - Ptctoralls
n--~....,...,.~:--'-;=...-;;
majOr, d;Madarp.;rt
liCI'Omlllartety
Ceph.!Uc
I The ci;MJNct:oral triangll iind dmJN!O' tllr.llhsd;a
Right shoulder, anterior llfew. Tbe dallfcular Pilrt of pectoralis m~jor h;ts been remCMd. In the davlpectoral triangle bounded by the del· told, pectorilllsmajor, .1nd davlde,. thecephillc vel'n runs upward In the deltllpect:Mill groc:we,. pierces the diVipectoral faKia, ~nd dr;rins into the subclavian vdn at the level of the lnfracl..vla.tlarfossa.
-~H~~
~In tn 6elto-
~~-
liP
major
Bla!P$
_......,w.~;._,_
·? -- .;;;:;;,_-
l'l!doralls
major,
br.Jchll BrachlllliBda -
-
Medlalind
lara! pectoral
Pec~a:~lls ~~m
-:-....:....
~mLll ---'-----~~
dorsi
334
Cllllllpeaoral
~~::~~~~--~~~---fMda
peaoral
sb!moC115!11 part
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Superior lflontdt arury
~andposll!rlat ---"'"'%'~,.,...==::::!!:!::'""""';;;
acumftexhumetal a ~----=::::=;--- llledlahnd lmral
BICI!pS brac:HI _ _-=..__:':-...z
pectoral-
Radlaln~ -----~-~~~~~·,......,
fl'eclllr.JHs minor
Subscapular nerve
UhlrneM
Clmunfltox sapullltarury
Tho nKli:IC!orHI lll'll!l'y
Tho raa:.dorsill n~
Extemal
1.<111mnus
abllqu~
dor:sl
C Theaxllla afterrem!MIIofthe pecborall$milforanddnfpe<-
taral fasd;~ Right shoulder, interior view. The nlllary ir1:efy runs approxlrrliltl!ly 2 em below the mracoid proa!SS and behioo the ped:Dralis minor. It
relms l~terally to the l;ater;l cord of the brachial plexus and medi;ally to the medial cord (both are retr;u:ted slightly upward In tile drawing). The posterior mrd of the bradllal plexus, which runs behind the axillary artery, is just visible.
Poectrlralls --OON!de Superftclal-thondcfllldll
-
lllil{or
I
Subc:lai/W
l'ec:taralls minor
Medal-----~~
pec:t01111 !'!eM!
~~-------~
musdeand lang thond'CI'M!f'l.oe
Stbsapularismusde - - - - llr!dstbsapulllrnerve
D loc.IUon ofthe superf'ldll•nd deep tfiDrack f.lldle
Siglttil section tflrough the anterior wall of the right axilla. Thedillllpec:t:oral fa1da,lcnown also as the "deep" thorlldcfa1da, enclosel the ped:Drali$ minor and subclavius musdes ~nd covers the subclil\llan vein while being fused to Its wall. The fa1da Is made tense by the pectoralis minor. Thedillllpectoral fascia exerts !rile· tion on the vein wall that can kftp iU lumen patent. thus fadlltatlng venous return tD the superior vena cava.
E Schemilttc tl\1-rse section through the light ;udll;~
Supel'lor llfew. The tilree muscular walls and the bony l;ater;l wall of ttle <~xilla ire cle<~Jfy dellneited In this view. Neurovascular strut·
tures (axlllary artery and vein plus the medial, I;Jtefal, and posterior axds of the brachial plexus)tr.avenettte axlll;a,lnvestl!d by llflbrous sheith ind embedded in the ixillary fat.
335
Upper Umb - - S. Nevl'OWJsarlfu Systems: Topo9raphk:alAMtomy
5.5
The Axilla: Posterior Wall Dl!lhlid
Coracoid process
Pemr.lils
minor suprasp~nms Medlal~nd latl!ral
ca~dbi';IChialplelu
SUPili'CIPCJIIr nerYe In SCipular notch
Subsc:apularne.w (superfld;llald lnfulorp~rts)
Aldlliry nerYe
Subscapularis ~I!Wll
allt8!or
Teresma)lr lltotorbrandlts
dradLJinen.oe
A Posterior wall of thnxlll;nwtth the postlriorCIII'd arid Its branches
Right shouldef', antl!riDt view. The medial and lateral cords of the bra· chlal plexus and the illdllaryvenels hive been re!TKIVed to demomtraw ttle course of the postllrlor cord and Its branches In the posterior axilla.
Vertebral ~~!fry
Ctomman c.wttd artuy
--.,)..~f'J!;I;:___ SubciMrn a ~!fry
Po:sUrtor Circumflex himtr.llilrtl!ry
Brac:HOQ!Ph aile trunk
Om~mllex
lntl!m1l thoradc a~!fry
sapular arury Subsc.!pular ill1l!ry Arm!rtordrwmflex himtnll.-tl!ty
Axlhryarttry
- ---.-IN
LorUalmw dcnl ---:--=ll~
UlnarnetW
lltedlalcand dbl'
I Relationship of the medlal,lmr.ll, ;md po:stl!ttorCOI'ds of the llr.ldllal plexus to the adlary artery Nok th~t ttle muKUiocutaneous nerve Pif$.St'$ ttlrough !he coracobrachialis, which aids In loc:.ttlllQ the nerve. Very r;arely, ttl Is nerve may be compressed as It pierces1he muscle.
336
lllo~o~l;~rtuy
-__,.--lf...._..l'"l
U!J!ralthorlrdc 1r11ry ---:-1'1-1H ._---l Br.rmlalart>!fy -
Profundl bntdll.-tl!ty
-:--+J
--1
Trtczps br.rmll, langhNd
C Orfglnarld br~~nchesoftheaxllllory art.ary
Right shoulder, ;mterforvlew.
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Pectoralis m'tlot
MUS1:111ocu!aneous
CliMcle Subdlr.llan ar1!1!ry Subc:lavfus
Subdlr.llan wil Thar.IICDICimllal ar1!1!ry
Ptc!Jr.lllsma)cr ----~~..l;::Z=>-11 (altedge)
~cord
of lr.lcNal plexia
Bla!p.Sbrac:Nl _ _.::..____c\,-...,-Brad!lal
Superior thoradc
----"i"""~
Long tlior.Jdc
nerw
Medial anll!brachlal altaMOUS nerYe
Subsupularts muse!~ ands.bsapularnerYe
Later.a! tllor.tctc ar1!1!ry Subsupular
Tholl!Cildarnl ar1!1!ry Thoracodonal
nerw
D
Axll~wfthtfleenttre;mtertorwaln!miM!d
Right shoulder, anterior lllew.
The axlllary vefn has been r4!1Tloved and the medial and la1zral cords of the bradlial plexus have been retrad:l!d upw.rtd to show more de<~rly the IO«t!ofl ~nd course of the posterior cord ;md Its terminal br;mches. the radial nerve and axillary nerve.
Not!! the supertldal course of the long thora de nerve on the serratus anterklr.
Jlnt211or circumflex Superior humeralartery thcraclc:ar1!1!1'y
1.11terlll thoracic ar1!1!ry Subsapular
a
E
artsy
B~nchls of the alllary artary.:
Subsapular
Tbaraooaaomlal
b
artsy
c
nonnal anatomy ;md nri;mts
(after Uppert arid Pabst)
a Normally (40X of cases) the axillary al'tl!ry gl- off the folklwl'ng branches: Superlor thoracic artery. lfloracoacromlal al'tl!ry, lateral lfloradc artery, subscipular artery, anterior circumflex humeral artery, and posterior drcumflex humeral artery.
artsy
c Common orfgln oflfle latzrallfloradc al'tl!ry and suprascapular artery (1 OX of cases). d The posterior drcumftex humeral al'tl!ry arfses from the subscapular artery(20%ofcases). e Common orlglr1 of the anterior arid ~rtor drcumflex humeral arteries (20X of cases). The common segment fonned by both al'tl!r· les ~ l!!rmed the common circumflex humeral al'tl!ry.
b-e Vlrtlllb: b The thor;roa~acromi;al artl!ry ari$e$ from the lateral thoracic artery (1 OX of cam).
337
Upper Umb - - S. Nevl'OWJsarlar Systems: Topo9raphk:alAMtomy
5.6
The Anterior Brachial Region
I'Ktlnlls
minor
SubdiMan
artery and win Medial btach· lal art.lneous
Sttewllerethe
nl!n't'
ulnarnenoe
plerctsthe septum
Medial~~
Bla:ps
btachtalcuta·
br~~ehll
neo:~oani!I'VI!'
Ale! It;ry ar!l!ry
Sub-
SCilpuln
C«.aco-
bt.achlab Medanl'lln'e
Un;rnerw
l'osb!rfar btxhtalcw. neot~~ni!I'Ve
Teres
ma}or
lrhr!or ulnar
A MilIn neui'CWoiSQII;utrut of tiN! llrm: till' medlal blclpltlll QI'OCIW The rtght arm has been abducted .md slightly rotated externally and Is viewed from the anteriarview. The delt:Did, pedllr.llis major, and ped:J). r~lls mln11r muscles haw been removed. The medial bldplt~l grvove Is a subo.ttaneous longitudinal groave an the medial side of !he arm that Is boc.inded deeply bY the bleeps brachll <1nd brachlalts muscles and tile medial intennuSClllar seprum of !he ann. It marks the I!Katian of the main neurovascular tract of the <~mn emndlng from the aid! Ia to the cubital ross... The most sCIPfl1klol structure of tile tract Is tile medlol
ontRrodllol altoiii!OUS tlfM!, whkh leaves tile medial bldpltll groove at
the basllk hiatus 11'1 comp.myw!lh tile bastlfc vein (seep. 329). The most medk11 structure is the ulnar nl!nlr, which initially murses an the medial ll'ltef'muSClllar septum. 11'1 the lower third of the amn, the ulr~ar nerw pierces the lntemnusculaueptum <~nd p<~ssesto the bade of the septum. entering tile ulr~ar grvove Ol'lthe medial eplconc¥e of!he humerus. The dnp port of the medk11 bicipitlll grotwttlr.lnsmits the principal artery of the ~mn. the btudJTol ormy, whkh extends from the axllla to the elbow accompanied bY tile median ni!M!.
B CnK1154!cUon tfii'OUQh tiN! middle third of die light Nore for orlenut!ol'l th
•rm
Coraccbract!lalls
Medial antebt.achlal cutl!neous nen.oe Medlaltntermuscular~m
v:;~t.;;..~-- Ulltilrne~W
- - . _ Medlllbnlct!llll cutl!neousnerw Radalcallltl!ral arteryandw\1
Rldllllni!I'VI!' / lnfeflor ~I ~ct!lal <Wneoui nen't'
338
SuperiorulnarOlllm!ni utl!ry1rMiwln
Medialhud } Langhead L.Jteolllhead
=
damedtaltotbeblceps)lsdlstalto(below)lhe level of this .section. Th~a the basilic vein and medial antebrachial cutaneous nerve are subfascial. The uln<~r nerve and ulnar collateral artery have left the medial bldpttal groc:we and have pierad the medial inn!rmuscular septum, and thus lie posterior to It, 11'1 tills section. Proodmal to {iboile) tills level, the profunda brachll artery has split Into tts two termlr~al branches, the radi;d col later; I and middle col· lateral arteries. wfllc:h are seen here posterior to tile humerus.
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Deltdd branch Aaamlal br.anch
Tbor.l~
acromlal
\---- - - Pt
Prcfunclabr.achll----1--~rJ
artery
C CouM of tile bnuchlllartl!ry In tlleann RadlaltOIIilte-411 - - --f .wry MlddlttOIIilte-.11 - - --1-.nty
Radial~
----......l.'-"'f.lf
ClJ rnnt a rte1y
R.ildtal~rte~y
- - - -----,Y
~hll!l'
..!:...!.!-- - - - - CDmmanlnll!l"
oaeouslr'te
Antle
OIHOIIUrlery
- - -+-#
i-_..:,____ Unarartay
Right arm. anterior view. The brachial artery arises from lfle axillary artery at the level of the teres major and descends In tile medial bicipital gi'DG1/e to the elbow. There it divides intD the radial artery and ulnar artery. On 11:5 way down the arm, It gins off branches to the arm muKies as well as the profunda brachO artery, which runs on tile eld:ensorsldeofU!earmanddMdesdlstaltotileradlalgroovelntothemlddle mllater.al artery (to the medial head of triceps bradlii) and the radial mllater.al artery (to the arterial network of the elbow). The bradtlal artery supplies tile arterial network of Ute elbow through the superior and Inferior ulnar collateril arterte.s. It Is slgnlfte<~nt cllnleilly that tile brachial artay can be ligated distal mthe origin of the profunda brachii with little risk (e.g.. to control heavy posttr.lumat!c bltedlng) because Ute arterial network of tile elbow (see C, p. 345) can establish an adequate collateral circulation. The bleeps brachllls a useful landmark for locating the brachial artery, whose pulse is palpable all along the ulnar border of!flat musde.
_______A 1
MuiCllloc:utanecus ~/ n~ (
c
b
D Course of tile bradllil
nonnallftltllmy 1ncl Vlllllnts (aftll!rwl'l L:mzand Wachsmuth) Right shoulder, ~nteriorview. a Usually (74~ of cases) the mediar1 nel'l/1! cro.ss:es _. the brachial artaylnthelowerthlrd of the arm.
11-d V.rtanb; b The median nerve CTOSSfS under the brachial artery (very rare. 1~of
c-. d
Brachial artery
d
Brachial artery
The brichlal .1rtery divides Into a supl!l'fldGI brachlil artery and a
brachial arterywhllesUIIIn the ann ("high dllllslon• pattern, 25 Xof e<~ses). Both of these arterielm;ry ~well developed and may flank
lfle unlor1 of the medlin nerve root3 and tfle median nerve Itself. In this ase the r.1dlal artery arises from the superfldal brachlil artery ("high origin of tile radial artery") while the ulnar artery Is the continuation of the br~chial artery (5ft p. 347).
cases).
339
UpperUmb - - S. NeulVIIUsarlar Systems: Topo9raphk:al Arurtomy
5.7
The Shoulder Region: Posterior and Superior Views A Musdennd arbini!CIUinerwsoftfle light shoulder Posterior view. The surf.rce contours of the shoulder ire defined chiefly by the deltoid
muscle, 'Which Is palpable subcutaneoll!lyOVI!f its full ment.
Desandlng ------=~+ part
Deltoid
Trai\IMM part
'll
Medal and latml cwneousbtanches ofdledors
Ten!! major
Sull81orlatml brad!W <Wneo~a
nerYe(aillarynenoe)
l'orte!la rbradi1l cut.tn-
eoUJ ne~W(nldllll ne~W)
Aso!ndlng p;Jrt
~
heed ~,.,.
head L
}
Tri~
br.tiChll
~arlaUralbrlldllal
6or.l1
cutanealll nenoe (radillln~!M!)
a Supta..:•P'II•r~on oftflelfght shoulder from the postertorW!w Aflap fi'om the transverse part of the ttapezlus muscle has been raised to demonstrate the
;;B*"---=li~~- CDraaxi;M.
rularligament
SGpular lplne
Deltllld
340
supraSCipular region. the central portion of the suprisplnatus has been removed. Noh! the course of the suprascapular nerve ill its fibl'l)oOSsecua canal bf!IDW the superior transverse scapular ligament In the scapular natch. Campresslon of this nerve ln Its canal, esped~lly on extreme exte~l rabtlon of the shoulder, can le |
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Ol!ltxlld
(cut~dge}
SubK~pul:l~s --;~~~uilF/ Supraosc..l~p~Aarllltl!ly --~~~~!:;;; Sup~pul:lrn~ -----';;-~
(In thsc;rpularnctdl}
Superlorlrln.wer.se - - - --="""--J sapulllrllgament
Supraspinatus
--~~~~~ry~ :
c
SuprMa~JifJIII' regJon lllftfle rfght thcdder. 'IIII!WI!d from allcwe The trapezius and deltoid muscles hive been re~ to demon straw the suprosplnatus, which originates In the supra1plnous foss;a ;md passes laterally beneath the humeralfornlxtD ItS lnsenfon on the greater tuber·
osity. The supras~pular artery and nerve nm along the anterior border ofthesupr;s,plnatusiltthe level oftfle supa!ortranmnes~pularllga· ment. just laterill to the omohyoid lnsertlon-lhe artery ibove the IISfi· ment.ilnd the nerve below It (see B.and D).
c.xnman arotld
D~warude
Mt!l'y
Right scapula, posterlor ~ew. The suprascap-
llr.uhio«pNNIc
ular ir1efy irises from the thyroceM~I trunk and passes CNI!Ithe sup610/' tunmne s~pu lar ligament to enter the supr;~spinous foss;a. From there It runs pastthe neck ofthe scapcJia, passing INlder tile fll{erfor transverse scapular ligament (often ab.sent), and enU!rs the Infra· spinous fossa where It communicates with the drtUmflex scapcJiar artery(from the SIJbs~pu lar artery) and the deep branch (dorsal s~pu lar artery) of the transverse cervical artery. Noretfle anastomosis betwem the suprascapular artery ;md !he drcumflex scapular 01rtery (5copular orauk). It ~ Important dlnlcally beaUK' it an provide a a~llater.ll cirtUlation In response to ligation or oa:luslon ofttte axil· lary artery (see alsop. 342).
trunk ~rsapl.fae ...:l~;.._=:;...
_____
ll"answneczrvt~:al.army --====t:;~:::=--~~~=='f'~~ Su~fnltlls Danalsapullrartery, deep branch af tra nto W11ean!GIIi1111ry l~lnous
foN
Sup~pularn~
nlhesc;rpulwnotdl Sup,.,lnauslos.sa
Nedcohapula Aldlliryaltey
Clrauntlex
scapular~rtsy
Subsapulir artery
341
UpperUmb - - 5. Neul'O'II'IIscular Systems: TopograplaklllAncrtomy
5.8
The Posterior Brachial Region
~--~---~-----s~pulir
1rtwy1nd nerw
OPJUieof .shoLider)o'ht
Detmld
.....,_____ Posterfardrallnflerc 1-ormmlarll!ryand axillilry nON!!
Orcumtlex - -- ---,"""--= ,:...- :::::!
QJadranp.rlir .sp;~ce
sapulir artwy ~---
Profunda brad111rt21y andradllllnt!M! ln!Jbpshlma
A Thetriiln1ulir ilnd
quad,_....,,,_ althe ulllil
I'DQJ!rlor sapul~r region on the rtght side. Most of the deltoid ~nd ~ portion of the i nf'raspinat:us muscle have been remCM!d ID demanstr.lte the ~natamlal relatl.onshlps more dearly. The slldllcr opening between the tEres minor.~ rNjor, 1nd humerus Is subdMded ~the long hod of trlteps brachn Into 1 quadrrlngular spaa (llltlrll oiDifllary funmen) and il lriongu/arspao! (medial illlillaryforaml!n).
I NIUVRKUI•tncb~With theiiCIIpull
The tri;r ngular and quadrangular sp;rca of the ixllli ind the triceps hlitus provide lmportint p;aHgeways tl\it tr~nsmlt neurov.ascular structures fTom the antl!rlor tD the postelfor .sapulir region.
Do,...sapulr 11'11!ry•nddorul
Japularnerw
SlnldUIW
bw•••lllid
• Triangular space
• Quadrangul•r
Meollal border - - -
space
• Trkllp5 hiatus
Clra~mflR ICipular
lr11ory
Pasmrlor d~a~mfla humerol ~rtary ~nd ••lllary nerw
Prorundo br.rrchll 1 r1lory and rodlal
ntaps brad!ll, langhsd
342
neNt
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
S~·
splllllus
- ---i? ==-
~~~-~~=-~~~
splnt
l'csti!I1Drdi'C\Im·
flex humeral artery.
Teres -....:4-~~::...,......;-,....,__,.-~~ mlnar (n:unflex SGpular
alllarynerve ~I '-ttl
-~~;....:........,...::;_.......,..~
tTl«~» br.Khn
MusOJiar lr.lnd!es
artlery
ofradlaln~
T~ --...:::,:::.__,~:.......,,..z,:r:,.
Profunda bradln artsyandr.adlal I'MM! In tile radal
m11]ar
111001/e Medial «ppalnd)'le
. .~~--Lmral lnttrmuscular Hptum
{postl!rlor:
ulnar11,_l E Nervesthlt 1re dll:lely relltl!d to the h\lmerw Right humerus, anterior view.
·-
C Couraeoftfler.adlillnarw lnthel'lldlill
Right shouldel.md uppe!" arm, posterior view. The l~te<;al he.-td of trict!p$ brllchii ~$ been dMded 1» show how 1he r.-adlal nerve spirals around Ute humerus. The dissection shows the bany radial groove betwl!en the origins of the medial ind lateral heids of trfcq» brachll. At Ute dlst.11 end of Ute groDYt. the radlill nerve passes tftrough Ute liltl!nllntennuscular sepwm to the frDnt of the humerus and contin·
ues ln1he radial tunnel I»the cubital fossa (not shown here; see .-alsop. 344). Notl! that the radial nerve branches for the trf· cep5 brachii ;arise proximal to the radial gro-. Thus the triceps brachll may stlll be functional .-after a humer.-al shift fracture at Ute level of the radial groOI/1!, even thaugh the radial nerve ~s been dimaged. because the muscular br.-anches 1» the triceps arise pi'Oldmall» the site of the lesion.
•
Vetllebral artlefY -:::::if4~ Thyroc:l!nic.al tnJnk
nanswne CI!Mall11'1:21'y
c ~llill'yarttry
Clrwmflex saj)l.farl11'1:21'y
- -1-!- -....,..-o:=::::f
Antl!rfor dr.::unftex humeralartay '-'~~-- Postl!ncrdrtumftex humeralarttry Subsapulll'~rttry
ProMda bradlllartl!r)'
BnH:t!lall11'1:21'y
D Artertel iupplytDtfle scapulllr rtglan Right shoulder. posterior view.
F Brnches ofthe bnchTII artery: norm1l a~ iltld v.Jrf;mts (after von Lanz and wachsmuttt) a Typically (77 ¥ of cases) Ute profunda bra· chiiartery~nd pNteriorcircumflexhumer~l
;artery arise from the brachial artlery. b. c V.ullrrts:
b The profunda brachll artery arises from Ute posterior circumflex humeral.;rrtery (7 ¥). c: A:$ in b. but the posteriorcircumflexhumer~l artery runs through1hetrfceps hlaws rather than Ute qu.-adr.-angular sp;r«! ( 16 %).
343
UpperUmb - - S. NeulVIIUsarlfu Systems: Topo9raphk:al Arurtomy
5.9
The Elbow (Cubital Region) Slm, sllxublneou~ Ussue,
Medlalantebll!Ctlilll
arldSJ~Iilsda
cut.w'leowneM
A Elbowofthe rtght111111fterremCMiof thef.lsdn ilnd epffilsc\al neui'O¥ll5a.llill' strudlJres
Anterior vi-. The mtd'IOillli!M! and the musculocuCIIneoi.IS t~etW wlth IU malr1 branches ire cle;nlyvlslble (variants In the course of the medlar! nei'Ye are shown In D}. The brachloradialis musde must be reb'icted (;15 in 8) before the radlil nei'Ye Cifl be seen. lnll!rlct ulnar
a.llmtal ai'IJ!ry SUperlct ulnar
cdl;neral;utery, urnarn~
U!ml antebrach·
fal tul
Medial
neM (musculo·
~ndyle
CU!II1e
~........,"+7---
l'rmllllr tms
,....,HfH.- - Flelcorcarpl radials
Rlldilllar!J!ry
l'liiiTIIIis longus
-+-1~,_,L-:-:i7~
:>-~H-Ex!el!
Bkfpllll
111dii1Hs longus
Sldn, subcutaneous tlssut..
Medial oanubrachlal
inds~d'alfzcll
cutlneousn~
Flelcore<~rpl
ulnarts Qphatcwln _
___;~~
Medal ---_:.:;~.,.,;::;r.a <11111!brac:Nal win
Muswlocut.w1eousneM --/'-jft~II~.J..t
SUper'lor urn ar
lkllctllondlalls
alllmralirt2ry, ulnarn~
WalneNe, ---,~fll. muKUIIr br.nches
Rlldlll {
nerw
Deepbr.Jndl
Superftdal brand! Bla!p.S
8 Deep dllsedlon of the cubltll fosM Right ;nm, interior view. The distil muscle belly of bleeps brac:hll has been removed, and the muscles af the radialif. gA:MJp (br.achiaradi· ails, extensor c.1rpl radialis longus. and exten· sarcarpl ridlalls briMs) hwe been pulled a1lde m better dernonstr.ate the caurse af the I'Odlol ne"M". After pa$Sing through the !'idial tun· nel. the nei'Ye gives aff Its smsary superficial branch and Its muscular branches m the musdes of the radialis group before enlll!rtng the suplnator(see p.345). Portions of the pronator teres have been retracted medlallym demonstratetbecaurseofthemedlannei'Yebetween the two heads of that muscle.
344
lncllll tmdon
- -+-+
)\\!!MiTT--
l'nlnlrtorb!n!!, h~.meralhead
Ra.tal rKllm!nt artery
umrarury Rad'alarury -
-'-+--'
SI.CIInrtor ----,~-
hlmart' IOII!JUS
Flelcor arpl ulnart'
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
A'ofunda - - - bracffiarb!ry
_j
Ridlil collaanlarb!ry
_j_
SUperior ulnar collateral
Middle callatl!ral arb!ry Reefal
~~~---~~~~r
collateral<111:21y
n!
Racial artery lnll!I'OS11!011S n!alm!flt artery
Postl!rfo r I nil!I'
Jl..ll:..----ulnar reamm<111:21y
•
1-- - - Ulnar<111:21y
oueousartery
Ant2flcrlntl!ram:eaur.<111:21y
llledl;lnnen~e
CDmmon~-
pleraitht
osseous arb!ry
C Arterfllllnntomosa llhut the elbowjoTnt; the 1rterlll network of the elbow Right ilnn, anterior view. The ilrterlal illlistomoses In the elbow region fonn a \r.lda.lar network Chat is fed by S4!1/1!till ill'teries: • The middle collab!rill artery and tildial CD! lateral atb!ry from the profunda br<~chn <~rtay (communle<~lt' with the radial <~rtery via the r<~dlal recurrent artery and lnta'osseous recurrent <1rtery) • The superior ulnilrcollateral artery and Inferior ulnar collaterill artery from the brachial artery (communicatto with the ulnar artery via the ulnar recurrent artery)
c
b
humeral head
D lll:lltlol'llhlp of the medllm ncn-eto pn~nlltor tl=f'el; norm;sl ;nrt.amy ;snd v.niants (iftErvon Linz and Wachsmuth) Right arm, anterlorW!w. a In the great majority or cases (95%) the median nente runs between the two heads of pronator teres.
b. c VI IIams: b The median nenlt' pi eras the humeral hel!ld of pronawr teres (2 2: of cases).
c The median nenlt' runs on the bone beneath the ulnar head (3% of cases).
Ilea UK' of this arterial network, the brachial artery an be lig~ distal to the origin of the profunda br<~chll without compromising the blood supplymthe elbow region.
Lllltrlll - ---:-- epancJ:j!e
Deepbrn:h
--....:,.,,..-~...--
l'olterler~ ~ ~ -ur.nUina----
E Supracondytarpi'OCitSSofthehumena Dirt.-11 humerus. right arm, ann!riorview. The siJI)I!ICOIHJylorproct~JS is an unusual anomaly (0.7 2: ofthe population). a bony outgrowth above the medial epicondyle (see p.214). When present. It an seNe as an attachment for il conlledtlle tissue band referred to as Struthers' ligament. which ends on the medial epicondyle. The nesultingfibro-OJROUUII~ condyloramal can entrap and compress the brachial artery and median
nerve.
F ltll;s\lonshlpofthe l"ildl;siiHIMI!DthesuplrYtor Right elbow region. radlallltew. just proximal to the supinator muscle, the radial nerve divides Into Its deep motor branch and supertldal sensory branch. Thisarrangementcanleadwentrapmentandcompression of the deep motor branch. with resulting selecUYe palsy of the extensor muscles (and abductor polllcls longus) served by this nerve.
345
UpperUmb - - S. NeulVIIUsarlfu Systems: Topo9raphk:al Arurtomy
5.10
The Anterior Forearm Region
MedlanneM
Medlann.!M! Tr!CI!pS
brachll ~~~~
lnfl!r'larulnar colat!talartsy
br.T~Chll
Su~r!or ulllilr
Brad11alls
ulllilrn~
Medial eploondylt
Brachlalartay
Blo!ps
!nc:NI
Pnlnamr
1Jen6on
b!res
Flean
lloldlalartery
arplradalls Bldpltll
Br.ldllorad'alll
Blo!ps br11dlil
«
ulnar nerve Brachlafl
lnferfou.fnar «
BracHa-
Medii!
r.rdlalls
eplaxld)i~
R.adlaln~.
su(le'fldal br11nd1
l'nlnllor !Jere,
hum.nl h9d
saps bractil b!ndon
~n~rosls
Common ln!B'0$1e0Uil11'121'y
P;im;R
~lnte'·
longus
Superiorulnu
Flo!or carpi radialis I>.JIIlliris longus l'nlnllor ure,
o:sseousl11'121'y
uharhead
Anterior lnte'· o:sseous..te
Exl:er'dor carplradllllls breo.!s
Fle110r arplll~
Exl:er'dor carplnrdllllls longus
FI-r dlghiM'Um profundus
F'-rarpl radialis
1"-r
Pronab:lr
d~nm
teres
supesftd'alts. humen~Uhar
Flelcor d!§torum superlldlllls. radalhmd
Flo!or carplulnarfs
lloldlall11'121'y
Ulnarlll'll!ly
head
Ulnarn~
--tf"f-!N~-- Flelcor
dlgltonJm supertlcSalll Median neow Pl'onatot
- -+Miii,_-rl -
4 !!;.1
quadratus
"- -~-~r «Jrplr11chi\J
f1);S'ift~--- Flexord~rum supertldalll b!ndons ~~---- Flexor
mln~a~lum
~· mUK!es
A RJghtforNnn, •nterlor vfew, MJperficT•II~ Thef.ssdae and superfldal neurov;rsa.tlar structures have been removed. Ma:st of the foreann's neurovascular structures are obsaJred lr1 this lltew. (The superficial veins are shown In D.p. 329.)
346
P.ahwrbllltlch of medlin nerve
a llghtfore'llnn, •rrtertorvfew,deep illyer The proflatXH' teres. flexor dlgltorum SIJperildalls, palmaris longus, and flexor carpi radialis hive been p;rrlially removed to demonstr.rte the median nerve. the superfldal branch of lfle radial nerve, and the radial and uln3r arterie5 (vari;lnu in the cou~ of the arterin are shawn in D).
Upper Umb - - 5. Ncurowscular Systems: Topogl'flphklll.Ancrtomy
The Posterior Forearm Region and the Dorsum of the Hand
5.11
.:......;_
___ llrad!lo-
radlals
~
~~·----~~~~~~~~~~~~---
olbowilld lit:eril
d~nm
DaBal
metaCMpQI .art2rlu
Ddltnsor - ----=,....;!!:"
----~~~~~idrlrl~'~ Wl~•T+!I-W!1'~0,....,~
opkundylo
carpi ulrwts
Dorsal
~ muscles Pmagedlowgh
----1~_,
die lnte'CISS<eOU$ ~mbrwn•
/'1..}--#-;fo..-;!'.7"77~"---'if-----T."i--
DoJSal digital
arte11es
~· lntenmeaUJ
----~~~
.m.y
---~-- EZB1scrcarpl
radlalsb<wls
and longus Ellb!nsa"
carplunarts Sitl!whfftoillb!rtor lnt.rosseous irlay plm:e the mtmbrue
A Arterfes afllle ll~~num aftt. hallllanll U.e me-rs1R1 aftt. tlngl!ll'lln tt. rfght lwld
The skin, su bcutilneous tlnu•. and dorsal fBda of the hand hOM! b.m removed to demorutnt. the dorsalartrries (for d;~r1ty, ltte vdns ;md nerws hOJWalso beB1 remowd). Th• dorsum ofltte hind receNes most of its biDGd supply from ltle radial arb!ry, while ltte ulnar arb!ry contributes only one small vessel (the dorsal carpal branch). The perforating brilnch.s, howevl!r, ci'NII! numerous connii!Ctlons betwl!t!n ltte pill m;u and dorsal artrri.s of ltte hand. In the ftngers, these connections are provided by lat.ralanastomose b.~n the dorsal digitlll arteria and the proper palmu dlgtula!Urles (not seen here).
348
- - - - - Abdudor pollcl
pollcl
Raclolorb!ry. dor.lll urpollnnch radlallsblfNfs
gin and reflected to the side. The triceps brachll has also been released from Its origin at a mare praclmallevel. On the l!ldl!nsor side of the fo~ ann, the extensor carpi uiN rls and l!llll!nsar dlgltoru m hOJW Ml!n partiilly raected. Nok how ltle posl2rlor l~rosseous artery pierces the Interosseous membr.1 ne just below ltte lower border of die suplnillll and enters the extensor comJNrlment of the fDreann. In the dlsbl fDrearm, parts of the ext.n,or pollicis longus and l!ldl!nsor indicis h~ been re~ to demonstr.IIE the sitE where the anterior Interosseous artEry pierces the Interosseous membrane to reach the back of the forunn. lkJth arteries are Important sources of blood tD ltte extensor comp<~rtment.
polldslongus
~4-- ~
Extensorarpl I Deep dlssecdon of die IIU!rfK on die exii!I15CirJ!R afthe fon!ann and dledanum of the hand lnllle11ghtann In the elbow region ltte anmneus muscle has been released from its ari·
~:--.l,--.1--- ~
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
1-:-!--fr?h-..--i-- - - Median ntl'lll!,
+-+--!--=!,--- Median n~.
dorsall:r.lnd!H cfp.llnwctgltal
darsal branches cfpahwrdlgltal
£xdusllleaA!i - +--t-+ofmedllnneM
neNK
nerves Dcnill dlgltalnerwe (txduslwa1'151
H -P-17-h-- u-~
dorsaldgltal
cfulnarnerw)
neNH
--+--unar~
darul branch
• C Nen~e 111pplyto die dorsum ofthe "-nd Right hand. posterior view. •
The~Jncnaondledanum~thehilnd. Noo:thatthe index
and middle fingers and die radial part of the ring finger are supplied bydllferem nerves In their proximal and distal po!1Sons. • Dlstx:rl: by the dors;~l br;mdtes ofthe palmar dlglt
• Pmrimal: by the dorsal digibl neMs from the rudia/ II
b E:aflllhe .nd cr-'1pplng • - cl senury lnnerwt!Dn on the dDr• 111mofthe h;md, forwn~r, mechn..nd nldl1l ~In lighter shild· lr~g, areas are Indicated thit receive sensory lnnuv.rtlon mostly from the corresponding nerve. Because the sensory dlstr1but1or1 of each neNe ill aCU!ality overlaps extensively with the adjacznt sensory tl!r· rltorfes of the other nerves. an lsolilted neM Iuton does not render Its entire tmftory anesthetic. Instead, extensive or complete loss of sensation k rest11cted to areas where there Is little or no overlap, depietl!d in he;Mer shading.
£xtensor
polllclllongLII
Extl!nsor
retinaculum
=:3=:.----'===-.iiii~":;i.;;~~'ii;#~:---
Extensorall'l nMIII!Jiongus StyloldprocatSS of radius Saphold
b
Arst
metacarpal
• --Dor.sal l!Jbo!rcle
D Bourtd;ufesoftfut;natomkill snuftbox. a Surface anatomy of the dorsum af the r1ght harld, posterlolateral view. b Musdesandtendonsoflhedorsumoftherfghthand,radlalvlew. The three-sided •anatomlcalsnuf!bQX•Is bounded or1 the palmar side by the tl!lldoiu of Insertion of abductllr poll ids longus and extensor pol· licis brevis ~nd dors~lly by the tendon of insertion of extensor polli· ds longus. The floor Is formed mostly by !he scaphoid and tt<rpezlum carpal bones. Fraci:IJres of the scaphoid bone ire thus often iSSod· ated Vlftl'l deep tenderness In the snuflbox. The snuffbox Is bounded proximally by the extensor retin;~culum. Nokth~t the r~d~l artery run$ deep in the snuffbox be~en thetr.lpezlum and scaphoid. providing a landmark for dlssectlor1.
349
Upper Umb -
5.
Neu~VMJSCJJiar Systems: Topographical Anatomy
The Palm of the Hand:
5.12
Epifascial Nerves and Vessels
,_..-llh--•~F--
Ptolnr
PolrtlllrdgiUI orUrles
--\"'~-~¥.--"!lt-----\1
d~
nones
~an-~~~~~~L
polmardlgltll ;lltllfe:s
lfi--,,J,.--PIImor
dlgblofthumb
A Superldal amlt•and nerws flf the piilm Right h;md, anr.rfor llfew. All of the t.Jsdae QQ!pt th~ palm~r aponeurosis ~ been mnOYed tD demonstrm the superftdal neurov.asculu structures ~ ~ p.Jim. The p.J~ m~r cilrJNI llg~nt has also been re~ tD clemonstrilta the neurov.HCU lllr structures that JNU through the uiMr tunn~ (the ulnu Mtay and nene; see p.l57). NoR the suf*lldal palmar branch ofthe radial artBy, whldlls highly varilble In Its course. In the ase shown, It runs between the origins of 1bductor 1nd Reur poll ids brevis tD the p.11lm of the hind. In .opplllldll'llt:ely 30 I of ases It combines with the ulnar artety tD form the supailclll p.ol mar arch (not shown here; see also p. 352).
Pllm;or dgiUI f'MM
Mlltilcilrpo>
with darHI b111Kh
pholongeoljont
Dorsol dlg!Uiorh!ry
~~~ ~
B Nerveuncl wsaelufthe right middle oar.:.l dlgltll """"'
~..:::~b::::::~::.-- C
P-po~lmor
dlgltllrww
350
flngll'
Latera111iew. The artef.a of the palm are antellor to the nenes, but they are dorsal tD the neJWS In the fingers (gen~nlly crossing at the level of the mmarpoph;i II nge.11l joint). The lltlnl and distil do~ I surfaa!s of the fingers are supplied by branches of the proper paiiNI r digital nenoes (from the mediln nene).
UpperUmb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
UlnaraxnmLr!latfng bn~nch
Medlin communlatfng bnnch
P
ofulnarnenoe)
c Nen~e
d
c
" ..ppt,totflel)lllmoftfleh•ncl
Vari~nt 1 (2011: of cases): The median nerve~nd uln~rnerve~re (n)U· connected by an ulnar communicating bra riCh and a median commu· nlcatlng br;mch • c v.ufant 2 {20:1 of cases): There are no communlalfng branches between the median and ulnar nerves.
b
Right hand. anterlorvlew. lnne~ pdtilml Tn the Pillm of the fwlrtd (after Schmidt ;and Lanz). The sensory Innervation patum Is marked by lfle presence of connecUng br;mches between the median nerve ;md uiBarnerve.The following innervation p.at:D!ms ~re most freqi.M!ntlyem:ountered: • Mostcommonly(46 :t ofases) the meclian n~ and uln~r n~ are lnten:onnected by "n ulnar communlc:.Jting brand!.
.-c:
d Exdi!Wt .,d owrbpplng . _ tJI ten.sory lnnervlt!Dn tJI tile hJnd. Plllmilr ~. NoD-0111!1i;!pping areas of exclus~ innet'\'ition "re lrldlcatecl by darklf shildlr~g. Compare with the donal a~pect (C,p.349). 0
.....--..,....--- DlsUI
..,...-
phillanx -i---Micldle phll;llllt
-
--;--
--'--
PmiC!n'llll phllalllt
~----:---
Tendondf~Dor
Tlllrdmet.tcul)ll
dlgllorum profundus ~+.1--I'JE---
Tendondfloor dlgllorum supeilclalls
Palmar a
b
D TheObentnerveblod:
Right hand, posterforvfew. This tJpe ofloal anesthesia Is dlnlally useful for lnjurtes of the fingers. spedflc.;llly for wounds that require suturIng.
dlgltaln
a The injectian sites are lacated in the intl!rcligital folds. b Ntfl!l the dorsal nerve branches have bea-1 numbed, the needle Is ac!Yanced on both the radial and ulnar sides toward the p;~lmar nen'I!S, and a subaJtaneous bolus of 1-2ml of local anesthelfc Is injected at e-ach site.
hlmardlglbllartery
E Blood supply to the fle.xortlr:ndGIIs of the finget' wltflln the tendon shea1:h {ilftef wndborg) Right middle finger, lateral view. The flexor tmdom are supplied within their sheath by branches of tfle p;~lmar digital arteries that ~re tr~nsmltted to the lll!ndans through !he mesotendineum (vina~lum longum and Yincu· Vl'u:ula btl!llla
Vlna~la
lumbre~~e}.
klnga
351
Upper Umb -
5.13
5. NeurowBaJiar Systems: Topogn~phlcal Anatomy
The Palm of the Hand: Vascular Supply
St.ptrfldal Pl'lrnar ~ ardl Unarar1rtry
Radial artery
• Palmar dlgblroenoes
·-~ Pillmar aodl
Palmar
Polmar
d~
Unr1rt1ry
dlglbil ......., ofthumb
artlrfa
..
~
Addudxlr pollids fto.cr palllr:fs b!W!VIs,super-
Camman
palmar dgltll •lUrie
Flmdarnl lnlleii)SSCOUS St.ptrflr:fol Pillmar aodl
bdlll
Unrartlry
ftdJI head
c
artery
Common ~
Pl'lmardl!1· tiii!Ufles
Unarar11ry
Medon
,. Ulnar .u.y and norw
artery
!wrf•nt)
B Tbe 1111perfidlll p11lr1lllr •n:h: 1'101'11'1111 ilrWDmJ and wrtants (ilb!r Lippert and Pabst) Right hand. palmar view (no stl.ldles have been done on possible variants of 1he dftp palrNr
--..~!f
F!...ordjptorum --44~+ superfldlllJ
arm). • Normally (37ll: of cases) the radial artery Flelllrpolllr:fs lengus
A Tbe liUpelfldll pal1111ran:h and lb branches Right hand, i litErlor view. Tlle p~l mar iponeurasls ;md other fudH have been removed to
nelaarpl
radiilis
demons!Jillle 1he superfldul polmor ordl (varf· ~nts are shawn In B).
ind ulnu artery contrfbub! equally Ill the superficlaI palmar arm.
b-d V•"-'b: b The pi l1111r arch 1rtses entirely from the uln;ar artery (37 S of cases). c All of the cum mon p~l1111r digital i rteries
1rfse from the uln;ar utery elfapt for the lirst, which arises from the radial artfty (13:11:). d The uln;ar al'll!ry and a median artery gllle off the tommon palmar digital uteries (wry rare).
352
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
~!mar-------~~~~~~--~
dl~toll-
~l~r--~~r-~n-~~
dllblllll'lftll!s Cllmmon
-~.rr----'il';.-lH.''---s.F-~__,...,~
Plhlardlg~
amrll'$
Abductor ---+IUIIiv o\\
digiti mrnrmr
~~---,~~,...,...._
W !F=:I''illl('t
Flexordgltl ----';;Fl~l. m'lllml
Mcllctwpollicls. tnnsvene head
Abctlctllr
P.llmarmett- ----'~~~~~~~~~~~~ alll"'IUIJ!rle
pollldsb~s
r''!~---
Flell«poltcls
bre>is
Opponens dJ!1tlmlnlml
Adducmr pol lids. obi~ bud
)o..'IJ_F-'~rif--- llldlllu!J!ry,
suptrlldlll Pllrnar
bnndl
Un;or army ---+"+HL.o~,. -~~--•
C 1111! deep p;~lmn arm ;rrnd Its lr.md!es
.-..dnerw
Right hand, anterior VIew.
The superficial and
deep fl~rteruion.s ha1le been n!mcwed along with tile tflmar ~nd hyp11thenar musdes to demonstrate !he deep polmor orch as Ule ter·
Prcnatlor----:--IF-..._,H~
ql.llldrmts
mlnal br.mch ofUie rlldlalarte!y.
Donal digital ar!J!rte
Common -e-4::-/~'--.,:!---1 p;~lrna-dlgl-
t.lhr!J!rle
~nd:ng Donal metaarpolll.udes
p;~lm.1r
4orwl
P.llmar
Dor.saldgltll army
d~
Suptrllclll palmararth Deep palmar
Unararmy, dorularpal
bnndl
~or
b
fntl!lll$Sl!OUS
Common I~
arury
•
~~~--~~~
n!almmarmy
D Arti!NI ;rrnastumoses In tfle h;rrnd The ulnar artery and radial artl!ry an! lntel'connec!N by the superficial and deep palmar arch. the perfor.rtlng branches. and the dorsal
• Right hand, <mterforvlew. b Right hand, po.ste!'for VIew.
c: Right middlt- linger,l;ateral view.
arpal networlc.
353
Upper Umb - - 5. Neu~VM~SaJiar Systems: Topogn~phlcal Anatomy
5.14
The Carpal Tunnel MechnrwNe
Sc.aphcld
U~rar11try
Tendon of obductor
andne""'
pollkls longus
Tendon ofext~onsor
Plslfonn
pollklsbn!VIs Cl~plnl ------!~~~-"-!
H)'poitoonlr
::....__ _ _ bdlalnerw,
eminence
superlldal b"'ndl
~l!tnlm
Plane ofsedlon lnAillldl
Tendon dood:l!nsor carpi racfollslong.ls
Tondonofexllonll>r dlgld rnlnlml
lion1allo
Tendonsof01112nsor dlgllllnmond exllonsor In
A Crau section th,_gll the right wrftl: (see also B) Distil view.ThealfJIIII tut!MIIs il flbro-c.sseous ~llil(see p. 248)1hrough which p.us the medliln nerve and th tendons of Insertion of fle~~~~r dlgltorum Juperfidali,, fluor digitorum profundus, flexgr pollici' longus. ;md flemrc:arpl rildlalls.lts dorsal boundary Is funned by the carpal sui-
cus on the fnlnt surfaae of the a rpal bones, and its palmar boundary is the flemr retlnaaJium (also known dlnlcally u the trilnsven:e ~rpalll!t' 1ment). The ulnar artery ilnd ul nilr new pw thRltlgh the ulntlr tu/IMI on the pal!llirvil'W of the retinilcul um (Jee p. 357).
Ulnortunnel
~:.:.,llliiiie~~- Tendon of flelllOI"carpl ...dials ;::~~~~.,:::~r_- Medlin nenoe
Suporflciol
pomoron:h Tendon oheoth ,. /offt.....
/
~----~~~+-- Tendon of flelllOI"polhds longus
"""
---+---- Cammon carpal
~~..!..-- Saphold
•
dlgltlll\lm prdmdLB
8 Jt.~unshlp of the JMI!Nr ant- til the Clllllill ilnd digital ll!ndonlllaths (OiftlerSchmldt ilnd uru) a 'nlndon .e-th1 ., tho c:~ll'll wnllll (detail !TomA). The long flemr tendons pom through the arpal tunM, en~sed In their palmar ten-
don sheaths. The tendons of fll!lUII' digitorum superfocilllis :oand profundus are axrtalned In their own ulnarsynovlilhheath. Ridlal to this sheath Is the tendon offlexor polllds longus. The mmmon mesoten-
354
tondon oheoth
..
Tendoru off1ev
pdlldslangus Deoppolmor
1-- - Rlldlll artery J-.:.-'-4 - - - Un;rar11ry
dlneum of all the digital fleJCOr tandons Is ilttllched tD the radlil and palmarw.alls of the carpal blnnel.l11e median nerve generallyocrupies a Hparilte space just deep til the flexgr retinaculum (thev;uiable murse of the tendon shuths Is desatbed on p. 29&). b ~lp olthe carpel and dlgltaltllnd011shMths til the piiiiUr ..-cha
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Palmardiglt<JI - """"'1:---l--- -dl..,-Ll.,....- -l-...;.,t nerws Palmardlglt<JI
--~...L.._,,.W!.....l;-{
artl!rfes
t --tr-
Palmardlglt.ll
nen~tSofthumb
Commonp;lmar
~~~-p.--
--~<'t-""""";':~
lntwos.secus
ctgtt<JI~rtl!rfes
P'":;jjj~a.....,,..---'-- ~ctorpcltlds
SUperftcial p;lmar~llh
Flexordlgltt
mtntmt
Fntdo!l\11
-';,~~.;r-- Flelupolllcisbrms,
sl.p«ffdal he.ad
·~
--~Ht--
~---
Abducllardlgllf mlriml
----'1~
Ulnun~.
Jlbductorpollds bn!vls
Median ntNe, lhtNt bra riCh
_ ___;..,_....:i..,:i4 1\~
superfh:ial bn~nch
Unarnerve, ---:.-~111 de!!p brand!
Vfew~tfleurpaltunnel of the right hand Antenor view. The trllnsvene urp.al ligament Is shown In light shilldlng. The uln;~rtunnel hifiS been QS~ened wdisplay the uln~r artery and nerve. Nott the superlldal course of the median nerve lr1 the c;npal tunnel and the ortgln oflts thenar motor branch jll!it distal to !he retlr~aculum (variants are shown In D). During surgiul division of the flexarretinacu·
C
Eorlyongn of tile them lnnch belowthe
lum for c.arpal tunnel syndrome, the hand surgeon must be aware of Its variable course to avoid Clltfing the thenar branch. The supaflclal p;~lmar branch of the radial artery runs on the flexor reUnaculum In the case shown here, but frequently It passes lhrough !he thenar mll!des (seep. 2110).
T1ll!na rb111 nch pie~ tile flmlr Mfr~~culum
flexormhlcuklm
D
Ortglr~ofthetiMnumotorlnncnofthemedlan nerw:
nonnill
<~ll
a Normally(46S ofcasu)themedlan nl!m!glves off liS lhenarbr.anch distal to the flexor retinaculum (transverse carpal ligament). b, c VII rial1ts:
b The thenar branch has a subltgamentous origin and course (31 S of cases).
c The lhenar br.anch pierces the tlexDr retinaculum (transverse c.arpal
Thenar brand!
b
Median n~
c
Thenar musdH
ligament; approximately 23 S of all cases), making it vulnerable dur· lng surglc:al dMslon of the retiniiClllum.
355
UpperUmb - - S. NeulVIIUsarlfu Systems: Topo9raphk:al Arurtomy
5.15
The Ulnar Tunnel and Anterior Carpal Region
H)'pedlenaremiMno:e - ---11...FielcDr~NCllum (trall:MI'Ie e<~rpal
llg;Jment) Urw~rury~nd
- --:..:- -&Ill
ni!M!, lle1!9 bnlndles "ft.~.....+-'---
A Superfid;ll s\nldur15 oftfHt ;mtartor c;np;~l r.glon Right hand, anterior view. The skin and antebrachial fascia have been 1'1!1Yloved mdemonstrmtile superficial structuresofthe antl!lforcarpal region, which is bounded distally by the flexor retinaculum (tr.ln~ carpalllgammt}. The tendons of Insertion of fle110r c;upl ulnarb. pal· marls longus. ;md fltl(DI" carpi radialis In p;u11cular are dear1yvlslble and palpable beneath the slcin, especially when the fist is tightly clenched
Tendonaf---palrnarts longus
Tendonafflelcor - - - - CMI)Ir.adtllls
• sumc.;mltolliJ of the right wrist Anterior view.
356
RadLJiartl!ry,wpl!l'·
ftclaljUhl.lrbr.anch
and the wrist Is In slight flexion (see 1). The tendon of flexor carplr.rdl· ails Is a useful landmark for locating the rodlol ol'll!ly pulse. The flexor arpl ulnarh tendon Is palpable pl'lllllmally over the pisiform bone. Nok: Due to their superficial courK>, the median and ulnar nervu and the radial and ulnar arteries are particularly susceptible to Injury from lacerations of the wr1st.
Uppa-Umb - - S. NftlrotiGSGllar Sy.JRms: Topogtvphkal Amrtomy
Superfldlll pamran:h
Deep
palmar ;n:h
•
b
C Course of the ulnnilrt.ll!fy ilnd nllf'ft In the ulnntunnllf ilnd deep palm Right hand, amzriorview.
a The palmar ~poneurosls ~nd anttbrachlal fasda hiM! been removed
" Bony l;mdlllillias wttHn the wn;rtunnel. The plslfomn bone on the
ulnar side of tile wrist and the hook of the hamate bone, 'Which lies more distally and radially, provide tile bony landmarks betwHn which the ulnar artery and nerve pas.s through the ulnar tunnel.
to clemonstr.ltt' the ~IW of tne uln;~r arttry and nerve through the ulnari:IJnnel.
--P~mar
apone
Ulnar artl!ly, superfiCial
br.Jnch(to superllcllll palrn.1ran:h)
Hypolhenar musdes
Ec:!:i~';----=.,-- Ulnar au
Ul~rn~.
andner\'t', dCCI) branch~
suP8'ftclll br.anch
~~zb----P~~
hlltus of ulnu tunnel
--....,....---
P~marc:arp;!l
)-----:---- Hook of Nmalle ~---,~-'---
Olstalhlatus
ohlnar tunnel
'\:\-----Flexor rS'haculJm ~---:=-~-~mil
hlatwof
llgiiTII!nt
• D
A9erture.s and walls of the uln•rtunnel wtth (a} andwltflout (b)
the niiii'V&ilnd - I s (after Schmidt and Lanz) Anterior view. Thepalmorroofoftheuln;~rtunr~ellsformed by sldn and subcubneous fat. tne palmar c:arpalllgament (proximal), ~nd 1be pal· maris brevism~~Sde(dinal). The ulnar I:IJnnel is bounded dorso'llybytne f!eliOr retlniiQIIum (transverse c:arpalllgament) and the plsohamate lfg· ament. The entre/nee tD the tunr~el begins at tne lew! of tne plslfomn bone bel- the palmar carpal ligament (proximal hiallls). The outlet is
at the level of tne hook of tne hamate, marbd by a but, tranMrse, aescent-shaped tendlno111 arth between the plslfomn and the hook of the hamate (distal hiatus), the latter giVIfl!l atbchment tD tne flexor digiti minimi. The def!p bnrnchl!s of the ulnar al'll!ry and nerve neach the antral compartment of the palm on the plsohamate ligament. passing deep tD the tendinous arch. The superfldol brcmdH!S of the artery and nerve run distally a!MM! the tendinous arth, passing deep tD the pal· maris brevis.
357
The Lower Limb Bones, Ligaments, and joints •.... •••••••....••••• 360 2
Musculature: Functional Groups ............ ...... 420
3
Musculature: Topographical Anatomy ...... ...... 442
4
Neurovascular Systems: Forms and Relations .. ... .. 464
5
Neurovascular Systems: Topographical Anatomy ... 484
Lo~,wrUmb
1.1 A
- - J. Bones,UgGmenB.amiJolnts
The Lower Limb: General Aspects
Unlqu~t~res ;md spectallzed function of the humin IDww
I lac
limb
tftSI
Coupled with the specialiution of the upper limb for visually-guided manipulation. the ewlutlon of the lower limb Into a medlanlsm spedf!CNeight of the abtlomin<~lviKera upon the peMs. Concomitantly, the Iliac wings ofthe pehlb have ~pre<~d farther apart irld the S<~crum his broadened, to generate a structure In humans that~ now speclallll!d for bearing the load of the lltscera. The effiCiency of upright gait has been improved further by stabiliution of the pelv~ and se<:ure <1nchortng tD the splnevla the sacrum. The unique proportions ofthe human lower limb prollfde a dramatic demonstration oftheex!l!ntofthlsspedillutfon.Beausetilelrfunctlon Is moreexclu· sively directed IJ:IWa~ support and loalmotion, the legs are exception· ally long <1fld powerful In humans. While the leg length Is 111 2: of trunk length In orangutans and 128" In chlmpanu!es,lt measures 171 X of trunk length in humans. Tbe specialization of the human lo-.w.r limb for bipedal galt Is ~lso reflt'CU!d In the substantial changes In funct!or1 of c:ertalr1 musdes. particularly the gluteal muscles. the knee-joint exten· sors, irldtile muscles of the calf.
Hlp bone
Hlplofnt
troc:Nnter
l'<emur
He~d
offlbula
a Olfemew of tile skeleton of the lower hmb ;a
Right lower limb. <1r112fforvfew.
b Right lower limb, posterior view (the foot Is In miiXfmum plantar flex· Jon In both VIews). As lfl the upper limb, the skeleton of the lower 11mb consists of a limb
girdle aoo tile attached free limb.
• The pelllk girdle In adults Is formed by the paired hlp bones (ossa o;1x.n, innominate bones). They differ~ the shoukle.-girdlc! in that they <1re flnmly Integrated Into the a1dal skdeton through the sKrOIIIac joints (seep. 116). The two hlp bones combine with Ule S<~crum and pubic symphysis to form thepeMcring(seep.365). • The free limb consists of the thigh (femur). the leg (tibia and flbula), and the foot. It Is confleC!I!d to tile peMc girdle by the hlp Joint.
Tllocrunll
""""- - - (llnlde)jotnt Lmnl
l'lllllleolts
Tirsills { Met.tt.r.Ais {
A\IIIMQU {
• 360
~
Cilt.111e
Piltlella~
l.ml\ll epl~
l.lrtml tibial QOndyle
Hmdofftbula
-----;1
~
)---
eplalnd)le
Jr- -
Medllltbllll
Med'al
-----; ~
QOndyle
II --:=~us
J...i:___ Cllcane81tubeto:slty ~TUberosltyd I ftfth ll'lO!UtiiS.ll
D Let length mHIMln:ment lr1 the stndlng posftton Leg lengttt dlsaep;~ncy an be measured Wltfl re
c
Pa. .blt bonypromlni!I'ICII!Softhe rtght lower limb ;a Anterior view. b posterior view. Almost all Ute skeler..l elements of Ute IOWI!f lrmb have bony prominences, margins, or $UI'facn (e.g .• Ute medial tibial surfice} th;at an be p;~lpiltl!d through the sklr1 and $oft tissues. The only oaptlons ire struc:tllres tftilt ire largelyCOYered by muscle, such as !he hlpJoint. Ute neck;and shaft ofthefemur,;and l;lrgepor· tlons ofthe flbulir shaft. Several stlndard ilnil· 1Zimlcal l;mdmarlcs have been defined In Ute lower limb for use in measuring tne length of
!he leg and ceruln $1o!letal4!1emer~t.s. They are !he illWrlor SIJpaior iliac spine. the gremr
trod!anteroftnefemur. the medlil Jolntsp;~ce oftfte kMe (superior rnitglrl oftfte medial tibIal cond:ile), arid the medial malleolus. The clinical eYiluation of leg ler~gth diK~ncy Is Important because "true• shortEning of !he leg (01 dlsp;~rtty of analJlmlalleg lengtfls) ~well as functional leg shortening (e.g., due to musde contr.lctures) an lead to ~ tilt ~well is scoliotic deformity of the spine (see p.106).
by plildng wooden bi~~Cks of known thldcness (0.5cm. lcm. 2cm) beneath the foot of the shorter leg until !he pelllls Is horlzcnUI. Horl·
zont;tl PQ$ition is confirmed wflen noting tnat both IIJic crests ilreitthesame level wflen pill· pmd from behind and the anal flssure Is Yet· tical. If Ute pelllls cannot be leveled by placing blocb under the apparently shorter limb, then ,. "functional" leg length dlscrep;~ncy Is present riltftertftiln 01 "true• dlscl'l!pancy. Most cases of this kirld ane caused by a fiXI!d pelvic tilt secondary to a hlp joint cor~tracture orllo.lls. The me01sured leg lengths lr1 these cases m;ay actually be equal, and the pelvic tlft only mimics a length disaepancy.
361
LotowrUmb - - J. IJcHJa, Ligaments, andJoints
1.2
The Anatomical and Mechanical Axes of the Lower Umb
-;:,=;-'---- - GIUIIus
....mas
A'--1---- c.e.ard.-.
(suponcrport)
aftllefoma"'l t..d(l'lpjaM) 1--1--- - Me
I~
eml......maf the tibial plamu (lmeejalnt) Kneebaoelne
,.lacnnl
jalnt b
A llle medwllcal ail ofh leg ( h MI~IIZ lne.) • Normal med\anical axis, anterior view. II Medlinlal uls In ~nu Virum. posterior view. c Medii nlal uls In ~nu Vi lg um. pasll!r1or vtew.
In in Jndlvldu;~l with norm01l ulalallgnment. the Arge joints of the 1 - limb (the hlp, knee, ;~nd ankle) lie on i straight line which represents the mechanlal longltlldlnal iiDCfs af the leg (the r.tllcullcz .lint). This mechanical ;uds exll!nds from the ~Wr of rotitiGn of there~ raJ heid through the lntest:ondylar anlnence af the tibial plateau and down through the anll!r of the anIde mortl2 (the pocket creab!d by the fibula and tibia fDr the tal us in the an Ide joint. from Atabic,. murtazz, fastened). While the mechanical uls and analllmlal uls colndde In the 11b/ol shoft, the iiNtomlcal and med\anlcal aes af the (mloral sho{t diVerguh 6" angle. Thus the longltlldlnal an.ltllmlcal axes of the femur
and tfbla do not lie on a stralg ht line but form i I~Wrilly Opal angle of ~the level afthe knee joint In the mronal plane (the (!motOiflllfll ~). In genu VinliTI (ll)ltle ~of the knee joint is ~~~ tG the medJiinlal illds, ;~nd In genu Vilgum (c) 1t b medlill to the mechanl· cal iiDCfs. Both conditions Impose ibn «mil, unbalanced loads on the joints (see I) th~ gradually cause degll'teratlw dli nges tG dewlap in the bcme and artil~e (osll!oarthritis of the knee) iiCOIITipanied by stretl:hlng of the associ~ joint capsule, ligaments, and muscles. In gll'tu varum (b), mr example, the medlll joint mmplex af the knee Is subjected to abnonm I pressure wh lie the lmr.l joint strudllres (e.g .• the lateral mllaWralllg~~ment). Iliotibial tract, and bleeps femoris musde are .wb]ected to abnormalll!nslon. Genu nrum also pAces greater streu on the I~Wril border of the foot. resulting In a fallen pedal ard!. 174"
B Polldon afthe medulnlalau~ wldl the feet slightly apart•nd together
Anterior vtew.
• 362
a In upright sblnce with the fftt piMI!cl slightly ~part. the mechanl· cal illds runs ;~I most voertlcally through the calter of the three Arge joints. b The legs are genr.~lly a~nsidered "stJaight" if, when the feet are together. the opposing medial malleoli and knea ~re touching. Accordingly. the Intercondylar dlsbince and the Jntermillleolir distance between the legs pnwlde an Index fDr the measurement of genu varu m and genu valgu m. When this stance is atWrnpted, an lntertondylu distance grelter than J em or an lnWrrNIIeohtr distance greatEr thin 5 em Is mnsldend abnormal (see C).
• c
Tlu~ norm~I leg - • dlffeni!M agM
Infant. b small dlild, c; school·<~ge child. Up t» about 20' of ge11u varum Is considered normal during the first year of life. Up to about 10• of genu valgum Is <1lso considered nonnal through 2 ye,;ars of age. By the time the child enters sc:hDOI, the le~ are ment!ally straight as a mult of musculoskeletal growth.
<1
flt...la--.
D Norm;ll 01nmxntal posltlon In n!latlon t» thellneof gr.ntty Right later<~lvlew. The line ofgravity runs vertically from !he whole-body anU!r of gr<~VItyt» lhe ground. In normal upright humans, It lnU!rsects the external .. udit»ry unal, the dens of the ax'i$ (dental process C2), the Inflection points between the normal c;urves In the vertebral column (between the aMc:al .and thor<~clc curves, .ind thor.iclc .ind lumbar c;urves}, the~ anter of gravity, and the hip, knee, and ankle joints. Chronic deYiatlon of ;my reference point from this ltne Imposes abnonnal stresses on different clusters of musculoskeletal elements.
E Sbletonoftheright~rllmb Right lateralllfew.
363
Lo~,wrUmb
- - J. Bones,UgGmenB.amiJolnts
The Bones of the Pelvic Girdle
1.3
Anterlar~
IlK '!line
Pa:rterlar super!ar
lnfefor
nlacspile
g~tne Anterlorl~rtor
llac'IJIMe
Pa:rterlar lnferlar
AtleUbllar rim
lllacsphe
Llnllle surliu:~
Acl!t.1bl.far fmsa Acl!t.1bl.fmlatdl
}--··
Pl.tllc llbm!e
Obturator fcr
A Therlghthtpbone l.ata'al 'lltew.
llaccmt-
lhcfcltra
I
.a~
Anll!r!or - - - ---;. InferiOr
Ilac!pine An:uat2llne
I Therlghthtpbone Medial view.
lnfu'lar pubiC~
364
Posl:e!lar
superlar
Olacsphe --~~~r.r---~rlw~
surflloe
ofllum
LDwerUmb - - 1. Bones,l.lgcrmenls. andjohtts
Arl\'m)r _ __,::,_
lnM!Icr IIKJplno
D The pi!lvfc gtnlle 1nd pelvk lfng
AntErior vtew. The paired hlp bones that ma Ice up the peMc giRlie are connected to each other lit the cartilaginous pubic symphysis and tD the sacrum .at the s.acrolllac Joints (see p. 116). This c~a stable ting, the bony pelvic rfng (shaded In red), that pennlts very little motion. This sta blllty throughout the pelvk: ring is"" importllnt prerequisite for the trllnsfer of trunk loads to the lower limb neassary for normal galt. C 111e rT11ht hlp bvne. Anter1or view.
Obtul'llllr
finmon
E
111etrt~ urlllilaeah rlaht hlp bane: thefunction afthe
lllum, ltdfWn, •nd pubis. IA!tenlvlew.
F SChemdc ndlognph !If the rtght•cetebuu.t of • dllld
IA!teral view (lateril proJection). The bony elements of the hlp bone come together In the ilcetabulum. with the Ilium ilnd Ischium e~~ch comprising two-frfths of the uet:o~ bulum and the pubis one-fifth. Oefirtltlve fusion of the Y-wped growth plilte (trlradliltl! artlbge) occurs b~the 14th ;nd l6thye;1rs oflife.
365
Lo~,wrUmb
1.4
- - J. Bones,UgGmenB.amiJolnts
The Femur: Importance of the Femoral Neck Angle
C!Wtlet ~t
-----'..........fL--
~al\
tltrlc'Mrt
}~
llledlol
tl.pl'i(JQ~at
- ----:!:.-.
II'!~
Adductor !U~tde
A 111ertghtfemur Anteriarview.
366
B 111ertghtfemur
Pas!J!riar view.
Tel'llion tnlbeallae
b
5'."""'-- - - Anltomlo:AII
ulsoft".!mur
• c 111e .,..l'lgl!mentand promlnence oftl!ftslon trabeaJiae and ampres&!Dn trabecdae as a function tlfh femDI'III neck al'lgle Right femur. amrlorvlew. a Coronal settion through the right hip joint ;at the level of the fgyea
on tile femoral heold. The angle betwHnthe longitudinal axis of tile femoral neck ilnd the axis of the femoral shaft Is e<~lled tile femorill neck angle or ceo ilri!Jie (e<~put
b The trabeo.tlar pattern associated with a normal femoril neck angle. Rildlogrllphs In the sagittal projection. c: Normal femoral neck angle with a normal bending load. d Acfemamffemoral neck angle (coxavara) leads to a greater bending l~d with higher tensile stresses, thereby stimulating !he fonnatlon of more tensicm trabeculae. • An /naeo.lledfemoral neck angle (CQlea valga) l~s to a greatcrpm· sure lo;td with higher compressive stresses. stlmulatlr~g the formation of more compression trabeculae. Cl-e
. - S•Parllll·
i '
bodyCI!flter
ofg;Mt:y h•IJMr41111\
oftllepartlill body weight
D Comprestlve and tl!lllslle stresses In a boM model a Ana.wiol(centl!red)WC!ight placed atop ;a Plexiglas model ofa pill;lrcreates a uniform prenure load that Is evenly distributed OVEJtile aoss sec:Uon of the pillar and whose sum lsequaltotheapplledwelght. b A ntllltlldol (eccentric) weight plaa!d on an OYe!'har~g creatl!s a bend· ing l~d that gener;~tes both tensile and compressive stressn in the pillar.
E 111epr1'ndpleofthetl!nslon bind (alb!rPiuwels) a The bending lo;ad acting on an l·beam model e<~n be reduced by placIng <1 high-tensile-strength member (dlaln) on the side opposite tile bending~- This added member transforms the bending lo;ad Into a pure compressllll! lo;ad. b In the leg, the fascia lat;a on the lateral side of the thigh is thicbned to fonn the Iliotibial tract (see p. 425). By functioning as a tension b.ilnd, the Iliotibial tract reduces Ute bending lo;ads on the proximal femur.
367
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1.5
- - J. Bones,UgGmenB.amiJolnts
The Femoral Head and Deformities of the Femoral Neck
A Ther1ghtfemur Pro!diTiill view. For clarity, the aat
lng" of the fan oral head In the hlp joint (seep. 378). When the femoral head Is centered In Ule acet.1bulum arid there Is normal anteYerslon of thefemorlll nedc, the pattllllls directed forwllrd.
added in light shading.
Nok the orientation of the
Ull!r<~l ----'~--
c:ancl)le
I~
B Ther1ghtfemur Dimlview.
Nokthe revenal of perspective from A.
368
nolm
LowwUmll -
1• .8cJ1Ju. ligaments, andJoints
Anf!Mrslan
angle (12')
l'lclln•l line
- --ti -
(
: ....
.\ - -
Femor.~lnedcDis
~Gkl!HI bbenlslty
CDn~Jr
Dis
•
Lhleaa.por.o
c
D lkltltlon1l dlfanntfm oldie retncnl MCk Right hlp Joint, superfor VIew. IIICI'Used or dKrNsed tor51on of the femoral wft resulb in tar5ian angles of varying size. When the hip is centered, lflls leads to Increased Internal or extern~l rotation of lfle leg with 1 a~rrespondlng change In galt (a "toeeng-In" or "toeeng-out" g;Jit). When the a~ndyfar nls Is t.ala!n ill the reference point, femoral torsion m
C The right femur. Medlilvfew. NoR the transW!rse mndylar uls and the h!mo111l nedc ilds. When the nes are .wpetfmposed, the two lines Intersect eich ather at a12" angle in ildults (antevtrsion anglr, see alsoD 1ndA).This angle is considerably huger ilt birth, rneilsurtng 30-40", but deae~se to lfle nonm1l adult Villlue t,. the end tl the second deade.
diremd furward. II An Increased ilntever51on angle (COlli onlftwtu} typlully leads to 1 toeing-In galt accompanied by a pronounced llmbtlon of utemal rotation.
c The femoral ne<:k 1J l"ett'cMr1rd (points badcwllrd In relitlon to the condylar ilxls). The rault Is CIII1CII mrowno with a toeing-out galt.
1.mwrUmb - - J. loMr. llgamen15, andJoints
1.6
The Patella
.....
---'---=-~- L*r.ll
tibial
(J)Ildyl~
A r.oc.tlon ofthe pttelll Right knee joint. llt«
Artlallar ourha 1!1
lllght pttella
~ Anterior view, II posterior view. c distil view. NoR that the apellof the prtelli polnt:s d--rd.
no
C Cross 54!C.Uon ttl rough the femorop;ltl!llar Joint Right knee, dlrt:llllfew. The level of!he cross section~ shown In A. The femoropatell~r joint is the site whe~ !he p;atell;!r surf\! a of the ~mur, often called the femoral trochlea (by analogy with !he dlst~l hummJS), articulates with the posterior articular surf.rce of the p;atella. The patella Is~ sesamoid bone (the largest s~mold), embedded In the quildrtceps ten cion. The p~telk! is well centered when the ridge Gn the undenur· f.lce of the patella Is seated within the grocwe of the femoral trochlea. The malnfunctlorlill role of the p;rtella Is to lengthen the effect!~ lever arm of the quadria!ps femotif. musde (the only extensor muscle of the knee), therebyredlldngtheforcerequlredtoextendtheknee}olnt(see also p.428).
D l!lNrtiR plltella Beause the p;atell.a dewlaps from multiple osslflc.iltlon centers, the failure of an ossification center to fuse rwu!B in .il two·part (bip~rtite) patella. The upper lmr.-al q~drant of the pmlla Is most commonly affected. Afracture should always be considered In the r.ildlographlc dlf· ferentlal dr.agnos&s of a blp;artrte pmlla.
Pa1ltllar
facet angle
Pat!lla
c
b
E TheC'IIllbltlonofplltellll'shlpe Dlagr.-ams of tingentlal radlogr.-aphs of the patella ("sunrise" ~ew: supine position, knee flexed 60", audocr<mlal beam directed par.allelto the postztior patellar surf;aa). Each diagram shOW31he relation of the p;atella to the femoral ttochlea In a hortzontil plane through the right knee joint. The posterior .ilrtlcular surface of the patella bears a vert!· al rfdge dMdrng 1t Into a lateral f.acet and a medl.al t.lcet. Gener.ally !he lateral facet is slightly conc;we while the medial facet is slightly convex. TbeanglebetwHnthelateralandmedlalfacm,calledthep;atellarfacet angle, Is noi1Tiillly 130""' 1o•. Wiberg, Baum~rt. and Flat devised the follOWing scheme for the classlffatlon of p;atell.ar sh.ape based on the facet.ilngle:
d
Patella with medial and latEral fa em of apprwdmatelyeq~l size and a f.-acet angle within the normal r.-ange. b Mo:st common patellar shape with a slightly smaller medial facet. c: Adistinctlysm~ller medial faat ("medial hypc:lpla.sia"). d Patellar dyspl;ala with a very stEep medial t.lcet ("hunter's hat" configuration). ~
Besides the wrtous pmllar shapes. the p;atellar surface of the femur (the femoral trochlei) also has a variable morphology {described In the Hepp dassilication system). Developmental dysplasias of the patella and femor.-al trochlea lead Ul p;atellar lnstiblllty marked by recurrent lat· er.-al or medial subluxation or dlslocitlon of the patella.
371
Lo~,wrUmb
1.7
- - J. Bones,UgGmenB. amiJoints
The Tibia and Fibula
Tbloflbular
nblotllu.far
joint
joint
Head offllula
Nedcoffllula
SNit--oftflla
Postietlcr --....,--~~ surface
Medial malledus
A The tM-. fibul-. and cnnlln1ei'OMeOII.IS membrane Right leg, ;mtaforvlew. The tibia and flbula artlculm at two joints that allow only WIY lrmlted motfon (rotation). Proximally, near tile lcnee. Is the synO\IIal tibiofibular join!; distally, .at the ankle, Is the tlblollbular ~smosis(fibrous joint with bony elements unitl!d by ligaments). The aurallnre~seous membrane (see also F) Is a sheet of tough connectiVe lfssue that SelVeS as an ortgfn for sewral muscles In the leg. Add I· tionally, it acts with the tibiafibular syndesmosis tD stabilill! the ankle mortise.
Ubi•.
a The fi'bul-. and crun~llntei'OMeOII.IS membrane Right leg, posterior view.
......__ _
Tran:r.<er.~euls
dtl!e lowe\' IIIIa
C Nonnalorfllflt.Jtfonofthetlblund ltr; rol~tlnmblllty When the tr.msverse axes of the upper tibia (tibial plateau) ;md lower tibia (ankle mortise) are superimposed, they form an angle of apptOXi· mately 23.,1. e., the transvene axis of the ;rnkle Joint Is rot.lted 23• lat· erally relat!Ye to the transvene axis of the ttblal plilte
orlfm:otlon, ;a). As ;r result of this. the loogltudln;rl;rn;rtomlc.;rl axis of the foot does not Ire In the SiiSJittal plane, and lhe toes point outward when the upper tibia is directzd farward (b). This signilic.;rntJy impi'CM!S the stability ofbtpeclal stance bypladng the line of gravity dose to the an·
ter of the area of support (seep. 363).
lnlercllndyl;r emlnencz
lllRr!or
altladrnmte
Tibial
Mf(ulmlriia! of
lllt!dliJI mafleol<~~>
llbla
tuberosity
E TherTght.nkfemort'lle Distal view.
D The rTfltlttlblll pi.Wu Pn:lximal view.
Posll!rfar Jurt.u:e
·=vf
I
1-seow m~mbnne
\....____-,___~ 1 Medial surfaa!
nbla
--Medial SJ~
F Crosuectlon through the middle tlllrd of th~t right leg - - - Anterfar
PrQJCfmal 'Yiew.
border
373
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
The Bones of the Foot from the Dorsal and Plantar Views
1.8
Dlst<~l philii!X
- --::--
ofblgcoe Dlsbl ph;llanx
c:lsmallcoe Mlckl~phalarut
Mel3tlrJUS
chmaiiC!le
(metm!S.11bones) )
flradn.1l ph;llaNt
chmalltoe
I
Antrnm·
Tanu
t.;nal
(t.;nal bon H)
C Armllmlc.11subGMslo115ofthe ped;~l skefeton lntl!nn~~
Right foat. dorul view. In the nomenclatuA! of desalptlve ~Batomy, the skeletal elements of the foot 01re subcltvlded Into three adjolnlng
- -+ ---ir---
segments: Head of -....S,~f----' talus Nedtof --~r--'i~". t
Cubcld
• The till'5us. composed of seYen borleS • The metata~. composed of tlve bones • The forefoot (antetarsus), comp0$ed of 14 phalanges
Compare this dlagr01m with the {ulldlooal subdivisions In D.
uteral malleclar striace
A The bones oftfle right foot Dor~lvlew.
- -a-B Thertghtbluund ulc:irneus Dors.al W!w. The two urs.al bones have .,_., separmd Jt the subtalar joint to demonstrm
their artfculir surf;u:es.
374
l'al>!lfor a'tfallar stJrfa~
fort
~,......---
Dlst<JI phalilnx ofblgtoe
DIIUI pNiar« clsmalltoe
- !!--- - Proldmal phalilnx ofblgtoe
h'lddepNiar« clsmalltoe
D Functlon;ll sulldlvllltonufthe pedill
Med';il
sla!feton
Right foot. dors.al 'VIew. The slleleton of Ule foot is often subdivided ;15 follOW$ based on functional and dlnlcal a1terla: • The hlndfoot (e<~lcaneus and talus) • Themldfoot{cubold, nil\llcular.cunetforms. and met.ttars.als) • The forefoot {the p~mal, middle and di$· tal phalanges)
cunelfoml lnl8'mecllte cunelfoml
Tuberosltycl flflh melllllU'III
o-fllr tnuJarls longus teldon
~~-~~--~!
--'=-~~
wnelfoml
-___:~--- Headoft.llus
- - - - Ne.:tolt.llus
1;-- - - Bod)lott.llus
lrY....- - - SUIII!n1aculJm t.111
r-- - - Pas!Jerlor
PIVCII!SScltlllus
Arb!rfar artlc:ular AJrf.aa! fer alc.Jneus
Articular Jurt.u:e
fer .wcular
Mlcldle;utkulu
S\l~foruiC
G-for f!el!Orhaluds lang ~a tendon
E The bDnes aftfle rTght foot Plantar view.
Medlal!llberde
Medial IH'OQ!'1S
clabneal wbera.stty lolll!r.liprocHS
cfcalcaneal wberoslty UC
wbenl:slty
- -.J.-- -
F The rfght tiillus nd c.Jicilneus Plantar view. The two tarsal borll!l have been separated ilt the subtalar joint wdemocutrate
their articular surfaces.
375
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1.9
- - J. Bones,UgGmenB.amiJolnts
The Bones of the Foot from the Lateral and Medial Views; Accessory Tarsal Bones
-......::1~--
Medllmalleallr Jurliu:e
A 111ertghttlluund c.JicilnNS Medial VIew. The two tilrsal bones have been separated .rt the subtillar joint to demonstrm their articular surf.aCI!s.
Headoftllus
Ptlsterfar
proc:ess ) of tabs
Distil plllllm ofblg~
B 111ebonesoftflertghtfoot Medial view.
376
llll!dlal pnx!!'1S of alaneallube!OSity
SuJ)I!ilor bodllear 5urf.n:~of taus
I
lnlerme1.11.11S.li bone-----'-~1
VHalkll"bone Emma~
Altlcula r1 urt.aae
tblal bone
r--'o-- - Flbularbone
for cuboid
C The rtghttlluund Cilk:•mt.atefal view. The two tilr5al bones hive been sep;u;ated it the subt.11ar
joint m demonstrlltl! their artlaJiar surf.ae2s.
E Acceuorytai"AA bDII• Right foot, dorsal 1/few. Anumber of accessory (lnconstilnt) ossldes are sometimes found In the foGt. While they rarely cause complaints, theoy do ~uire differentiation from fractures. Aclinic;~lly import.'lnt ac:teS· sory bone Is the external tibial bone, which c;~n be a source of diKm!· fort when tight shoes are worn.
Nedtoftllu5
Lltmlpnx:l!§d Medlalpn~CUSd ala neal tuberosity ala neal tube1011ty
l'niUnal phalanx Middle phalanx Dlsbll phalanx ohmlllltoe ohrniiii!De dsmaiiiDe
D Thebonesofthel'lghtfoot f..;ltefal view.
'S77
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1.10
Antw!r!or
- - J. Bones,UgGmenB.amiJolnts
The Hip joint: Articulating Bones
- ---'7-JI
~uperlor
llacsplnt
' L'nte~n· terlc crest
autllill tube1011ty
A The rtght hlp Joint from 1M antertontew
~-:-:-~---Pedfneal
liAe
In the hip joint, the head of the femur ;articulates with the a~oolum of the pehlb. Owing to the shape ofthetwo <1rtkulat!ng bones, the joint Is a special type of spheroidal (bilh1nd·socket) joint. The roughly spheri· Clll femoral hNd, which has ;m aver;age r also C).
8 The rtflrt htp folntfrom tilt> postl!riorwtew
378
Tr.Jill'fi!MiiflSIIe oftheeaubtlar tlletplim Acet.1bular Inlet plane
Aaubtlum Ischial jplne Aaubular
fossa lntirlar aa!tlbular
rtn
C 'n'il-neilngleoftheilcebblllulnletplirtelntfle;~dult Right hlp joint, ilntenor 'Yiew. Coronal section at the lew! of the icetabular fossa. The ac&aoolar inlet plane. or bony acetabular rim. fatl!s lnfa'olilter.llly (tnrnnome ~mglr) and also anterolnfaforly (54glttlrl angk; see D). The lnferoliltefal Ult of the acetabulum e<~n be dete!mlned by drawing .a line from the supenor acetabular rim to the Inferior acetabu· Jar rim (lowest point of the ~cetabular notch) and meawring the angle between thilt line and tile true horizontal. This transverse angle nor· mally measures approximately s1• at birth, 45• at 10 years of age, and 40• In adults (after Ullmann .md Sharp). The 'Yalue of the lrilnswne angle a~ several pa~meters. induding tile degree of lateral coverage of the femoral head by the acetabulum (the onglr of W1befg, see p.3S9) .
anf:Jlr•
•
a
D S;~glttillilngltoftheilcebbulntnletplirtelntheildult Right hlp joint, superior llfew. HO!t.!Dntal section through the ant:l!r of tile femoral he
b
The bony aatabular rfm Is angled anterolnftrforly relaUve to the sag· lUll! plane {compare this With the horlzont.tl plane In C). Th~ aperture angle measures approximately7• ilt birth and incrllases to 17• by adult· hood (after Chassard and L1plne).
379
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1.11
- - J. Bones,UgGmenB.amiJolnts
The Ligaments of the Hip joint: Stabilization of the Femoral Head
lltat Cltit - (AI*rfor-Sllperlor
Antleriot
lilac spine
sla'OIIK ll!lilments
·e~=-=-- Saaotllbews ligament
~r--
S;iaosplnow;
li91ment lid!Ill
spine
b
A Thellg;lments of the rfght hlp joint • Latefal11few. b .antenor VIew, c porterlorvlew. Tbe strcmgest of the thn!e ligaments, the iliofemor.al ligament, arises from the a~rior Inferior Iliac splr~e and f.lns out at the front of the hlp, att.;u:tllng along the lntEJtroc:ha~rtc: line (see b). With a tensile strength greatef Ulan 350 N, It Is the most powerful ligament In the human bcdy and ptollides an important mnstraint fDr the hip joint: It ~the pelVIs from tlltfng postenorly In upright stanct', without the need fDr muSOJiilr effort It also llmll3 adduction of the extended limb (parucul.arfy tfle lateral elemerns of tfle ligament) and It stabll~ the pelvis on the stanc.e .side during gait, i.e., it acts with the small gluteal muscles to~ the pehlls from tilting toward the swing side.
8 Thellgamentsofthe hlpfolnt rubo!t'ous lig;Jment
<
• • • • •
llioNmoralllgament Pubofemoral ligament IKhiofanoralllgament Zona orbicularis (anular ligament)" ugamentofheedof~mur••
• Nat 11fslble oumally,lt endrcles the femoral neck lll1u button·
hole. •• His no mechanlal function, butnnsmltS ~ssels that supplytht ~moral head (see alsop. 383).
380
tower limb - - J. Bones, Ligaments, andjoints
l
b
I
c ActiOns of die llaaments• • fundion ofJOint paltlon
a Right hlp joint In extension, lab!n~l vtew. The capsular ligaments of the hip joint (see facing page) fonn a ringlik2 cvllarthat encircles the femoral neclc. Wl1en the hlp Is extended, these ligaments becDrne twisted upon themselves (as shown here), pushl~~g the femoral head more finnly into the aatlbu lu m (joint-stabilizing function ofthe ligaments). b Right hlp joint In flexion, lateral view. During flexion (alll:ellersion), the ligament tlbers are lax and pressthe femoral head less flm1ly Into the acetabulum, allowl~~g a greater degree of femon~l mobility.
•
r
b
lgament
D Weak spots " die mpsule of the lfght hlp Joint Anterior view, b posterior view. There are weak spots In the joint apsule (color-shaded areas) loab!d between the ligaments that strengthen the fibrous membrane (see A). ~mal trauma may cause the femoral head to dislocate fn:lm the acetabulum at these sites (see E). The combination of great ligament strength and the close cvngrulty of the femoral head In the aoeta bulum make the hlp joint very stable, and dlslacatjons relatlw!ly r.~re. The situation Is different, however, following a hip replaament arthroplasty. The hip joint ligaments must be at least partially dlvtded to Implant the prosthesis, and the r1sk of dislocation Is maricedly lrx:reased.
1
~d
l
The twisting mechanism of the apsular ligaments can be re~ sented by a model conslstl~~g oftv.Q disks lnbi!rconnectl!d by parallel bands. The situation in c represents the position of the ligaments when the hlp joint Is extended. Wl1en one of the two disks rotates (blue arrow), the bands become twisted and draw the two disks closer together (red anrows). Panel d models the situation in the flexed hlp. The ligaments are no longer twisted, and so the distance between the two disks is increased {dter Kapandji).
.r""~'---
buum
PUbic dlt-
lac21an
lsdllclomaral
PUbcllomarol
ligiment
d
c
I
b
lsdliol tuberosity
ObllRior cllllawlan
E Trilmiltk dislocation of the hlp • It is most common for the femoral head to dislocate upward and backward from the acetabulum (lilac dlsloc.rtlal1) between the libfemoral ligament and lsd!lofernoralllgament Typically this Is caused by a fall from a great height. a motor vehicle accident (fn:lnt-end collision). etL In this type of dlslacatjon the leg assumes a position of adduction and slight Internal rotation. b t..lteral vrew. Position of the femoral head In vartous types of dislocation. The gneater trod!anter may be abDIII! or below the RoserNfla nton line.
381
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1.12
- - J. Bones,UgGmenB.amiJolnts
The Ligaments of the Hip joint: Nutrition of the Femoral Head
A Tile llfllmerm ofthe right hlp Joint The jolnt e<~PliJie hu ~ divided at tile h!Yel of the iCI!tabulir librum <~nd the femor<~l he..d has been dlsloca!td to expose the divided ligament of heed of femur. This ligament tr;msmlts lmport<~nt nutl1entblood~sels forthefemor;al head. b Anterior view. The fibrous membr<~ne of the joint capsule has bcal reiTIO'IIed at the level of the femoral neck to show the con· tixmiltlon of the synovial membr;me. Tills membrane extends later<~lly from the ilcet<~bular rfm and, <~bout 1 em prwdmal to the attachment of tile flbrous membrane. It Is reflected onto the femoral neck within the joint aYity. It c:onlin~~eS up the femor.-al neck to the chondro-osseous junction of the femoral he.-ad (see 01lso the coronalsectlonlfiC).
;a L<~ter.~l 1/lew.
l'lguln~lllglment
S:accosplnous
----'"--:T---'~
lil!lment
~~-+--- ~bu~r
libn~m
----:----'Ilk---
F-.aon
feman~lheld remoralh~
•
Neck of femJr
ln!J!rtrocfwl· tl!rlcll'le
382
- .=.,---..:........:
c:
Po~riorview.
LowwUmll -
1• .8cJIJu. ligaments, andJoints
Aatlbular ~--~·-- lolrum
I The •cetabuklrn of the rtght hlp )oint wtt11 the femol'll hHd rwnowd ~I view. The Cillrtilige~owred artlcular su rfMJ! of the ic:eblbulum
Is crescent-shiped (luNte surfaCI!) and rs bnwidest and thldest over the acetabu lilr roof. The lunate surnce b bounded externally by the slightly protruding bony rim of the aa!tibulum, which Is extended by i lip (the acetabulir labrum) c:omposed of tough mnnectiYI! Ussue and fibrocartilage. The cartilaginous artiwlar surfaa lines much of the ac:eblbular fosSll, which Is occupied by loose. flbrohrtty tbsue ind Is bounded lnferlor1y by the tran~e itebbular ligament In the anei of the acetabular notch (not Wlslble here). The ligament of hud of femur, which has been sectioned in the drawing, transmits blood vessels that nourish the femoral head (see C).
Ttii'IM!..e llgoment afocmbull.m
Ug;ment
of head offemlr
Mecllol tklrn· fllraus rnenbrine
-+..:...........:...;:..::..,:...
lla~onol
irll!ry
llopsoos
lindon l'rclmdl ftmorts arllry
• c
lheblaodsupplytllthehmor~lhHd
a Coronal section through the right hlp joint, antErior view. b Course of the femor1l nedc YUSels In relition to the joint capsule (rtght femur, ~nterlorvlew). The femoral helld derllll!s 11:1 blood supply from the lollberal and medii I circumftex femoral arberies and tile arb!ry of the ligament of head of
femur, which branches from the obturator artery (see p.490}. If the a nastomosa between the vessels vi tfle ligament of helid of femur and the femoral neck ~sels are absent or deficient due to the avulsion of blood ~- Cillused by i dislocation or femoral ned!: frictu re, tt.e bony tissue In tfle head ofthe femur maybec:ome necraac (Wo11Scular necrosis vi tfle femoral head).
383
Lo~,wrUmb
1.13
- - J. Bones,UgGmenB. amiJoints
Cross-Sectional Anatomy of the Hip joint
A knowledge ofaoss-sectlonal anatomy Is lmport;mtfor Ute lntapreti· tlonofMR lrnagesofthehlp joint. Bec.1wethe bonesoftftehlpJolntare not ~ble w dirett II!Xilmination by palpation, the ex;~miner mun be famnlarwlth the relationships ofthe muscles to the hlp joint.
~c-----~~~-~ card ";:\.l;~1f.~ffiT7--- R.eclla ten! oris Urin~l)'bladdet
I lOp$~
---
0~~--------------~~~ e<~nal
n\1~~==~~---G~
medius
U~m~tof---------------f,~~~~.~
had of femur
A.oellbulum
----;i;i;iiiii;~~~~~r.l.lt\1;.'
~~:.~;;~~~~~~~~~t(\1---H~dftrn~ --~~~~~--nb~
membrane
-~;~;._....q.,,_,c:.;J-+- G~
tro
::""'::::=i-:ii.i!51"""l'iiK:l9-T-rschl~
~c
bun a
~~~~~~~----G~
llli!dmus
A TnlniM!f'Se tec:Uon through the rtght hlp jobt
Superior view (drawing based on <1 ~pedrnm from the Anilt0mlc.1l Collection ofklel University).
Pedlneus a Mil ofthe h~regton:mal {tran:sverse) n '"'1111'411ghted SE rrn;lfll ;Itthe lewIot the h!mor.ll neck (from V
ing them very difficult to diJtingui,s;h from the musculature. which has similar signal lnten· Slty.
384
l'llbfs Urtnary bladder
Obtlr*t anal
~tectum
bcNum
Tensor fasciae l;iUe
lllapson He:ildoffemut Nedc of femur
Cteib!f tnxh1nla"
Obturator ln11emus
Iliacus CWos mcdmUI 1111.11'1
CWos medius
Aoetibull.ll'l
Gkllals
mnimus
Head of femur UQIIrnentd head offtrnur
£plphysealline
Aoetibullr {\)$sa
Neck offtrnur
Ciatl!r tro
Obturator
l!llb!mus Trochantl!nc bi.n.a
Adductor mwcleJ;
C Coron•l Mdlon th~h the lfght Np jcint Anterior ~ew (drawing based on a spedmen
tRim the AnatomiCO!I Collection of Klel University). CWos maxim us
Gutl!UI
medius Head of ftrnur Aaabular labrum
Ne
£plphysealline
D MRJofthehtpreglon:coronal n-Jghtl!d SE Image at the level c1 die acet.bulllrfoMa (from Vahlensieck and Reiser: MRT des Bewegungsapparates. 2nd ed. Thieme, Stuttgart 2001 ).
385
LmwrUmb - - J•
.&anu. Ugcrments, tmd}alrrts
The Movements and Biomechanics of the Hlp joint
1.14
A The ua GfITMIIIon In thllllpjoint Right hip joint, an~ view. As a sphet"Oiclal joint. the hip has thl'ft pr1ndpal ilii!S of motion. all afwhlch pass through the center ofthe fanoral hNd (the rotational center of the hip) and-muhlallyperpendicular. Amlrdlngly. the joint hillS thl'ft degrees of freedom allowing movemtnt in silt princip;ll directions:
1 - - - - - Longlludll1ill
.us
1. Transverse illo'ds: flexion (1n~.rJIDn) and extension (retroversion) 2. Silglttll ilxls: ilbductlon and adduction 3. Longitudinal iiXIs: lntanal I"Citilfon and external rotation
Eid:lmll rot.tlan
I
lurrDorlanl.,.
-*wSIIptnor
"*spiM
Antieftorwpertar IIIKspine
- -.%..=--. 30' .. Abduction
0'
Adduction
c
c
0'
30'~4V
I lblnt• vfcxteiWion ofthe right hlp Joint detam!Md with the
_ @W_
TIKI..- m1neUVB" The ThomiD maneuver Is UJed to meDure tfle range Df hlp extension while the pilltlent lies supine on a hard surf~ce. ~
st;Jrting po$ition with a slight degl'ft of anterior pelvic tlt (approx· lmately 12"). In this PQ$IIIon It cannot be determined whether or not there is a flexi011 contraction of tfle hip joint This is because the pilltlent can compensm for any llmltiltlon of extension by lnaeasing lumbar lordCISis (arching the lower back to hyperlordosis) and lncr&slng the degree of antl!rlor pelvic tilt b Pelvic:tlt can be tempol'tlrily eliminated by drawing the opposite hip joint (In this ~e the left hlp) lnlrl 1 po$lllon of miiXImum flexion. If the right thigh remains nat on the table, the right hip joint will be in ippraxlmmly 20" of extensl011 (normol emnslon). c Ifhip men3icln is limited (e.g.. due to a shortened rectus fanoris or Iliopsoas muscle) and the oppolb (left) hlp Is plilced In maximum flpion, the femur of the affected leg will be r~ised hvm the table by an amount eqUill to the lossof atenslon.lnaeased lumbir lordosisIs gen~al ly pr.-.t when hip extension is limited and iseesilydmmd cllnlca lly by p;~lpatfng the back.
r-
386
rot:JUon
rot:JUon
• c bnge of matllln of the hlp)Dint from the neutr•l (an~--degree) pcll!hlon (0') (1fter Debrunner) The rilnge of motion of the hlp Jol nt Is measured using the neutral-zero metflod (see p. 39). 1
Rilnge of flexlon/l!llb!nslon.
It Rilnge of ilbdudionJ,ddudion with the hip extended. c Range of ibductlon/ildductlon with the hlp fleucl90'. d Rilnge of internill rotation/~rnill rotation with the hip flllfed 90". e Range of lntemil ~on/edlern~l rotation In the prone position with the hip extEnded (when nw.suring rcJtlltion. the euminer use the leg,llexed 90", as a polnt«to determine the range of motjon).
LowerUmb - - 1. Bones, Ugoments, and joints
D Loads on the right hlp ]oint dultng the !ltilnce phase of galt Anterior view. In one-legged stance or during the stance phase of gait, the partial-bodycenterofgravity (S) is shifted toward the opposite swing side so that the partial body weight (K) acts along a line that runs medial to the hip joint. This eccentric load produces a rotational moment, or torque, whic:h tends to tilt the part of the body above the joint toward the side of the swing leg. To maintain stable balance, a counterforce must be applied (e.g., by muscles and ligaments) that is suffident to counteract the torque. In the hip joint. this force is supplied mainly by the muscular force (M) of the hip abductors (gluteus medius and minimus). This force, however, acts upon the hip joint with a lever arm that is only about one-third the lever arm of the partial body weight, i.e., the ratio of the lever arm of the muscular force (b) to that of the partial body weight (a) is approximately 1:3. Consequently, the muscular foru needed to stabilize the hip in one-legged stCJIICI! is equal to about three times the body weight. This means that the rompressivl! foru that the hip joint must be able to withstand (e.g., during walking) is approximately four times greater than the partial body weight K (according to Pauwels). As a result, the hlp Is constantly subjected to extreme loads which predispose the joint to osteoarthritic changes.
Diseased hip
l'ilrtial body Wl!ight
Dis...,ed hip
l'ilrtial body Wl!ight
Muscular force Muscular
--+--1'--Jl-/
Hlp abductors
foi'CI! Lover arm of muscular
--+=t+'f'~~
F----1-- Shortened lover arm of the load
force
Center of
_____J_::
l.ongthened lever arm of the load Opposing force
rotation
b
E Redudng the stresses on an osteouthrltlc right hlp Anterior view. In patients with advanced osteoarthritis of the hip, various measures can be taken to alleviate the stresses, and thus the pain, on the affi!cted side.
a Shift the partial-body center of gravity (see above) toward the affi!cted side. One way to do this is by carrying a shopping bag on the affected right side, as shown here. This moves the partial-body center of gravity closer to the center of the femoral head, thereby shortening the lever arm of the load (in this case the partial body weight)
and also reducing the torque generated by the partial body weight. The same effi!ct is produced by adopting a Duchenne Jim/)-iln unconscious response in which the patient leans over the affi!cted side with the upper body during the stance phase of gait (see also p.476). b Use a cane on the unaf{l!cted (left) side. While this lengtt-s the lever arm of the load (the partial body weight), it also provides a force (the cane) which counteracts the body load at the end of that lever arm. This reduces the torque generated by the load (as in a).
387
Lo~,wrUmb
1.15
- - J. Bones,UgGmenB.amiJolnts
The Development of the Hip joint
• •
Qs,111atfon anla'
A a.dlog.-.phTc app-.nce of the right hlp Joint
Anteroposterior projection.
P!JIIs
b
<
B stases rn the .-.dlog.-.phk:devefopment ofthe hlp Joint Schematic representations of IJ' radiographs tala!n at various stages in tht' development of the right hlp joint. The O$SII!c;atlon anters are lndl· c:ated by dirk shading. ;a
The ossi!ICitlon center far the femoral head can be ldentiHed at 6 months ahge.
b Ossification centers far the femoral head and greatertrachantef are
a Boy, 2 ye.li"S of age (original fllm from the Dqmtment of Dlagnos· tic Radiology. Schlesv.lg-Holsteln Untvenlty Hosplt;rl, Kfel Campus. Prof. 5. MDIIer-HQisheck, M.D.). Nok: The onificationanter for the femoral head is already visible. b Man 25 years of01ge (from MOiler and Ritlf:PodletArklso{Radfogroph/c AnatGmy, 2nd ed. Thieme, Stuttgart 2000).
lsd!lum
vlslblt'at4yearsofagt'.
c: At 15 ye;rrs ahge, the growth plates hil\le not yet fused. The init'Omlc.-al differentiation of ill sti'IJCtUres that (l)fllprise the hlp joint Is largely completl! by the 12th weelc of development (crown-rump length 80 mm). Whereti osslftCitlon of the .ilcetabulum begins between the thi~ and sixth months of fetal dMapment. the onific.rtion cente!' for the c.-apltal femoral epiphysis (femoril head) does nat appe
lnfetlor m.gln ofllkJm
b
C Uttr-.lnd 4!\lilluAion ofthe Infant hlp (from Nlethard and Pfeil: Or1ttopadle. 41h ed. Thieme. StUUgart 2003). a Normal hlp joint In a S.month-old child. b Hip dislocation (type Ill} in a 3-month-old d1ild.
longitudinally ave!' the hlp joint ;md perpendicular to the skln. The key landmark Is the superior acetabular rim, I. e., the bony and c.-artllaglnous roof of the acetabulum (see D). Infant hips are dassiHed Into four types bitsed on their sonographit features:
Ultrasonography is the most important imaging method for sD'I!ening the Infant hlp, demonstrating ~ntlal morphological d1anges during the first year of life wllhout exposure to Ionizing r.-adlatlon. The dllld Is examined In the lateral decubitus position {on his or her side, othef hip an ttle ex.amin;ation table) with the ulnsound trinsdua!r plaa!d
• • • •
388
Type! Type II Type Ill Type IV
Narmalhip Phyllologla~lly Immature hlp
SubhDcmd hlp Dlsloated hlp
--~ Pertiu-
.......
------J
Orr.bn!dlnne line
VU11ullineltlrough
O!l'afot ll!mo~ head
Saaum
Ilium
Am
roof line --JI.mabular angle of
Hlgenrelner
Htigenretner
line
Ufm!r-edge angle of Wberg
-+-r
(plph}wal line Osllflcatlcn aentl!rfar greatl!f tror:hantN
•
b
D Rdlogl'lphTc ev~lllltfon ofthe pedllltrk hlp Sdrematit n:!PI'C!$C!ntilti~ns of AP pelvic radiggr;~plu. Radiographic eval· uatfon of lfle lnf~nt hlp Is INslble after three months of ~ge, by which time there h~s been sufficient osslflc.rtlon of Ute joint. Bolfl hips should always be imaged on the same radiagr.1ph.
a Normal findings (left half of figure) contrasted witt! flndings In congenitoll hip disloc.rtion (right half af figure) in .1 two-ye<ar-old child. The following mnclard refenmtt' lines are used ln Ute radlggraphlc ~nafr.ils of the Infant hlp: • Hl/genmt?ulfi!f: connectsthelnferolater~l edgeofthelllum~bove the trfradiate cartilage on both sides. • Pettins-Ombn!danr!l! Iiiii!: dr.1wn from the IYIC)st lateral edge of the amabular roof. perpendicular to Ute Hilgenrelner line. • M!!rnmi-Shenrrxt lln!!: aJrved line driWn from Ute superior border of the obturator foramen along the medial border ofUte fl!mor.ill neck.. • Aattrbctlar angk of HllgenrelMr (l'rC angle): angle formed by the lntenectlon of the Hllgenrelner line ;md a line connecting Ute
l.l!g shor!Jening
superior acet.ilbular 11m 'With Ute lowest part of the Ilium at the trf· rad~te cartilil!le (see p.365). This angle measures approximately Js• at blrlfl, ~pproxlmiltely 25• at 1 year of age. and should be less than 10• by 15 years of age. Typically the ~cet.ilbular ;mgle of Hllgenrelner Is Increased on Ute affected (left) sldewhlletfte center-edge angle ofWiberg (see below) is decreased. Additionally, there is a disaMrtinuity in tbe MenardShenton lrne and the Paldru-Ombre~nne lrne runs medial to the femor;~l shalt b Evaluation oflatl!r;~lfemoral head aM!rage based on the center-edge angle of Wiberg (drawirlQ of a rarf~Cgraph of the right hip in a 5-yearold child). The ;mgle Is formed by avertical line through lfle center of thefemor.-al head (v.fthln Ute future epiphyseal line) and a line driiW!l from the center of the fernor.-al head m the superior acetabular lim. The anter-edge ~ngle should not be less than 10" betwl!en 1 ~nd 4 years of age. and It should be In the range of 15-20' at 5 years of age.
E alnkill UOimbltlon of congenltitl dyspiMI~ ~nd dlsloc:iiUon oftfle hlp Hlp dysplasia Is c:harad!!rtud by an abnormal development of the aatabulum (i~at.ilbu~r dysplasia) In which the steep, flattened ac:etolbular roof provides lnsuffldent CO'IIefage for the femoral head (see ;also D). The principal complication lsdisloc
dlsloc.rtlon ts0.2X(wtth a 7:1 ratloofglrls m boys). The following cllnlalJ sJgns may direct .1ttentian ta a dysplastic or dislacated hip: • lnst.ilblllty of the hlp Joint: paucity of Ieick· lng activity or a positive Ortolan! dick caused by subluxation of the femor;~l head. The Ortolanl test requires a very experi· enced ex;amfner. Willie still mnsldered part of lfle dinical ex-amination, it is performed less often today owing to tbe availability of ultrasound. • Leg shartening with asymmetry of the pos· tenor leg folds
Giuteall'dd
389
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.16 The Knee joint: Articulating Bones
l'opOtal !Kirfacle lnll!n:ondylar
notch Pllt81a l..at!l'al epicondyle
IJr1Jinl femoral condyle ~r.lltlbl~l
condyle
11blal p~;rtsu
Medial
~~ ~ Medial femonl ca1d:l!e Medial llblal ca1d:l!e
Llrl8'lll eplalnd:l!e
Llrl8'lllfernoral anlyle lnll!n:ondylar emner.oe 11bloftbular !oint l-leladofft1u.fa Nedcofftbl.fa
T1>lil t\lbEmlty
• A The right lcnee jotnt from the illltarforvJew (a) and postaior
mon apsule and haYe communlc<~tlng articular c.JVItles (see p.40D).
vtew(b) Three bonesartlculate.rtthe kneejolnt.nefemur. tlllla, and patella. The femur and tibi;l form the (emflrofibifzl joint, while the fl!mur and ~~~~ form the ~/Qr joint. Both joln13 are conblned within a com-
Conttastlr~g with
390
the elbow Joint, where the forearm bones arUculm
With the humerus, the tlbula Is not lnduded In the knee joint. Itforms a ~r~. rigid articulation with the tibia ailed the tJ}iofibular joint.
B The knee Joint knee joint a ;mteropo.stenor projection, b lateral p~or1 (original films from the Department of Diagnostic Radiology. Schles<Mg-Holsteln Un!W!rslty Hospital, KJel Camp liS, Prof. S. Miillet·Hillsbedc, M.D.). There ue three standard radlographlcvlews of the knee that demonstrate the joint lr1 three plane.s: anteropostertor, lateral, and tangent~!. The cm~rlliewis particularly useful for evaluating the width of the joint space and the contours of the tibial plateau. I.Qtm/1 \'Sews are good for evaluatlf19 the shape of tile ~moral ce~ndyle$ arid tne height of the patella. The txlr/gfntlal (surrrm) vfew Is used mainly for examining tile femoropiltellar Joint and evalu· ating tne position of tbe patella in the femoral trochlea (see C)• Right
• l'h!p;ltella r bii'Sa
Pmlla
- ---f----f':-?''rr--
Lmr.lllilaet ----,~Hj,f-1--lf=.:::::loo~
Pmhrw"-
offem~~r
--_.j~_;f.~f::.~;::~~"T;~-:-'~~->r""""":r-- synoo;~a~
mernbrane
b
Fibrous ----i:+.~
membr.an~
uteralalllmfal
ligament
+ 4 - - Mediah:llhb!\'111
-----~~;;,....,;:
Lmr.llftmcr.al _J...,.rll~t-"~ alndyfe
l111ment
---'--...,:.;.;;;,.-.,....:..i-1-4--+-- Cruclllte ligamems --+1-+.- -4- - Medlalfemoral
c The nmorop;ltellnjoint a Transverse section itthe level oftile femoropatellarjolnt. Right lcnee joint In slight tlexfor1, distal vlew(drawn fnlm a specimen rn the Ana· tomic;rl Collecti~n ~f ICiel Unilll!llity). b Tangential radiographic view of the p;ttella and femor;ll troch· lea ("sunr1se• view of !he r1ght knee joint lr1 60" flexion 'With tile bellm parallel to the postl!rlor p.rtl!llar surface). This llfew Is ext:el·
Cllnd)le
lent far evaluating the irlicular surface of the patella and the femoral trochlea. The radlogriphlc •joint space• appears partirularly wide owiriQ to the relatively tnidc: attia.lar cartilage In this reglor1 (articular cartilage Is not visible on radiographs). (Or1glr~al 111m fnlm the Dep;rrtmern of Diagnostic Radiology, Sdtles~·Holstelfl university Hospital, Klel Cllmpus. Prof. S. MOiler· HOisbeclc, M.D.)
391
Lo~,wrUmb
1.17
- - J. Bones,UgGmenB.amiJolnts
The Ligaments of the Knee joint: An Overview
.,...,"""""~~- Popltttal f~
---~~~~-- Medal held of gntroall!ml~
•
Ncul!z
popIleal ligament
B Ciastroalemfo-temflnembnlno:sus bursa ("lllla!f c:yflt:') In tfle poplrte~l re9'011 ~
A The C.PIU~, lgaments. and perl•rtlcUW burtae ofthe poplteal fosA Rlghtlcnee, pos!l!riorllfew. Be.sldesthe lfgarnems thilt reinforce the Joint apsule (the oblique popllte.alllgament~IMI ~rcuate popliteal ligament), tne apsule is also strengthened porteri~rfy by the tendinous ~ch· ments of tne muscles In the popliteal region. There ~re sever~! sites where tne joint c:.JIItl:y communlc.1t2.s with periarticular bursae-these Include tile subpopllt~l recess, the sernlmembr~nosus burw, ~IMI tile medial subt:endlriOIJS bu~ oftne giiStTOcnemlus.
392
Deplcdon of a B;rker cyst In tne right popllt~l fos~. A p;~lnful swell· lng behind the knee may be a used by a cystic outpoudllng of the joint capsule ("syn011lal popliteal cyst"). This frequently results from ~ jaint effusion (e.g., in rllaunatoid arthritis) causing a tise of intra· articular pressure. Acommon Bolm' cyst ls a c:y5tk: protrusion O«Ur· ring In the medial p;~rt of the popliteal fossa between the semimembranosus tendon and the medial head of gastrocnemius at the lew! of tile porteromedi;al femoral condyle (;;~strocnemie>-iemimembr;~· nosusbursa- communlc.atlonbetwHnthesemlmembranosusbursa and the medial subtendlnous burs<~ ofthe gastrocnemius). II Axial MR l~ge of .a knee with ~ B.aktr cyst_ The c:yltlc m~ss In tile popliteal f0$$il aDd its communic.'ltion with the joint aYity appe.1r as conspicuous areas of high signal Intensity In the T2-welghted Image (from V..hlensleck and Reiser: MRT des Bewegung~pp;~rates, 2nd ed. Thieme, Stuttgart 2001 ).
-~--hmur
Tendon of lnHI'tloncfvastus lntl!nntdus Valus
medialis
Tendon of Insertion of rectus femarts
I.Oc:itfon ofpmlli l.
Mechlcollatler.ll ligament
venepmllar mlnaculum l.
tuclllillpmltu mmwklm
- --:-tt-
Anterior view of the right knee, in which the apsule and p;~tella al1! shown ln light shading.
The cruclate ligaments are colored dark blue. the menlsd red.
tr+-:-1-+~1---- Mtd'altr.w~S
wn:e pitS Jar
nean.aculum
1
Lmr.IIG:illa11eral-tg;ment
D l..oGitlon ol the G\ldate llg;lmlnb and menlsd In the knee Joint
1
E OVervtewafthe llgamentsoltflelmee Joint Because lts articulating b~ny surf\ras are not dosely apposed OW!' a large anea, the kMe must refy upon a group of rtn:Mlg and eld:l!n· ligaments for stability. These ligaments of the knee joint can be segregated Into two groups. extrfnslc alld Intrinsic. si~
~~--t--- ~~~
me
• Anterfor side - Patdlar ligament - Medial longitudinal pDIIar retinaculum - Lateral longitUdinal tntdlar retinaculum - Medial tra~ patellarn!linaculum - Lateral ttansvene pD!Iar rellnaculum • Medial and ~al sides - Medial collaiBnllllgament (tibial collaiBnllllgament) - Lateral Olllateralllgament (flbularcol~lllgament)
C The anterior and lateral capsule and llgillmlnts ahhe rt;ht knee Jalnt
the tl!nd~ns ~f inRf"tion of 11!ctus femoris and of vastus medialis and lal:efalls. the longii:IJdl-
Anterior view. Thecapsule;mdllgamentsatthe fn:lnt of the knee serve mainly ta stabilize the pat~ella. The keyrtabilizer.s forthi$ PU!Jit!Se al1!
nal ;md tt;msverse p;rtellar retinacula. and. at a deeper level. the menlscapatellar ligaments.
• l'lllstl!riorsicle
- Oblique popliteal ligament - Arcuate popllte.alllgament ~l1llllc tlgamenb
- Ant.rlor cn.~clam ligament
- Posterlorcrudall! ligament - rranMrSe llg;lment of the knee - Posterior menlscofemor.alllgament
393
Lo~,wrUmb
1.18
- - J. Bones,UgGmenB.amiJolnts
The Knee joint: The Cruciate and Collateral Ligaments
\
\
~or
Aim!!lor
audl'cnn ligament
crud~
ligament
TllllliWrwll!iit-
~
ment of lcrlft
l.mnll menlsaa
menll=limctll
-~t:~==~~;
~~~~~
lgarnent
Anll!rlar -.-----..:1 llg;rmentof fibular head
ligament ~..mt;al
menllclls !..mt;al
t>OIImnl
ligament ~
ligament of f'bularhl!lld
Hl!\ldotflbula
Flbull---
~?---+- ~us
membnrne
A ThecrucT.te hg•menuofdlertghtlkneejoTnt Antafor view. The p;n:ellar ligament has been reflected downw.~rd
;a
w1t11 the al:tilched p;n:ella. b Postl!rlorvh!W. The cruc'iirte lig;aments of the lcnee Jtn!tch between the anteri~r and posterior Intercondylar areas of the tibia (not visible here: see p. 396) and the Intercondylar no!dl or the femur.
• The anterior audate ligament runs from the anterior Intercondylar area or the tibia to the medial surface or the lateral femoral condyle.
394
• The po5terigr crud~ ligament is thicker than the anterior ligament and runs apprcxlmiltdy at right ;mgles to ft. passing from the posterfor Intercondylar area to the lateral surface of the medial femoral conc¥e. The crudate ligaments keep the artlc:ularsul"i'aas ofUie femur and tibia ill contact while stabilizing the knee jaint primarily in the sagil:till plane. SCime portions ofthecrudate llgammts are taut In every posltlor1 af the jolr1t (seep. 398).
_ ,_,:or:;;--
Medal collltml ligament
Laten!
menlscul Plrtellar
ligament
··-:=-~~---'--7::'--+-- AnUrlat
ligament
offtbular ~d
• B The collllter~~lllgllments and patell!lr llfllment ofthe right knee jornt
a Medial view, b laterill view. The knee joint has 1:11.0 collilter~lllgaments: • The medial collateral ligament on the medial VIew of the knee. • The lateral CDIIateralligament on lfle lateral view of lfle Ia-. The medial ctllfatl!tfllltgamtrtt {Ublal collrter~lllgament) Is lfle broader of the two ligaments. It runs obliquely downw~rd and foi'Wi!rd frvm the medial epicondyle oftfte femur to the medial surface oftfte upperttbla
apprvxfmrtely 7-lcm belowtfte Ublal plateau. The~~ ctlllatl!tflll/gommt (fibular CDIIateralligament) is a round au1:1 that nms obliquely downward and backward from the lateral epicondyle of the femur to ttle heo~d of ttle flbulil. Botil of ttle collateralllgilments iltetaut when the knee Is In emnston (see A). When the knee Is rn flexion, the radius ofcurviltUre ~ decteo~sed and lfle origins and insertions of lfle collaterallig;~· rnents move closertDgelfler, causing the ligaments to become la11. Bolfl collateral ligaments stabilize the knee Joint In the coronal plane. Thus, damage or rupture of ttlese ligaments an be diagnosed by examining
b
the medlolater~l sbblllty of ttle knee and the extent of medial alld lat· eral opening of the joint sp;~ce with manipulation. Not!! ttle different rdatlonshlp of each collateral ligament to the Joint capsule ilnd associated meniscus: The medial collater.ill llgilment Is firmly .rttached bott1 mthe capsule ~IMI ttle medial meniscus, wheteo~s the~~ collateral ligament hu no direct conbct with lfle apsule or the lateral meniscus. A:5 il result. tfte medial meniscus Is less moblletftan the lateral meniscus and Is ttl us filr more susceptible to Injury (see ilso p.397).
395
Lo~,wrUmb
1.19
- - J. Bones,UgGmenB.amiJolnts
The Knee joint: The Menisci
Tbloftbular
Jotlt Hmdof fibula
Medial all !aUral ligament
•
Poru!tlor 0'11C~ Pcml!r!or merisco· ligament
li!monllllglrn.!nt
Lain
merisws
Head« flbule
A Thetfbfal plm:.a11 wttfl the medllll•nd lnenll menhd •nd the sltes of;attachment of the m~nhd 01nd G'I.ICbte llg;unents Rlghttlblal plateau, proxlrnalvlew'With the crudate irld collateralllga· ments diVIded and the femur removed. a Shapeind itt.lchmentsofthe menlsd: The medial and lateral menisci ~re both cres~t·sh~ped when vi~d from ab~We (Lmenilals•
crescent). Their ends (the antertor irld posterior homs) are attiched by short ligaments to the bone ofthe interior irld po.ill!!1or lnterc:Gn· dylar <1reas oftheUbla. The lottralll!o!lllscusforms almost a complete ring, while the meditll meni$al$ h;Js a more semicircular sh~JK'. On ttlewhole. ttle medial meniscus Is less mobile thin the lateril meniscus bee<~ use Its points of attichment to the bone ire spaced f.rrther
b
Area ohttadunent
~of
erudite l!iimMI
literal mt!nlsws
«poste'lor
attachment of
~part (see b) irld it is also finnly attichecl peripherally to the medial collaterallll)ament. The lateral mmlsaJs, by contrast. h;Js no attach· menttothelateril collateralllgammt(seeE). b Sites of attichment ofthe medlil and lateril menlsd and !he crudate ligaments: The red line indiC<~ttJ ttle tibial ~tt.lchmentofttle ~I membrine, which coven tile cruclate ligaments anteriorly ind at the sides. The auclate ligaments lie In the subsyncMil connecUwoe tissue of the jolnt capsule and are CDIII!red post:erlorty by the heavy flbrous membrane. Bee<~use ttle cruc~te ligaments migrate ~Wward into the knee joint during devdopment. ttley are extracapsular but Intra· artlaJiar In their location, irld they derive their blood Sllpplyfrom !he popliteal fDssa (middle genicular artery, iee p. 501).
Cln::ular<~r.~nge-
I
Flbrout
:J......
membn~ne
mentofalllagen
flberbundes
.....::::::::,. JO!ntcapsl.fe
a
BloodS1JPplytothemenf~oe1
Schematic coronal section ttlro~~gh ttle femorotibial joint. The flbrous porttonsofttlemetllsd locatedidjacenttottleapsuleh;Jvearlchblood supply (!he medial irld lateral Inferior articular arteries &om the popll· teal artery, see p. 501). But the more central portions of the menisci, composed of fibrocartilage. are iV
396
C Stl\lc:t\lneofthemenbaas The meniSOJs has a wedge-shaped cross section. ttle base of the wedge being directed toward the periphery irld att.lched 1» the joint e<~psule. The iUrfice facing the Ublil plateau Is flat, while the upper surface fie· ing the fi:!moral condy!H is concave. The central, innertwottlirds of the menlsd ire composed of flbroe<~rtilage and ttle outer ttllrd of to~~gh connecthte Ussue. The bundles of collagen libel's In both the flbroar· tilage and the cnnnectilletinue have a predominantly cirrular arrangement reflecting the high tensile stresses that develop In the meniKI. The abnlty of the mmlsal Ussue to move outward In response to load· lng Is slmllarl»thatfourld In lnterwoertebral disks (converting pressure to tl!!nsilefora.s) (aftl!!r Pett!rsen arid Tillmann).
Lmfal
colmral lgament
D Coron~l !lfttfon ttl rough tfll!femoroUblal Joint Right knee, an1l!rlor VIew. An essential task of the menisci rs to Increase the suri'aa ;rre;~ ;w;~il~blc! fW loi!d tr.!nuer ;rcro$$ the knee joint. With thetr dlffa'ent cuMtures. the menlsd compensate fW the mls!TiiltXh In the irtlallatlng surf.rces of the femur ind tlbla. They ibsorb ipproxlmately one-third of the loads imposed crltbe knee, aoo theyhelpmdis· tribute the pressures more evenly within the femorotibial jolrrt.
E Mowments of the menlsd durfng flexkln of tfle knee The drawings show a rfght knee .)clntfrom the laterallltew In extenslol\ (ll) and flexi~n (b) ;rnd the a$$oci;rteod tibi;al pl~teau 1liewed r-. ;rbove In extension (c) ind fieldon (d), Nore thit the medial meniscus, 'Which Is ancllored more seauely thai\ the lateral meniscus, undergoes considerably less displaament during
knee fieldon.
c
Medial
Posto!r'lar
Lmfal
menlscus audme l!9am«1t menlsclls
F Different patt:ern1 of menllal tun. Rlghttlblal plateau, proximal view. <1
Peripher;ll ttoar.
b Bucket-handle tt'ar. c I.Dngltudlrl.ill or flap ttoar ofthe antenor horn. d Radial tea ref the posterior horn. The medial meniscus. being le.ss mobile. rs InJured far more often tharl the lmral meniscus. Menisal injuries mort commonly n!$Uit from sud·
den extension or rotlltioml movements of the flexed~ (extemal;rnd lntemil rot:ati~n)'Whlle the leg lsffx.ed, as may oa:urwhlle skiing or playIng soccer. The resultant shearfng forces car1 tear the substance of !he me111scus cr aiiUise It from Its peripheral attacllment. The cardinal fea. tune of a fresh menisc;rl injury is ;r painful limitation of iiCtive and pa$$ive knee extenslor~lmmedliltdy after tile trauma, 'While the patient f.lwors the knee by keeping It slightly flexed. Degeneratllle changes In 1he melllsd oc01r w1th aging and are I!X
397
1.20 The Movements of the Knee joint
A 111eright~ totnt In tleltlon
Antelior vlewwlth the jolntcapsule .1nd patell.1 removed.
c
c BehJVIoroftlw crudnund GIIIJtelal llgiiMIIb ln fteldltn and l!llbniTM
• B COI'IIIItlon after Npblre ofthe anterior
audmlllgaiTIM!t a Right knee joint In flexion, anter1orvtew. b Right knee joint in fleo
b
lted w1111 the l.ad\JMn test). A rupture of the anterior erudite ligament, as shown In the diagram, 11 appniiCimatelyten times more CDI!lmon hn a rupture of the posterior ligament. The most common mechanism of injury is an lntemilrcmllontrauJMwlthlhe legfb!ed(see D). A lateral blow tD the fully extendl!d knee, with foot planted, tends tD cause concomltilnt rupb.J re of the ilnter1or erudite ligament .1 nd the medial (l)llateral ligament. and te<aring of the ilttilched medlill meniscus, ~to colloquially u die •unhappytl1ad."
Right knee, ilnterlor vtew. Ligament flbers that are taut are colored red.
a Elrtenslon. b Flexion. c Ae:xlon and lnterNI robtlon. Whlle the collateral lcnee ligaments are taut only In txtl!ll$i0n (a). the cruciate lig~menu, or a least portions ofthem,lretlu tln rvrty)olnt posmon: 1he medial portions of both eructate ligaments in extension (1), the llteril part of
ltle anterior erudite ligament ilnd the enUre posterior eruciate ligament in floion (b), the medial part of 11te anterior ligament and the emlre posteltor llg<~mentln fieldon ind lntem.JI rotiltfon (c). The erudite Iigaments thus help stablllze ltle knee In any Joint position.
LowerUmb - - 1. Bones, Ugoments, and joints
Transverse motion axis (•flexion{ extension axis)
'1;--+-- Radius of curvature (r)
e
Femur Posterior crud;lb! ligament
---;i'-":::~.,..-- Anb!~or
crudate ligament
Fibula
Tibia
c
b
of the knee (c. d), the dynamic flexion axis moves upward and backward along a curved line (the evolute, e). The momentary distance from that curve to the articular surface of the femur is equal to the changing radius of curvature (r) ofthefemoral condyle. The total range of motion, especially In flexion, depends on various parameters (soft-tissue restraints, active lnsuffldency or hamstring tightness, see p. 43 1).
D Flexion and extension of ttle knee joint Right knee joint, lateral view. Flexion and extension of the knee joint tala! place about a transverse axis (a) that passes through the dynamic center of rotation In any joint position. That center Is located at the point where both the collateral ligaments and the cruclate ligaments Intersect (b). With Increasing flexion
o•
0"
0"
30-40'
0"
Medial collateral ligament
•
Medial tlblal condyle
E Robtlonal movements of the Ubla relative to the femur with the knee flexed 90" Right knee joint, proximal view of the flexed knee and conresponding tibial plateau. a Neutral (zero-degree) position. b External rotation. c Internal rotation.
Medial
Lilb!ral
meniscus
meniscus
The axis of tibial rotation runs vertically through the medial part of the medial tibial condyle. Because the cruclate ligaments (not shown here) twist around each other during Internal rotation, the range of Internal rotation In the knee (approximately I o• ) Is considerably smaller than the range of external rotation (30-40•). As a result, the majority of cruclate ligament tears occur during Internal rotation and Involve the anterior cruclate ligament. Ntlte the different degrees of displacement of the lateral and medial menisci.
399
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
The Knee joint: Capsule and joint Cavity
1.21
SuprapRIIr -
""""t'"---::;,-.. . . _
I'C'Ir:h
~--~::--..,...--
l'lm!lar S\lrfiU:It
dh!m...-
l.ll1o!r.ll flmcral alnd)!~
Anttllor crudate
- -1117-- Medial fllmoral con d)!~
l!lilrnt!l\t Lllttrlll collattrlll
~~rg__ Medial meriK\15
1'91ment Lmr.al mentsaa
- ---::.,..---71--
lnfnl· pa!Jellr
fatp;ld
- --t---P-<.0---
Pmlla
(articular mface)
/~~-'-- Cut~dgeof
B Extent of the jo~ Glllfty Right knee Joint, lateral VIew. The Joint c.illllty was demonstrmd by injecting a liquid pl;tstic into tht- lcnee joint ;and later 11!moving tne cap-
suleafteftheplastlc had cu~.
joint CAIPSUie \,-~....,iF:----:-:.....- Supr.~pa11!11ar
I'C'Ir:h
A The right bee wtththe jornt Clpsulupcned The pall!! Ia has been reflected downWilrd. In the anterior menlscofem· oral portion of the Joint apsule, variable folds of the apsule project into the joint c;Mty (al;rr folds on both sides ofthlt infr.lpatell;rr fat pad). lncre;rslng Its ap;rclty.
c
Antl!rforfemol'll 1nd Ublll lttadlments of the Jolntapde Right knee joint. anterior view.
400
~-+-- Slb!sof ;rtt.xlment
oftne)ont capsule
Supra- - ---f- -i--riiEI
patr!lillr pouch Quadrl-
----'-~-
aps tmdan
D Mllkaglttlll sectfon ttnugh tfle r'l!ltlt lknee.JoTnt Nok tfle extmt: of the suprapatellar pouc:h (ilso called the supripateUar bww) ;md compare It witt! F. Note .also the placement of the
infrapatell;ar fat pad ~ the ~nterior lnterconclyl;ar area ind the dHp surface of
the patellar ligament. A f.all onto the knee or chrvnic mech
b
c E 1be •IJIJiottable patl!lluTgn• of knee elfullon
When in effusion develops In the knee joint due to Inflammatory changes orlnjury. wrtous degrees ofjointswelling may be seen. To dlffel'enti;ate an intra-<~rticul;ar effwion ~ $WCIJ.. lng of the joint c<rpsule Itself, the leg Is placed In a position of maximum extension. This will force the (potl!ntlally rnaeased) lntJa...arlfcular fluid out of the suprapatellar pouch and Into the space betwea'l the patella and femur. The examiner tften pushes Ute patella downwa~ Wllh the Index flnger. If there Is excessllle fluid in the joint. the patella will rebound wflen released, signifying a posltiYe test. l'tmur
Effusion
llbll
{t \
F Unfolding ofthuuprapatl!llllr pouch during flellfon
Right knee joint, medial view.
• Neutral (ze~degree) position. b 80" of flexion.
c
130"offlexfon.
The suprapatellar pooch extends proxlnn
Abula
401
LoMrLimb -
1. lloMS. Ligaments, ondjoinf:S
1.22 The joints of the Foot: Overview of the Articulating Bones and joints
AnIde
Mediol
I1'Klrt1sl>
malleoha
Medial
Tilw
-
maleclus Talu•
Calane1.11
Cuboid
Lloll!"'l molleoiU5
culumtall
lniBTnedi* cmelfunn
Tubeoslty
of fifth Nlllllaliar
metm~l
Utonl cunodann
Medial Cll1elfunn
~- --~~~+-~~~~-
blrsols
I Overview of tile JoTnb In the foot
-!
• • • • • • • •
• • • • •
1111otnJ1111 Joint (;ankle Jolntl Subqlar Joint (totlot;~ICIInQn Joint and taloala ,_n;rvlcularjolnt)' calcaneocuboid joint (betwe81 the calcaneu' 1nd cuboid bone) T~lonwlcullr joint (betwem lhe ulus 1nd n1Vtcul1r bone) Tran~taruljoint''
c:uneoniVtculir ]oint (betwftn tht cunelfonn ind navicular bones) lnb!rcunolform joints (between the a.onelfurm bones) C:uneocu bold joint(betwten lhe literal cuneiform and OJbold bones) lllrsomel:iltilrwl Joints lnb!rmmt.arsoljolnt:s (between the .....,. of the mebt.arsol bones) MebtarsophilangeiiJolnts Proxlmallnterphilangealjolnt:s Dlstilllnterphalangul joints
A Thll! •rt'lclllatlng .._, In dlfl'erent Jcllrltl of the rtghtfoot
• Anterior view with the talacrurnl joint in plantar flexion. b Posterlorvti!W with the foot In the nelltr.ll (ll!!~degree) position.
402
• In the subtlllrjoint the talus articulata wflh the calaneus and the novi
Cllaneo- --~...,g~;.- cuboldJont
c
Obllquetn~nsvers.e section dnugh the
fggt
Cuboid - --f---,,..--b.;,.o'
Right foot. superior view. The foot Is plant'lr flexed at the t'llocrural (<mkle) joint (dr.iiWfl from a specimen in the Anatomical Collectian of IC!cl Unlvmlty).
lnll!n:unelfonn - --f..,;.;..,.....\f.o:',_..!;-'.,.;:.,;.,;,...+ joints Tarwmetm~IJo'nts ---Mt-""~*'-+"'-..,...:.k,
(llsfranclolnt fnel AbWclllr ----i:-+11
d~lt!mln'ml
lnll!rossei
--HW'.!!i:::~!::-!r::i~~· :l
~-~\--
Middle phllanx offourtii!De
Dlst.llfnll!r·
Metmr50J)hllillge;JI jont d big IDe
.'11:--+- - l'n:ildmal ph.lfalllt ofblgtoe
plwllange.~ljolnts
.,....;.-+-- Dlltllphalalllt ofblgtoe
Anl:lemortlse
D Coron•l Hdlontfnwghtfu~talocf\ln~l
ilndsulltllnjcints Right foot, pnlldrnal vfew. The tllloaurill joint Is plant'lr fl~. and the subtalar joint Is sectioned thrwgh it5 PQm!rior a~mp;rrtmc!llt (drawn from a spedmeo In the AniltOmlcal Collection of Klel Unlllerslty).
~or--~~~~
tlblal'\oiiiSSels Abductor ----'::-:-~~)\ haluds ~acr..tus-__:
_
_J.._~...
plantae
403
Lo~,wrUmb
- - J. Bones,UgGmenB.amiJolnts
1.23 The joints of the Foot:
Articular Surfaces
•
trtl!m1 eel late
cunelfcnn
A
PI'Oidm~l
Right foot. proximal vft'W. a Metatarsophalangeal joints: bases of the first through frfth proximal phalanges. b Tarsomet
joint: proximal articular surfaceJ of the medial. Intermediate. and lateral aJndform bcrleS and the cuboid. d Talonilllfcular joint arid c:alcaneccubcld joint: proximal articular surfaceJ of the navicular and OJ bold bones.
404
Lm!'al cunelfonn
Superior troch&r surfatA!oftllus
Til
Medial
malealar NIYic:ul1r
surface Headoflllw wtthaltfcular sllfaael'or l'lll\llalar
~
I@
~ ll
Cllaneus lOith b ..UWIII' surliu:e for abold
CIIGineuswtthartfcular sumo:efarabold
Talus
N;Mcul;r
t
tntmnedm cuneiform
FnUhroughflfth
metmr.sals
d
B Dfltlll 1rUcullrsurt.H Right foot. dim! view.
a The talonavicular}ointand caleo~neocubokl joint: distal arth:ular surfaas oftne calclancu and talus. b The cuneonavicular joint and eo~leo~neOOJbold joint: distal articular surfaces af!he nilllfcular and caleo~neus.
c The tarsometatarsal joints: distal ar!Sclllar surfaces of tile medial, intenne
405
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.24 The joints of the Foot: The Talocrural and Subtalar joints Tibia
Mediill malleclus
I
I
Tlbli Abl.f;~
--
Anl:le
mortise
U!ml malledus Qk:antUS
..
Superior troc:tl&r s:urt.K:eof t
b
SUsttntl· culumt
Ul.a(pam!rtordl;~meur)
A Tile lltTculltfng skefetal elements of the tllocnn'lll Joint b Right foot. pomnorYiew.
c Trochlea oftherfghttalus. superior view. The t
B
Pom!ffor dtameur
S~ortrod!le;rmt.u:e of
a Right foot. anb!riorview.
!Jrtml malleolar artlcularsurlilce
Supa!or trocllle<ar surface of til us
than the postertor p<~rt), the bony stability of the uloaural joint dlffen in flexion and extension. When the b!Wder anterior p;~rt of the trcu:fllea articulates with tile ankle mortise In domf/exlon (where tne foot moves doserto tile leg, as In squatting), the syndesmotlcllgaments(seep. 409) are tightly stretdled and there is excellent bony stability. But when the narrower porterlor p<~rtof the trochlea comes In contact with tne ankle mortise In planmrfle;don (e.g .. standing on the toes), lhetal.a no longer provides <1 high degree of bony stabllltywlthln the ankle mortise.
Medlll malleolar artlc:Uusurfltuo
111eartk:ulllrsurfecesof!Manlde ~--+--
mor1fse
lnl8"oueous
bloalane.an llg~ment
Right foot. distal Ylew.
~---~-s~
culumtlll
-.,--..:!!i--
11ant.ar
aponeuro.sls
C Oftrwkw of an opened subtalllr Joint Right foot. medial view. The Interosseous uloale<~ne
406
calcaneus
l.ongplllrtlr Plllntlrcalaneo·
llglment rm!cularllgament
Nok the course of the planur c
tlons with the long plantar ligament and plantar aponeurosis to 51lpport thelongltudiBal ardlofthefoot(seealso Dand p.414).
D Course of tfle plantar ca'-'eonnkular ligament
Rfth
Right foot, plantar vieoN. The pl~ntar c.11c~neonavicular (spring) li!Ji!· mmt stretdles between the sustent
mea·
Medial wnelfolm
tr.llll
completes the bony socket of the t.1loc.1lc.1nean joint from the plantar 5kle. ~'ff--l'lilnt<Jr
alanHnll'ffwllr
llsllment -.!..J-11---Su~ w~rntlli
E Tile ut1c:W1r surtilcc1 ohn opened Utill;n Joint Right foot. dorsal view (after separ.atton oftile talus). In tile subtalar joint the t~lus articulates with the c.1lcaneus and the navlaJiar. It consists of 1:VIO completely separate artlaJiatlons: ....-,!~!.'--
CUboid
~~,...-ij----IIINrcatellgament
+---Dorsal akllneoc:ubold
ligilllent
DMded lntl!rosseous tlloab~n
• a posterior compartment (the talocalca· nean Joint) and • an anterior compartment (the talocalca· neonavlcular Joint). The boundary ~ the two compart· ments Is formed by the Interosseous talocalca· nean ligament located 1r1 tile tarsal car~al (bony anal farmed by the sulcus tali and sulcus c.1l· cane!; Its entrance Is the sinus tarJI). The plan· tar calc3neonavlaJiar ligament. which has cartilage cells In Its medial sulfate, loops like a tendon around tile plantar he;~d of the t~lus. which acts as a fulaum. It stabilizes the posl· tlon of the titus on the calcaneus and helps to support the apex of the lor~gttudlnal pedal arch (see p.414). Oventmchlng of the plan· tar calc3neonavlaJiar (spring) ligament due to flattening of the plantar vault promotes tile deveklpmentofflat faot.
lig;Jment
407
Lo~,wrUmb
- - J. Bones,UgGmenB.amiJolnts
1.25 The Ligaments of the Foot
A T11e ligaments ofthe rtghtfoot. med'll llfew The medial and lateral tollateralligarnents, along with the $Y11dHmotic ligaments (see E), ~re of ma)or lmportai'ICe In stabilizing ~nd guiding the subtllar joint. beause portions ofthHe ll~ments are ~ut In every Joint position il'ld thus In every movement. The ligaments of the foot are classified by their location a.s belonging t1:1 the taloaural or subtalar joint, the metatlrsw, the forefoot. or the sole ofthe foot.
v
~r!ortlbll)-
Hbularlgament Antmlr tlblo·
talarpart
'llllanMcular
part
}
Dettold lpnent
TiblofbUar'Y!ldesm<XS'a (~cllgamenb)
Qlaneo- _ ....:.:,_ _ _.....,."
flbl.far ll9am81t
Cllcaneur.
-....,..-==---
!Dngplant.lr -~----=:--=:::!!!!!!!I"J:;;:<'"1 ligament In~
taloalc:.ll'le.-IIIQIITM!nt
Dornl«llc.wnowbold llljiiTIIrltt
B T11e llg;~mentsofthe rtght foot.lmr.ll v1l!w Sprlllru of the ankle joint and especially of Its lateral ligaments (usually supination trauma • buckling of tne ankle in a supinate
408
leisure actMtfes when the <~nkle gives W1l'/ on uneven ground. Typically tne trauma will awe stretching or tearing oftne antl!rlor~lollbularllg· ament. tne c:alcaneofibular lig;ament. or both. If the leg is twisted vi.,. lently while the foot Is fbced, tilere may also be separ~tlor1 of the ankle monlsewlth dlsrupt1or1 oftile Ubloflbular$YIIdesmosts (see D).
..-----:r--
lntero:sseour. membrane Fibula
"'t""- "t-- - ~orllbk> flbularligln.nt
Anterior abloftlu.far 1'91ment
l.olt2ral malleolus
l.allmll
Posll!rfo r t.11oflbl.farl'91n.nt
m~lleolus
n - - - Cllal-'llulu IQIIme<~t
-.....~7-:----'~--
0or£alt3rsal llgamems b
Donal-~--ii....-~-_,.e-.,.rll.'l,
metmnal llgamen1s
c The llfllmenu ofthe right foot a Anterior view (talocrural joint In plantar fieldon). b Po5terlorW!w (plant:lgr.ilde foot position). The anterior .ilnd posterfor portions of the taloaur.ill Joint eo~psule hwe been remO'VI!d to demonstrate more de..rly the placement of the llg<~· mt!l'lt$.
Aacfmal phalanx ofblgtoe
...e~-- Distil
•
phalanx ofblgtoe
E The llf;lment:s ofthe alocrural Joint (the ligaments ofthe subtalar joint are rtY!ewed on p. 407).
a.tenll..._.... o
Fibula
o
o
Synclemosls
malleoiLll
Anterior talofibular ligament PosiBior blloflbular llgam81t Calc.aneollbular ligament
Meclllllllga1Mftb0 o Ddtold ligament
l.olt2ral malleolur.
- Antertorablobllar part - Posterior tibiotalar part
Tal .a Cllanew
b
c
D Weberfndlns A Webef fr.-acture Is an avulsion fracture of the 1.-ater.-al malleolus from the fibula. Weber fractures are classified as type A. B. or C depending on whether the fibula i5 fractured below, level with, or abcwt- the $yn· desmosls. The syndesmosis may be torn In a Weber type Bfracture (as shown here). butltls alwoystom In ;a WebertypeCfr.-actiJre.
- nblannlcular part - nbloalc.an~~~an part Syndelmotk 11...-ofthe •nllle mortfle o Anterior tibiofibular ligament o
Posller1or tlbloflbular ligament
"The mecllal.ilnd latleralllgaments are .illso b!rmed the medial and laiB'al colla!B'alllgaments.
409
LowerUmb - - J. Bona, Ugammts, andjoints
1.26 The Movements of the Foot
A:llsof
tlloaural }llfntmollon
A:11s af UIO
AX!oafso.btalar )clntmatlon
• A Th• plindp;~l-s vf matlan In th• rtghtfvat • Anterforvtewwfth theuloaural joint In plilntarflexlon. II I'Dstl!rlor vlew In the fu nctlonal position (.see B). c lsolitcd rightfvrefogt, proximallliew. d Superior vlew. The u.es of ilrtlcu lu motion In the foot ue mmplex. and the descriptions of n-.,ents In the pedal joints ilrll often lnmnslstent ilnd mnfuslng. The following ues of motion ilfll Important ln c:llnlal p.ari.Jnce and fvrthe tati"!! ofjoint mgtkln {com~re with the 00"!1 p~e): • Ads af bbnnl joint llllltiDol (plantarflalonldamllexlon): This
Mls runs ;IImost nnswntfy through the lateral and medial malleoli. It forms an ilppraidmately 82' angle with the tibial shift axis In the
frontal plane. ilnd It forms il 10' angle with the frontal plilne on the medial side {1, d). • A:dl tJJf mlltllar joint maliGn Pnwnlllll/-*111): This Dis runs obliquely up~~~~<~rd through the foot in a posterolateral-to-;mterom~ diil direction. I.e.. from the latcnl alc:aneus through the medial portion of the tarsal caNI to the center of the NVtaJiar bone. It fvrms an appraxim~ly lO" angle with the horilontal plane and a 20' angle with the Soilglttlll plil ne (b. d). • A:dloffonloatlnlltiDn lnthetnrawnRtilrYijofntilllll til~ tlnal joTnb fllr-tlonls•rwaan): This IDds lies approximately In the sagittal plane. running from the c;alc:anlllll1 through the navicular and along the second ray (1, c).
Medf.11 malleol~a
c B The l'undloul posman of the hlot
Right fDat. laberal view. In the neutral (nrc-degree) pcMition, the skeleton of the fvot Is angled approximately 90" relative to the sbleton of the leg. This plonlignJdr foot position Is termed the "functional position• and Is ;m Important biiSis for normil standing and walldng.
410
C Ax1s of the hlndfvot Distill rtght I~ and hlndfoot. posterior vtew. a With normal mal alignment In the hlndfoot, th•tlblal illlls and c:alc:aneal axis lie 1111 a vertical line {pi!S I'W!ctus). The calcaneal axis bisects a line drawn between the two malleoli. b Pes valgus: The foot Is In in everted position. c Pe.s v.aNS: The foot Is In .an lnwrtcd pcMIUon.
LDwerUmb - - 1. Bones.l.lgclmenll. andJoints
D Nom11l r1ng1 of motton ofthe tllloaunll )Clint Lite~I vi-.
•
IUghtfootontheground(sbn~leg).
It !tight footoff the gn~und (5Winilleg). St3rtlngfrom the neutril (11!1'0-degree) (pliinlfgrllde) posltfon, tile non-welghtllearlng foot has an approodmaWy ~-so• range of plantar fle:Qon 1nd 1n 1ppradrnmly 20-30' nmge of dorslftexlon (extension). When the foot Is planted on the ground (in the stance phne of g~lt), tile leg CIA be moved 1pproxlmmly 50" backward (pia ntar flllXIon) and 30' forward (donlfleldon). 40-SO"
F Range tJI p.-t~onJsupln.Uan flltlle tnniWrM tlll'lllllnll tllrHmdlltuNI )aInti. Right foot, i nterlor v1rw.
E Range tJI mallan tJI tile tdlbllr)olftt Right fuGt. il nterlor v1rw.
• Everted by1o•.
It Neutnll (11!1'0-degree) position. c lrM~ by 20".
• Range of pro!Ytlon of tile fomoot: 20". b Range ohupinatfon of the forefoot; 40".
~ of th~ ak.n~us
Range of motion istestedwitlltlle hindfootfiRd. Pronation/supination of the folrilot Is tested by rotating the flnfoot outward relltlveto the hlndfoot (raising the latenl border of the foot), or Inward (raising tile
mecuUy tm~rsion) i111d literally (ewnion)
Is meuured from tile neutrll (~degree) pasltlon. This Is done dlnlcally by holding the leg rtatlon1ry and 1n01111ng the c.alcaneus bade ;and
fortft. EstlrTIIUon of the r1nge of lrMrslon/everslon Is biSed on the e~l canellals.
medial border ofthe foot). 70'
60"
I
45'
C Total range tJI motTon tJI die foNfoot and hlndfool: Right fuGt. a ntel'ior Ylrw.
H Range ol matfan ol tile JCIIntl flllhe big toe Linnlview.
• Everlion and pronation of th~ forefoot; 30". It lnw:rslon 1nd suplnitlon ofthe forefoot: 60'.
• Flexign/CJCten$iOn ofthe first metat
Because the mCMII11ents In tile joints are complelc. 1nd different joint movements are almost always mecNnically mupled. the range of all jointmcMITlents can be uJeSsed by holding the leg stationary iind raJ~ lng the entiA! foot In the medii! iind lmnl dln!ctlons.
The toes, and especlii lly the big toe, CIA be passively extended to appraximmly 90". This is an important pnrequisite for w:alking, espec:lally dur1ng the phase between heel tlb!-off1nd toe strike.
411
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.27 Overview of the Plantar Vault and the Transverse Arch
Medial-~+-~~'
I'IY'
I
4-1..,_-
utenlnrys
CUboid
•
b
A The plantar vault • Right foot. superior view. b Right foot. pomromedlalvlew. F~ the perspeclive of structural engineer· lng, the forces borne by the foot are distributed among I:\IWI later.ill (fibular) ril'fS and three medial (tibial) rays. The lateral rays extend across tile 01bold bone to !he e<~lca nem, wltlle the medial ril'fS extend aaoss the 01nelform .ilnd 1\Mcular bones to the taiiiS. The arrangement of these •ll'fS-'Idjacent dis· tally and OYe!Tidlng proximally-creates a lon-
•
gltudlnal arch and a transvene arch In the sole of the foot. These plantar arches enable the fvot to adapt optimally to uneven terrain, ensuring that the compressive forces can be transmitted under opUmum mechan· leal conditions In any situation. The .ilrches thus perform a kind of shoclc·absorber func· tlon, creating a springy fleldblltty that helps the foot .absorb vent'cal IO.ilds. The deficient arthes in a flat fDot or splayfoot. fDr I!XO'Imple, can IN
Subtllar
Jont
C Tr.lnsfer of compreulve stresses In the welght~rfng foot Schematic sagltt.ahectlon at the level of the tlrst ray, medial VIew.
a During stance. the partial body weight on thetalocrural joint~ transferred ;acrws the talus to theforefvot and hindfoot.
412
B The plantar an:fllted.ure aftfle rTght foot Superior view showing the bony points of support fDr the plant
b
b A schem
acting on the forefoot and hlndfoot (a) (after Rauber and ICCipsdl).
LDwerUmb - - 1. Bones,l.lgomenll. and joints
/-ii--lri+-....-:~.;:o.,,...--
Pla..Ur llgirnenb
Baseolllnt pl'*lmal pbUIIX
Deeptr..- . llld3tarUIIS)Iment
phalanx of hlgme Mmtonophalang..l Jotrtaf big me
t__,., ~Mt!brul
lgament
o-:!"-:-:-!-!!'------l!!---
Plantor
llg;rnenll
a
Prmolmol
Dft9 _.;;,._,....~
- 1---
Adductor holluds, tr......... head
loseafftfttl
motmBOI
Fnt IMtlbnal
JN.,.;..l.,,......___ Adductor
Bno offlnt
holluds, obllquehsd
h
rnomt;n.al
Adductor hlllucll. oblique hl!llld
Medill
""I!Gius ~
culumtlll Medol cunelfann
Tlblolls
c
postw1or
E Adtve and !MUM sbbllze1"5 oldie t,._ne ilrdl, pi'CIIIhil vfi!W
Right foot. D Al:ltlle 1nd pMIIW lbbdlzers oldie tn.-,. 1rdl, plantlr vfi!W
Right foot. Both uUve and piSSlYe stabilizing structures malntilln the curvature of theiJ';nsverse peda I;rch. The p;ulve stabilizers are ligaments, and the ldive mbdlzers are muscles. In the foot, ligamentous structures are usually able to malntilln the pedll.uches without asslstilnce from the musdes. But when the loads on the foot are incre0Sed, as during walking or running on uneven ground, acUve musaJhu forces •re also recruited to give ;ddltlonal support.
Arch st.ablllzers In the forefoot (anterior ilrch). The deep trann"erse metiltilrsal llga ment stilblllzes the anterfor arch at the 1-1 of the met.at..rsal heads. The ardr gf the forefoot thus relies entirely on Jl(>ssfolor stabilizers, while the uches of the metiltilrsus and tarsus (b, c) have only «1M! stilbilizen. b Stabilizers of the metatarsal ilrdr. The trann"erSe head of idd uctor halluds Is the prfmary muscular stabilizer ofthe metatilrsal arch. c The princip;rl ;m::h-supporting mu$de in the tilrsal ~ion is the fibulilrls longus. After winding uou nd the cuboid, Its tendon of Insertion runs from the lateril border of the foot and across the sole to the medial cuneiform bone and the base of the first metatarsal. Another ictlve stabilizer In this region Is the tibialis postll!rlor, whose tendon of insertion gives off exp;~nsions tD the or neifonn bones. Lib the fibuliirls longus, Its obllquecoune enllbles It to support the longitudinal iirch In addition to Its triinSYI!r~ component 1
413
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.28 The Longitudinal Arch of the Foot
r.roalcar>eoNMwllr)olnt ~cmpartmt!nt ~hubt.Jiarjolnt)
N;Mcular
A AcUVe stabilizers ottfl~ longltlldln1lardl S;rgitt;~l R
The second ray (consisting of the secood toe, second metatll'$.11, Inter· mediate amelform. lliVIcular, ;md alc:ilneus) forms the highest ;m:h within the Olll!ralllongitudinal plantar arch, its height diminishing lat· erally. The mall'l active stabilizers of the longitudinal 01rdl 01re the milS!Xsoftlir foot: abductor halluds. f!exDrhalluds brevis. flexor dig ltDrum brevis, quadrab.ts plantae, ;md .ilbductor digiti mll'llml (draw!'l from a specimen in the Anatomical Ccllection ofKiel Uni..ersity).
mort Flexorhalluc:ls lang us
+-'i-+-- Flexordigttorun
Nmcular
longus
----.!~--;.,::f--
Medial
maleolus
B P;mtlle mblltn!rs ottfle longitudinal arch
Right foot, medlalllfew. The main paS$Ive stabiiW!rs of the longltlldl· nal arch are the plantar aponeui'V'Sis, the long pl;tntar ligament. and the plantar calaneonav!cular (spring} llgiment. The plantar apon~rosls Is par1kular1y lmportal'lt owing to Its long !eYer arm, while the p&;tnw c:o~l· c:o~neonavlcular ligament Is the we.tkest component (shortest distance
414
1Mg Ilia ntar
Pli nti r«~kiln eolliJYialar
llgament
ligament
Su stl!nlitOJklm tiO
from Ule ipex of the longitudinal arch). The tendons of fnSI!rtlon Gf the kmg f/alrs Gf the foot (flexor hallucls longus and flexor dlgltoMJm longU$) also help to p,_nts;agging of the longitlldin;al arch. The flexor hal· lllds long II$, which MJns beneath the sustentaculum tall, Is particularly effective In tightening the longltudln<~lirdlllke the chord of an arc.
LDwerUmb - - 1. Bones,l./gclmenll. and joints
Pllnbr aponui'CIIIs
Long plantor
llgamert
..
•
-·-···-..+ + + + + + +
q-N/an
_l_b .d
D Flllllpfnts (podogl'llms) ol rtghtfeet (aftl!r Riuber and Kopsch) a Nonnal plantar uches (pes ~Kills). It Increased height ofthe longlrudln~l ~rch (pes ciiiiiiS). c Loss ofth~ tran!M'r" arch (spleyfoot • pes transversoplinus). d Loss of the longltlldlnal 1rch (flatfoot • pes plinus).
!- - - -
..
'
Foot deformltl~evlatlons from 1 nonmal, hulthy foot sbil pe--may be cangenlt:oll, or acquired through paralysis or trauma. 51ructural ilbnonna lilies caused by ch ron It loads Imposed on the foot by the body weight are referred tD spedflally as strrttc de(otmltles.
qxl2
H(o::orstrllnlng force)- axf
c
SUpport of the langltlldlnlllnfl Ligamentous support f1f the longitudinal arch (right foDt. medial view). It Calculating tile canstraining faou (H) needed to maintllin the arch (after Riuber and l(opsch). il
Comparing the longitudinal arch f1f the foot to 1 theoret!Cill pariibolk: iirch, we see tNt a constraining fora (H) must be iipplled tD rNlnbln tile arch curvnune. The m~gnltude of thisfora depends on tile load (q), tllechoRIIength of the ilrch (1), mdthe helghtofthearch(f).Asaresutt. the structurath.ta"'! most~ve in rNintiliningtheped;ol arch ane those dosest to the ground, slna the long lewt" iiRm of those structures requtnes the least experodltllne of force. The fonnul;a .also dlcblti th;at the canstJalnlng force must lncrene ;as the dlstilnee I between the points of support lncl'l'iiH'S, ons the arth becan"lll!5 flitter (snnillll!f" f).
----+- AddueU~rl\illllds tn...wrsehNCI
AoldodOr ---1-.....,..,-"""haluds.
oblique
lltc:ep$
head llblolls
posb!rlor
SUI'M
--+--~~
Abulalll
ian9ll
l 't
E l.oc:adon of pillIn BSOdmld wid! spl;ryfoot 1ncl nat foot (afmr
Loeweneck} a Right spll)'foot viewed from the pll ntar aspect. The collapse of the transverse arch nesu Its In a brooodened fonefoot (a!TOWS) wltil gre;ater pnessure acting on the heads of the semnd through fourth metatarsals and the assodmd metiltarsophalangul joints. Typically, very painfu Icalluses will form betwftn the !Nils oft he large and little toes In this sftu;atlon. It Right ft.at foot viewed from th1t medial ~ect. With callipse of the longitudinal arch, marked by dCMnW~RI displacement f1f the talus and niiYicular (arrow), weight belirlng oftt~~ lncftl!s a dlffusltfoot pain that is most intense in th1t aNG of the stretdoed calcane«oavicular (spring) ligament. ulf pilln miiY also develop ;as a resultflf sustillned. lncneilsed tl!nslon on thlt calf muscles (iind the pedal muscles iiS which must compensiltl! for the deficient JN1Shle mbillzen).
-n.
.. 415
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.29 The Sesamoid Bones and Deformities of the Toes
C:!h ! - - Flexor Headofflrst meutonal
haluds lang us
--+~--+-,--~
Lmllll
maleolus
Medial ---!----'~-';-....,..: ses.~makl
~-r;;_---+--- SW12nt..-
Tendanoflns:e!' --+--~,.....;:_;,.+- tkin of flex« hlllucls longus
a.fumtal
A Cross II4!C\Ion through the had of the first lni!At;IFAI a the lll!wlofthesesamolds
Big toe of right foot. prcmmal view. The plane of section is indicab!d in
B. The lateral and medial senmolds 01re hemlspherfe<~l bones. eadl presenting a slightly convex dorsal ;u11cularsurf.rcethilt artiCIJiiltes with Ute grooved planur artiCIJiar surf.aces on Ute heilld of !he ftrst metaursal. Sesamoids prom:t the~nclons from exce55~friction. They ~re imp or· tant functionally for thetr ability to lengUtm the effective lever arm of Ute muscle, so that musaJiarforces c.1r1 be ipplled more efficiently. The development of se.s;amolds e<~n be Interpreted as a functional ad.apU· tion to the presence of pre$$Ure tendons.
B The58110111101dsofdleblgtoe Right foot. posteromedial 'lllew. The tendon of flexDr hallucls longus ruriS betwel!r1 Ute two sesamolds. The box .ilrourld Ute sesamolds lndl· cates the plane of secticm shclwn in A.
Distil ph 111m
Proximal phallnx
l.mnl
~mo~~
D~tr.lr~S\'e!V
-
mttltlrsaiiJ91mmt " ' adduc:tor d halklcls
r·-~ (1)1= hfid
Lateral
sesamdd
AbduciJo< hallucD. adductor hai
C The arttcularsurt..ces ofthues;mtotds Dorsal vlewwltfl Ute ffrst metatars;ll removed.
416
~
Medial JallmOid )olntc.~P!tle
AbduciJo< hlllucfs
Flrstm~
D The captule and ligaments of the sesamoid• and muwar ltt.ldwncnt5 First met.iiUrsophalangeal joint of the lightfoot, plantar view. Both se.s-
amolds are atuched to the )oint capsule and to the colliltl!ral ligaments of the mc:t.m~rsoph~lange;~l joint. They are embedded in the tendon$ of lr1Sef11or1 oftile follov.ing mwcla: • Medial sesamoid
-Abductor hallllds -Medial he
• late!"al sesamoid
-Literal head offleKOr halluds brevis -Transverse he..d of adductor hallllds - Oblrque heilld of adductor h.allucls
Ar.rtmmtln:ophtlan~<~nglt
Proximal-phalanx of big !De
G EtiolotJofh•IIIDlVIIgu$
• E Cha~~t~~ln the lint lntermetltiii"AA ~ngle nd first ml!tiltinoph~lqeal ~ngle b hallux Vllglll Right foot. superiorview.
• Skel$n of a norm;al right foot. b latl!r.ll deo~lalion oftheflrrt r;rywltluubluxalion of !he metat:arsophalange<~l joint In hallux valgus,.
flrst ;md second metat
trrst tnf!tX:ItXJrsophakmgf!OI angle
(angle between the longiWdinal axes of the proximal phalanx of the big toe and the first metat
Hallux valgus usually develops serondary tD splayfoot. When;r broidenedforefootls forced into a nai'I'OIN, pointed shoe,. the outertoeuA! crvwded against the middle toes. Thls results In the pressure points and pain !hit ;rre typl· cal of hallux valgus and predominantly affect the medial side of the head of the first metawsal, with dhronlc Irritation of the first metil· t
In a nonnnal foot. the ttrst: 1nf:l!rmf!tllfxlml angle (angle betwl!en the langitudinal ~ of the
Medial deW!fon
Abductor haluds
A-r halludllongul
F P.nhogenlc mecNnrsm of halm wlg111 Right forl!foot, superforvlew. As the flrrt meti· tarsal deviates medially ;md the big toe devi· ates later;rlly. a muscular Imbalance develops marlced by a change In the direction oft2ndon pull, which pe!pttuates and e~~aC4!1bates !he
£lr.tl!nsor
halkldslongus
defonnnlty. Most not;rbly. the abductor hallucls moves laterally wllh the medial sesamoid, awing it tD berome an odducw. Meanwhile thelor~gfle1!Drandextensort2ndonsmcwelat
erally, reinforcing the lateral angulation at the flrst metat.ilrsopl\alange.al joint.
H CliiWIDKilnd h~mml!f'txll!s Toe defonnnltfes ~re a very carnmon ~ssod ;ated featul'l! of h
417
Lo~,wrUmb
- - J. Bones,UgGmenB. amiJoints
1.30 Human Gait
A Tile pressure dl;~mber system Ill thuole ofthe foot 5.agll:till sectfol\ tilrough tile right foot .at tile level of the secorld rJY, medial view (see cleuil in 8). During walking and partfCIJiarly In stance, large compressive forces are exer1:ed on tile heel pad ind on the bills oftile big ind llttletoes. To dis· tribute these amcentratl!d strl!sses more evenly 0\ll!r a larget" area, the sole of the fotlt Is covered by a layer of subcut.ltleOUS connective tissue
uptll2 an !hide.As atiJnctlonilidiptatlontll thesedet'ninds,lhetlssue has a •pressure chamber" ccnsb'uction which acts as a shock absorber while ibo enhancing the mechanlt.llstiblllty of the sole. Without this pressure chamber system, !he loads on tile foot would generate very high, locaiW!d stresses tilat would result In pressure l\eCI'OSIS (drawn from a specimen in the AnanKnical Collection of Kiel Univer~}.
~r·~~~~~~~----~--~~---OMm~
sept\lm\Mih bloochesselr.
~-.....:..-H---Presslft ~m~
a Tile plantar pressure dl•mbers
C Strumlreofthepra~urechlmbers
Oet<~nfromA.
DeallfromB. The fat:tytlssue his beel\ removed from tile chambers on the left side of !he dra~ng to det"nonstrate !he blood vessels til.at permeate tile sept.l. (The sole of the foot is one of the most highly v.ucularized regions of tfte body surface.)
Eich ofthe pressure chambers contilns irllntemal flbrofat:tvtlssue arvered externally by tllugh conDI!dflte tissue mide up of collagen tlbers. Thest' fib~ sept;! are firmly Jttached between the planur aponeu· rosls and plantar corium and are supplied by an emnslve network of blood vessels Ulit furtfler stabllill! the walls of the pressure chambers (~e dose-up in C).
418
I
: - - - - St
I I I I
+
0~ ~lstrilile)
I I I I
+
+
60~
(toe-off)
•
b
D MCM:fllenb ofdte leg durfng one g11t c:yde During nonnal walldng, each leg functions ~lb!rn~tely ~s the mnce leg ~nd swing leg. The stance phase begins when the heel contacts 1he ground (heel strlkl!) and ends when
the tves push off from the ground (toe-off). This phase makes up 602: of the galt cycle. The s<Mng phase begins with the ~fl' and ends with the heel strilcl!. It makes up 40t; of the galt cycle. (tOO Xof galt cycle- the period between twoheelstr11ces ofthesamefoot.)
E Step wtdth (•) •nd mplength (b)
The step width (track width} Is evalllated from behind. Generally It Is narrowtf than the distance between the two hip joinu. The step length (ev;lluated from the side) equals approximately 2 to 3 foot lengths. The track ..with and step length deflnethearea ol suppc~rt and thus play~ critic;~!,. in subil· lty. Thlslspartlcularlylmportantln hemiplegic patients, for ex.1mple, In whom Impaired pnoplfoceptlan c;~n lead mlnit41bnltles of galt and sunc:e.
419
lower Limb - - 2. Musculature: Functional Groups
2.1
The Muscles of the Lower Limb: Classification
In most mammals, the upper and lower limbs share many functions and have analogous functional groups of muscles. In humans, however, the specializations of the upper limb for manipulation and the lower limb for ambulation have imposed radically diffl!rent requirements upon their respective muscle groups. For instance, the shoulder girdle has consid· erable freedom of motion on the trunk and is acted upon by an array of muscles, but the pelvic ring is firmly fixed to the vertebral column and changes position very little relative to the trunk, and has no comparable muscles to move it. In contrast, the hip and glureal muscles have evolved into massive and powerful movers and stabilizers of the femur, countEracting the loads imposed by support of the whole body weight on two limbs and maintaining balance and stability during bipedal locomotion; these muscles are, in aggregate, larger than their countErparts that act upon the humerus, with a significantly ditrerent arrangement and orientation.
A The hlp and gluteal muscles
tion. Each sudl classification sysrem has advantages and disadvantages, and so several schemes are presented here. Segregation of muscles that act at the hip into specific functional groups is valid only for a particular joint position, because the axis of motion changes relative to the muscles as the joint is dynamically reoriented, causing abductors to become adductors, for example. Muscles surrounding the hip can be categorized topographically into an inner and curer group, relative to the pelvic girdle (see A). Muscles acting on the knee and foot can be grouped logically in an arrangement that uses both functional and topographical criteria, because these muscles tend to be clustEred by functional groups into discrete compartments and act in a consistent way on joints with restricted ranges of motion. As with the upper limb, it is also instructive to categorize the lower limb's musdes by the pattern of their innervation (see E). a pattern that reveals the underlying logic of different clinical syndromes involving nerve damage. C Tbe leg muscles
Inner hlp muscles • Pso;~s major • Psoas minor
As with the upper limb (see p. 256), the muscles of the lower limb can be classified on the basis of origin, topography, function, and innerva-
} Act in unison as the
• Iliacus
·~iopsoas'
Anterior comjMrtment • Tibialis antErior • Extensordlgltorum longus • Extensor hallucis longus • Fibularis tertius
Ooarhlp muscles
• • • • • • • •
Gluteus maxim us Gluteus medius Gluteus minimus Tensorfasciae liltae Pirifonnis Obturator inremus Gemelli Quadratus femoris
Literal mmpillrbnent
• Flbularls longus • Flbularls brevis PosUrtor compartment Superficiill p¥t
• Triceps sur.te
Muscles of the adductor group' • Obturator externus • Pectineus
• • • • •
Adductor longus Adductor brevis Adductor mag nus Adductor mlnlmus Gracilis
• For functional reasons the muscles of the adductor group, all of which on located on the medial side of the thigh, are classified as hlp muscles because they act mainly on the hlp
-Soleus - Gastrocnemius (medial and lateral heads) • Plantaris Deep p¥t • Tibialis posterior • Flexor digitnrum longus • Flexor hallucts longus • Popliteus
joint
D Tbe short muscles of the foot B The thigh muscles Anterior thigh muscles
• Sartorius • Quadriceps femoris -Rectus femoris - Vastus medl;olis - Vastus latrralis - Vastus intermedius - (Artkularls genus, the 'fifth head' of quadrlceps femo~s. seep. 428) Postertor thigh muscles
• Biceps femoris • Semimembranosus • Semitendinosus
420
} The hamstrings
DorHI muscles • Extensor digltorum brevis • Extensor hallucis brevis Plant..- moudes MecMal compartment • Abductor hallucls • Flexor hallucls brevis (medial and lateral heads) latEral compartment • Abductordlgld mlnlml • Flexor dlgld minimI brevis • Opponens digiti mlnlml Central compartment • Flexor dlgltorum brevis • Adductor hallucis (transverse and oblique heads) • Quadratus plilntae • First through fourth lumbricals • First through third plantar intErossei • First through fourth dorsal interossei
LowerUmb - - 2. Musculat»rr. FunctlonGI Groups
E ClaBTtlmtlon of mulde llllled on their matart-nerwtlon Alllhe m.ades of tne lower limb al'l! supplied by branches of tne lumbar plelws (T 12- L4) ilnd the sacral plelws (L5-S 3). They may be supplied by short, direct branches or by long nerws emanating from tne cor..spondlng pleJIIIS (seep. 470).
s.tmplaus s~
gkrtftlnaw lnfMar gk.r!NINNt
Femorolnerw
- -+-- -'
IIIKlll, pectl....s; Jartllrlus, qu.Jdrlctpo fMiorts
Obb.oralllr I!Xtanus, pectineus, 1dductor longus, ildductor b~l. 1dductor m~gnus (deep P40rt), 1dductor mlnlmus. gr«llls
Plrtforml!, obturotor lnllrnus, gemelli, qu1dnotus femar1s
nblal110n1e
Common - - ----i-+1
ftbullrnaw
Superior gluwl,.,..
Ttnsor fasd•lltle. gluta~s medius 1ndmlnlmus
Inferlor glu!MI nerw
Glut.us malmus
Sclltlc nerw (see 1ko F)
AdductDr m<~gnus (superftclll P41 rt. tibill plrt); Blmps r.morll (long hud, tlbl;ol p;ort); ~taps (emorll (llhart hllild, ftbuiM
S~l-----fl-t+-1
ftbuMri'BW
Oeep ftbulilfi!Onle
PIRl SernrnembriiiOSUS. S811bncllnows (tibial plrt) Tibialis ill'ltelfor,lltteMOI' dlgltorum longus 1nd brwis. fibullris tertius.
-nsorhalludslongus and brevis Abularislongus •nd brwls • Tiblllnaw
Poplhus. tr1cep5 sur~e, pli nblrts, tlbillis ,-terior, fluor digitDN m longus, fiUDr hlllludslongus
- Medial planbor nerw
AbductDr h•llud5, flnor hlllluds brwls (medl1l hud), fiUDr dlgllDRJm brevis, first •nd ...,nd lumbrlcals
-l..alllnl plonbor...,.
Fluor halluds brevis (lamr~l had), 1ddue1Dr halludl. ilbductor dlgllf mlnlml, fte!IOI' cl!lltl mlnlml brevis, opponens d\Jlll mlnlml, qUidratus pllntM.third 1nd fourth lumbric:ak. first thn~ugh third pl1nbor lnl:enlael, first thn~ugh fourth dorsallnt2IOSSI!I
• Themmmon ftbulor nerw1nd Its dMslDns •no 1Im ...nrnodm• "peronul nerws.•
F 11te bnncha lllfthe lumbaN'I"'II pluul thd lnnernte the mu1daofthe '-'11mb Right leg,lateralvlew.lheventral rami of the lumbilr and Silcral nerves, with contributions from the subcostal nerve and coa:ygeal nerve (not shown here), combine to fvrm the lumbosi1C1'11I plelws. While tbe branches arising from the lumbar plexus run antmor to the hlp Joint and mainly supply tne muscles on the antertor ilnd medial views of the thigh, the brilnches from the siiCI'ill plexus run bfhind the hip joint to wpply the posterior thlg h musdes and all the muscles of the leg and foot. The grossly visible division of lhe sditlc nerve Into Its two tl!mll· nal btilnches (the tibial nlt'YI! ilnd common flbular ni!IVI!) Is genenlly located j.at above the knee joint. " picbJ red h~ (low dMJion). But the n~ flben thm m~lr.e up the two tl!mllnal briinches become organized Into bundles ilt a much more proxlmallewl, wh~ tney alre.01dy appe.~r as separ:ate nerve branches within their common fibraus sheath. In the high division pilttem. the n~ divides Into Its termiNI brilnches while still In the lessa- pelvis (see p.493).
421
2.2
The Hip and Gluteal Muscles: The Inner Hip Muscles ort!lln:
IIIHftfon:
Ad!-=
•
lnneiWifon: Femo111l nerve (lllacus);lnd direct branches fn1111 the lumbar plelcus (psoas)(L1-L3)
A Sdlem.Jtlcoftflelnnerh_,mll!ldes
PropertTes nd dl'nlcala~pectsofthe lllopso~s muscle The iliopsoas is classified as a hip flela:lr along with the l'eldlls f\!morls. 5<~rtorlus. and tensor fasciae lat."! e. It Is the most powerful f!tlCOr,lts long vertical travel making It an lmport;rnt muscle for st.lrldlng, walk· lng, .arid running. As a typical p051:1.1r~l muscle With a preponder.ance of si~JN-twitch red (type I} fiber$, hCl'NCM!r, the mop$0i1$ is inherently SUJ· ceptlble to pilthologlcal shortening (p;rrtlcularfy In older piltlents with a sedent.lry llfe5tyle or ctn-onk lmmoblllz;rtton corldltlons), ;rnd requires regular stretching to maintain nonnal tone (see p.40). Shortening (t1lntrncture) of the hip flexors le;tds to: • increased anterior pelvic tift, • lncre;rsed lumbir lordosis, and • llmlt.l!lonofhlpex:tenslon.
422
UnJiott!rol shortening of the Iliopsoas, In which the Ilium on the .ilffected side is tilted forward, can be diagnosed with the Thomas manewer (see p. 386}. This t1lndtt!on leads to pelvic tDrslon. In wfllch tfle pelvis becomes twisted upon Itself. This m;rlnly altefs the function of the SOIC· ronracJoints but also compromises the ln1lervertebr~l joints and the lumbosacral junction (increased lordo.sU of the lumb~r spin~with clegener· alive dlinges In the venebr;rl bodies, seep. 104). P.rtfents with bllamal Iliopsoas weakness or paralysis are unable to raise the trunk from !he supine position, despite lnt.lct ;rbdomlnal musdes, without using their anms and ~re greatly limited in their ability to walk and dimb stairs with· out assbt.lnce.
f.otltlw Umb - - 2.
Musa~lature: funetlonGI Groups
Silaotuberol.ll ---.:::~
ligament
llopsoa
----..::....~
__....~--::::.:::=!~-1~·
lc1Xfllnl«
line
Pllblc
symphysis
8 The Inner hlp II!UIIdls Anterior llfew.
The psoas major unites with the Iliacus at the level of the lngutnaiii!Ji· mern to fonn a conJoined muscle, the Iliopsoas. Approximately 50% of the population also hillll! .a pSOti minor mll!de (as shown here). which arisn from the T 12 and l1 vertebr~e and inserts into the iliopectineal arch Ollacfascla).
423
2.3
The Hip and Gluteal Muscles: The Outer Hip Muscles m
Gluteus-anus Orfgl..: t.mral part oftt. donal surface oftt. sacrum, polbrlorpart of theglulllal surfam of lhe Ilium (behind the posterior glute
lloablal trxt
®Giuwusmelllla Ol'lgl..: Gluteal surface of lhe Alum (belowlhe llllc crest betMen lhe anterior and posterior glutalllne) 1-'1•: t.mral surface ofthe gre~~llertrochanter of the ~ur ~ • Entire musde: abducts lhe hip. stabe1ias lhe pelvis in lhe coronal plane • Anterior part flexion .and lnlllrn.al ratatlon • Postll!r1or part exllenslon and atemal rotation ,....,..,...: Superior gluteal nerw (L4-S 1) GIUIIIUI mlnlmus Orfgl..: Gluteal surface of lhe Hium (below lhe origin of gluteus medius) 1-'1•: Anterolateral surface of the gruter tnldlanter of the femur ~ • Entire musde: abducts lhe hlp. stabAlzll!s lhe peMs In lhe coronal plane • Anterior part flexion .and lnlllrnal ratatlon • Post!erlor part exllenslon and extemal rotation ,....,..,...: Superior gluteal nerw (L4-S 1) (J)
A Sdlematfcoftflevert'lc:lllfw'-ortented outl!f' hlp murde1
Ci)T-falclle . . . Ol'lgl..: Anterior superior llllc spine lllleftf•: Iliotibial tr.act ~ • Tenses lhe fascia lata • Hlp joint: abduction, ftexlon, and lnlllrn.al rabllon lnneiWif•: Superior gluteal nerve (L4-S 1)
Orfgl..: lllleftf•:
PeMc surfxe of lhe saaum Apa ofthe gre~~ller trochanter of the ~ur
~
• Extemal rotation, abduction, and -slon of lhe hlp joint • StlbliiZies lhe hlp ]Oint ,....,..,...: Direct branches from lhe saaal plexus (L 5-S Z)
Q) OlltuNtorlnlllmus Orfgl..: Inner surfxe of lhe obturamr membrane and 11s bony boundaries lnHrtf•: Medial surface oftt.g-lrochanter ~ Extanll rotation, adduction, and tldlenslon of lhe hlp ]Oint (also a~ lnabductlon, depending on lhe position of lhe joint) I...U•: Direct brandies from lhe saaal plexus (LS, S 1)
ill Gemelli Orfgl..:
• Gemellus superior: Ischial spine • Gemellus lnNrlor: Ischial tubnslty lllleftf•: jointly with ablurator lntemus t.ndon (medial surface, g,_lrochanter) ~ Extanll rotation, adduction, and tldlenslon of lhe hlp ]Oint (also a~ lnabductlon, depending on lhe position of lhe joint) lnneiWif•: Direct brandies from the saaal plexus (lS, S1)
® Qued-flmods 8 Sdlemil\fc oftfle hortr.onblly-orfl!fltl!d outl!f' hlp murdes
424
Orfgl..: 1-'1•:
t.mral border of the Ischial tuberosity lnlllrtro
f.otltlw Umb - - 2. Musa~lature: functlonGI Groups
llraccrest
Gk!teus medius
Anterior SUJ)I!rior
Thora~
lliKSI)IM!
lumblr linda Gkm!~Js
Gluteus medius
Tens« lindae
Plrifom~ls
lela
Q!melkls Obturator ~us
Q!melw Inferior Saao-
t\lt.!rous lgarnent
JUJ)I!rlcr
Q.ladratus
femolls Gremr ~
lnll!r~
crest
Clute;~I
tllbe!Wiy
~r!or--~-i~--~rr
gklteollllne
GIUIJ!us m'rllmUJ
Saaum
Pkffmnis
Obturator
GemeU.a
~us
supErior Quadratus lo!mor!s Grstef
tcvchanter
ln!J!r·
lnKhanle1c: at.lt
b
C 1be outer hlp musd1111: suptriicf;rl r;.,.r Right side. posterior view. ~the positron of the gluteus maxlmus musde 11'1 relation tD the axis of hlp abduction and adduction. While the flbers of gluteus maxim us that run oboYe lfle alds and lnsut on the tibia Ilia the Iliotibial tract are acttve In abducting the hlp joint, the musde fibers that run below the axis are acttve 11'1 adduction.
D 1beouterhlpmusda:d~~~plii'JW Right side, posterior vfew. ;a With the gluteus maxim us removed.
b With the gluteus mediU5 r4!1Tloved. If there Is wealcness or p;rralysls of the small gluteal muscles (gluteus medius and mlnlmus), the peMs can no longer be subllrztd rn tile coronal plane and will tilt towird the ursafli:!cted side (positive Trendelenburg sign, see alsop. 476).
425
2.4
The Hip and Gluteal Muscles: The Adductor Group {1) Oblll-raiBnus Orfgl..: Ou• surfacz « tl'e obb.lratarmembrane and Its bony boundaries 1-aen: llodlantellcrossaofthefemur ~ • Adduction and exbmal rotation« the hlp joint • SbbiiiZies the pdvls In the sagittal plane 1_,...•: Obb.lratarnerve(L3.L4)
® Pedlneus Orfgl..: 1-aen:
Pedal pubis Pectineal line •nd the praclm•l hneaasper• of the femur ~ • Adduction, extemal rot
Superior pubic ramus and anterior side ofthe symphy!ls Lint~~ aspera: medlllllp In the middle third «the femur ~ • Adduction and ftexion (up to 70') of the Hp joint (-nels the hip past 80' «flexion) • Sbblllla the pelvis In the coronal and sagittal planes 1-clen: Obb.lratarnerve(L2-L4) Orfgl..:
1-'len:
® Mductorbrevl5
._.....: Orfgl..:
~
._.....
lnfwior pubic ramus Linea aspera: med!llllp In the upper third «the femur
• AdducUon and ftaon (up to 70') of the .._,Joint (-nels the hlp past 80' «flexion) • Sbblllla the pelvis In the coronal and sagittal planes Obb.lratarnerve(L2,L3l
® Mductor~M~n• Orfgl..: 1-a...:
lnfmor pubk ramus. Ischial ramus. and Ischial tuberosity • Oeep part('flelhy insertion'): mecliallip « linu aspera • Superfldal part (*tendinous Insertion"): medial eplmndyleof the femur ~ • Adduction, extemal rot
® Adductorml..mut (upt~et4llvlllonf!ll edductot ,..._, lnferfor pubk ramus Medial lip of the linea aspera ~ Adduction. -mal rotation and slight fleaion of the hip joint lnneiWifen: Obb.lratorneNe(L2-L4)
Orfgl..:
'-""':
(1) Gredls
Orfgl..: 1-'len:
lnferfor pubk ramus bel-the symphy!ls Medial border of the tuberosity of the tibia (along With the tendons of sartorius and semitendinosus) ~ • Hlp jOint: adduction and flexion • Knee jOint: flexlon and lntemal rotation l_,...en: Obb.lratarnerw(L2, LlJ
B ~levers;!! of musde icUons,lllustmed for the adductDr bl'fttland longus Right hip joint, l~teral view. The fl!mur in 80' of flexion Is shown In lighter shading. In addition to their prfmary ictlon as adductors. bo!h muscles mq also be actiVe In flexion and exl!!nsion, dCFending on the joint PG$ition. • They i!$$ist in flexion~ tne ne\ltr~l (zerodegree) position to approxlnnitely 70'.
426
• Thefr ictlon.s reverse past appro!dnni!l!ly 80' of ftexlon, and they become active In extension. The fl90r components of both muscl~ are transformed Into extensor components as soon as thelrlnsertlon (the linea aspaa} moves higher than their origin (tile Inferior or su~ f!Of pubic ramus).
LowerUmb - - 2. Musa~lature:functlonGIGroups
Promontory
~'------
Anll!riorsul)«!or lfec'l'lne
+ ------ Antlerlortnfellor lfK3Pfl'lt
b~:-:'::'l":;~!=-'!~--
Supeller
publcr.unus
....-----,,..---:!-- - Oblura1Dr f
l
J
~
c
u
d
d
A
exllemus
_ _ ___,....__ _
mtrimw
-~--11!mLr
Adductor magnus
- --7---- -
:j----,f-- -7-- - - Adductor mag nus, tltndnous ~rt
' -'I:....-- Grad lis bend on
oltnr
::-:-4!1H~-
ntllal tlb ti'OSity Fibula
C The •ddlldor$ (obturator extern us; pedfneus; addudlllres longu~. bnrvls. magn•. ;md minim us: ;md 9!';1Ctlls) Antenor view. Aportion af the addudlllrs, pectineus. and gracllls musdes on the left side have been remtwed jLirt past their origins tD demon· strate the ooui'Je of obturator extemus more dearly.
Note: Unil~ter.~l shortl!ning of the shortallng on lfle affected side.
~tk!Uctol'$
leads to
functi~n~l
leg
427
2.5
The Anterior Thigh Muscles: The Extensor Group
Anterior superior lilac spine Medial to the tibial tllberoslty (together with gradlls and semitendinosus) • Hlp ]Oint: flexion, abducaon. and extemal rotation • Knee ]Oint: flexion and lntemal rotation l....wlfon: Femoral nerw (L2, L3)
iJl Qladrkeps r-.rfs Orfllln: • Rectus femoris: anller1or Inferior lilac spine. aceabular roof of the hlp ]Oint • Vastus medialiS: medial lip of the linea aspera. distal part of the lntertrochanll!rlc
lllleftfon:
~
line • Vastus lateral Is: lamralllp of the Rna aspera,lateralsurface af the gretrochanter • Vastus Intermedius: anterior side of the femoral shaft • Arlfcularls genus (chstal fibers of the vastus lntl!rmedlus): anterior side of the fwnoral shaft at the lew! of the suprapall!lllr reCI!SS • On ttletlblal tuberosity '~!a the patellar ligament (entire muscle) • Botto sides of the tuberosity on the medial and lalllral condyles via the medial and longltllcllnal fl'llellar retinacula (vastus medialis and laller
1-'!on: Femoralnen~e(L2-L4)
UneofgnMty
B Det'ldl!nt stablltutfon ofthe !awe jotnt clJe to Wl!ilkness or pal'liylfs of qUidrtreps fl!morts Right lower limb,l;ateral vi eoN.
a Wilen the quadriap~ femoris is intilctandthe knee is in slight flexi~n. tfle line of griVIty (seep. 363) falls bfhtndtfte transverse axis of knee motion. As the onlyext2nsormll!de ofUte kneejoint. Ute quadrlceps ftmor1s lleep1 the body &om tipping b.'lckward and ensurtl stabll· ity.
b With weakness or paralysis of!he qui!drfceps ftmorls. tfte knee joint can no longer be actlllely ext2nded. In order to stand upright, !he patient must hypet'extend Ute knee so Utat !he line of gmfty. and ttl us the whole-body Cll!nter ~f grJVity, ~ shit'tl!d forward, in frGnt of tfle knee. to utilize griYlty as tfle extending force. The joint Is stabl· Jrzed lr1 this situation by Ute postertor capsule and ligaments of !he
knee.
428
•
b
f.otltlw Umb - - 2. Musa~lature: funetlonGI Groups
Anl8!orlnfetlcr lllltspiM
Alattlbularrocf _ ___..:\::::::!~ Grea!er
troc:hanter
Quad~
iemorts
......:-H--+.,1--
~hr
lliarnent ~-- ~~es~n:semus·
c
The exter.rs (quaclr'la!ps femorfsand saotortus) Right si~ anteriarview. As. its name implies, the quadriceps fi!moris is baslt.llly a faur·headed muscle consisting of the rectus femoris and the vastus medlalls,lal:er.llls. ;md Intermedius (thevastus Intermedius. coveredherebytherectusfemorts,lsvlslblelnD).Itmayalsobeconsldered as having a fifth heed. the articularis genus. The latb!r is com()CI.Hd of distal flben of the Y
D The exter.rs (deep portion of qllldrfceps femoris) Right side, anterior view. The sartoriLIS and rectus femorif. have been removed to their origins and Insertions. The are<~ of origin of the rectus femoris Is lntimiltdy related to the ;mrerlor aspect of the apsule of the hlp joint. a relation with functlonal and dinical consequences. ~thological swelling of the joint capsule can cause pain that Induces reflex reactions when the rectus Is used for knee flexion: such reflexreactlonsarethebaslsof ausefultert. With the patient ¥ng pro Ill!,. the ex;amlner flexes the patient's knee. This c.1uses passive stretching ofthe rectus femoris ;and adds signifit;!nt pressure to a hlp joint c.1psule alre<~dy distEnded by effuslor1. The patient reflexively •escapes" the painful stimulus by raising the buttock. a poslttlle •rec· tusslgn.•
• The pes ;msertr~us Is the common tendinous expansion far the gradlls, sartorius. and semitendinosus.
429
2.6
The Posterior Thigh Muscles: The Flexor Group CD llapsfHiorts • long hnd: Ischial t1oberoslty, sacrotuberous ligament (CDmmon head with semitendinosus) • Short head: lalleral lip tA the linea aspera In the mlddl& third tA the hmur 1-aon: Headofftbula ~ • Hlp jolnt(long head): utends the hlp. stabllbu the peMs In the sagltt.l plane • Knee joint (entire muscr.): flexion and extemal rvtatlon 1-aon: • Tiblalnervt,L5-S2~ongheecl) • Commonftbularnuw.L5-SZ(shorthead) Orfgln:
IZl s.mn.nbrwlosus Orfgln: lsdllal tuberosity 1-'!on: Medial llblal condyle, oblique popliteal ligament, poplllllus faK1a ~ • Hlp ]Oint: extends the hlp. stablllas the peMs In the sagll:t
® Pophlleus A SdlemaUc of tfre l'lellllrs
430
Lateral femoral condyle. posller1or hom of the !~Wral meniscus Posterior tlblll surface (a~ the origin of soltus) ~ Fieldon and Internal rotatiOn of the lcneeJOint (stabliiZies the lcnee) 1-clon: Tibial nerw (L4-S 1) Ortllln: 1-'lon:
LowerUmb - - 2.
Musa~lature:functlonGIGroups
Ant2flor superior
lltacsplne
-"111-r--------+----- ~rlofwperlor lltac spine
~~~,...._,~--------- ~rlorW'mor
lltacsplne
G!'f>a12r ~ '' ~--~--IM~C
om
Glutal
tubero.slty
Se
---t-+\ '-'•
- - - 8lo!ps femoris.
lang held
He.iddflbula
• B Theflelllllrs(d!e hllmltlfr~gund poplteus) Right side, posterior vi eoN.
a The namstrin9S are the pDStl!rior thigh muscles that arise from the
lsdtlum and Insert on the leg: bleeps femoris, semhnembr.rno-
b
sus, and semlb!ndlnosus. All butti\e short head of bleeps femoris are "biarticular." spanning both the lllp ~nd knee joints. b A portion of the l011g head of bleeps femoris has beal reiTIOYed to display the short head ;md Its orfgln from the lmr~lllp of the linea aspera.
431
2.7
The Leg Muscles: The Anterior and Lateral Compartments (Extensor and Fibularis Group) tD nlllllls enterter Orfgln: Upper two thirds of the r.teral surface ofthetlbla, the crur.~l lnmrosseous membr.~ne, and the highest part of the superftc._l crural fisc'la 1-'len: Medial and plantar surface of the med._l cuneiform. the medial base of the tlrst metatarsal ~ • Talocn~ral joint: danlftexlan • Subtalar joint: l.werslon (supination) IIIIIBWifen: Deepflbularnerw(L4,LS)
® ~._.....lonlus !Meraltiblal condyle. head of the fibula, anterior border of the fibula, and the crural Interosseous membrane 1-'!en: By four slips to the donal aponeu,_ of the second through 111\h IDes and the bases of the diStal phalanges of the second through fifth toes ~ • 'llllocrural jOint: dorslftexron • Subullar joint: ewnion (pronation) • Extends the metata~phalangeel and Interphalangeal Joints of the second through flf\h toes 1-'len: Deepflbularnerw(L5,S1) Orfgln:
Mlcldlethlrcl ofthe medial surface of the fibula, the cruralln!Misseous membrane Dorsal aponeun~~ls of the big- and the base ofIts distal phalanx • 'llllocrural ]Oint: danlftaon • SUbullar Joint: actiVe In both -rslon and lnwrslon (pronatioll,lsuplnatlon). depending on the initial position ol the foot • Extends the metata~phalangeel and lnterph.alangeal Joints of the big IDe IIIINIWifen: Deep fibular nerw (lS)
1D Flllur.rts leng• Heid of the tlbula, pi'Oidmal ~thirds of the lateral surface of the tlbula (arising partly from the intmnuscularsepta) l...tfen: Plantar slcle of the medial cuneiform, base ofthe first mebtarsal ~ • Talocn~ral jOint: plantar flexion • SUbullar Joint: ewnlon (pronation) • SUpports the lnn~e ardl of the foot l..mt•: Superficial fibular nerw (LS. S1) Orfgln:
a> Flbur.rtsbmlls DlsUI half of the lateral surface of the tlbula, lntmnuSOJiar septa lllberoslty at the base of the fifth mebbrsal (With an ocasiOnal dMsiOn to the dorsal aponaero~is of the fifth IDe) ~ • Talocn~ral joint: plantar flexion • Subtalar joint: ewnlon (pronation) 1 - ' 1 • : Superft~lftbularnenoe (LS, Sl) Orf!lln: l...tfen:
Anterior border of the distal tlbula Base of the flf\h ..-tarsal • 'llllocrural ]Oint: danlftaon • SUbullar Joint: ewnlon (pronation) l..mfen: Deep fibular nerw (LS, S1)
a Sdlemdt of tile letenl tompartmerrt
432
LowerUmb - - 2. Musa~lature:functlonGIGroups
Medial tplconclyle
Medial ablal o:.ndyle Tibial tuberoslty Medial cundfom> .:1.1~---:::!'-----
intl!roJireous membrane
Cuboid Tendon of ll'li«tton of
flbullrislongU~>
E Course of tfle fl'bUIIIIIIongus tendon on tfle sole of diefoot Right foot, plant.1rvlew. 1- fr-t-il--
Extensor
dl9torum longus
\+ tt-- - Exb!nsor haludS longt~~
\--!;-;!;!~--!----
Tendon« \-..L......J........L
flrstlhroudl flflh dst<JI phal1nges
c 111untl!rformmJWtml!ftt (tlblllh5 antl!tfor, extensor dlgttorum long•. ;md ext.!nsor halluds longus)
flbLiarls longus
FlbLiarls bnMs
Tendon of Insertion of flbullnbrms
D 1be Iatini comp1rtment
(fiWarblongus and bn:wft) Right leg. lateral vlew.
Right leg, ;mterforvlew.
433
2.8
The Leg Muscles: The Posterior Compartment (Superficial Flexor Group) tD
'ftkllpf-··
Orfgln:
l...tf•:
• Soleus: posterior surbce of the heed and ned< oftfleflbula; .ttached tD the soleal line of the tibia vla a t81dlnous arch • CilstiOCJ'Iemlus: Medial heed-medial epicondyle of the femur Lab!ral heacl-latnl epicondyle of the femur The aluneal tuberosity via the Achilles tandon
~
• Talacn.~ral joint plantar flexion • SUbtalar Joint l~rsiOn (supination) • Knee Joint flexion (g~strocnemllls) 1-'!GII: Tibial ne.w(S1, S2) (2) .....,....
PIQ!Idmal tD the lateral head ~ g~strocnemrus The ak
Orfgln: 1-'IGII:
A Sdrem;rUcofdruu~rfkfilltl--.
I llllpturuftheAch111Ktlndon Right leg, posteriori/lew. The Adlllles tendon (calc.;meafl te11dor1) Is tile commor1 tendor1 of lnsertlor1 of the muscles that complfse tile tlfaps su~;~e (the solew and both heeds of g~Jtrocnemius). The tendon h
434
LowerUmb - - 2.
Musa~lature:functlonGIGroups
Plantlrtl
Tendinous lii'Chol soleus
MediiI lllileolus "t.lkis
Mille'! undcn IJrll!nll lllileolus
N;Mcular Flrstm~l
"t.lloaural joint Takis Slbtllar jOint
b
c
The superficial fle.m:n (btcep$ turae and plantaris) Right leg, posterior view.
a The three heads of triceps surae
b Portionscrftfle lateral and medial heads ofg;utrocnemius hi!lle been rat1oved to eJIPOSe the soleus
bits, 'Which arises proximal tD the latl!ral head of gastrocnemius, Is ol'b!n viewed as the fourth he
435
2.9
The Leg Muscles: The Posterior Compartment (Deep Flexor Group) tDnlllllls..-rf• Orfgln: Crural Interosseous membrane and the adjacent borders of lhe llbla and tlbula I....,•: Tuberosity ofthe n;lll
Middle lhlrd of the posterior surface of the llbla Bases of lhe second lhn~ugh fifth distal phalanges • Talocrural jOint: plantar fleclon • SUiular Joint: lnvoerslon (suplnalon) • Metatarsophalangeal and Interphalangeal jOints of lhe second lhrough fifth toes: plantar flexion IIIIIBWif•: Tibial nerw(L~S2) ®A-haludsi...OI'Igln: Distal ~lhlrds of the pe~&tellor surface of the fibula, adjacent crural Interosseous membrane ,......,.: Base of lhe distal phalanx ofttle big IDe *"• Talocrural jOint: plantar flexion • SUiular Joint: lnvoerslon (suplnalon) • Metatarsophalangeal and Interphalangeal jOints of lhe big toe: plantar fieldon • SuppCN131he medial longitudinal arch of the foot IIIIIBWif•: Tibial nerw(L~S2)
A Sdlerm\lcofdledMptlexors
~~nml----~~--~
tubera.slty ~I
malleolus Qbold
1\Jberosltyof the cuboid Ten dans dhso!rtlcn oftblalrs postmar
------£,...,.-,~,..
....
""~A--1\Jberoslty
Medl;ll----~
ofltleflfth
meut.;u:£.11
cunelfonn -.-H:>+-P--!...P.H~-
a ln.erUonofthetlblllll$posterlor Right foot In plantar flexion, plant
436
Fhtthrough ftftllmetatarsals
LowerUmb - - 2.
Medial
m;~lleolus
Clllanealwb~Rslty
lara! m.lllealus
UICIMUS
Tendon of h14!rtlon oftlb!ills
Tenclon:scf
po.s!J!rior
posiA!rior
Ub!ral
m;~lleolus
lmet!~Jo
Tendon offlelu
Flrstth!W!tl tlfthmetlltlii'His
halluc1s
longus
Musa~lature:functlonGIGroups
Tendons of flexor dlglto111m longus
C The deep flexors {tlbllll' posterior. flexor dlgltllrum longu'- .-.d tl_.haluctslongus) Right leg With !he foot In planurflexJon, postertorvtew.
D The tibialis postedor Right leg With the flel!.OI' dlgltorum longus and flexor halluds longus 1'1!moved. Foot In plantar flexion, posterlorvlew.
437
2.10
The Short Muscles of the Foot: Dorsum and Medial and Lateral Sole tD ~clgnonnlnvls Dorsal surface of the calcaneus llllel'lfon: Dorsal .aponeurosis of the second through fourth tDes. blses of the mlddle phalanges of th- tDe5 ~ EXII!nslon of the metatarsophalangeal and pi'CIIdmallnllerphalangeal Joints of the second thn~ugh fvurth toes l....,..,on: Deep tlbular nerw (LS, S 1)
Orfgln:
a> Eldmlar heluds bmlls Dorsal surface of the calcaneus Dorsal aponeurosis of the big toe, base ofthe pi'OICimal phalanx ofthe big llle ~ Emnslon of the metatarsophalangeal jointof the big llle l....,..,on: Deep tlbular nerw (LS, S 1)
Orfaln:
llllel'lfon:
CD Allduceorhelluds Medial proms of the calcanul tuberosity, plant~r .aponeui'OSIS Base of the pRIIdmal phalanx of the big 111e vla the medial sesamoid First metatarsophalangul JOint: fieldon and medial abduttlon of the first toe: supports the longituclinalarth l....,..,on: Medial plantar nerve (S 1, S 2) ~
R - heluds bmlls
Clltg~
l....tlan: Adlan:
r-u(J)
Medial cuneiform, Intermediate cuneiform, plantar calcaneocuboid ligament • Medial head: base ofthe proximal phalanx ofthe big tDeVIa the medial sesamOid • LateralhRcl: base of the pi'CIIdmal phalanx of the big llle ¥Ia the lateral sesamoid Flau the first metatarsophalangeal Joint, supports the longitudinal arth • Medial head: medial plantar nerve (S 1, S2) • LateralhRcl: lateral plantar nerve (S 1. S2)
AdciUCIOrhllluds (for dartty, the adductllr hallucls 1s deplcWd here. although ItIs located In the antral mmpartment)
Clrlllln:
• ObliQue hod: bases ofthe semnd through fourth metatarsals. cuboid,
lalleral cunelfonn • Transverse head: metatarwphalangetl joints of the third through fifth toes. deep transverse metatanalllgament llllel'lfon: Base of the tlrst proximal phalanx bv a mmm..,12nclon ¥Ia the lateral sesamoid Ad...: FleJC~eS the first metatarsaphalangul JOint. aclducts the big toe: transverse hod supports the transverse an:h, oblique hod supports the longitUdinal arth l....,..,on: Lateral plantarnerve(S2, S3)
® Allduclordltlllmlnlml Lateral process and Inferior surf.acz of the calcaneal tuberosity. plantar aponeurosis Base of the pRIIdmal phalanx of the little toe. tubei'OSity of the fifth metatarsal Flau the metatarwphalangul Joint of the little toe. abducts the little toe. supports the longitudinal an:h ,....,..,..,: Lateral plantar nerve (S 1-S3)
I Plilllltlr vtew of the medial ilnrl lm!r.irl ODmp;utmerrts
® R-•!llltl mlnnt bmlls Base of the fifth md:ltarsal,long plantar ligament
Orf!llln:
Base of the pi'CIIdmal phalanx of the little tDe Flau the metatarwphalangealjoint tJI the litlletDe ,....,..,..,: Lateral plantar nerve (S 1, S2) llllel'lfM: ~
® Opponens •!llltl m..nl (often lndudedwfth.._cllaltl mlnfml brwvls) Long plantar ligament. plantar tlendon shRth of the fibula lis longus llllel'lf•: Fifth metatarsal ~ Pulls the fifth metatarsal slightly in the plantar and medial direction
Orf!llln:
,....,..,..,: Lateral plantar nerve (S 1, S2)
438
f.otltlw Umb - - 2. Musa~lature: funetlonGI Groups
Fifth distal phalanx Fifth nidcl~ phalanx
Flfth.-cml phalanx
-l!!~+~.-!-...S+-'~~!r--
Flrsttlu'Ol.g. ftfthmetatil~ls
M~lal
SHama'lll
~
/I I C~f-::::,;..-
hal kids breW
Lllter.at SM.amald
~
dlgltorum breW ~ty
-#'!~H--
dftfth
Flemrhaluds breW,Imral
-~1
head
./ Hh .....-.,;~ Adlfucll)r Opponens dgltlmlnmr
Tuberosity dftfth
metltlrsal
hallucls. oblique head
[-...L......:~~).J.;_..-41-- Tendon of lnsertlcn of
flbullllls AbdJcbr dgltlmrnmr
c
longus
The dorsal mu1des aftflefoot {exteMOr dlgttlnum brll!lll:s •net exten10r hllludJ brevlll)
Rlghtfoot.dors;~l view.
D The pl;mt.Jr muscles of die 1111dlil ;rrnd liitlnl a~mp;rrrtmentr; {abduc:tur halluds, ;rdductorhalucls•.flexor hill kids bl'l!llfs, 1bdur:tDr dlgtu mtntmt, flexor dlgtu minimI, 1nd oppon- dlgtu mlnlml) Right foot. plant
439
2.11
The Short Muscles of the Foot: Central Sole
Medlallllberde ofttoe alaneal tuberosity, plantar .aponeurosis The sides of the middle phalanges of the second ttorough fifth taes • Fl-s the metatarsophalangeal and pi'Oidlnallnte~phalilngeal Joints of the seoond through fifth toes • Suppor13the longitudln~~lardl of the fvat ,....,..,..: Medial plant.ar nerve (S 1, S 2) (2)
Quedm.lllent.•
Medial and plilnt.ar borders on the plilnt.ar side of thealaneellllberoslty tmral border of the flemrdlglblrvm longus tendon ~ Redlleets and augments the pull of flemr dlgllllrum longus ,....,..,..: tmral plilnt.ar ne.w (S 1-S3) Orfgl..:
1-'1•:
® Flntlhrough r..th l~nbdalls Medial borders ofthe 11-r digilllrum longus tendons Dorsal aponeuroses of the seCDnd through fifth toes ~ • Flues the metatarsophalangeal joints of the second through fifth toes • Extension of the lnte~phalangeal Joints of the second through fifth tiles • M-s the toes d -tugether (adclucts the second through fifth toes toward the big tae) ,....,..,..: • First and sec:ond lumbrlcals: medial plant.ar ne.w (S2, S3) • SeCDnd through fourth lumbrfals: literal plantar nen~a (S 2, S 3) Orf!ll..: IIIHftf•:
A Pl;mGrvtew offtexor dlgltol\lm bn!ollfs,
quldratus pllntae. nd lumbrkal1
® Flntlhrough tto-.1 plantarlnta.-.11 Medial border of the third through fifth metatarsals Medial base of the pn~~~lmal phalal'llt of the third ttorough fifth toes ~ • Flues the metatarsophalangeal joints of the third through fifth toes • Extension of the lnte~phalangeal Joints of the third ttorough fifth toes • M-s the toes d -tugether (adclucts the third through fifth taes toward the second toe) ,....,..,..: tmral plant.arne.w(S2, 53)
Orf!ll..: IIIHftf•:
t1l Flntlhrough r..th donllllllteNuel By two heads from opposing sides of the first through fifth metatarsals 1-'1•: • First Interosseus: medial base of the second pradmal phalanlf, dorsal aponeuoasls of the second tDe • SeCDnd through fourth lnterosser: lateral base of the second through fourth pn~~~imal phalanges. dorsal aponeurosis of the second through fourth toes ~ • Flues the metatarsophalangul joints of the second through fourth toes • Extension of the lnte~phalilngeal Joints of the second through fourth toes • Spreads the toes apart (<~bducts the thlrd<~nd fourth toes from the se01nd toe) ,....,..,..: tmral plilntarne.w(S2, 53) Orfgln:
I Pl;mGrvtewofpl;mtannd dorsal Inti!~
440
"The addiiCtor halluds. though part of tile Cl!fltral compartment. Is not plctl.lred here (seep.439).
f.otltlw Umb - - 2.
Musa~lature: functlonGI Groups
Tendons of
l'lsertlan afllexor
dgltorUm longus
\~~*1~~..._,-+-
ArJtthrwg. fourth
..,mb!lals
Q.ladmus - -i+-....,""+""" piiOOie
~~~~~~~-~~
plant.le
• C 111e pl;~ntar nu:cl8 of the Gl!fll:rill compillrtment Rlghtfoot, plant.nW!w.
• Atl(Df dlgltorum b~s. q~~adratus plantae. the flrst lhrough foul1h lumbrfcals (always numbered rn the medla~tD-Iateral or tlblaJ.tD.ftbulardirection), the fir$t lhrough third plantarinterosi'C!i, and the first through fourlh dorsallnterosM!l (fof clarity the adductor halluds, though part of the central compartment, Is not shown; see p.439}. b Ael(M dlgltorum brevis has been remOYed m ItS ortgln to display more dearly the iruertion of quadr
f!e*lr dlgltorum longus contracts and therefore shortens, the ortglns of the lumbricals ~ proximild. Thi$ "pre5tretthing" of tne lumbri· cals Improves their ability to contract. enabling tltem todevdop greater force.
441
f.ol,wr Umb
3.1
- - J. Musarlaturr. Topogtvphlml Anatomy
The Muscles of the Thigh, Hip and Gluteal Region from the Medial and Anterior Views
15wrtmr.albody
I lac crest
A'omontory
lliaa.5 Anll!r!or super!o r llllcsplne Sacrum
1'5oasmlnor Psclas major
Obturamr InUrn!a
l'lrtfonnls
Plblc symphysis
Gkllals maxim ~a
Sartori ~a
Adductor rnegnus
Adductor longus SenI-
ltKI:us
ll!ndlnasus
!\!mads
G-adls Sen!-
membranasus
Vastus medats
A Then'llllldelofdle rtghtthfgh,hlp,andglutMI regtortfromtfle medtahftiW
442
Tibia
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
- - Anttrforlongltud lnalllga me1t
lropso.K
lngl.fnal
R.ec:tus
IQ~~mnt
ftmolfs
Nile ~Is
I'KIIneus
Adductor long~a
Sai1Dfus
lteclus
femoris
Adductor mag~u;
llatlllll tnlct
Vlstus medllls
I.
V..stus lmflllls
~ M~
(axnmon ll!ndonof lrllll!l'tlon)
Pmlla
Pmllar ligament Pe~rlnus
• 8 TheiiiUIIdl!rs of the right thigh. hlp. ;md 91ut.eil ret~lon fNm the ilntl!ftorW!w
b Portions of the sartorius and removed.
rectus
fanorls have also been
a The fascia lataofthethlgh(seep.485}has beenremovedasfaras the late<;~l ilic:ltibi~l trirt.
443
f.ol,wr Umb
- - J. Musarlaturr. Topogtvphlml Anatomy
The Muscles of the Thigh, Hip, and Gluteal Region from the Anterior View; Origins and Insertions
3.2
Pscas
m.ljor Iliacus S;utortus
Tensor fasclaelme
ClutEUS
l'fr!fannts
Cluteus
Al!cb.ts II!morts
mec!U
mlnlmus
Plrlmnls
- -+,......,:
Cluteus medius Cluteus
mlninus
- +-E-1,
Piriformis
llot'unoral ----:IF-....,...+-~t.. ligament
Obturator
\lasllls
elltiemUI
~~~ ----'~:s-..,.'f.....,
la1!er.alls lllopson
f'ed!MUS
Vast\IS
lar.!Hs
Adductor mlnlmus
\lasllls medlillls
Mductor
bm!s Mductor
for9Js Gntdlls Vllmil;
lntmned'us
-+:-HI--
,.oij~.........,-
Adductor mag nus
Adductor hlltus
Vllmilo --.....;:~
llltler.llls
& t--*f.ll-- - Artlrular'ls
/=!~i:P'~I I
genus
-M-i+-- - Vartui medlds
llklllblal lr.lrt
A The murdes of the rtghtdigh. hlp. ;md tllltfil n!tlon fnlm the ;urtertonfew The orlgiM and ln.sertfoM of the muscles are Indicated bymlor shading (red • origin, blue• insertion).
444
The Iliopsoas and tensor f.lsdae latae have been partially reiTICMCI. The sartolfus, rectus femoris, vastus lateralls, ;md v.astus lateralls have been mmplet!!ly removed. b The quadria!ps femoris. iliopsoiiS, tensorf~sciae latae, and pectineus have been completely removed. The mldportlon of adductor longus has been removed.
;a
LowerUmb - - 3. Musculature: Topogrophlml Amrtomy
P.loallll}or
Psoam1}or lltacus
liacus
So~rtarw
Sinon us Plr!folmls
Pl'l!l'annls
ltec:tw;
femoris
Rectus
femoris Pectbeus
Pfr!fonnls
Obtu~r
Clute~JS
menus
mlnlmus Gndls
\'a'itus
lit«ill Is
Adductor longus
lliap50aS
Pl'l!famls
Pectineus
G~
Gn~dlls
mkllmus
Adductor longus
Vlstus
literal Is
Adductor
iliopsoas
briMs
Adductor
Adcllcbr
minim us Vlstus
med'alts
Valtus medialis
'iastl1s
int!lmedlus
---=-
Vast!Js
Ndcullr!s
Attltullris gems
--~~
l'ntl!rmedlus
Jl.dQJcbr
genus
hiatus Tendnow; 11\5e111on of adducmr 1na91us Adductor
Jl.dQJcbr
magrw
UJbcroe llioclblil tm:t Bllzps femolfs Quad'la!ps
femolls
SenImembnmosus Grad Is Solrtarlis
Smll-
tl!ndl'losus
• 8 TheiTIUIICII!s of the right thigh. hlp. ;md 91ut.eil ret~lon fNm the .antl!ftorW!w The origins and IMertfons of the muscles are Indicated by color shading (red • origin, blue • insertion).
.a All c4 the muscles have been removed except for adductor milgnus and q~~adratus femods• b All of1he muscles !\ave been removed. Nat!! the adducmr hla1lls, lhrough ~Mllch the femoral .ar1e!'y .alld vein
entl!r the popliteal foss;~ of the le-g.
445
f.ol,wr Umb
3.3
- - J. Musarlaturr. Topogtvphlml Anatomy
The Muscles of the Thigh, Hip, and Gluteal Region from the Lateral and Posterior Views
IA!p!nous
pnw:es.s
auuus medius
---~'Jiir")
...;
---:!!!:-.:-::::~:=,,
~.,...---
J ~ft---
J1n1:e!ior 3Uperior iliac spine
Tensor flllclaelltile
A Then'llllldel ofdie rtghtthfgh, hlp, and glutMI reglort from the
da lata. Thk thlt:lcl!lled band, c:alled tilt tlfol:tblal 1r«t because It runs
~lvl'ew Noktile ~nsorfaKiae lme and gluteus ITiiDdmus muscles. wflose ~n
between the iliac (n$t ~nd the later.~! side of the upper Cibio. functions med!anlc:ally as a~nslon band to reduce the bending loads on the prox· lmal femur (after Pauwels, see alsop. 367}.
don.s of Insertion strengthen and thicken the latefill part of the fas.
446
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
15sp!nal5 proass
lllaccrut
lllaccrat Aim!nor
Jupedor lhcJplne Gluteus mlnmus
QU!J!~A
m.sdmta
Teruor
f&'ldaelme Gemelha S\lptrlar
Plr!faiT!IIS
Gluteus medius
Geme!IUJ lnh!rlar
(cut edge)
Obtumor
Q.ulctlll:lls
nt2mus
femolls
Saao-
Gluteus maxlmus
~us
lig;Jment lsttllll tubemlty
MWclllr
m111J1ta
llollblal tract
St!mlll!ndilC!!iUS
&I~ femoris. long head
St!mlteodll05UJ
Bioeps
h!morb, long hod
Grad ill
Semi-
Semi-
membranD!W
m
l'llntn
l'llntn
b
B Tile II'IIUIIdes of the rtghttHgh, hlp, and glutHI reg1on from tfle poster'~or view ;a The f.lsda lata has be\!!\ rem DYed as far as the nlotlblal tract (the portion owrtlle bllttOck Is called the glutleal f.lsda).
b The gluteus miiX!miiS aoo gluttus medius hoM! been partially
remcm!d.
447
f.ol,wr Umb
3.4
- - J. Musarlaturr. Topogtvphlml Anatomy
The Muscles of the Thigh, Hip, and Gluteal Region from the Posterior View; Origins and Insertions
Tensor
faltlael;rtn Gklb!ur. maldmt~~
Gluteus mlnmus
Gemelha
Cil!meUus suf)8!ar
SUJ)j!r'ior
Gemellus In~'~nor Obtumor ntl!mus
Plrtfom'ls
Glulals medius ~l
flmods Sacrotube!QIS
ligament Adducb:lr n'IOI!JMW
Glutesa mlrfmus
GIU!J!us maxmus
vastus laler.llls
Cil!mellus Wer!ar Glutws medlusand mlrfmus
Obtumcr lnll!mus Sen!I· membrancuus
Gluteus mmmus Mcllcb:lr
mag nus
Vastus llkmedus Se
Grad Is
Gllslrocnemlus. medlllllWld lmnllhelds
-~;;.._....;:o-r
W.4HIH+-"-- Soii!Ui
-+:t--
A Then'llllldel ofdie rtghtthfgh, hlp, and glutMI regtor1 from tfle postleftorvlew The origins and Insertions of the muscles are lrldlc:3ted by color shi!dlng (red • origin, blue •Insertion).
448
llblalls
pomncr
a The semttendlnos~a and bla!psftmorfs have been partially removed. The glut!!us m;rximus and medi~a h;ave been CQmpletely removed. b The hamstrfngs (seml!l!ndlnosus. semlmembr;mosus. and bleeps ftmorts} .arid glutNs mlrtlmus hiM! been completely removed.
LowerUmb - - 3. Musculature: Topogrophlml Amrtomy
Tmsa" fasda~latl~
Ten~or
hadae lirble
Gluta5 llli!dmus
Gluteus rrinlmus
-...!-----:-"~=:1
Gluteus rrinhna auteus r!\illUnus Gemellus super'lor
Ciemelus Juperlat
CiemeiU'J lnl!rior
Gluteus medlus<~nd
Clb!:iJ'.atar lntl!mus
rrinlmLtS, plr!fonnls
GemeUU"J lnh!rlor
Gluteus medius .and mlnmlll, p)1fcnnls
Obturmr lrt2mis
Quadmus h!ITIOI1s
QuiChlus h!mods
lllap.Sem
Gluteus !Nld'mus
Gluteus madnus
Ped!MUJ
V'a5tla lm!rafs
Vzrllls lm!llllls Mcllctor bre\'fs
V'a5tla lnll!nnedkls
Vailus lnt811ledus
Adductor
Mcllctor
mag nus
lf.lltus
mag nus
Blc:l!ps
1!1czps
l'emorls, short head
ftmorfs.. short head
l'lantuls
l'lantn
l'lleChlls
Gastroa>emlus, - -t="---"'-,... medial and
Glllotmc:nerrlus, medial and
&,ter~h~
l~llleads
Sem~
rnembrano.sUJ
-~"'---"'-:~
--'=:!!• •
1f4f4.l~It-~- SoleUJ
-+:! --
J\'#:ow.-~- Soleus
Thlills
-+:! --llbfillls postalar
~trior
fltl(Or - --ffiil dlgltl:lrun longus
B Tile II'IIUIIdes of the right tHgh, hlp, and glutHI reg1on from tfle poster'~or view The origins and Insertions of the muscles ;rre Indicated by color shading (red • origin, blue •Insertion).
a All muscll!lha~ been removed em!ptforlbe;rdducmrbrevls, ;rclduc-
tor longus, gemeiiU'S superior and inferior, ;and obturator externU'S. b All oftile muscles hiiYe been reiTIO'IIed.
449
f.ol,wr Umb
3.5
- - J. Musarlaturr. Topogtvphlml Anatomy
The Muscles of the Leg from the Lateral and Anterior View; Origins and Insertions
Bleeps femoris, laf\llhud
llectus femoris V..stus
lmtalls
vastus laterals
ilatlblll
illodblill
tract
Ox! Is
Silrtmls V..stus
tract
~alii
l'lltella
Pmhrlig;unert l'esi~U!i
a~emlus,
(cammon b!ndan
n11111 111be'cslty
laralhead
ofMrtlanof Hltarll.ll, grKIIS, 1nd semltencfnosus}
Flbularls langoa
'lb!Oit$ anterior Rbllarls longus
Soleus Extl!rdor
dfc1!0rum lang1.11 Trla!PS
surz
Flbular'ls ----'-~1
lT"t-11'----- £xbruor
bl'l!l/ls
h1llud'slangus
l.all!ral malleoha, flbula
FW1r1slertlus - --#Afll l 't>"Y.--Prl-- - Extensor {wr!able) h1llud'sbrellls Flbulal'ls lang .a
Exllensar dlgllorum lang .a
lf'lllf.H.~il-4...--lnte-1 '1-PJ~HM~-+'---
A Tile IIIU!Ides of1M rtght leg a U.teral W!w, b
450
~nterior lllew.
£mnsor ctgillx'um longus
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
Head cfflbula
Abularls
Fbulllrls -
longus
longllS
--'llll1n l ,
E---+- - - Tibialis
Tlblat'
anterior
antl!rlct
Dcl:ens«
Extmscr
dgltllrumlongus
dlgltllrum longus
Exl:enlar
haluds longllS
Flbulllrts brws Abularls t«ttur.
Rbl.farls breW Dr.teruot halku:r' ~sand ~
£xtl!nJi«
d!Sflorum bn!llls Rbl.farls
b!flw
Emnsor
d'tlttlrunbrws
haluds breVIs
Tibialis
anllrfor
llblds lntl!rlct
+-!!7!-~lf':--H.~- Emnsor
dJ91:orum longl5
• B Tile musc:les of the rtght leg from the ilntertorllfew The origins and Insertions of the muscles are Indicated by color shading (red • origin, blue • insertion).
Extensor dlgltorum longus • The Ublalls anterior and flbularfs longus have been completely 1'1!1110\ll!d, as h.we the dlst:al portions of Ule extl!nsor dlgltorum loniiU$ terldcu't'l. The fibularis lertiU$ is a dM.!ion of Ule extensor digiWrumlongus. b All ofUle muscles have been removed.
451
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
PI;IIIUrts
l'lllrtllrls Gll5tcvcrwm\ls.
COIS!rommlkls, ~II-'
Gaslnlcnenius, IMI!ral head
medal held
Gaslnlcnenius. lar.Jihead
Poplltl!ils
Popltals
Bl~ fl!morls
BIC
Fibula lis longus
Fibula lis bngus
Sola~~>
Soleus
11blalls
11b'lllls
~
~
flexor dgllllrumlongllS
Flexor dlg!torum longus f!tliM
FltliM
halludr. bngus
hallucls longut lntl!ro.siseous
membrane Fibula lis brew
Crural - - - - ( i[l"
cHasm
Plantaris ----i--::~~-. .4--- - Trlc:l!ps
sura
Plantlrts
11blalls poiltl!lfor Tblah anterlor Flexor - -H haluds longus
11bllllls - -""f''..~~ftrl.--- Flbulalfs anterior longllS
IH -bHH - - - Flexor dlgltorum longllS Flexor
hallur:ls longus
• a The~ of the right let from the posterior view The origins ;rnd Insertions of the muscles ;rre lndlc3ted by color shild· lng (red • ortgln, blue • Insertion). The foot Is shown In a planar..flexed
..._~_..._....__
b
• The triceps surae,
pi;lnt~rif.
Flexor dlglton.m longus
and popliteus musdes hoM:! bftn
removed. b Alloftilemusclesha'Yebeenremowd.
position tD bl!tlz!r demarutrate lfle plantarb!ndans.
453
f.ol,wr Umb
3.7
- - J. Musarlaturr. Topogtvphlml Anatomy
The Tendon Sheaths and Retinacula of the Foot
Rbd~rls
longus
Tr!~sullll!
'llbl:llls ~IIUf!or
'llbla
Emns« dgltlltumlongus
Ellt«nsct
hallucls longus Fbdaris bm!s s~ extfn$01" retln;~CUium
Med'al malleciLll uter.al malledus
lnfel!or
elditnsar retfn.ICIIIum
Fl>ularts b~s
Flblllortstltrtlus (Vall~ble)
Tubercslty of flfttt met.11.1r.sal
Abci.lcmr
dglttmtnml
T«ntlan
shel1tl Extltnsor halltldsbmls Extltnsor dlgrtorum b~s Extltnsor dlgltorum lcngus lntU'O$$el
Extltnsar hllltlds longus
A The tendon shuth$ Md mrn.cullt ofthe right foot hm tfle iilltaiof'llfThe foot Is plantir·flexed, 'With supe!i!dal fascia removed, to display tile deep fascial b.arld~lo-tflat hold In pliKI! the tendon sheaths of tne long fvot extensors and flexors. The superior ;nd inferior extensor
retinacula retain lfle long emnsor tendons. allowing effldern: redirection of !he forces gener;ated by !heir muscles (tibialis antel1or. extensor dlgttorum longm, extensor halluds long~~S, and flbularfs tertiiiS) while
454
preventing the tenclocu ~m rising JWi'l'l from tne bones of the ankle when lfle foot Is do1'5lf!exed. Similarly. !he fibular retlniiCUia, laterally. hold the fibular muscle tendons In place posterior 1D Ute later
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
nbfalb--' \"'itt:-- r - - - Trfaps antlertor
11bli
'
sura~
- --tt--
11blalls postl!rior
Medal malleolus
':.11!r-1:----Remr
hlllucls longus
~>--'"--7---
Teodon shmh Adlllles
t2ndan
.....;:.......-""!-- - Remr retfnacuh.m
Remr
hlllucls longus
a
Flexor halluclslongus
Rbilarts ---::-+-F-.:.ii~+.-:.~11//11 longus
Tblah anll!!far
~~ , ~=~r Jl__
B 1'1lii!tendonthotNand reanaculaof ttl~! rTght foot .. Mli!dialvlew,b lmralvlew.
Extern«" hlllucls longus
Trla!pssurae - - -....,........,
I
I
Exlcn!
clgltllnlm loo!ius
~l;-H1 Rbila
Fbulartslangur. lnli!rfar flbl.far retfnaalum
b
Abducb:lr
digltlm~lml
455
f.ol,wr Umb
3.8
- - J. Musarlaturr. Topogtvphlml Anatomy
The Intrinsic Foot Muscles from the Plantar View; the Plantar Aponeurosis
- """"'ii!t-:-- 1#---:-H J-:-.....:O.---'P.....,_-
SUperficial lr.lnSIII!flle met~u:arp;~l
ligament
T111mwne lind des Flelra~lll----l:-:+:-·•
mtnmt Jnools
Tlllrd plan!ar ----!1-+--1114· lnlll!lvl5e UI
Tube1051tyof f!fthmetm~l
~---Mrldlal
Abductar dtglllmlltmt
pl<~nt;r~eptum
~~--~~-.~~
pllnllrRP~Um
Abducllr
hallucls
Planur
--T-"~~~
iipooi!UI'O.Iis
t -- - nbiallspusll!dor I'.;;:__ _ _ Fle110r d1Qi1orum longus •~.;r----- Flexor
halkldslall!US
A The pl•r~Ur aponeurotl• ofthe rlghtfootfrom the pl~r vTew Thepfantorapotlt'Cirosls Is a tough aponeurotic sheet that Is thicker cenll'illly U!ilfl medially ;arid laterally ;arid blends 'With the dors;al f;ascla (not shown here) at the borders of the foot. TWo Silgltbl expansions of1he tniclc antrvl aponeurwis (the medial and lateral pl;ant;~r septa) extl!nd
456
dC!IC!SI to tne bones of the foot. defining tne boundaries of tnnee mUKie compartments In the pl;ant;ar region: the medlill compartmatt. l;ater.~l compartment. ;and centt;al comp;artment (not labeled here. see p.440). The m.-.ln function of the plant.lr apar~eurwls rs to giVe ponM support to the longitudin;ahrth (see ;also p.415).
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
·~-1:1+---
Flex.or halluc'lllongus
lhlrdplanur - -+-t..-11'-
'~ Fcur1hdo~:£ai--H~II-tll& ~
Flerardf9ti--H t:: mnlml brellls
11-f...J'I--..::f-- - - Flexor dlgltonm brellls
Abdlcblt dgltlmlnml
Abductor hallucll
Rbl.faris - ----;l'-' lang us Plolnur 'I)Oneul0$ls -----lfi-~~-:-
(cutedge)
t ----lblallsposttrfor
,JJ-- - FlfMr digltonm lcngUi
..#-- - - - Flexer
halluclllcngul
- - - - CIICIM.al IUlet'OS!ty
a The shoct mulldes ofthe right foot from the pi•!Qr view The entire plantar aponeurosis. lndudlng the superficial nnsvene ITI4!tic.;npal ligament. has been remOYed.
No«> the anular ligaments on the p~nt:arside of the toe$. Together with the oblique auclform ligaments, tiley strengthen tfle ta1dor1 sheaths and help to hold the tendons In position.
457
Lor.wrUmb - - 3. MIISallature: Topogrophlml Amrtomy
~r------~--~~~ dlgltonm lcngus
Flel!«
halluc~ langus
Flelalr dgllonJm bnNis
UlmbllcMS
Adductorlwllluc:!s, lranM!r.le held Flexer hallucls bmls, medial and lat2tal meads
Plillt<Jr.n:l donill1111!10554!1
Opponens dl!1tlmlriml
Adductorlwllluc:!s, obUquehe.d Abductorh
Flecordlcjtl ml'llml~
Tube10$11.yof fifth mcuursal
Tcn6on of lnSCI'IIon offtbtlartslongus Tendon of I n of athlls posti!!1Cr
IJlng pia nt.1r llga ment
Q.uldmus planta Flbular111cngus Abductor
digltlm~lml
Tibialis posttrlar Abductor lwiiiOOs FielD'
dlgltonm len gus
- - - - Cllcane.allllbe10$11.y
a The shoct muldes ofthe right foot from the pi•!Qr view The planw i!poneurosls hils been re!TICMd In addition to the following muscles: flexor dlgltorum b~s. abdiiCtor digiti mlnfml, abductor hal· !Lids, quadr.rtus plantae. the lumbrtcals, and the tendons oflnsertlon of flexordigitorum long~~J and flexor hallucis long~~J.
Note thilt e;~ch of the four tendons of insertion of flexor digitorum brevis dtvldes Into two slips, ind thilt the tendons of flexor dlgltorum longus pass between these slips to Insert on the distal phalanges.
459
f.ol,wr Umb
- - J. Musarlaturr. Topogtvphlml Anatomy
3.10 The Intrinsic Foot Muscles from the Plantar View; Origins and Insertions
Plantlrlt~
First ltuwgh faurtll klmbrlc.als Mductor halt.lds. tr.~nswrse~
~~·
Flsordl9'tlmlriml breVIs
obtque~
"'
t'ifi.~~1W:11l..jl~..lyj~-- Flexorhaluclsbl'e\1s
Abductordtgltl mtntml
1·'111' -- ..f!f.- - - Flmdorsall-
Thtrdpllnllrlnll!~us _ ___.:~1:1[""'"1 Fourth clon.11tnll!roueus
~~-W,~'{--- Addut\orhalllcls,
,l"ll,...r - -t'-- - - S«md c1on.11 tnll!.weui
- --f'>.Jtf""iili
Sealnd pllntlrlnll!~us
1..:-- - - Abductorhalllds
Third don:altnll!roueus
\~'IIIIJ,_~-::l~iiiiii!IIT---- Mdut\orhalllds, oblique~
Rrstpllntlrln-us
*1-7+-+'~-- Flexorhaluclsbl'e\1s
Opponens digiti mtllml
1+-- - - Tendonoftnsett~on
Flexordtgtttmntmt - ---f-..'""1 bl'e\15
oftiblillls ;mll!ilor
..-+---/-;--,..,.,,....,?".--'~-'-'-+-----
Tendon oftnsett~on offlbulalfsloiiiJLS
QuDZw;plantle
---+-!!hf=~f-¥:~1
Flbulartslangus --j:J.tf//Mj~~~
Abductordljjtl---f-,:,----\ mlnlml
A The short~ ofthe rtghtfootfrom the plar~U~r llfew All of the short foot m111des except for the donal and plant.n Interossei have been removed, leaving behlrld their ortglns and lnsei'Uons.
460
Nok the courK' of the tibi31is posterior 3nd fibularislongus b!nclons of lnsenfon, both of ~Mllth help ttl support the transverse arch of the foot.
LowerUmb - - 3. Musculature: Topogrophlml Amrtomy
Fli!la'
haluds long~a
Rt1«
FlelCI;IrdijJI!Orun
------,..,..-.....::=~.......M
bmili
dlgllorum IOI\III.D
Ant lfl'«
do~:~al~
Flexorhalluclsb~s
fltlt«dlgltlmlnml btellls
Ahductarhalku:ls Adduc:torhalucls
Abductor dlg11l mlninl Ftntl!lraughltllrd plantarlnlerG.RSd
Adduc:torhalucls, tra n5\ll!ne I&d
Opponensd~ mlnlml
Flrstdors.all-
llirdplanblr~
Sealnd clonallnll!nosseus
Fou1h dotwl lnii!I'O$.Ie\$
Flrstplanutl~
Seoondplantlr~
11blatun-
llirddotwl~
Adductor hal kids, obllquehud
Flbullrls longus
fltii(Ord~mlnlml
brei/Is
11 blats past!!riot
Abductor digit! mlnlmland Hbuloris bnMs
~~---QUildra111s
plillt<Je ~----
Abductar haluds
a Muscle Otfgln$ •nd lnsettlon• on die pl•ntarvlew of die right foat The origins and Insertions of the muscles ire Indicated by color shading (red • origin, blue •Insertion).
461
f.ol,wr Umb
3.11
- - J. Musarlaturr. Topogtvphlml Anatomy
Cross-Sectional Anatomy of the Thigh, Leg, and Foot
auteus
maxim us
l'lr!farmls
Gemellus 3\lperlar
Obbr.ltor
lntlmus c:.emellus lnfl!rlar
Cilu!J!us maxinus ~~!':----
Ischial --':'~~' tuberosity
""""'!,._..;;,.....___ Adductor
crac~rs
m1gnus
Adductor - - -;;"""'
'-....._Iliotibial
miJPlus Semitendinosus
trlld:
113'!,_,___
A Cross-S4!dfon tfuough tiM! rfght th1gh l'rllldrnalvrew. The level of the section lsshclwn In c.
Adductor longus
Quadr.atus fellliX'Is
==~~~~~~~~
Rectvs femoris Vas!ui
~~
lm!lllls
Blaeps fernarts. short head
tllatlbllll trlld:
-4+--
Emnsor hllluctr.langut
Blain
femoris, long head Plantaris
Flbulall'' brei/Is
Ga stroult!mlus
Flbulall''
Flelaar
longus
~IID'um
Fostl!rlcr In·
bngus
termuKUillt
nblaii'M!I'Ye
T1>lf
---Fbula
Soleur.
ln!J!mi8US mtmbr-
sepblm
Tr!aeps
Fibula
Sine
B Cross-sec:Uon through the rfght leg Prolclrnal VIew. The lew! ofthe section Is shown In C.
c
"Wlr~c~Mwd• dlner.tlon of the right !Mwr limb Posttrlor VIew. P«tlans of the glutl!us maxlmus and medius have been
remCMd (the removed crvn·$C!ICtiOn$ an! shown in Aand B). The 1_.-
llmb Is or~e of the body regions most frequen'dy examined by tomogr.itphfc methods, .itnd .a knowledge af ItS cross-sectional .an.rtomy Is aiticllly important in the identificrtion of lanodmarks in bath radiol~:~gi·
c.1l and rnagnetk·resonance (MR)·based fmilges.
462
D er-dlon throuah tt. rlaht hlat at the Ieoni llfthe..abnllls Vinvofthc distlii
tions of the tarsus and mebbrsus, may lead lXI compos1mcnt JY~~dromrs of 1M foot. They ire caused by lnaused tissue pressure In the
ExiBisor dgiiDnm
E'Xb!nmr
lang.ls ond brwls
Plontarand danol lnt.."'""ol
Flfthmetltlnol Opponi!RI
hilluds longus
and breoi•
.-.'JI,"'-F.~F;;::o..,~--=...1 ~"A---
aflKted wmpartment due to the local extr""' asaUon of blood. The r;~lsed pressure In the compartment leads tD impaired venous drain•ge ind diminished capllliny perfusion, manifested dlnlcally byswrelllng and pain. This leOids in tum to neuromuscular cly$function with circulltory compromise tht lllilY culmlnote In muscle neaosls (drawn from a spedmen In the Anatxlmkal Collection of Kiel University).
Am: ml!tmnll
li'ti!rJ~~~~~~~~~rr- Adductor holludl,
d!!ttlmlnml
ablrquehood
AbdudDr
flemr
d!!ttlmlnml
holludl biWis
fli!IIDI'dlgltl nmlml bre¥ls
Abductor holluds
L*ril plo~emlnence
Tendon«
llmrholludslongus
F Tbefvur mmp;~rti'MI1III vfthl foGt and thllr mu1111.1lar Clllftll!nb (seulsoE)
............ -
~-• Dorsol and plontor lnll!roael
Medlelalllll)ll'tn*d
• Abductor hollucil • Aexor hillluds bre"l$ • Tendon of lnseruon of flelcor hllluds longus L;QI;II Qllllp;ort....nt
• AbductordlgiU mrnlml • Flexor digiti minimi • OpponensdlgiU mlnlml
O.ntnol aHIIIM'Iment, wnsldlng afthrft !.wls • lew!l1: Adductar holluds
E LOAtlon vfthe wmJNII'tmllnb vi the hiat Schellliltlc aoss section through a right foot, dlsta I view. The different muscle compartments are indica tad by color shllding.
• Lew!l2: Quildmus plllntn,lumbrttills, and fttl!Dr dlg'IIDium longus tendons • Lew!l3: Flemr dlgllllnlm bnMI (ilfter Mubilr<~kand Hirgens)
463
4.1
The Arteries
I OVerview of the pltn~lllteltes lith lower limb The arteries of the lower limb vary conSider;~bly in their arigins and br~nching patterns (the main Yirlants ~~ re'llnRd In Chaptw s. Neu· rov;rscular Systems: Topogr;~phiCill Anatomy. The br;rndtes are Hsted In the order ln which they ;rr1se from the p.11rent vessels.
Common ---=--~ llilc ortlry
Eld<m•l _ _ _ _,.,. lilac art.ry
_.......__ lnguln•l llgomtnt
llnnciMI of the ediniiiiiiK ll1l!ty • I ilMrfor epl,_trlurtery
F
- Crenasteric 1r11ry - Arllry of the round ligament Ill the ut.r111 - Pubic br1 nch • D~ circumflex 1111c 1rtery
l'rcfU1do femolts ~ •rtlry
Addudor~
aNI Addudor
\
hllb.D ) - - - l'llpbalartBy . / Antertor Ublalar111)'
~
lr;lndlls gfthet.m...l• art.ry • Superfdal eplgutr1c: 1rtery • Supa11dal drc:umfta Jllic: artery • Supridal _,.1 pudendai11Ury • Deep external pudend.ol.ortery • Profunda fMiar1••rt.y - Medlil drcumflex fl!mollllllrtery - Lillteraldrc:umftafemoralartery - Perforating branches • OIIICelldlng genlcul1r .ortery lnndlel afthe ,......_,__,
• • • • Medlll
m1llooha ............ Medlol--
-~1
malleol1.5
pllntor •r11rry
. A ~l'lnt setmlnll of the ilrtl!lf• ollhe IGWB'Imb • Right leg, ~ntartor 111-, b right leg, post2rlor lllew. The dlfferern a~rial segments ares'-> in d~nt mlors.
bll!malllk -ry: arises with the internal iliac artery from the com-
mon lilac artery and descends along the medial border of psoas major through the lacuna Vilmrum (see p. 419).1t becomes the fan oral artery at the level of the lnguln~lllgament. Femcnl•tWrr. the mntinuatlon of the extem;ol iliac artery, runs dvwn the medial side of the thigh to the adductor anal, through which It passes from the antl!rlor to the pastart or side of the limb. On leaving the illldductor hiatus, It becomes the papllbYI artery. l'llpltt.l•tWrr. rui\J from the adductor hiatus through the poplitul fmsa to the popliteus, dlllldlng It the Inferior border ofthat muscle Into Its termIna I branches, the antertor and posterior tibial arteries. Antl!rlar llblll •rtety: enters the extensor compartment of the leg illt the upper border of the interosseous rnembr;~ ne and desands brtwftn the tibia lis antl!rlor and extensor hall uds longus. Distal to the extensor retlnaallu m, Itcontinues onto the dorsum ofthe foot as the dorsolpedal Ottlty. ~or tlblll•ltrt: the dlrm mnttnllitlon of the popliteal artery, enters the flexor compartment of the leg and passes behind the medial malleolus. ~ thillt level It diVIdes Into Its two terminal br;~ nches, the medir:tl and la!MII p/antDr llr1lrlifs (the latter is shown in D), which con· ttnue onto the plantar side of the foot. The postErior tibial 1rtery also glws rtsetDtheftbularartery.
464
Mecll.lllnd J.t.r.ol superior gwolcul.or 1rtwla Suralar11rrlu Middle genlcular1rtery Mtdlal and J.t.rallnftrlor genlcullr arteries N
....,...,..._.......,.,_, .....-rent.ury Ararlar!Dnl.........,.,._, '• AnlerlortlbW
• .1\rnrlor medlll"** ~ • Dorl
- Medial tars~~lartery - Artwt.irt.ywlth the donal motllbnal.orterla (- dars•l dlgltil•rterles) llhndlel afthe ,_-tartllll•l.,-,
• Pasllorior ttbl•l ~rrent ort.y (arterial network Ill the knee) • Abul;or 1 rllry - Perforating branch - Communlcaang br;rnch - Lillter~l malleollr brancha - Calcaneal branches • Mtdlal malleol1r br~nch • Cllc:aneal branches • Mechal plantar artery - Supemdal branch - Deep br~nch (- deep pllnt.or 1 rd!) • L.a....,l plonbr •.Ury(-deep pbonbr .ordl) • Planbr mttatarsal arteries • Common plantar dlgrtalartertu • Often , . , . .til dlnlcolly 11 the suporfldlll femo111I11Ury.
-. •Is continuous With
Abdcmnal aort.l Common lllllcartltry
l'ropef pi;lntl r di!tt.11<111:2f!K
lnll!maliliac<~rtltry
Oeej)drumflex IIlK <Jr18y
Superior and Inferior gk!teaiiM!es
Supriclll eplg1511!c lr1:l!l'y
Suptrflclal
Planur meta-
lnfetlor
!a~Salarti!I!K
eplg1511!c.ury
Flr!fomiiS
Common plantlr
fxtemlllllec:artltry
E'mmal pudendal artltrfes
d~
Su~brandl}
DeEp
plantar arm
Dftpb!llndl
!JIImlch:umflexfemorllar18y l'ld'undll
Abductor hduds
l
1\modslr'b!l'y
Medial plantar
Pl!rfor.ltfng
arteries
Medial planur <1112\'y
Ft!moral artery ~or
tblilalt8y
D Thurterleufthuoleofthefoot Right foot. plantarvlew.
l'l:lpllteillartltry
Latini superior .andtnfl!rfor gentcularartltrfK
maunus
!..1tl!ralwper!or gentcularartery
Medial !Wlperfor genlalaral'tltl'y
Sur.~lart81es
t.mraltnfemr gentcularartery
t.tddegenlo.far lr1:l!l'y
tnt--
membr.Jne
Medlalnfmor genlalaral'tltl'y
Past!!!lorll blal rec:u!Tent artltry
Mil!!lor
Jlntl!flor ll blal
llblalaury
recu!Tent artltry
Pl)stcrior tlblaiMU~Y
lbular artery MlliCUiar
branches
AntetiGr !Unl malleolar ute~y Latini t.r.l.liMU~Y ArcumMU~Y
- --ff-\11
Communlatlng blitlch Med1lmalleolar -<(A br.~nches '
A
Medial plant. artery
c Theartertes of the ki'Mr limb Right leg, anteriorviewwith the foot in plantar flexion.
Perfonrllng
br.~nch
I~ Lmnlmalleolar :}
bnmches
J.& ---- Glle<~neal branches ~
E ThurteriKofthe poplltl!alfoua and leg Right leg, posb!riorview.
465
The Veins
4.2
B l'lgutnal lf9ament Pfrlfamlls
£liUmll
I lac win
uaral draunflex flmcnlw!n'
Papltmal win Short $<1phenous win
Medial drwmflex
femonlwlns
Antl!l1or
Deep femoralw'n
s.JPiwnow win
Fenoralwln
s.JI)Iwnow win
hlng
Al:llzs:lary
Adductor anal
tlbtalwl'l Fllular wins
Short saphenous win
Pc511!11or tibial wins
Papllb511wln Adductor hlatia
b
OW!mewoftfu~prf~lveTMoftfu~
lower limb Theveinsofthelowerllmbaresubdlvlded Into three sys!l!ms: a superlldal {eplfasclal}system, ~ dHP (lntennuscular) systl!m, .md a Pfl'forrtt· ing systl!m that interconn~tts th~ sup~rfici;d and deep veins. The upright human body posture places an oaptlonal load on the veins of the 1-r limb, wflich must act
~gainst
the fortt' of gravity In retumlng the blolld to the hmt (!he deep venous systl!m handles approximately 85% of tile venous return, !he superficial wins appraximortely 15X). A series of venous valves help tD maintain the normal supa'f!dal·t:o-deep direction of blood flow (see also p.467). Note !hat. for tile sake of darity, not all of th~ veins in the table below have been depicted In lhese Illustrations. DeepwlnsaftheI -limit • Femoral win • Deep ~m0111llleln • Medial and fateraldra.tmftex~m0111111tfns • PopiiiNiveln • Suralvelns • Genlcular llelns • An!l!rfor and po.sWrfor tibial veins • Abufilrvdns
• Dorsal and plantar metatarsal wns (seek) • Pfilmr digital veins (see Ac)
~1-lmltwlns
• Long saphenous win
• • • • • • •
• • • •
0o1'5<1lveoou5
ne-w
l'llrfordll!ll . . . Of the many perforallng veins 111 the leg, three groups have the greatest dl11lcal lmpcwtana {see E):
-~.,f,J;Of ll'\
oflhefoot
• A Thedeep;mdsuperfid;llwlnsofthe rfght lower 1mb a Thigh, leg, ~nd dorsum of!he foot. ~nterfor view. " Leg. po5tet1or11tew.
466
EX!I!mal pudendal veins Superlicial ci~umftex itiiC vein Superlldal epigastric vein Accessory saphenous vein Posterior a~h ~~~etn Short saphe110us win (see 01 FemoropoplltiNiveln(seeO) Dorsal ve110us ~rk(see C.) Dorsal venous arch Pfilntarvenousnetwork Plantar ~~~enounrch
c
c Sole of the foot. plant;rr view. For dat1ty. only the mort lmpottlnt veins are demonstrated here.
• The Dacld group (medial stele of the thtgh, middle thlld) • The~group (medial side of the leg below the knee) • The CocMtt group (medial side of the distal leg)
Supo!fftdal clmnlflexlllac win Saphenous -+--~· hlmls
F
remaro-
tubl~wln
poplltle.11wln
Long
saphenous Yl!ln
Lang saphena us win
Short saphena~a
Yl!ln
b
c SUperflc'lll (epl'flldlll) veins ofthe rtght IGWa'lmb
a Thlgh.leg, and doi'Jum of the foot. anterior \Ilew. b Leg, posU!rfonlew.
E Olnkally lmporUnt petfonrtfng velnl Right leg, medial view. Numerous perl'orat·
lng veins Interconnect the deep ;md superficial venous systems of the leg. Tbelr\lenous valves normally pl'elll!nt blood flow fn:lm the deep veins to the superlldal cutaneous wins. The dlnlcally Important members of this system are loe
D V.nbs ofthe supetfid;llleg wlrt5 a Spider wins (tiny lntradennal varices). b Reticular varices (webtilcto dilautiOtU of small suball:aneous veins). c I.Dng saphenous varicosity. d Short s;aphenous varfcoslty.
Varfcose disease of the supeifklalleg veins Is the mCISI: common d!I'OIIic venGllf. dise
c 111rkl!s result from dtronk ocduslon of the defp venous system Mth Incompetence of the
perforator veins and a rewnal in the direction of venous flow. Besides chror~lc conditions. there are also lmport;mt oaJ!l> diseases that may afl\!ct the superficial venous system (e.g .• l:hrombophlebiti$) and dftP venous syJtem (e.g., venous thrombosis).
• Dodd vd~ locatl!d betwftn the long 5iphenous velr1 and femoral vein at !he level of the adductor e<~rial. • Boyd vdr111: located betwftn the long 5.1phen0115 vein and posterior tibial veins on the medial side of the proximal leg. • Cocla!U vel115 (J-11): l0c.1ted between a auved branch of the long 5iphenous vein behind the medial malleolus (the posterior arch win) and the posterior tibial wins. The Cockett veins on the medial side of !he distal leg are of special clinical importance because of this region's susceptibility to ulceration.
467
4.3
The Lymphatic Vessels and Lymph Nodes
A Tile superflcTIII frmphltk system ofdie rtght hrwl!r 1mb ll Antaiorview,b posterforvlew.(The~miW5
lndlc::ate the main directions of lymphatic drilfnage.) The lymph in the l~r limb is drained by a superficial (eplfasclal) symm and a deep (sul>fasclal) sy3tem. similar to Ule am~ngement rn the arm. The largest lymph ves:sels. called collectors, baiically follow the course of the superficial veins (long and short saphenous vefns) and deep veins (popliteal vern. femor.~l vefn) and are rnten:onnected by anastomoses loc;~ted moJtly in the popliteal and ingui· nal regions. While the superficial lymph vessels prlmar11y drain the sldn and subcutan~ ous tissue, the deep system drains lymph from the musdes.}olnts. and nerves. The superficial lymphatics consist of an anteromedlal bundle and a posterolateral bundle. Thuntl!romedlll bundle nuns along the long saphenous vein to the superildallt!gulnal lymph nodes. It dr.~lns all of the skin and suba.Jt:aneous tissue of the lower limb except for the lateral border of the foot ;and a narrowroipon the calf. Those areas are dr.~lned by the ~l'il bunch (see b), which thus receives drainage from a considerably smaller region. The lymph In the posterolateral bundle fim: passes along the short saphenous veln to the superficial pop/1tx!allymph nodes and Ulen dr.~lns lflrough the deep poplite..allymph nodes tD the deep ingui· nallymph nodes.
S~al
MUS
-+-=-!o..._1tv
lngutlal lymph nodes
Ant«o-
medal
Lcng
s.1IPhe nau s
bundle
SuP8'fld;JI
pop!teal
- +.J,""""·
~ph nodes
vein
I'Dsaro-
lmral bundle
b
B 111edeep lymph nodes of the ll'llluhll regTon
Right inguinal negion aftzr nemoval of the albrtform hoscia ~bout the saphmous hiatus, anterior view. The veins and lymphatic syr tem above Ule rngurnalllgilment are shown In light shading. The deep inguinal lymph nodes are located near the tamlnation of the long s.1phenow vern. medial to the femoral vein. They are Important because all the lymph from the limb filters through them befwe reaching the lilac lymph nodes. The largest lymph node of this group (the RosenmDIIer lymph node) Is also the highest. placedatlfleleYelofthefem· oral canal. The group of pelvic lymph nodes, which Includes the external lilac nodes. begins Just above the Inguinal ligament.
468
SUP8'flct.ll clram- ---::---------'~ flslhcveln SUperflc:lal--7------~'lil
eplgas!Jic win
Saphenous Natus
- -+-------<
c:ulaneaus Win
superomtdlal
lngut~allymph
N!rncr.ll
Antl!rfarfimcr.!l
'lr-....;;;::...,..- - - SUP8'flclaland
-:--........~'----T--,--..,./1
- -+- -+-----,,.:. . .r.....!..:{
no6es Deep Inguinal Jvmphnades
SUP8'flclal and Inferior tlguln.al Jvmphnades
Long
saphenous ve'tl
c.m.... IIKIJmphniMies o
C Tile IJmph node sbtfons .nd dl'lllnage patfrwayJ In
Reulw chlneg• from - t11em11 n-mal
llacnodes o
Drafn malliyto: - wmberlymph noda
Commonlhclldn o
bce!wdrall'llgefnm: - Deep Inguinal lymph nodes - Urll'llry blacldl!r, shaft and glans of potnls, utena
o
Realw chlnege from: - Pfilcorgans - Pfilcwall
- c.lumal mlliCIIs -EredlletiiiUes - Deepperlllllll ~lon o Onln malliyto:
- Common lilac lymph nodes
DHpiiiK.,..... . . . o Rea~w
chlneg• from:
- DeepporUo115dth•lrrA>
o ~41rall'llgefrom:
- Sldn dtheiiii'A> (eliC!ept the ajf and the latEral bordl!r of the fvot) - AbclorniNIIMII belowtheumbllaa
o
Onln mainly to: - Emmllllaclymph nodes
-LIIWwbeck
- GIU!elll ~on, bGMI, enel region - Emmal gl!ra.ila (In warn.,, also the umrlnefundus along the round ligament) o
Drain malnlyto: - Deep Inguinal lymph nodes
- a-All border of loot
-Leg
-Foot o Drain malnlyto: - Deep lntulnallymph nodes
• Lymph nodes 01rranged paral· lei to !he Inguinal ligament (!he superomedi~l and superDiateral Inguinal lymph nodes) • Lymph nodes distributed vert!· ally along !he termini! segment of the long saphenous win (the lnfa!or Inguinal lymph nodes) These nodes first drain Into the deep Inguinal lymph nodes (see B) and then .along the external lilac Vl!in to the external and common lilac lymph nodes. finally reaching the lumbir lymph nodes.
o IIKeM! chlnage from:
o ~41ralnagefrom:
the IINitf' lhnb Rightllmb,;mtelforvlew. Theai'TOWJ Indicate the maln directions of lymph flow in the superlici~l and deep lymphatic systems. NoR:: Lymph from !he sldn ind su~ OJbneous tissues of !he calf and the lab!r~l border of !he foot passes through the superficial 01nd deep popliteal lymph nodes along !he deep system of lymphatics dtff!Ctly to the deep inguinal lymph nodes. By contrast. lymph from the rest of !he skln of lhe lower limb first drains lhrough the anterom~ dial bundle along the long saphenous vein tD !he superflclallngulnil lymph nodes (see also A). The supfl!l'{idal inguinollymph nodts, located on the f.lsda lata, consist of the following:
- Qlf
o Onln malliyto:
- Deep popliteal lymph nodes
S
__:~--11""1
membllllosus Popii!Hiartl!ry --+-~ nwln ~ --..;.,.,~-~
Plantlrls
~mllll
~:----....,;...--Short
saphenous Win
D The deep !Jmph nodK of the popllt.eill
l'l!flon The popliteal fossa of !he right leg, posterfor view. Lymph from the di!ep lymphitia of the leg drains (through the deep popliteal nodes bei:VIeen !he posterior knee joint capsule and popliteal vtS$els) along !he femor~l vern and then ~nteriorly thrwgh the addiiCtor hiatus to the deep Inguinal lymph nodes.
469
4.4
The Structure of the Lumbosacral Plexus
B Sptr11l cord segments and nerws at tile lumbosMnll plexu• The lumbosacral plexus supplies seruary and motor lnnerv.rtlon tD !he lower limb. It Is formed by Ute ventr.ll rami af1he lumb.ar and sacral spinal nerves, with a~ntributions from the subcost;al nerve(T12) ;and coa:yge;~l nerve {Col) (see D). ThelumbosiiCralplexuslssubdl· Wled Into 1he lumbar plexus and sacral plexus based on its distribution ~nd topggraphy.
-
Gen~moral
- - -=-'==-=,.::-,...--- """"',....... L5
Yel'!ebr.l
Sl Wflebnl
Lumblrplaus(T12-L4) • lllohypagastrlcnerve(T12-L 1) • Ilioinguinal nerw: (1.1) • Gen~oralnerw(Ll,L2) • Lateral femoral cutaneous nerve(L2, Ll) • Obturatornerve(L2-l4) • Femcnl nerw: (L2-L4) • Short. direct muscularbrancl1es to specific
hlp muscles Salcr.llil plaus (L s-s4)•
l.mnlh!maral-----:~
wblneouoJ n~
~!!::::=-- S...,e~~Cr
-
and lnffi1or
guwl
~Nip~s.---~--~~~~-~~~~~
anococxygNII'IeM!S ""--':-'1~-
~-{ ·~
lmiW"-..-..:~-...,....,c_
Am!r!or
femoral Cllt.Jneous bnmdlH MuKUillr br.Jndles
br~ncl1es:
·~
Musalar
- llblal nerw (L4-S3) -Common flbular nm~e (L+S2) • Pudendalnerve(S2-S4)
branches PIJiienclalnenoe
• Short. direct muscularbntncl1es to specific hlp muscles
lnguln.al fpnent
• Often the sacral plexus 1s further
S~phenot5
subdMded Into 1 sdatlc plexus and a pude~l plexus. The main br~nch of the pude~l plexus, the pudendal nerve. supplies theslcln and muscles afthe peMc floor,IICfl~m. and extefnal genitalia.
·~
A The lumbosMnl pii!IIUI a'ld Its bnnches Right side. ~ntl!rior 1/iew. For ci;lrity, the mus·
reiiiCh !he abdominal wall and thigh, except for lfle obturator nerve, which n.tns down the lat·
des of the pelvis and lumbar spine have been removed. Ultefal to 1he Intervertebral foramIna of!he lumb.ar spine, the Wfllnlllllml of!he fil'$1: four fltmbcrr spinal nerves (L1-L4) fvnn the lumbar plexus and pass through the psoas major muscle. The smaller, mll!aJiar branches are distJibLJted diredly to lfle psoas major. The larger branches emerge from the muscle at various sites and pass sharply downward to
er.~l w.~ll of the lesser pelvis to the thigh. The ventr.ll r;aml ofthe flJ'$1: foursacrol spinal nerves (S 1-54) emerge from theantl!rklrforamlna af the siiCn.tm and unitl! on the anterior surfact' ofthe plrtformlsmformthe sacr;al plexus. The nerves from the sacral plexus are distributed to lfle bade d lfle thigh, lfle leg, and the foot (after Mumenthiller).
470
• Su))Cflorgluteill nm~e(L-4-Sl) • lnfel1orgluteal nerw(L5-S2) • Posterior femoral cutaneous nerw (S 1-S3) • Sdatlc ner.oe (L4-S3)w!th Its two~~~
llohypo· g&IIJ!c
nerw lllllinguln1l
nerw Cerito·
Lumber pi-
Inferior ell neal ni!M!i
fl!lll0r1ll nerw l..atl!r.ll fimoral cUtMli!OUS
neiW
Obtumor nerw culllneous neme
F;moral
nerw
--l.-1-- - Deep flbularneNe
Y -+- - Superftdol
flbularne111e
~~-+--
Lmmdsur.dcuuneous nenund axnmunlatlng bnnc:h
Mtdlaland --+-........,,-.~ lmr.al
pl;mtarneNeS
D strucbJre of the lumboucr~l plexus The lumbir nenres combine to fonn the lumbir plexus, while the saml nl!f\le:S form !he S<~Cril plexus. A portion of the venttil r.1mus of L4 and all of!he LS ventral ramus combine to form !he lumbosacral trunk. This trunk combinn with the sacr;rl plexus to form the $Ci;atit nerve. The lifst splrlillnerve.tftecocqge<~lnerve.emergesfromthesi!Cnlhlatus.ltunltes
witt! the venttil riml of 54 and S5 to form the coccygeal plexus (see
p.-482).
C Topogr<~phyofd!elumboi.JcnlplllllUIS Rlghtlowerllmb,laterilvlew. Thenervesoflhelumbirplexus read! the lower limb fn front of!he hlp }oint and malnlysupptylheoniJ!Iforsldtof the tfrigll, wflile !he nei'II\!S of the _,..cral plexus deS«!!lcl ~d the hip joint ;rnd lnnel\late the postmor side of the !Ngh. most of tfte leg. ;rnd the enUre foot.
471
4.5
The Nerves of the Lumbar Plexus: The Iliohypogastric, Ilioinguinal, Genitofemoral, and Lateral Femoral Cutaneous Nerves
Quadmus klmbon.rn
lnb!mll oblique
rna~
£mmal
Mln'l>
ablrqu~
rrarngl.fnal
rrmmar abtque
·~
Psa.1a rna)Cir
Psoli51Njar
llacaest
Iliacus
rnguhal
Anter'lo rcuta neausbrandl
~ment
l:xtemlll Inguinal mg
•
lllloa
lngu'nal IQ~~mnt
lliolngu'nal nerve
b
A Courae ofthelllo~st.ric;, lllolngulllil, 91nltGf.m0f111l. ;md latl!r.ll femol';ll altiiMOUs nl!f'VI!S after emeJ'11hlfj from the tumbar pltx111 (ilfter Mumenthaler). Right l~ter"al ~nd posterior ~bdamin;al w~ll re<JJion. ~nterior view.
• The llo~rllt -
genel';llly emerges with the ilioinguin;al nave (see b) at the lateAI border of the pso;ss m~jor and rum lat· erally ;md obliquely on the antl!rtor surface of the quadratus lumborum. Appmxlrnatt!y 3-4an piiSt the lateAI border of 1hat m~a de. it pi~s the transversu5 abclominis ~nd rum antl!riorly above the lilac crest. passing between the transversus abdomlnls and Internal oblique. AftfS giVIng off several muscular branches to both of these muscles and a sens«y lateral cutaneous branch to
Nlrw
Quadmus klmbor11m
_.._
the slclr1 of the lateral hlp region, the terminal br.aflch of the ntohypogastric ni!M! courses medially, nJnning pal';lllel tD the inguinal ligament. Above the extern;al Inguinal ring It pierces the aponeu· rosls of the external oblique musde and supplies a sensory ;mrerror ctttaneous branch to the skin above the Inguinal ligament. b The Ilioinguinal genmlly courses With the lllohypogas!Jfc nerve (see a) on the quadratus lumbonJm but soon separattJ from It and runs at the level of the lilac crest to the lateral abdominal wall, which It pierces at avat1able loc.rtron. It nJns medially .at the level of the inguinal ligament between the tranM!rsus abdominis and intl!t· nal oblique. supplying tWigs to both muscles, and It db!Jfbutes sen· sory fibers thro~~gh the external Inguinal ring to the skln over the symphysis and to the later.ill portion of the labia majora or saotum.
~IIIIWtlldmUICIN
Oden- bnnchea (to the region receMng sensory lnnem~tlon, see C and pp. 474 and 475)
• lllahypcgastrlc neM
T12-L1
• Transversus abdomlnls,ln!ll!rnal oblique (the rnf\!nor portions of t.ildl)
• An!ll!rlorcuuneous branch • L.ilt«ill art.Jneous branch
• Ilioinguinal nln'e
L1
• TranM!I'sus abdomlnls,ln!ll!rnal oblique (t~ lnf\!nor portions of eadl)
• Anterlors=t.lneri.'I!Slnm•les.. an~or lab~l nerves In females
• GenitOfemoral MM!
L1.L2
• Cremaster In males {genltill branch)
• Genital brand!, femor.ill branch
•
L2,L3
~nrlfemor~lcublneous
• L.ilt«al femanll cuuneous nerve
neM!
• Obtura!llrneM(seep.474) - Anterior branch
L2-L4
- Posterior brand! • 11!maral nen~e(sel'p.474)
L2-L4
• ObtiJra!llr ext«nus • Adductor longus, adductor brt!llls, gracilis, pectineus • Adductor magnus • Iliopsoas, pectineus, sartorius, quadrlaeps
femoris • Short. direct muscular branchH(see p.474)
4n
T12-L4
• Psoas major. qLIIIdr.rtus lumborum. iliacus. ln!ll!rtr.lns\lersarlllumborum
• Cuuneous br•nch
• An!ll!rlorcuuneous branches, saphenous MM!
LowerUmb - - 4. Neunwasculflr ~ Fonns and R21Gt1ons
c The .~,_.lnerw pierces tfte psOis ll'liljor .ilnd descends upon lb .ilnts'lorsurf~ce. drvtdlng Into Its two terminal branches: the genttil branch and ~mor.ill branch: • The purely sert.llll)' femoral branch pierces the laa. na vason..m in tfte <~rea of the Aphenous hlmls (see p.-439) ilnd becomes superflcl;!l, supplying tftuldn l*owtfte lngulnil llgiment In both seRS. • The miXI!d ge~IIDI bnlndt runs In tfte spermatic mrd In m.ales. In fe!T'Iilles it initially passes thrvugh tfte inguinal Cilni!l ii«<mpanied by the round ligament «the uterus. In Its further mune It distributes sensory fibers to tfte scrotil Isldn In ll'lil leund to tfteskfn of the lilbla IT'Iiljora In fem.illes. It .ill so supplies momr ftbers to the Cl'l!ll'lilster musdein IT'Ii!les (seep. 1-43).
wtll-•
n - emerges frvm the lateral bord The l.atlll ""'*-' der of the psOis m.ii]Dr and runs obliquely downw3rd and laterally
lllohypo-1 gatrlc: •~
~t~: Amrbr---4~~--~--, cutlnooL&
br.ond!
beneath tfte fllicus bscli lxiW3 rd tfte antertor supetfor Otx spine. Mt-d~l to the ili~c spine, tfte n~ INVe$ the pelvis through the lit· erallaruna musculorum (seep. -439) and flrrt runs bene.ath tfte fasda i;IU ;md then upon It tD the sldn of the interior tftlgh, piercing the bsd.il ippralllmmly 2-l em below the .iln!Bfor supetfor lll~.c spine. The n""" is susapCible to oa:.ilsional mechanical injury it its ~~ of emergence from the pelvis below the lngulnilllrgament, as It makes an approxlmmly ao· .ilngle it th.ilt site and Is susapUble to stretching, especially on extension of the hip. Ttte nerve also has only scant CIM!r.lge by f.iltty tissue at tftat loCiltian. Stnetdl injuries are IT'Iilni· rested by sensory dbturb;mces (paresthesln) or pain In the lotrrul part of the tfttgh.
C Sen111ry hlerwUan Gfthe lngul.-..1 I"'!Qianandthtuh Right Inguinal region of .illl'lille, anterior view.
The territories of the various sensory nerves 01re lndlc3ted by different mlors. NoR: lkJth the lffolngulllill nerw ilnd tfte genItal br.ilnch of the genltafemoral nerve pass through the externel inguillill rin!J. The two nerves ire frequently confused. Ttte genital branch In males Is loab!d by first opening the sperm.iltlc mrd. In fem1les, the genital br.ilnch ucompanies the ute"lne rvund Ii!Jilment to supply the skin of the labl;! major<~ (see i lso ~).
473
4.6
The Nerves of the Lumbar Plexus: The Obturator and Femoral Nerves
L4
lll!l'tl!bra
Obtunrmr
nerve
- ---:'------¥-- ---¥
0~~~--~~~~~
eld:2mis
!::!!~~=--- Antedor bn~nch
-H~I--- l'a.ltl!rlar
branch
B Sensory dlltr11H.tt1on of tfle obtlntor
nerw Right leg, medial view.
A Course ot tfle obC:unrtor nerw The right inguin31 region ~nd thigh, 3nterior view. The obt\Jr;ttor nerve receives flben from the L2-L-4 spinal segments. After leaving the lumb.ilr plexus, It descends bl!illnd .ilnd medial to tile pso.as major (not shown here)tDwardthelesserpelvisandenterstheobturatoranal(notshown here. seep. 498) below the linea termlmlls. ;~ccumpanled by the obwr<~· tor vessels. Farther distally ltdls!Jfbutes muscular branches to the obtu· r.iltor extern us and subsequently diVIdes Into an .ilnterfor branch and a posteriorbram:h. The.se branches ccntinue distillly, passing respectively anterior and post\!rlor to the adductor brevis. and supply motor Inner· vitlon to !he rertof !he adductor muscles (pectineus. adductor longus. adductor bnM's, .adductor magnus, .ildductor mlnlmus, .and gracilis). The anterior branch gi~~tS off a terminal, sensory artaneous branch at the anterior border ofthe gradlls. which plences tile fascia lata to supply a palm-sized area of skin on the medial vfew of tile distal thigh. In ev.al· uatlng motor defk:lts that .ilre associated With obturator neM! InJuries (e.g., intrapartum 01' due to pelvic fractures). it is important to know that the femoral nerve contributes to tile supply of the pectineus musde'Whlletile sciatic neM! helps to supply the adductor magnus.
474
LowerUmb - - 4. N«!I'OIIGsaJlar Systf!ms: fonns and Relations
Psoasma)ot L4 wrtl!tlr.i
Musalarb111ndl llaa.ls lngl.fnallgament
lllap.IOaS
Sarmnus
p.mlar } Infra· branch Saphmous Medial nen~t cutantous branches
Lacuna mwaJiorum
Femor.llnenoe
Muscular branche.s Anb!rlcr cutaneall5 branches of the
ltKtus femoris
1\!maraln~
D S4!nsorydlstrfbut1onoftfleh!mor.~l Saphenous llt!M!
nerve Right leg, anterior view.
Mus.rular branches
vastus rnunnedlul 1/'astus ~rt«j)S
femoris
·~....~ R!clul
\l.lloltoadductor membrane
ftmor'll V..ltul
medialis
...:;..fl- - - lnfrllpOitlelarbrandl
r-- - Saphenousnenoe
C CcKne vittle femcnl nerve The rtght lr~gulnal region ;rnd thigh, ;rnterlor view. As the largest
475
4.7
The Nerves of the Sacral Plexus: The Superior Gluteal, Inferior Gluteal, and Posterior Femoral Cutaneous Nerves
A NIIWiafdwucnlplaus(JM~J) {llle motor ~nd senJOry nerws ofthes1CDI pluuure rewr-.1 In puts II and Ill, see pp.478 md 482.)
l4- S1
• aumu. ........ • Clu~ mlnmus • Tensor l'ascl-.lalae
• lnlerlor glulllllrww •
l5-S2
Po~~rlor femcnl cutlneous nerw
•
Glu~111 mDimu•
S1-S3
• I'OsCIIrlor femor1l cutlneouJ nerw - lnr.riorduneelnerws - Perlrw~l br~nches ( - Ffar •nsory dl~trlbul!gn)
• Direct lll'lmchs from ltle plexus:
L5,S2 L5,S1
- Nerve of plrlfonnls - Nerve of obtllrnor lnliM'nus - Nen~e of qwdrltus lemor1J
Glutow nfnlmus
• • • •
Plrlfonnls Obt!Jrlltor lnternus Gemelli Quadl3bJJ femoris
GlllleJsrnedLII
lnsullldont
ondmlnmus
small gllteols
-
Superior
ShlftH Cll!nt2r ofgnvtty
gt.ltalneM
~or
/
supafor lilac spin-.
---Iliotibial tract
B Motor di.Citbutlon of the MJpeltor glull!illn.w Right hlp region, lata"al lltew. Amlm~nled by blood -.esels with the wme n1me, the supeltor glute~l nlfW II!IW!S the lesser peMs through the greater sciatiC fo!"llmen superior ttl the plrlformls(see p.-494), runs In the lnterglutelll spaa., and supplies motor llbers ttl the srMII gluttil musda (gl~us medius and mlnlmus) and tl!nsor fud1e lit3e.
476
.. c
Olnlarllndlcdors ofsm•ll glute.l
tion af the 4lffected hip joint and an inability
musde Wllillcnels: the Tn!ndelenbwg
ttl mbllla the pelvis In the coronal plane. In a poslt!W! ll"'lndelenburg test. the peMs
sign 1nd the Dudlenne limp
I..Dwer half af body. posterior view. In normal one-legged mnce, the sm~ll glutl!ill muscles on the suna. side can sbbOta! the pelvis in the toronal pi;! ne. lo WNkness or paralysis of the small gluteiI musdes (e.g., due tD a bulty Intramuscular Injection causing dimage to the superior gluttil nerw) Is rM nlfestl!d by WNk abduc-
1
sags tuward the nonnal unsupported side. c Tilting the upper body tuw~nl the ~ffected side shifb the centl!r of gmrity onto the sbna side, thereby elev~ng the pelvis on the swing side (.Duchenne llmp). With bilateral lens af the small glutei Is, the patient exhlbltntyplal Wollddllng g11t.
LowerUmb - - 4. Neui"DDIflKKIIar .sy.mmu: Fonns and lllelatlons
Plrlfannls
....,.. --i.....;.._....._....:....
~-J....,...,.--
lnfertlr
9u!RI...,..,
Gemdlta
Ciluii!LB
Ciemelha l~~~~~i-- sl4'ft!or
1'11111)1\15
_ __
•:r~:yL
Museu~¥
llftrtor
b01nch..
Qullbbls flma1s
E Muld111 that are 1uppllecl bof dlrert bral'ld!ll!l from IN! SHI'III
D MotDr dlmtbullon afthe lnferlorglutal nerw
Right half of the pelvb, posterior view. The Inferior glum.I nerve leaves the lesser pelvis with the .sclitlc nerve through tne greiter sdat:lc foramen illRI'ior to the piriformis (see p. 494) and supplies numerous musculilr branches to the gluteus miiXImus. P1nlysls ofthe gluteus ll\illdmus causes lltlle lmpiilrment of nornul gilt on even ground because the defldt Is well compensilted by the hamstrings (see pAJO). The affected pitlent Is unable to run, jump, or d 1mb mrrs, hDWI!III!r.
pleJWJ
Right half ofthe pelvts, posterfor view. The direct br;~nches of the saa11l plexusarelisted inA.
Vl!nlnlromus (to .., ...1pleJu)
Ventral (anl!!rtor) root
/
Lab!nl
brondl or~ gostric 110M!)
Cludo equlno
G SeniiGIY lnnor-Atlon Gfthaglutul
reglan Right buttock. posterior viiL'W. The gluteal region receives sensory lnnervitlon from portions of the sacral plexus and lumbar plexu5 (wntral rami of the spinal nerves) and
also from dors~l rami: F 5e-rydbtrlbutlon oftht portertor fwmclnl cuti-I'II!IW Right lower limb, posbrtor vtew. Besides
the skin of the posbrior thiuh. the posterior
femor;ll cutilneous nerw distributes sewral branches to the skin of the glut&11 tuh:us (infe... r1orduneal ne~). and lb pertnul branches supply tne skin of 1tte perlnul region (darilw sh<~dlng Indicates the U~:lusln uea).
• From the sacral plexus: Inferior d une.JI
(postaiar) root
Ma11l foramen
(lD lite dun..t
nerws)
H An lmll'lllng Mini rwrn
Horfzontill section through the right haIf of the sacrum lilt the level
n~s (from the po5terior femoral cutaneous nerve). • From the lumbar pll!lCUS: the lateral branch of the lllohypog;~strlc nerve. • From dorsal rami of the spinal nerws: tne supefoor duneal nerw:s (dors~l rami of l1L3) and middle duneal nerves (dorslll rami
ofSl-Sl).
477
lower Limb - - 4. Neurovascular Systems: Fonns and Relatlons
4.8
The Nerves of the Sacral Plexus: The Sciatic Nerve (Overview and Sensory Distribution)
A The motor ilnd sensory nerves of the saaill plexus (part II) The largest and longest of the peripheral nerves, the sciatic nerve, leaves the lesser pelvis through the greater sciatic foramen inferior to the piriformis and passes below the gluteus maximus to the back of the thigh. It divides into its two main branches, the tibial and common fibular nerves, at a variable level but generally before entering the popliteal fossa. The muscular branches of the sciatic nerve, however, can already
be identified as consisting of a fibular part (Fib) and a tibial part (Tib) while still proximal to the bifurcation (see also p.480). Injuries of the sciatic nerve may be caused by compression of the nerve at its emergence inferior to the piriformis (usually by extrinsic pressure, such as sitting). Other potential causes are misdirected intramuscular injections (in which the nerve is accidentally pricked), pelvic fractures, and surgical procedures (e.g., hip replacement).
lnn~mllldes
5cllltlc nerw
L4-SJ
• Common fibular nerve
L4-S2
- Superficial fibular nerve
cut...... br...nes
• Semitendinosus (Tib) • Semimembranosus {Tib) • Bla!ps femoris - Long head {Tlb) - Short head {Fib) • Adductor magnus {Tlb). medi;!l part • Lateral sural cutaneous nerve • Fibular communicating branch • Flbularlslongus • Flbularls brevis
• Medial dorsal cutaneous nerve • lnb!rmedlate dorsal rntaneous nerve
• • • • • •
Tibialis anterior Extensordigiton.•nlongus Extensor digitorum brevis Extensor hallucis longus Extensor hallucis brevis Fibularis tertius
• Lateral rntaneous nerve of the big toe • Medial cutaneous nerve of the seCI)Ild toe
• • • • • •
Triceps surae Plantaris Popliteus Tibialis posterior Flexor digitorum longus Flexor hallucis longus
• Medial sural cutaneous nerve (-sural nerve) • Lateral calcaneal branches • Medial calcaneal branches • Lateral dorsal rntaneous nerve
- Medial pl.1ntar nerve
• • • •
Abductor hallucis Flexor digitorum brevis Flexor hallucis brevis, medial head First and second lumbricals
• Proper plantar digital nerves
- Lateral plantar nerve
• • • • • • • • •
Flexor hallucls brevis, lateral head Quadratus plantae Abductor digiti mlnlml Flexor digiti mlnlml brevis Opponens digiti minimi Third ;md fourth lumbricals First through third plantar inb!rossei First through fourth dorsal interossei Adductorhallucis
• Proper plantar digital nerves
- Deep fibular nerve
• Tibial nerve
- - is continuous with
478
L4-SJ
Fibular axnmunlatlng branch
a 5et'lsory dlstlfbutlon of die sdllltk ntn~e Right leg. ;a l
SUperficial }
~bularnerYe
Culanec~us branch old~ fbullrn~
•
't-~!-++--Llm!ralsun~l OJtlnec~ta
nl!l"<<e
~la1lt dors<~l (UUMeOU$
netw
b
H -+--Fbdar o:Jmmunbtfng b111no:h
Meihl calc:ane.al brautlK
Medial donal artaneousnl!l"<<e
~--·-}
Lltlnl alanal br1rdres f'tWerpi;Jntlr
nl!l"<<e of the big me
Deep
Medii! artaneous ne111eofthe
flbulllr netw
seollld toe
uaral do13al cuuneousnetw
d!QitllneMS
c
479
4.9
The Nerves of the Sacral Plexus: The Sciatic Nerve (Course and Motor Distribution)
A Course nd motDr cllstrtbUUon ofthe tdltfc nerw:: the ftbullr ~rt (common fib11llr nerve) Right lcJwer ltmb.later.-al view. AftergMng ofhever.-al musculu branches from Its tlbular part (to the short head of bleeps femoris). the scliltlc neNe au\Sistendy divides in the lower third of the thigh into the tibial
nerw ;rnd common fibular nerve. The common tlbular nerw then fol· lows the medial border of bleeps femoris to the head of the flbula and Winds .uound the neck af the flbula to the front of the leg. lmmedf· ately af'b!r entering the fibula(.s longus, it dillidl!l into its twa terminal branches. tile d«p fibular nerve ;rnd sii,Ot'ljltfolflbular nerve. The super· flclal tlbul.-ar nerve supplies the tlbularts musdes and runs betwHn the flbularts longus and ftbula to the doi'SIJm of the foot. The deep tlbular neNe nms through the interosseus membrane to entef' the f!lrtensCir compartment. After supp~ng tile tibialis anterior, extensor dlgltorum longus, and extensor hallucls longus, It runs lfl a SJFOOIIe between tibialis anterlar and extensor hallucls longus on the crurallfltef'osseous mem· brane. acce~mpanied by the anterior tibial ~els, to the dorsum of the foot. •
lftllene!'Yelsdamagedattlleleveloftlletlbularneck(averyeJq~osed
location!) before dMdlng Into Its twa terminal br;mdtes, the n!SUit Is weakness or paralysis af the anterior and laterill compartment m.a· des, resulting in 1\xlt d111p with some ii1VC!Qion. • If the nel'llt' Is damilged ilfter drvtdlng Into Its terminal branches. !he result may be iln Isolated weakness or parillysls of the anterior com· partment or the lateral musdes, depending on whether the deep fibular or the superildal tlbular nef'Ye Is af'l'emd. Accordingly. the result may be weak dorsiflexion or weakness of em"Sion. All Isolated lesion of the superficial ftbulilr nerve generally affects only the sen· sory temninal branch. with p;~in inwllling the distill leg and dorS~Jm of tile foot. Gilt disturbance will ocaJronly with an Isolated lesion of the deep tlbularnerve (as In comp;~rtment syndnomecaused by anteriOr comp;~rtment hemonf!age. see p. 507}. resulting In foot drop and a •stepp;~ge gait". Increased flexian of the hip and knee joints is necessary Ul keep the toe fnom drngglng the ground during the s>Mng phase of galt.
,I •H- - - Eidl!nlor
d~rumlong1.11
D~f.l---
480
SUperftlill flbularl'll!flle
I Course and motor dlltrlbu\lon of the lda1fc niii'VI!: the tlbl;!l p;1rt (tlbl;!l nerve) a Right lower lrmb, postenorvlew; b rtghtfoat, plantar view. While stlll in tne thigh, the tibioll p;~rt of tne $Ci;atic nerve distribute$ $C!IIl!r~l museu· lar branches to tne semitendinosus. semimembranosus. bleeps femoris (long head), <md .ildductor mag nus (medial part). Aftef dMslon of !be $Cial:ic nerve. the tbial nerve continues sb'aight down through the an· terofthe poplltealfoss.il and runs bdclwthe tendinous arch ofthe soleus muscle to tne supertldal and deep plantar flexors. which It supplies. lr1 the deep postl!rtor compartment. tne tibial nerve car~tlnues distally In a neurovascular bundle with the posteriartbialwssels (ne~t shown here) and piiSses ttl rough the t.lrl.ill tunnel, accompanied by the d~ flexor tendons. to the plantar side of the foot (b).ln passing through tne tar· S.ill tunnel, ttle tibial nerve d!llldes Into Its two terminal branches (!be l~teral and rnedi;al plantar nerves). which .wpply ~II the musdes on the plantar side af the foot. Compression af the tibial nmoe ar Its terminal brilnches ilt this site leads to ilfl entrapment syndrome(· t.1rs.1l tunnel syndrome). This C.ilfl result rn p.iln .ilnd sensory dls!IJrbafiCI!S .ilfli!cUng the sole oftne foot or even p~lsin of the intrinsic fvot m~~Sdes, p;~rticu· larly following sewn nerve trauma In cor~nectlor1 with a frac!IJne of the tibial shaft or medial malleolus.
481
4.10 The Nerves of the Sacral Plexus: The Pudendal and Coccygeal Nerves A Tllenervesoftflesaaal pll!.lllll{partll}
The pcJdend~l netve, the lowest branch of the s~a.al pima, ~rises from asep;~r.atesmall plexus formed bytfleventr~lramlofS1-S4; hence ltls occasionally referted to as the pudendal p/f!IWS.
--S2-S4
• Pudendal nerve (pvdrndol plrJius}
• PeMcfloor muscles - LevlltOr;~nl - Superftclal nn~ pelfneal
• lnfelfor rectal nerws ·~nealneNeS
- Deep transverse perineal
- Postelfor labial neMS In females - Postelfor scrotal neMS In males
- Bulbosponglosus
- Dol'lolll clitoral nerve In females
- External anal sphincter - U~hralsphln~ S5-Co2
• Coccygeal nerve
• Coccygeus
(CO«J9eCCI plaus)
• AnOCOCC)'9ell nerve (wntral rami) • Dorsal rami
B Tile cU'bmews bnnches oftfle pudend;~IIM!f'WI! ;md Its Sl!f!SOI"Y
dlltrtbutTon In tfle l'l!mlle Lithotomy p05ition, inferior view. The skin I~ h;ve been ~moved on lfle left side to demonstrate the tamlnal br.mches of the pudendal
nerve In the lschloanal fossa (seep. 496). The 01rea of cutaneous sensory lnne~Y.~tfon Is color-shaded. La~e por!Sons of the urogenital region and anal ~ion ~ceive their sensory supply from the plidendal nerve. The sldn area supplied by lfle pudendal nerve can be anestnetfzed during childbirth bylnflltr..Uon anesthesia or a nerve block. enabling theobs~ trldan to perform and rep;~lr an l!plslotomy wthout pain (see p. 202). This can be done either by lnflltratfng the perineum between lfle anus and posterior fomlx with a IDC31 anesttletfc or by tanporarlly blocking the pudendal nerve wth localinesthetlc Injected near tile Ischial spine (before the neNe has br.anched; see diagr.am in C).
Urogen11.11 - - -
rt9on
.. _ _
neNH
~Mor----------~
kM=----rectiI
Glutals mulmw
C Tedlnlque of a left-sldl!d pudelllbiiM!f'WI! block Ulhotomy position, lnfelfor view. The most common type of conduc-
tion ane:sthelia used in v;oginal deliveries i' the pudendal nerve bloclc. ~lsd!lal
~ -
A
tubera.llty
------= -
,....----PUdendal spine
482
which renders the perineum. vulva. and lower third of the nglna Insensitive to pain. In the 11Vn5W1!Jllllll opproach, " spedal guide cannula Is
introduced into the v.1gina, and 10 ml of a IDeal anesttletic solulior1 Is Injected ~pproxlnnately 1em above and 1em lateral to the p;~lpable Ischial spine on eo~dlslde. An lnjectfon at this site wll block the pudendal ne!'lle ~It has enttred the pudendal ca~l (Aicoclc"s canal) and ~it has divided into its b!rminal branches. Often the nerve bloclc: is administered at lfle end of the expulslor1 stage to relieve stretch pain lr1 the perineal region (seep. 202).
LowerUmb - - 4. N«!I'OIIGsaJlar Systf!ms: fonns and~
D Courseoftflepudendalnerwand muygeel nerve tn the fl!imlle and male
S;aosplnous
li91ment ......:...-r,-+- - 1'\!dendal 1'11!1'1/e
u~~----~~~-
~~---~.-~~~~~;s~ dltllt.al n~
•
Plr!fonnll Cin!at!r JCiatlc:
Domoge to 1M pudelldal MNe (e.g., result·
pertu!
for.rmen
Siircnr:!pln au s lllfiiTN!nl. CDCX)'III!Ia
Pudendal "~
\:=---'-=--;-- I.I!Vrtor ani
""-r--.11--+--
The pudend1lnene emerges from the leSier pelvis through the g~m- sciatic foramm• It then courses around the Ischial splne and s.;~crosploous llg<~ment <md passes through the ~r sciatic foramen into tbe ischiDanal Qschlom:t<~l) foua (see p.496). It ruru for· w.~rd In the later
Del!!) tnlr!Mn1!
Ollais
a S
RKtllm
--,,<......;p=.=;r.--- lnli!rlar 11!Ctri!'Mn'eS lii"~fL--- ~rnalallal
ing ~m perine;~l injuries during childbirth) le.ilds to loss of function of the musdes of the perineum, especially the sphincter m~~Sdes or the bladder .ilnd bowel, c.~uslng urinary and fec.~l Incontinence. Pudendal nerve lesions can also lead to sexual dysfunction (e.g.. male Impotence). The ventral rami of the fifth s.aa.al nerve and the flrrt or second coccyge<~l nerve form the
s))illncter
Erecale --~*l !t\.1 ti£SUI!S
aans Fomr1af
b
Testis
Scrotum
saotrlnerws
483
f.ol,wr Umb
5.1
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
Surface Anatomy and Superficial Nerves and Vessels: Anterior View
(¥[\~~
AnteriorsuJ)eior - - - iliac59(ne
.\ ') .\-·= .) .\-'= ,) 8
n.e ~ Cillmmon vaitlnts oftfle ronetoot ;md toes (after
Debrunner arid Lelrevre} Three types of foot shape are distinguished based on the relative lengths of tile first and second uaes:
• The •Greek" type, in wnicfl the sea:ond toe is longer th
P.atl!lla
Headofftbl.fa - - -
......;...i - - - l b l l l
tuberosity
~.o~~n--
mallflolur. Dcnumoffoat ---::.........
A Surfila!ultomyofthe right krMrllmb Palp;able bonypromJnl!tlCeS on the lower lrmb are n!llfewed on p. 361.
484
C TlleciOI'SliiS\Irhceofthe rfghtfoot
The superficial wnous network Is visible on the dorsum of the foot (comp;are with D).
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
n1 - +----''1 n2-t-- -
nguNIIIgament Supeildll _ ......._ drwmflex Ollcwn
L1-f-- S2 ---ir----
.....,..
L2
Lolt2falfemoral cu!aneous nenoe
11!mor.JI neM. -
<~nller!orreroortl wtlneous
..:..,........,.,K
brandies
---1- - -
E Segmentll or redlalllr altlneous rnnerwtlon p.llttem (dam1to~) rn the rfght lower limb As In tile arm. tile outgrowth of tile lower limb during development c.;~ uses the S'l!l'lsory cuta· neous segments to become elongated and drawn out Into narrow bands. The L4,l5, and s 1 segments In partlcular move so far perlph· erally th~t they no longer h~ any connettlon ~th the correspondlr~g segments of the trunk. Nottthatthedennatllmesofthe lumbartrunk segments lie rn~»tly on the front of the leg while !hose of the saaal segments are mostly on tile bade of tile leg (seep. 65). This can be of diagnostic importance in patients with a herniated disk, for example. lr1 order to d~r· mlnetlle level of the herniation (after Mum en· thaler).
IJxlg s.l~Phenous wil
1<111eralsur.al nenoe
cu!anea~a
l ~~-- Superficial
flbulllrneM
Superildal fllullrn~
D Superlldill al't.1neou5 wfnund IH!f'VI!S of the rfght I _ . limb Antenor view. The dors.al venous network of the foot Is drained by two l~rge venous trunks (the long ~nd short saphenous veins). which l'l!CI!ivc! a wrlable pattern of ctJtaneous veins. While the short saphenous velr1 (see p.487) enters the popliteal vein at tile lew! of tile popliteal fossa. the long saphenota vein extl!nlh up the medial side of the leg to .a point jiiSt below the inguin~l ligament, whel'l! it paues th~Wgh the S<Jphe· nous hiatus of the f.l5da IMa to enter the fan oral vein. The supafldal veins of !he lower limb are commor1!y affected by varlco$1ty, c:<~talng them to become tlllckl!ned, tortuota, and dlstlnc11y visible and palpa·
bk!(seeaho p.467).
F Pattin! of perip!M!I'ill Sl!fl'IOIY lnnllfWtlon In the right low« limb As In tile arm, tile sensory distribution In tile lower limb COITI!.Sponds to
the br~nching PJtterns of the peripheral cutaneous neNU in tile subcut;meous connective tissue. The terrltllrfes of the lrldtvldual peripheral nerves overiap, especially at tllelr margins. Hence the dlnlc:ally dell!r· mined l!lldiiSNt Off!O of a particular cubneous nerve (the area supplied bytllatnerve~lone)tendstobeconsid~blysm~llerti!O!nthem(Diimum a~W tllat can be demorutrated anMDmlcally. l'or this reasor1, tile trau·
matfc disruption of a nerve c:<~use.s a complere lo.is of sensation (inesthesla) In the exdusllle ~rea but often 111111 c:<~tae only diminished S'I!I'ISOI· tion (hypoesthesi
485
f.ol,wr Umb
5.2
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
Surface Anatomy and Superficial Nerves and Vessels: Posterior View lllaccmt - - - Ball of the big toe
Ball of the snail toe
b
vastus lmr.ails
8 r.tprin'b (podGIJ1111111) of the norm11l rf~toot luudult A podogram provides a graphic represent.rtlon of the loads borne by the foot. Besides 'Yisuallnspectlon of the sole of the foot. ;maly51s of the poclogr.am iupjllies the most Uiml information on the weight-bearing dynamics of the foot. • Footprint cre~ted with an inlc pad. b Pressure podogram showing a normal weight-bearing pattlem on the foot. The c:oocen!Jfc lines lndlc.tte thiltthe pressure Is evenly distributed over all the major points of support. These three areti .are dearly defined, wflile the in~ning pl~ntilr arches bear esMilti~lly nowdght(see p.412).
Semi·
membranosus and ~mltendln05us
--~~--G~
Balloltht blgtae
cnemlus
A Surface•natomyofthe rtght'-rllmb The foot Is In plantar flexion. (Palpable bony promlllfOO'.S on the lower limb are reviewed on p. 361.)
486
C The pl•r~Ur Mlrface of the tight toot The skin on the plant.1r surface cl the foot senres as a sensory organ for contact 'With the ground, perceMng Its conslsll!ncy during st.1nce and locomotion by means of receptors In the sole of the foot. stresses act· ing on the I!eel pad and the b
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
-L4 L
,\)If'
~
S~dunetl llt!M.S
M'ddleduneal
r
llohypogartric
Mfi'Vl',liitml
cublneous bnlndl
S1---
\'
111!1'\'tS
..
lnfertorduneal llt!M!S
:i : -+
(_
L$
E Segmentll or redlalllr altlneous rnnerviltlon p;mem (d11111illtoi1HIS) of tfte right lower limb As lnthe.;um, the outgrowth of the lower limb during dellll!l~pment c.1uses the RI'ISOry cuta· neous segii'IEirtS to become elongated Into narrow bands. The L4, LS, .;md S1 segments In partlCIJiar move so far peri'pherallythattheoy no longer hiM! any aH~nection with the correspoodlng segmenl3 of the trunk. .!1/oh!that !he dennatomeJ of the lumbar trunk segments lie mo.sdy on the front of the leg whlle thim of the sacral segments are mostly on the bad:: of the leg (seep. 65). This can be of dlagnosuc Importance In patients With a hemiatl!d disk, for I!X;lmple, in order to deb!r· mine the level of the herniation (after Mum en· thaler).
utl!ralfemoral
cutane.aur.nenoe
L4 L5
l
SuP'Itlordul'fil
~ nerws{L1-13)
Iliohypogastric neM!, lmr.ll cutaneous brand!
~-
utl!ralsural cutane.aur.nenoe
(almmon flbular netVr)
Short - ---'-+--1
Solphenow;wfn
h+-- - SUraiMM
Medial planur ni!M!,
cuuneous branch
-
1
utl!ralplantarNrW,
cutantt~L5 brand!
F Pattl!m of perfphel'ill sensory lnni!MIUon In the right~ limb As In the arm, the sensory dlstrlbutlon In the ki!Ner limb CO!TeSponrh to Pilnlllrcut.wleous ---"/;...___ bn~nctU!S
D Theeplf'Mdlol QIUneous~~elnund nenesoftfterlghtl-llmb Posterlor view.
the br~nching p;atterns of the peripheral cutaneous nervu in the subcut.;rneous connective Us sue. The terrltorfes of the Individual peripheral nerveJ overiap, especially at their margins. Hence the dlnlcally dell!r· mined exdusille omJ af a p;arlicular cutaAeOUS nerve (the area supplied bythatnerve alooe)tends to be consklmblysmallerthanthe maxlmcHII oTN that can be demonstrated anatomically. l'or this reason, the traumatfc disruption of a nerve causes a complete loss of sensation (anesthesia) In !he exdusllle ~rea but often 111111 ca1.11e only diminished Rl'lsa· tion (hypoesthesi
487
f.ol,wr Umb
5.3
- - 5. NeuratfGKUiar .s)ste.ms: Topographical AnGtumy
The Anterior Femoral Region Including the Femoral Triangle Anterlars~ar
llac'IJ(ne
lngunal
Superfldlll
llQiment ejl!Q1151rlc:arll!ry
A 11let.!m01111l trf~ngle Rlghtthlgh,.iln1J!rtorlltew.Theskln,subcutan~
~tissue.
and fascia lata ha\'1! been removed
to demomtrate the
Elm! mal puclenllll
artery
Pro!Unda femarlsartlry
neu~scular
structures
In the femoral triangle. The femoral triangle Is bounded superfor1y by the Inguinal ligament. laterally by the sartorius muscle. and medially by the ;rdductw longus. It contalm the neu.,_ vascul;rr structures th
-..-;--1-::--4 r_,.iitl
II olfllal tract
Common lllec:arll!ry lnt:emalnlec:
Anlerfarsuperfar - lilac spine
arl:el'y
1-- - - Eltt!m.al11ac arl:el'y
.)-- - - Inferior ~artlry
Fe
l'lblc llbefde
B The bnnches of tfte extem1llllac •rtl!fy It ltl{UncUon wtdlthe femDrelerteryrn tile region lllfthe lnguiMIIIgement
488
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
~I ---,---~.,...._
obllqut! mulde l..iltl!talfe'nor.ll
---~~
---------'----~obliQue
C1J!
t.acun.a {
~·~10$1$
~~---------~~~~~
mUSCJiorum
·~
IIOP50<1S { Iii!~...:.,-.:....----
--n-----
llledlilaus } Emma~ !Jm!ralaus I19Jinalrfng Reflexi19Jinalllgament
F
c 1,..11\111 ~glon and the con1letltt oftfle l•cuna m~~MUIONm and lacun;~ ViiiiOI'Um
Antenor view. The drawing shows a po!1lon of the 11ght hlp boDe and the adjatl!nt anteriar inli!riat abdomiool wall with the extemal inguiool ring and the conta1U of the liiCUna musculorum and lacuna Yo~sorum below the Inguinal ligament. The site of emergence of the muscles and vessels, bOCJnded by the Inguinal ligament and the supenor peMc 11m,ls subdivided by the fibraca iliapectineal an:h into a lmral muscular part (Ia cuBa musculorum} and a medial vascular port (liiCUna vasorum). The lacuna VI!ICII'UII'I Is located medial to tile lllopectiDeal an:h. This "vascular port.al" rs tr.avened from lateral to medial by the femoral branch of the geninlfemoral Derve, the fi:!moral artery and vein, and the deep lnguiBallymphiltlc vessels (only one lymph node Is shown here). The part of the liiCUna vasorum that lle.s medial to the femoral vein Is
Antltr'larstlpel'lor M~;~CSI)n~
l..lana ----T~'~
musculon.m
Elm!mal
lngllnalrfng
Reftet
1 - - - lngtlr111l
ligament
llopub'k:emlnence
PUbic tub8de
called the (emorul dng. The lymph veuels fnlm the thigh pass through thilt ring to entEr the peMs. The femor.-al ring Is covered by a thin sheet of connectiVe tissue called theftmaral septum (not shown here), whiCh usuallyaM'Itains a lymph node (the Rosen muller node) belonging wthe group of deep Inguinal lymph nodes (see also p.468}. The I;Kun;~ ITIII!IGionm Is lateral to the Iliopectineal arch. This •muscular portal" Is travemd by the Iliopsoas must~~!. femoral nente, and lat· eral femoral cutaneaus n-. Nokthe lllopecdneal butllllouted below the Iliopsoas. It Is the largest butlll ofthe hlp region and communicates In 15~ ofase.s with the joint c;Mty of the hlp. For this reason, an Inflammatory disease of the hlp joint may incite inflammatiarl of this OOI'lll (bunilis). When inflamed, the Iliopectineal butlllls frequently painful ~nd swollen ~nd may oca· slonally be mistaken for a neoplasm on MR Images.
D 111e ~tluue ;md bony bound;~rtes of tile IKUIIil musculorum •nd lllalna V8M'IIm Diagram of the right inguinall'l!gion, anterior view. The connecti~tis· sue boundary bei:Weal the lacuna musculorum and lacuna v.ssorum Is formed by the Iliopectineal arch, a thickened band In the medial portion of the Iliacus bsda. It extends between the lngulool ligament and the iliopubic eminena. The fibrous band that cuNU downwa~ from the medial att.-achment of the lngulnalllg.-ament Is called the lacunar llga· ment. This sharp-4!dged ligament def!DeS the medial boundary of the liiCUna wliM.Im (femaral ring) and may entrap the hernial sac in patients with ~ ftmor~l hemIa (see p. 186}. Above the Inguinal ligament Is the external (superficial) lnguln.-al ring. which lstheemrnal opening of the Inguinal canal (seep. 182). The lacuoo mumJforum Is bounded laterally by the anterior superiat iliolc spine.
489
f.ol,wr Umb
5.4
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
Arterial Supply to the Thigh
-
Adduct(Jr
Abdominal
IOrQU'J
Site of femoral ~ligation
c anmon
1tac~
OHj) dra.mftelt
tltac artltry S~d1l
eplglstrlc
artery Su))t!rfldll circumflex tracarury l'lr!fonnls
Medial
cl"c1mfte~C
YAth col later.al drcullll!on
SUpt!rlor glute;~latery
l.irtl!1111 SIIC!liii!Ury
lnli!rlor tplgastrfc
.ury lnli!rlor glulellatery
Adduc:tor ITIII!InUS
Obl1n1or ~
femoralartltry
P\blcbnr!dl
Medtaldrcum· flexftmoral arury (dttp. ascend:ng. and detandtng branc!les)
l:xb!mal pudendal artltrfes
} Lab!ralct"almflex femoralartery
Perforztng a-
• B Course oftfle profund;a femorfs artl!iry arid sltl!s where tfle
perfontfng art1!111!s plerce tfle adductor muscles a Right thigh. anterior view; b schematit longitudinal Rdion through tnt' adductor muscles at the level of the perforating ;uterlt'S. Tht' profunda femoris ;uuryhas approxlrnatety3-S terminal bl'anchesU\at pass &om the front to the bick of the thigh through the femoral Insertions of the
femoris artery Is relat!Yelywell tolerated owing to a good collateral supply from br.-arldtes ofthe lntematrliacartery (supenor glutHI artery and obturamr artery).
c V.r11111b In the femoral ar-tery br~nchlng paUem (aftel- Uppert A Course arid br'lnchesofthefemor~lartl!iry
The ~mor;al ~l'l!!ry, the dim! continuation of the external ilia<: al'l!!ry, runs along the medial side of the thigh to the adductor c
and Pabst) • U$ualtythe profunda femoris artery and medial and literal drcumflex femor.al arteffes ~lise from the femoral artery by a common trunk (582: of c;~~es. also shown in theotherfigutHon thi5 page). b The medial circumflex femoral artery arises directly from the femoral artery (18% of cases). c The lateral circumflex femoral artery arises directly &om the femoral ~rtery (1 S%of cases). d The drcumflex arterles arise sep;rrmty from the femoral .-a!Ury (4 Xof ases).
e The desanding bf~nch of the lab!r~l circumflex fe~l ~rtery splir~gs directly from tht' ~oral artery(l% of cases). f The circumflex .-a!Urles arise by a common tnunk (1 %of ases).
490
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
Ant!tfars~cr
Extmtallllac artayandw'h
- - -...:,....:-,
llilCiplnt
,.1111!1-- - S~andlrmnor
lngubalhgament ---....r:;~.,...
g~larteries
,;:;n;,--- ~llli!M!
~~~hrna~l---++~
Adductor
langur.
cutlntOWI'Mn'e
Femor~
al'b!ryand
Tensorfasdae - -+-
w'h
latae
Rectus fl!maris
. .+-1111-----.fl-_,.~
Adductor
mag.u; C111dlls
a.-..lac:umflex h!moral~.
a'lot'8'ld'ngbramh Prvfunda --+f--IF-:--I!::Jf.j~·· fl!marlnrtery 1'8fmrting-ry - -tt--'IHHifll
Lateraldrnunflex -~~~~~lit\ !\!moral~. ~ncll\0 brardl
V115tus medialis
lliaablal tract
E Thalocatlon ofthudductur c;m;ll Vastus fntl!rmedlus
---Lt--T-~;,..._·
----
~lullery;mdwln
- - - - Obc!Jratcr MeNe. cutlntOOS branch Saphenausnenoe
Right thigh, antl!rior lltew. The saphenous nerYe passes down the adductor anal on the ;anterior side of tne thigh, i!ICXOmp<Jnied by the femoralilrteryand vein. Whllebothvesselscontlnue tOYtard the popllb!.al fossil through the ~dductor hla~. the saphenous ne~Ve pierces
the ~~;~Sto
F 'nll!boundalieundcontentsofthe adductor can1l
>--- Dela!ndl'lg
genlallar ariJ!ry
Bounda.tes o Adductor longuund magnus {posterior) o Sartorius (medial) o Vastoadductor ~brane (anb!rlor) • vastus medialis Qateral and anterior) CGnttntt o
D 'The blood IUpplytothettllghfromthe
profunda femOI'II artery Right thigh, anterior view. Tbe sartorius, rectus femoris. adductor longus, and pectineus muscles have been partially removed along Wllh the antral portion of the femoral
of the medial and latl!fal cii'Qimflex arteries mainly supply blood to the hlp jolnt.ilnd extensors and adductors of the thigh, the tenninal brandles of the profunda femoris artery (the first through third pertoralfng ilrterles, see B) on the medial side of the femur pass to the
p~
back of the thigh through !J'!I» in the in.HI'-
funda femorfs artery In the thigh. F'or clarlty. the veins have illso been remOYed to the leYel of the ex!l!mallllac Yeln. This dissection does
tlons of the ildductor muscles ilnd supply the hamsttlngs {bleeps femorts. semltelldlnosus, 0100 semimembranosus).
not show the ;anterior abdominal w.~ll or the
No~: The V<JJtoadductor membrane is pierced
peMc and ilbdomlnal organs above the leYel
by lfle descending genlcular artery arid saphenousnerve(seeEand F).
arl!!ry to demonJtrm the course of the
of the lngulnill llgamern:. While the branches
Fenoralartery
Fenoral vein • Saphenous nene o Descending genkular artery o
}
plerathe Yastoadductor membrane
491
f.ol,wr Umb
5.5
- - 5. NeuratfGKUiar .s)ste.ms: Topographical AnGtumy
The Gluteal Region: Overview of its Vessels and Nerves
1\,'i~.~r-M~r---
llolrjpogastrlc nervt',
c:llnealnM~tS
tmrallrllndl
.,....-i!-- - llohypogastncn~.
>-'"-lr---- SuperiOr
l;l1lrallrllndl
du-eal neNeS
Gutalfasdl (!IIUIJ!us med\15)
G~lflDda
{giUIJ!us med\15) ./----'------i~--
Superior
llllddleduneal ni!M!i
__,.,..;....4/,.J,-+-I,...--- Gk!Wal hDdi {giUIJ!us IIIIDdmus) ------,~-~~--l~r
dLneill
..
~ ~.....:..--,....-~,...."""T-4-•-
nti'VK
lnli!!or dl.llell nem!S
Posterior femoral am.neaus
·~ '$;--~----,~-
Pcm!lfor li!moral cutanl!(lus
"~
Glub!al sl.fcus
A Thef.udaendcutllneou• MI'Wf.ofthetupetftdllgkltHI region
Rlghtglll'lul region, po:sterlorvftw. The glutei Iregion Is covered by tile gluteal faSCia, which Is part of tfle fasda lata (although the tenn "fas. cia lata" strictly l'l!fl!rs only m the part bel- the glub!us medius and rnaxlmus). The fascia awering tfle glmus maldmus fonns septi·llke lnwglnatlons between tile musde bundles. At tfle {unction of the glu· wl region with the billc:lcof the uppertfllgh Is the genUyauved gluteal sulcus. in which tflicblled fiber tracts of tfle fascia lata run traru~rsely iiO'OSS !he thigh it tfle level of !he lschlaii:IJberoslty. fllotl! on surface anatomy: The oblique Inferior borde!' of the gluteus rnaxlmus (see B) O'MSI!s tfle glub!al sulcus.lt.s murse. then, is not identi· cal to thit of the gluteal sulcus.
......;;!----'--- - Blaeps li!morls,
lang had l'ostJ!flcr --~H-11.
-
li!moral
cutaneous
Se'nlme
-----'~Hffi-1/A
Poplfte\11--'-ltll'-' a'U
"'-'- - - Common flbulu l1liW II';,:.~,.,....-- ~I
sural
am.neous ._
B The glutell region and tfllgh wtth the f8lldle remowd Right side, pom!rior11iew. With the fasci
492
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
Glub!us ---,-------~i!.- mDI'mus S~oruk!Walartay,
wlnandni!I'W
l'lldl!ndll nerve. ----'"-=!'::"'3!1 pefnul brlii!Che Obbr.ltor 'hl:2mls ~usl'91ment
GlutaJs mlldn'US
liehill wbeta:slty
Sdlltlc nenoe Adci.!cta"mag~L&
~----~i---- ~femo1111 CJtlneGUSIIENe
Adductor mag nus
+----:-;~--
G~~~-------~·11
c
Tllevesselund nerves oftfu~ deep glutNI reglon Right sidt', pomnor Ylew, with tnt' glmus milldm~JS p;~rtially re~.
The neurov.asa~lar structiJres of the deep gluteal region tr.JYene ;m extensive fatty .and connect~tlssue sp;~ce below the glmus miiXI· mus. The floor of this sp;~ce is fDrmed by the piriformis, obturatDr internilS, gemellus supafor, and quadratus femoris muscles. It communi·
Piffannls
Semlb!ndlnosL&
c.atl!S thrCIIJ!Ih tnt' stiJtic foramina with the a~nnecti~tiS$Ut' SPiltH Clf the lesser pelvis and lsch!Cianal fGssa (not s'-n here). A useful tCI~ griiphlc landm.arlc Is the piriformis, which extends from the pelvic surface Clftheucrum throughthegre.atersclatlc foramen tothetlpoflhe gre-atcrtrochanter(seeA, p.494).
D vart;!ble a~urse of thesdatk nerve In relaUon to tfle plrffonnts {ifter Raub6/ICQpsch)
1lblal netw
The sciatic nerve leaves tht' !mer pdvls Inferior tD tht' piriformis (ilmost 85 2: of cases). b This vartant Illustrates a high dMskJn of the SCiatic nerve (approxl· matl!ly 15 !1: of cases). In thi$ patn!m the fibular diYision (comiTICin fibular nerve) and sometimes the posterior femoral cut3neous neNe p;~ss through the pliffonnls muscle ;md may become compressed at that loutkln, a using a "piriformis synd~e.• usually this term ref~ to tnt' a~mplaints that may develc:lp following traum.a to !he gluteal region and are mirlced by severe gluteal p;~ln.lt Is still unart
;a
•
b Sdltlc nenoe
Common
Cam IT*> fllulw
flbulllr
f"orllml!n
ne~"W
nenoetns~prtlmn ra~men
In lnfnlplr!farm
493
f.ol,wr Umb
5.6
- - 5. NeuratfGKUiar .s)ste.ms: Topographical AnGtumy
The Gluteal Region: The Sciatic Foramen and Sciatic Nerve a lhe bound•r'IK ofthe schtlc foramina •nd tfle strucblres tNt fRYIIFM diem The subgluteal mnnecU~Ussue space communltoltes lhrough !he sd· atic fcramina with the connective·tissue spaal of the lesser pelvis and the ischloanal fossa.
' r Antl!rforsl.peffcr !:_ lllacspl'le
-----)+-~} =~
ranm..
...........
• Grater sdatlc foramen
• Gre,m,r sciatic notch • S..crosplnaus ligament • S..crum
tilr.Jmm
Tnll8mllled llnldlns
• Supropirifomt ponion
- SuperlorglutHI amery and win - SuperforglutNinerve • tn[roplrffonn pcrf10n - lnM'Ior gluteal artery and win - lrmerlor glutr.allli!I'W - ltmemal pudendal artery and win - Pudendal nerve -Scilticlli!I'W
- Posterlorfemoral
l.e~r
sclltftfol'llmen
ruunmus nerve
·~
A lociiUon ofthe treater 01nd lesser sdltkfor.~mlna Right hlp bone, lateral view.
L4spl'!ow
proc:us
sdatlc foramen
• Ll!sHr sclatlc nab:h • S..aosplnaus ligamEnt • S..crotub«ous li91ment
- lntemal pudendal amery and win - Pudendal nerve - Obtural»r lnll!mus
Mk:hlells mombold
C ttefenna! llrtes used for loaUng neui'OY8KIIIIr ttrucblres Tnthe gkltul ~on
Right and left gluteal regions. posterior ¥few. The reference lines .ilre drliW!l between !he fol·
----~-- Plrlfonnl$ ~--~~==~~---l~cr
gklt2awssels and nl!nl', pudendll ntM
494
lowing points: the posteriarsuperi~:~r iliac spine (lateral point of the Michaelis rhomboid). the Ischial tuberosity. <md !he greater trochanter. • Spine-~ line The superior glute
men between !he middle and upper thlnds oftflisline. • 'Mierol~ line: lhe sdatlc nerve rurtS downward between the middle and medlallhlrds of!his llr~e. • Splne-tWarvsly line: The sciatic nerve, lnfafor gluteal nave. and the pudendal and Inferior gluteal ve.ssels emerge from !he infr~piriform for~men at the midpoint of thlsllne.
lOMJ' UmiJ - - S. NeunwascularSymms: TopographlaJI Anatomy
~---
AntErlorsupelor dlactpln~
I'
----7.-':-'::..._-=-:-:--
5~9~1----~~~~~~ artEry
Sup..targ= nr.riorglutllll
n""""
Oull!ul
minim us
D Tlle-ls Mid nei'Vel cltlle gkitnl reg!CIII Mid IKhiCiilral fawil
TI!IIIOrr-ioe loin
vi-, with the g lute.. miDimus and
-~~
glutul region, poitlffor
mtdlusre~.
No« the murs:e of the pudendill vessels 1nd pudendill nlfVI! In the
----.W---
~Jtmol W<~ll of the isd>iOin;~l rv-. They run In the pudendill aNI (Aicodc's an;~l}, whldlls formed by the obblntor lntl!rnus bsd1 (see
-----=-..,--
lnh!rlor9uiul --4.:......!......:....--d!' Pudendolrww
Right
---+-_,..-:---,
p.42A).
"I'IM!or llnlncholmechl
dn:urnflex femorol11tsy ~11c
bulla Quodl"llla
Sac...tubonlus lgament
femorts
~d~r---~~· •
SdatlcneM!
mag nus
~duotor
mag nus
linnet... afmedlol dn:urnflex femarolartlry Semi-
,_,br.........
I
Cikll2us --~-:?--
medius Su~rlor
9utNin~
.
/
II"'P' fwma!S, lang hHd
-a::~
c - u s neM!
wnH~
__- Anta1orsupelor ~
.
1'1111:81arfemcnl
Illangle
ftlactplne
~---1---
..-------,-- lil'nlnlglutul fhjed!On slllt
Antl!rlor su~rlor
llacsplne
j -r =~
Palm an
-- I ,~ ==-
thegrenor ~
I
E i..ogdon ofthud~t IWIW ilnd supelfarglutul MJWSilnd
tllelr pnll:edlon durTng lntnglutMIIIn)ectlons Right gluteell'l!gion, ~Jter~l vitw.
a TWD very important nerves are found in the gluwl region: the sci· 1tlc ne~ and the wperiorglutml nerve. To MJ!djeopardlzlng these nerves du ling lntrimusrulil r Infections. the needle should be Inserted with the gre~Wt possible safety m1rgln with respect to these structures. Mailing the injection within the •wn Hoc:hst2tt« tfoang Je• ensures thitthls safety margin Is maim Intel.
b LoaUng the von Hod'IStetter b11ngle: The tilrget site Is loc:.Jted In the anteralatl!ral glutml region (accounting for the tei!TI "Yentrogluteal injection"). To give ~n inlr.lmusc:ular injection on the right side, for example. pliKZ the p<~l m of the left hilnd on the gl"'!iter trochanter and the tlp af the Index finger on the anterior superior lllic spine. ~lng the hand In plae2, abduct the middle ftnger
crest.
495
f.ol,wr Umb
5.7
- - 5. NeuratfGKUiar .s)ste.ms: Topographical AnGtumy
The lschioanal Fossa
~~----~----~------~~~~~~
st~pmar lllacspll~
GIU!I!us ----.!1~-t--< mum us
~iO-----::--:-:--'---:;:-~,----Sa£nii!Jberous
ligament
~~~--~~~--~~~~~~foua
A The murcul1n bound.te1 ofdte 1Rhlolr11l loiN l.dt and right gluteal reglor1, posterfor view. The lschloanal fossa Is a pyr.ilmld·shaped space located later.ill to Ule levamr ani muscle on each side. The tip of Ule thn!!Mided pyramid points mward the symphysis, and the base of Ule pyramid faces posteriorly. The IKhloanal fossa Is bounded byUie following muscles: • • • •
Super.-amedlally by the lev.rtor ani u.terallybythe ob11Hamrlntemus lnfl!!riorly by the deep tran!M!rse perineal The entrance to the lschlo.-anal fossa Is bounded pcmerlorly by the gluteus maxlmus ;md sacrotuberous ligament.
496
Thefattytinue that ocaJples mostohtte lschloanalfossa (the f.-at pad of the lschlo.-anal fossa) functions .iiS a mobile pad that c;an slide downward and b.ackward, for example. during bowel evacuation or during labor. It is lravl!rsed by the branches of the internal pudendalwsselsand puden· dal nerve (see 8}, wflose trunks run In the pudendal canal or i\lcock's c;an.-al: seeA.p.498.
5. Neunwascular Sy.mnu: TopographlcalAnatomy
LOM!rUmb -
B'-'lder
l'o!rituoeum
A /•o,ff---- - -- - Obluflll)r lntBtlUi
~~;;~~~~~~~~----~---DHP~~
I'Udondll aral (AkDdc's aral) with 1M lnb!rral
porineal
pudend~lvmds ~nd pudondll
llc:hb~OSUI
nerw
•
Suporfldll pertn111l faodo
Bulb ofpenis willl llul~ngiDIW
-,..._...._,,..,.,. "'"::;~~~~6~- Sub...n-lspoCII "-NC:....,."-_,.fC:.:::...___
~
...,
~'-------~
irtzmUJ
_____ DeepIn~
}g.~~~~:_
pelnul
IKtloavomDIW
Dllc:hmnol..,..
..
Sldn
Bulbo· ~nglooul
Vulvl
Subalblneaw perlneaiJ~CII
B The lschlo..... ,_.. Coronal section through the male peMs ill: the level of the prost3te. b Oblique coronal section thi'GUg h the fern;~le pelvis at the level of the vagina.
1
The pelvic organs make varying contributions to ihe shape of the peritoneal avlty and subperftoneill space. but they are not represented In the lschiCYnal fo$$il. While the peritoneal clllllty Is lined by the parletlll perltonet~m and the visceral peritonet~m (on intraperitonea Iorga ns.sudl as the CMry), the subper11Dneal spacr Is lined by the pelvic fasciae (composed of par1etolll and visceral layers, see p. 155).
497
f.ol,wr Umb
5.8
- - 5. NeuratfGKUiar .s)ste.ms: Topographical AnGtumy
The Pudendal Canal and Perineal Region (Urogenital and Anal Region)
A loc.ttfon ofthe pudendal c.tllll (Alcock's QINI)Mdthenev~lllrttrucQI~
ltCIIII't.1tlll Right half of the pelvis, medial view. All of the muscles have be.!n removed exa!pt for the p$0<1S major. piriformis, and obturator Inter· nus. For clarity. the lndl¥ldual vdns ire not shown. The pudendal canal Is formed by the obU!rator intern us faiaa. It begins just below the IKhlal spine 01nd courses In the laterill Will of the lschloanal fmsa below the tendinous arch of levator inl, pisslng toward the pubic symphysis and the posterior border of the urDgmltal musdes (seep. 136). The ncuroYiKU· lar structuresthiltire trinsmltted by !he anal (the lntem.11 pudendal vessels, of which only ttle ~rtery is shown, ~nd the pudendal nerve, see I) exltthe lesser peMs through the gre<~l:ef sciatic foramen and enter the pudendal a nil through the lesser sd.atlc for01men. Tiley pass ttlrough ttle anal Wward ttle pubic $YI1'Physls 01nd the posterior border of ttle urogenlt<~l muscles.
Common lilac artery
- - --r.=--..;
Internal lilac artery Exlemlll lilac artery
Plr!fom~ls
lnli!rlor glu!HI artl!ry
illop:rO;IS
lntemlll pudendal
artl!ry, pudendal n~
Femor.JI artery
lnlerlor gutl!al lnlerlor arll!ryandwln glutealnl!nle
B DldributSon ofthe pudendlllll!fft 1nd
lntmYI plldendllvesscb to the--. pet'fneum, ..nd extl!mJI genitalIii Clllll!.ill region and lschloanal fossa on the 11ght side, postzriDrview. Tile gluteus maximus and Siltrotuberous llgiment hive been partially removed ind all f.myUssue hils been removed from the IKhfoanal fossa to demonstrm ttle courw of the pudendal n~ and the inter· nal pudendal vessels. On their w;ry ttlrough the pudendal a nil (not shown here In ordef tD display the a~~.~rse of the nerve and vessels beb¥ ttle sacrot\Jberous lig01ment), the vari· ous ncuril ind vasculir branclles are succ:er s'lllely dlstnbuted In a fOlD-shaped p.attem to the anus, perineum, 01nd extl!rnal genitlllia. It Is very common In obstetrics to perform a pudendal nerve block by anestttelizlng the pudendal nerve it the levd of the Ischial spine (i.e., before it brandies into the infi:!rior rect;~l, pesfne<~l, dorsal clttoril, 01nd postafor liblal
n~
Posterior femoral Cl.ltl·
Gemellus lupetlcr
necuan~
!!Jiii!ii~iii;;;:=::;;..-Obt\J~ 11 ll'temU!i
lnumal pudendal
Gemellus lrhr'br
- ........~~
ni!I'VI!S
Quact.atus ~$
SaaoiiJberalll ligament llidltal 111beruslty u,,~~--
n~seep.482).
CluteJS mufmw
P.!r!r!eal bnnd!es,posteriar femoral cut.w'H!aus nerw
498
Sda!lc:
~eriarlemanll
culllleolll nen.<e
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
BulboSj)Ong'(llus
-
PuclencW ne~Vt,
PQSteriOt sawI
D
Pu6en~l nerve
D
~neot~~nen~t
D
Anoeo«WtalnerlleS
~Ot~l
D
Middle duMa! neNei
D
SUperlordune<~lneNei
D
~atckmeal nti'W.l
D
llallgulnal nerw and genll~lnerw,
!Je
Pu6en~l ni!Nt'
lsd!lal tuberosity
c Sen10rylnnervltfon lllfthe male pcrfne~l n=ghm (1n1l revton 1nd Uf'Oienltill n!tlon) Exbmlillrllll sphlncb!f
£xbmal
urtth1111«iffao
Pu6en~l nem,o,
Lltttommy posltlon.Thesklfl hili been removed
lnfl!llor n!clll nerve
on the left side ID demonstrate the course of the pudendal nerw (after Mumenthaler).
Glinsaf
dltoris
Bubosponglo$u$
Pudend1lllln'l!.
dors<~l dlto111lnew
,____ _ _ _ l'astl!!1crfl!moral
PUdendal,_,
cut.lneous nerw. perineal brandies
- - : - - - - - - - - - - - -....l!i
perfrltal nt
~tfemor~~l
D Sen10rylnnei'Vil1fon lllfthefelllille pertneal region (1n1l regTon and urot~enltill n!tlon) Elttletn;~l al\al
P\lclencW ne~Vt,
spN:nctet
lnie!lot nectill-
Gluteus rna011us
r~ot
Lltttommy posltkln.Thesklr1 hili been removed
dune<JI nerve
on the left side m demonstrate the coune of
the pudendal ni!M! (after Mumenthaler).
499
f.ol,wr Umb
5.9
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
The Posterior Thigh Region and Popliteal Region
A The vetteh and nerw.s of the I)C)MelfOt thigh Right tftlgh, posterlor view. To demonstr.tte Ute vessels and nerves In tftelr course &om !he gluteel region down tne b
Superlet 9.ml~
supetlor
~~H~--
!lutelllnerw
Gluteus
mlnmus
Inferior glutll!aln~
Pudenclaii'M!IW
lrhrlor glutll!alllrtl!ry Saaol1b«ous
ligament
Glull!us rnax)nus
~Ot ----lo=='~~
femoral
Quadrallls I\!morts
Cl.ltlneous
nerve Oblur.rtor klb!mus ~~-=:-,,.,.....~!--
Flrstperfor211ng
artery
+Wo----:1-+- - AddJcblr mag nus
-.+~~~-~--
s-nd perfor211ng llrtl!ry
Fnt perfor.!Ung
artery
\....__Se
~m~----~~~~~.
tendl'la:sus
artery
'M-"""""-Thlnl
perfor.!Ung
artery
~cblr ----~4-~~
hi;tus
Poplltl!al
artery
Semi· membranCtSus
---L~....,!r-'
nblalneM
a Sites of emergence of the petfor~~tlng al'tllril!l on the back ofthe thigh Right thigh, posterior view. All of the muscles hiVe been removed e:xapt for the adductor magnU5. Not!!: The femoral artery enters tne popliteal fossa tftrough Ute adductor hiatus, tbereaftef becoming the popliteel ai'IZ!ry.
500
- - -4-+Y
llledlalsural----.......!.-!----1;:~1/}
Clt.lni!OUSMM
1+¥,...:,....- - - Later.alsural all:aneousn~
Gll5tnlalemlus
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
Olmman Olmman lb.farn~ Medals~
ger/aJiolr artery Subt2ndlnaus burs.adth~
medtal gastrocnemlus head Medtahur~~l
- --f-::--'-:--,-:!11
Mlddltgenlallar
Semlm~bra=
cutlneous ne'lle
E;..----- ----if----
L
#--4-+?.---..l.....Gh- - Gastro-
cn~lus,
bursa
latl!r.al head
--~~..!J \li~~~~~- Llrtmllnlerlor
geriadanrtery
Poster'lar tblal
C The nuculllr boundllries ofthe poptte.lro.... Right popii!NI fosw. posterior view. For darltyth~ skin. fasdi!e. and f.rt pads have been relnOIIl!d.
reaJm!lrt artery
\W'~:-:f-i. .-
Plantllrfs tendon
',·\:--+--+--- AdOJcla' magnus
1..3t!talsupelfar
Medal si4M!Ifar gtl'icularartery Sll'llllll'l:ftlu -
genlrulanrtery
+-----,.1.1
Lmnllnti!!ior genlaJir artery
Pa:s1J!rlor tibial recum!lrt arll!ry - - - - HNdofflbula AnUrlorllblal recu rTent a rt2 ry
D Bl'llnches ofthe popl'tell•rtl!fythat murse Tn the poplteal
fossa Right knee joint. posterior view. The popliteal artery begins
F Deep rteUI'IMI!ICUiar muctures In the popliteal fosSil
Right kne~ joint, postel'for VIew. Pcrtlons of boltl hNds of th~ gastn). cnemius and porti~ns of the hamstrings have been removed to demon· s!Tate the cou~ of the dHP neurovascular structures In the poplitE<JI fosS
• Urter.ll and medial superior genlcular artel1es • Middle genicul~r artery • l.ater.ll and medial Inferior genlcular arteries One of these vessels, the middle genlcular artl!ry, pierces the Joint c:.~psule of the knee In ltle <~rea ot the oblique popllte<JI ligament and supplies the crucltonm ligaments. The other vessels run forwand on the medial and later.al .sides to fDnm the al'tJ!rial nl!l:work (articular rete) of the knee. Th~ posterior and anterior t!blal recurrent arteries contribute to the articular rete. The paired sural arteries supply the two heads of th~ gaSU'ocnemlus (se~ D, removed In F). Nok on the m~i~l ~~the subterldinous bursa of th~ g;~nrocnemius, 'Wfllch consistently communicates wlth the }oint cavity of the knee, and the burY ot th~ semimembranosus. which occasionally communi· c.l1:I!S With the bursa ofth~ ganrocnemlus head (this forms an extensl~ I'C!Ia.$$ in the joint cavity of the knee. which ITIJY bec:om~ abnonn;ally enlarg~ m fDrm a Biker cyst: seep. 392).
E PalpaUon otthe poplltHI.UIYTnthe poplltol foul
501
f.ol,wr Umb
5.10
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
The Posterior Leg Region and the Tarsal Tunnel
S
tl!ndlnouus
Semit!l!ndlnasus
BICIIPS fimol1s
Semimembranouus
Gnlcllls Sllml-
membranosta llbllllni!M!
llblalnen.oe
l'lllnt.wfs Common
Clastro-
Canmon ftbl.f1rni!M!
cnemlus
ft)ularn~
Popi~
Me
andw)l
Popii!Niilrtl!fy
utenlsunll
!Mig
HPhenouJ
Tendnounrcn oholeus
SoleuJ
cutliMG~Snerve
win Gilstrocnem\is,
later.alhead Gilstroc:nem\is,
medial head
fascia
afthell!g (c:utedge)
CommuniU(Ing bNnch
lit! art saphenouJ
PosiB!or tblal..-tl!ly nblllnerw
win
Abl.f.-ar
Flelalr d lgltO rum
ilrMy
longus
nballs posl:eflor
S1pheMus nenoe
S11illni!I'VI!'
Flemrhllluds longus
llblalnenoe, medlalalalnal 1:.-.lch
--...!..~ J
'\10,-~--
Dolsalcutlneous Nro>eclth~foct
A Tile neurvwillscdill'struc:tures In tfle superflchl ;md deep po:ltl!ftar Clllll'lplrtments
Right leg, pC<Steriorview. • Neurov.ascularstructul'l!s in I:Jle superficial ~ritllrccmportlMnf:: The superficial layer of the faKia of the leg ensheaths the triceps surae and h;ss been p;~rlially remoYed proximally. b Neurovascular strudllres In thedtl!p postettorcomparlment after partial rem~l ofthe tricl!ps surae and tfle deep layer oftflefaKia of the leg. The popllreal arrery divides Into the anterior and posterior tibial arti!Jtes atthe distal border ofi:Jle popliteus. The anterior tibial artefy
502
pierces the lnterC<Sseous membrane (not shown here, see 8) and p;~sses to the anterior side of the leg, entering the antertor comp;lrt·
ment. The postenor Ublal artery, accomp;~nled by the Ublal nerve, passes belaw I:Jle tendinous arm of tfle saleu!. jnb) the deep po~ rlor compartment. almC<St Immediately gives off the fibular artery, and I:Jlen continues distally behind the medial malleolll!i to the plantar side of I:Jle foot. The deep posttrlor comp;~rtment Is or~e of four poorly dioltensible muKie compartrTIC!Ilts in tfle leg ("fib-us canals"}, which are potartlal sites fDrtfle development of a comp;lrt· mentsyndromefollowfng a vascular Injury (seep. 507).
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
Popll~l
lr1:l!l'y
Mldde
gefllculu artl!fy
Medlill'ilferior
ablal artJery 1
ge!11c:ularaltl!l'y
b
FlbulolrartJery
popiJtHI111a"11nd Vlrflnts (after a
Anll!r!or tlblalartey
•
e
c "JYp'ICII bl'llll'ldllrtg pattem ofthe artay
Pq,llb!us
trunk
\
Flbulolmtey
Rbl.far
Rtxlo!lblal
lllilllrtl!ry
IN!k
:~/ ~
Sural artlerles
Antaiar
Flbulotlbill
Ante!1
Uppert ;md Pibst) Typle<~l p;rttern: The int«
b The interior tlblal artery .ilnd fibular artery arise fly o common trunk from Ule popliml artery behlrld the popliteus (4 ~of cases}. c: The fibular artery arises fi'om the anterior tibial artery (• fibulotibial trunk, 1 X of c;aes). d The flbulol1blal trunk arises proximal to Ule popliteus {1 X of cases). e The anterior tibial al'b!ry arises from the poplttul artery pi'Qidmal to the popliteus ( 1X of cases). The antenor tlblal artl!fy runs between Ule popliteus and the tibia (1 X afases).
!!==-"--.,......- Tibial neM,
pclrtl!r!ortlblal
aUty
B Tllurtertes of the leg Postl!rlorvlew.
Me.lllll
malleolar
Inn dies Tibialis pastl!fiCr
f!emrdlgllxlnJmlongus
D Pillp;dlon of the posterfor ttbrilll ;ntery below the me dill m.~lleoiLII
~~+--- fl_.h~IU
longus
Actllles
undon ~~4--~111
alaneal lnndl
T1rnlt:uMO!I
Flr.rtmeta-
Medlalplllmlr
Abducla'
t.lr.lll
arwyandl'lln'e
hallucls
E Tile ni!UI'O'WiiiSOJiarstrudiJres of the medial malleolilll' regton Right foot. medial VIew. The neurovascular structures p.ass from the dftl) flexor comp~rtment to the pl~nur side of the fvot through the
t
Medl1l pllnl
utml pl11rtn
autyandnerve
Nore tile dlvlslon of !he postertor tibial
nerve Into the medial arid lat·
er~l plantar nerves arid the diVIsion af !he postenor Ubral al'tl!ry Into the
medial and lall!ralplanur arteries within the malleolar can~l. ComprtS· slon of the nerves atthlsslre can cause a medial ar pasterforta1'5al tun· nel syndrome{see p.481).
503
f.ol,wr Umb
5.11
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
The Sole of the Foot
~pet pi~d~!;t.ll.wries
Properplantlr
dl~i1<JiarteriH
Properpla'ltlr
~pet pl~nt.Y
dlgi1<JineMS
du11<11.-
FlfllOOC'dlgJ.
tonJmbn!'Ois.
tendons of
l'nHrtlon Plilrtlr met1t.11n:al arti!I1K
Cammon plantadlgbllneMS l
-
Medal plantlr
Medal plantlr artery, super-
flclal branch
l.oltl!ral plant.r ~supel'
Medal plllntar
flclal branch
artery,supel'
Ull!ral
llclll branch
plant.lr~
Medal plantar artery, deep
deep branch
Lmnl pllntlr nerw. superlldal brwui1H
plantae
Medal pllntlr ~super-
Lmnl plllnt.lmlcus
branch
Quadmus
flclal branch
Medal plantlr IUCUI
F~dgl-
tonJm longus, tendon of
l
Insertion
.,dlldn
Medial pla'ltlrnen.oe
l.ab!l-.!1
plantarll8'YII!
Ab~r:tor
hallucls
Plontlr llpOnt<Jrosls
A The plantar artertes 1ncl nerves ottfle foot (superfldlllayer) Right foot. planur view. The skin and subcutaneous ti$$Ue h;ve bftn
B The pl1ntar artertes 1ncl nerves aftfle foot (middle layer} Right foot, plantilr view, with the plantar aponeurasis and flexl:w digiW-
removed to demonstrate the plant.1r aponeurosis and superildal neu-
rum brevis removed.
tOYascular structures.
c The plantar artertes of tfle foot: possible YMints Right foot. plantar view. Atry of faur baiic anatomicalva(.ant.s may be _,(after Uppert and Pabst):
Plllntnrnm·
tarsalarur!eoJ ,-..__
DHpplantll'bnrnch
II
of donal pedal
I
• The deep plantar arch and tne plantar metaursal artl!ril!.$ ariling from It are supplied entirely by !he dHp plantar branch of the dorsal pedal arll!ry (53 X at cases). b The flrrt through !hi~ plantar metatarsal arte!'fes are supplied by tne deep plantilr branch of the dors.1l pedal artl!ry, tne fwrtn plan· tar metatars.1l artery bytnedeep branch at the later.~ I plant
deep plant
d The deep plantar arch and tnefirrt thrwgh fwrtn plantilr metaursal arteries are supplied ent:lrelybythedeep branch at the lateral plantar artery (7% of c<~ses).
504
DHp bra riCh ctlmral pl;rntar.:wt!i'y
DeEp
plant.Y anch
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
P~rp~r-------4~~~~~~.
D The pllntar arterteuncl nerves of the
Flsordlgltorum
dlultilnerws
!angus, tendons
foGt (deep layer)
cfiiRI'tlon
Right foot. plantir view. The plantar ;rponeurosls, flexor dlgliiK'um brevis, the tendoru of
Pllnlllr
Aclducmr
~
)
halluc~
'!!-!~+-~-- Medial plant
.mry, deep lr.ruh
Lmr.!l --.....--l~~fl planlllr~
Flexarhalluds
deep branch
longus, tendon cfiiRI'tlon
flexor cligiton.lm longus, and tne oblique heid vi ;tdductor halluds have been ~moved to demonstr.rte the deep plantar ardl ;rnd the deep branch of the laterill plantilr nerve. Note The superlicial branch of the later.ill plan· tar nerve and the lawral plantar artl!ry course In the lattrol planttlr sulcus while the superfl· dal brindles of tne medial plantir nerve and medial plantar.ilrterycoutse in the medio/plrmmr sulcus (Sft A). The superfldal branches of the medial ;rnd later;rl plantir artl!ries help to supply the a1!fcally Important pressure-dlam· bef'system in the sole of the foot(see p.418).
~~--+....-+~
pi;lnt.le
'IUR. ...:..:...f--
~Iii pl~nur ------'H=~•
Medial planlll'arury
li11-#......-+- - Medial
.mry.n:lwln
planlli'118'Ve
Lmr.!l
planlllrnerw ~r------~~~~~
..
dlglton.m
~H--7--- l'lartor
Jno.ls
aponeuro.s~
Common plantar
--~=f-~\+#'~1"9~~..,
d~ar1:eflu
Distil perfar.ltfng --+~rliif-4'Hrt br.~ndlH
l'llntlrmellltll~l
E Oftmew of the pllntar armies of die
foGt Right foot. plant.1n1ew. Thedtepp/allttlro/dt Is an .ilrte11al<~rcade lntne $Oieofthefootthon:isformedbythedeeppl~n·
W branch oftne domJI Pftlolarttryand also by the deep brand! of the knl!ral p/anttlr artrry. Often these tv..o arterfes that supply the deep
plantar arth dilli:!r in size and thus m.aloe dilli:!r· ent contr1butlons to lfle flrrt through fourth plant;rr metatars.1l artl!ries that consistEntly branch from the deep plantar ardl (see C).
.urles Prmdrnal perfar.ltfng brandlei Flfthplantlr dlgltila!Ury
!i!tal plantar .ilrtet)', deep br.~ndl -~~----Medal
utl!ral plant.ar ------=-~!l a!Ury
plantlr a!Ury
505
f.ol,wr Umb
5.12
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
The Anterior Leg Region and Dorsum of the Foot: Cutaneous Innervation
Iliotibial lnrt
Pmlar llg;unart
PK ansmnus
(lnse
gadls.l!nd sem~dlnosus)
Gastrocnemius
Com man flbularnerw Headofflblll
Flbulartsbngus llbtalls .antufor Pllneaf IKtllanlnC
utl!r.alsural Clltline
nei" MUIGII
lnndles DH!)f'butar
Emnsor
halkldslongur.
-
AnUrtor ablal
.amyandwfn Emnsor
cnemlus Medlalsunll C\ltlneous
nenoe{tlbllll ner~~~t)
Commu,~
dlg11CM1Jm long ~a Sdeus
Superftdal flbularneM Flbulllrlsbrellls
Soleus
Extem« dgltxrum longus
Sur.alnef'llle S~oll!nsor
retinaculum hferiarextensor reti\la.fum
l.mt111 don.1l wti!WOUSOI!I'Ve
lnt:2mled!m don.1l cutlneous n~ Medial don.1l wtineous nen-e
Dars;lmet.1t.ln.ll arter'les
S~dal
Do11.111 pedalarury
Fascia ofthe leg
Ex1ensct
h.alluclsbr<Ms
Medlildornl lrtb!mledtm
Tendon of oll!nsor h
nerve
A The neurvw!KU1r stn.Jdura of the Interior C«llplrtmcnt 1nd dorsumoftllefoot Right leg With the foot In plantar tleldon, <mterfor llfew. The skin, 5Ub-
cuuneous tinue. ~nd fasciae 1\;M:! been remcwed ~nd the tibi~lis anterior and emnsor halluds longus muscles have bHn retr.ilcted to dem· onstr.rte the .ilnterfortlblal vessels(- anterlortlblal.ii!Ufy .ilrld vein). The ont:Mortrbralorttlyaosses beneath !he tendon of eld:ensor halluch lon· gus .ilt the junction of the leg with the dorsum of the foot. Belcwt the extensor retinaculum It becomes the dorsal Pfdal arttry, which runs lat· er.ill to !he halluds longus tendon on the dorsum of the foot, .ilccomp.il· nled by the tennln.ill branch of!he dt1!p flbuklrllo!Ne (the sltdor t.ilk!ng the pedal pulseinhown inE}.Thedreptib~Sicrr-maybec:ompre$Sed In 113 pasS.ilge bene<~th the lnfafor extensor retln.i!culum (with sensory dlsturb.ilnces .ilffecUng the ffm: and 5econd toes).
506
f'butarn-
Medal malleolur.
cutlneous
dorsal
t.ater.al
malleolur.
B DMIIIon of die CDmmon tiW1r IH!f'ftlntDdie dee9 1ncl
superiidal fibullir nerves Right leg, lateral view. The origins of the flbularls longus and eld:en· sor dlgttorum longus have been ex~:lsed below the head of Ule tlbula and Ute lateral tibial cond)ie. Aftl:rthe common (1/x.tlarllo!Ne blfui'C.iltes in the P111Ximal part of the lateral camp<~rtment. the superficjol fibular nerw remains In the latEr.ill camp<~r1ment. The d«p fibular- pierces the anterior rntennusaJiar 5eptum .ilnd descends With !he .ilnterfor tibial vessel$ in the I!Xten.sor mmpartment (C gives .il sectlonalllfew of the c:ompar1mel1t$ in the leg).
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
He.ldci----flbula
b.-
Anbltar .......
T1)la
•Tibl~lls~~
Anterior
Deep flbular nerw. anurlor ablal artery andw'b
~U5War
• £xtensordlg11Jorum longus
Sfl)bJm
• £m!nsor haiiJds longus
SiphMOUS
Superficial
....,.._.........
nerw.long HJ)tienous win
flbular nerve
• Flbul
• Tibialis poslierlor
• Fl$0rd~I\Jmlongus • Fl!!*~rhllludslongus
• nl"l)$ lint
•l'lllrtlrls
c The comJ)III'tmentund ne11nMKUIIir ~'"the leg
Cross section lflrough a right leg one hilndwldth below the neck of the ffbula, distal vlew (the lew! of the section Is shown In A). The Intermuscular septa and rntero.sseous membraDI!, tngether Mth the suPI!I'flclal ~nd deep layer$ of the fa sci~ of the leg, define die boundaries of fvur distinct. poorly dlmnsible flbro-osseous computments In which the ne\lrovascular structures descend through the leg. A rtse In tissue pres· sure, which may l'l!sult frDm conditions such as muscular edema or a fracture hematoma, can le.o~d to n~roYascular compresslon.lnduclng a IOC3llschemla that can cause lrrevenlble neuromuscular damagewlthlfl a fuw hours (compartment S'Jildromes such as the tlblalls anterior syn·
drome).llt greatest risk are the n~rcw.~scular structures of the deep posterior compartment (the posterfortiblal irtefy and veins ind the ti~ lal nerve) ind the anterior compartment (the interior tibial irl2ry ind velfiS and the deep flbular nerve). Tibialis .anterior syndrome ls ch.arllc· terized in its acute stage by severe pain and an inability to d01'$iflex the toes d~~e to the unopposed action of the plantarflexon. This causes the toes to "daw up.• Generally the only effective treattnent option at this stage is emergency incision of the fascia of the leg. This immediatl!ly decompresses the compartment and relleYeS the pressure on the ves· sels that supply the musdes.
Superior --4......,oliensor
retinaculum
•--~-"""
7 +--r- lnferlctoliensor retln.aculum
H~f---
Medal dors.il
cuuneousnerve ~flbularn~ ~I cut.1neow;
0!--'-t-- !liii'Yeofthe blgtoe
Medal CUUne<M
MrYeofthe
S
E PalpatlonofthepedlljUse The dorsal pedal artery is palpable on the dorsum of the fDot. just lat· eral to the extensor hallucls longus tmdor1. In addition to determining regional skfr1 temperature, cheddng the pedal pulse Is .an lmportilnt step In the examination of patlents With suspected lower limb ~rterfal diSe<~se (one foot is m~rkedly colder or paler than die other due to diminished blood flow).ltlsgenEJ"allybesttobegln bypalpatlnglflefemoril artery it the groin crease, then proceed distally to the popliteal fossa (popll· teal ~rtefy), the medial malleolus (posterior tibial art2ry), and flnlllly to thedorsum ofthefoot(clorul pedal artery. which is die terminal branch of the interfortlblal irtefy). The palpable pulses should ilw.lys be com· pared between the right .and leftsldes.ltshould benotedtll.rtthe pedal pulses may be dlfllcult or Impossible to palpatl! when peripheral edema Is present, and so It ls best to ex<~mlne the supine patient.
507
f.ol,wr Umb
5.13
- - 5. Neurati'GKUiar .s)ste.ms: Topographical AnGtumy
The Arteries of the Dorsum of the Foot
Adduclar mag nus PopllteiriMUty
Fllular .-tery, - - --fA-+IIJ perior.tlllng bnlldl
·~~+f~-------~r
hlllkldslongus
4~~---
Tendonof ablatsantl!r!or
~~·---~~~~ malleolar MUfY
-
DHpflbulllr ----lf~~~""t"tY-11\
Extensor
dlgltonmb~s
Laten! t.n.JIMUty
----,~~~
~---:i-----1-us
membrane
l----:i---- Arrt81or
lbiii~M')>
Deep plantamt
Tendons of -
extleruct dg~
~a-'"----
Tendonsof ottnsor halluc'lslongus andbrel.(s
-!-.f./-+-J!t!'!-1-,!i:!H!...,
1\1~~-+-¥-H---
mrumlongus andbrt!W
Deepflbular nerlle.
bnlldl
~·--4~~~~-H~~~.
dlgll
MW~ar medal
malealarartery lnr.lltars~hrtery
Dors.al pedal~rwy - · - - - Amlatleartlery l'r~~IL!--- Deepplanl.lr ~My
.lY~~~~---
A The dornl ;u1zdes ;uld nerws ofthe
reiTICMd for darlty. ;rlong with the extensor
foot Right foot in plantar flexion. dol'lal view. The skin, subcutaneous tl55ue, and superildal and deeplayersofthedorsalpedalfa1dahawebeen
dlgrtorum longus tendons and the extensor digitorum brevi$ and extensor hallucis bm'i$ musdes. Possible varlanu of the arteries are shown InD.
Dor.s.llmetmrsal
artl!rfes
Flerfomlng branches tr'-lrl''rl'lr:~-
Dor.s.ll dlglbrl artl!rfes
a TbearteriKoftheleg•ndfoot Right lower limb. anterior view. Note:Thedorsumofthefootlssupplled mainly by brandles aftile anterfortlblal artefy.
508
l.o!Na'Umb - - S. NeurotlaSGliGrSym!ms: TopogrGphlall Amrtomy
lntem1edlllte
l'!tero:s:seous 6cr.wll alllneous muscles nerve
&tens«
dlgltor~m longus
ii-~-'!'l'*li--''---"'--~--
.F.lii:W•~tt---:--':-''---'--+---
Abcllctor
Second rne1at~n:al Medial cunelbm
dgltlmlnlml Oppon.m
clsrlt!mlntml
--r---l~~l;~~\ij~
Flellcrdgltl mlrimlbreW
--+-~-~~~s!~~t·l~~. ~~~~~~~~-~~~ ~
;:;r;:-:t;~~-- Deepi~Y!fof
plln!lrlllscle S;phenousn~.
cuto~neous branch
C Tile neurvwillscdilll'struc:tures In tfle sole of tfle foot Cross sectfor11hnough tile rlghtfoot.atthe level ofthe medial cuneiform bone (the loati~n of the $«lion is shown in A), distal view (after Rau· ber and Kopsch}.
lllorethe deep layer of the plantar fasda,ln which the deep neurovascular rtructures of the sole (the deep plant'lr arch and deep branch of the lateral plant'lr nerve) are embedded in connect:M! l:iS$1Je wtlich cush· Ions and pnotects them (for tile arrar~gcrnent of the pedal compart· mern.s. see p. 463).
D V1rfants Tnthe dorsal arterf1lsupp~ of
Donalpedll artl!ry
•
'11II
Flrrtthraugh bJrthdorul met3tlrsal <Jrtl!r!es
1
IV
)
Dars;~l
metm!:£.il arterfes
b c
b
c: Da13.11lpedal artery
d
tile foot (after Uppat and Pabst) ;a All of the dors;rl metat
Flrrtthraugh faurthdo"-11 met3tlr£al artl!rles
l'l!rforaltlg brandies
•
Dorsal pedal
.uty
Arrtdorsal metltl"-11 llll12l'y
d e
from the donal pedal .utery (20X of Caies). The fourtll dorJ;II met'lt'lrJ;II artay ls supplied by a perforatlr~g branch from the plant'lrsldeofthefoot(&S of cases}. The third and fourth d~rsal metat'lrul arter· les ;rre supplied by perfor;rtlng branches from the plant'lr met.atars;rt arurtes (5 X of caies). The first donal metat'lrJ;II artery is the only branch of the dorsal pedal artEry (40% of cases). All of the donal metat'lrsal arteries are SUPSJlied by perforating branches from the pl;rnt'lr metilt'lrJ;II ;rrtafes (1 0%). Only the tlrst donal met.atars;rt artery Is suPSJlied by a perforating branch (5 Z).
509
Appendix References ...••••••....•••••••••.. • ••••••.....•••• 513 Index ........••••••....................•••....•••• 515
References
~hr. M .• M. Frotscher:
Duus' Neurologisch-topische Diagnostik, 8th ed. Thieme, Stuttgart 2003 Bilumgartl, F.: Das Kniegelenk. Springer, Berlin 1969 Chassard, j •• C. Lapine: trude radiologique de l'arcade pubienne chez Ia femme enceinte. J Radiol Electrol7 (1923), 11 J Christ, B., F. Wachtler: Medizinische Embryologie. Ullstein Medical, Wiesbaden 1998 Debrunner, A.M.: Orthopadie. Die Storungen des Bewegungsappa· rates in Klinik und Praxis, 2nd ed. Hans Huber, Stuttgart 1985 Debrunner, H. U.: Gelenkmessung (Neutral-a-Methode), Langen· messung, Umfangmessung. AD-Bulletin, Bem 1971 Drews, U.: Color Atlas of Embryology. Thieme, Stuttgart 1996 Faller, A.: Anatomie in Stichworten. Enke, Stuttgart 1980 Feneis, H., W. Dauber: Anatomisches Bildw1irterbuch, 8th ed. Thieme, Stuttgart 1999 Ficat, P.: Pathologie Femoro-Patellaire. Masson, Paris 1970 Fiildi, M., S. Kubik: Lehrbuch der Lymphologie. G. Fischer, Sb.Jttgart 1993 Frick, H., H. Leonhardt, D. Starck: Allgemeine und spezlelle Anatomle. Taschenlehrbuch der gesamten Anatomle, Vols 1 and 2, 4th ed. Thieme, Stuttgart 1992 Fritsch, H., W. Kiihnel: Taschenatlas der Anatomie, Vol 2, Thieme, Stuttgart 2001 Goerke, K.: Taschenatlas der Geburtshilfe. Thieme, Stuttgart 2002 Grants Anatomie: Lehrbuch und Atlas (A.M. R. Agur), Enke, Stuttgart 1999 Hansen, K., K. Schilack: Segmentale Innervation, 2nd ed. Thieme, Stuttgart 1962 Hees, H.: Grundrlss und Atlas der Mlkroskoplschen Anatomle des Menschen, Voll: Zytologle und Allgemeine Hlstologle, 12th ed. Gustav Fischer, Stuttgart 1996 Henne-Bruns, D., M. Diirig, B. Kremer: Chirurgie, 2nd ed. Thieme, Stuttgart 2003 Hepp, W. R.: Radiologie des Femoro-Patellargelenkes. Biicherei des Orthopaden, Vol 37, Enke, Stuttgart 1983 Hilgenreiner, H.: Zur Friihdiagnose der angeborenen Hiiftgelenks· verrenkung. Med Klein. 21, 1925, Hippokrates, Sb.Jttgart 1981 Hochschild, j .: Strukturen und Funktionen begreifen, Vols 1 and 2, Thieme, Stuttgart 1998 und 2002 Hiiter·Becker, A., H. Schewe, W. Heipertz: Physiotherapie Vol1: Biomechanik, Arbeitsmedizin, Ergonomie. Thieme, Stuttgart 1999 junghanns, H.: Die funktionelle Pathologie der Zwischenwirbelscheibe als Grundlage fiir ldinische Betrachtungen. Langen becks Arch. Klin. Chir. 267 (1951), 393-417 Kahle, W., M. Frotscher: Color Atlas and Textbook of Human Anatomy, Vol J, Thieme, Stuttgart 2003 Kapandji,I.A.: Funktionelle Anatomie der Gelenke, Vols 1-3, 2nd ed. Enke, Stuttgart 1992 Kaufmann, P.: Rl!ife Plazenta. In: Becker, V., T. H. Schiebler, F. Kubli (eds.): Die Plazenta des Menschen. Thieme, Stuttgart 1981 Klinke, R., S. Silbernagl: Lehrbuch der Physiologie, Jrd ed. Thieme, Stuttgart 2001
Koebke, j.: Anatomie des Handgelenkes und der Handwurzel, Unfallchirurgie 14 (1988), 74-79 Kristic, R. v.: General Histology of the Mammals. Springer, Bertin 1985 Kubik, S.: Lymph system der oberen Extremitl!t.ln: Lehrbuch der Lymphologie fiir Mediziner und Physiotherapeuten (eds: M. Foldi and S. Kubik), G. Fischer, Stuttgart 1989 Kummer, B.: Biomechanik derWirbelgelenke. In: Meiniclce, F.-W.: Die Wibelbogengelenlce. Hippokrates, Stuttgart 1983 Lehnert, G.: Dopplersonographische Diagnostik der erektilen Dysfunk· lion unter Anwendung des Papaverintests, Dissertation, University of Kiel (Medical Faculty) 1995 Lelievre,].: Pathologiedu Pied, 2nd ed. Masson, Paris1961 Lippert, H., R. Pabst: Arterial Variations in Man. Bergmann, Munich 1985 Loeweneck, H.: Diagnostische Anatomie. Springer, Berlin 1981 Liillmann-Rauch, R.: Histologie. Thieme, Sb.Jttgart 2003 Lundborg, G., R. Myrhage, B. Rydevik: The vascularization of human flexor tendons within the digital synovial sheath region - strucb.Jral and functional aspects. j. Hand Surg. 2 (1977), 417-427 Luschka, H.: Die Halbgelenke des mensch lichen Korpers. Reiner, Bertin 1858 Masuhr, K. F., M. Neumann: Neurologie (Duale Rl!ihe), 4th ed. Hippokrates, Stuttgart 1998 Moiler, T. B., E. Rl!lf: Taschenatlas der Riintgenanatomle, 2nd ed. Thieme, Stuttgart 1998 Mubarak, S. j., A. R. Hargens: Compartment Syndromes and Volkamn's Contracture, W. B. Sanders, Philadelphia 1981 Mumenthaler, M., M. Stohr, H. Miiiler-Vahl: Liislon perlpherer Nerven und radikulare Syndrome, 8th ed. Thieme, Sb.Jttgart 2003 Netter, F. H.: Farbatlanten der Medlzln. Thieme, Stuttgart Nlethard, F. U., J.Pfeil: Orthop~dle (Duale Relhe), Jrd ed. Hlppokrates, Stuttgart 1997 Nlethard, F. U.: Klnderorthop3dle. Thieme, Sb.Jttgart 1997 O'Rilhilly, R.• F. Miiller: Developmental Stages in Human Embryos. carnegie Institution of Washington, Publication 637 {1987) Pauwels, F.: Eine neue Theorie iiber den Einfluss mechanischer Reize auf die Ditrerenzierung der Stiitzgewebe (X). Beitrag zurfunktionellen Anatomie und kausalen Morphologie des Stiitzapparates. Z.Anat. Entwicki.-Gesch. 121 (1968), 478-515 Petersen, W., B. Tillmann: Z. Orthop. 137 (1999), 31-37 Pette, D., R. S.Staron: Transitions of muscle fiber phenotypic profiles. Histochem Cell Bioi 115 (5) {2001 ), 359-379 Platzer, W.: Color Atlas and Textbook of Human Anatomy, Vol1, Thieme, Stuttgart 2004 Platzer, W.: Atlas der topographischen Anatomie. Thieme, Stuttgart 1982 Rauber/Kopsch: Anatomie des Menschen, Vols 1-4, Thieme, Stuttgart. Vol1, 2nd ed.: 1997, Vols 2 and 3: 1987, Vol4: 1988 Rohen, j. W.: Topographische Anatomie, 1Oth ed. Schattauer, Stuttgart
2000 Rohen, j. W., C. Yokochi, E. Liitjen-Drecoll: Anatomie des Menschen, 4th ed. Schattauer, Stuttgart 2000 Romer, A. S., T. S. Parson: Vergleichende Anatomie der Wirbeltiere, 5th ed. Paul Parey, Hamburg und Berlin 1983
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References
Sadler, T. w.: Medlzlnlsche Embryologle, 1Oth ed. Thieme, Stuttgart 2003 Scheld11.1p, E. w.: Tendon sheadl patterns In the hand. Surg. Gynec. Obestetr.93 (1951), 16-22 Schmidt, H. M., U. Lanz: Chlll.lrglsche Anatomle der Hand, 2nd ed. Thieme, Stuttgart 2003 Schumpelick, V.: Hernien, 4th ed. Thieme, Stuttgart 2000 Schiinke, M.: Funktionelle Anatomie-Topographie und Funktion des Bewegungssystems. Thieme, Stuttgart 2000 Silbemagl, S., A. Despopoulos, Taschenatlas der Physiologie, 6dl ed. Thieme, Stuttgart 2003 SOkeland, J., H. Schulze, H. Rubben: Urologie, 12th ed. Thieme, Stuttgart2002 Starck. D.: Embryologie, 3rd ed. Thieme, Stuttgart 1975 Streeter, G. L.: Developmental horizons in human embryos: age group XI, 13-20 somites and age group XII, 21-29 somites. Contrib Embryol30 (1 942), 211 Vahlensieck, M., M. Reiser (eds): MRT des Bewegungsapparates, 2nd revised and expanded ed. Thieme, Stuttgart 2001 von Hochstetter, A., H. K. von Rechenberg, R. Schmidt: Die intragluteale lnjektion, Thieme, Stuttgart 1958 von Lanz, T., W. Wachsmuth: Praktische Anatomie, Vol1/3, Arm, 2nd ed. Springer, Berlin 1959 von Lanz, T., W. Wachsmuth: Praktische Anatomie, Vol1/4, Bein und Statile. Springer, Berlin 1972 Weber, U.: Orthopadische Mikrochirurgie (eds. Weber, Greulich, Sparmann), Thieme, Stuttgart 1993 Wiberg, G.: Roentgenographic and anatomic studies on the femoropatellar joint. With special reference to chondromalacia patellae. Acta Orthop Scand 12 (1941), 319-410 Wiberg, G.: Studies on dysplastic acetabulum and congenital subluxation of the hlp joint with special reference of the complication of osteoarthritis. Acta Chlr Scand.83 (suppl), 1939, 58 Wolpert, L., R. Beddlngton,J. Brockes, T. jesseI, P. Lawrence, E. Meyerowitz: Entwlcldungsblologle. Spekt11.1m Verlag, Welnhelm 1999
514
Index
A Abdomen -classification criteria 171 -lower 171 -regions 32 Abdominal breathing 134 Abdominal cavity 22 - transverse planes 31 Abdominal organs, projected onto ilbdomlnal Willi 171 Abdominal press 128, 130, 134 Abdominal region - classification criteria 1 71 - quildrants 171 Abdominal testis 194 Abdominal wall - anterior 184 - - hernia 188 - - Internal surface anatomy 184 - - weak spots 1 84 - lymphatic vessels, superficial 167 -muscles 7,118 - - anterior 1 18, 128 ---straight 149 - -functions 130 - - lateral, oblique 1 18, 126, 148 --posterior 118, 128 - -suspensory system 129 - projection of abdominal organs 171 -structure 150 Abduction of hand 255 AC angle (acetabular angle) 389 Acetabular angle 389 Acetabular dysplasia 389 Acetabular inlet plane, angle -sagittal 379 - tranVI!rse 379 Acetabular margin 113, 114, 364, 378 Acetabular rim -Inferior 379 -superior 389 Acetabular roof 379 -dysplasia of 389 -line 389 Acetabulum 34, 114, 152,364, 368,378 - mronal section 385 - horizontal section 384 -Inferior rim 379 -orientation 368 - radiograph 365 Acetylcholine 73 Achilles tendon (calcanean tendon) 434, 450, 452, 455, 462 - rupture 434 -surface anatomy 27. 486 Acromioclavlrular joint see joint, acromioclavicular Acromion 28, 34, 138, 208, 21 0, 212, 226.228.230. 232. 234. 258, 264, 341
- surface anatomy 328 Acropodlum 18 Acrosome 5 Action potential, nerve cell membrane 60 Adductor canal see Canal, adductor Adductor hiatus 427. 444, 464, 466, 490, 500 Adrenal anlilge 56 Adrenal medulla, disease of 57 Adrenorortical hyperplasia 193 Adrenogenital syndrome - rongenttal 193 - external genitalia 193 Adduction of hand 255 Adventitia 46 Alar plate 55, 64 Albinism 57 Alcock's canal see Canal, pudental Alzheimer's disease 60 Amnion 6 Amnlonlc cavity 6, 8 Amphiarthrosis 36, 38, 117, 254 Ampulla -of rectum 160 -of vas deferens 160 Anal cleft 1 53, 173 Anal fissure 192 Anilstomoses. portocilval 164, 170 Anatomical snuffbox 330, 349 - surface anatomy 349 Androgen. and development of genitalia 1 92 Anesthesia 487 Angle - rostal 109 - deep Inguinal 186 - Inferior see Scapula, angle,
inferior - infrasternal 1 1 0 - mandibular 28 -sternal 30,106,108 - subpubic 1 14 - Vl!nous see Venous angle Ankle joints - subtalar joint 34, 402, 406 --axis of motion 410 -- compartments --- anterior 407 - - - posterior 407 -- rangeofmotion 411 - talocrural joint 34, 363, 402, 406 -- articulating skeketal elements 406 --axis of motion 410 -- rangeofmotion 411 Ankle mortise 360, 372, 402 - articular surfaces 406 Ankylosis 36 Ansil cervicalls 257, 258 Antebrachium see Forearm Anterior horn tear, of meniscus 397
Anterior pituitary, prerursor of 10 Antetarsus see Forefoot Antetorslon angle 369 AntlmOIIerlan hormone 192 Anular ligament(s) see Ugaments anular AnulusfRing -femoral [ring] 185, 186,489 - [anulus] flbnosus 92, 102. 104 -- anlilge 80 --Inner zone 92 -- outer zone 92 - inguinal [ring] -- external (superficial) 148, 182,185,195,198,472,485, 489
-- - perforating branches 308, 353 -- superficial 308, 347. 350, 352 -- - perforating branches 353 -- - variants 352 - plantar -- deep 464, 504, 509 -- In crcm section of foot 509 - posterior. of atlas 84 -- posterior tubercle 97 - pubic 113, 115 -tendinous -- of levator ani 136, 157, 1 58, 498 -- of soleus 434, 481, 502
---crus
-- dorsal, offoot 466 --palmar ---deep 311 - - - superficial 311 -- plantar 466 - vertebral 3, 82. 84, 89 -- ligaments 94 - zygomatic 28 Areola 26, 171, 180 Arm 18, 34,208.217,220 - anterior brachial region 33, 338 - arteries 308 -- development 347 - cross section 338 - rutaneous Innervation -- anterior 67, 329 -- posterior 67,331 - dermatomes 65 -- anterior 66, 329 -- posterior 66, 331 - dissection, windowed 297 - lymphatic Vl!ssels 31 2 - measurement of segment lengths 209 - posterior brachial region 33, 342 Arteries 45 - close to heart 44 - distant from heart 44 - elastic type 44 -limb --lower 464 --upper 308 - luminal radius 46 - musculilr type 44 - pressure changes 47 - scapular region 175 - trunk wall 1 62 -- anterior 170, 179 - - posterior 172 - wall structure 46 - wall thickness 46 Arteriole 46 - precapillary 48 Artery (arteries) - accompanying, of sciatic nerve 493,500 - ilcromial 334 - anterior malleolar -- lateral 464, 508 --medial 464, 508
--- -laterill 182 ----medial 182 --- Intercrural fibers 182 -- internal (deep) 149, 1 83, 185 - umbilicill [ring] 188 Anus -ascent 159 - blood supply 498 - innervation 498 - descent 159 Aorta - abdominal 162, 176, 490 -- in cross section 139 - ilscendlng 45, 1 62 - descending 45, 1 62 -dorsal 10,12 - passage through diaphragm 147 -thoracic 162, 177 -ventral 10, 12 Aortic arches 10, 12 Aortic root, ventral 12 Aperture see Hiatus Apex - of patella 370 - of sacrum 90 Apocytosls 52 Aponeurosis 41 - bicipital 271. 297, 310,338, 344,346 - palmar 274,280, 297,302,329, 346 -plantar 406,412,414,418,438, 440. 460. 463. 504 -- In cross section of foot 509 Apophyseal plates - lower limb 17 - upper limb 1 6 Apophysis 35 Appendix - of epididymis 196 - oftestis 196 - vermiform 50 Arch - anterior, of atlas 85 - of aorta 162 - costill 147 - Iliopectineal 182, 423, 489 -palmar -- deep 308, 347, 353
-venous
515
A Artery (arteries)
- anterior scrotll198 - arcuate 464, 508 -Biliary 45,162,179,181,229, 308, 314, 333, 335, 336, 341, 343.347 - - sequence of branches 336 - -- variants 337 - - arrangement of cords of brachial plexus 314, 336 - brachial 45, 308, 336, 338, 343, 344 - - branches 343 -- branches - -- acromial 339 - -- deltoid 339 - -- pectoral 339 - - course 339 - - course of median nerve 339 - - high division 339, 347 - - in cross section of upper arm 296 - - superficial 339, 347 - bulbar - - of penis 200 - - of vestibule 204 - canotld -- common 12, 45, 162,309, 333,336,341 - -- development 12 - -- In cross section 139 - - external 45 - -- development 12 - - internal 45 - -- development 12 -cervical - - ascending 333 --deep 163,175,308 - circumflex femoral - - lateral 383, 464, 490 - -- branches - --- ascending 490 - --- descending 490 - - medial 383, 464, 490, 500 - -- branches - --- ascending 490 ----deep 490 - --- descending 490 - circumflex humeral - - anterior 308, 335, 336, 339, 343 - - common 337 - - posterior 175, 308, 335, 336, 339 - - Injury 216 - circumflex lilac -- deep 162, 179,464,488, 490 -- superficial 162, 178,464, 488 - -- harvesting skin flaps 179 -circumflex scapular 175,308, 333, 335, 336, 339, 341, 342 - - i!lni!lstDmosis with suprascapu-
lar artery 341 - - posterior 342 -collateral - - medial 308, 338, 345 - - radial 308, 338. 345. 348 -- ulnar - -- Inferior 308, 338, 344, 346 - -- superior 308, 338, 344, 346 - common hepiltlc 45 - coracabrachlal 339 - cremasteric 464
516
- deep clitoral 204 - deep penile 198, 200 - descending genlcular 464 - descending genicular 490 -digital -- dorsal 308, 348, 350, 508 -- palmar 350 --- common 308, 350 --- proper 308. 350 -- plantar --- common 464, 505 --- proper 465, 504 -dorsal -- of clitoris 204 -- of foot 45,464, 506,508 --- deep plantar branch 505 --- in cross section of foot 509 --- palpation 507 -- of penis 198, 200 -- of scapula 341,342 - dorsal carpal 309. 353 - epigastric -- Inferior 162, 178, 464, 490 --- pubic branch 464, 490 -- superficial 162. 170, 178. 464. 488,490 -- superior 162, 178 - femoral 45, 162, 170, 179, 182, 184.186,198.445.464.485, 488, 490, 498 -- branching pattern, variants 490 --course 490 -- In tromsverse section 161, 462 -- sequence of branches 490 - fibular 45, 464, 502 -- branches --- calcaneal 464 --- communicating 464, 502 --- lateral malleolar 464, 503 --- muscular 503 --- perforating 464. 502. 503, 508 - gluteal -- inferior 490, 493, 498, 500 -- superior 490. 493. 495, 498 - hellclne 201 -iliac -- common 45, 176, 488, 490, 498 -- external 45, 154, 162, 176, 179, 464, 488, 490, 498 --- pubic branch 488 --- junction with femoral artery 488 -- internal 45, 162, 176, 200, 488, 490, 498 - iliolumbar 162 -lmerlor -- lateral Inferior genlcular 464, 490, 501' 503, 508 -- medial inferior genicular 464, 490, 501' 503, 508 - lmerlor articular --- lateral 396 --- medial 396 - lmerlor rectal 200, 204 - lmerlor thyroid 308, 333 - intercostal 145, 178 -- anterior 162 -- chest tube Insertion 179 -- posterior 162, 177 --- branches
----collateral 163 ---- cutaneous -----lateral 163 -----medial 163 - - - - posterior 163 ---- lateral mammary 163 ----spinal 163 ---first and second 163 -- supreme 163, 308 -- thoracentesis 179 - Internal mammary see Artery, thoraric, internal - interosseous 347 -- anterior 308, 339, 345, 346 --- posterior branch 309 -- common 308, 339, 345, 346 -- posterior 308. 339, 345, 346. 348 --- perforating branches 309 -- recurrent 308, 345, 348 -- regression of 347 - left gastric 45 -lumbar 162 -median 347 -- regression of 347 - mesenteric -- Inferior 45 -- superior 45 - metacarpal -- dorsal 308, 348, 353 -- palmar 308, 353 - metatarsal -- dorsal 464, 506, 508 --- In cross section of foot 509 -- plantar 464, 504 - middle genicular 464, 501, 503 - musculophrenic 162 - nutrient 35 - obturator 383, 490, 498 - occipital 175 -ovarian 45 - palmar metacarpal 353 - perforating 464, 490, 500 - perineal 200, 204 - plantar 503 --deep 508 -- lateral 464, 503, 504 --- in cross section of foot 509 --- deep branch 504 -- medial 464, 503, 504 --- In cross section of foot 509 ---branches ----deep 464, 504 ---- superficial 464, 503, 504 - popliteal 45, 396, 401, 464, 490, 500, 502 -- branches 501 -- branching variants 503 -- palpation 501 - princeps polllcls 308 -profunda -- brachii 45, 308, 336. 339, 342, 345, 347 -- femoris 45, 383, 464, 488, 490 --- course 490 -pudendal -- external 198, 488, 490 ---deep 464 ---superficial 464 -- Internal 199, 200, 204, 495, 498 --- in horizontal section 161
- pulmonary 44 -- development 12 - radial 45, 308, 339, 344, 346, 350,352 -- branches --- Calllill ----dorsal 308,348 ---- palmar 308 --- superficial palmar 308, 350. 352 -- In cross section of forearm 296 -- perforating branches 309 -- radialis lndlcls 308 -radicular -- anterior 1 63 -- posterior 163 - recunrent -- middle 309 -- radial 308, 339, 344 --tibial --- anterior 464, 501, 503, 508 --- posterior 464, 501, 503 -- ulnar 308, 339, 345 -renal 45 - sacral --lateral 162,176,490 -- median 162 -splenic 45 - subclavian 12, 45, 162, 308, 317,335,336,341,343 -- branches 333 -- development 12 -- right, course of 333 - subcostal 162 - subscapular 308, 333, 337, 339, 341,343 -superior -- lateral superior genlcular 464, 490, 501,503, 508 -- medial superior genicular 464, 490. 501. 503, 508 - suprascapular 175, 308, 333, 336, 340, 342 -- ani!lstDmosis with circumflex
scapular artery 341 - sural 464, 501 -tarsal -- lateral 464, 508 -- medial 464, 503 -testicular 184, 195, 196 -thoracic -- internal 45, 1 62, 170, 178, 181. 308, 333, 336 --- branches ----anterior intercostal 162 ----mammary 181 -----lateral 181 ----- medlal163,181 ---- perforating 163, 181 ----sternal 163 --lateral 162.178, 181,308. 333, 335, 336, 339 -- superior 162, 179, 308, 333, 335,336 - thoracoacromlal 1 62, 308. 333. 335 -- branches --- acromial 308 --- clavicular 308 --- deltoid 308 --- pectoral 308
Bone(s)fOs(sa) B
- thoracodorsal 1 79, 308. 333. 336, 339, 341. 343 --axilla 335 - of thumb, medial plantar 505 -tibial -- anterior 45, 464, 490, 501, 502, 506, 508 -- - in cross section 462 -- posterior 45, 464, 501, 502, 505 -- - branches -- -- calcaneal 464 -----medial 503 -- -- medial malleolar 464, 503 -- - In cross section 462 -- - palpation 503 - transverse ceNical 308. 333, 341,343 -- branches ---deep 175,341 -- - superficial 175 -- course 174 - ulnar 45, 308, 339, 344, 346, 350, 352, 354 -- branches ---carpal -- -- deep 308 -- -- dorsal 308, 348 -- -- palmar 308 ---deep 352 -- - perforating 309 -- in cross section of forearm 296 -- superficial 31 0, 347 -- ulnar tunnel 354, 357 -umbilical 9 -- obliterated 184 - urethral 198.200 - of uterine round ligament 183, 464 - ofvasdeferens 184,197 - vertebul 143,162.175,308, 333, 336, 341, 343 -- course 84 - - reli!ltion to uncinate process 102 Arthrodesis 36 Articular cartilage 14 - structure 36 Artlculilr clrcum~rence - of radius 218, 221, 238 -of ulna 218 Articularfacets 100 Articular process see Process, ilrtlcular Assimilation disorders 79 Associative neurons 69 Astrocyte 71 -fibrillary 61 - protoplasmic 61 Atlanta-occipital capsule 96, 98 Atlas 34, 78, 83. 84, 96, 21 1 -arch -- anterior 85 -- posterior 84 - articular surface -- ln~rlor 84 -- posterior 84 - transverse process 84, 142, 175 -tubercle -- anterior 84 -- posterior 84, 97
Auditory canal. external. relation to line of gravity 79 Autopodlum 18 Axilla see Region, axillary Axillary fold - anterior 334 - posterior 334 Axillary lymph nodes see Lymph nodes, axillary Axillary nerve palsy, Isolated 321 Axillary spaces - quadrangular space 321, 342 - triangular space 342 Axis 34, 78, 83, 84, 96 - articular surface - - inferior 84 - - posterior 84 - process - - spinous 84, 1 42 - - transverse 84 Axon 57. 60. 70 - afferent, development 57 - efferent, development 57 -long 60 - myelinated 70 - parallel contact 61 -short 60 - unmyelinated 70 Axonal hillock 60
B Back muscles 138 -Intrinsic 7, 118,140,142,175, 177 -- fibro-osseous canal 139 -- In cross section 139 -- lntertransverse system 118, 120 --lateral tract 118,120,140 --medial tract 118,122,141 -- sacrosplnal system 118, 120 -- spinal system 118, 122 -- spinotrans-erse system 118, 120 --surface anatomy 27,173 -- transversospinal system 118, 122 - nonlntrlnslc 138 Back, regions 32 Baker cyst (gastrocnemio-semimembranosus bursa) 392, 501 Ball of big toe 486 Ball of little toe 486 Bartholin glands 202, 205 Bartholinitis 205 Basal lamina 71 Base of - first proximal, of foot 404 - metacarpal 222 -- fifth 274, 278 -- first 252, 278 -- second 274, 276, 280 - metatarsal --fifth 404 --first 404 -patella 370 - phalanx 222 - sacral 82, 90 Basement membrane 46, 49
Basipodium 18 Big toe, sesamolds 416 Bipedal galt 360 Bladder, urinary 155 - in trans-erse section 161 - location 22 Blastocyst 5 - implantation 5, 8 Blood - arterlilllzed 44 - -enous 44 Blood flow, capillary 49 Blood poisoning 312 Blood pressure, hydrostatic 49 Blood vessel(s) 44 - diaphyseal 14 - development 12 - metaphyseal 14 Blood-brain barrier 71 B-lymphocyte region, of lymph node 51 B-lymphocytes 50 BMI (body mass Index) 21 Bochdalek's triangle 146 BodyilxiS 59 Body height 17 Body mass Index 21 Body measurements, percentiles 20 Body proportions 20 Body surface area 21 - relative 21 Bone - endochondrill formation of 15 - epiphyseal 14 -mature 15 - membranous formation of 15 - subchondrill 36 Bone collar, perichondrial 14 Bone development 14 -direct 15 - indirect 15 Bone marrow, hematopoietic 35 Bone remodeling 14 Bone tissue - Cilncellous 14, 35 - compilct (cortical) 15, 35 Bone(s)/Os(sa) - accessory 34 - capitate 29, 34, 209, 222, 224, 280,354 - - ossification 17 - carpal see Carpal bones - coccyx 34, 78, 81, 90. 114, 116, 152,158,496 - cuboid 34, 363, 374, 376, 402, 413,433 -- articular surfaces 404 - cuneiform 34, 413 -- Intermediate 374, 377, 402, 413,414,438 --- articular surfaces 404 -- late rill 374,377, 402,413 --- articular surfaces 404 -- medial 374,376,402, 432, 436.438 --- articular surfaces 405 --- In cross section 509 - femur 360, 363, 366, 390 --condyle --- lateral 360, 366, 390, 400
--- medial 360. 366, 371. 390. 400 -- epicondyle --- lateral 28, 361, 366, 390 --- medial 28, 361. 366. 390 --ossification 17 -- proximal, fusion of growth plates 388 - fibula see Fibula - fifth metatarsi! I 375, 403 ---base 438 - first metacarpal 222, 252, 280 - first metatarsal 34, 374, 376 -- base 374, 376, 432 -- head 374, 376 -- shaft 374, 376 -flat 34 -frontal 28 - hamate 34, 222, 224, 249, 354 - hip 37. 114, 360, 363, 364 -- fusion of growth plate 388 -- growth plate 365 -- ossification 17 - humerus see Humerus
-ilium 34,114,116 -- ossification 17 - [os]lntermetatarseum 377 - irregular 34 - ischium 34. 114 -- ossification 17 -long 343 - lunate 34, 222, 224, 249 - metacarpals 29, 34, 280. 301 --base 208 --head 208 -- ossification 16 --shaft 208 - metatarsals 34, 402 -- ossification 17 - nasal 28 - navicular 34, 374, 376, 402, 414 -- articular surfaces 404 - occipital 29, 34 -- basilar part 96 - parietal 29, 34 - peroneum 377 - phalanges - - of foot 34, 402 -- of hand 29, 34, 209 - pisiform 28, 34, 209, 222, 224, 248, 280, 357 -- ossification 17 - pneumii!ltic 34 - pubis 34, 114 -- ossification 17 --ramus --- in~rior 364 --- superior 364 - sacrum 29, 34, 37, 78, 82, 90, 114,116,152,360,365 -- base 82, 90 -- curvature 79, 81 -- gender-specific differences 113 -- lateral part 82, 90, 114 --surfaces ---pelvic 82, 114,493 --- superior articular 82 - scaphoid 34, 222, 224, 249, 280.354 - - fracture 349 - second metatarsal 414
517
B Bane(s)fOs(sa)
- seSilmold(s) 34, 43 -- capsule and ligaments 416 -- function 43 --foot 375,416 --lateral 416 --medial 416 -- ossification, limb ---lower 17 ---upper16 -- radial 222, 280 -- ulnar 222, 280 -short 34 - [os] supranaviculare 377 -tarsus 34 -- ossification 17 - temporal 29 - [os] tibiale externum 377 - trapezium 34, 222, 224, 249, 252, 280, 349, 354 - trapezoid 34, 222, 224 - [os] trigonum 377 - triquetrum 29, 34, 209, 222, 224, 249, 354 - [os] vesalianum 377 Bone-to-bone connections. types of 36 Bony prominences, palpable -head 28 -limbs -- lower 28, 361 -- upper 28, 209 -trunk 28 Bony trabeculae 14 Border(s) -anterior --of radius 218,221 -- oftibia 372 - interosseus --of radius 218,221,242 -- ofulna 221,242 -lateral -- ofhumerus 214,216 -- of scapula 21 0, 213, 262 -medial -- ofhumerus 214,216 -- of scapula 29, 138.209, 210. 21 3, 260, 263, 341 • 342 --- surface anatomy 27, 173 -posterior --of radius 218 --of ulna 218 - superior scapular 213 Bottle sign 326 Bouton 1!11 passage 61 Boyd veins 466 Brachial fascia 43, 334, 338 Brachialgia paraesthetic• nocturna 326 Brachium see Arm Brain 58 -development 54 Brain capillary 71 Brainstem, nuclei, parasympathetlc 72 Branch see Rllmus Branchial arches 2, 1 0 Brand!iostoma lanceola!Um (klncekt) 3 Breastcarcinoma 181 Breast. female 26, 171, 180 - blood supply 181 - lactating 180
518
-
lymph nodes. regional 181, 313 lymphatic drainage 181 nerve supply 181 nonlactating 180 quadrants 181 terminal duct lobular unit (TOW) 180 Breathing - costodiaphragmatic 11 0 - sternocostal 1 1 0 Bucket-handle tear, of meniscus 397 Bulb -of penis 155,194, 19g -- In transverse section 161 -vestibular 154,202, 204 Bulbs of fingers. ridge pattern 328 Bulge In Inguinal region, dlfferential diagnosis 190 Bundle of lymphatics - anteromedial 468 - posterolateral 468 Bursa - gastrocnemio-semimembranosus (Baker cyst) 392, 501 - lliopectlneal 384, 489 - lnfrapatellar 400 - of semimembranosus muscle 392,501 - prepatellar 391, 401 - subacromial 43, 226, 232, 234, 341 - subcoracoid 231 - subcutaneous -- acromial 43 -- of medial malleolus 503 - subdeltoid 43, 226, 232, 234, 341 - subtendlnous --of -- - gastrocnemius 501 -- -- lateral 392 -- -- medial 392 --- subscapularis 43,229,231, 232 - synovial 43 - trochanteric 495 -- in coronal section 385 -- in transverse section 384 Bursitis 43 - lllopectlneal 489 - infrapatellar 401 - prepatellar 401
c C cells of thyroid gland -disease 57 - hormone production 53 C7 see Vertebra prominens Calcaneocuboid joint 402 Calcanean tendon see Achilles tendon Calcaneus 34, 360. 363. 374, 376, 402,414, 438 - articular surface for cuboid 405 - ossification 17 Canal - adductor 464, 466, 475, 491 -- boundaries 4g1
-- contents 491 - carpal see Carpal tunnel -femoral 187 -inguinal 148,182,194 --contents ---In female 182 ---In male 182 --location 182,186 --opening --- external 182 --- Internal 1 82 -- wall structures 183 - malleolar 481, 503 - obturator 158, 474 -- In transverse section 384 - pudendal (Alcock's canal) 154, 482, 495, 4g6, 498 -- location 498 -- neurovascular structures 498 -sacral 90, 104, 114 -spiral 322 - supracondylar 345 -tarsal 407 Canals, fibro-osseous, in leg 502, 507 Cancellous bane 14, 35 -primary 14 - secondary 14 Cane. use of 387 Capacitance vessels 44 Caplllary 46 Capillary endothelium 49 Capitellum of humerus 214, 216, 238,241 Capsule - articular Ooint capsule) 36 -fibrous 139 Caput
Carpometacarpal joint of thumb see joint, carpometacarpal, of thumb Carpus see Wrist Cartilage -costal 37,106,108,144,227 -cricoid - - derivation from pharyngeal arch 11 - - surface anatomy 28 -thyroid - - derivation from pharyngeal arch 11 -- surface anatomy 28, 171 Cartilage - mineralized 14 -resting 14 Cauda/Tall -[cauda] equina 81,104,477,498 - [tail] of epididymis 1 96 Cavities, serous 22 Cavity - abdomlnopelvlc 22 - articular Qoint cavity) 36 - glenoid 34, 210. 213, 229, 230, 232, 235, 264 -- angle with sagittal plane 215 -pelvic 22 -pericardia! 22 - peritoneal 22 -pleural 22 - thoracic 22 Cavity/Space - epidural space 1 04 - peritoneal, of scrotum 1 96 - scrotal cavity 194 - serous. of scrotum 196 ceo angle [caput-collum-dlaphyseal angle) 367 Cell(s) -milieu 48 - myellnatlng 70 Cement line 35 Center~ge angle 379, 389 - decreased 389 Central canal, development 55 Central nervous system see Nervous system, central Cerebellar cortex. neuron, efferent 60 Cerebellum 81 - development 54 Cerebrum (endbrain, telencephalon), development 54 Cervical flexure 54 Cervical lordosis 79 Cervical lymph nodes SO Cervical rib syndrome 317 Cervical spine 84 - curvature, normal 79, 81 - degenerative change 103 - ligaments 96, 98 - range of motion 101 -total range of motion 101 - unmvertebral joints 102 Cervical triangle. lateral 332 Cervical vertebrae 78, 82, 84 Cervix of uterus 202 Cervix. uterine 154, 160 Chest breathing 11 0 Chesttube 179
Cutaneous nerve(s) D
- relation to neurovascular structures 179 Chest wall - lymphatic vessels, superficial 167 -muscles 118,144 - posterior 145 - unstable 106 Chiasm -crural 453 - plantar 453 Chondroclasts 14 Chandran 36 Chordata 2 - features 3 Chorion - frondosum 8 - laeve 8 Chorionic cavity 8 Chorionic gonadotropin, human (HCG) 9 Chorionic mesoderm 8 Chorionic plate 8 Chorionic sac 8 Chorionic villi 8 Chromosome set -diploid 5 -haploid 5 Chrondrocytes 36 Clrculiltlon 44 - embryonic 12 - pressure changes 47 - pulmonary 44 - systemic 44 Circumcision 198 Circumferential lamella - external 35 -internal 35 Cisterna chytl 50 Cli!VIcle 28, 34, 208, 21 0, 229, 230, 258, 264, 341 - anomaly 212 - articular surface -- acromial 212 -- sternal 212 -end -- acromial 29, 209, 212, 227 -- sternal 212, 227 - fracture 212 - ossification Hi - range of motion 236 - surface anatomy 26, 171,328 Clavicularfracture 212 Clilvlcular joints - acromlocli!VIcular see Joint. acromlocli!VIcular - sternocli!Vicular see Joint, sternocli!Vicular Clavicular line 101 Claw toes 417 Claw hand 324 Cleft, synaptic 61 "Clergyman's knee" 401 Clitoris 202 - development 192 - lymphatic drainage 204 Clumping of neuroflbrlls 60 CNS see Nervous system, central Coccygeal nerve -course 483 -plexus 483 Coccyx see Bone, coccyx
Cockett veins 466 Coelom 6 - lntraembryonlc 6 Collagen fibers 42 Collectors. in lymphatic system 51 Colles' fascia see Fascia, superficial perineal Colles' space see Space, superficial perineal Colllculus, seminal 155 Colloids, radlolabeled 181 Colon, aganglionic 57 Colon, location 22 Columnar cartilage, zone of 14 Compact bone 15, 35 Compartments -of foot 463 - of leg 502, 507 - - anterior 507 - - lateral 507 - - posterior. parts of ---deep 507 - -- superficial 507 Compartment syndrome - of foot 463, 480 - of leg 502, 507 Compression syndrome - brachial plexus 317 - carpal tunnel 248, 326 - cervical rib 317 - coracoid process 317 - costoclavicular 317 - cubital tunnel 324 - Frohse arc01de 345 -muscular - - flexor carpi ulnaris 324 - - pectoralis minor 317 - scalene interval 317 - tarsal tunnel 481 Compressive stresses, In upper femur 367 Concave joint member (socket) 36 Condylar axis 369 Condyle - of humerus 217 - lateral 34 -- of femur 360, 366, 370,390, 400 - - of tibia 28, 361, 372, 390 - medlill 34 -- of femur 360, 366, 371,390, 400 - - of tibia 28, 361, 372, 390 Conjugate - AP diameter of pelvic outlet 115,116 - diagonal 1 15 - extemal115 -true 115 Connective tissue spaces 22 Constraining force, to maintain pedal arch 415 Constraints, to joint motion 39 Conus medullarls 81, 104 Convex joint member (ball) 36 Cooper ligaments 180 Coracoacromlal arch 226, 231, 232,234 Cord - notochord 3, 6, 5S, 56, 80 -oblique 242 -umbilical 9
Cornu(a) - coccygeal 90 - greater, of hyoid bone, derlvation from pharyngeal arch 11 - lesser. of hyoid bone. deriv;rtion from pharyngeal arch 11 -sacral 90 Corona glandis 199, 200 Corona radiata cells 5 Corpora cavernosa, crura of 199 Corpus/Body/Pad/Shaft - [corpus] cavemosum -- of clitoris 205 -- of penis 198, 200 - [body] of cli!VIcle 212 - [shaft] of clitoris 205 - [body] of epididymidis 196 -fat [pad] -- Infra patellar 400 -- of ischioanal fossa 496 - [shaft] of femur 366 - [shilft] of fibula 372 - of first metacarpus 252 - [shaft] of humerus, surfaces -- anterolateral 214, 216 -- anteromedlill 214, 216 -- posterior 214 -of hyoid 28 - of ilium 364 - of Ischium 364 - [ corpus]luteum 5 - of metacarpus 222 -[shaft] of penis 199 - perineal [body] 152 - [shaft] of phelanx 222 - pineale [body], hormones produced by 53 - of pubis 364 - [shaft] of radius, surfaces -- anterior 218, 221 -- lateral 218, 221 -- posterior 218, 221 - [shaft] ofrlb 109 - [corpus] sponglosum of penis 155,198,200 -- development 192 - [body] of sternum 28, 34, 106, 108 - [body] of talus 374, 376 - [shilft] oftiblil 372 - [shaft] of ulna, surfaces -- anterior 218, 221 -- medial 218,221 --posterior 29,209,218,221 - [body] of vertebrae see Vertebral body Cortex - lymph node 51 -motor 68 -- neuron, efferent 60 Costal angle 109 Costal arch see Arch, costal Costal cartilage 37,106,108, 144, 227 Costal margin 27,106,147 Costal pleura 145, 150 Costal tubercle 83, 106, 109, 111 Costoclavicular syndrome 317 Costotransverse joint 106, 111 Costovertebral joints 11 0 - axesofmotlon 110 - ligaments 111
Cotyledons 9 Cowper glands (bulbourethral glands) 160, 194, 200 Cranial flexure, of embryo 54 Cranial nerve pairs 59 Cranial nerves - derivation from pharyngeal arch 11 - location 59 Cranlovertebraljolnt muscles 118, 124 Craniovertebral joints - lower see joint, atlantoaxial - upper see joint, ortlanto-oclpltal Cranium 34 Crease see Sulcus
Crest -of head of rib 111 -lilac 28,34, 114,141,266,360, 363,364 --lip ---Inner 114 ---outer 114 -- surfaceanatomy 27,171,173, 486 - Internal occipital protuberance 96 - intertnochanteric 366, 380
-sacral -- lateral 90 --medial 90 -- median 90, 114 - of tuberosity -- greater 214, 268 -- lesser 214, 216, 266 Cross-sectional area of vessels 48 Crowning of fetal head 203 Crown-rump length, fetal 4 Cruciate ligament see Cruciform ligament -of atlas 98 - of finger 250.298 - of knee see Ligament. cruciform Crura of corpora Ci!Vemosa 199 Crural sling 147 Crus - of clitoris 154, 202, 205 - lateral, superficial inguinal ring 182 - medlill, superflclilllngulnal ring 182 -of penis 155,199 Cryptorchidism 194 Cubital angle 244 Cubital tunnel syndrome 324 Cubitus valgus 244 Cuneocuboid joint 402 Cuneonavicular joint see joint. cuneonavicular Curvorture, scoliotic 107 Cuhneous innervation -limbs -- lower 485, 487 -- upper 329, 331 -trunk wall -- anterior 170 - - posterior 172 Cutaneous nerve(s) - autonomous area 487 - distribution(s) -- maximum 65 -- overlapping 65
519
C Cutaneous veins
- injury in autonomous area 487 Cutaneous veins - of upper limb 329 Cutaneous vessels - of trunk wall -- anterior 170 -- posterior 172 Cyst, synovial, popliteal 392 Cytotrophoblast 8
D Deddua -basalis 8 - capsularis 8 Deddualsepta 9 Dendrite 60 Densofaxis 78,81,84,211 - articular surface - - anterior 84 -- posterior 84 Dermatoglyphs 328 Dermatome(s) 7, 66, 80 - course of fibers from dorsal root 64 - derivatives 7 -limb -- lower 65, 66, 485, 487 -- upper 65, 66, 329, 331 - scheme for learning 65 - sensory loss 66 -trunk wall 65 -- anterior 66, 1 70 -- posterior 66, 172 Dermis 328 Descent - of pelvic organs 137 - oftestls 182,194 -- transabdominal 1 94 -- transinguinal 194 - of uterus 137 Determining range of extension, hip joint 386 Diameter -oblique --left 115 --right 115 - transverse 115 Diaphragm 118,134,145,146, 150,177,184 - apertures 147 - central tendon 134 - function 134 - Innervation 134 - insertion 134 - location 147 -origin 134 -parts --costal 118, 134,146,150 -- lumbar 118. 134. 176 ---crus ----left 134, 146 ----right 134, 146 --sternal 118,134,146 -shape 147 Diaphragm - pelvic 118, 136, 154 -- function 136 - urogenital 118, 136, 154, 199 Diaphragmatic breathing 134
520
Diaphragmatic hernia 147 Diaphysis 14, 35 Diarthrosis 36 Diencephalon, development 54 Diencephalon-telencephalon axis 59 Digit see also Anger Digit of fuot (toes) 18, 360 DIP joint see ]oint, distal interpha· langeal Disk - articular, of joint -- acromioclavicular 227 -- sternoclavicular 227 -- ulnocarpal 36, 225 - intervertebral 3, 37, 78, 92, 96, 104 -- fluid shifts, pressure·depen· dent 93 -- spaces 102 - ulnocarpal (articular disk) 225 Disk herniation - lumbar, posterior 104 -median 105 - mediolateral 1OS - transligamentous 104 Dislocation of hlp 388 - radiographic diagnosis 389 - traumatic 381 Distal interphalangeal joint crease 328 Distal interphalangeal joint of finger 208, 223, 254, 301 Distal interphalangeal joint of toe 402 Distal phalanx of flnger 251 Distal phalanx of thumb 274 Distance - Intercristal 115 - Interspinous 115 Dodd veins 466 Domes of diaphragm 135 Dorsal digital expansion 278 - of big toe 438 - of fingers 282, 294, 300 - of toes 438,455 Dorsiflexion -of foot 410 -of hand 255 - of spinal column 1 01 Dorsum -of foot 27, 33,374, 506,508 -- arteries 508 -- - variants 509 -- cutaneous Innervation 507 -- muscles 420, 438 -- surface anatomy 484 -- arteries 309. 348 -- cutaneous nerves, course 349 -- extension crease -- - distal 330 -- - proximal 330 -- lnnerviltlon 349 -- lymphatic drainage 312 -- muscle insertions 300 -- muscle origins 300 -- surface ilniltomy 349 -- tendon sheaths 299 - of hand 33, 222, 330, 348 - of penis 199 - - nerves 200 - - vessels 200
Drawer sign, in knee joint 398 Duchenne limp 387, 476 Ductus/Duct/Vas -(ductus(arteriosus 12 -(vas] deferens 184,194,196 --ligation 195 -ejaculatory (duct] 160, 196 - epididymidal(duct] 196 - lactiferous (duct] 180 --milk duct 180 - MOIIerlan (duct] 192 - right lymphatic (duct] SO, 166, 181,313 -- area drained by 167 -thoracic (duct] 50, 166 -- area drained by 167 - (ductus] venosus 13 Dupuytren contracture 302 Dura mater, spinal 104 Dysfunction, erectile 201 Dysostosis -cleidocranial 212 - craniofacial 212
E Early development 4, 6 Ectoderm 6 Ectopic testis 194 Edema formation 49 Ejaculation center 201 Elbow 26, 338, 344 -Veins, subcutaneous 310 Elbow joint see joint, elbow Ellipsoid joint 38, 254 Embryo 4 Embryoblast 5 Embryonic development 2 Embryonic disc - bllamlnar 6 - trilaminar 6 Embryonic period 4 Eminence
-carpal --of radius 249 --of ulna 249 - hypothenar 328 - lllopublc 114 - Intercondylar 362, 372, 390 -thenar 328 Emissary veins 201 Encephalon see Brain Endocrine cells of heart, disease 57 Endocrine cells of lung, disease 57 Endoderm 6 Endometrium 5 Endomysium 41 Endoneurium 57. 71 Endosteum 15 Endosteum (lining medullary cavity) 15 Endothelial cell 49 Endothelial gap, intercellular 49 Endothelium 46 -closed 49 - fenestrated 49 Endplate. motor 41 Epiblast 6 Eplcondylar axis 217
Epicondyle -lateral -- offemur 28,361,366,390 -- of humerus 28, 209,214, 216, 219, 238, 240, 272, 276, 278, 345 -medial -- offemur 28,361,366,390 -- of humerus 28, 209,214, 216, 219, 238, 240, 274, 344, 346 Epidermis 328 Epididymal duct 196 Epididymis 194, 1 96 - bimanual examination 197 - structure 196 - lymphatic drainage 1 97 Epididymitis 197 Epigastrium (upper abdomen) 32, 171 Epineurium 57 Epiphyseal line, bony 35, 37 Epiphyseal plate(s) 14, 37 -limb --lower 17 --upper 16 - ossified 35, 37 - proliferation zone 14 -reserve zone 14 - synostosis 16 Epiphyseal ring 89, 92 Epiphysis - distal 14, 35 - proximal 14, 35 Episiotomy 203 EPSP (excitatory postsynaptic potential) 60 Erectile muscles 136, 154, 205 Erectile tissues - In female 205 -in male 1g8 Erection 201 Esophagus 10, 177 - passage through diaphragm 147 Eversion of foot 41 0 Eversion weakness, of foot 480 Exocytosls 52 Expiration, diaphragm position with 134 Extension 39 Extension of knee 399 Extensor tendons, of hand 300 External oblique aponeurosis 127, 148,151,182 External rotation of leg 369 Extracellular space 48 Extraocular muscles, embryonic 119 Extraperltoneal space 22 Eye - development 54 - parasympathetic nervous system effects on 73 - sympathetic nervous system effects on 73 Eyeline 101
F Face, palpable bony prominences 28
Fossa F
Facet ;mgle 371 Facet joint 38 Fallopian tube 154, 202 Fascia - antebrachial 302 - axillary 180, 334 - brachial 43, 334, 338 - cervical 22 -- in cross section 139 --layer -- - pretracheal 139 -- - prevertebral 139 -- - superficial 139 - Co lies' see fascia, superficial perineal -cremasteric 182,187,195,196 - diaphragmatic -- pelvic -- - Inferior 153, 154 -- - superior 154 -- urogenital - - - Inferior 153, 154, 199 -- - superior 154 - endotlloracic 144,146,150, 177 - gluteal 492 - Infraspinous 340 - lata 178, 485, 492 - leg 485, 502 --deep 507 - nuchal, deep layer 138, 140 - obturator 153, 158 - pectineal 187 - pectorill 180 -pelvic -- parieteal 497 -- visceral 497 -penile -- deep 198, 200 -- superficial 198 - phrenicopleural 145, 177 - plantar 509 --deep463 -- In cross section 509 - renal, anterior layer 139 -spermatic --external 187,195, 196,198 -- internal 186, 195, 196, 198 - superficial abdominal 1 29, 1 51, 180,334 - superficial perineal 153, 154, 497 - thoracolumbar 129, 174, 266 -- course 140 -- deep layer 139, 141 -- In cross section 139 -- superficial layer 1 38 -transversalis 149, 150.182,186 -- duplication 191 -- In cross section 139 Fascia enclosing a muscle group 43 Fascicles - longlb.Jdlnal 98, 302 - transverse 302, 456 Fat marrow 35 Fat, perirenal 139 Feminization, testicular 193 Femoral axis - anatomical 362 - mechanical 362 Femoral canal 187
Femoral head, iiVasrular necrosis of 383 Femoral neck 34, 360, 366, 369, 378 -angle 367 - anteverted 369 -axis 369 - coronal section 385 -normal 367 - retroverted 369 - rotational deformity 369 - transverse section 384 -valgus 367 -varus 367 - vessels 383
Flow velocity 48 Fluid - extracellular 48 - intracellular 48 Fluid exchange 48 Fluid flltratlon 49 Fluid reabsorption 49 Fold(s) -alar 400 -umbilical --lateral 183,184 --medial 184 --median 184 Fontanelles 37 Foot 18
- suprapiriform 493, 494, 498 -- transmitted structures 494 - supratrochlear 214 - transverse 82, 84, 96 -- course of vertebral artery 102 -- of atlas 84 -- ofaxls 84 - of transverse process see Foramen, transverse - vena ciiVal aperture 134, 146 - vertebral 82, 85, 86 Force arm 39 Forearm 18, 34, 208, 220 - anterior antebrachial region 346 - axis of motion 242, 245
Femoral region. innervation.
- articular surfaces 404
sensory 473 Femoral ring 185, 186, 489 Femoral torsion 369 Femoral triangle 32, 488 Femoral trochlea 366.368. 371, 391,400 Femoropatellar joint see joint, femoropatellar Femorotibial angle 362 Femorotibial angle, In coronill plane 362 Femorotibial joint see joint, femorotibial Femur see Bone, femur Fertilization 5 Fetal membranes 8 Fetal period 4 Fiber bone (woven bone) 15 Fibroblasts, subsynovtal 36 Fibrocartilage zone 42 Fibula 34, 360, 363, 372, 390 - frilcture of 409 - osslflcatlon 17 - surfaces 372 Fibular compartment 506 Fifth sacral nerve 482 Filtration 49 Filum termlnale 104 Finger(s) 18, 222 - abduction 255 - adduction 255 -joints 254 - - range of motion 255 -- functional position oflmmobl· llzed hand 251 - ligaments of 250 - little finger 328 - middle flnger 328 - ring flnger 328 Finger-to-floor distance 1 01 First cervical vertebra see Atlas First coccygeal vertebra 90 First metatarsophalangeal joint 403,413 - joint capsule 409 - range of motion 411 First rib 30, 210 Fish 3 Flat foot 407 - location of pain with 415 Flexion 39 Flexion of knee 399 - meniscal movements during 397 Flexor tendons of flngers, blood supply 351
-axes of motion 410 - compartments 463 - cross section 463, 509 - functional position 41 0 -joints 402 - ligaments 408 - longitudinal arch 414, 436 -- constraining force 41 5 --stabilizers 414 -movements 410 - muscle compartments 463 - oblique transverse section 403 - pressure loads 41 2
-bones - course of arteries in 347 - cross section of 221, 296 - displacement during pronation 245 - dissection, windowed 297 -flexors 239 -length 209 - muscles 256, 274, 276, 278 -- anterior 256 - - extensors -- - common head 278, 293, 295 -- - deep 256, 278 -- - superficial 256, 278 --flexors -- - common head 275, 292, 294, 2g7 -- - deep 256, 274 -- - superficial 256, 274 -- Innervation 257 - - posterior 256 -- radial 256 -- rildialis group 256, 276 - perforatorvelns 311 - posterlorantebrachlal region 348 -pronation -- displacement of forearm bones during 245 -- positions of radius and ulna 219 -- range of motion 245 - supination, positions of radius and ulna 219 - supination, range of motion 245 Forearm skin flaps 309 - cross section of 296 Forefoot 374 -range of motion 411 - varlilnts 484 Foregut 3 Forel's axis 59 Foreskin 198 - constriction of 198 Forward bending - function of abdominal wall muscles in 131 - of cervical spine 101 Fossa - acetabular 364, 379, 383 -- coronal section 385 -axillary 33 - coronoid 214, 216, 238, 241 - rubltal 26, 338, 344 -- veins, subrutaneous 310 -iliac 114,364 - Infraclavicular 32, 332, 334 - Infraspinous 208, 213, 341
-rays --lateral 412 -- meidal 412 - retinaculil 454 - sesilmolds 416 - structure of plantar vault 412 - tendon sheaths 454 -transverse arch 413,436 Foot drop 480 Foot position, plantigrade 41 0 Foot shapes, variants 484 Footprint (podogram) 412, 415, 486 Foramen(-lna) -axillary --lateral 321,342 - - media I 342 - Infraorbital 28 - infrapiriform 493, 494, 498 -- transmitted structures 494 - Intervertebral 58, 78, 86, 88, 169,470 -- course of spinal nerves 102 -- narrowing 103 - sciatic -- greater 117, 483, 494 --- boundaries 494 ---hernia 189
--- ... part --- - Infrapiriform 493, 494, 498 --- - supraplrlform 493, 494, 498 -- lesser 117. 483, 494, 498 --- boundaries 494 -mental 28 - nutrient 35 - obturator 114, 159, 364, 497 -- hernia 189 -sacral -- anterior 78, 90, 112 -- pelvic 470 -- posterior 78, 90, 112, 477 - scapular 213
521
F Fourth lumbar vertebra, spinous process
-inguinal - - lateral 184 -- medial (Hessel bach's triangle) 183,184,186 - intercondylar 366. 371, 390 - Intertrochanteric 366 - lschloanal 154, 483, 496 -- boundaries 496 -- in transverse section 1 61 -- nerves 495 -- vessels 495 - ischiorectal 483 - jugular 26, 32 --surface anatomy 171 -lumbar 176 - lateral malleolar 372 - navicular 1 99 - olecranon 21 4, 238, 240 - saphenous hiatus 185, 186 - paravesical 155 - popliteal 26 -- lymph nodes, deep 469 -- muscular boundaries SOl -- neurovascular structures 501 -- surface anatomy 486 - radlill 214, 216, 238,241 - retromandlbular 32 - subscapular 213 - supraclavicular 27 -- greater 32 -- lesser 32 - supraspinous 208, 211, 341 - supravesical 184 Fourth lumbilr vertebra, spinous process 77, 173 Fovea - ilrtic:ular -- femoral 366, 368 -- radial head 242, 330 --- angulation during pronation 245 - costal facet -- Inferior 78, 86 -- of transverse process 78, 82, 86,111 -- superior 78, 82, 86 -of dens 85 Frohse arcade 322, 345 Fromment sign, positive 324 Frontal (coronal) plane 25 Fulcrum 42 Functional position of hand 255 Fundus of uterus 1 54
c Galt 360,418 - stance phase 41 9 - swing phase 419 - toeing out/toeing in 369 Galtcycle 419 Ganglia of head, parasympatlletlc
72 Ganglioblasts 56 Ganglion (ganglia) - cervical -- inferior see Ganglion, stellate --middle 72 -- superior 72 -cellae 72
522
- dorsal root 62 - mesenteric -- inferior 72 -- superior 72 - parasympilthetlc. neilr organs
72 - paravertebral 73 - P"""'rtebral 73 - spinill (dorsi! I root) 62, 102, 169,314 -- neuron, primary afferent 60 -stellate 72 - sympathetic 72 - of sympatlletlctrunk 63, 169 - topography 58 Gap junctions 49 Gas exchange 48 Gastrointestinal tract - parasympathetic nervous system efh!cts on 73 - sympathetic nervous system efh!cts on 73 Gastrulation 6 Genital folds 1 92 Genital swellings 192 Genital tubercles 192 Genitalia -external -- blood supply 498 -- development 192 -- Innervation 498 -female -- external 154, 202 -- - arterial supply 204 -- - Innervation 205 -- - lymphatic drainage 204 -- - veins 204 -- Internal 202 -male 194 -- external 196, 198, 200 -- - developmental factors 192 -- Internal 194 -- - development 1 94 -- parasympatlletic nervous system effects on 73 -- sympathetic nervous system effects on 73 Genu
- valgum 362 - varum 362 Girdle, pelvic see Pelvic girdle Gland 52 - endocrine 52 -exocrine 52 - multicellular, lntraepithelial 52 Gland follicle 52 Gland(s) 52 - areolar 180 - bulbourethral (Cowper glands) 160, 194, 200 - parathyroid, hormone production 53 - seminal vesicle 194, 384 -- In cross section 161 - thyroid see Thyroid gland - vestibular 202 -- greater (Bartholin glands) 202,205 -- lesser 202, 205 Glans - of clllxlrls 1 52, 205 -- development 192
-of penis 27,152,194,198 -- development 1 92 Glial cells, disease 57 Gluteal folds, asymmetry of 389 Gluteal muscles 420, 422, 424, 426, 442, 444, 446, 448 Gluteal region see Region, gluteal Goblet cells 52 Golgi ilpparatus 52 -neuron 60 Gomphosis 37 Gonadal ligament, lower (gubernaculum) 1 94 Gonadal vein, left 13 Graafian follicle 5 Grip, types of 252 Groin flap, with vasculilr pedicle 179 Groove see Sulcus Groups of lymphatics - forearm territory, middle 31 2 -radlal312 -ulnar 312 - upper arm territory, middle 312 Grynfeltt hernia 189 Grynfeltttrlangle (upper costalumbartriangle) 174 Gubernaculum of testis 194
H Hallux valgus 417 Hammertoe 417 Hand 18, 34, 208, 220 - blood supply 348 -bones 222 - extensor tendons 300 - functional position 255 - innervation 349, 351 - ligaments 246 - lymphatic vessels 312 -- dorsal descending 312 -muscles 256 -- Innervation 257 - range of pronation/supination 245 - tendon compartments, dorsal 299 - tendon sheaths 298 - - communicii!ltion 298 Hand area rule 21 Hand length 209 Hand lines 328 Hand muscles, short 280, 282 -deep 306 - middle layer 304 - superficial 302 Hand of Benediction 326 Haversian canal 15, 35 Haversian vessel 15, 35 HCG (human chorionic gonadGtropin) 9 Head 22 - of epididymis 196 - of femur 34, 366, 368, 378, 382 -- center of rotation 362 - - coronal section 385 -- eplphyseiilllne 385 -- growth plate 388
-----
nutrition 383 ossification center 388 stabilization 380 transverse section 384 - of fibula 28, 34, 360. 372, 430 -- surface anatomy 27, 484 - of flfttl metatarsal 41 2 - of first metacarpal, surface analxlmy 349 - of flrst metatarsal 41 2 -- sesamolds 416 - of humerus 34, 214, 216, 226, 229, 230. 235. 264 - Innervation, sensory --- nudear 66 --- peripheral 67 - Medusa's 164 - of metacarpi!I 222, 251 - palpable bony prominences 28 - of phalanx 222 - of radius 29, 34, 208. 21 8. 220, 238, 241, 243 -- articular circumference 21 8, 221,238 -- articular fovea 218,221. 239. 241,242 -- lunula 241 -regions 32 -of rib 83.109.111 - of talus 374, 376 -- articular surface for navicular 405 - of tibia 34. 372 - of ulna 208, 218, 220, 242 -- articular circumference 218 Head and neck region, neural crest derivatives 57 Heild of biceps, long 215, 232. 270, 288, 320 -tendon 229, 231, 232,335 Head of epididymis 196 Headofrib 83.109,111 -joint of 111 Heart - parasympathetic nervous system effects on 73 - pumping ilctlon 44 - suction effect 47 - sympathetic nervous system effects on 73 Heart and liver, rudimentary 10 Heel pad 418, 486 Helicine arteries 201 Hemiarthroses,lateral 1 02 Hemllumbarlzatlon 79 Hemlsacralizallon 79 Hepatic sinusoids 13 Hermaphroditism, true 193 Hernia - diagnosis 190 - epigastric 188 - external 1 85 - femoral 185, 186, 489 - diagnosis 190 - infrapiriform 189 - inguinal185 -- direct 183, 185, 186 --- diagnosis 190 -- indirect 185, 186 --- congenital 186. 190, 1 94 -- lateral see Hernia, Inguinal, Indirect
}oint(s)
-- medial see Hernia, inguinal, direct -- Shouldlce hernia repair 191 - internal 185 - ischiorectal 189 -lumbar -- Inferior (Petit's hernia) 189 -- superior (Grynfeltt's hernia) 189 - obturator 189 - perineal 189 -- anterior 189 -- posterior 189 - reduction, complete 190 - sciatic 189 - spinotuberous 189 - suprapiriform 18!1 - suprapubic 185 - supraveslcal 185 - symptoms 191 - timing of repair 191 - treatment 191 - umbilical 185, 188 Hernial contents 185 Herniill coverings 185 Hernial opening 185 - external 185, 186 - internal 185, 186 Hernial sac 185 - peritoneum 186 Herniated disk 1 04 Hessel bach triangle 183, 184, 186 Hiatal hernia 147 Hiatus/Aperture/Opening -adductor [hlatus]427, 444,464, 466, 490, 500 - anal[aperture] 137 - ilartic (aperture] 134, 146 - baslllc(hlatus]311 - esophageal[aperture] 134, 146 - levator (hiatus] 157, 1 58 - sacral(hiatus] 90,114,117, 157,471 - saphenous [opening] 185, 186, 467. 468, 485 - urogenital [hiatus] 137 High pressure system, arterial 44, 46 Hilgenreiner line 389 Hlndfoot 375 -axes 410 -range of motion 411 Hinge joint 38 - Interdigitating 254 Hlp - physlologlcly Immature 388 - subluxated 388 Hip dysplasia, congenital 389 Hlp flexors, contracture 422 Hlp joint see joint, hlp Hip muscles 420, 422, 426, 442, 444, 446, 448 - adductor group 420 -- stance phase 387 - extrinsic 420, 424 -- horizontal 424 -- vertical 424 - Intrinsic 420, 422 Hip region, magnetic resonance imaging of 384 Hlrschsprung dlseilse 57 Histogenesis 4
Holoc:ytosis 52 Hook grip 252 Hook of hamate bone 28, 209, 222, 224, 248, 274, 280, 357 Horizontal axis 25 Harmon release 52 Hormonal gland 53 Hormone production 53 - placental 9 Howshlp lacuna 15 Hueter line 240 Huetertriangle 240 Humeral fracture 216 Humeral head axis 217 Humeral shaft fracture, radial nerve lesion 322 Humeroradial joint see joint, humeroradlal Humeroscapular joint see joint, humeral Humeroulnar joint see joint, humeroulnar Humerus 34, 208, 214, 220, 238, 338 - border -- literal 214, 216 -- medial 214, 216 - epicondyle - - lateral 28, 209, 214, 216, 219, 238, 240, 272, 276, 278, 345 - - medial 28, 209, 214, 216, 219, 238,240,274, 344, 346 - ossification 16 - proximal, fracture 216 - torsion angle 217 "Hunter's hat• patella 371 Hydrocele, testicular 197 Hymen 202 Hyoid arch 11 Hyperabductlon syndrome 317 - provocative test 317 Hypoblast 6 Hypoesthesla 487 Hypogastrium (lower abdomen) 171 Hypospadias - glandular 193 -penile 193 - perineal 193 - scrotal 193 Hypospadias 193 Hypothenar 328, 354 - musdes 256, 280, 346 - surface anatomy 356
lilac spine -anterior -- inferior see Spine, anterior Inferior Iliac -- superior see Spine, anterior superior iliac -posterior -- Inferior see Spine, posterior Inferior Iliac -- superior see Spine, posterior superior iliac lllofemorillllgament (of Bertini) 39,380
Ilium 34,114,116 - ossification 17 Impingement syndrome 234 Impression for costoclavicular ligament 212 Incarcerated hernia 190 lnclslonal hernia 185, 188 Incus, derivation from pharyngeal arch 11 Index finger 328 - lymphatic drainage 312 Indifference level, hydrostatic 47 Induration of testis, painless 197 Infant hlp, ultrasound examination of 388 Information transmission,
hormone-mediilted 53 Infrapatellar fat pad 400 Inguinal canal see Canal, Inguinal lnguinalligilment see Ligament. inguinal Inguinal lymph nodes 50 Inguinal region - innervation, sensory 473 - lymph nodes 166, 468 lngulnill testis 194 Injection - arterial, unintended 310 - intravenous 310 - ventrogluteal 495 Innervation -motor 68 -- neural circuit 69 - sensory 64, 66 -- neural circuit 69 -- nuclear, head 66 -- peripheral 64 - - - pilttern 67 -- radicular (segmental) 64 - - - pattern 66 Inspiration, diaphragm position with 134 Insula, development 54 Intercondylar area - anterior 373, 394, 396, 401 - posterior 373, 394, 396 Intercondylar distance 362 Intercostal vessels 109 Intercostal arteries see Arteries, Intercostal Intercostal nerves see Nerves, intercostal Intercostal veins see Veins, Intercostal Intercrural fibers 182 lntermalleolar distance 362 Intermediate sinus 51 Intermediate tendon 41 lntermetatarsal angle 417 - hallux valgus 417 Internal rotation of leg 369 Interneuron 60, 69 - development 57 Interosseous compartment, foot muscles 463 Interosseus slip 301 Interphalangeal joint - distal see joint, Interphalangeal, distal - proximal see Joint. interphalangeal, proxlmill Intersexuality 193
J
Interspinous diameter 115 Interstitial lamella 15, 35 lntertendlnous connections 294, 300 Intervertebral disk protrusion 105 Intervertebral disk see Disk, Intervertebral Intestinal lymph nodes 50 Intima 46 Intracellular space 48 Intrinsic knee ligaments 391, 392, 394 Inversion of foot 410 IPSP (Inhibitory postsynaptic potential) 60 Ischiofemoral ligament 380 Islet cells, hormone production 53
joint - constraints to motion 39 - degrees of freedom 38 - fillse (pseudarthrosis) 36 - plane 38 - stiff (amphiarthrosis) 36, 38 -true 36 joint capsule 36 joint cavity 36 joint mechanics 38 Joint space 36 jolnt(s) - acromioclavicular 34,208, 210, 212,226 -- injury 228 -- llgilments 227, 228 -- surface anatomy 27 - atlantoaxial -- lateral 96 -- ligaments 98 -- median 96, 99 - atlanto-occlpltal 96, 98 -- ligaments 98 - calcaneocuboideal 402 -- articular surfaces 404 - carpometacarpal 208 -- of thumb 34,208,223, 252, 254 -- - axes of motion 252 -- - incongruity, rotation-induced 253 -- - movements 253 - costotransverse 1 06, 111 - cuneocuboid 402 - cuneonavicular 402 -- articular surfilces 404 - elbow 34, 208, 238 -- bleeps brachll muscle function 270 -- capsule and ligaments 240 -- fat pad 239 -- joint capsule 239, 241 -- movements 244 -- skeletal elements 238 -- soft-tissue elements 239 -- valgus, physiologic 244 - femoropatellar 34, 390 -- in transverse section 391 --joint space 391 - femorotibial 390, 396
523
J
junction
-- in coronill section 397 - of finger 254 -of foot 402 - glenohumeral see joint, humeri! I - of head of rib 111 - hlp 34, 38, 360, 363, 378 -- axes of motion 386 -- biomechilnics 386 --click 389 -- compressive load during walking 387 -- coronal section 385 -- determining range of extension 386 - - development 388 -- dislocation, traumatic 381 -- extension 386 -- external rotation 386 -- flexion 386 -- in transverse section 384 -- instablllty 389 -- Internal rotation 386 -- joint capsule 382 --- weilk spots 381 -- ligaments 380, 382 --loads --- in stance phase of gait 387 --- reduction of 387 -- longitudinal axis 386 -- magnetic resonance Imaging 385 -- movements 386 -- neutral (zero-degree) position 386 -- pediatric, radiographic evaluation 389 -- rildiogrilph, anteroposterior 388 -- range of motion 386 -- sagittal axis 386 -- stabiliz;~tion 387 -- transverse axis 386 -- twisting mechanism 381 -- ultrasound ev.!Jluation 388 - humeral (glenohumeral joint, humeroscapular joint) 34, 208, 226, 230, 234 -- abduction axis 264 -- adduction axis 264 -- ankylosis or arthrodesis 237 -- axis of motion 237 -- biceps brachii muscle function 270 --joint capsule 228,231, 232 --- Innervation 322 -- movements 237 -- neutrill (zero-degree) position 237 - humeroradlal 208, 219, 238 -- range of motion 245 - humeroulnar 208, 219, 238 -- range of motion 245 - lntercunelform Oolnts between cuneiforms) 402 - intermel
524
-- - collilterillligilments 246, 250 --- joint capsule 247 --- joint space, location of 330 --- range of motion 255 -- ofthumb,rangeofmotion 411 -- proximal (PIP joint) --- offoot 402 --- of hand 208, 223, 254, 301, 402 - knee 34, 363, 390 -- articulating bones 390 -- axis (axes) of motion 398 --- movement of 399 --- transverse 399 -- capsule and ligaments --- anterior 393 --- lateral 393 -- collilteralllgaments 391, 392, 395,400 -- cruciform ligaments 394 -- drawer sign 398 -- effusion 401 -- extension 398, 399 -- flexion 397, 398, 399 -- intrinsic ligaments 393 -- joint capsule 392, 400 --- attachments 400 -- joint cavity 400 -- lilteralligilments 391. 393. 400 -- llgilments 392 -- medial ligaments 391, 392, 394,400 -- medial/lateral opening of joint spilce 395 -- midsagittal section 401 -- movements 398 -- radiograph 391 -- sunrise view 391 -- stabilization --- deficient 428 --- in coronal plane 395 --- in sagittal plane 394 - metacarpophalangeal (MCP joint) 28, 208, 209, 223, 254 -- capsule and ligaments 251 -- collilteralligilments 246, 250 -- joint space, location of 330 -- range of motion 255 - metatarsophalangeal 28, 361, 402 -- articular surfaces 404 --first 403 --- joint cilpsule 409 --- rilnge of motion 411 -- joint capsule 408 - midcarpal 34, 223, 254 - radioc•rpal 34, 208, 219, 223,
254 -- articular surfaces 225 - radioulnar -- distal 34, 208, 21 9, 220, 223, 242 --- articular surfaces 218, 220 - - - cross section 299 -- proximal 34, 38, 208, 219, 220. 238. 241 --- articulilr surfaces 218, 220 - sacrococcygeal 90 - sacroiliac 34, 38, 114, 116, 158, 365 -- ligaments 117 -- nutation 116 --pain 117
- sternoclavicular 28, 34, 208, 210,226 -- articular disc 227 -- ligaments 227, 228 -- range of motion 236 - sternocostal 227 - subtalar see Ankle ]oint - synovi•l 36 - talocalcaneonavicular 402 - talocrural see Ankle joint - talonavicular 402 -- articular surfaces 404 - tarsomehtarsal 402 -- articular surfaces 404 --axis of motion 410 --range of motion 411 - temporomandibulilr 34 - tibiofibular 34, 372, 390 -- proximal 38 - transverse tarsal 402 - - axis of motion 41 0 -- rangeofmotlon 411 - zygapophyseal (facet joints) 84, 86, 88, 96, 1 00 --joint capsule 98, 100 junction - cervlcothoracic 79 - craniocervical 79 - lumbosacral 79 - thorilcolumbar 79 -- ligaments 94
K Keygrip 252 Kidney -capsule --fatty 139 -- fibrous 139 - hormone production 53 - In cross section 139 - location 22 Knee b•seline 362 Knee joint see joint. knee Kneecap see Patella Knob, presynaptic 61
L Labial commissure - anterior 202 - posterior 152, 202 Labioscrotal swellings 192, 194 Labium (labia)/Up(s) - Inner (lip] oflllaccrest 114 - majora (labia] 152, 205,499 - minora(labia] 152,205, 499 -outer (lip] oflllaccrest 114 Labrum - acetabular 368, 382 -- in coronal section 385 - articular 36 - glenoid 229, 230, 232, 235 Lactic acid bacteria 199 Lactiferous duct 1 80 Lactiferous sinus 180 Lacuna - musculorum 488 - vasorum 185, 186,488
Lilmellar bone 15, 35 Lilmlna of neural arch 82, 85 Lilncelet 3 Lilngerhans cells, pancreatic, hormone production 53 Lilnghans cells 9 Lilrrey's cleft 146 Lilryngeal muscles, derivation from pharyngeal arch 1 1 Lilrynx, surface anatomy 27 Lilteral compartment 420, 438, 463 Lilte
Line(s)fLinea(e) l
-
anterior sacrococcygeal 117 anterior sternoclavicular 227 anterlortlbloflbulare 408 anular 250,298, 301, 380,457 -- of radius 239. 240, 242, 244 - apical of dens 98 -arcuate -- lateral (quadratus arcade) 134, 146, 176 -- medial {psoas arcade) 134, 146,176 -- median 146 --pubic 157,200 - bifurcate 408 - calcaneocuboid -- dorsal 408 -- plantar 438 - calcaneoflbular 408 - cardinal 154 -carpal -- palmar 352. 354 -- transverse (flexor retinaculum of hand) 248, 297, 298,302, 304, 306, 346, 354 -- - surgical incision of 355 - carpometacarpal -- dorsal 246 -- palmar 247 - mllateral -- accessory 250 --carpal -- - radial 246 -- - ulnar 246 -- of joint -- - knee 391, 392, 394, 400 -- - proximal interphalangeal 250 -- - mel:ilcarpophalangeal 250 -- lateral (fibular) 391, 392,394, 400 -- medial {tibial) 391, 392, 394 -- radial 239. 240, 242, 244 -- ulnar 239, 240, 242, 244 ---parts ----anterior 240 -- -- posterior 240 -- -- tranverse 240 -conoid 227 - mramacromial 227, 228, 231, 232, 234, 341 - coracoclavicular 226,228, 231, 341 - mramhumeral 231 - costoclavicular 226 - costotransverse 111 -- lateral 111, 144 -- superior 111 - costoxiphoid 108 - cruciate see cruciform - cruciform 36, 391, 457 -- anterior 393, 394, 396, 400 -- - sites of attachment 396 -- - rupture 398 -- ohtlas 98 -- posterior 393, 394, 396, 400 -- - sites of attachmerrt 396 - deltoid, parts -- tlblocalcaneal 408 -- tibionavicular 408 -- tibiotalar -- - anterior 408 -- - posterior 408
-
dorsal tillonavicular 408 dorsal tilrsal 408 falciform, of liver 184 fundiform, of penis 148 glenohumeral - Inferior 231 - medial 231 - superior 231 of heood of••• - femur (capital femoral ligament) 380, 382 - -- in coronal section 385 - -- in transverse section 384 --fibula - -- anterior 394 - - - posterior 394 --rib111 - Iliofemoral (of Bertini) 39, 380 - Iliolumbar 114, 380 - inguinal 114, 148, 178, 182, 185. 186. 380. 382, 464, 472, 488 - - surface anatomy 484 - intercarpal - - dorsal 246 - - palmar 247 - Interclavicular 227 - interfoveolar 183, 185 - interosseous talocalnnean 403, 406,408 - Interspinous 37, 94, 97, 104 - intertransverse 94, 99, 144 - ischiofemoral 380 - lawnar 182, 187 - ligamentum flavum 37, 94, 96, 98,100 - ligamentum teres -- of femoral head 380 -- of liver 184 - - of uterus (uterine round ligament) 154, 182, 187 - longitudinal --anterior 94, 96, 104, 114, 144,380 - - posterior 94, 97, 98, 104 - mel:iltarsal - - dorsal 409 - - transverse ---deep 413 - -- superficial 456 - nuchal 94, 96, 98, 144 - oblique (cruciform ligaments of fingers) 250, 298 - palmar 247, 251, 306 - patellar 393, 394 - phalangoglenold 250 - pisohamate 357 - plantar 413, 460 -- long 406, 408,414,438,459, 460 - plantar calcaneonavicular 406, 414 -popliteal - - arwate 392 -- oblique 392, 501 - posterior menismfemoral 393. 394,396 - pubofemoral 380 - radiate sternocostal 108, 144, 227 - radiocarpal - - dorsale 244, 246
-- palmar 244, 247 - radioulnar -- dorsale 242, 246 -- palmar 242, 247 -reflex 182 -sacroiliac --anterior 114,117,159 -- dorsal 380 -- interosseous 114, 117 --posterior 114,117 - - ventral 380 -sacrospinous 114,117,156, 159, 380, 382, 423, 483, 494, 498 - sacrotuberous 114, 117, 156, 159, 380, 382, 423, 430, 494, 496,498 - sphenomandibular, derivation from pharyngeal arch 11 -spring 415 - stylohyoid, derivation from pharyngeal arch 11 - supraspinous 37, 94, 97, 1 04, 144 - suspensory -- of breast (Cooper ligaments) 180 --of ovary 154 --of penis 198 - taloflbular -- anterior 408 -- posterior 408 -transverse -- oficel:ilbulum 383 --of atlas 97,98 -- of knee 393, 394 --of humerus 231,232 -- perineal 200- -of scapula --- Inferior 342 ---superior 227,228, 231,233, 340,342 --- ossification 213 - transverse metacarpal -- deep 247, 250,301, 302 -- superficial 302 - trapezoid 227 - ulnocarpal -- dorsale 244 -- palmar 244, 247 -of vertebral body 94 Umb - loWi!r 22, 360 -- abduction axis 425 -- adduction axis 425 -- apophyseal plates 17 -- arteries 464 -- basic sla!letal structure 18 --bone growth 16 -- cutaneous Innervation --- peripheral 485, 487 --- radicular 485, 487 --- segmental 485, 487 --deep 466 -- dermatomes 485, 487 -- epiphyseal plates 17 -- lymph nodes 468 -- lymphatic system 468 -- movements during galt cycle 419 -- muscles 420 --- Innervation 421 -- nerves 470, 472, 474
-- - epifascial 485, 487 -- neurovascular structures, eplfasclal 484, 486 -- ossification centers 17 -- palpable bony prominences 28,361 -- perforator veins 466 -- position, development 19 -- regions 33 -- skeleton 360 -- superficial 466 -- surface anatomy 484 --veins 466 -- - eplfasclal 485, 487 -- windowed dissection 462 - upper 22, 208 -- apophyse;ll plates 16 -- arteries 308 -- basic sla!letal structure 18 -- bone growth 16 -- wt;meous innervation 321, 329 -- - radicular -- -- anterior 329 ----posterior 331 -- - segmental -- -- anterior 329 ----posterior 331 -- epiphyseal plates 16 -- lymphatic vessels 312 -- lymph nodes 312 --- regional 313 -- muscles 256 -- - Innervation 257 -- neurovascular structures, epifascial 328, 330 -- os.sification centers 16 -- palpable bony prominences 28,209 -- position, development 19 -- regions 33 -- skeleton 208 -- surface anatomy 328, 330 --veins 310 ---deep311 -- - subcutaneous 329 --- superficial 311 Linea see Line Line of gravity 25, 79, 363, 373 Llne(s)/Linea(e) -[linea] alba 27, 127,128,148, 150 -- gaps 188 -- surface anatomy 171 - [linea] aspera 34 --lip -- - lateral 366, 430 -- - medial 366 - arcuate]llne]114, 149,150, 159, 184, 364 - axillary [line] -- anterior 30 --mid 30 - - posterior 30 - gluteal [line] -- anterior 113, 364 -- Inferior 364 - Intercondylar [line] 366 - intermediate [line], of iliac crest 114 - Intertrochanteric [line] 366, 380,382
525
l
Lip see Labium (labia)
- lateral supracondylar [line] 366 - lire [line] (thenar crease) 328 - mldclavlcular [line] 30 -midline -- anterior 30 -- posterior 30 - nipple [line] 30 - nuchal [line] -- inrerior 96, 143 -- superior 96, 142, 258 - parastemal]llne] 30 - paravertebral [line] 30 - pectineal]line] 366 - scapular [line] 30 - semilunar (line] 27, 149 --surface anatomy 171 - soleal [line] 372, 434 - sternal(llne] 26, 30 - (linea] termlnalls 115 -transverse ]lines] 37,90 Up see Labium (labia) Uthotomy position 31, 33 Uver - hormone production 53 - lociltion 22 loild arm 39 Lobules of testis 196 Locomotor system 22 Longitudinal axis 25 Longltudlnill growth, retal 4 Longitudinal pedal arch 414, 436 - constraining force 415 -stabilizers 414 Low-pressure system, venous 44, 46 Lumbar anesthesia 104 Lumbar hernia 174 Lumbilr lordosis 79 Lumbar puncture 1 04 Lumbarrlb 82 Lumbar spine 76, 88, 104 - curvature 79, 81 - degenerative change 104 - ligaments 95 - range of motion 101 Lumbar vertebrae 78, 82, 88 Lumbilrizatlon 79 Lumbosacral angle 79 Lumbrical slip 301 Lumlnill radius of veins 46 Lunate column 224 Lung - location 22 - parilsympathetlc nervous system effects on 73 - sympathetic nervous system effects on 73 Lung bud 10 Lunula of radial head 241 Lymph 50 - transport 51 L¥mph follicle 50 Lymph nodes -axillary 50,166,312 --apical 181,313 -- centrill 181,313 -- lnterpectoral 1 81, 313 --lateral 181,313 --pectoral 181,313 -- subscapular 181, 313 - brachlill 313 - cervical 1 66, 313
526
- cubital 31 2 -lilac -- common 166, 469 --external 166,468 -- internal 166.204, 469 -Inguinal --deep 166,187,204,468,489 -- inrerior 468 -- superficial 166, 204, 468 -- superolilteral 468 -- superomedlal 468 - lumbar 1 66, 469 - paramammary 181 -parasternal 166,181 -popliteal --deep 469 -- superficial 468 - supraclavicular 313 - supratrochlear 313 Lymphangitis 312 Lymphatic capillaries 50 Lymphatic drainage 49 Lymphatic organs -primary SO - secondary 50 Lymphatic pathways 50 - breast 181 - genitalia, female, external 204 -limb --lower 468 --upper312 -trunkwall 166 Lymphatic system 44 -deep 51 - organ-specific 51 - superficial 51 -- ofleg 468 Lymphatic system 50 Lymphatic vessels 468 -deep 312 - intercostal 166 - peripherill 50 - superficial (superftclallymphatlcs) 312 -- abdominal wall 167 -- chest wall 1 67
M Malleolar region, medial 503 Malleolus - lateral 28, 34, 360, 363, 372, 402 -- articular surface 403 -- fracture 409 -- surfilce anatomy 26, 484, 486 - medial 28, 34, 360, 372, 402, 414,503 -- articular surface 403 -- surf01ce anatomy 26, 484, 486 Malleus, derivation from pharyngeal arch 11 Mamillary tubercle 54 Mammal 2 - characteristic features 3 Mammary gland see Breast, female Mammary ridge 180 Milndible 34 Mandibular arch 1 1
Manubrium (sternI) 28, 34, 1 06, 108,210 Marginal sinus 51 Marginal spurring of vertebral body 105 Mass, lateral, of adas 85 Maturation divisions, meiotic 5 Maxilla 28,34 MCP joint see joint, metacarpophalangeal Measurement of leg length 361 Mechanical axis, of leg 362 Meckel's cartilage, derivation from pharyngeal arch 1 1 Media (tunica media) 46 Medial compartment 420, 438. 463 Medial meniscus see Meniscus, medial Median nerve compression syndrome 248 Median nerve lesion 326 Median nerve roots, union of 314, 327 Median plane 25 Mediastinum 22 - of testis 196 Medulla -oblongata 81 - - development 54 - spinal see Spinal cord Medullary cavity 14, 35 Medullary sinus 51 Melanoblasts 56 Melanocytes, disease 57 Melanoma, malignant 57 Membrane - atlanto-occlpltal -- anterior 96 -- posterior 96, 98, 143 -elastic -- external 46 -- Internal 46 - fibrous 382, 384 -- ofjoint --- remorotlblill 396 ---knee 391 -- joint capsule 36 -- tendon sheath 43 - external Intercostal 144 - Interosseous 37 -- antebrachial 221, 242, 244, 274, 278, 295 -- crural 372, 464, 480 --- In cross section 462 - obturator 1 17, 382 -- in transverse section 161 - oropharyngeal 6 -perineal 153,154,199 - postsynaptic 61 - presynaptic 61 -sternal 108 - suprapleural 145 - synovial 36, 382 --of knee joint 391 -- tendon sheath 43 - tectorial 98 - wstoadductor 475, 490 Membrane potential, neuron 60 Menard-Shenton line 389 Meniscus 396 - articular 36
- blood supply 396 - change, degenerative 397 -injury 395 - lateral 394, 396, 400 - - sites ohttachment 396 - medial 394, 396, 400 - - sites of attachment 396 - structure 396 -tears 397 Mesencephalon (midbrain) -derivatives 54 - development 54 Mesodenm 7 - embryonic 6 - extraembryonic 6 - intenmediate 6 -paraxial 6 - prechordal 7 Mesogastrium (midabdomen) 171 Mesorchium 196 Mesotendlneum see VInculum Metabolic exchange 48 Metacarpal head see Head, of metacarpal Metacarpal musdes 256, 280, 282 Metacarpophalangeal joint see joint, metacarpophalangeal Metacarpus 18, 222 Metameric organization 168 Metaphysis 14 Metapodium 1 8 Metatarsophalangeill joint see joint, metatarsophalangeal Metatarsus 18, 360, 374 Metencephalon 54 Michilelis, rhombus of 26, 173, 494 Microcirculation 48 Microglial cells 61 Midabdomen (mesogastrium) 171 Mldbrilln see Mesencephalon Mldclavlcular line 171 Middle crease, in palm of hand 328 Midsagittal plane 25 Midsagittal section 23 Mikulicz line 362 Mons pubis 26, 1 52, 171, 202 Morphogenesis 4 Morula stage 5 Motion segment 93, 1 00 - development 80 - Instability 103 - lntervertebrill disk position 93 - loading 1DO a-motoneuron 60, 68 Mullerian duct 192 Multiple sclerosis 70 Muscle compartments -of foot 463 -of leg 502 Muscle fascia 43 Muscle flber(s) 41 -prerectal 157,158 Muscle pump 47 Muscle(s) - abductor dlgiU mlnlml -- of foot 403, 414,420,438, 454, 456, 458, 460 - -- Insertion 438, 461 - -- action 438
Musde(s) M
-- - in cross section of foot 509 -- - Innervation 421, 438, 478 -- - tendon 459 --- origin 438, 461 -- of hand 256. 280. 302, 304, 306 -- - action 280 -- - innervation 257, 280, 318, 324 -- - Insertion 300, 307 -- - origin 307 -abductor hallucis 403,414, 438, 456, 458, 460 -- action 438 -- In cross section of foot 509 -- innervation 421, 438, 478 -- insertion 438, 461 -- origin 438, 461 - - tendon 459 - abductor pollids -- brevis 256. 280. 302. 304. 306 -- - action 280 -- - Innervation 257, 280, 318, 326 -- - insertion 307 -- - origin 307 -- longus 256, 278, 294, 297, 346,349 -- - action 278 -- - In cross section of forearm 296 -- - innervation 257, 278, 318, 322 -- - Insertion 278, 292, 295, 300,307 -- - origin 278, 295 -- - surface anatomy 349 -- - tendon 300, 306 -- - tendon compartment 299 - adductor bnevls 420, 426, 444, 449,462 -- action 426 -- blood supply 491 -- In cross section 462 -- innervation 421, 426, 472, 474 -- Insertion 426, 449 -- origin 426, 445 -- reversal of action 426 - adductor halluc1s 420, 438 -- action 438 --head -- - oblique 413, 438, 459, 460 -- -- origin 461 ---transverse 413,438,458, 460 -- -- origin 461 -- innervation 421, 438, 478 -- Insertion 438, 461 --origin 438 - adductor longus 40, 420, 426, 442, 444, 449, 462, 488 -- action 426 -- adductur canal 491 -- blood supply 491 -- in cross section 462 -- Innervation 421, 426, 472, 474 -- insertion 426, 449 -- origin 426, 445 -- reversal of action 426
~dductor m~gnus 420, 426, 442, 444, 447' 448, 462, 488, 490, 492, 495 - - action 426 - - adductorcanal 491 - - Insertion 426, 445, 449 - - Innervation 421, 426, 472, 474, 478, 481 - - in cross section 462 - - origin 426, 449 - adductor minim us 420, 426 - - action 426 - - innervation 421, 426 - - Insertion 426 - - origin 426 - adductor pollicis 256, 280 - - action 280 -- Innervation 257,280, 318, 324 - - insertion 300, 307 --head - -- oblique 280, 302, 304, 306 - -- transverse 280, 302, 304, 306 - - loss of 324 - - origin 307 - adductors - - in cross section 161 - - surface anatumy 484 - anconeus 239, 256, 272, 286, 294 - - action 272 -- innervation 257,272, 318, 322 - - Insertion 272, 287 - - origin 272 - articularis genus 420, 428, 444 - - origin 444 - auricularis, derivation from pharyngeal arch 11 - back see Back muscles - bleeps br~chll 39. 40, 256. 270, 297' 334, 338, 344, 346 - - action 270 --head - -- long 21 5, 232, 270, 288, 296,320 - --- tendon 229, 231, 232, 335 - -- short 229, 232, 270, 288, 296, 320, 335 - --- origin 270, 289 - - in cross section 296 --innervation 257, 270,318 -- Insertion 270, 291,292 - - supinating action 270 - - surface anatumy 328 - - tendon 239, 344, 346 - - tendon of insertion 292, 297 - - tendon of origin 232 - bleeps femoris 40, 420, 430, 501 - - abnormal stresses on, with genu varum 362 - - action 430 - - blood supply 491 --head - -- common 430 - -- long 430, 446, 448, 450, 492, 495 - --- in cross section 462 - -- short 430, 448, 450 - --- In cross section 462
-
-- innervation 421, 430,478 -- Insertion 430, 444, 448, 452 -- origin 430, 448 -- surface anatomy 486 - brachl~lls 239. 256. 270, 287. 288, 292, 297' 320, 338, 344, 346 -- action 270 - - in cross section 296 -- Innervation 257, 270, 318 -- Insertion 270, 291, 293 -- origin 270, 291 - brachioradialis 40, 239, 256, 276, 292, 344, 346 --action 276,18, - - in cross section 296 -- innervation 257, 276, 31 8, 322 -- Insertion 276, 292 -- origin 276, 293 -- tendon 300 - bulbosponglosus 118, 136, 153, 156, 199, 200, 204, 482, 499 --in females 154,156 -- In males 155, 160 -- Innervation 136, 482 - coccygeus 156, 158, 498 - - innervation 482 - coracobruhlalls 229, 256, 268, 288, 290, 297' 320, 334, 336, 338 -- action 268 -- Innervation 257, 268, 318 -- Insertion 268 -- origin 268 -cremaster 148,182,186,195, 196 -- Innervation 126, 472 - deltoid 40, 138, 174, 229, 234, 256,264,284, 286, 288,297, 334,340 -- action 264 -- Innervation 257, 264, 318 -- insertion 264, 287, 291 -- origin 264, 290 -- parts of --- acromial 264, 286, 289 --- clavicular 264, 286 --- spinal 264, 286 -- reversal of muscle action 264 -- surface anatomy 26, 171, 173, 328,330 -digastric -- anterior belly, derivation from pharyngeal arch 11 -- posterior belly, derivation from pharyngeal arch 11 -erector spinae 7, 118, 140,175, 177 - - in cross section 138
--lateral tract 118, 120,140 --medial tract 118,122,141 --surface anatomy 27,173 - extensor carpi l'ildialis -- brevis 40. 256. 276, 292, 294, 297. 346, 349 --- action 276 --- in cross section 296 ---innervation 257,276,318, 322 --- Insertion 276, 294, 300
-- - origin 276, 295 -- - tendon 294 -- - tendon compartment 299 -- - tendon of insertion 300 -- longus 40, 239. 256. 276, 292, 297. 344, 346, 349 -- - action 276 -- - in cross section 296 -- - innervation 257. 276, 318, 322 -- - Insertion 276, 295, 300 -- - origin 276, 293, 295 -- - surface anatomy 328 -- - tendon 294, 300 -- - tendon compartment 299 -- - tendon of insertion 300 - extensor arpi ulnnis 256, 278, 294 -- action 278 -- in cross section 296 --innervation 257,278,318, 322 -- Insertion 278, 294, 300, 307 -- origin 278, 294 -- surface anatomy 330 -- tendon 243, 300 -- tendon compartment 299 - extensor digiti minimi 256, 278,294 -- action 278 -- In cross section 296 --innervation 257,278,318, 322 -- Insertion 278, 294, 300 - - tendon 300 -- tendon compartment 299 - extensor digitarum 40, 256, 278, 294, 349, 403 -- action 278 -- brevis 420, 438, 450, 454 -- - action 438 -- - innervation 421, 438. 478 -- - Insertion 438 -- - origin 438 -- - tendon 455 -- - tendon of insertion 439 -- In cross section 296 --innervation 257,278,318, 322 -- Insertion 278, 294, 300 -- longus 420, 432, 450, 454, 507 -- - action 432 -- - in cross section 462 -- - Innervation 421, 432, 478, 480 -- - insertion 432 -- - origin 432 -- - tendon 433, 450, 454 -- surface anatumy 330 -- tendon 294, 300 -- tendon compartment 299 -- tendon of insertion, surface anatomy 330 --origin 278 - extensor hallucis 403 - - brevis 420, 450. 454 -- - action 438 -- - In cross section 509 -- - innervation 421, 438, 478 -- - insertion 438 -- - origin 438 -- - tendon of Insertion 439
527
M Musc/e(s)
-- longus 4{), 420. 432. 450. 454,507 --- action 432 --- in cross section 462, 509 --- innerv;~tion 421, 432, 478, 480 --- Insertion 432 --- origin 432 --- tendon 433, 450. 454 --- - surface anatomy 484 - extensor lndlcls 256, 278, 294, 349 -- action 278 -- Innervation 257, 278, 318, 322 -- insertion 2g5, 300 - - tendon 300 -- tendon compartment 299 -- tendon of Insertion, surface anatomy 349 - extensor polllds -- brevis 256, 278, 349 --- action 278 --- in cross section 296 --- innerv;~tion 257,278,318, 322 --- Insertion 278, 295, 300 --- origin 278, 295 --- surface anatomy 349 --- tendon compilrtment 299 -- longus 256, 278, 294, 349 --- action 278 --- in cross section of forearm 296 ---lnnerv;~tlon 257,278,318, 322 --- insertion 278, 295, 300 --- origin 278,295 --- surface anatomy 330, 349 --- tendon of Insertion, course 299 --- tendon 294, 300 --- tendon compartment 299 - external oblique (obllquus externus abdominis) 7, 4{), 118, 126,138.140,148,150,174, 177. 178, 334 --action 126 --aponeurosis 127,148,151, 182 -- Innervation 126 -- insertion 126 -- origin 126 --surface ilniltomy 171 - flbularls -- brevis 40, 403, 420, 432, 450, 452, 454, 507 --- action 432 --- In cross section 462 --- lnnerv;~tlon 421, 432, 478, 480 --- insertion 432, 453, 461 --- origin 432, 453 --- tendon 450, 452, 454, 459, 460 --- tendon of insertion 433 -- longus 4
528
-- - innervation 421, 432, 478, 480 -- - Insertion 432, 453, 461 -- - origin 432 -- - surface anatomy 486 ---tendon 433, 441,450,452 -- - tendon, course In sole of foot 433 -- - tendon of insertion 439, 458,460 -- tertius 420, 454 -- - action 432 -- - innervation 432, 478 -- - Insertion 432 -- - origin 432 - - - tendon 450 - flexor carpi radlills 4{), 249, 256, 274, 292, 297. 346 -- action 274 -- in carpal tunnel 354 -- in cross section 296 -- lnnerviltlon 257. 274, 318, 326 -- insertion 274, 293, 307 -- longus 344 --origin 274 -- surface anatomy 356 -- tendon 306 -- tendon sheath 298 - flexor carpi ulnarls 40, 256, 274, 292, 294, 297. 325, 344, 346 -- action 274 -- head -- - humeral 274 -- - ulnar 274 -- in cross section 296 -- innerviltion 257. 274, 318, 324 -- Insertion 274, 292, 307 --origin 274 -- surface anatomy 356 -- tendon of insertion 247 -- tendon 306 -- - sesamoid 224 - flexor digiti minim I 256, 280, 302, 304, 306 -- action 280 -- brevis 420, 438, 456, 458, 460 -- - action 438 --- In cross section 509 -- - innervation 421, 438, 478 -- - insertion 4311, 461 -- - origin 438, 461 -- Innervation 257, 2110, 318, 324 -- insertion 280, 307 -- origin 280. 307 - flexor dlgltorum --brevis 414,420,440,457, 4511,460 -- - action 440 --- In cross section 509 -- - Innervation 421, 440, 4711 -- - insertion 440 -- - origin 44{), 461 -- - tendon 457, 458 -- longus 403, 420, 436, 452, 456, 4511, 507 -- - action 436 -- - aponeurosis In cross section 509
--- in cross section 462 --- Innervation 421,436,478, 509 --- insertion 436, 453, 461 --- origin 436, 453 ---tendon 441,452,455,458 -- profundus 256, 274, 282, 293, 325,346 ---action 274 --- In carpal tunnel 354 --- In cross section 296 ---innervation 257,274,318, 324,326 --- Insertion 292, 307 --- origin 274, 293 --- tendon 250, 301 --- tendon of insertion 304 --- tendon sheaths 298 -- superflclalls 256, 274, 292, 297,346 ---action 274 --- dlgltale tendon shei!ths 354 ---head ---- humeral 274 ---- humeroulnar 346 ---- radial 274, 293, 346 ---- ulnar 274, 293, 346 --- in carpal tunnel 354 --- in cross section 296 ---Innervation 257,274,318, 326 --- insertion 274, 292, 307 --- origin 293 --- tendon of Insertion 303, 304 --- tendon sheaths 298 --- tendons 250, 301, 346 - flexor hillluds -- brevis 414,438,456,458, 460 ---action 4311 ---head ---- lateral 459 ----medial 459 --- in cross section 509 --- innervation 421,438,478 --- Insertion 438, 461 --- origin 438, 461 -- longus 4{)3, 420, 436, 452, 455, 456, 507 ---action 436 --- in cross section 462, 509 --- innervation 421,436,478 --- Insertion 436, 453 --- origin 436, 453 --- tendon 452, 455, 457. 458 --- tendon of insertion 437 - flexor polllcls -- brevis 256, 2110 ---action 280 ---head ---- deep 280. 305, 306 ---- - Innervation 257 ---- superficial 280, 302, 304, 306 ---- - innervation 257 --- Innervation 280, 3111, 324, 326 --- insertion 307 --- origin 307 -- longus 256, 274, 292, 297, 346
--- action 274 --- In carpal tunnel 354 --- In cross section 296 --- innervation 257,274, 318, 326 --- Insertion 274, 292, 307 --- origin 274, 293 --- tendon of insertion 304 --- tendon sheath 298 - gastrocnemius 40, 420, 442, 446, 448, 462 --head --- lateral 434, 450, 452, 501 - - - - In cross section 462 ---- origin 452 --- medial 392, 434, 450, 452, 501 - - - - In cross section 462 ---- origin 452 -- innervation 481 -- origin 448 -- surface anatomy 484, 486 -gemellus -- inferior 420, 424, 447, 448, 462, 495, 498 --- action 424 --- Innervation 421, 424, 477 --- insertion 424 --- origin 424, 449 -- superior 420, 424, 447. 448, 462, 495, 498 --- action 424 --- innervation 421, 424, 477 --- Insertion 424 --- origin 424 -gluteus -- maxim us 40, 138, 140, 153, 200. 420. 424, 442. 446, 492, 495, 496, 498 --- action 424 --- in coronal section 3115 --- in cross section 161,384 --- Innervation 421, 424, 476 --- Insertion 424, 448 --- origin 424, 448 --- surface ilniltomy 486 -- medius 39, 138, 420, 424, 444, 446, 495 --- action 424 --- In coronal section 3115 --- In cross section 384 --- innervation 421, 424, 476 --- insertion 424, 448 --- origin 424 --- surface anatomy 486 --- weakness 425 -- minimus 39, 420, 424, 444, 447. 448. 495 --- action 424 --- In coronal section 3115 --- innervation 421, 424, 476 --- insertion 424, 445, 448 --- origin 424, 448 --- weakness 425 - grilcilis 40, 420, 426, 442, 444, 447. 448. 452, 462, 4811. 492. 495,501 -- action 426 -- in cross section 462 -- innervation 421, 426,472, 474 -- Insertion 426, 444
Musde(s) M
-- origin 426, 444 -Iliacus 128,150,154,176, 184, 420, 442, 444 -- innervation 128, 421, 472 -- origin 128. 422, 444 - lllococcygeus 1 18, 136, 157, 158 -- innervation 136 -- insertion 136 --origin 136 -Iliocostalis 118,120,140 --action 120 -- cervicis 120, 141 -- Innervation 1 20 -- Insertion 120 -- lumborum 120,141 --origin 120 - - thoracls 120, 141 - Iliopsoas 1 28, 182, 420, 443, 444, 488, 498 -- action 128. 422 -- blood supply 491 --lncrosssectlon 161,384 -- in hip extension 386 -- innerviltion 128,421,422, 472,475 -- Insertion 128, 422, 449 -- origin 128, 444 -- shortening, unilateral 422 - Infraspinatus 40, 138, 175, 229, 232, 256, 262, 285, 286, 340, 342 -- action 262 -- iltrophy 213 --Innervation 257,262,316 -- insertion 262, 287 -- origin 262, 287 - lntercostlll 11 8, 132 -- action 132 -- external 132, 140, 144, 177 -- innervation 132 -- insertion 132 -- Internal 132, 144, 1 77 -- Inner most 132, 177 --origin 132 - Internal oblique (obliquus Intern us abdomlnls) 7, 118, 126, 138, 140, 148, 150, 174, 178,183 -- - ilctlon 126 -- - aponeurose 127, 148, 1 51 -- - innervation 126, 472 --- insertion 126 -- - origin 126 - Interossei -- dorsal -- - of foot 403, 420, 440, 450, 457,458 ----action 440 -- -- In cross section 509 ---- innenr.!ltion 421, 440,478 -- -- insertion 440, 461 -- -- origin 440, 460, 461 -- - of hand 256, 282, 300, 302, 304,306 -- -- action 282 ----atrophy 324 -- -- lnnenr.!ltlon 257, 282, 318, 324 -- -- insertion 282, 300, 307 -- --lossof 324 -- -- origin 300, 307
- - pillmilr 282, 256, 305, 306 - -- action 282 --- Innervation 257, 282,318, 324 - -- insertion 282. 300 - -- origin 282, 307 - - plantar 420, 440, 456, 458, 460 ---- iiCtion 440 - --- innerviltion 440 ----insertion 440, 461 - --- origin 440, 461 - interspinales 118, 122 - - ilctlon 122 -- cervlcls 122, 141,143 - -- insertion 143 ---origin 143 - - Innervation 122 - - Insertion 1 22 --lumborum 122,141 - - origin 122 - lntertransversarll 118, 1 20 - - action 120 - - cervicis 143 ---origin 143 - - Innervation 120 - - Insertion 1 20 - - laterale lumborum 120, 141 - - lumborum, innervation 472
-- medlale lumborum 120,141 - - origin 120 - - posteriores cervicis 120 -intrinsic of the back 7, 118, 140, 175, 177 - - lateral tract 1 18, 120, 140 --medial tract 118,122,141 -- surfaceanatumy 27,173 - Ischiocavernosus 118, 136, 153,154,156,199,204 - - Innervation 136, 482 -- insertion 136 - - origin 136 - latissimus dorsi 40, 118, 138, 140, 174,256,266, 284, 288, 290, 334, 340 - - iiCtion 266 - - ilponeurosis of origin 138 - - in cross section 139 --innervation 257,266,318 - - Insertion 266, 290 - - origin 266 -- parts - -- costal 266 ---lilac 266 - -- scapular 266, 286 - -- vertebral 266 - - tendon of insertion, murse 266 - levatur(es) -- ani 118, 136, 153, 154, 156, 160, 204, 482, 498 --- iiCtion 159 - --lntransverse section 161 - -- Innervation 482 -- costarum 118,120,141 ---breves 120.141 - -- lnnerviltlon 1 20 - -- Insertion 120 --- longi 120,141 ---origin 120 -- scapulae 118, 138, 175,256, 260, 285, 341
--- action 260 --- lnneiVatlon 257,260,316 --- Insertion 260, 287 --- origin 260 -longissimus 118,120,140 - - action 1 20 --capitis 120,141, 142,175 --- insertion 143 -- cervicis 1 20 -- lnnenr.!ltlon 120 --Insertion 120 -- origin 120 -- thoracis 120,141 -longus --capitis 118,124 --calli 118,124 --- in cross section 139 --- Inferior part 125 --- oblique part --- straight part 125 --- superior part 125 - lumbrlcals -- of foot 420, 440, 457, 458, 460 ---action 440 --- lnneiVatlon 421, 440, 478 --- Insertion 440 --- origin 440 -- of hand 256, 282, 302, 304, 306 --- action 282 --- inneiVation 257,282,318, 324,326 --- Insertion 282 --- origin 282 - masseter 40 -- derivation from pharyngeal arch 11 - multlfldus 118,122,141 - - action 1 22 -- innenr.!ltion 122 -- insertion 122 -- lumborum, surface anatumy 173 -- origin 122 - mylohyoid, derivation from philryngeill ilrch 11 - obliquus capitis --inferior 118,124,141,142, 175 ---action 124 ---insertion 124,143 ---origin 124,143 --superior 118,124,141,142, 175 ---action 124 ---insertion 124,143 ---origin 124,143 - obturatur -- extern us 420, 426, 444, 449 --- action 426 --- in transverse section 161 --- lnneiVatlon 421, 426, 472, 474 --- insertion 426, 449 --- origin 426 -- lnternus 153,154,156,158, 420, 424, 442, 447. 448, 483, 495, 496, 498 --- action 424 --- filscla, duplication of, see Canal, pudendal
-- - in transverse section 1 61. 384 -- - Innervation 421, 424, 476 -- - insertion 424, 449 -- - origin 424, 449 - ocdpltalls, derivation from pharyngeal arch 11 - omohyoid 256, 258, 340 -- action 258 -- lnnerviltlon 257, 258 -- Insertion 258 -- intenmediate tendon 258 --origin 258 - opponens digiti mlnlml 438, 459,460 - - of foot 420 -- - action 438 -- - In cross section 509 -- - Innervation 421, 438, 478 -- - insertion 438, 461 -- - origin 438 -- of hand 256, 280, 303, 304, 306 -- - action 280 -- - innervation 257. 280, 31 8, 324 -- - Insertion 300, 307 -- - origin 307 - opponens pollids 256, 280, 302,306 -- action 280 --innervation 257,280,318, 326 -- Insertion 307 --origin 307 -palmaris -- brevis 257, 280, 297, 302 -- - action 280 -- - Innervation 257, 280, 318, 324 -- longus 40, 256, 274, 292, 297. 344. 346 -- - action 274 -- - In cross section 296 -- - innervation 257, 274, 318, 326 -- - Insertion 274, 292 -- - origin 274 -- - surface anatomy 356 -- - tendon, surface anatomy 328 -- - tendon of insertion 302 - pectineus 420, 426, 443, 444, 488 -- action 426 -- blood supply 491 -- in cross section 161 -- innerv~tion 421, 426. 472, 475 -- Insertion 426, 449 -- origin 426, 444 - pecturalls -- major 40, 118, 229, 256, 268, 297,334 -- - action 268 -- - innervation 257. 268. 318 -- - Insertion 268, 290 --- parts ----abdominal 148, 268, 288 -- -- clavicular 268, 288, 334 -- -- sternocostal 148, 268, 288,334
529
M Musc/e(s)
--- origin 268 --- surface anatomy 27. 171 --- tendon of Insertion. twisting of 268 -- minor 118. 229. 256, 260. 289,317.335 --- action 260 --- innervation 257,260, 318 --- insertion 260, 290. 290 - -- origin 260 - peroneus see Musculus. flbularls - piriformis 156, 158, 420, 424, 442, 444, 447. 448, 494, 498 -- action 424 -- Innervation 4.21, 424, 476 -- insertion 424, 445, 449 -- origin 424, 445 -- relation to sciatic nerve 493 - plantaris 420, 434, 447. 448, 452,507 -- action 434 -- Innervation 421, 434, 478 -- Insertion 434, 453 -- origin 434, 448, 453 -- tendon 452 --- In cross section 462 - popliteus 420, 430, 452, 502 -- action 430 -- innervation 421, 430, 478 -- Insertion 430, 448, 453 -- origin 430, 453 -pronator -- quadratus 256, 274, 292, 346 --- action 274 - -- Innervation 257. 274, 318, 326 --- insertion 274, 293 --- origin 274, 293 -- teres 40, 256, 274, 292, 295, 297. 344, 346 --- action 274 ---head --- - humeral 274. 344, 346 ----ulnar 274,344,346 --- in cross section 296 --- innervation 257.274, 318, 326 --- insertion 290, 293, 295 --- relation to median nerve 345 -psoas --major 118,128,146,176, 184, 420, 442, 444 ---action 128 --- In cross section 139 --- Innervation 128, 421, 4.22, 472 --- insertion 128 --- origin 128,422.444 --minor 147,176,423,442
- puborectalls 118.136.157. 158 -- Innervation 136 -- insertion 136 --origin 136 -pyramidalis 118,128,149 -- Insertion 128 --origin 128 -quadratus -- femoris 420, 424, 445, 447, 448, 495, 498 -- - action 424 -- - innervation 421, 424, 477 -- - Insertion 424. 449 -- - origin 424, 449 -- lumborum 118,128,141, 146,176 -- - action 128 -- - In cross section 139 -- - innervation 128, 472 -- - insertion 128 -- - origin 128 -- plantae 403,414,420,440, 458,460 -- - action 440 --- In cross section 509 -- - Innervation 421, 440, 478 -- - insertion 440 -- - origin 440, 461 - quadriceps femoris 40, 420, 428 -- action 428 -- biarticular part 429 -- "fifth head" of quadriceps 420 -- In cross section 462 -- innervation 421, 428, 472, 475 -- insertion 428, 444 -- lever arm, lengthening of 43 --origin 428 -- paralysis 428 -- surface anatomy 27 - rectusabdomlnls 7, 118, 128, 148,150,178,184 -- action 128 -- innervation 1 28 -- Insertion 128 --origin 128 -- surface anatomy 171 - rectus capitis --anterior 118,124 ---action 124 - - - innervation 142
-- - Insertion 124 -- - origin 124 --lateral 118,124 -- - action 124 -- - innervation 142 -- - Insertion 124 -- - origin 124
- - - innei'Vii!tion 421
- - posterior
-pterygoid -- lateral, derivation from pharyngeal arch 11 -- medial, derivation from pharyngeal arch 11 - pubococcygeus 118, 136, 157. 158 -- innervation 136 -- insertion 136 -- origin 136
---major 118,124,141.142. 175 ----action 124 ----insertion 124,143 ----origin 124, 143 ---minor 118,124,141 , 142, 175 ----action 124 ----insertion 124.143 ----origin 124, 143
530
- rectus femoris 40. 420. 428. 442, 444. 446 -- blood supply 491 -- in cross section 462 -- in hip extension 386 -- In transverse section 161 -- origin 444, 448 -- surface anatomy 484 -- tendon of insertion 393 -rhomboid -- major 118, 138, 140, 174. 229, 256, 260, 285 ---action 260 ---Innervation 257,260,316 --- Insertion 260, 287 --- origin 260 -- minor 118, 138. 140. 256, 260,285 ---action 260 ---innervation 257,260,316 --- insertion 260. 287 ---origin 260 - rotatores thorads --breves 118,122,141 -- longi 118.122,141 - sartorius 40, 420, 428, 442, 446, 462. 488, 491 -- action 428 -- blood supply 491 -- In cross section 161,462 -- Innervation 421, 428, 472, 475 -- insertion 428, 444 -- origin 428, 444 -- surface anatomy 171 - scalene(-i) 118, 132, 144 -- action 132 --anterior 132,144,315.317. 320,333 -- In cross section 139 -- innervation 132 -- insertion 132 --middle 132,144,315,321, 333 -- origin 132 -- posterior 132. 144 - semimembranosus 40, 392, 420, 430, 442. 447. 448, 462. 501 -- action 430 -- blood supply 491 -- in cross section 462 -- innervation 421, 430, 478, 481 -- Insertion 430, 444, 448 -- origin 430, 448 -- surface anatomy 27, 486 -semispinalis 118,122.175 -- action 122 --capitis 122,140,142,175 ---insertion 142 -- cervicis 122. 142, 175 -- Innervation 122 -- Insertion 122 -- origin 122 -- thoracis 122 - semitendinosus 40, 420, 430, 442, 447, 448, 452, 462, 492, 495,501 --action 430 -- blood supply 491 -- In cross section 462
-- innervation 421. 430.478. 481 -- Insertion 430, 444 -- origin 430, 448 -- surface anatomy 486 -serratus -- anterior 40, 118, 138, 148, 177,226,229,256,260,285, 288. 334. 337 --- action 260 --- Innervation 257,260, 316 --- insertion 260, 291 ---lassof 316 --- origin 260 ---surface anatomy 171 - - posterior
---inferior 118.138.140,174 - - - - In cross section 139 ---superior 118,140 - soleus 40, 420, 434, 450, 452, 462 -- In cross section 462 -- Innervation 481 -- origin 453 -sphincter --ani --- externus (external anal sphincter) 118, 136, 153, 156, 160, 200,496 ---- Innervation 136, 482 --- Intern us (Internal anal sphincter) 160 -- urethrae extern us (external urethral sphincter) 118, 136, 156,160 --- innervation 136, 482 -spinalis 118,122,140 -- action 122 -- cervlcls 122,141 -- Innervation 122 -- insertion 122 --origin 122 -- thoracls 122,141 - splenius 118, 120 --action 120 --capitis 140.142, 174 --- Insertion 143 -- cervicis 140,142 -- innervation 120 -- Insertion 120 --origin 120 - sternocleidomastoid 40, 138, 142, 175,256, 258, 288 -- action 258 --head --- clavicular 258 --- sternal 258 -- innervation 257, 258 -- Insertion 143, 258, 289 -- origin 258 -- relation to neck veins 332 --surface anatomy 27,171 - stylohyoid, derivation from pharyngeal anch 11 - stylopharyngeus, derivation from pharyngeal anch 11 - subclavius 118, 256, 260, 289, 335 -- action 260 -- innervation 257, 260. 316 -- Insertion 260, 290 -- origin 260, 290
Nerve(s) N
- subcosbll 118, 133 - subocclplt~l 118,124,142 - subscapularis 226, 229, 232, 256, 262,290,335,337,341 -- action 262 --Innervation 257,262,318 -- Insertion 262, 291 -- origin 262, 291 - supinator 239, 256, 278, 292, 294, 322, 344 -- action 278 -- innervation 257, 278, 318, 322 -- Insertion 278, 286, 293, 295
-- parts ---deep 345 -- - superficial 345 -- origin 278, 293, 295 - supraspinatus 138, 232, 256, 262, 285, 286, 289, 290, 336, 340.342 -- action 262 -- atrophy 213 --innervation 257,262,316 -- insertion 262, 287, 291 --tendon -- - calcification 235 -- - degenerative change 235 -- - rupture 235 -- - thickening 234 -- origin 262, 287 -- "starter" function 235 ---weakness 316 - temporalls, derivation from pharyngeal arch 11 -tensor -- fasciae latae 40, 420, 424, 443, 444,446,491,495 -- - action 424 -- - In cross section 161 -- - innervation 421, 424, 476 -- - insertion 424 -- - origin 424, 448 -- - surface anatomy 484 -- tympani, derivation from pharyngeal arch 11 -- veil palatlnl, derivation from pharyngeal arch 11 -teres -- major 40, 138, 175, 256, 266, 284, 286, 297. 340, 342 -- - action 266 -- - innervation 257, 266, 318 -- - Insertion 266, 291 -- - origin 266 -- - surface anatomy 173, 330 -- minor 175, 232, 256, 262, 285. 286. 340, 342 -- - action 262 -- - Insertion 262, 287 -- - innervation 257, 262, 318 -- - origin 262, 287 -tibialis -- anterior 40, 403, 420, 432, 446, 450, 454, 507 -- - action 432 -- - In cross section 462 -- - In cross section of foot 509 -- - innervation 421, 432, 478, 480 -- - Insertion 432, 461 -- - surface anatomy 484
- -- origin 432 - -- tendon 455 --- tendon of insertion 460 -- posterior 403,413, 420,436, 453. 455. 456. 507 - -- action 436 - -- In cross section 462 - -- innervation 421, 436, 478 - -- insertion 436, 453, 461 - -- origin 436, 453 - -- relation to malleolar groove 372 - -- tendon 452, 455, 458 --- tendon of insertion 436, 459,460 - b".1nsverse perine1l - - deep 118, 136, 154, 156, 159, 1 99, 204, 496, 498 - --lnfemale 156,160 ---in male 160 - -- innervation 136. 482 - -- Insertion 136 ---origin 136 - - superficial 118, 153, 156, 496 - -- Innervation 136, 482 - -- Insertion 136 ---origin 136 - transversus abdominis 7, 118, 126,141,146,149,150,176, 178 - - action 126 - - aponeurosis 127, 149, 1SO - - Innervation 126, 472 - - Insertion 126 - - origin 126 - transversus thoracis 118, 132, 150 -- Insertion 132 - - origin 132 - trapeaius 40, 118, 139, 140, 142, 174,256.258. 288. 340 - - action 258 - - Innervation 257, 258 - - insertion 258, 286, 289, 290 -- parts --- ascending 138,258, 284, 340 - -- descending 138, 258, 284, 340 - -- transverse 138, 258, 284, 340 - - origin 143, 258 - - surface anatomy 26 - triceps brachll 40, 239, 256, 272, 294, 297. 334, 344, 346 - - action 272 - - aponeurosis, surface anatomy 330 --head - -- lateral 272, 286, 296, 338, 340,342 - -- long 272, 286, 296, 336, 338, 340, 342 - -- medial 272, 286, 296, 336, 338.343 - - In cross section 296 --Innervation 257,272,318, 322 - - insertion 272, 287 - - origin 272, 287 - - surface anatomy 328, 330
- triceps sur~e 40, 420, 434, 450, 454, 502, 507 - - action 434 -- innervation 421, 434,478 -- insertion 434, 453 -- surface anatomy 27 --- origin 434 - vastus -- intermedius 40, 420, 428, 443,444 --- blood supply 491 --- in cross section 462 --- origin 444, 448 --- tendon of Insertion 393 -- late ralls 40, 393, 420, 428, 443, 444, 446 --- blood supply 491 --- In cross section 161,462 --- surface anatomy 484, 486 --- origin 444, 448 -- medialis 40, 393. 420, 428, 442,444 --- adductor canal 491 --- blood supply 491 --- in cross section 462 --- origin 444, 449 --- surface anatomy 484 Muscle, tendon of insertion 41 Muscle, tendon of origin 41 Muscles - bicipital 41 - branchiogenic 119 - cross section -- anatomical 41 -- physiological 41 - digastric 41 -epaxial 7, 80, 119 - extrafusal 40 -flat 41 -hypaxial 7, 80, 119 - infra hyoid, in cross section 139 - ischiocrural (hamstrings) 39, 420 -- blood supply 491 -mimetic 40 -- derivation from pharyngeal arch 11 - multigastric 41 - pen nation angle 41 -phasic 40 - quadrlclplbll 41 -radial 41 -red 40 - somatic 119 -tonic 40 - trlclplta I 41 -white 40 Muscles of foot - central compartment 440, 463 - Interosseous compartment 463 - lateral compartment 420, 438, 463 - medial compartment 420, 438, 463 -short 414, 420,438.440 -- plantar 456, 458, 460 - small 438, 440 Muscles of movement 40 Muscles of arm 256, 270, 272 - anterior 256, 288, 290 - Innervation 257
-posterior 256,286 -- Insertions 287 -- origins 287 Muscles that lower the ribs 132 Muscles that raise the ribs 132 Myelin sheath 69 Myenteric plexus 56 Myofibril 41 Myometrium 5 Myotome 7, 80 - derivatives 7
N Navicular see Bone, navicular Neck 22 - anatomical, of humerus 214, 216,230 -- fracture 216 - cross section 139 - of femur 34, 360,366,369, 378 -- coronal section 385 -- rotational deformity 369 -- transverse section 384 - of fibula 372 - innervation, sensory, peripheral 67 - palpable bony prominences 28 - of radius 218, 238, 240 - regions 32 -of rib 83,109 -of scapula 213,231,341 - surgical, of humerus 214, 216 -- fracture 216 - of bolus 374 Neck muscles, prevertebral 118, 124 Neck of rib 83, 109 Neck region - nerves. epifascial 332 - veins, eplfasclal 332 Neck veins -deep 332 - relation to sternocleidomastoid muscle 332 - superficial 332 Nerve block, Oberst 351 Nerve cell see Neuron Nerve conduction velocity 57, 70 Nerve conduction, saltatory 71 Nerve fiberts) - myelinated 57 - somatomotor, Information flow 59 - somatosensory, information flow 59 - unmyelinated 57 - visceromotor, Information flow 59 - viscerosensory, information flow 59 Nerve plexus 58 Nerve(s) - accessory 174, 257, 258, 332,
340 - anococcygeal 173, 482, 499 - antebrachial cublneous -- lateral 318, 320, 329,331, 344 - - - posterior 318
531
N Nerve(s)
-- medial 31 8, 320, 323, 329, 331, 337. 338, 344 - -- cord segments 31 8 --- relation to basilic vein 310 --- sensory distribution 67, 318 -- posterior 322, 331, 349 - antebrachial Interosseous -- anterior 257 --- in cross section 296 -- posterior 322, 345 -auricular -- great 172, 175,332 --- sensory distribution 67 - axillary 64, 175, 257, 260, 31 4, 318, 320, 336, 342 -- cont.actwith humerus 343 --cord segments 318 -- motor branches 321 -- sensory branch 321 -- sensory distribution 67 - brachial cuhneus -- lateral --- Inferior 318,322,329, 331, 338,340 ---posterior 318 ---superior 172,318,321,329, 331,340 --- - distribution 321 -- medial170,315,318,320, 323,331.338 - -- cord segments 318 --- sensorydistribution 67,318 -- posterior 322, 331, 336,338, 340 - duneal -- inferior 168, 172, 471, 476, 487. 492, 499 --- sensory distribution 67 -- middle 169, 172, 174, 487, 492,499 --- sensory distribution 67 --superior 169,172,174,487, 492 - coccygeal 470, 482 - - course 483 -- main branches 482 -digital -- dorsal - - - of foot 508 --- of hand 318, 324,331,349, 350 --- - anastomoses 322 -- palmar 349, 350 --- common 31 8, 324, 326, 329 --- dorsal branch 350 --- of thumb 350 --- proper 318,324,326,329, 331.350 -- plantar --- common 481, 504 --- proper 478, 481, 504 -dorsal -- of clitoris 204, 482 -- of penis 198, 200, 482, 499 -- ofscapula 257,260,315,316, 342 --- cordsegments 316 - dorsal cutaneous 502 -- intermediate 478, 480, 485, 506 --- In cross section 509 -- lateral 478,487, 506
532
-- - in cross section 509 -- medial 478, 480, 485, 506 --- In cross section 509 -facial 11 -- parasympatlletic part 72 - femoral 128, 176, 182,421, 422, 426, 428, 470, 472, 474, 488 -- branches -- - anterior cutaneous 1 70, 176,470,472, 475, 485 -- - muscular 470, 475 --course 475 -- In cross section 161 -- sensory distribution 67,475 - femor.1l cutlneous
-- lateral 170, 1 72, 176, 472, 485, 487' 488, 491 -- - distribution 67 -- posterior 172, 470, 476, 487, 492. 495. 498. 500 --- distribution 67, 477 -- - perineal branches 476, 482, 493,498 -fibular -- common 421, 430, 470, 480, 485, 487' 493, 500, 502 -- - division 506 - - - fibular communicating
branch 478 -- - sensory distribution 67 -- - trauma 480 -- deep 421, 432, 438, 471, 480, 485, 506, 508 -- - cutaneous branch 506, 508 --- in cross section 509 -- - sensory distribution 67 -- - trauma 480, 506 -- superficial 421, 432, 471, 480, 485,506 -- - sensory distribution 67 ---trauma 480 - genitofemoral 126, 168, 176, 470,472 -- branch -- - femoral 170, 176, 472, 485 --- genltal126,173, 176,182, 1 95, 472, 485, 499 -- sensory distribution 67 - glossopharyngeal 11 -- parasympathetic part 72 -gluteal -- inferior 421,424,470,476, 493, 495, 498, 500 -- - distribution 477 -- - locating 494 -- superior 421, 424, 470, 476, 493.495 -- - distribution 476 -- - locating 494 - iliohypogastric 126, 168, 170, 176, 470, 472 -- cutaneous branch ---anterior 170,176,183,472 -- - lateral 170, 172, 176, 472, 485. 487. 492 -- sensory distribution 67 - Ilioinguinal 126, 168, 170, 173, 176, 182, 1 98, 470, 472, 485, 499 -- sensory distribution 67
- inferior rectal 200, 204, 482, 498 - lntercost.al 126,128,132, 145, 168,178 -- and chest tube insertion 179 -- branch(es) --- anterior cutaneous 169, 170,177 ---- distribution 67 ---collateral 177 ---dorsal ramus 177 --- lateral cutaneous 1 69, 1 70, 172,177 ---- distribution 67 --- lateral mammary 170, 181 --- medial mammary 169, 170, 181 --- ventral ramus 177 -- chest tube 1 79 -intercostobrachial 170,315, 318.329.331 --cord segments 318 -- cutaneous lnneiViltlon 319 -- lateral cutaneous branches 318 -labial -- anterior 472 -- posterior 482 - lateral cutaneous, of big toe 478,507 - long thoradc 168, 257, 260, 315, 316,335,337 --axilla 335 --cord segments 316 --trauma 316 - mandibular 11 -- sensory distribution 67 - maxillary, sensory distribution 67 - medial cutaneous, of second toe 478,507 - median 64, 248,257, 274, 280. 282,314,318,320,326,333, 338, 344, 346 --axilla 335 -- autonomous area 326, 349, 351 -- branch(es) --- articular 326 --- communicating, with ulnar nerve 326, 351 --- muscular 326 --- palmar 318, 326, 329, 351 --- thenar muscular 326, 355 ---- variants In origin 355 -- compression syndrome 326 --cord segments 318 -- course 327 --- relative to brachial artery 339 -- in cross section 296 -- maximum area 349, 351 -- motor branches 326 -- pressure Injury, chronic 326 -- relation to pronator teres muscle 345 --root ---lateral 315,327 ---medial 315,327 -- sensory branches 326 -- sensory distribution 67, 326
-- supply to dorsum of hand 349 -- supply to palm of hand 351 - musculocutaneous 64, 257, 268. 270,314,318,320.323. 333, 336, 338, 344 --axilla 335 -- cord segments 318 -- in cross section 296 -- motor branches 320 -- sensory branches 320 -- sensory distribution 67 - obtufiltor 168, 176,421, 426, 470, 472, 474, 498 -- branch(es) --- anterior 470, 472, 474 --- cutaneous 472, 474, 485, 487 --- muscular 474 --- posterior 470, 472, 474 --course 474 -- sensory distribution 67, 474 - occlplt.al --greater 172,175 --- sensory distribution 67 --lesser 172,174 --- sensory distribution 67 --third 172, 174 - oculomotor, parasympathetic part 72 - ophthalmic, sensory distribution 67 -pectoral -- lateral 257,260, 268, 318, 333,334 --- cord segments 318 --medial 257,260,268,315, 31 8, 333. 334 --- cord segments 318 - perineal 200, 204, 482, 498 - peroneal see Nerve, fibular - phrenic 134 -plantar -- lateral 421, 438, 440, 471, 480,503 ---branch ----deep 504, 509 ----superficial 481, 504, 509 --- sensory distribution 67 -- medial 421, 438, 440, 471, 480, 503, 504 --- in cross section 509 --- sensory distribution 67 --- superficial branch 504 - pudendal 136,200, 204,470, 482, 495, 496, 498, 500 - - course 483 -- cutaneous branches 482 -- distribution 470 -- In cross section 161 -- perineal branches 493 -- trauma 483 - radial 64, 257, 272, 276, 278, 314,318,320,322,338,342, 351 -- autonomous area 349 -- axilla 335, 336 -- compression syndrome 322 -- cont.act with humerus 343 --course 323 -- In cross section 296 -- maximum area 349
Orifice 0
-- motor branches 322. 336 -- branch(es) -- - articular 322 -- - deep 257, 322. 344 -- -- compression 322 -- --traumatic lesion 322 -- - muscular 322, 344 -- - superficial 257. 31 8, 322, 329. 331. 344, 349 -- -- autonomous area 322 -- -- In cross section 296 -- cord segments 318 -- sensory branches 322 -- sensory distribution 67 -- supply to dorsum of hand 349 -- trauma 216 - recurrent luyngeal 1 1 - saphenous 470, 472, 475. 485, 487,491,502 -- branches -- - calcaneal 487 -- - cutaneous 509 -- -- medial crural 475 -- -- plantar 487 -- - infra patellar 475. 485 -- sensory distribution 67 -sciatic 421,424.470.477.478, 480, 493, 498. 500 -- course 480 -- distribution -- - motor 480 ---sensory 481 -- high division 493 --lncrosssectlon 161,462 -- locating 494 -- trauma 478 -- variable course 493 - scrot;ll -- anterior 472 -- posterior 200. 482. 498 - spinal see Spinal nerve - splanchnic 63 --pelvic 72 - subclavian (to the subclavius) 257,260,315.316 -- cord segments 316 - subcostal 128, 168, 176. 470 - suboccipital 175 - subscapular 257, 260, 31 5, 318,335, 336 -- cord segments 318 - superior laryngeal 11 - supradavicular 168. 170, 172. 181' 318, 320.329.331' 332 -- sensory distribution 67 - suprascapular 175. 257, 260, 315,316,336.340,342 -- compression 213 -- cord segments 316 -- trauma 316 - sural 471. 485, 487, 502, 506 -- lateral calcaneal branches 506 -- sensory distribution 67 - sural cutaneous --lateral471,478,485,487, 500. 502, 506 -- - communicating branch 471 -- medial 478, 487, 500, 506 - thoracodorsal 257, 266. 318. 337 -- axilla 335, 336 -- cord segments 318
- tibial 421. 426. 430. 434. 436. 470. 480. 487. 492, 500, 502. 506 -- branches - -- lateral calcaneal 478 - -- medial calcaneal 478. 502 ---muscular 481 -- compression 481 - - distribution ---motor 481 - -- sensory 67 - - in cross section 462 - transverse. of neck 332 - - sensory distribution 67 - trigeminal 66 - - nucleus. sensory 66 - ulnu 64. 257. 274, 280, 282. 314, 318.320.324, 333, 336. 338, 344. 346, 350, 354 --axilla 335 - - autonomous area 324. 349. 351 - - branch(es) - -- articular 324 - -- deep 324. 352. 355 ---dorsal 318,324,331,349 - -- muscular 324 --- palmar 318, 324.329.351 - -- superficial 324, 355 - - connecting branch with median nerve 351 - - contact with humerus 343 - - cord segments 318 - - course 325 - - In cross section 296 - - maximum area 349, 351 - - motor branches 324 - - piercing medial intermuscular septum 338 - - sensory branches 324 - - sensory distribution 67, 324 - - supply to dorsum of hand 349 - - supply to palm of hand 351 -- ulnar tunnel 354,357 -vagus 72 Nerves of arm. subfascial - anterior 329 - posterior 331 Nervous system - autonomic 72 - - circuit diagram 73 -cells 60 - central 58, 62, 68, 70 - - afferents 57. 59 - - development 54 - - efferents 57. 59 - - myelination 70 - - terms of location 59 - enteric (visceral) 72 - - disease 57 - information How 59 - parasympathetic see Parasympathetlc nervous system - peripheral - - myelination 70 - - topography 58 - sympathetic see Sympathetic nervous system - topography 58 Nervous system 22 Network - arterial
-- of elbow 308. 345. 348 -- of knee 464. 488, 501 - calcaneal 503 - carpallnetworkl -- dorsal 308. 348. 353 -- palmar 308, 353 -patellar 491
-venous --dorsal --- offoot 466 --- - surface anatomy 484 ---of hand 311,331 -- plantar 466 Neural canal 3 Neural crest 55, 56 Neural crest derivatives 56 - diseases 57 - head and neck region 57 -tumor 56 Neural crest of head 7 Neural crest of trunk 7 Neural folds 6. 56 Neural groove 6, 55, 56 Neural plate 6, 56 Neural tube 3. 54. 56 -lumen 55 Neural tube closure 6 Neurite see Axon Neurobl•stom• 57 Neuroectoderm 56 Neuroectoderm 6 Neuroectoderm cells. epitheliamesenchymal transformation 56 Neuroflbrlls 60 NeurofibromatDsis 57 Neurofil•ments 60 Neuroglial cells 61 Neuromodulator 53 Neuron (nerve cell) 60 - action potenzial 60 - basic forms 60 - cholinergic, synapse with adrenergic neuron 73 - elektron microscopy 60 - functionally adapted variants 60 - membrane potential 60 - multipolar 60 - postganglionic 73 - preganglionic 73 - pseudounlpolar 60 -soma 60 Neurons. synaptic patterns in small groups 61 Neurosecretion 53 Neurotransmitters 53. 60 Neurotubules 60 Neurov~scular structures, eplfascial -limb --lower 484.486 -- upper 328, 333 - palm of hand 350 -trunk wall --anterior 170 --posterior 172 Neurovascular tracts. about the scapular 342 Neurulation 6 Neutral-zero method 39 Nipple 26, 171. 180 Nlssl substance 60
Norepinephrine 73 Nonnal body position. anatomical 24 Notth - acetabular 364, 379 - clavicular 1 06. 108 -costal 108 -frontal 28 -jugular 106 - radial. of ulna 218, 220, 239, 241 - scapular 210, 213. 230,233, 336, 340, 342 -sciatic -- greater 364, 494 -- lesser 113, 364. 494 - sternal 108 - superior thyroid 28 - supraorbital 28 -trochlear 218. 220,239, 241, 242 -ulnar 243 -vertebral -- inferior 86, 88 -- superior 82. 86. 88 Notochord segment 80 Notochord sheath 80 Nuchal ligament 94, 96, 98, 144 Nuch•l muscles, short 118. 124, 142 Nuclear column -somatic 55 - somatosensory 55 Nuclear pore. neuron 60 Nucleus pulposus 92, 104 - development 80 - function 93
0 Oberst nerve block 351 Obturator membrane 114 Ocdusal plane 101 Olecranon 29, 34, 208. 21 8. 220, 238. 240, 242. 272. 274, 278 -function 39 - surface anatomy 27 Olfactory bulb 54 Oligodendrocytes 61, 69, 70 Ombredanne-Perkins line 389 Omphalocele 188 Ontogenesis 2, 4. 6. 8 Ontogenesis (embryogenesis) 2. 4.6.8 Ontogeny 4, 6, 8 Oocyte formation 5 Oogenesis 5 Opening see Hiatus Opposition of thumb 253 Opticcup 54 Orbit 34 Organ systems 22 Organization, somatotopic 66 Organogenesis 4 Organs. Internal. location of 22 Orifice - ureteral 155 -urethral -- external 152. 199, 202 -- Internal 155. 199
533
0
Ortolani click
- Vilginill 1 52. 202 Ortolan I click 389 OsseeBone Ossification - ilpophyseill 16 - diaphyseal 16 - epiphyseal 16 Ossification center(s) -limbs --lower 17 --upper 16 - membranous 14, 15, 212 - primary 14, 16 - secondary 14, 16 Osslflcadon zone 14 Osteoblasts 14, 35 - ilctive 15 Osteoclasts 15 Osteoclasts (bone-eating cells) 15,35 Osteocytes 15, 35 Osteogenesis (bone development) 14 -direct 15 - indirect 15 Osteoid 14 Osteon 15,35 - development 15 Osteoprogenitor cell 15 ott method, for measurement of foiWaRl flexion 1 01 Ovary 154, 202 - hormone production 53 Ovotestis 193
p Pad see also Corpus Palm of hand 33, 222, 328, 350, 352 - blood supply 350 - flexion creases 328 - innervation 350 - neurovascular structures, eplfasclal 350 - ridged skin 328 - tendon sheaths 298 Palmar aponeurosis 274, 280, 297. 302, 329, 346 Palmar arch - deep 353, 354, 357 - superficial 352, 354, 357 Palmar crease - dlst.!l 328 - proximal 328 Palmar flexion 255 Pancreas - parasympathetic nervous system effects on 73 - sympilthetic nervous system effects on 73 Paracortex, of lymph node 51 Paralysis -central 68 -flaccid 68 - peripheral 68 -spastic 68 Paralysis from axillary crutch use 322 Paraphimosis 198
534
Pilrilsympilthetic nervous system
72 - effects 73 - transmitters 73 - visceroilfferents 72 Paratendlneum 42 Parathyroid gland, hormone production 53 Pilraurethral ducts 205 Park bench palsy 322 Part(s) - costal, of diaphragm 1SO - lumbar, of diaphragm, cnus -- left 146 --right 146 -of body 22 - sternal, of diaphragm 146 Partial body weight, stance phase 387 Partial-body center of gravity, stance philse 387 Patella 28, 34, 360, 363, 370, 390 - ballott.~ble 401 - bipartite 371 - dysplilsie 371 -facet -- lateral 371, 391 -- medial 371, 391 - function 43 - hypoplilsla, medial 371 - location 370 - midsagittal section 401 - ossification 17 -shapes 371 -surface -- anterior 370 -- articular 370, 391,400 - surface anatomy 26 Patellar lnstablllty 371 Pecten of pubis 114 Pedal pulse 506 - palpation of 507 Pedicle of vertebral arch 82, 85, 89 Pelvic cavity 22 - levels 154, 497 - subdivisions 154 Pelvic dimensions 11 5 Pelvicfasciae 497 Pelvic floor - erectile muscles 1 36 - hernia 189 -levels 154 - loss of function 483 -muscles 118, 136,152,154 --female 137,154,156,160 -- function 137 -- innerviltion 482 --male 155,160 - sphincter muscles 136 - stnucture 1 54 Pelvic floor, repair of 137 Pelvic giRlie 114, 208, 211,360 -bones 364 Pelvic inclination angle 79 Pelvic inlet 113 Pelvic Inlet plane 79, 115 -diameter -- sagittal 115 -- transverse 115 Pelvic movements, function of abdominal wall muscles 131
Pelvic muscles. pilrietill 1 57. 158 Pelvic organs, descent 137 Pelvic oudet plane 11 5 Pelvic ring 112, 360, 365 Pelvic tilt 361 Pelvic torsion 422 Pelvic wall muscles 157 -female 156 - pilrietill 157' 1 58 Pelvimetry 115 Pelvis -bony 113 -- female 113 --male 112 - female 113, 154, 156, 202 -- fasciae 1 54 -- transverse section 161 -lesser --lymph nodes 166 -- muscles, parietal 157, 158 -- peritoneal cavity 154 - ligaments 1 14 -male 112,155 -- fasciae 155 -- transverse section 161 Penile fasciae 198 Penile skin 198 Penis 27,152,194 - arteriill supply 200 - development 1 92 - Innervation 200 - neurovascular structures 200 - venous drainage 200 Perforator veins 45 - limb, lower 466 Pericardia! cavity 22 Pericardium 177 Perichondrium 14 Pericyte 49 Perimysium 41 Perineal incision see EpisiotDmy Perineal laceration 203 Perineal protection 203 Perineal region see Region, perineal Perineal raphe 1 52, 202 Perineal space - deep see Space, deep perineal - subcut.lneous 1 54, 497 - superficial see Spilce. superficial perineal Perineum 152 - blood supply 498 -fibromuscular framework 157 - In female 1 52 - Innervation 498 Perineural cells 71 Perineural sheath 71 Perineurium 57 Periosteum 14, 35 Peritendineum - external (epitendineum) 42 - Internal 42 Peritoneal cavity 497 - lesser pelvis 1 54 Peritoneum - of hernial sac 186 - parietal 139, 1 50, 497 - visceral 497 Periumbilical region 171 Pes 18,360 - anserlnus 429, 430, 442, 444, 447,450
- equlnovilrus 480 Petit hernia 189 Petit triangle 174 Peyer plaques SO Phillanges of fingers, osslflciltlon 16 Phalanges of toe, ossification 17 Phalanx - distal -- of foot 34, 374, 376 -- of hand 208, 21 9, 222 - fifth dist.!l, of fuot 374 - fifth middle, of fuot 374 - flrstdlst.!l --- of foot 374,376,403 --- of hand 219, 222,274 ----base 278 - fifth proximal --- of foot 374 --- of hand, base 280 - first proximal --- of foot 376,403 - - - - base 374, 376 - - - - head 374, 376 - - - - shaft 374,376 ---of hand 222 ----base 280 -fourth middle, of foot 403 -middle -- offoot 34 --of hand 208 -proximal -- offoot 34 --of hand 208 Pharyngeal arch muscles 1 a Pharyngeal arch nerve 10 Philryngeal arches 2, 10 - derivatives -- muscular 11 -- sla!let.~l 11 Pharyngeal cleft, ectodermal 1 0 Pharyngeal gut 1 0 Pharyngeal muscles, derivation from pharyngeal arch 11 Pharyngeal pouch 12 - endodermal 10 Pheochromocytoma 57 Phimosis (constriction of prepuce) 198 Phylogeny 2 Plane>- key sign 228 Pinch grip 252 PineilI gland, hormone production 53 Pineal gland, hormone production 53 PIP joint see Joint, proximal lnte.,halangeal Piriformis syndrome 493 Pituitary gland -anlage 54 - hormone production 53 Pltult.~ry, hormone production 53 Pivot joint 38 Placenta 8 - hormone production 53 - main functions 9 Placental barrier 9 Placental circulation 12 Placodes, ectodermal 7 Plane -axial 24
Ramus/Branch R
- Cilrdinal 24 -coronal 25 - Interspinal 31 - intertubercular 31 - sagittal 24 - scapular 211 - subcostal 31 - supracrestal 31 - transpyloric 31 - transverse 24 Planes of section 23 Plantar aponeurosis 406, 412, 414,418,438,440,460,463, 504 - In cross section 509 Plantar calcaneonavicular ligament
406,414 Plantar fascia see Fascia, plantar Plantarflexron 410 Plantarvault 412 Pleura - parletalrs, part -- costal 145, 150 -- diaphragmatic 145, 150 -visceral 145 Pleura 145 Pleural cavity 22 Pleural effusion 179 Pleural space 145 Plexus 58 - axillary lymphatic 313 - brachial 64, 168,229, 257, 333 -- compression syndrome 317 --cord -- - lateral 64, 257, 314, 320, 327. 335, 336 ---medial 64,257,314,327, 335,336 ---posterior 64,257,314,321, 323, 335, 336 -- cutaneous branches 318 -- divisions - - - arrterlor 314 ---posterior 314 -- long branches 318 --nerves 257,315 -- parts - - - infraclavicular 315, 318, 320, 322, 324, 326 - - - supraclavicular 315,316 -- primary trunks 314 -- - spinal cord segments 31 5 -- secondary trunks (cords) 314 -- - spinal cord segments 31 5 -- short branches 318 -- structure 314 -- topography 58 --trunk ---Inferior 64,314 -- - mlddke 64, 31 4 - - - superior 64, 314 - cervical 168, 257, 258 -coccygeal 168,471,482 - hypogastric 72 - lumbar 168, 176,421, 470,472 -- muscular branches 421, 472 - lumbosacral 421, 470 -- topography 58 - pampiniform 195, 196 - pudendal 470, 482 - sacral 136, 168, 205, 421, 470, 476, 478, 480, 482
- - muscular branches 421, 424, 477 - sciatic 470 - testicular 195 -venous 155 - - prostatic 200 - - vertebral - -- external ----anterior 165 - - - - posterior 165 - -- lrrternal ----anterior 165 - - - - posterior 165 - - vesical 200, 204 Plexus formation 64 Podogram(footprint) 412,415, 486 Polar bodies 5 Polythelia 180 Pons 81 - development 54 Popliteal fossa see Fossa, popliteal Portal circulation 44 Portal hypertension 164 Portal sinus 13 Portal vein 13, 44 Posterior crural region 502 Posterior femoral region 500 Posterior horn tear. meniscus 397
Postural muscles 40 Posture -active 131 - function of abdominal wall muscles In 131 - passive 131 - upright 360 Potential, postsynaptic - excitatory 60 - Inhibitory 60 Pouch see Recess Power grip 252 Precollectors, in lymphatic system 51 Pregnancy, duration of 4 Prepuce - of clitoris 152, 205 - of penis (foreskin) 198 Pressure - colloid osmotic 49 - diastolic 48 - Intra-abdominal 130 - intravascular 48 -systolic 48 Pressure chamber system, In sole of foot 418, 486 Pressure podogram 486 Pressure tendon 42 Pressure trabeculae 357 Priapism 201 Primates 2 Primitive groove 6 Primitive node 6 Primitive streak 6 Process - accessory 82, 88 - articular - - Inferior, of vertebra 78, 82, 86, 88,100 - - superior 88, 1DO - -- of sacrum 90 --- of vertebra 78, 82, 84, 86 - coracobrachlal 268
- coracoid 28, 34, 208, 210, 213, 226, 229, 230, 232, 234, 260, 317,341 - coronoid 218, 220, 238, 240, 242,274 - costal 78, 82, 88 - lateral, of calcaneal tuberosity 375 - mamillary 82, 88 - mastoid 29, 96, 258 - medial, of calcaneal tuberosity 375,376 - posterior, of talus 374,376 - spinous 3, 29, 78, 82, 84, 88, 106 -- as landmorks 31, 77 -- of axis 84, 142 -- ofC7 77, 78, 81,210 -- ofLl 106 -- ofL4 77,173,494 -- ofT3 77 -- ofT7 77 -- ofT12 77 --torsion 107 -styloid -- of radius 28,209, 218, 220, 225, 242, 276, 349 --- surface anatomy 26, 330, 349 -- of temporal bone 96 --- derivation from pharyngeal arch 11 -- of ulna 28, 34, 209, 218, 225, 242 --- surface anatomy 27, 330 - supracondylar 214, 326,345 - transverse -- of atlas 84, 142, 175 --of axis 84 -- of vertebra 3, 78, 82, 84, 86, 106 --- lumbar 78 - uncinate 102 -- of cervical vertebra 82, 84 - processus vaginalis -- of peritoneum 194 --- obliterated 194 - - - patent 185 - - oftestis 194 - xiphoid 28, 34, 1 06, 108 --surface anatomy 171 Projection neuron 60 Prolapse - of Intervertebral disk 105 - uterine 137 Prominence, laryngeal 28 Promontory 78, 81, 90, 104, 11 5, 380.423 - pelvic Inclination angle 79 Pronation axis, of forearm 242, 245 Pronation, of forearm 219, 242, 244 Pronator teres syndrome 326 Prosencephalon 10 - deriv;Jtives 54 Prostate 155, 160, 194 - In pelvic cross section 161 Protuberance -mental 28 -occipital -- external 29, 94, 96, 142
-- internal 96 Proximal Interphalangeal joint crease, of flnger 328 PrO>
Q Quadrants, abdominal 171 Quadratus arcade 134, 146, 176
R Radial artery pulse, palpation of 356 Radial nerve lesion 322 Radial tunnel 322, 344 Radialis muscles 256, 276, 323 Radioulnar joint - distal see joint, distal radioulnar - proximal see joint, proximal radioulnar Radius 34, 208, 218, 220, 238 - articular surfaces 220 - borders -- anterior 21 8, 221 --Interosseous 218,221,242 - - posterior 218 - ossification 16 - surfaces -- carpal articular 218, 221,225, 243 -- lateral 274 Ramus/Branch - anterior [ramus], of spinal nerve 62,168,174 - communicating [branch] -- median 351 --ulnar 351 - dorsal [ramus] of spinal nerve see Spinal nerve, ramus, dorsal - inferior pubic [ramus] 1 13, 136, 152,154,157 - [ramus,] of Ischium 1 13, 136, 152, 156
535
R Range ofjoint motion, measurement of
- obturator [branch] 1 84 - posterior [ramus] of spinal nerve see Spinal nerve, ramus, dorsal - superior pubic [ramus] 113, 152,156 -ventral [ramus], of spinal nerve 62,168,174 Range of joint motion, measurementof 39 Range of thoracic and lumbar spl· nal flexion, measurement 101 Ranvier, node of 71 Raphe - anococcygeal 158 - perineal, development 192 Rathke's pouch 10 Reabsorption, in capillaries 49 Rl!cess{Pouch - axlllary]recess] 231,232,235 - costodiaphragmatic [recess] 145 - sacciform [recess] 239,240 - subpopllteal [recess] 392,400 - suprapatellar [pouch] 400 -- unfolding of. during flexion 401 Rectum 160,483 Rectus diastasis 188 Rectus sheath 129, 150 - layers --anterior 127,150,268 --posterior 127,150,184 Rectus sign 429 Redlldl·Oberstelner zone In dorsal root 69 Reference lines 30 Reflex arc 68 Region - anal 32, 152, 482 -- Innervation, sensory 499 - i!lrm -- anterior 33. 338 -- posterior 33, 342 - axillary (axilla) 32, 334 - - anterior wall 334 -- inferior wall 334 -- lateral border 334 -- posterior wall 336 -- regions 33 -- superior wall 334 -- trilnsverse section 335 -buccal 32 - calcaneal 33 -carpal -- anterior 33, 356 -- posterior 33 - cervical -- anterior 32 - - lateral 32 -- posterior 32 - cubital (cubital fossa) 344 -- anterior 33 -- arterial anastomoses 345 -- posterior 33 -deltoid 32 - epigastric(epigastrium) 32,171 -forearm -- anterior 33, 346 -- posterior 33, 348 -frontal 32 - genual -- anterior 33
536
- - posterior 33 - gluteal 26, 32, 492, 494 -- cutaneous nerves 492 -- fasciae 492 -- innervation, sensory 477 -- nerves 493, 495 -- reference lines 494 -- vessels 493, 495 - hypochondriac 32 -- left 171 --right 171 - inframammary 32 - infraorbital 32 - lnfrascapulilr 32 - Infratemporal 32 - inguinal 32 -- left 171 --right 171 - Interscapular 32 - lateral abdominal 32 -leg -- anterior 33, 506 -- posterior 33, 502 -lumbar -- left 171 --right 171 -mental 32 - nasal 32 - occipital 32 -oral 32 -orbital 32 - parietal 32 - parotid-masseteric 32 - pectoral 32 -- lateral 32 - perineal (perineum) 33, 152 - - a.~taneous innervation 173 -- female 204 -- Innervation, sensory 499 -- male 200 - - - neuro\liJscularstructures 200 - presternal 32 - pubic 32, 171 - retromalleolar -- lateral 33 -- medial (medial malleolar region) 503 - - - neurtJVi!lscularstructures 503 -sacral 32 - scapular 32, 175 - sternocleidomastoid 32 - suboccipital 143 - suprascapular 32 -- muscles 340 - temporal 32 -thigh -- anterior 33, 488 -- posterior 33, 500 - umbilical 32, 171 - urogenital 33, 1 52, 482 -- Innervation, sensory 499 - vertebral 26, 32 - zygomatic 32 Rete see also Network Rete testis 196 Retention cyst of Bartholin gland 205 Reticulum, endoplasmic, rough 52 - neuron 60 Retinaculum
-muscular --extensor --- Inferior, of foot 454, 503, 506 --- of hand 299. 300. 349 - - - - surface anatomy 330 --- superior, of foot 503, 506 --fibular --- inferior 455 ---superior 455 --flexor --- of foot 455, 503 --- of hand (transverse carpal ligament) 248, 280, 297, 298, 302, 304, 306, 346, 354 ---- surgical incision 355 -patellar -- longitudinal ---lateral 393 --- medial 393 -- transverse ---lateral 393 --- medial 393 Retroperitoneal space (retroperitoneum) 22 Return, venous 47 Rhombencephalon, derivatives 54 Rhythm, humeroscapular 237 Rlb 28, 30, 76, 107 - accessory 82 -false 107 -floating 107 -movements 110 - rudimentary 78 - torsion 109 -true 107 Rib hump 107 Rlb(s) 28, 30, 76, 107 -false 107 -floating 107 -true 107 Rib, accessory 82 Ridge - supracondylar -- lateral 214, 216,238, 240, 276 --medial 214,238 Ridge skin 328 Ring see Anulus Rolling veins 310 Root - motor see Spinal nerve, root.
ventral -of penis 199 - sensory see Spinal nerve, root, dorsal -spinal -- dorsal see Spinal nerve, root, dorsal - - ventral see Spinal nerve. root.
ventral RosenmQIIer lymph nodes 187, 468,489 Roser-Nelanton line 381 Rotation of limbs 19 Rotational movement 38 - function of abdominal wall muscles in 131 Rotator cuff 226, 232, 262 Round ligament, of uterus 154, 182,187
s Sacral angle 79 Sacral apex 90 Sacral cord 72 Sacral hiatus anesthesia 90 Sacral kyphosis 79 Sacral nerve 91 - emergence 477 -ramus -- dorsal 477 -- ventral 477 Sacral spine, curvature, physiologlc 79, 81 Sacral triangle 27, 173 Sacralization 79 Sacrocardlnal veins 13 Sacroiliac joint see joint, sacroiliac Sacrum see Bone, sacrum Saddle joint 38 Sagittal axis 25 Sagittal axis 25 Sagittal plane 25 Salivary gland - parasympathetic nervous system effKts on 73 - sympathetic nervous system effKts on 73 Saphenous varicosity 467 Sarcolemma 41 Sarcomere 41 Satellite cells 61 -disease 57 Scalene Interval 308, 315, 333 Scalene syndrome 317 Scaphoid see Bone, scaphoid Scapula 34, 208. 21 3 -angle of -- Inferior 29, 208, 21 213, 260,266 --- lateral rotation of 236 --- surface anatomy 26, 173 -- lateral 213 -- superior 29, 209, 210, 213, 260 -borders - movements 236 - neurovascular tract 342 -- lateral 21 0, 213, 262 -- medial 29, 138,209, 210, 213, 260, 263, 341, 342 --- surface anatomy 27, 173 -- superior 213 - ossification 16 - surface anatomy 173
o,
- surfaces
-- clavicular articular 212, 215 --costal 210,213 -- posterior 213 -winged 316 Scapular arcade 341 Scapular notch syndrome 213, 316 Scapular plane 211 Scapular region 32, 175 - arterial supply 343 Scapulothoraclc joint 226, 229, 236 Schober method, for measurement of forward flexion 101 Schwann cells 61, 69, 70 -disease 57
Spinal furrow S
Scintigraphic mapping, with radlolabeled colloids 181 Sclerotome 7, 80 - derivatives 7 Scoliosis 107 Scrotal skin 1 96 Scrotum 27, 1 52 - arterial supply 200 - development 192 - lngulnill hernlil, palpation of 190 - innervation 200 - lymphatic drainage 197 - masses, differential diagnosis 190,197 - venous drainage 200 Secetion - ilpocrlne 52 - autocrlne 53 -eccrine 52 - endocrine 53 - holocrine 52 - merocrine 52 - neurocrine 53 - paracrine 53 Second cervical vertebra see Axis Second rib 30 Secondary follicle, of lymph node 51 Secretions - releilse of 52 - synthesis of 52 Secretory vesicle 52 Segmental gap, between ilnterlor trunk wall dermatomes 170 Seminal vesicle 161, 194 Seminiferous tubules 196 Sentinel lymphadenectomy 181 Septum - femoral 1 86 - intermuscular -- ofarm -- - lateral 43, 272, 276, 338, 343 - - - - in cross section 296
-- - medial 43, 272, 338 -- -- In cross section 296 -- -- pierced by ulnar nerve 338 -- ofleg -- - anterior 462, 506 -- - posterior 462 -- - transverse 462, 507 -- of thigh -- - lateral 462 -- - medial 462 -penile 198 - plantar -- lateral 456. 463 -- - In cross section 509 -- medial 456, 463 - - - in cross section 509 -[septulum] of testis 196 Serosa 22 Sesamold(s) 34, 43 - capsule and ligaments 416 - function 43 - offoot 375,416 -lateral 416 -medial 416 - ossification, limb --lower 17 -- upper 16
- radial 222, 280 - ulnar 222, 280 Sevenltl cervical vertebra 29, 77, 78, 81, 84, 94,96 - surface anatomy 173 - spinous process 77, 78, 81, 21 0 Sex glands, accessory 194 Sex-determining region ofY gene 192 Sexuill reflexes, In milles 201 Shaft see also Corpus Shaft of clitoris 205 Shaft of penis 199 Shaft of rib 109 Sharpey fibers 35 Sheath 152, 154, 160, 202 - carotid, in cross section 139 - common flexor tendon 298 - In transverse section 161 - of rectus abdominis muscle see Rectus sheath - synovial 43 -tendon 43 - - carpal 298, 354 - -- communication with digital tendon shealtls 298 - -- dorsal 299 - -- palmar 298 - - digital 250 - -- palm of hand 298 - -- reinforcing ligaments 250 - - interb.Jbercular 231, 232, 234 - - of foot 454 - - of hand 298 Shingles 66 Shoulder - arteries 308 - bursa 234 Shoulder blade see Scapula Shoulder disloCiltion 230 Shoulder girdle 208. 21 0 - movements 236 -muscles 256 Shoulder girdle muscles 258, 260 - anterior 288 - innervation 257 - posterior 284 Shoulder joint (see also joint, acromioclavicular and joint, humeral) 226, 228, 230 - capsule and ligaments 230 - functional articulations 226 - muscles 256, 262, 264, 266, 268 - - anterior 256, 288, 290 - - innervation 257 - - posterior 256, 284, 286 Shoulder region - anterior 332 - cutaneous nerves 340 -muscles 340 - nerves, eplfasclal 332 - posterior 340 - superior 341 - veins, eplfasclal 332 ShouldIce repair, for Inguinal hernia 191 Sibson's fascia (suprapleural membrane) 145 Slldenafll 201
Silver salts, nerve tissue impregnatlonwlth 60 Sinus - coronary 13 - - development 13 - epldidymldal 196 - lactiferous 180 -tarsi 407 - urogenital 1 92 -venous 13 Skeletal age, estimation of 16, 17 Skeletal muscles 40 Skeleton of trunk 76 Skene ducts 205 Skin 328 Skin flaps 309 - superficial circumflex iliac artery 179 Skin on palmar side of ftngers 328 Skin, sympathetic nervous system effects on 73 Skull - coronal plane 25 - sagittal plane 25 Sliding hernia 1 47 Small Intestine, loCiltlon of 22 Smegma 198 SOlder lines 66 Sole of foot 33, 504 - architecture 412 - arteries 465, 504 - muscle insertions 461 - muscle origins 461 - muscles 420, 438, 440 -- central compartment 420 -- lateral compartment 420 -- medial compartment 420 -nerves 504 - neurovascular structures 509 - pressure chamber system 418, 486 -skin 486 - surface anatomy 486 -veins 466 Somatopleura 7 Somites 6, 80 - derivatives 7 - original 1 19 Space see also Cavity Space - extraperltoneal 22 - costoclavicular, narrowing 317 - deep perineal 137, 154 -- boundaries 1 55 --contents 155 - lntergluteal 476 - intervillous 8 - retroperitoneal 22 - subacromial 232 -- narrowing 234 - subfascial 154, 497 - subperitoneal 22, 154, 497 - superficial perineal 153, 154, 200,205 -- boundaries 155 --contents 155 Span, of outstretched arms 20 Sperm, formation of 5 Spermatic cord 148,182, 186, 195,200,488 - contents 1 95 - coverings 1 95
- in transverse section 161 Spermatlds 5 Spermatocele 197 Spermatocytes S Spermatogenesis 5. 195 Spermatogonia 5 Spermatohlstogenesls 5 Spheroidal joint 38, 230, 236, 378 Sphincter - postcaplllary 49 - precapillary 49 Sphincter muscle(s) 41 - pelvic floor 136 Spider veins 467 Spigelian hernia 189 Spina/Spine - ilnterlor lilac [spine] -- Inferior 114, 152, 156,364 -- superior 28, 1 14, 148, 152, 156. 360. 363. 364. 380. 489. 495 -- - hernia palpation 1 90 ---surface anatomy 26,171, 484 - [spina] blflda 80 -lschlal[splne] 114,116, 152, 156, 158, 363, 364, 380, 494 - posterior iliac [spine] -- Inferior 114, 364 -- superior 29, 1 14, 116, 360, 364,494 -- - surface anatomy 173 - scapular [spine] 29, 34, 138, 208, 228, 258, 263, 264, 340, 342 -- surface anatomy 27, 173 Spinal Cilnal 81 - relation to spinal cord segments 59 - stenosis of 103 - venous plexus see Plexus. venous, vertebral Spinal column 34 -anlage 7 - curvature, lateral 107 - curvatures, physiologic 79, 81 - development 80 - integration into pelvic girdle 79 - kyphosis, neonatal 81 - ligaments 94 -orientation 77 - range of motion 1 01 - stabilizing function of abdominal wall muscles 130 - straightening 81 Spinal cord 81, 104 - anterior horn 63 - development 55, 80 - lateral horn, sympaltletlc ganglion 63, 73 - posterior horn 63 -topography 58 Spinal cord segment - afferents 63, 64 - brachial plexus 315 - efferents 63, 64 - funcdonal organization 63 - relation to spinal canal 59 - structure 62 - topography 63 Spinal furrow 26, 173
537
S Spinal ganglion see Ganglion, spinal
Spin;ll ganglion see Ganglion, splnill Spinal nerve 80, 1 00 - development 7 -lumb;~r
-- muscular branch 470 -- ventral ramus 470 - ramus/branch -- [ramus] communicans ---gray 62,169 --- white 62, 169 -- cutaneus [branch] --- lateral 62, 172, 174, 340 --- medial 172, 174, 340 --dorsal [ramus] 62, 168,172, 174,177,314,340 ---branch ----lateral 62 ----medial 62 --- sensory distribution 67 -- meningeal [ramus] 62, 169 -- ventral [ramus] 62, 168, 174, 314 - relation to uncinate process 102 -root -- dorsal (posterior) 62, 64, 1 02, 169,314,477 --- course of fibers to dermatome 64 --- ganglion 62 --- immunologic diseases 69 --- Redlich-Obersteiner mne 69 -- ventral (anterior) 62, 64, 102, 169,314,477 - sacral(branch], of ventral ramus 470 - topography 58 Spinal nerve pairs 59 Spinal root - dorsal see Spinal nerve, root, dorsal - motor 62, 64, 102, 169, 314, 477 - sensory see Spinal nerve. root. dorsal - ventral 62, 64, 1 02, 169, 314, 477 Spinal rootlets -dorsal 63 -ventral 63 Spine see also Spina Spine synapse 61 Spine-trochanter line 494 Spine-tuberosity line 494 Splnocostal muscles 118 Spinohumeral muscles 118 - anterior 256 - posterior 256 Spinous process see Process, spinous Spiral arteries 8 Splanchnopleura 7 Splayfoot, pain due to 415 Spleen 50 Spondylolisthesis 80 Spondylolysis 80 Spondylophyte 105 SRY gene (sex-
538
Stapes, derivation from philryngeill arch 11 Stem cells, embryonic 5 Step length 419 Step width 419 Steppage galt 480 Sterlllzatlon 195 Sternal angle 30, 106, 108 Sternoclavicular joint see joint, sternoclavicular Sternum 76, 106, 1 08, 268 Stress incontinence 137 Stroke 68 Struther'sllgament 326, 345 Stylopodlum 18 Subacromial space 226, 232 Subcardinal veins 13 Subcutaneous tissue 328 Sublntlma 36 Suboccipital triangle 175 Subperitonealspace 22 Subsynovlalis 36 Sulcus ulnarls syndrome 324 Sulcus/Groove/Crease -[groove] fur artery - - subclavian 1 09 - - vertebral 84, 175 - bicipital [groove] 311 - [sulcus] calcanei 407 - capltulotrochlearls(groove( 215,238,241 - carpal]sulcusJ 224,248, 298, 305, 306, 354 - costal(groove] 109, 145, 177 - deltoldeopectoral [groove] 171, 311,332,334 - [groove] furflexor haliucis longus tendon 374 - gluteal [sulcus] 492 - - surface anatomy 486 - inguinal(crease] 26 - intertubercular [groove[ 214, 216, 230,271 - malleolar [groove] 372 - [groove] for nerve - - radial 214, 21 6, 272, 322, 343 - - spinal 84, 96, 102 - - ulnar 214, 238, 240,324, 338, 343 - plantar [sulcus] - - lateral 504 - - medi•l S04 -[groove] for subclavian vern 109 - [groove] for subclavius muscle 212 - [sulcus] tali 375,407 - telodiencephalic [sulcus] 54 Sunrise view, of knee joint 391 Superficial ectoderm 6, 56 Supination axis, of foreo~rm 242, 245 Supination, of forearm 219, 242, 244 Supinator syndrome 322, 345 Supracardinal veins 1 3 Supraspinatus syndrome 234 Supraspinatus tendon - calcification 235 - degenerative change 235 - rupture 235 - thickened 234
Surface - artlculilr - - acromlalls 233 - - anterior, of dens 84 - - calcaneo~n - - - anterior 375 - - - middle 375 - - - posterior 375 - - clavicular 233 - - fur cuboid 374, 377, 405 - - fur navicular 374, 376, 405, 406
--inferior - - - ofiltlas 84 ---of axis 84 ---of tibia 373,406 - - - of vertebral bodies 84 - - of costal tubercle 111 - - ofheadofrlb 111 - - of malleolus 373, 405, 406 - - of patella 370, 391. 400 - - posterior, of dens 84 --superior ---axis 84 - - - ofiltlas 84 ---of sacrum 82 - - - of vertebral bodies 82, 84, 88 - - talar - - - anterior 366, 374 - - - middle 374, 376 - - - posterior 366, 374
Sympathetic trunk see Trunk, sympilthetlc Symphysis - intervertebral see Disk, intervertebral -pubic 28, 34, 37, 114,360,365, 380 -- pelvic inclination angle 79 Synapse 60 - axoaxonal 61 - axodendr1tlc 61 - axosomatic 61 - drug actions 61 Synarthrosis 36 Synchondrosis 36 Synchondrosis - manubriosternal 1 08 - xlphostemal 108 Syncytial trophoblast 8 Syndesmosis 36 Syndesmosis 36 - tibiofibular 34, 37, 372, 403 Synostoses 36 Synostosis 36 Synostosis of pubis and ischium 17 Synovial fluid 36 Synovial fulds, menlscold 100 Synovial joint 36 Synoviocytes, type B 36 Systemic circulation, lntraembryonlc 12
- auriaJiar. of --Ilium 116,364 - - sacrum 78, 90, 116 -costal - - inferior 111 - - superior 111 - gluteal 364 -lateral --of fibula 372 - - of radius 274 - - of tibia 372 - lunate 364, 382 -malleolar - - lateral 374, 377, 405 - - medii!I 374, 376, 405 -medial --of fibula 372 - - oftlbla 28,361,372 - patellar (h!moral trochlea) 366, 368, 371, 391, 400 - pelvic 82, 114, 493 - popliteal 366 - symphyseal 364 - urethral, of penis 199 Surface anatomy -~male 26 -male 27 Sustentaculum tall 374, 376, 402, 414 Suture - lambdoid 29 - sagittal 29 Swing leg 387,419 Sympathetic ganglia 56. 72, 73 Sympathetic nervous system 72 -effects 73 - synapses 73 - transmitters 73 - visceral afferents 72 - visceral efferents 72
T Tactile corpuscles 328 Tail of epididymis 1 96 Talar trochlea see Trochlea, of talus Talonavicular joint 402 Talus 34,374,376,402,414 - surface -- articular, for navicular 405, 406 --malleolar - - - lateral 373, 405, 406 - - - medial 373, 405, 406 - ossification 17 Tarsal bones 374, 376 - accessory 377 Tarsal tunnel syndrome 481 Tarsometatarsal joint 402 - articular surfaces 404 - axis of matron 410 -range of motion 411 Tarsus 18, 360, 374 Tc-99m sulfur microcolloid 181 TOLE (terminal duct lobular unit of breast) 180 Telencephalon, development 54 Tendinitis, calcifying 23S Tendinocyte 42 Tendinous Intersections 27, 129, 149 - surface anatomy 171 Tendon42 - stretch protectors 42 Tendon compartments, dorsale, of hand 299 Tendon insertion - chondral-apophyseal 42 - periosteal-diaphyseal 42
Tubercle/Tuberosity
Tendon sheath see Sheath, tendon Tendon tissue, composed of para I· lei fibers 42 Tensile stress, in upper femur 367 Tension band principle 367 Tension trabeculae 367 Teratogens, developmental stages sensitive to 4 Terminal duct lobular unit of breast 180 Terminal villus 9 Terms of direction 24 Terms of location 24 Terms of location and direction, general 24 Testicular feminiution 193 Testicular lobules 196 Testicular tumor 197 Testis 194, 196 - anomalous position 194 - bimanual examination 197 - blood supply 197 - coverings 195 - hormone production 53 - lymphatic drainage 197 - structure 196 Testosterone 192 Tetrapod limb, pentadactyl 18 Thenar 328, 354 - surface anatomy 356 Thenar atrophy 326 Thenar crease 328 Thenar muscles 40, 256, 280, 297, 327,346 - Innervation 355 Thigh 18, 34, 360 - arteries 490 - cross section 462 - muscles 420, 442, 444, 446, 448 -- adductor group -- - blood supply 491 -- - pierced by perforating arterles 490 -- - surface anatomy 484 -- anterior 420 -- extensor group 420,428 -- - blood supply 491 -- flexor group 420, 430 -- posterior 420 - nerves 500 - vessels 500 Thomas maneuver 386 Thoracic and lumbar spine, total range of motion 101 Thoracic aperture - inferior (thoracic outlet) 106 - superior (thoracic inlet) 106 Thoracic aperture - Inferior 106 - superior 106 Thoracic cage 76 - bony see Thoracic sla!leton Thoracic cage muscles 118, 132, 134 Thoracic cage. posterior surface 145 Thoracic cavity 22 Thoracic diameter 110 Thoracic duct see Duct, thoracic Thoracic filscla -deep 335
- superficial 335 Thoracic kyphosis 79 Thoracic movements 110 Thoracic scoliosis 107 Thoracic segment 109 Thoracic sla!leton (thorax) 106 - position at end-expiration 110 - position at end-inspiration 110 - regions 32 Thoracic spine 77, 86 - curvatures 79, 81 - range of motion 101 Thoracic vertebrae 78, 82,86 - Tl, spinous process 77 - T7, spinous process 77 - T12, spinous process 77 Thoracic vertebral bodies 86 Thoracohumeral muscles 118 Three-finger rule, In hernia diagnosis 190 Thumb 328 - distal interphalangeal joint crease 328 -flexion 324 - lymphatic drainage 312 - metacarpophalangealjolnt crease 328 Thumb adduction 324 Thumb position relative to fingers 253 Thymus 50 Thyroid anlage 10 Thyroid carcinoma, medullary 57 Thyroid cells, parafolllcular, disease 57 Thyroid gland - hormone production 53 - in cross section 139 Tibia 34, 360, 363, 372, 390 - anterior border 372 - orientation, normal 373 - ossification 17 - surface anatomy 26, 484 - surfaces - - inferior articular 373, 406 - - lateral 372 - - medial 28, 361, 372 - - posterior 372 Tibial plateau 34, 360, 372, 390, 396 Tibialis anterior syndrome 507 Tibiofibular joint see joint, tibiofibular nghtjunctlons 49 - blood-brain barrier 71 - capillary endothelium 71 - perineural epithelial cells 71 Tissue hormones 53 T-lymphocyte region, of lymph node 51 T-lymphocytes SO Toes 18 Tonsil -lingual 50 - palatine 50 - pharyngeal 50 Torsion angle, of humerus 21 7 Tossy classification 228 Tracheal anlage 10 Tract - corticospinal 68
- iliotibial 40, 424, 443, 444, 446 - - In cross section 462 -- insertion 444 - ilioitibial, tension band principle 367 Traction tendon 42 Transformation, epitheliomesenchymal, of neuroectodermal cells 56 Transitional vertebrae 79 Translation, movement in 38 Transmitters 53, 60 Transvere plane 25 Transverse axis 25 Transverse pedal arch 413, 436 Transverse process see Process, transverse Transverse section 23 Transverse tarsal joint 402 -axis of motion 410 -range of motion 411 Transverse tarsal joint see joint, transverse tarsal Trendelenburg sign 476 Triangle -carotid 32 - clavipectoral 32, 311,334 - femoral 32, 488 - of Grynfeltt (upper costolumbar triangle) 174 - iliolumbar (lower costolumbar triangle, triangle of Petit) 174 -- hernia 189 - lumbar 32, 138 -- fibrous (upper costolumbar triangle, triangle of Grynfeltt) 174 ---hernia 189 - lumbocostal 146 - muscular 32 - of Petit (iliolumbar triangle) 174 - omotracheal 32 - sternocostal 146 - submandibular 32 - submental 32 - suboccipital (deep nuchal triangle) 175 - vertebral artery (deep nuchal trl;mgle) 175 Triangle, costolumbar - Lower see Iliolumbar triangle - Upper see Rbrous lumbar triangle Triceps hiatus 342 Triquetra! column 224 Triradiate cartilage of hip 365 -synostosis 17,388 Trochanter - greater 28, 34, 360, 363, 366, 368,494 -- growth plate 388 -- ossification center 388 -- transverse section 384 - lesser 34, 360, 363, 366, 422 Trochlea - of humerus 214, 216, 21 9, 238, 241,244 - of talus 374 -- superior surface 376, 403, 405,406 - - - diameter 406
T
Trophoblast 5, 8 Trunk 22 - brachlocephallc 45, 163, 308, 336 -- de»elopment 12 -- variants 12 - bronchomedlastlnal 166 -- right 313 -celiac 45 - costocervlcal 163, 308, 333 - flbulotlblal 503 - intestinal 166 -jugular 166 -- right 313 -lumbar 166 - palpable bony prominences 28 - reference lines, vertical 30 - subclavian 166, 313 -sympathetic 176 -- branch -- - from spinal nerve 62, 169 --- to spinal nerve 62, 169 - thyrocervical 163, 308, 333, 336,341,343 - types of hernia 189 Trunk arteries, segmental 12 Trunk movement, function of abdominal wall muscles in 131 Trunk wall -anterior -- arteries 179 -- neurovascular structures 178 - arteries 162 - cutaneous Innervation, segmental 170, 172 -- segmental gap 170 - lateral, course of nerves 169 - lymph nodes 166 -- regional 166 - lymphatic vessels 166 - muscles 118 -- embryonic development 119 -- nonlntrlnslc 118 -nerves 168 - neurovascular structures.
epifascial 170, 172 -posterior 174, 176 -- neurovascular structures 174, 176 - surface anatomy 171, 173 -veins 162, 164 -- epifascial 164 TuberfTuberosity - [tuberI calcanei 29, 361, 375, 376,412,440 -- surface anatomy 26, 486 -- medial process 438 - ischial[tuberosityJ 28, 34, 114, 152, 156, 159, 361. 363, 364, 380,430 Tubercle/Tuberosity - adductor [tubercle! 366 - anterior [tubercle! -- ofatlas 84 -- of cervical vertebra 82, 84 -bony -- [tubercleI of scaphoid 28, 209, 222, 224, 249 -- [tubercle! of trapezium 28, 209, 222, 224, 248, 252 -conoid [tuberclel212
539
T Tuberosity see also Tuber and Tubercle
- cosl:ill [tubercle] 83, 106,109, 111 - dorsal [tubercle] 218, 220, 225, 299 -- surface anatomy 349 - greater [tuberosity] 28, 34, 209, 214, 216, 230, 232, 262 - infraglenoid [tubercle] 213, 230,272 - lateral [tubercle[, of talus 374, 376 - lesser [tuberosity] 28, 34, 209, 214, 216, 230, 262 - medial [tubercle], of talus 374, 376,414 - posterior [tubercle] -- of atlas 84, 97 -- of cervical vertebra 82, 84 - pubic [tubercle] 28, 114, 182, 361, 363, 364, 380 - [tubercle[ for scalenus anterior muscle 109 - supraglenoid [tubercle] 213, 230,270 Tuberosity see also Tuber and Tubercle Tuberosity - of cuboid 375 - deltoid 214, 264 - of distill phalanx 222, 250 - of fifth metatarsal 28, 361, 374, 404,454 - for serratus anterior muscle 109 - gluteal 366 - Iliac 113, 116,364 - of navicular 28 - of radius 218, 221, 242, 244, 270 - ofsacrum 90, 116 - of tibia 28, 34, 361, 363, 372 -- surface anatomy 27, 484 - of ulna 218, 221, 242, 244, 270 Tuberosity-trochanter line 494 Tubular bones 35 - development 14 Tunic:i!l - albuginea 196 -- of corpus cavernosorum 198 Tunica vaginalis 194, 196 Twelfth rib 30 Types of bone 34
u Ulna 34, 208, 218, 220, 238 - articular surfaces 220 -borders -- Interosseous 221, 242 -- posterior 218 - movement during pronation 245 - ossification 16 Ulnar nerve displacement 324 Ulnar nerve lesion 324 Ulnar nerve palsy 324 Ulnar tunnel 324, 350, 356 - bony landmarks 357 -hiatus -- distal 357 -- proximal 357 - In cross section 354
540
-walls 357 Ulnar tunnel syndrome 324 Ulnocarpal complex 243 Ult.-.sound evaluation of infant hlp 388 Umbilical arteries 9 - obliterated 184 Umbilical mrd 9 Umbilical hernia 185, 188 Umbilical vein 9, 13 - development 13 - obliterated 13 Umbilicus 26, 148, 171 Uncovertebral arthrosis 102 Uncus of vertebral body 84, 102 Unhappy triad injury 398 Unkilrthrose 103 Upper abdomen 32, 171 Ureter, location 22 Urethra -female 202 -male --course 199 -- development 192 -- parts -- - membranous 155, 199 ---penile 198 - - - prosl:iltic 161, 199 ---spongy 198 Urethral folds 192 Urethral orifice, anomalous, In boys 193 Urinary bladder see Bladder, urinary Urogenital fold 194 Uterine tube (fallopian tube) 154, 202 Uterus 154, 160,202
v Vagina 152,154, 156,160,161, 497 Valves of lymphatic vessels 51 Varices 467 - reticular 467 Varicocele 197 Varicose veins, intrunkwall 164 Vas see also Ductus Vascular bed, terminal 46, 48 Vasa.Jiar resistance 48 Vasectomy 195 Vasoconstriction 44 Vasodilatation 44 Vater-Pacini corpuscles 328 Vein wall thickness 46 Veln(s)IVena - anterior femoral cutaneous 467 - anterior interos.seous 311 - ullliory 45, 164, 1 66, 170, 181' 311,333,335 - azygos 13, 45, 164, 177 -- tributaries 164 - baslllc 45,181,310,329.331, 337' 338, 344 -- relation to medial antebrachial cul:ilneous nerve 31 0 -- surface anatomy 328 - basivertebral 165 - brachial 45, 311,335,338, 344
-- in cross section 296 - brachlocephallc 45, 164, 166 -- left 13, 332 - - - development 13 --right 332 - [vena] cava --Inferior 13,44, 164,176,197 --- in cross section 139 --- passage through diaph.-.gm 147 --- sacrocardlnal segment 13 --- tribul:ilries 164 -- superior 44, 164, 332 - - - development 13 ---tributaries 164 -cephalic 45,164,170,178,310, 329, 331, 333, 334, 338, 344 --accessory 310,331 -- shoulder region 332 -- surface anatomy 328 -circumflex --femoral ---lateral 466 ---medial 466 --iliac ---deep 164 ---superficial 164,170,178, 466,485 - collateral -- middle 338 -- radial 338 -- superior ulnar 338 - cremasteric 197 -deep -- clitoral 204 -- femoral 466 -- of lower limb 466 -- ofupperllmb 311 --penile 200 -digital -- dorsal,ofhand 311,331 --palmar 311 -- plantar 466 -dorsal -- deep, of clitoris 204 --of penis ---deep 198,200 --- superficial 198,200 - epigastric --Inferior 164,178 -- superficial 164, 170, 178, 466, 485 --superior 164,178 -facial 332 -femoral 45, 164,170,182,184, 186, 198, 445, 466, 485, 488, 491 -- in cross section 462 -- In transverse section 161 - femoropopllteal 466 -fibular 466 - genicular 466 -gluteal -- Inferior 493, 498 -- superior 493 - hemiaz:ygos 13. 1 64 --accessory 164 -hepatic 44 -iliac --common 45, 164 -- external 45, 154, 164, 466 -- Internal 45, 164, 200
- lllolumbu 164 - Inferior rectal 200, 204 - lntercapitular 311,331 - intercosl:ill 145, 178 - - anterior 164 -- chest tube 179 - - posterior 164, 177 - - superior 164 - - supreme 164 -Jugular - - anterior 332 - - external 45, 164, 170, 332 -- internal 45, 164, 166.333 - -- In cross section 139 -lumbar 164 - - ascending 164 - medial antebrachial 344 -median - - antebrachial 310, 329 -- basilic 310 -- cephalic 310 -- cubital 310,329 ---deep 310 - -- surface anatomy 328 -mesenteric - - Inferior 13, 45 - - superior 13, 45 - metatarsal - - dorsal 466 - - planl:ilr 466 - musculophrenic 165 - nutrient 35 - obturator 164 - occipital 332 - omphalomesenteric {vitelline vein) 12 - - anastomotic networtc 13 - - development 13 -ovarian 45 -- left 13 - palmar metacarpal 311 - paraumblllcal 170, 184 - of penile bulb 200 - perforator --forearm 310,344 --leg 466 - perineal 204 - periumbilical 164, 170 -plantar - - lateral 467 - -- In cross section 509 - - medial 467 - popliteal 45, 401, 466, 501, 502 - portal (vein of porta hepatls) 13, 44 - posterior arch 466 - posterior labial 204 -pudendal - - external 164, 170, 198, 204, 466,485 - - internal 164, 200, 495, 498 - -- In transverse section 161 - radial 45, 311 - renal 45, 197 - right common cardinal (cardinal venous trunk) 13 -sacral -- lateral 164 - - median 164 - sacrocardinal 13 -saphenous
Zygapadium Z
-- accessory 466, 485 --long 45,164,178,187,466, 485, 501, 502 -- - varicosity 467 -- short 466. 487, 502 -- - varicosity 467 -scrotal -- anterior 198 -- posterior 200 -splenic 13 -splenic 45 - subcardinal 13 -subclavian 45,164,166,311, 332, 335, 338 - subcostal 164 -superficial -- of lower limb 466 -- of upper limb 311 - superficial temporal 332 - supracardinal 13 -sural 466 - testicular 184, 195, 196 -- left 13, 197 --right 197 - thoradc -- Internal 164, 178 --lateral 164,166,178,181 - thoracodorsal 311 - thoracoepigastric 164, 170, 178,311 -tibial -- anterior 45, 466, 506 -- - in cross section 462 -- posterior 45, 466 -- - In cross section 462 - transverse cervical 332 - ulnar 45, 311 - umbilical 9, 13 -- development 13 -- obliterated 13 - ofvasdefenens 184,197 - of vertebral column 164 - of vestibular bulb 204 Veins 45 - pressure ch;mges in 47 - intracr;mi;ll 45 -limb --lower 466 --upper 310 - subcutaneous -- cubital fossa 310 --limb ---upper 311,329 -- - lower 466, 485, 487 - superficial 45 --limb -- - lower 466, 485, 487 ---upper 311,329 -- trunkwall -- - anterior 170 -- - posterior 172 - trunk wall 164 - wall structure 46 veins of arm, subfasclal - anterior 329 - posterior 331 veins of spinal column 164 Vena cava - inferior see vena, cava, inferior - superior see vena, cava, superior Venous angle (Junction of jugular and subclavian veins)
- left 50, 166 - right 50, 166,313 Venous plexus of spinal column see Vertl!bral venous Venous valves 46 - Incompetence of 47 Venule 46 - postc.apillary 48 Vertl!bra 3 - structure 82 Vertl!bra - cervical 78 -lumbar 78 - promlnens 27, 29, 77, 78, 81, 84, 94,96 - - spinous process 77, 78, 81, 21 0 -- surface anatomy 173 -sacral 78 - thoracic 78 Vertebral arch see Arch, vertl!bral Vertebral body 3. 82, 84, 86 - cervical vertebra 84 - endplate 92, 93 -- osteochondrosis 1 05 --sclerotic 104 - LS 104 - lumbar vertebra 88 - nutrient vessels 80 - thoracic vertebra 86 Vertebral body anlage 80 Vertebral column see Spinal column Vertebrata 2 - characteristic features 3 Vertebrates (vertebrata) 2 -- characteristic features 3 Vertical axis 25 vesicle, cytoplasmic 49 Vesicle, seminal 194, 384 vessel(s) - afferent, of lymph node 51 -deep circumflex iliac 184 - efferent, of lymph node 51 -gluteal -- inferior 495 --- locating 494 -- superior 500 --- locating 494 - iliolumbar 176 - Inferior epigastric 184, 186 - Inferior rectal 200, 204 -internal thoracic 177,181 -lumbar 176 -lymphatic --deep 312 --Intercostal 166 -- superficial167, 312 - popliteal 500 -pudendal -- external 200 -- internal 200, 204, 483, 496, 498 -- locating 494 vestibular bulb 154, 202, 204 Vestibular glands see Glands, vestibular vestibule ofvaglna 154, 202, 205 - development 192 Vinculum -brevis 43,301,351 - longum 43, 301, 351 VIscera 22
Visceral ganglia, parasympathetic
72 -disease 57 Vitelline artl!ry 12 Vitelline circulation, extraembryonlc 12 VItelline veln(s) 12 - anastomotic network 13 - development 13 Volkmann canal 35 Voluntary skeletal muscles 40 von Hochstettertriangle 495 von Recklinghausen disease (neurofibromatosis) 57 vulva see Genitalia, female, externii!ll
w Waistline, asymmetrical 107 Watershed 167 Weber fractures 409 Weight gain, fetal 4 Whole-body center of gravity 25, 79,363 Wiberg, center-edge angle of 379, 389 - decreased 389 Wing - of Ilium 113, 365 - ofsacrum 90 Wolffian duct 192 Woven bone (tlber bone) 15 Wrist 18, 222 Wrist crease -distal 328 - proximal 328
X X chromosome 5 Xiphoid process 28, 34, 106, 1 08 -surface anatomy 171
y Y chromosome 5 Yolk sac 6.8 - vascular plexus 12
z Zero degree see Neutral-zero method Zona - orbicularis (annular ligament) 380 - pellucida 5 Zone of veslcularcartllage 14 Zygapophyseal joint 84, 86, 88, 96,100 - joint capsule 98, 100 Zygopodlum 18
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