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www.anatomedia.com
Credits About the authors
Acknowledgements
Department of Anatomy and Cell Biology, the University of Melbourne
Courseware Development Unit, the University of Melbourne
Department of Anatomy and Cell Biology, Monash University
St. Vincents Hospital, Melbourne
The Fiji School of Medicine, Fiji National University, College of Medicine, Nursing & Health Science
The Visible Human Project (National Library of Medicine) 16 figures have been used (with permission) Ch.: 1, 13, 14 & 25)
Contents
Preface
SECTION I: THE HUMAN BODY Page
Chapter 1: Human Anatomical Terms 3
Chapter 2: Human Form and Structure 6
Chapter 3: Human Sexual Characteristics 15
SECTION II: BODY SYSTEMS AND ORGAN STRUCTURE
Chapter 4: Skeletal System and Bones 19
Chapter 5: Articular System and Joints 29
Chapter 6: Muscular System and Muscles 41
Chapter 7: Integumental System and Skin 55
Chapter 8: Visceral Systems and Viscera 68
Chapter 9: Nervous System and Nerves 86
Chapter 10: Arterial System and Arteries 105
Chapter 11: Venous System and Veins 117
Chapter 12: Lymphatic System and Lymph Vessels 126
SECTION III: BODY REGIONS AND ORGAN POSITION
Chapter 13: Regions of the Body 135
Chapter 14: Arrangement of Body Regions 140
Chapter 15: Body Compartments and Fascial Planes 144
Chapter 16: Body Wall and Cavities 147
Chapter 17: Neurovascular Pathways 151
SECTION IV: HUMAN DEVELOPMENT AND VARIATION
Chapter 18: Growth and Development 157
Chapter 19: Normal Variation 162
Chapter 20: Anatomical Variation in Structure 166
Chapter 21: Anatomical Variation in Position 172
Chapter 22: Pathological Changes 177
SECTION V: PRACTICAL PERSPECTIVES
Chapter 23: Surface and Functional Anatomy 200
Chapter 24: Radiographic Anatomy and Imaging 200
Chapter 25: Sectional Anatomy, CT and MRI 200
Chapter 26: Ultrasound Imaging 200
Chapter 27: Endoscopic Anatomy 200
Chapter 28: Clinical Procedures 200
Chapter 29: Postmortem Examination of Organs 200
Chapter 30: Cadaver Dissection 200
Appendices
Glossary
Index
Annulus
i
Preface
ii
Section I
THE HUMAN BODY
Introduction: Anatomy accommodates ancestry'
1
Introduction: Anatomy accommodates ancestry
Kingdom: Animal
Superphylum: Coelomate
Phylum: Chordate
Subphylum: Vertebrate
Class: Mammal
Order: Primate
Family: Hominid
Genus: Homo
Species: Homo sapiens
2
Chapter 1: Human Anatomical Terms
TERMS OF RELATIONSHIP
TERMS OF COMPARISON
TERMS OF LATERALITY
TERMS OF MOVEMENT
TERMS OF COMPARISON
Alternative pairs of terms may be used when comparing
the position of structures, or even the same structure in
different species. Terms of comparison apply to any
position of the body without it necessarily being in the
anatomical position
Proximal (L. nearest) is closer to the origin of a part
while distal (L. distant) is further from the origin.
Superficial is closer to the skin while deep is further from
the skin. For a hollow structure, external (or outer) is
further from its cavity while internal (or inner) is closer.
Ventral (L. belly) is closer to the belly surface while
dorsal (L. back) is closer to the back surface. The dorsal
surface of the penis is in front of its ventral surface when
flaccid but behind it when erect. Fig.1.7 Surfaces of hand and foot
4
1. Human Anatomical Terms
TERMS OF LATERALITY
Paired structures on both right and left sides of the body Fig.1.11 Examples of special movements
are regarded as bilateral. Unpaired structures may be
midline or, if they are only on one side, unilateral. Other examples include movements of the foot (plantar
Ipsilateral refers to structures on the same side of the flexion and dorsi flexion as well as inversion and
body while contralateral refers to those on the opposite eversion) and of the scapula (protraction and retraction
side. as well as elevation and depression).
TERMS OF MOVEMENT
Movements at joints occur in pairs, each in an opposite
direction. Flexion (L. bend) is to bend, decreasing the
angle between two levers while extension (L. stretch) is
to straighten, increasing the angle. Abduction is to move
away from the midline while adduction is to move towards
it. Medial or internal rotation is to turn inward around the
long axis while lateral or external rotation is to turn
outward. This pair of movements tends to occur in the
transverse plane.
5
Chapter 2: Human Form and Structure
COELOMATE FEATURES
ANIMAL FEATURES A coelomate has a segmented body wall (allowing
greater movement) but a fluid-filled internal body cavity,
COELOMATE FEATURES termed a coelom (G: hollow) situated towards its ventral
aspect.
CHORDATE FEATURES
SEGMENTATION
POLARITY
VERTEBRATE FEATURES
MAMMALIAN FEATURES
PRIMATE FEATURES
HUMAN FEATURES
Germ Layers
The organism develops in three germ layers:
ectoderm, mesoderm and endoderm.
Ectoderm is exposed to the external environment and
also forms nerve cells.
Mesoderm develops into structures providing support
and splits to form the coelom around the gut and the lining
of the body wall. It also conveys and forms vessels.
Endoderm forms membranes for absorbing nutrients
and becomes continuous with ectoderm at openings to the
external environment.
CHORDATE FEATURES
Chordates (G. 'cord') have the following
characteristics, at least during some stage of development:
Fig.2.1 Mouse embryo at 5 weeks - a dorsal hollow nerve cord (neural tube)
Although humans have a particular form (external - a notochord and a tail
appearance) and structure (internal construction) all belong - pharyngeal pouches
to the animal kingdom, the coelomate superphylum and
the chordate phylum. We share characteristics of each of
these, particularly seen during embryonic development
(representing a record of preceding evolution).
ANIMAL FEATURES
An animal (L. 'breath') is a living organism capable of
independent movement.
Animals require an external energy source from
oxygen and organic foods (in contrast to plants producing
sugar via photosynthesis).
Animal cells are surrounded by a cell membrane
(rather than a rigid cell wall). Fig.2.3 A chordate
6
2. Human Form and Structure
Neural tube of ectoderm Other caudates (air breathers) develop lungs (from an
outpouching of the foregut) instead. In humans, a middle
A longitudinal midline thickening of ectoderm (termed
ear cavity develops from the first pharyngeal pouch with the
the neural plate) along the dorsum of the embryo forms a
tympanic (L. 'drum') membrane intervening between it and
groove. This neural groove has folds that meet and
the external auditory meatus derived from the first branchial
become buried as the neural tube. The brain develops from
cleft.
the expanded cranial end of the neural tube while the
spinal cord develops from its narrowed caudal part. The
cavity of the neural tube remains relatively wide throughout SEGMENTATION
most of the brain (as its ventricles) but becomes very
narrow in the spinal cord (as its central canal). Segmentation and polarity are important anatomical
features of all chordates, including humans. Blocks of
muscle termed myomeres (G. 'muscle parts') are arranged
segmentally along the body of a chordate. Although only
present briefly during human development, their derivatives
persist into adulthood. Segmentation is clearly manifested
along the trunk but modified in the head.
Somites
Segmentation along the trunk ('metamerism') is seen
in the embryo as mesoderm arranged in a paired series of
similar paraxial segments, termed somites (G. body).
Each somite subsequently develops into a sclerotome (G.
hard + cut) and a derma-myotome (G. skin + muscle
cut).
Notochord of mesoderm
The notochord (G. back + cord) is a mesoderm-
derived flexible rod, providing support. The nerve cord lying
dorsal to it is ectoderm-derived, while the gut tube ventral
to it is endoderm-derived. The notochord and the tail
disappear almost completely (the notochord remnant as the
nucleus pulposus of each intervertebral disc, the tail
remnant as the coccyx).
7
THE HUMAN BODY
8
2. Human Form and Structure
9
THE HUMAN BODY
The nerve supply to a muscle is retained even if the Fig.2.17 Foetus at 5 months with spinal cord exposed
muscle migrates during development.
The bony vertebral column (derived from mesoderm of
This also applies to both peripheral nerve supply and the sclerotome) replaces the notochord as the primary
segmental nerve supply of limb muscles. structural support. The notochord is incorporated as
gelatinous material (the nucleus pulposus) within each
Left-right axis intervertebral disc. In humans, the coccygeal vertebrae
regress and the tail disappears.
With establishment of polarity along the vertical axis,
there is also the development of the left-right axis, thought Four limbs with five digits
to be due to the beating of certain cilia (L. eyelashes) Vertebrates include fish and quadrupeds (L. four +
These hair-like mobile cellular projections direct a net footed) as well as humans. Except for fish, vertebrates
leftward flow of influential local fluid. The differential possess two pairs of jointed limbs attached to the vertebral
chemical concentration induces changes in left-right column via girdles (pectoral girdle to upper limb and pelvic
symmetry. A defect in ciliary motility may disrupt this girdle to lower limb, respectively).
process and even cause situs inversus, a rare anatomical
variation where the thoraco-abdominal viscera are in mirror Each limb develops with a principal bone proximally, a
image to normal. pair of long bones distal to it, then short bones and
five digits.
VERTEBRATE FEATURES
Although modified by development in other vertebrates
Humans are vertebrates. A vertebrate (L. 'jointed') is (e.g. birds, horses etc.) for specific roles, this pattern
characterised by the presence of a backbone (the vertebral remains in mature humans.
column or spine).
Spine, skull and skeleton
Vertebrates are also characterised by a skeleton (L.
'dried up') for protection, support and locomotion, including
a skull (housing the brain, derived from the expanded
cranial end of the neural tube). The head also has special
sense organs (associated with eyes, ears and a nose) and
teeth. Vertebrates have a heart pumping blood under
pressure into blood vessels. Lungs develop from a
diverticulum arising from the foregut in air breathers.
10
2. Human Form and Structure
Skin appendages, cheeks and lips Binocular vision and opposable thumb
Mammals are characterised by skin with appendages Primates are characterised by a large brain (within
(hair, sweat glands and sebaceous glands) and in surrounding skull), well-developed eyes (located at the
particular mammary glands (modified sweat glands that front of the head enabling binocular vision) and a short
produce milk). nose (reflecting less reliance on smell). There are 4 upper
Mammals also have muscular cheeks (for sucking) and and 4 lower incisor teeth (for biting).
lips. Primates are brachiators (L. arm) and are able to
grasp objects with their hands. They possess a clavicle,
Placenta enabling free movement of the upper limb. The limbs are
True placental mammals also develop within a uterus also freed from the body with no webs of skin between the
(L. womb) of the mother connected by an umbilical (L. hip and the shoulder. The five digits (which include a first
navel) cord to the foetus. digit that may be partially opposed to the other digits) also
The placenta (L. cake) is incorporated in the lining of possess nails (rather than claws). These features, coupled
the uterus. The umbilical vessels convey blood between with the greater brain and visual capacity, provide primates
the foetus and the placenta (until birth). with their hand/eye coordination.
Fig 2.19 Human foetus within uterus Fig.2.20 Foetal head and hand
Pulmonary and systemic circulations Less heat loss and long life stages
Mammals have a higher body temperature, being Primates tend to have an extended period of growth
warm-blooded, with a circulation pumped by a four- and development, primarily associated with their body size.
chambered heart. Large body size enables better conservation of energy and
This enables two vascular systems arranged in parallel: thermoregulation. Large primates, including humans, are
pulmonary (to and from the lungs) and systemic (to and characterised by greater longevity, duration of pre-natal life,
from the rest of the body). Within the trunk, a muscular lactation period (and interval between births) and age at
diaphragm is located between the thorax and the abdomen. maturity than small primates. They also have lower
metabolic needs, smaller litter size (with humans generally
Forebrain, mandible and ear ossicles producing only one offspring at a time) and only one pair of
Mammalian features include a forebrain (and cerebral nipples. Large male primates tend to have a pendulous
cortex), a lower jawbone (hinged at the penis (longest in mature human males).
temporomandibular joint) and teeth replaced a maximum of
once in a lifetime (if at all). Other bones associated with the HUMAN FEATURES
jaw are much reduced in size, creating the chain of three
linked middle ear ossicles (to conduct sound-derived Humans belong to the hominid (L. 'man form') family,
vibrations from tympanic membrane to the inner ear) the homo (L. 'man') genus and sapiens (L. 'wise man')
species.
PRIMATE FEATURES
The most distinctive human characteristic is the
Humans are primates. A primate (L. 'first') is able to habitual adoption of upright stance and locomotion
grasp objects. based solely on the two lower (hind) limbs.
11
THE HUMAN BODY
12
2. Human Form and Structure
It continues through the S-shaped vertebral column It is no accident that the most commonly disrupted
behind the centres of the cervical and lumbar spine and in intervertebral disc is the lumbosacral disc and the most
front of the centres of the thoracic and sacral spine. It then common vertebra to sustain a stress fracture is the fifth
passes behind the centre of the hip joints and in front of the lumbar.
centre of each of the knee and ankle joints.
While standing (with hips and knees extended and BIPEDAL LOCOMOTION
ankles dorsi-flexed) the weight bearing joints are in the
position of maximal stability. Articular surfaces are apposed In contrast to standing where muscular effort is
and associated ligaments taut (to conserve muscular conserved, bipedal locomotion enlists the actions of
effort). Minimal skeletal muscle tone is therefore required to many muscles.
maintain upright posture, other than to correct for body Walking on level ground involves cycles (between heel-
sway. strike of the same foot) of swing (limb not in contact with
the ground) phase and stance (weight bearing) phase.
Muscles not only act to accelerate the swinging lower limb
(from the beginning of swing phase to mid-swing), but also
to decelerate it (from mid-swing to the end of swing phase).
13
THE HUMAN BODY
SPEECH VIA A LENGTHENED PHARYNX An important modification to the swallow reflex is that
during swallowing breathing is stopped.
Another distinctly human characteristic is speech by Protective reflexes involving muscles (and associated
sounds formed into words. This confers the advantage of nerves) of the branchial arches have saved us from literally
using the voice to communicate ideas (via strings of words) choking on our own words.
but comes at a price. The larynx, the organ of phonation
(G. 'voice') consists of cartilages housing the vocal cords
together with special muscles controlling vocal cord
vibration. In order to prolong movement of an air column
through the mouth, where sounds (particularly vowels) can
be shaped for speech, a sufficient length of airway is
required between the larynx and the mouth.
14
Chapter 3: Human Sexual Characteristics
FEMALE
A genetic female is characterised by the absence of a
Y chromosome. There are normally two X chromosomes.
16
Section II
BODY SYSTEMS AND ORGAN STRUCTURE
17
Introduction: Structure mirrors function
Organ structure 1.
The unit or building block of anatomy is termed an
anatomical structure (L. build) or organ (G. tool).
Organs are made up of tissues, which in turn, are made up
of cells.
There are four tissue types (see diagram):
1. epithelial
2. connective
3. muscular
4. nervous
Somatic systems:
- skeletal system
- articular system
- muscular system
- integumental system
Visceral systems:
- respiratory system
- digestive system
- urinary and male genital systems
- endocrine and female genital systems
Supply systems: 4.
- nervous system
- arterial system
- venous system
- lymphatic and haemopoietic systems
18
Chapter 4: Skeletal System and Bones
SKELETAL SYSTEM
The skeletal system is made up of bones and
cartilages. In an adult there are approximately 206 bones.
However, the number may vary due to the presence of
accessory bones (anatomical variants created by bony
parts that have separated to become discrete bones). At
different stages of development cartilage (and membrane)
precursors are converted to bone.
19
BODY SYSTEMS AND ORGAN STRUCTURE
Fig.4.4 Trabeculae along stress lines Fig.4.6 Upper end of an embalmed femur.
20
4. Skeletal System and Bones
Bony markings
An end of a long bone may include a head with a neck
(between the head and the shaft). A short or flat bone may
also have a head with a neck (between the head and the
body).
Markings may be classified into four groups:
elevations, facets, depressions and holes. An elevation
may be a line, a crest, a spine (L: thorn), a process, a
condyle (G. knuckle), a tubercle, a tuberosity or a
trochanter. A facet (Fr. little face) is a smooth, flat area.
A depression may be a fossa (L. ditch), a fovea (L. pit),
a groove or sulcus (L. furrow) or a notch. A hole may be
a foramen (L. bore), a fissure, a meatus (L. passage), a
canal or a hiatus (L. aperture).
21
BODY SYSTEMS AND ORGAN STRUCTURE
Elastic cartilage
Elastic cartilage contains bundles of elastic fibres
providing flexibility. It forms discrete structures in the
external ear, auditory tube and parts of the larynx.
Fibrocartilage
Fibrocartilage is a mixture of fibrous tissue and hyaline
cartilage. It forms special structures in joints (disc, Fig.4.10 Primary centres in a 12 week foetus
meniscus, labrum) that can withstand prolonged
pressure, contribute to articular surfaces and act as shock A bones blood supply develops during the
absorbers. Fibrocartilage is not glassy in appearance due transformation of cartilage to bone. Blood vessels (from the
to the vastly increased numbers of collagen fibres arranged nutrient artery and vein) invade the primary centre
in irregular bundles. together with cells that subsequently form bone
Except for around the periphery where pressure is (osteoblasts).
minimal, fibrocartilage is avascular and aneural.
Chondrocytes in fibrocartilage receive their nutrition via Unlike cartilage, bone requires a blood supply, as the
diffusion through the matrix. calcified matrix does not allow diffusion.
22
4. Skeletal System and Bones
23
BODY SYSTEMS AND ORGAN STRUCTURE
24
4. Skeletal System and Bones
Nutrient arteries
The major artery supplying a long bone is termed the
nutrient artery. This artery occupies a passage (termed
the nutrient foramen) penetrating the shaft of the bone
through to the medullary cavity. The canal of nutrient
foramen (when viewed from its outside opening) is directed
away from the growing end. Differential longitudinal growth
results in the nutrient artery taking an oblique path (from
outside to inside) through the full thickness of the bone
Fig.4.18 Growth of a long bone while the bone is still growing (unequally). Equal growth
The more time an epiphysis (and associated epiphysial would have resulted in the artery penetrating perpendicular
plate) exists the greater the opportunity for growth in length to the shaft.
at that site. No further longitudinal growth occurs after
epiphysial fusion (with disappearance of the epiphysial
plate).
Epiphysial judgement
The appearance of primary centres of ossification in the
distal femur and proximal tibia is of medico-legal
importance in determination of maturity and interpretation Fig.4.20 Orientation of nutrient foramen to growing end
of radiographic imaging.
Most lower limb growth in length occurs near the knee, Epiphysial damage
as these associated epiphyses also the last to fuse. In children and adolescents, injury to an epiphysis or a
Most upper limb growth in length occurs near the ends fracture extending through the epiphysial plate carries
of the long bones at the shoulder and wrist. The first special significance.
epiphyses to fuse are at the elbow.
25
BODY SYSTEMS AND ORGAN STRUCTURE
26
4. Skeletal System and Bones
Vascular circle
The arteries supplying the ends of a mature long bone
arise from a vascular circle, (circulus vasculosus),
derived from articular branches of arteries to the
associated joint.
Fractures
A broken bone is termed a fracture (L. break). A
fracture may be associated with stripping and/ or tearing of
the periosteum (particularly if there is displacement of the
bone ends). There is typically swelling from bleeding due to
the rich blood supply (particularly of bone tissue and
marrow). It is accompanied by severe pain due to the rich
sensory nerve supply (particularly of periosteum).
Fractures occur commonly in children.
Fracture healing
Bone receives a rich blood supply creating much
bleeding at the time of injury.
Vascularity enables numerous vessels to invade the
Fig.4.26 Anastomoses after epiphysial fusion fracture site during repair. This occurs within the mass of
connective tissue (termed callus) as a result of periosteal
The branches of articular arteries that correspond to and endosteal proliferation. New bone is formed within the
epiphysial and metaphysial arteries are able to link callus then subsequently remodelled. Uncomplicated
(anastomose) with each other because the intervening fractures therefore tend to heal well, provided the bone
(avascular) hyaline cartilage of the growth plate has ends are correctly aligned and immobilised for an
disappeared with epiphysial fusion. appropriate length of time.
27
BODY SYSTEMS AND ORGAN STRUCTURE
28
Chapter 5: Articular System and Joints
SYNOVIAL JOINTS
FIBROUS CAPSULE
LIGAMENTS
ARTICULAR SYSTEM
The articular system is made up of joints including
associated ligaments. Bones and/or cartilages meet at
joints.
Fig 5.1 Modules of an articulated adult skeleton Fig.5.3 Fibrous and cartilaginous joints
29
BODY SYSTEMS AND ORGAN STRUCTURE
Fibrous joints
In fibrous joints (suture, syndesmosis and
gomphosis), bones are bridged by fibrous tissue. The
periosteum of each bone forming the articulation is
continuous with the fibrous tissue of the joint.
30
5. Articular System and Joints
31
BODY SYSTEMS AND ORGAN STRUCTURE
32
5. Articular System and Joints
The elbow joint capsule permits rotation of the radius by Synovial membrane
merging with the annular ligament of the proximal
Synovial membrane is a serous membrane. It consists
radioulnar joint (instead of attaching to the radius).
of a layer of flattened cells (mesothelium) on a thin bed of
Although loose enough to allow sufficient mobility, the
loose connective tissue that is highly vascular and can be
fibrous capsule becomes taut on stretch and contributes to
thrown into folds or fringes.
stability.
Migration of capsule from epiphysial plate Synovial membrane lines the internal surface of the
capsule and all non-articular structures on the interior
With long bones, the capsule is initially attached to the of a synovial joint.
periphery of the epiphysial plate then migrates (usually
towards, but occasionally away from, the articular margin). Synovial membrane is delicate and does not extend
over the articular cartilage (where it would be damaged).
At sites where the capsule does not attach to the
articular margin, synovial membrane is reflected onto bone
(covering periosteum between the capsular margin and the
articular margin).
Synovial fluid
The volume of a synovial cavity is normally very small
(less than 1ml, even in a large joint). The synovial
membrane secretes fluid into the joint cavity thus providing
nutrition for the articular cartilage. Synovial (L. with + egg
i.e. consistency of egg white) fluid acts as an adaptable
lubricant for the articular cartilage. Its viscosity decreases
with increased loading minimising friction (because the
contained muco-polysaccharide hyaluronic acid can
change its configuration accordingly). A film of synovial
fluid lies between apposed articular cartilage surfaces,
particularly during movement.
Synovial effusion
Synovial membrane has a rich blood supply derived
from articular arteries (via branches from the vascular
circle, around the capsular attachment).
Irritation of the delicate synovial membrane (e.g. by
mild, repetitive trauma) results in an increased blood supply
to it (due to vessels dilating) and a subsequent increase in
secretion of synovial fluid. An accumulation of synovial fluid
is termed a synovial effusion. It produces (often visible)
swelling of the joint (particularly where it is least
Fig.5.14 The interior of a synovial joint supported). Tissue resistance limits the degree of effusion.
33
BODY SYSTEMS AND ORGAN STRUCTURE
LIGAMENTS
Ligaments (L. bind) are fibrous connections between
bones. The vast majority of ligaments are primarily
composed of collagen fibres (for tensile strength), which
blend with the fibrous covering (periosteum) of the bones
taking part in a joint.
Elastic ligaments
Fig.5.17 Ligaments of the elbow complex
Some special ligaments, termed elastic ligaments,
contain large numbers of (yellow) elastic fibres. Being able Uniaxial joints enable no other (pairs of) normal
to stretch (and recoil) they are less susceptible to injury. movements. Modified hinge joints (e.g. knee) permit some
They have a poor nerve supply (as pain fibres would rotation when collateral ligaments become slack during
otherwise be triggered by stretch). Ligamenta flava (L. flexion. This slackness is facilitated by the ligaments being
yellow) of the vertebral column are elastic ligaments. situated eccentrically (i.e. not perpendicular to the axis of
movement during the entire range of flexion).
Intrinsic and extrinsic ligaments
The majority of ligaments are intrinsic ligaments. Accessory ligaments
Intrinsic ligaments are thickenings of the fibrous capsule of Accessory ligaments are extrinsic ligaments of a joint
a synovial joint. Their primary role is to reinforce the that are located at a distance from it. Although structurally
capsule. Extrinsic ligaments are separate from the separate, they function with the associated joint.
34
5. Articular System and Joints
Intracapsular tendon
Fig.5.23 Special structures of knee joint Tendons attaching to a bony area between the articular
margin and the periphery of the capsule occur in two major
Labrum joints (shoulder and knee). The associated muscles (long
A labrum (L. lip) deepens the socket of a ball and head of biceps and popliteus) by the location of their
socket joint (e.g. hip and shoulder). A labrum is made of tendon, contribute to shoulder stability or enable rotation
fibrocartilage. Being articular it is not covered by synovial that unlocks the knee joint, respectively.
membrane and is avascular (receiving its nutrition from the An intracapsular tendon leaves a joint through a
synovial fluid). defect in the fibrous capsule. The tendon is covered by
synovial membrane throughout its intracapsular course.
Disc and menisci
Bursae
A complete disc subdivides a synovial cavity (e.g.
temporomandibular and sternoclavicular) while menisci (L. A bursa (L. purse) is a double fold of serous
little half-moons) partially subdivide a synovial cavity (e.g. membrane (containing a small amount of fluid) interposed
knee). between structures that rub together (e.g. skin, bone,
ligament, tendon) reducing friction.
Discs or menisci create compartments, allowing
different movements to occur simultaneously on each Bursae tend to be more numerous at joints with greater
side of the partition. mobility.
36
5. Articular System and Joints
Pairs of movements
The shape of the articular surfaces primarily determines
Fig.5.26 Olecranon bursitis ('student's elbow') the type of movements allowed.
These movements may be gliding (at plane joints) or
Joint cavity communication pairs of movements (one pair at uni-axial joints, two pairs at
Infection introduced into a bursa that communicates bi-axial and three pairs at multi-axial joints).
with a synovial cavity may easily spread directly by the The most common pairs of movements are flexion/
synovial fluid into the joint and lead to septic arthritis. extension, abduction/ adduction, and medial rotation/
lateral rotation. Other specific pairs of movement include
plantar flexion/ dorsiflexion (at the ankle joint), inversion/
eversion (of the foot) and pronation/ supination (of the
forearm).
37
BODY SYSTEMS AND ORGAN STRUCTURE
The factors responsible for stability (and limiting tendons blend with the capsule to form a cuff and act as
mobility) are classified as bony, ligamentous and dynamic ligaments.
muscular. These factors are involved to varying degrees This arrangement helps compress the ball against its
for different joints. socket, without limiting mobility (unlike ligaments).
Close-packed position
The position of maximal stability is termed the close-
packed position. Articular surfaces (and articular
cartilages) are most apposed and the majority of ligaments
are maximally taut (including the capsule, which may spiral
and tighten). This is also the position of least volume in the
synovial cavity (and most discomfort, if there is a synovial
effusion).
All other positions of a joint are loose-packed,
allowing normal movement to take place (but with greater
potential for unwanted movement). Articular surfaces will
not be fully apposed and, in multi-axial joints, not all
ligaments will be taut.
38
5. Articular System and Joints
39
BODY SYSTEMS AND ORGAN STRUCTURE
Articular vessels
The major artery of a limb tends to give branches as it
passes near a joint. The branches link with each other
(anastomose) particularly within the surrounding muscles,
to ensure adequate blood supply. They form alternative
pathways when the artery is kinked (e.g. by flexion at the
joint).
40
Chapter 6: Muscular System and Muscles
MUSCULAR SYSTEM
MUSCULAR SYSTEM
Fig.6.2 Major groups of skeletal muscles
The muscular system is made up of skeletal muscles
together with associated structures. These are
condensations of fibrous tissue (including tendons and MUSCLE STRUCTURE AND ATTACHMENTS
fibrous tendon sheaths) as well as synovial tendon
sheaths.
Types of muscle
The other types of muscle are smooth muscle and Muscle (L. mouse) is the active producer of movement.
cardiac muscle. The former is found throughout the visceral There are three types of muscle: skeletal, smooth and
and vascular systems in the wall of a tubular viscus or cardiac.
blood vessel. The latter is found only in the walls of the Skeletal muscle typically moves bones and is capable
heart. of voluntary movement. It is composed of large striated
Muscles are arranged in groups that tend to share a muscle fibres, which are dependent on a (somatic) motor
common fascial compartment and produce a common nerve supply to generate contraction. Each fibre is a
action. discrete unit.
Muscles are typically paired, except for those in the The strength of skeletal muscle contraction is
midline. proportional to the number of fibres recruited.
41
BODY SYSTEMS AND ORGAN STRUCTURE
Smooth muscle forms the walls of blood vessels and A muscle may consist of more than one part. Adductor
hollow viscera. It is composed of small non-striated magnus has adductor and hamstring parts originating
muscle fibres that function as a collective unit in separately (from the pubis and ischium of the hip bone,
contributing to regulation of the bodys internal respectively) and inserting separately (on the femur).
environment. Smooth muscle is under autonomic nervous These parts act as discrete functional units that even
control. receive a different nerve supply, reflecting their
Cardiac muscle forms the walls of the heart. The atria development from different compartments
and the ventricles are composed of striated muscle fibres
that function as a collective unit. Cardiac muscle contracts
automatically and rhythmically to pump blood around the
body.
42
6. Muscular System and Muscles
43
BODY SYSTEMS AND ORGAN STRUCTURE
44
6. Muscular System and Muscles
45
BODY SYSTEMS AND ORGAN STRUCTURE
Fascial septa
A fascial septum (L. partition) is an extension of dense
connective tissue that separates structure(s) from each
other. Fascial septa typically form a perpendicular
Fig.6.20 Compartments for muscles with a common action
connection between deep fascia and periosteum (at these
junctions the collagen fibres blend). Fascial septa also bind Fascial sheets
down skin to underlying deep fascia (e.g. in the palms,
soles and scalp) or aponeurosis. Deep fascia is generally in the form of a single sheet
although occasionally it is in two parallel or concentric
sheets (allowing mobility between them). It typically forms
the roof of a compartment for muscles.
Additional sheets of fascia may be located between
muscle layers within a fascial compartment (e.g. in the
posterior compartment of the calf).
46
6. Muscular System and Muscles
47
BODY SYSTEMS AND ORGAN STRUCTURE
A small amount of fluid is secreted into the potential Effect of mesotendon injury
space between the two layers of the pouch minimising
Damage to the mesotendons, by interruption of blood
friction (when the tendon glides back and forth within its
supply, may lead to tissue death and subsequent rupture of
overlying sheath during movements). A synovial sheath
the tendon.
develops from a single layered pouch that becomes
invaginated (L. in + sheath) by the tendon. The serous
membrane forming the connecting stalk between the lining
of the fibrous sheath and the reflection onto the tendon
breaks down (except at a few sites along the synovial
sheath).
Tenosynovitis
Irritation (e.g. by unaccustomed or repetitive movement)
or infection of synovial tendon sheaths may result in
inflammation (tenosynovitis) with accumulation of fluid or
pus. Inflammation of the tendon sheath may also be
associated with inflammation of the tendon (tendinitis) or
of its fibrous tendon sheath (tenovaginitis).
Mesotendons
Small remnants of the connecting stalk that existed
between the two layers of a synovial sheath convey blood
vessels. These remnants are termed mesotendons (L.
middle + tendons).
Fig.6.27 Blood supply to a tendon Fig.6.29 Third order levers (for range and speed)
48
6. Muscular System and Muscles
Muscle form
The form of a skeletal muscle is determined by the
arrangement of its fibres.
49
BODY SYSTEMS AND ORGAN STRUCTURE
Some muscles have long parallel fibres (e.g. strap and There is a trade-off between degree of shortening and
fusiform muscles) while others have obliquely oriented strength of contraction. Muscles with long parallel fibres
fibres. Pennate (L. feather) muscles contain obliquely tend not to have as great a cross-sectional area as those
oriented fibres. These may attach on one side of the with intramuscular tendons. Pennate muscles can fit more
tendon (uni-pennate), both sides of it (bi-pennate) or be muscle fibres in the belly (to produce greatest cross-
packed around a series of intramuscular tendons sectional area). This is most pronounced in multipennate
(multipennate). muscles. They tend to be packed with muscle fibres to
enable the strongest contractions.
Length and orientation of fibres
Under normal conditions a muscle fibre cannot shorten Strength is proportional to the cross-sectional area of
passively. During contraction an individual muscle fibre is the muscle.
capable of shortening up to about half of its resting length.
Assessment of muscle function
Muscle function may be tested using active range or
resisted contraction. A movement at a joint is active when
it is directly due to contraction of its associated muscles.
Active movements may also be assisted (active
assistance) or resisted (active resistance) by an external
agent. In clinical assessment of muscle function, the active
range of movement (associated with muscle contraction) is
compared to the passive range (allowed by joint mobility),
to determine which structures may limit movement (or
produce pain).
Muscle strength is gauged by the degree of active
resistance required to prevent movement.
Fig.6.35 Strength and cross-sectional area Fig.6.36 Isometric and eccentric contractions
50
6. Muscular System and Muscles
Active insufficiency
Even a normal muscle will produce a weak contraction
if there is insufficient overlap of its myofilaments. This is
termed active insufficiency.
Profound weakening of contraction occurs when it is
attempted from an excessively shortened position of the
prime mover.
Passive insufficiency
The prime mover action is restricted when an
antagonist is unable to relax or to stretch sufficiently from
lack of flexibility. This is termed passive insufficiency.
Fig.6.37 Muscles crossing 2 joints can generate extra force
This is due to maximal overlap of the contractile units
(myofilaments). However, stretching beyond this point
prior to contraction leads to a weaker contraction (tension
is reduced, as the myofilaments are too far apart).
51
BODY SYSTEMS AND ORGAN STRUCTURE
Synergists as balancers
Excessive shortening of a prime mover may occur if the
muscle crosses more than one joint because it tends to
exert an unwanted action on the proximal joint. This
undermines the desired effect at the distal joint. A prime
mover crossing more than one joint enlists the support of
synergists (G. with + work) that oppose the movement at
the proximal joint(s). Synergists augment contraction by
keeping the prime mover on stretch.
Motor unit
A muscular branch of a peripheral nerve contains both
somatic motor and sensory nerve fibres. Each skeletal
muscle fibre receives an independent supply from a branch
of a motor nerve fibre.
52
6. Muscular System and Muscles
Sensory nerve fibres to muscles It is made up of two parts: an adductor part, supplied by
the nerve of the medial compartment (obturator nerve) and
Almost half of the nerve fibres to a skeletal muscle are
a hamstring part, supplied by the nerve of the posterior
sensory. Proprioceptive (L. ones own receiver; i.e. from
compartment (sciatic nerve).
internal rather than external receptors) fibres arise primarily
from stretch receptors and are particularly important in the
(unconscious) control of posture.
Stretching a muscle (or its tendon) beyond a threshold
stimulates a reflex contraction of the associated muscle
fibres (via a circuit involving sensory nerve fibres, the spinal
cord and motor nerve fibres).
Muscles also receive a supply of pain fibres.
Adductor magnus is located in the medial compartment These are generally distributed via a single peripheral
of the thigh but it also forms the floor of the posterior nerve (although the nerve may contain fibres from
compartment. additional segments, to supply other muscles).
53
BODY SYSTEMS AND ORGAN STRUCTURE
Muscles in the same group share a common action and Vascular territories and networks
tend to receive their nerve supply from the same spinal
Many blood vessels and anastomoses (links between
cord segments.
blood vessels) are found throughout muscles (whereas
Flexor musculature for a particular limb joint usually
tendons have a poor supply).
receives two segments while extensor musculature
receives the next two in series. Thus a total of 4 segments
The majority of anastomoses in the body are via
are associated with a joint (although a segment may be
skeletal muscles.
involved in more than one joint).
54
Chapter 7: Integumental System and Skin
Dermis
Roles of skin
The major roles of skin are protection, sensation and
thermoregulation. Skin provides a mechanical barrier as
well as protection from microbe invasion and fluid loss.
Skin may also be regarded as a sense organ, due to its
contact with the external environment coupled with a rich Fig.7.4 Dermis and its contents
nerve supply.
55
BODY SYSTEMS AND ORGAN STRUCTURES
The dermis contains collagen fibres and elastic fibres. The relaxed skin tension lines (of Kraissl) are different
Loss of elasticity with aging results in wrinkles. Damage to to the skin cleavage lines (of Langer). The latter are the
collagen fibres (e.g. in skin of anterior abdominal wall from lines along which dead skin tends to split in cadavers with a
pregnancy) may result in stretch marks (termed striae). sharp spike.
Folds termed dermal papillae (L. nipples) project
upward under the epidermis, increasing the surface area
for attachment and for diffusion between the vascular
dermis and the avascular epidermis.
The dermis may be subdivided into two merging layers.
The papillary layer adheres to the epidermis, while the
reticular layer, with thicker elastic fibres and bundles of
collagen, adheres to the subcutaneous tissue.
SKIN APPENDAGES AND SPECIALISATIONS Sweat glands are particularly abundant in the palms
and soles. They are absent from nail beds, lips, nipples and
Skin consists of more than connective tissue, vessels eardrums. Odoriferous glands (modified sweat glands) are
and nerves. Additional skin structures are termed skin located in the skin of the armpits, genitals and around the
appendages. anus. Ceruminous (L. wax) glands are present in the
external auditory meatus. Mammary (L. breast) glands
Pilosebaceous units are also modified sweat glands.
Pilosebaceous (L: hair + grease) units are made up
of hairs and hair follicles together with their associated Regeneration of skin after burns
sebaceous glands and muscles. Hair follicles (L. small Skin may regenerate from its appendages provided at
bags) are located in the dermis. Hairs project from hair least some fragments remain.
follicles through the epidermis to the exterior. In severe burns involving the dermis regeneration may
occur from the bases of deeply located sweat glands.
Thick skin
Skin covering all of the body, except for the palms and
soles, is termed thin (hairy) skin. Thick (hairless) skin is
located on the palms and soles, where the epidermis is
greatly thickened (particularly its outermost layer).
Thick skin is strongly bound down to underlying dense
connective tissue (improving grip).
58
7. Integumental System and Skin
59
BODY SYSTEMS AND ORGAN STRUCTURES
Cutaneous sensory nerve fibres arise from numerous A lesion of a single peripheral nerve may produce only
receptors almost exclusively located in the dermis. These a small area of complete cutaneous sensory loss, or none
may be classified as mechanoreceptors (touch and at all.
pressure), nocioceptors (pain) and thermoreceptors (hot
and cold). Overlap for pain and temperature is more extensive
than that for touch.
Vasomotor, sudomotor and pilomotor fibres
Even though there are no visceral organs (visible to the Internervous lines
naked eye) in the skin there are microscopic collections of An inter-nervous line is an imaginary line of non-
visceral tissue (smooth muscle and glands). overlap between adjacent territories supplied by particular
peripheral nerves. Inter-nervous lines on the skin are
located where cutaneous nerve branches do not enter
adjacent territories. The major inter-nervous line of the
body is along the midline (the major line of fusion during
development).
60
7. Integumental System and Skin
Therefore, more than one peripheral nerve may need to in the anatomical position, with flexor compartments
be blocked to ensure an adequate area of anaesthesia. For posteriorly and extensor compartments anteriorly.
example, intercostal nerve blocks should also include the
nerve above as well as the nerve below the targeted nerve
involved.
61
BODY SYSTEMS AND ORGAN STRUCTURES
(of non-overlap) along the limbs where dermatomes from Distribution of referred pain
non-consecutive spinal cord segments lie adjacent to each
Referred pain is pain that is experienced at a site
other. This map is preferred for assessing sensory loss.
different from its source. Pain is typically mapped on the
body surface (which has a topographical representation on
the cerebral cortex). There is no map drawn so far, for the
interior of the body (including its contained viscera).
Pain from skin (superficial somatic pain) is sharp and
particularly well localised (providing accurate information
regarding the surface of the body). Pain from deep
structures is both of a different quality and location.
Fig.7.39 Rash in shingles of a thoracic spinal nerve Fig.7.41 Structures sharing spinal cord segments
63
BODY SYSTEMS AND ORGAN STRUCTURES
64
7. Integumental System and Skin
Vascular planes
Arteries travel with connective tissue via fascial planes
particularly associated with muscles.
65
BODY SYSTEMS AND ORGAN STRUCTURES
Communications via choke vessels Lymph vessels passing to a lymph node are termed
afferent lymphatics. Although very numerous in
Adjacent source arteries and their branches are linked
subcutaneous tissue they are normally not visible because
together, forming a continuous network. Some meet as
they are thin-walled and contain colourless lymph.
large calibre anastomoses between arteries. However,
most adjacent arteriosomes communicate via small calibre Lymphangitis
anastomoses between arterioles, termed choke vessels.
Inflammation of lymphatics (lymphangitis) in the
Adjacent angiosomes meet at each connective tissue layer
(skin, fat, muscle, bone and even fibrous nerve sheaths) subcutaneous tissue (e.g. due to infection) may cause red
via choke vessels and communications between oscillating streaks along the overlying skin.
veins. The boundary of an angiosome typically passes Lymph node groups draining skin
across a muscle.
Ultimately lymph is returned to the venous system.
The vast majority of muscles are part of more than one
Lymph from the skin passes through at least one set of
angiosome.
lymph nodes before reaching the venous system.
Lymphotomes
The cutaneous lymph drainage may be mapped into
territories that drain to the first group of lymph nodes
encountered.
Fig.7.48 Lymph capillary plexuses in the dermis The area of skin that drains to a particular lymph node
group is termed a lymphotome.
These networks are arranged in superficial and deep
plexuses adjacent to the epidermis and the subcutaneous
tissue, respectively (accompanying the associated
superficial and deep dermal plexuses of blood vessels).
66
7. Integumental System and Skin
Fig.7.51 A watershed
Extensive overlap of lymph drainage occurs across
adjacent lymphotomes due to the presence of numerous
communicating networks of lymph capillaries. These zones
of overlap are termed watershed areas. A watershed area
of lymph drainage is of particular significance as lymph
may drain in more than one direction from it. Fig.7.53 Horizontal watersheds
67
Chapter 8: Visceral Systems and Viscera
VISCERAL SYSTEMS
Viscera (L. sticky) have a variety of structures and
functions. Collectively they are responsible for regulating
the internal environment of the body. Viscera occupy
cavities within the body framework and are involved with
secretion, excretion, digestion and absorption.
Viscera are either hollow or solid. They are typically
organised into systems comprising a tract of hollow tubes
with associated solid glands.
Respiratory system
Fig.8.2 Digestive system
68
8. Visceral Systems and Viscera
69
BODY SYSTEMS AND ORGAN STRUCTURE
70
8. Visceral Systems and Viscera
Structures directly related to an organ tend to produce Fig.8.14 Narrowest part of duct at orifice
grooves or impressions on it. Types of duct obstruction
The aorta grooves the left lung and the azygos vein The major ducts from exocrine glands may also be
grooves the right lung. Although the lungs contain air, their regarded as tubular viscera. Obstruction of a duct (as with
external form is similar to a solid viscus. Their internal a tubular viscus) may be classified anatomically into three
structure resembles an exocrine gland with air conveyed types. Extramural (external) obstruction is from outside
via duct-like bronchi rather than secretions filling ducts. compression of a duct (e.g. by a tumour in a neighbouring
structure). Intramural obstruction arises from the wall of a
Ducts duct (e.g. by a fibrous stricture following inflammation).
Glands secreting into a duct are termed exocrine (L. Intraluminal (internal) obstruction is from a blockage within
outside + secrete). a duct (e.g. by a calculus).
71
BODY SYSTEMS AND ORGAN STRUCTURE
Fig.8.20 Migration of gut away from midline Fig.8.22 Nerve supply of gut and pain referral
73
BODY SYSTEMS AND ORGAN STRUCTURE
Both sensory and motor nerve fibres overlap The parietal (G. wall) layer of a serous membrane
extensively across the wall of an unpaired viscus. lines the interior of the body wall and receives its nerve and
vascular supply via the body wall (i.e. by somatic nerves
Pain from an unpaired viscus is felt over the midline of and parietal vessels).
the body as impulses are simultaneously received by The visceral layer covers the viscera (as the serosa)
the left and by the right side of the spinal cord. and receives the same nerve and vascular supply as the
viscera (i.e. by visceral nerves and vessels).
Pain from the small intestine is referred to the umbilical During development, viscera (with their neurovascular
region; pain from the uterus is referred to the suprapubic supply lines) invaginate the serous sac of a body cavity.
region.
Mesenteries
The parietal layer of a serous membrane is continuous
with the visceral layer via connecting roots to the viscera.
These are termed mesenteries (G. middle intestine - an
intermediary structure).
A mesentery consists of two sheets of serous
membrane with loose connective tissue (containing a
variable amount of fat) between them. The sheets of
serous membrane of the mesentery become continuous
with the parietal layer of serous membrane at the parietal
attachment of the mesentery (adjacent to the body wall).
Roles of a mesentery
A mesentery has two major roles. A mesentery
(particularly a long mesentery) provides an attachment
enabling mobility. A mesentery also contains the supply
lines. Vessels and nerves are transmitted in the connective
tissue between the two sheets of serous membrane
Fig.8.24 Visceral and parietal layers of a serous membrane forming the mesentery.
74
8. Visceral Systems and Viscera
75
BODY SYSTEMS AND ORGAN STRUCTURE
During subsequent development the dorsal mesentery The testis, being suspended in the scrotum by a long
fuses with the parietal peritoneum at particular sites vascular stalk, is particularly prone to torsion of its blood
(duodenum, ascending colon, descending colon and vessels.
rectum) while it is retained at others (stomach, small
intestine, transverse colon and pelvic colon). The former
become retroperitoneal while the latter remain
intraperitoneal.
Torsion of a viscus
A viscus suspended on a mesentery (e.g. intestine) is
in potential danger of twisting (torsion). This may
subsequently cut off its blood supply.
76
8. Visceral Systems and Viscera
77
BODY SYSTEMS AND ORGAN STRUCTURE
Fig.8.42 Sphincters at external orifices on perineum Fig.8.44 Functional sphincter for gall bladder
Both voluntary and involuntary sphincters are present Functional sphincters at orifices
near the external orifice of the anal canal, vagina and
urethra as a dual safeguard against unwanted passage
(from either direction).
78
8. Visceral Systems and Viscera
Epithelium and lamina propria where no sensory nerve overlap occurs across the midline
(creating an inter-nervous line of non-overlap).
The mucous membrane (mucosa) consists of
epithelium covering a vascular connective tissue layer
termed the lamina propria (L. plate + special).
79
BODY SYSTEMS AND ORGAN STRUCTURE
Epithelial interfaces
80
8. Visceral Systems and Viscera
Neural and vascular interfaces Fig.8.56 Anal sphincters and their innervation
Arterial anastomoses, venous communications, There is a corresponding change of underlying motor
watershed areas of lymph drainage and inter-nervous supply.
lines (of sensory nerve supply) occur at
mucocutaneous junctions. Visceral nerves supply smooth muscle sphincters,
while somatic nerves supply skeletal muscle
These vascular, lymph and nervous interfaces are sphincters.
located in the connective tissue underlying the epithelium,
at the transition between lamina propria and dermis. The internal anal sphincter is supplied by sympathetic
The vascular interfaces are broad bands of overlap. nerves while the external anal sphincters are supplied by
The sensory nerve interface is typically a line of non- the inferior rectal nerve).
overlap. The dentate line overlies the centre of a zone of
arterial anastomosis (between branches of the unpaired Transmucosal junctions
superior rectal artery, above and paired inferior rectal Junction zones also occur between different mucosal
arteries, below), venous communication (between territories. Transmucosal junctions involve epithelial
tributaries accompanying the arteries) and lymphatic and/or neurovascular interfaces. They may also be
communication (between vessels draining to internal lymph associated with muscular interfaces. A change in
nodes, above and bilaterally to external lymph nodes, epithelium (from stratified squamous to columnar) occurs
below). Visceral afferent nerve fibres (pelvic near the gastro-oesophageal junction.
parasympathetics) supply the mucosa above the dentate
line. In contrast, below the dentate line, the skin of the anal
canal is supplied bilaterally by superficial somatic
(cutaneous) afferents (via the inferior rectal nerve).
81
BODY SYSTEMS AND ORGAN STRUCTURE
Internervous lines for reflexes particularly occur where Fig.8.61 Visceral pain lines
mucosa overlies skeletal muscle.
The thoracic pain line projects through the
Internervous lines for reflexes are located in the upper oesophagus to the sternal angle. Above the oesophagus
digestive and respiratory tracts at interfaces where specific (to the mucocutaneous junction at the lips) the mucosa is
areas of mucosa (and associated muscles) are each derived from pharyngeal pouches. General afferent fibres
supplied by a designated cranial nerve. convey pain from it via cranial nerves.
82
8. Visceral Systems and Viscera
Fig.8.62 Segmental supply of viscera and overlying skin Fig.8.64 Renal vascular segments
The pelvic pain line projects through the rectum to Vascular segments may be associated with
the pubic symphysis. Below the rectum (to the subdivisions of ducts (e.g. bronchopulmonary segments of
mucocutaneous junction in the anal canal) the mucosa is a lung); they receive a separate, exclusive arterial supply.
derived from the cloaca. Visceral afferent fibres
There tends to be no arterial anastomosis across
accompanying parasympathetic nerves convey pain from it
vascular segments although there may be some
to spinal cord segments S2-4 (and refer to the perineum).
venous communication.
All smooth muscle of the gut (with its connective tissue Hollow viscera generally receive a dual motor supply of
and vessels) is derived from splanchnic (G. visceral) visceral efferents (parasympathetic and sympathetic).
mesoderm, which in turn developed from part of the Parasympathetic nerve fibres are distributed primarily to
mesoderm lateral to the somites. the muscle coats. They augment motility and promote
Originally, this lateral plate mesoderm splits into two expulsion. Sympathetic nerve fibres inhibit motility. They
layers (around the developing serous body cavities), the are primarily distributed to sphincters and promote
somatic mesoderm and the splanchnic mesoderm. retention (as well as supplying blood vessels of the viscus).
Exocrine glands also tend to receive a dual motor
supply. This is primarily by parasympathetic nerve
(secretomotor) fibres that promote secretion.
The majority of sympathetic fibres to exocrine glands
supply the associated blood vessels (vasomotor fibres).
Neuroendocrine connections
Certain endocrine glands have major connections to the
nervous system.
The pineal gland and the posterior lobe of the
pituitary gland are outgrowths of the brain. The
suprarenal medulla developed as a modified sympathetic
ganglion and is supplied directly by sympathetic nerve
Fig.8.67 Distribution of visceral and somatic nerves
fibres. The anterior lobe of the pituitary gland receives
chemicals (releasing factors) released into its blood vessels
The body wall and the (parietal) layer of serous indirectly from the neighbouring area of brain (the
membrane lining it are supplied by somatic nerves, hypothalamus). The other endocrine glands function
while the gut and the (visceral) layer of serous independently from the nervous system (although their
membrane around it is supplied by visceral nerves. associated blood vessels receive sympathetic fibres).
Fig.8.68 Dual motor supply of tubular viscera Fig.8.70 Bilateral arterial supply to thyroid gland
84
8. Visceral Systems and Viscera
Viscera being actively metabolic have a rich vascular system) before being drained by the hepatic veins (into the
supply. Endocrine glands have a particularly rich supply as systemic venous system).
they secrete directly into the blood stream. The thyroid
gland is the most vascular major organ in the body. Strangulation of a viscus
Like other highly vascular midline viscera (uterus and The blood supply to a viscus may be endangered from
vagina) it is supplied bilaterally, from above as well as from external compression. Strangulation (L. choke) affects
below. The thyroid gland is not only drained by paired veins veins earlier than arteries, being thinner walled (and with a
(directed upwards and downwards) but also by a large lower blood pressure). Swelling from venous congestion
unpaired vein. may further aggravate the compression and ultimately the
arterial supply is compromised.
Strangulation of a tubular viscus (e.g. loop of intestine)
irreversibly lodged in a tight hernial orifice (e.g. the
femoral ring), occurs when its blood vessels are
compressed. Strangulation may also occur from associated
twisting of blood vessels to a viscus suspended by a
long vascular stalk (e.g. torsion of the testis) or by a
mesentery (e.g. volvulus of the sigmoid colon).
85
Chapter 9: Nervous System and Nerves
NERVE GANGLIA
NERVE PLEXUSES
NERVOUS SYSTEM
Fig.9.2 Central and peripheral nervous systems
The nervous system consists of the Central Nervous
System (CNS) and the Peripheral Nervous System NERVE FIBRES AND REFLEX ARCS
(PNS). The CNS is made up of the brain and spinal cord.
The brain consists of the forebrain (primarily the paired Roles of nerve fibres
cerebral hemispheres), the midbrain and the hindbrain
Nerve fibres have two special abilities. Excitability
(pons, medulla and cerebellum).
enables an area of cell membrane to change electrical
polarity when stimulated. Conductivity enables a wave of
excitation to be propagated along a cell membrane.
86
9. Nervous System and Nerves
87
BODY SYSTEMS AND ORGAN STRUCTURE
A typical sensory neuron has no dendrites. Instead, a Somatic and visceral fibre types
sensory nerve has a short single axon with two axonal
There are four major groups of functional fibre types
extensions branching at right angles. The proximal
that may occur in a peripheral nerve: somatic afferent,
extension synapses in the CNS, while the (much longer)
visceral afferent, somatic efferent and visceral efferent.
distal extension travels within a peripheral nerve. The cell
body of a sensory neuron is located (in a sensory ganglion)
The functional fibre type of a sensory nerve fibre
near, but not in, the CNS.
corresponds to the type of organ associated with the
A typical motor neuron has a single long axon arising
receptor.
from its cell body. The axon travels within a peripheral
nerve. However, the cell body and dendrites of a motor
This may be somatic (e.g. for skin) or visceral (e.g. for a
neuron are located in the CNS.
mucous membrane). Somatic afferents may be subdivided
into superficial and deep. Superficial somatic (cutaneous)
Although some peripheral nerves are purely motor or
fibres convey touch, pressure, temperature and superficial
purely sensory, the vast majority are mixed.
somatic (sharp prick) pain. Deep somatic (proprioceptive)
fibres convey joint position sense, vibration sense, skeletal
Impulses pass from distal to proximal along sensory
muscle stretch and deep somatic (dull ache) pain.
nerve fibres and from proximal to distal along motor nerve
fibres.
Receptors
A receptor (L. receive) is at the origin of a sensory
nerve fibre. This is typically located on the end of the distal
axonal extension. There are several types of receptors.
Exteroreceptors are located in the skin and in the special
sense organs. Cutaneous exteroreceptors are
mechanoreceptors (for touch and pressure),
thermoreceptors (hot and cold) and nocioceptors (for
superficial somatic pain). Proprioceptors are located in
somatic structures deep to the skin (in skeletal muscles, Fig.9.10 Major types of nerve fibres
joints and bones). They include mechanoreceptors (for
stretch, joint position and vibration) and nocioceptors (for Visceral afferent fibres are non-myelinated and conduct
deep somatic pain). Interoreceptors are located in internal slowly, conveying smooth muscle stretch and visceral (e.g.
organs. They include baroreceptors (for arterial blood vague) pain.
pressure), chemoreceptors (for arterial oxygen tension)
and nocioceptors (for visceral pain). The functional fibre type of a motor nerve fibre
corresponds to the type of effector.
Effector and neuro-effector junction
An effector is just distal to the termination of the axon This may be somatic (for skeletal muscle) or visceral
of a motor nerve. An effector may be a muscle (voluntary or (for smooth muscle, cardiac muscle and glands). Somatic
involuntary) or a gland. efferent fibres are large and rapidly conducting, while
visceral efferent fibres are smaller and slower conducting.
88
9. Nervous System and Nerves
Sympathetics supply dilator pupillae of the eye Although certain components of the sympathetic
(stimulating contraction of radially oriented smooth muscle nervous system are most active in alarm reactions (fright),
fibres) while parasympathetics supply sphincter pupillae stimulating the heart and diverting blood from viscera to
(stimulating contraction of circular fibres). Sympathetics skeletal muscles (for fight or flight), this role is relatively
supply ventricles as well as atria of the heart (to suddenly minor compared to that when the body is at rest or
increase stroke volume and heart rate, respectively when changing posture.
necessary), while parasympathetics supply atria only (to Sympathetics dilate pupils (increasing peripheral vision)
maintain a low basal heart rate). and bronchioles (facilitating lung ventilation). They also
Sympathetics and parasympathetics tend not to be fully stimulate contraction of gastrointestinal and urinary tract
activated simultaneously. However, they act in concert on involuntary sphincters.
viscera and the vasculature, catering for a wide range of Sympathetic nerves supply the suprarenal medulla,
bodily activities and external environments. which secretes the hormone adrenaline into the blood
stream that, in turn, potentiates the actions of sympathetic
stimulation on many of its effectors. Sympathetics also form
the efferent pathway for the ejaculation reflex (via
contraction of ductus deferens).
Reflexes
The nervous system is the sole control mechanism for
skeletal muscle action. It also complements hormonal and
local mechanisms in the control of smooth (and cardiac)
muscle and of glands. In particular, it has the capacity to
act almost instantaneously on specific distant targets.
A reflex (L. bend backwards, as in feedback) is an
active response to a stimulus that is involuntary and
stereotyped. It is a negative feedback mechanism; the
response feeds back on the stimulus (and progressively
shuts it off beyond a certain threshold).
A reflex is characterised by an active rather than a
passive response. More energy is expended in the
response than is provided by the stimulus (i.e. it is primed Fig.9.15 Reflex arc for biceps tendon jerk
like a spring). Although modified by voluntary control, a
Somatic and visceral reflexes
reflex may occur without conscious awareness (i.e. it is
automatic) and is stereotyped rather than random (i.e. it is There are two major types of reflexes: somatic and
pre-programmed along a specific path). visceral.
With somatic reflexes the effectors are skeletal
Components of a reflex arc muscles, while with visceral reflexes the effectors are
A reflex arc is the pathway between stimulus and smooth muscle, cardiac muscle or glands. Somatic reflexes
response. It involves both the PNS and the CNS. There are may be subdivided into superficial and deep according to
five components of a typical reflex arc: receptor, afferent, the afferent nerve fibre type. Superficial somatic
CNS, efferent, and effector. (cutaneous) reflexes (e.g. withdrawal reflexes) arise from
The simplest reflex arc involves only one synapse skin.
within the CNS (between the afferent neuron and the A special group of superficial reflexes (e.g. cough and
efferent neuron). The vast majority have more than one swallow reflexes) arise from mucous membranes, although
synapse within the CNS (involving at least one they involve skeletal muscle effectors. Deep somatic
interneuron). A stretch reflex for skeletal muscle (e.g. a (proprioceptive) reflexes (e.g. stretch reflexes and tendon
tendon jerk in a limb) is monosynaptic. It involves the jerks) arise from skeletal muscles and joints. Visceral
following sequence of events: reflexes include pupillary, lacrimal, salivary, baroreceptor
- stretch receptors in the muscle (e.g. biceps brachii) and chemoreceptor reflexes.
are stimulated by a sudden pull on the associated tendon,
- deep somatic afferents convey impulses via a
peripheral nerve (e.g. the musculocutaneous nerve) to the
spinal cord,
- a spinal cord segment (e.g. C5 for the biceps jerk
reflex) links respective afferent and efferent neurons (via
synapses)
- somatic efferents convey impulses via the same
peripheral nerve to the muscle,
- the effector contracts in response, moving a lever that
simultaneously reduces stretch of the muscle (completing a
negative feedback loop shutting off the stimulus).
Fig.9.14 Components of a reflex arc Fig.9.16 Superficial and deep somatic reflexes
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9. Nervous System and Nerves
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BODY SYSTEMS AND ORGAN STRUCTURE
Fig.9.20 Major motor pathways cross the midline The descending fibres are primarily in the lateral funiculi
and include the voluntary pathway (from the motor area of
A lateral column (containing the cell bodies of the cerebral cortex) plus many fibres to control skeletal
sympathetic neurons) lies in all thoracic, plus the upper two muscle tone. There are also sympathetic pathways
lumbar, segments of the spinal cord. (primarily from the hypothalamus).
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9. Nervous System and Nerves
Fig 9.23 Ascending fibres from sensory neurons Fig.9.25 Posterior and anterior nerve roots
The ascending fibres convey most cutaneous sensation A serrated fold of pia mater (the denticulate ligament)
(via spinothalamic tracts), conscious proprioception plus within the subarachnoid space separates the posterior and
fine touch (via the posterior columns) and unconscious anterior nerve roots. A swelling, termed a ganglion, is
proprioception (via spinocerebellar tracts). Within the found on each posterior root. A posterior root ganglion
funiculi, both descending and ascending fibres are comprises clusters of cell bodies of sensory nerve fibres
arranged in laminae. In the anterior and lateral funiculi, (which unlike motor fibres have both proximal and distal
fibres associated with caudal segments are superficial to axonal extensions).
those associated with more cranial segments. In the
posterior funiculi, fibres associated with caudal segments Afferent fibres in posterior roots
are medial to those associated with more cranial segments. Somatic afferent fibres, both superficial (cutaneous) and
The left cerebral hemisphere controls movements for, deep (proprioceptive), form the vast majority of fibres in a
and receives conscious sensation from, the right side of the posterior root of spinal nerves at all levels.
body. Similarly, the right cerebral hemisphere is connected
to the left side of the body.
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BODY SYSTEMS AND ORGAN STRUCTURE
Efferent fibres in anterior roots Each recurrent meningeal nerve receives sensation
from the adjacent anterior wall of the vertebral canal
Somatic efferent fibres comprise the vast majority of
(ligaments, periosteum and the periphery of intervertebral
fibres in an anterior root of all spinal nerves.
discs) and dura mater, including the dural sleeve of the
associated nerve roots. These structures are highly
sensitive to painful stimuli (in contrast to the spinal cord
and the spinal nerve roots which are totally insensitive).
Dural sleeve
The union of an anterior nerve root with a posterior
nerve root forms a spinal nerve. Each spinal nerve
emerges from an intervertebral foramen. Nerve roots are
invested by thin pia mater, continuous with that surrounding
the spinal cord. As anterior and posterior nerve roots pass Fig.9.31 Typical spinal nerve and its components
into an intervertebral foramen they also receive an
Posterior rami of spinal nerves directly supply skin,
arachnoid lined extension of dura mater (a dural sleeve).
intrinsic back muscles and joints of the dorsal aspect of the
The dural sleeve merges with the epineurium of the spinal
trunk and neck.
nerve.
Fig.9.30 Recurrent meningeal nerve and its branches Fig.9.32 A thoracic spinal nerve
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9. Nervous System and Nerves
Anterior rami of thoracic spinal nerves typically supply VI abducent (to one eye muscle)
the ventral aspect of the trunk directly, while anterior rami VII facial (for facial expression, salivation and taste)
of cervical and lumbosacral spinal nerves supply all parts of VIII vestibulocochlear (for hearing and balance)
the limbs and ventral aspect of the neck indirectly (via IX glossopharyngeal (for sensation to throat)
peripheral nerves derived from plexuses). X vagus (to pharynx, larynx and multiple viscera)
XI accessory (to two neck muscles)
Segmental nerve distribution XII hypoglossal (for tongue movements)
Unlike the motor (anterior) or sensory (posterior) nerve
roots, spinal nerves and rami are mixed (containing both I and II are continuous with the forebrain, while the
motor and sensory fibres). others arise from the brain stem (midbrain, pons and
Each spinal nerve supplies a continuous strip of skin (its medulla).
dermatome) via cutaneous branches of the posterior III and IV arise from the midbrain.
ramus and of the anterior ramus (e.g. lateral and anterior V and VI arise from the pons. The trigeminal nerve is in
cutaneous branches of an intercostal nerve). three divisions: ophthalmic (V1), maxillary (V2) and
A spinal nerve also supplies a mass of muscle (its mandibular (V3).
myotome) via muscular branches from the posterior ramus VII, VIII, IX, X, XI (cranial part) and XII emerge from the
(segmentally to intrinsic back muscles) and from the medulla.
anterior ramus (e.g. branches of an intercostal nerve to The spinal part of XI arises from upper cervical spinal
muscles of the associated intercostal space). cord segments. It passes up through the foramen magnum
Thoracic spinal nerves are regarded as typical spinal in the skull to join with the cranial part. Some cranial nerves
nerves. The segmental pattern of distribution from a are purely sensory (I, II and VIII), others purely motor (III,
thoracic spinal nerve is retained in both its posterior and IV, VI, XI and XII) while the remainder (V, VII, IX and X) are
anterior rami. mixed nerves with both motor and sensory fibres.
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BODY SYSTEMS AND ORGAN STRUCTURE
Remaining derivatives (bones, cartilages and muscles) half of the retina in each eye (stimulated by light from the
of the (six) original branchial arches retain their nerve medial half of both visual fields) do not cross the midline.
supply despite migration. The fifth branchial arch Each half of the visual field is thus represented on the
disappears early while the sixth can be included with the cerebral cortex in the opposite side of the brain.
fourth. Each arch has a designated cranial nerve (V, VII, IX
and X, respectively).
Each half of the brain stem contains a set of three Cranial nerve ganglia
columns of motor nuclei (medially located) and a set of
three columns of sensory nuclei (laterally located).
NERVE GANGLIA
Posterior root ganglia
A nerve ganglion (G. swelling) is a localised
enlargement on a component of the PNS. It is due to a
collection of cell bodies of neurons. These occupy much
more space than axons. Nerve ganglia may be sensory or
motor.
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BODY SYSTEMS AND ORGAN STRUCTURE
Parasympathetic ganglia
Parasympathetic ganglia tend to be smaller and
located more peripherally than sympathetic ganglia. They
are typically situated adjacent to the viscera they supply.
Parasympathetic post-ganglionic fibres are short,
correlating with the more localised effects of
parasympathetic stimulation. The major autonomic ganglia
Fig.9.43 Ganglia on sympathetic trunk in the head with synapses that are purely parasympathetic
have specific names.
More than 20 pairs of ganglia with synapses that are They are the ciliary ganglion (supplying the eye), the
purely sympathetic are located on the sympathetic trunks. pterygopalatine ganglion (supplying lacrimal and nasal
These are termed paravertebral ganglia as they are also glands), the otic ganglion (supplying the parotid gland) and
situated alongside the vertebral column. the submandibular ganglion (supplying submandibular
Sympathetic postganglionic fibres are much more and sublingual glands).
numerous than preganglionic fibres and are typically long,
correlating with the widespread effects of sympathetic
stimulation (enhanced and prolonged by adrenaline). In
addition to supplying arteries, sympathetic postganglionic
fibres may form a plexus around arteries and accompany
them to their peripheral destinations.
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9. Nervous System and Nerves
Central sympathetic pathways originate in the brain A grey ramus communicans contains post-ganglionic
(from the hypothalamus and the medulla). They pass down fibres that are not myelinated (hence termed grey). It
the spinal cord to synapse primarily in the lateral column typically connects with each spinal nerve at its division into
of grey matter. The lateral column is present only in posterior and anterior rami. Sympathetic postganglionic
thoracic and upper lumbar spinal cord segments (T1-L2). fibres subsequently pass into both rami. In this way
The peripheral sympathetic pathway originates in the vasomotor fibres are distributed to the limbs and trunk, and
lateral column and consists of two neurons that synapse in (together with sudomotor and pilomotor fibres) to the
a sympathetic ganglion. associated skin. A grey ramus communicans is located just
proximal to a white ramus communicans (at the origin of its
White ramus communicans anterior ramus of a spinal nerve).
Each spinal nerve from T1-L2 is connected to the Sympathetic supply to head, neck, & thorax
sympathetic trunk by a white rami communicans.
Sympathetic supply to the head and neck emerges from
A white ramus communicans contains pre-ganglionic the superior cervical ganglion of the sympathetic trunk at
fibres that are myelinated (hence termed white). It is the base of the skull. It is then distributed via sympathetic
located at the origin of the anterior ramus of a spinal nerve. perivascular plexuses, which follow the major arteries
Some preganglionic fibres synapse immediately in the and their branches. Thoracic viscera receive their
paravertebral ganglia they enter, while others pass up or sympathetic supply by cardiac, pulmonary and
down the sympathetic trunks and synapse in ganglia with oesophageal branches from cervical and upper thoracic
further connections to all 31 pairs of spinal nerves. ganglia of the sympathetic trunk.
NERVE PLEXUSES
A plexus (L. braid) is the linking together of nerves (or
of vessels). A nerve plexus involves the intermingling (but
not joining) of axons from different nerves connected by
continuous sheaths of fibrous tissue. In this rearrangement
of bundles there is no mixing of electrical impulses (unlike
vascular plexuses where the fluid contents mix within the
interconnected lumens). The largest nerve plexuses are
created from linking anterior rami of certain spinal nerves.
In a similar way, although on a smaller scale,
communicating branches can also occur between Fig.9.52 Limb buds and supply from anterior rami
neighbouring nerves, particularly their cutaneous branches. Limb buds arise only from the ventral aspect of the
trunk (i.e. in front of the coronal morphological plane)
Somatic plexuses
and are supplied only by anterior rami. Posterior rami are
not involved in their associated nerve plexuses (or the
cervical plexus) as posterior rami are distributed to the
back (and the back of the neck) rather than the ventral
aspect of the trunk.
Fig.9.51 The brachial plexus Fig.9.53 Coronal morphological plane and supply from rami
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9. Nervous System and Nerves
Anterior and posterior divisions of plexuses are termed superficial somatic (cutaneous) afferents.
Those arising from receptors in bones, joints and muscles
The brachial and lumbosacral plexuses each form two
are termed deep somatic (proprioceptive) afferents.
divisions.
Articular branches are sensory. They are variable and joint capsule) and terminates as the lateral cutaneous
may arise indirectly from muscular branches. nerve of the forearm (supplying skin over and beyond the
Vasomotor branches are purely sympathetic insertion of biceps).
postganglionic fibres. They are very fine, variable and may
arise at multiple levels. Variations of nerve branching
Branching patterns for peripheral nerves (as with
plexuses) depend on how nerve fibres are bundled within
connective tissue deep to the epineurial sheath. This
provides plenty of scope for variations, which are common.
Variation may be in number (with branches combining or
separating) and in level (with branches arising more
proximally or distally). Communications may occur between
nerves anywhere along their course, including within the
spinal canal, within a plexus or between their peripheral
branches. As a result, there are multiple possible paths for
a nerve fibre to reach its target.
Hiltons law
Peripheral nerves link somatic structures to create
functional units. There is a relationship between
structures supplied by a particular nerve (according to
Hiltons law).
Branching sequence of nerves Fig.9.59 Protective withdrawal reflex and biceps jerk
There is generally a sequence in type of branches from This draws the bones together, reducing the degree of
a peripheral nerve. Each nerve of a particular compartment stretch and protecting the joint from injury. Stretch of the
supplies muscular branches (to the associated flexor or flexor aspect of the capsule (e.g. of elbow joint) from
extensor muscle group), then articular branches (for hyperextension elicits a reflex contraction of flexor muscles
sensation from that aspect of the joint underlying the (e.g. biceps brachii) producing flexion at the joint. A painful
muscles) and terminates as a cutaneous nerve (supplying stimulus to skin elicits muscle contraction that tends to
skin overlying the part that is moved). move the associated part away from the threat. Such
superficial somatic (cutaneous) reflexes may be involved in
a generalised withdrawal reflex. Contact with a sharp
object (e.g. to skin on the sole of the foot) elicits reflex
contraction of muscles (e.g. calf muscles) producing plantar
flexion at the ankle joint, withdrawing the foot (particularly
when accompanied by contraction of flexor muscles at the
hip and knee joints).
be overcome when reducing a joint dislocation. Pain from of small branches termed vasa nervorum (L. vessels of
other types of deep somatic structures, including meninges nerves).
and the parietal layer of serous membranes (in addition to These involve both arteries (arteriae nervorum) and
its referral to skin) is also associated with reflex muscle veins (venae nervorum). Arteriae nervorum typically arise
spasm. as direct branches from a major artery or one of its named
branches. They may also arise indirectly from muscular or
cutaneous branches. Arteriae nervorum are given off at
multiple levels along the course of a nerve and form
branches that run longitudinally in the epineurium as well
as penetrating to create communicating plexuses around
fibre bundles.
A major peripheral nerve is typically a part of more than
one angiosome and (like the other components of these 3-
dimensional territories) is supplied by choke vessels
across the boundaries of adjacent angiosomes.
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BODY SYSTEMS AND ORGAN STRUCTURE
NERVE INJURIES AND NEUROGENIC PAIN if the gap of damage is bridged and scar tissue negotiated,
many axons may regenerate along functionally different
Types of nerve injuries endoneurial tubes. This may be minimised by careful
realignment of nerve fibre bundles in the surgical repair of a
A peripheral nerve lesion impairs motor and sensory
severed nerve.
(including reflex) functions (and in the long term may lead
to muscle wasting). Mild injury causes a transient loss of Pain from meninges and dural sleeves
function. A peripheral nerve may be injured by laceration,
Paradoxically, nerve tissue (including the brain and
traction or compression.
spinal cord) can be cut painlessly. However, the coverings
Compression may directly damage nerve fibres (e.g.
of the brain and spinal cord, together with their extensions
from a crush injury), compromise the blood supply to the
along nerve roots, are highly sensitive to painful stimuli.
nerve (e.g. from entrapment) or both.
The meninges of the brain are richly innervated with pain
Large nerve fibres within a peripheral nerve are the fibres in meningeal branches of cranial and upper cervical
most susceptible to pressure. nerves. Similarly, meninges of the spinal cord and
extensions of them along nerve roots (dural sleeves) are
Grades of nerve injury also richly innervated by the recurrent meningeal branch of
a spinal nerve.
There are three major grades of peripheral nerve injury.
Inflammation of the meninges (meningitis) results in
The mildest injury is a temporary interruption of conduction
without loss of continuity of axons. The intermediate grade severe headache as well as referred pain to all structures
supplied by other branches of the same cranial and cervical
of injury involves loss of continuity of axons but without
disruption of endoneurium. More severe injuries have nerves. It is also accompanied by neck stiffness (due to
associated reflex muscle spasm).
disruption of endoneurial tubes. In addition to loss of
Irritation of dural sleeves around nerve roots (e.g. from
continuity of axons, there is loss of continuity of nerve
a prolapsed intervertebral disc) causes severe pain. It may
fibres. If the perineurium is also disrupted in these injuries,
be referred (via the recurrent meningeal branch of a spinal
there is loss of continuity of nerve bundles and if the
nerve) to the areas of the body supplied by the same spinal
epineurium is disrupted as well, the nerve as a whole is
cord segment. It is also accompanied by back stiffness
severed.
(due to associated reflex muscle spasm).
ANASTOMOSES
END ARTERIES
ARTERIAL SYSTEM
The arterial system arises from the ventricles of the
heart. It is divided into two separate systems.
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BODY SYSTEMS AND ORGAN STRUCTURE
Throughout postnatal life, blood in the pulmonary Elastic arteries act as conducting vessels.
arteries (to the lungs) is deoxygenated. Blood becomes Their elastic recoil also prevents a sudden drop in blood
oxygenated in pulmonary capillaries by diffusion of oxygen pressure during ventricular filling.
from air in lung alveoli. Muscular arteries have a media predominantly of
smooth muscle and form the majority of named arteries.
Foetal arterial blood Muscular arteries act as distribution vessels by
Prior to birth, foetal blood is oxygenated in the placenta branching extensively and progressively reducing their
and returns via the umbilical vein. This blood enters the calibre.
foetal heart via the inferior vena cava (after bypassing the
liver), mixing there with deoxygenated venous blood, and
exits via the aorta (after bypassing the lungs).
Structure of arteries
Arteries consist of a cylindrical wall surrounding a
central channel, the lumen (L. light, as at the end of a
tunnel). The inner layer (intima) of the wall is connective
tissue lined by endothelium (G. within + nipple i.e. an
inner surface lining). The middle layer (media) contains
Fig.10.7 Arterial tree and changes in its dimensions
concentrically arranged smooth muscle fibres and elastic
fibres. The outer layer (adventitia) is primarily composed Arterioles
of collagen fibres. The adventitia also contains vasomotor
nerve fibres and even vasa vasorum (L. vessels of Arterioles are small branches that feed the capillary
vessels). bed. They have the largest ratio of wall thickness to lumen
calibre, which is maintained by smooth muscle tone
controlled by vasomotor nerves. Vasomotor nerves are
almost exclusively part of the sympathetic nervous system
(although parasympathetic nerves also supply arterioles
associated with erectile tissue).
Arterioles act as resistance vessels. Control of
changes in their calibre regulates blood flow and blood
pressure.
Capillaries
The thinnest walled vessels are capillaries (L. minute
hairs) consisting of a single layer of endothelial cells (plus
basement membrane) permeable to water, electrolytes
and gases as well as cellular nutrients and wastes.
Capillaries act as exchange vessels, creating a
Fig.10.6 Layers of arterial wall microcirculation.
Water moves across capillary walls according to the
Elastic and muscular arteries difference between hydrostatic pressure (decreasing from
Elastic arteries (e.g. the aorta) are closest to the heart the arterial to the venous end of a capillary) and osmotic
and have the largest diameter, with abundant elastic tissue pressure. There is net water movement out of the arterial
(yellow in appearance) in the media. end and into the venous end of a capillary.
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10. Arterial System and Arteries
Sinusoids
Capillary permeability varies at different sites and in
different organs. It is also dramatically increased as part of
the inflammatory response to tissue injury (producing
leakage of fluid into the tissues, with swelling).
Sites often subject to great hydrostatic pressure (e.g.
the limbs) have less capillary permeability, minimising fluid
leaking out of the vascular system.
Certain organs (e.g. endocrine glands), where the
capillary membrane is involved in transport of large
molecules (e.g. hormones), have greater capillary
permeability. Sinusoids (L. space-like) are specialised Fig.10.9 Avascular tissues
capillaries with a larger calibre and more sluggish flow. Arterial branches
They are found particularly in components of organs with
haemopoietic and defence function (i.e. liver, spleen and In the trunk, arterial branches are classified as parietal
bone marrow). In these tissues, sinusoids have a modified (to the body wall) or visceral (to viscera). Arteries often give
endothelium with a discontinuous or absent basement many branches with a change in direction (and reduction in
membrane (and greater permeability) and phagocytes (G. calibre) tending to occur where a large branch is given off.
eat + cells) that scavenge particles including old blood
cells.
The presence of sinusoids enables newly formed red
and white blood cells to pass into the vascular system (as
well as certain white blood cells to pass out of the vascular
system).
Rete mirabile
A rete mirabile (L. net + wonderful) is a capillary bed
located between two arteries.
In certain animals arteries may break up into capillary
beds, and then arise as arteries again. Retia mirabilia occur
only at special sites (e.g. in the testes of marsupials or
base of the brain in grazing animals) for special functions
(e.g. temperature regulation influencing spermatogenesis
or assisting venous return when the head is dependent,
respectively).
In humans, retia mirabilia only occur as microscopic
collections termed glomeruli (L. little balls of thread)
within the cortex of the kidney (between each pair of
afferent and efferent arterioles). Their special function is
the filtration of plasma. Unlike typical capillaries, those of a
rete mirabile are not designed primarily for exchange of Fig.10.10 Parietal and visceral branches of arteries in trunk
gases, cellular nutrients or wastes.
Where arteries divide into terminal branches, the larger
Avascular structures branch tends to be more directly in line with the main
Structures not derived from mesoderm are avascular trunk, with the smaller at a greater angle.
(they do not have capillaries).
Tissues that do not possess capillaries include Arterial branches to somatic structures (e.g. in the limbs
epidermis (ectoderm derived) and all other surface epithelia and body wall) may be regarded as cutaneous, muscular,
(primarily endoderm derived). arteriae nervorum (to nerves), nutrient (to long bones)
Capillaries are also absent from hyaline cartilage. and articular (around joints).
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BODY SYSTEMS AND ORGAN STRUCTURE
108
10. Arterial System and Arteries
Measurement of blood pressure decrease in arterial elastic tissue. They tend to become
less compliant (reflected by increased systolic blood
Systolic and diastolic blood pressure can both be
pressure). Arteries also tend to become tortuous in old age.
measured clinically (utilising a sphygmomanometer and
cuff) by auscultation (with a stethoscope). The cuff is Atherosclerosis and arterial aneurysm
wrapped around the arm to overlie and (when pumped up)
compress the brachial artery. This site is selected because In contrast to the normal variation of arteriosclerosis
it is at the approximate level of the heart (thus without due to aging, arteries may also undergo pathological
changes of atherosclerosis. In atherosclerosis (G. gruel +
additional hydrostatic pressure). The diaphragm of the
stethoscope is placed over the brachial artery near its hardness) fatty deposits are distributed irregularly along
termination. Tapping sounds are produced when flow the wall of elastic and muscular arteries, in addition to
fibrosis and calcification in the wall. An aneurysm (G.
becomes intermittent (between systolic and diastolic blood
pressures) as pressure in the cuff is gradually released. widening) is a localised dilatation of an artery. It is due to a
weakness in the arterial wall (e.g. due to atherosclerosis).
Aneurysms tend to increase in size and may rupture,
resulting in massive haemorrhage and death.
Haemorrhage
Haemorrhage (G. blood + gush) is loss of blood from
a blood vessel. Haemorrhage may be arterial, capillary or
venous and is typically due to external injury of the vessel
wall. It also occurs with rupture of a weakened vascular
wall. Vessels constrict and, if possible, plug (by platelet
aggregation) the wall defect, minimising blood loss. Blood
clotting or platelet defects predispose a patient to
haemorrhage, as does increased blood pressure (which
also accentuates bleeding).
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BODY SYSTEMS AND ORGAN STRUCTURE
otherwise occurs with movement and with anxiety. Ice Anastomosis is the term used for links between arteries
enhances vasoconstriction. Compression over the vessel or between arterioles (although a special type of
is the most important factor in first aid management as it anastomosis, between arterioles and venules, occur in
directly arrests bleeding. certain regions). Links between veins or between lymph
vessels are generally termed communications.
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10. Arterial System and Arteries
Arteriovenous anastomoses
Arteriovenous (AV) anastomoses are direct
communications between small arteries and veins without
an intervening capillary bed.
The wall is thickened and the lumen diameter can be
varied (via neural control of the smooth muscle tone). They
are located in areas where there is intermittent blood flow.
Arteriovenous anastomoses occur in exposed parts,
including the skin of the nose, lips and ears.
Fig.10.20 Potential anastomosis
Erectile tissue
Arteriovenous anastomoses also occur in erectile
(cavernous) tissue, where they are associated with
vascular spaces (venous sinuses) arranged like a
honeycomb and capable of expansion. Erectile tissue is
present in the nasal mucosa, where it warms and
humidifies inspired air. Erectile tissue is especially
prominent in the penis and clitoris. A tube of dense
connective tissue (tunica albuginea) surrounds a mesh of
Fig.10.22 Alternate pathways open when artery is kinked venous sinuses in the corpora cavernosa of the penis.
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BODY SYSTEMS AND ORGAN STRUCTURE
End organs
An end organ is a body part or organ that is isolated
from others. It tends to be supplied by a single artery or at
least via a single avenue of arterial supply.
Fig.10.25 The anatomical end artery to the retina Arteries to terminal body parts
Although terminal body parts (e.g. fingers, toes, penis
Effect of central retinal artery occlusion and tip of the nose) each receive more than one artery,
Occlusion of the central retinal artery causes total these tend to be via a single avenue and may (collectively)
blindness of the affected eye. be regarded as end arteries.
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10. Arterial System and Arteries
Vulnerability to vasoconstrictors
Vasoconstrictor drugs (e.g. adrenaline) should not be Fig.10.31 End arteries in a developing long bone
injected into the digits or penis. These drugs can produce
intense arterial spasm resulting in death of tissue in these Arteries to visceral segments
terminal body parts. The branches of arteries supplying solid viscera that are
divided into separate vascular segments (e.g. kidney and
liver) are typically end arteries.
The lungs are also divided into separate
(bronchopulmonary) segments, although each receives a
dual arterial supply (bronchial and pulmonary).
End tissue
Fig.10.30 The vermiform appendix and its end-artery Within an organ, the furthest area from its arterial
source may be regarded as end tissue as it tends to be
The spleen is a solid organ suspended within the supplied by terminal arterial branches.
abdominal cavity by its attachment at the splenic hilum
where it receives the splenic artery. The brain and spinal End tissues within end organs are most vulnerable to
cord are suspended within the cranial cavity and vertebral having their arterial supply interrupted.
canal, respectively, while the heart is suspended within the
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BODY SYSTEMS AND ORGAN STRUCTURE
The periphery of solid organs (e.g. spleen and kidney) In contrast, although segmental arteries to the kidney or
receiving supply via branches that penetrate from a central liver are end arteries, the functional reserve of the rest of
hilum, may be regarded as end tissue. This will even the organ may compensate for death of one or more
include the capsule and/or serosa for those solid organs segments.
(e.g. spleen) suspended within a cavity as they do not
receive any additional external supply. However, central Inadvertent ligation or injection
parts of the brain and spinal cord are most vulnerable Care must be taken during surgery to avoid inadvertent
because their arterial supply penetrates from their exterior. ligation of an end artery (e.g. of a posterior intercostal
Similarly, the coronary arteries pass around the external artery that may supply part of the spinal cord or of
(epicardial) surface of the heart, with branches penetrating accessory renal arteries that may supply segments of the
the myocardium. The deepest part of the wall of a heart kidney). Care must be taken during general anaesthesia to
chamber is the endocardium lining its internal surface. The avoid inadvertent intra-arterial injection of drugs that
endocardium itself is bathed in the blood inside the produce intense vasoconstriction or during local
chamber. However, subendocardial myocardium may be anaesthesia to avoid injecting vasoconstrictor drugs into
regarded as end tissue and is therefore particularly terminal parts.
vulnerable to ischaemia in coronary disease.
Within hollow viscera, internal (mucosal) surfaces are Thrombosis and embolism
furthest from arteries that penetrate from the external A blood clot formed in the vascular system of a living
(serosal) surface. Epithelia are avascular (despite being person is termed a thrombus (G. clot). This is in contrast
highly metabolic) relying on diffusion via capillaries derived to a post mortem clot (occurring after death) or a
from terminal arterioles in the underlying connective tissue haematoma (occupying tissues outside the vascular
(lamina propria) of the mucosa. The mucosal lining of a system). Thrombosis may be due to endothelial damage,
hollow viscus is particularly endangered by interruption of decreased blood flow or abnormal blood constituents.
its arterial supply. A substance transmitted by the blood stream that
lodges in a vessel is an embolus (G. plug). A thrombus,
Types of arterial occlusion or part of one, that dislodges (and is transmitted by the
Arterial occlusion may be classified into three types blood stream to a distant site) becomes a
based on the location of its source relative to the wall. thromboembolus.
Internal (Intraluminal) occlusion is from within the lumen of An embolus tends to occlude arteries because they
an artery (e.g. by a thrombus or an embolus). Intramural progressively narrow by branching.
occlusion is from within the wall (e.g. thickening of the
intima by atherosclerosis or spasm of smooth muscle in the An embolus within an artery tends to lodge
media). External (extramural) occlusion may occur from immediately distal to a branch point, where the main
compression or ligation. artery narrows.
Effects of anatomical end artery occlusion An embolus is particularly dangerous if an end artery is
Arterial occlusion to an end artery produces potentially occluded.
serious adverse effects. These range from decreased
blood supply, termed ischaemia (G. keep back + blood)
to tissue death from complete loss of supply, termed
infarction (L. stuffing).
Sudden occlusion of an anatomical end artery
compromises its entire territory of supply. Even gradual
occlusion of an anatomical end artery affects its entire
territory of supply. This occurs because there is no other
avenue (new vessels not being created). Occlusion is
particularly significant for anatomical end arteries that
supply the whole organ. Central retinal artery occlusion
causes total blindness of the affected eye.
Arterial occlusion to vital areas Fig.10.33 Emboli tend to lodge at branch points
Occlusion of end arteries supplying an organ with
specific functions corresponding to an anatomical location Pulmonary embolus
(e.g. the brain and the heart) is potentially most serious. Emboli originating from systemic veins (e.g. deep veins
Occlusion of even a relatively small branch of a cerebral or in the calf) pass through the right atrium and ventricle, then
of a coronary artery may produce tissue death in a vital into the pulmonary arterial system, to occlude a pulmonary
area, resulting in profound effects (e.g. hemiplegia or artery or branches of it in the lung. Pulmonary emboli may
cardiac arrhythmia, respectively). also arise from the right side of the heart.
114
10. Arterial System and Arteries
115
BODY SYSTEMS AND ORGAN STRUCTURE
Vasa vasorum
116
Chapter 11: Venous System and Veins
VENOUS SYSTEM
The venous system comprises three separate major
systems.
117
BODY SYSTEMS AND ORGAN STRUCTURE
Structure of veins
Veins are more numerous than arteries. However, like
arteries, veins consist of a tubular wall surrounding a
central channel, termed the lumen. The wall comprises an
(inner) intima lined by endothelium, a media with smooth
muscle and an (outer) adventitia.
118
11. Venous System and Veins
Venous tributaries correspond to arterial branches. The hepatic portal venous system is regarded as the
However, as well as having thinner walls, they are more portal system. It consists of the portal vein that enters the
numerous (and more variable than branches of arteries) liver at the porta hepatis (G. gateway + liver), together
with many tributaries remaining un-named. This correlates with tributaries of the portal vein (prior to its formation) and
with their development from even more extensive networks branches of the portal vein (within the liver).
(creating more opportunity for variation).
119
BODY SYSTEMS AND ORGAN STRUCTURE
These veins transport special hormones (releasing Valves in long veins of limbs
factors from nerve endings) to regulate anterior pituitary
Valves in the superficial and deep veins of the limbs direct
hormone production.
flow from distal to proximal (generally against gravity) to
prevent pooling of blood distally.
VENOUS VALVES AND VENAE COMITANTES
Role and structure of venous valves
Venous valves (L. flaps) are folds of endothelium
lining veins, typically with a pair of cusps. They allow blood
to flow in one direction only, thus directing venous return
towards the heart.
Fig.11.14 Valves located near entry of a major tributary Fig.11.16 Venae comitantes
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11. Venous System and Veins
These veins conserve heat (by transfer of heat from Muscular venous pump
warm arterial blood to cool venous blood returning from the
The muscular venous pump is the main factor
periphery). Venae comitantes are primarily located in the
responsible for flow from peripheral veins. In the limbs,
limbs, particularly distally. Their arrangement around the
fascial sheets and septa (e.g. of the leg) subdivide muscle
artery also assists venous return.
compartments. Contraction of the belly of a skeletal
muscle compresses (deep) veins within the associated
compartment.
Venous flow
Venous return is directed towards the atria of the heart Fig.11.19 Muscular venous pump
(via systemic veins to the right atrium and via pulmonary
veins to the left atrium). Venous flow is due to blood Thoracic venous pump
pressure, contraction of adjacent skeletal muscles and
Venous return in the trunk is via a double pump
the oscillation of intra-thoracic pressure with respiration.
mechanism that is coupled to respiration.
Vascular venous pump
The arrangement of venae comitantes (coupled with the
presence of valves) aids venous flow in the periphery.
Valveless veins of the trunk Varicose veins tend to become more prominent with
prolonged elevation of venous pressure. Oesophageal
Venous blood is trapped within the trunk by major
varices are dilated veins under the surface lining of the
valves above, at the junction of the thorax with the neck (in
lower oesophagus, associated with elevation of venous
the terminations of the subclavian and internal jugular
pressure in the portal system (portal hypertension).
veins), and below, at the junction of the abdomen with the
They tend to bulge into the lumen and may rupture
lower limbs (in the termination of the femoral veins).
producing catastrophic bleeding.
The veins of the vena caval systems traversing body Haemorrhoids are dilated veins under the surface
cavities of the trunk, together with the entire vertebral lining of the anal canal, associated with chronic straining
and azygos systems of veins, are valveless. (e.g. from weightlifting, constipation or coughing) or
pregnancy (e.g. from the foetal head compressing pelvic
This means that flow may occur in either direction within veins). They tend to bulge into the lumen and may bleed, or
these systems. Flow may also occur in either direction if large, prolapse beyond the external anal sphincter.
between these systems (due to valveless communicating Haemorrhoids may even thrombose.
veins).
Fig.11.22 Features of a varicose vein Fig.11.24 An incompetent venous valve and effect on flow
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11. Venous System and Veins
Incompetent valves of perforating veins in the leg are Calf muscle venous sinuses
particularly significant as the muscular venous pump
Extensive venous sinuses occur in the soleus muscle of
shunts blood back under pressure from deep veins
the calf. Blood tends to pool in these soleal venous sinuses
(surrounded by the calf muscles) to superficial veins (not
with gravity (e.g. from prolonged standing) and without
surrounded by muscles) where the blood pools. Circulation
muscular activity (e.g. prolonged bed best).
to the skin is impaired by the high venous blood pressure
and the skin may ulcerate and heal very poorly.
Perforating veins
Links between veins are generally termed venous
communications. Communications between superficial and
deep veins in the lower limbs are termed perforating veins.
They perforate the deep fascia (via openings in it). Valves
are present in perforating veins (of particular importance in
Fig.11.26 Venous sinuses and deep vein in calf the calf) directing flow from superficial to deep.
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BODY SYSTEMS AND ORGAN STRUCTURE
Portal-systemic anastomoses
Communications between the portal system and the
systemic system have the special term portal-systemic
anastomoses. The portal venous system is valveless so
flow may occur in either direction.
Emissary veins
Communications between intracranial and extracranial
veins are termed emissary (L. out + send) veins. They
arise from the dural venous sinuses and exit via foramina in
the skull.
Fig.11.30 Emissary veins pass via foramina in the skull Venous plexuses
Just as venous tributaries tend to be more numerous
Azygos venous system than arterial branches, they communicate more freely (and
The azygos system of veins may be regarded as a have even more capacity for variation). Tributaries of veins
large set of venous communications. tend to form intercommunicating networks where they are
particularly numerous. These networks are termed venous
plexuses.
124
11. Venous System and Veins
Deep vein thrombosis in the calf A potential avenue of spread for infections of the face is
to venous sinuses in the cranial cavity via (valveless)
The deep veins of the calf are predisposed to
emissary veins that communicate with them. This may lead
thrombosis if surrounding muscles are not contracting
to a septic thrombosis (e.g. cavernous sinus thrombosis).
regularly (particularly in postoperative, postpartum or
bedridden patients and from long aeroplane flights). Venous congestion and oedema
Increased venous pressure creates an abnormal
pooling of blood in veins within organs, termed venous
congestion (L. bring together).
Water moves across capillary walls according to the
difference between hydrostatic pressure (decreasing from
the arterial to the venous end of a capillary) and osmotic
pressure. Affecting this equilibrium (e.g. by increased
venous pressure, increased capillary permeability or
decreased plasma protein osmotic pressure) causes an
abnormal accumulation of tissue (interstitial) fluid, termed
oedema (G. swelling).
Back pressure from a failing right ventricle of the heart
(right heart failure) leads to congestion in systemic veins
Fig.11.34 Deep vein thrombosis in calf from stasis and peripheral oedema. Oedema around the ankles tends
Stasis and pooling of blood in soleal venous sinuses to occur from standing, while oedema over the sacrum
occurs if not emptied by regular contraction of the calf tends to occur from lying supine. Back pressure from a
muscles. failing left ventricle of the heart (left heart failure) leads to
A thrombus in a deep calf vein, especially one that congestion in the lungs. This may progress to accumulation
propagates proximally, may dislodge (or part of it may of fluid there (pulmonary oedema).
break off) to become a thromboembolus. Pulmonary Increased pressure in the portal venous system tends
thromboembolism (occlusion of a pulmonary artery or to produce venous congestion and abnormal accumulation
major branch of it in the lung by a thromboembolus) is a of fluid within the peritoneal cavity, termed ascites (G.
potential consequence of deep vein thrombosis originating bag). Increased venous pressure (e.g. from portal
in the calf and is life-threatening. hypertension) may also produce dilated (varicose) veins.
Thromboemboli are carried via the inferior vena cava Eventually varices tend to develop at sites of portal-
and the right side of the heart into the pulmonary arterial systemic anastomosis (particularly the lower end of the
system. One or more arteries subsequently become oesophagus). Rupture of oesophageal varices produces
occluded, as they become progressively narrower by severe haemorrhage, often resulting in death.
branching.
Thromboemboli are more common in veins than
arteries because of the more sluggish flow. Usually these
are small and are filtered by the lungs without damage.
Organs supplied by systemic arteries are protected as all
venous blood passes through the pulmonary capillary bed
before proceeding to systemic arteries.
125
Chapter 12: Lymphatic System and Lymph Vessels
LYMPH VESSELS
Lymph capillaries
There are two types of lymph capillaries. Superficial
(initial) lymph capillaries are located directly under an
epithelium. In the skin, they are found in the papillary layer
of the dermis. Deep lymph capillaries are located in the
reticular layer of the dermis.
Initial lymph capillaries have a blind origin. This
distinguishes them from other capillaries, although the wall
of both lymph capillaries and arteriovenous capillaries is
made up of a single endothelial layer. Tiny filaments (of
fibrillin), between the endothelial cells and the surrounding
extracellular matrix, produce temporary intercellular gaps
Fig.12.2 Components of lymphatic & haemopoietic systems when interstitial fluid volume increases.
126
12. Lymphatic System and Lymph Vessels
Fluid enters the lymph capillary until interstitial volume (primarily endoderm derived). Lymph capillaries are absent
reduces, slackening the filaments with closure of the gaps. from the central nervous system (ectoderm derived).
Initial lymph capillaries are saccular and have no basement Although abundant just deep to surface epithelia, lymph
membranes. capillaries are absent from the epithelia themselves. Lymph
Deep lymph capillaries are transitional in structure, capillaries are also absent from hyaline articular cartilage.
between initial capillaries and lymphatics. There are Although mesoderm-derived, articular cartilage has a solid
occasional valves, an intermittent basement membrane matrix and is subject to continuous compression which
and patches of smooth muscle cells in the surrounding would collapse any lymph (or blood) capillaries if present.
wall.
Where abundant, lymph capillaries link freely to form
communicating networks.
Lymphatics
Lymph capillaries drain into progressively larger
tributaries termed lymphatics. Those from the skin drain
into lymphatics located in the subcutaneous tissue.
Fig.12.4 Features of initial lymph capillaries
Although these vessels have thicker walls than lymph
Lymph capillary plexuses capillaries, they are still at low lumenal pressure (and are
therefore easily compressed). They possess a basement
Lymph capillaries are most numerous beneath surface membrane, circumferential smooth muscle cells and
epithelia. pacemaker cells (producing spontaneous rhythmic
contractions). Lymphatics resemble veins and venous
Skin and mucous membranes, being the surface of the tributaries. However, as well as having thinner walls, they
body, are its first line of defence. Lymph capillaries are are more numerous (and more variable than veins and their
particularly abundant in dermis (the subepidermal layer of tributaries). This correlates with their development from
the skin) and lamina propria (the subepithelial layer of even more extensive networks (creating more opportunity
mucous membranes). for variation). Lymphatics have valves (formed by infolding
of the endothelium) for one-way flow. The flow is directed
ultimately to the venous system.
127
BODY SYSTEMS AND ORGAN STRUCTURE
Lymph trunks
Lymphatics are tributaries of lymph trunks. These larger
lymph vessels typically accompany major blood vessels.
The paired jugular, subclavian and
bronchomediastinal lymph trunks collect lymph from the
head and neck, upper limb, and thorax, respectively. The
jugular lymph trunk accompanies the internal jugular vein
and the subclavian lymph trunk accompanies the
subclavian vein. The bronchomediastinal lymph trunk is
atypical in that it runs independently of blood vessels. The
unpaired intestinal lymph trunk and paired lumbar lymph
trunks drain the abdomen, pelvis and lower limb. These
lymph trunks accompany the aorta or its branches.
Lymphatic pathways
As well as having a similar structure to veins,
lymphatics have a common direction of flow with them.
Lymphatics also tend to accompany veins.
LYMPH RETURN
Mechanisms of lymph flow
The pressure within the lymphatic system is much lower
than that of the cardiovascular system and for many lymph
vessels throughout the body lymph flow is often against
gravity. Lymph flow is dependent on three potential pumps
coupled with the presence of one-way valves. The
vascular lymph pump is provided by rhythmic contraction
of the smooth muscle wall of lymph vessels, intimate
contact with veins and the common direction of flow
(milking effect). The muscular lymph pump is from
contraction of adjacent muscles (squeezing effect). The
thoracic lymph pump is due to the oscillation of
intrathoracic pressure with respiration (sucking effect).
Cisterna chyli
The thoracic duct typically originates in the abdominal
cavity from a small sac termed the cisterna chyli (L.
reservoir + juice), lying adjacent to the aortic opening of
the diaphragm. The cisterna chyli receives the intestinal
lymph trunk plus the lumbar lymph trunks. However, the
thoracic duct often arises directly from a confluence of
these lymph ducts without the presence of a cisterna chyli.
129
BODY SYSTEMS AND ORGAN STRUCTURE
Lymphoedema
Lymph capillaries normally take up fluid that has leaked
from blood capillaries, which would otherwise accumulate
Fig.12.15 Paths of lymph return to venous system in the interstitial compartment (between intravascular and
intracellular fluid compartments).
Effect of thoracic duct laceration Although there are many lymphatic and lymphatico-
Although the thoracic duct can be ligated without venous communications, with multiple avenues of lymph
significantly impeding fluid return, laceration causes return to the venous system, extensive lymphatic
profuse lymph leakage. The subsequent accumulation of obstruction may prevent sufficient lymph return.
this lymph in the thoracic cavity is termed chylothorax. The abnormal accumulation of tissue fluid (oedema)
due to this mechanism is termed lymphoedema. Causes
Lymphatic spread include surgical removal of lymphatics (e.g. from a radical
Tumours and infections can spread by lymphatics, mastectomy for breast cancer) and parasitic occlusion of
particularly as tumour cells and microbes tend to be carried lymphatics (e.g. elephantiasis of the lower limb and
along with the lymph. However, since lymph drained from external genital organs from filarial worm infestation and
any particular organ tends to pass through at least one set subsequent inflammation).
of lymph nodes (prior to reaching the venous system),
tumour cells or microbes carried in it are exposed to LYMPH NODES
defence cells at these sites.
Lymph nodes tend to enlarge in response and may also Lymph nodes (L. knots) are multiple, discrete,
become tender (particularly with infection) or firmer encapsulated collections of lymphoid tissue lying along the
(particularly with tumour involvement). course of lymph vessels.
130
12. Lymphatic System and Lymph Vessels
Signal node near end of thoracic duct Fig.12.19 Major palpable lymph node groups
The lymph node (Virchows or signal node) adjacent
to the termination of the thoracic duct, which has The major palpable lymph node groups are typically
communications with the duct, may be regarded as the final subdivided into superficial and deep groups, each located
lymph node, guarding entry into the venous system. adjacent to a major vein.
Superficial cervical nodes (e.g. along the external Breakdown products of red blood cells are taken (via
jugular vein), drain to deep cervical nodes (along the the portal venous system) to the liver and excreted in the
internal jugular vein). Superficial inguinal nodes (e.g. along bile.
the great saphenous vein) drain to deep inguinal nodes
(along the femoral vein). The majority of axillary nodes (e.g. Accessory spleens and splenectomy effect
along the axillary vein or its major tributaries) may be Additional discrete anatomical variants, termed
regarded as superficial nodes and drain to deep (apical) accessory spleens, are sometimes found along the
nodes (along the termination of the axillary vein at the apex course of the splenic artery. These may enlarge after
of the axilla). splenectomy.
133
Introduction: Everything is somewhere
Organ position
Organs occupying a common location are regarded as Head and neck modules:
belonging to a particular region (L. area). An organ is - head 15 regions
therefore simultaneously the structural (and functional) unit - neck 6 regions
of a body system as well as an occupant of a region. Total = 21
Trunk modules:
- back 3 regions
- thorax 8 regions
- abdomen 4 regions
- pelvis 6 regions
Total = 21
Limb modules:
- upper limb 15 regions
- lower limb 15 regions
Total = 30
Body regions
A cluster of neighbouring regions may be grouped into
a common module.
The human body can be conceptualised as being made up
of (or divided into) 8 modules containing a grand total of 72
regions.
134
Chapter 13: Regions of the Human Body
REGIONS OF HEAD
REGIONS OF NECK
REGIONS OF BACK
REGIONS OF THORAX
REGIONS OF ABDOMEN
REGIONS OF PELVIS
REGIONS OF NECK
The neck may be divided into 6 regions, arranged in (2)
anterior and (4) posterior groups.
1. - anterior triangle of neck
2. - root of neck
3. - sternomastoid region
4. - vertebral region of neck
5. - posterior triangle of neck
6. - back of neck
REGIONS OF BACK
The back may be divided into 3 regions, which span its
entire length from the 1st thoracic vertebra to the tip of the
coccyx. These may be arranged into (2) muscle
compartments and the vertebral column (with its
enclosed vertebral canal).
1. - superficial compartment of back
2. - deep compartment of back
3. - vertebral region of back
136
13. Regions of the Human Body
The vertebral region of the back includes the The anterior thoracic wall is covered by skin of the
thoracolumbar and sacrococcygeal parts of the vertebral pectoral region (of the upper limb). The posterior thoracic
column (with associated intervertebral joints and discs), as wall is directly in front of the thoracic vertebral column
well as the enclosed vertebral canal (with associated (classified as part of the back).
intervertebral foramina). The compartments of the back are The thoracic walls have superior and inferior apertures.
continuous above with the back of the neck region. The The inferior aperture is filled by the diaphragm, which in
vertebral region of the back is continuous with the turn contains major and minor openings.
corresponding region of the neck.
REGIONS OF THORAX
The thorax may be divided into 8 regions arranged as Fig.13.12 Thoracic wall regions
(3) thoracic wall regions and (5) thoracic cavity regions.
The thoracic cavity, made up of paired pleural sacs with
the mediastinum between them, contains the thoracic
viscera.
REGIONS OF ABDOMEN
The abdomen may be divided into 4 regions arranged
as (3) abdominal wall regions and the abdominal cavity.
The abdominal wall regions are primarily the large
muscular and posterior abdominal walls. The anterior
abdominal wall includes overlying skin while the posterior
abdominal wall is directly in front of the lumbar vertebral
column and hipbones (classified as part of the back and
Fig.13.11 Modules overlapping thorax lower limb, respectively). The inguinal canal is at the lower
137
BODY REGIONS AND ORGAN POSITION
REGIONS OF PELVIS
The pelvis (L. basin) may be divided into 6 regions
arranged into pelvic walls, the pelvic cavity and the two
triangles of the perineum (L. discharge).
The pelvic wall regions are primarily the lateral and
posterior pelvic walls (formed by the lesser pelvis). The
posterior pelvic wall is directly in front of the sacrum and
coccyx (classified as part of the back).
The pelvic cavity is enclosed by the pelvic walls and
located above the pelvic floor. Its contents include pelvic
viscera and the peritoneal cavity. The pelvic cavity is Fig.13.20 Subdivisions of perineum
continuous with the abdominal cavity above the pelvic brim,
but is separated from the perineum by the pelvic floor, The perineum is covered by skin with cutaneous orifices
which in turn contains openings for certain viscera. for the urogenital tract and for the (lower) digestive tract.
138
13. Regions of the Human Body
139
Chapter 14: Arrangement of Body Regions
PAIRED REGIONS & BILATERAL SYMMETRY PAIRED REGIONS & BILATERAL SYMMETRY
42 regions of the body are paired (while the remaining
FLEXOR AND EXTENSOR REGIONS 30 are unpaired). Paired regions include those (12) regions
of the trunk not in the midline, together with all (30) regions
BOUNDARIES OF REGIONS of the limbs. The latter are further from the midline.
Bilateral symmetry
APERTURES BETWEEN REGIONS
Animals, being capable of independent movement, tend
to have bilateral symmetry (in contrast to the myriad of
forms evident in plants). This is particularly important in
UNPAIRED REGIONS & MIDLINE OF BODY humans to maintain balance in (bipedal) gait and
locomotion.
The mid-sagittal plane is the most important reference Symmetry facilitates movement and is exhibited by the
plane. It represents the midline of the body. skeleton and its associated muscles, especially in the
30 regions are unpaired (while the remaining 42 are limbs.
paired). Unpaired regions are located in the midline
although they may be divided into two halves by the
midline. These regions are confined to the head, neck and
trunk.
141
BODY REGIONS AND ORGAN POSITION
Divisions of limb plexuses Bony boundaries may also include imaginary lines
between them. For example an imaginary line between the
During development, the upper limb buds and the lower
medial and lateral humeral epicondyles demarcates the
limb buds rotate through 90 degrees in opposite directions
base of the cubital fossa.
to each other when viewed in the anatomical position.
Bony boundaries are often expressed in terms of
surface markings or vertebral levels that can be determined
on living bodies.
Bony boundaries
Fig.14.9 Key bony boundaries in upper limb Soft tissue boundaries of regions may also include
borders of connective tissue thickenings (e.g. intermuscular
Bony boundaries of regions may be bony features, septa, retinacula, tendons, ligaments). Medial and lateral
prominences or borders. For example the apex of the intermuscular septa separate the anterior from the posterior
axilla (bounded by the medial border of the first rib, the compartment of the arm. The flexor retinaculum
clavicle and the superior border of the scapula) demarcates demarcates the carpal tunnel (between the anterior
the upper limb from the neck. compartment of forearm and the palm of the hand).
142
14. Arrangement of Body Regions
APERTURES BETWEEN REGIONS Pathways between regions may be via both major and
minor apertures. For example, the diaphragm has major
Major and minor apertures apertures (centrally) providing pathways to and from the
abdominal cavity and minor apertures (around the
Pathways between regions are through gaps in their
periphery) providing pathways to and from the abdominal
boundaries termed apertures.
walls.
143
Chapter 15: Body Compartments and Fascial Planes
144
15. Body Compartments and Fascial Planes
Flexible and rigid compartments The anterior compartment of the leg is particularly
prone to this condition (termed 'anterior compartment
At least one of the walls surrounding a compartment
syndrome').
(particularly if transmitting a major vessel) is generally
flexible, or at least has a sufficiently large aperture, to allow
for expansion. However, unyielding walls may almost
completely surround certain compartments.
These compartments may be absolutely rigid bony
cavities (e.g. cranial cavity) or relatively rigid fibro-osseous
tunnels, canals and foramina (e.g. carpal tunnel, vertebral
canal, intervertebral foramina). The contents of a rigid
compartment may be cushioned by fat (e.g. around the
dural sac in the vertebral canal, within the median nerve in
the carpal tunnel) or fluid (e.g. cerebrospinal fluid within the
dural sac in the cranial cavity and vertebral canal).
145
BODY REGIONS AND ORGAN POSITION
146
Chapter 16: Body Walls and Cavities
147
BODY REGIONS AND ORGAN POSITION
148
16. Body Wall and Cavities
149
BODY REGIONS AND ORGAN POSITION
Prolapse
A prolapse (L. falling) is the descent of an organ from
its normal position.
Organs affected include those supported within a large
body cavity (e.g. uterus, rectum). Prolapse of an organ is
due to weakened supports (e.g... from stretching during
childbirth or from aging) coupled with gravity and
aggravated by straining.
150
Chapter 17: Neurovascular Pathways
NEUROVASCULAR BUNDLE
NEUROVASCULAR BUNDLE
Nerves and vessels tend to accompany each other as
components of a neurovascular bundle.
Fascial sheath
Large vessels and nerves are typically enclosed by
connective tissue as a discrete fascial sheath forming a
tube around them.
Fig.17.2 Neurovascular bundle in the calf Fig.17.5 Venae comitantes in the calf
Within a neurovascular bundle, the vein and lymph COURSE THROUGH A REGION
vessels are located more peripherally.
Nerves and vessels, being the supply lines for
In addition, the fascial sheath of a neurovascular bundle anatomical structures, tend to traverse many regions on the
tends to be thin or absent around the vein and lymph way to their destinations. However, a particular nerve or
vessels (or have a vacant compartment next to it) allowing vessel along a path may change its name according to the
room for expansion. region in which it is situated.
151
BODY REGIONS AND ORGAN POSITION
Components to a course include those between regions A limb bud develops initially with an axial artery located
(e.g. through an aperture) and those within a region (which along the line of least tension. The line is altered during
may also be divided into parts). subsequent growth and development (including rotation)
with accompanying changes in the arterial pattern.
Preferred channels enlarge while others regress. This is
reflected in the final path of a major limb artery.
In addition to being minimally stretched by movement,
major arteries, being deeply located on the flexor aspect of
a joint, are less vulnerable to injury.
The femoral artery runs on the flexor aspect of the hip
joint (which is anterior). Its continuation (as it passes
through the hiatus in adductor magnus muscle) is the
popliteal artery. The course in the popliteal fossa (divided
into 3 parts by the components of the floor; bony,
ligamentous and muscular) is on the flexor aspect of the
knee joint (even though this is posterior).
152
17. Neurovascular Pathways
Tortuous arteries
Many arteries are tortuous and accommodate
movement (e.g. facial, splenic), protrusion (lingual) or
expansion (uterine) of the organs supplied.
153
BODY REGIONS AND ORGAN POSITION
154
Section IV
HUMAN DEVELOPMENT AND VARIATION
155
Introduction: Derivation determines destiny
156
Chapter 18: Growth and Development
Implantation and bilaminar germ disc Fig.18.3 Three-layered germ disc in 3rd week
The fertilized ovum is termed a zygote (G. yolk). This
single cell undergoes a series of divisions (cleavage) Mesoderm forms all connective tissues (including bone,
producing a ball of cells termed a morula (L. mulberry). muscle, fascia, dermis and the sheaths of peripheral
nerves). Mesoderm also forms vessels (only mesoderm-
derived structures are vascular).
157
HUMAN DEVELOPMENT AND VARIATION
Features of a foetus
158
18. Growth and Development
cranial bones also slide over each other allowing moulding POSTNATAL GROWTH AND DEVELOPMENT
of the cranium as the foetus passes along the birth canal.
General features of a neonate
Foetal circulation
The postnatal period of growth and development occurs
The placenta, forming part of the internal lining of the until maturity. Infancy is the first year (including the
uterus, is the site of exchange between maternal and foetal neonatal phase for the first four weeks after birth).
blood vessels, providing oxygen and nutrition (while The neonate (L. new + birth) is a full-term infant,
removing carbon dioxide and wastes) throughout prenatal delivered between 37 and 42 weeks. Neonates delivered
life. The umbilical cord is the connection to the placenta. before 37 weeks are pre-term (or premature) while those
delivered after 42 weeks are post-term. The neonatal
phase is associated with rapid maturation and growth of all
organ systems.
159
HUMAN DEVELOPMENT AND VARIATION
Neonatal head and neck The sacrum is more upright than in the adult, as is the
iliac bone, contributing to the small, funnel-shape of the
At birth the brain is large relative to the rest of the body
pelvis.
and so is the skull accommodating it (the head represents
approximately 30% of the newborn body mass). The bones Changes to head and neck during infancy
of the cranial vault are ossified in membrane and at birth
are separated by fontanelles (L. small fountains), gaps The fontanelles of the cranium commence closure
during infancy. The frontal and mental sutures begin to
filled with fibrous tissue. The anterior fontanelle is the
largest (about 2.5 cm across). disappear (resulting in a single frontal bone and a single
mandible).
At approximately 6 months the primary (deciduous)
dentition begins to appear. Lower central incisors erupt
first and by the end of the first year both upper and lower
central and lateral incisors have usually erupted.
The neck lengthens and the larynx (with its epiglottis)
descends. This elongates the pharynx, creating a region
(the oropharynx) between the soft palate and the larynx
enabling phonation. However, the capacity to
simultaneously breathe and swallow is lost. Weaning
normally occurs during the first year, when the infant
Fig.18.14 Fontanelles in a newborns skull accepts foods other than milk.
The cranial bones become united at fibrous joints
termed sutures. The frontal bone is in two halves, joined in Changes to trunk and limbs during infancy
the midline at the frontal suture. Secondary curvatures of the spine form during
The external auditory meatus consists of only a infancy. The cervical curvature appears when the head is
cartilaginous part. The tympanic membrane is superficial held erect and the lumbar curvature when walking
and prone to be damaged unless care is taken during commences. At birth, the bones of the pelvis and lower
examination with an otoscope. The mastoid process is not limb are less advanced than those of the pectoral girdle
developed, exposing the facial nerve, which is endangered and upper limb but catch up by growing at a faster rate
in a forceps delivery. The mandible is small, with two during infancy. The concavity of the sacrum increases as
halves joined in the midline at the mandibular symphysis the infant begins to crawl, the bones of the pelvis become
(mental suture). Generally no teeth are present at birth. stronger and the acetabulum deepens. The feet are
inverted and appear to lack arches (due to the presence of
a large fat pad).
The infants high centre of gravity (at the level of the
umbilicus) accentuates instability when the first attempts
are made to walk.
Features of a child
Childhood may be divided into two phases, early
childhood (years1-6) and late childhood (about years 7-13).
In childhood the remaining secondary centres of
ossification appear, as well as primary centres in short
bones (of the hand and foot).
160
18. Growth and Development
161
Chapter 19: Normal Variation
Prostatic enlargement
The prostate gland tends to enlarge with age.
Eventually, elderly men tend to have associated
enlargement of the bladder due to increased thickness of
its muscle wall (hypertrophy). This is a consequence of
urethral obstruction (distal to the bladder neck) caused by
enlargement of the surrounding prostate.
There is no abrupt cessation of spermatogenesis,
although there is a gradual reduction in hormone
Fig.19.2 Lymphoid organs involute first production from the testes. The stage of decreasing
162
19. Normal Variation
Senescence
Senescence (L. growing old) refers to the changes
that take place in the elderly. Adulthood may last for 40
years (from about age 20 to 60 years) while old age is from
about 60 years to death. Normal life expectancy in western
societies is approximately 80 years (females slightly
greater than males).
Normal aging processes may merge with pathological
changes (especially degenerative disorders). Bone mass
decreases gradually with loss of collagen and of calcium.
Osteoporosis (G. bone + porous) results in thinning of
bony trabeculae with an increase in susceptibility to
fracture and delayed healing.
Thinning of articular cartilage exposes underlying bone
to increased stress while loss of water in the nucleus
pulposus of intervertebral discs produces narrowing of disc
spaces and loss of height. Soft tissues tend to calcify and
skeletal muscles atrophy.
Sutures of the skull begin to fuse. Teeth deteriorate
through gum disease (gingivitis) and tend to fall out.
Alveolar bone is exposed and the body of the mandible is
resorbed (especially in the edentulous).
Skin loses its elasticity and pigmentation. Hair of the
head tends to become grey and may fall out. This occurs
particularly in males although coarse hair appears, Fig.19.4 Sex differences in the pelvis
especially in the nostrils and external ear. There is loss of
elasticity throughout the cardiovascular system, including Obstetric assessment of pelvic dimensions
arteries, which also become harder (arteriosclerosis) and Dimensions of the birth canal indicate the probability of
more tortuous. obstetric complications due to bony limitations.
The weight of the brain tends to decrease especially the
frontal lobes with fissures becoming deeper and wider than Heavy, medium and light build
in the young. Due to genetic, hormonal and environmental factors
there is considerable normal variation in body size (both
SEX AND BODY BUILD DIFFERENCES height and weight) and body build. This also applies to
dimensions of particular body parts and even individual
Aside from reproductive organs, there are certain organs. Body build may be regarded as heavy, medium or
differences between typical males and typical females light.
elsewhere, particularly in the musculoskeletal system.
However, there is also a range of variation that blurs the
distinction between the sexes.
163
HUMAN DEVELOPMENT AND VARIATION
In general, males tend to be larger and of a heavier The most mobile viscera are those suspended by a
build than females. However, there is considerable mesentery.
variation between the sexes, as well as between, and
within, different racial groups, let alone age groups. The stomach and transverse colon are especially
mobile, with mesenteries of considerable length. In certain
Vulnerability to fractures from a fall individuals the stomach or transverse colon may even
Lightly built elderly females are particularly vulnerable descend into the pelvis.
to bone fractures from a fall. In this group, the surgical neck
of the humerus or lower end of the radius is particularly
endangered from a fall on the outstretched hand and the
neck of the femur is endangered from a fall on the hip
FUNCTIONAL DIFFERENCES
Normal variation in size, shape or position of organs
may occur due to functional differences.
The major physiological factors influencing anatomy are
posture, phase of respiration and pregnancy. These
particularly apply to mobile or expansile viscera. Other Fig.19.7 Movement of organs during breathing
factors include exercise (e.g. on skeletal muscles and the During inspiration the lungs expand and viscera directly
cardiovascular system), presence of contents (e.g. food below the diaphragm, particularly the liver (and gall
and fluid in the gastrointestinal tract) or activation (e.g. of bladder), spleen and kidneys, are pushed downwards as it
erectile tissue). descends.
Normal variation with posture Palpating abdominal organs on inspiration
When standing, due to gravity, all abdominal viscera Physical examination of abdominal organs includes
descend, particularly those that are more mobile. attempting to palpate them on full inspiration.
164
19. Normal Variation
165
Chapter 20: Anatomical Variation in Structure
SIZE OR SHAPE
FEATURES OR ATTACHMENT
PRESENCE OR PERSISTENCE
FUSION OR SEPARATION
NUMBER OR DUPLICATION
Fig.20.2 Variation in size of arterial branches
166
20. Anatomical Variation in Structure
167
HUMAN DEVELOPMENT AND VARIATION
rib or down to the sixth rib (incidence: about 15%) from its
normal attachment to the third, fourth and fifth ribs. The
insertion of the tendon of peroneus longus may fall short in
its migration across the foot, attaching to the base of the
second metatarsal instead of to the first. Additional slips or
heads of muscles are common (e.g. three heads of biceps
brachii or three insertions of coracobrachialis). These
normally occur in certain primates and are generally
curiosities in man, rather than of clinical significance. There
appears to be no functional disadvantage (they may even
provide some advantage).
168
20. Anatomical Variation in Structure
169
HUMAN DEVELOPMENT AND VARIATION
170
20. Anatomical Variation in Structure
In cranial shift, sacralisation of L5 is associated with Accessory suprarenal tissue (about 22%) can lie in the
non-fusion of the fifth piece of the sacrum (and fusion of S5 kidney, testis or scattered on the posterior abdominal wall.
to the coccyx), a short twelfth rib (resembling a transverse
process) and the presence of a rib on the seventh cervical
vertebra (cervical rib). In caudal shift, lumbarisation of the
sacrum is associated with non-fusion of the first coccygeal
vertebra (and fusion of it to the sacrum), a long twelfth rib
and the presence of a rib on the first lumbar vertebra
(lumbar rib). An alteration in the number of vertebrae may
also be associated with anomalies in the corresponding
contributions of spinal nerves to limb plexuses (e.g.
resulting in pre-fixed or post-fixed plexuses).
NUMBER OR DUPLICATION
Supernumerary and accessory arteries
Supernumerary (L. above + number) arteries arise
when one or more additional arteries branch from the same
arterial stem and they are equivalent in size. With
supernumerary arteries it is difficult to distinguish which is
the normal one. An accessory artery is the artery that is Fig.20.19 Potential sites of supernumerary nipples
clearly additional to the normal one. It may even start from
a different arterial stem (an aberrant accessory artery). Double and bifid structures
Supernumerary and accessory arteries occur when more Duplication of a ureter or the pelvis of the kidney, (about
than one of the multiple arterial channels that appear 1%), may be present unilaterally or bilaterally. Partial
during development is retained. A succession of renal duplication creates a bifid ureter or a bifid renal pelvis
arteries arises from the aorta (and normally disappears) as (about 1% each). Such anomalies may be associated with
the kidneys migrate upwards from the pelvis to their final recurrent urinary tract infection.
position in the abdomen. Supernumerary or accessory
renal arteries (about 25%) result if these intermediary
arteries do not disappear.
Accessory nerves
An accessory phrenic nerve can occur in addition to the
phrenic nerve (which arises from the cervical plexus). It is a
small nerve that arises from the nerve to subclavius and
may accompany the phrenic nerve and even join it. The
accessory obturator nerve (about 0.8%) is an additional Fig.20.20 Complete and partial duplication of ureters
branch from the lumbar plexus.
Bifid ribs (about 1%) can arise by duplication of part of
Accessory organs and tissue the rib body. A double aortic arch encircling the
Supernumerary nipples (about 1%) may occur oesophagus and trachea is a rare anomaly caused by
anywhere along the milk line (between the axilla and the retention of part of the original embryonic arterial pattern
thigh). They may even be associated with breast tissue. (six pairs of arches associated with the primitive aorta). It is
Many other animals, particularly those that produce litters, a normal feature in certain other animals (e.g. frogs). A
have multiple breasts (bilaterally) along each milk line. double vagina (or vaginal septum) and/or double uterus
Accessory spleens (about 10%) termed splenunculi, are (about 0.1%) are uncommon human variants. However,
aggregations of splenic tissue along the course of the multiple uterine horns occur in mammals that produce
splenic artery. They enlarge after splenectomy. litters.
Accessory hepatic ducts (about 7%) can arise from the
liver and join the common hepatic duct, or the cystic duct.
They are endangered in gall bladder surgery.
171
Chapter 21: Anatomical Variation in Position
SIDE OR COMMUNICATION
Vessels on opposite side of body
Fig.21.1 Failed ascent of left kidney A left sided superior vena cava and/or a left-sided inferior
vena cava may be present. The vena cava develop from a
The thyroid gland sometimes does not descend into the complex bilateral set of venous channels (cardinal veins)
neck from its origin (the foramen caecum) on the dorsum of which typically disappear on the left but may abnormally
the tongue, but remains as a lingual thyroid (about 0.3%). disappear on the right instead, or at least persist on the left.
172
21. Anatomical Variation in Position
There may be no impaired function (at least overtly). Variable patterns of communication between individual
However, a left superior vena cava drains into the coronary synovial tendon sheaths of the digits with the common
sinus prior to entering the right atrium, creating gross synovial tendon sheath in the hand may occur (about 28%).
enlargement of this vein.
ORIGIN OR BRANCHING
Aberrant arteries
An aberrant (L. straying) artery arises from a different
artery.
Aberrant arteries tend to arise from a neighbouring
artery, close to the normal artery of origin. An aberrant left
vertebral artery arises from the arch of the aorta (about 5%)
instead of the left subclavian artery. An aberrant superior
thyroid artery arises from the common carotid artery rather
than the external carotid.
Situs inversus
Fig.21.4 Aberrant left vertebral artery
Rarely there may be a complete situs inversus (about
0.01%) where the thoracoabdominal viscera are in mirror An aberrant cystic artery (to the gallbladder) arises from
image to normal. The heart may be situated on the right neighbouring arteries and not from the right hepatic (its
side of the body, termed dextrocardia (in an additional usual origin). Anomalous origins include from the left
0.01%). hepatic artery (about 6%), the common hepatic artery
Patients with Kartageners syndrome present with situs (about 2%) or the gastroduodenal artery (about 2%). An
inversus, respiratory infections and male sterility. The aberrant dorsal pancreatic artery arises from the coeliac
common factor is a defect in motility of cilia on all ciliated trunk instead of the splenic artery.
cells. Arteries that normally arise from a common trunk may
instead arise independently. An aberrant right hepatic
Patent endothelial channels artery can arise from the superior mesenteric artery (about
Abnormal communications may occur from endothelial 12%) instead of the common hepatic artery. A branch of
channels failing to close during development. the thyrocervical trunk may arise directly from the
subclavian artery. Aberrant circumflex femoral arteries can
A probe-patent foramen ovale (about 25%) occurs arise directly from the femoral artery instead of the
without any functional impairment, as its overlying flap beginning of the profunda femoris artery. Aberrant
remains apposed during life. In contrast, an atrial septal perforating branches can arise from the femoral artery
defect is regarded as a congenital malformation, being an rather than the profunda femoris artery. An aberrant
open pathway allowing shunting of blood. posterior circumflex humeral artery can arise from the
subscapular artery (about 20%) instead of the axillary
Patent mesothelial channels artery and an aberrant profunda brachii artery can arise
The testis descends into the scrotum with a from the posterior circumflex humeral artery (about 7%)
prolongation of the peritoneal cavity (the processus instead of the brachial artery.
vaginalis), which normally closes prior to birth. A patent Aberrant arteries may also occur in addition to, rather
processus vaginalis through the inguinal canal into the than instead of, the normal artery. Such aberrant arteries
scrotum predisposes to an indirect inguinal hernia. are termed aberrant accessory arteries.
173
HUMAN DEVELOPMENT AND VARIATION
A left hepatic artery can arise from the left gastric artery
(about 22%) instead of, or as well as, from the normal
origin (the common hepatic artery). Half of these aberrant
accessory hepatic arteries arise from the left gastric artery
in addition to a normal left hepatic artery.
174
21. Anatomical Variation in Position
175
HUMAN DEVELOPMENT AND VARIATION
ENDING OR DISTRIBUTION may terminate in the femoral vein. The external jugular vein
may terminate in the cephalic vein (and pass superficial to
Abnormal duct termination the clavicle prior to this).
The cystic duct may terminate lower than normal on the Arterial dominance
common hepatic duct or drain abnormally into the right
hepatic duct at a higher level. The pattern of vascular distribution is compensatory. If
The bile duct and main pancreatic duct may terminate one territory is larger (from arterial dominance) a
separately on the duodenal papilla (about 5%). In about 9% neighbouring territory tends to be smaller.
of cases, the accessory pancreatic duct does not open into The heart is supplied by the left and right coronary
the duodenum (about 50%) but into the main pancreatic arteries. Typically, the right coronary artery provides the
duct. posterior interventricular branch also known as the
posterior descending artery (PDA). It supplies territory
Abnormal arterial termination beyond the posterior interventricular groove. This is termed
right dominance.
The arterial circulus vasculosus (circle of Willis) at the
base of the brain is created by the terminations of the two
internal carotid and two vertebral arteries (via the basilar
artery) that form the anterior, middle and posterior cerebral
arteries. This anastomosis is typically completed by an
anterior and a pair of posterior communicating branches
(between the anterior cerebral arteries and between the
middle and posterior cerebral arteries, respectively). The
normal pattern occurs in just over 50%, with the most
common variant being absent or small posterior
communicating arteries (about 20%). There are also
variations in the relative sizes and distributions of the
cerebral arteries, which can also be asymmetrical.
Spontaneous abortions
About 50% of conceptions do not result in a live birth
but spontaneously abort early (and if prior to implantation,
Fig.22.1 Defective closure of interatrial septum
undetected). At least half have severe chromosomal
abnormalities.
177
HUMAN DEVELOPMENT AND VARIATION
Defective closure of the distal part of the urethra results sinus, fistula or cyst (incidence: about 1%) is not
in hypospadias (about 0.3%). uncommon, although a branchial fistula or cyst is rare.
A patent ductus arteriosus (about 0.2%) may persist, An undescended testis (about 0.3%) results from failure
rather than closing at birth. of a testis to migrate into the scrotum. Although a testis has
Communication between the pleural and peritoneal not quite reached the scrotum in 3% of full term births and
cavities may persist causing a congenital diaphragmatic in 30% of premature births, it does so soon after. An
hernia (about 0.005%) with a large part of the stomach ectopic testis is one that has migrated to a site other than
lying in the chest. However, a minor deficiency at the left the scrotum. Malrotation of the gut may occur.
vertebrocostal trigone of the diaphragm is not uncommon, Failure of ganglia to migrate from the neural crest to the
with the left kidney lying in contact with pleura. wall of the large intestine results in congenital megacolon
The umbilicus may rarely fail to close resulting in an (Hirschsprungs disease).
omphalocoele with large herniation of gut, although a minor Transposition of great vessels occurs with the aorta and
congenital umbilical hernia (about 15%) may be present for pulmonary trunk in the heart.
a short time after birth.
Failure of a lip or the palate to unite may result in hare Defective opening or formation
lip and/or cleft palate (about 0.1%). Defective opening or canalisation may occur with tubes
A congenital cerebral aneurysm results from deficiency or tubules.
of the media of arteries at a branch point in the circle of Oesophageal atresia, intestinal atresia and biliary
Willis (about 1%). atresia result from failure of the lumen to canalise .
Spina bifida cystica (about 0.1%) is a serious defect Imperforate hymen and imperforate anus (about 0.02%)
involving exposure of the coverings of the spinal cord result from defective opening of the cloacal membrane.
(meningocoele) or even the spinal cord/cauda equina in Polycystic kidneys (about 0.2%) occur when tubules of
addition (meningo-myelocoele). the nephron fail to open into those derived from the ureteric
bud. Multiple cysts occur in polycystic liver and in cystic
fibrosis of the pancreas.
178
22. Pathological Changes
179
HUMAN DEVELOPMENT AND VARIATION
180
Section V
PRACTICAL PERSPECTIVES
181
Introduction: Anatomy involves exploration
Endoscopic anatomy is the basis for interpreting
views of the body from within which also may be applied in
new surgical techniques.
Endoscopy (G. within+look) is a procedure utilising a
long optical instrument (an endoscope) to illuminate and
view the interior of a (living) body. The endoscope may be
a rigid straight tube or a flexible fibre optic cord. There are
two types of avenues for endoscopy. An endoscope may
be passed along the lumen of a viscus (e.g... stomach,
colon or bladder) via a normal opening on the exterior of
the body (e.g... mouth, anus or urethra). Alternatively, a
portal may be created by an incision to enable access into
a body cavity (e.g... peritoneal cavity, pleural cavities), a
Exploring a living body joint cavity (e.g... shoulder joint, knee joint) or even a
Examining, investigating or treating a patient is a region (carpal tunnel, mediastinum). Endoscopy may also
privilege and even if non-invasive, require informed provide a route for surgical and/or imaging procedures.
consent. Practical (including emergency) diagnostic and
Surface anatomy (including projections of underlying treatment procedures may be required of a first port-of-call
organs) together with functional anatomy (movements doctor. They are invasive and may involve manipulation of
actions and reflexes) forms the basis for conducting a tissues (e.g. with the aid of surgical instruments) as well as
physical examination. piercing them. Ideally, procedures should be rehearsed on
Radiographic anatomy forms the basis for interpreting (dead) cadavers rather than performed for the first time on
the findings of imaging investigations. (live) patients.
In plain radiography, an X-ray film (radiograph) is a In addition to knowledge of relevant surface markings,
two dimensional representation of a three dimensional the anatomical basis of a procedure specifically requires
entity. The images comprise superimposed components, awareness of the:
which correspond to the actual anatomical structures. In - anatomical factors in selecting an appropriate site
order to identify them and understand their relationships, - anatomical structures observed, palpated or pierced
each component of an image is analysed by following the - anatomical hazards that may be encountered en route
path of the X-ray beam through the living body (from the (i.e. structures endangered by the procedure).
source to the X-ray film). Different types of anatomical The associated clinical techniques and judgements are
structures absorb X-rays to different degrees (which beyond the scope of this book (with readers strongly
determine their radiodensity). On a radiograph, structures advised to confirm that these comply with accepted current
containing air which does not absorb X-rays (hence standards of practice).
radiolucent) appear black, while structures such as
compact bone which absorb X-rays (hence radiodense) Exploring a dead body
appear white. Soft tissues are of intermediate radiodensity. Viewing body parts, attending an autopsy or dissecting
Hollow viscera are made of soft tissue density. Although a human body are also privileges and require permission,
certain hollow viscera contain a variable amount of gas, usually within the context of a certified professional course.
demonstration of the lumen and examination of the mucosa Respect for the deceased is important at all times.
is made impossible if the viscus is collapsed (as the two An autopsy (G. self + view) or postmortem (L. after
soft tissue density walls do not make a contrast edge). death) is performed as soon as possible to determine the
Similarly, blood vessels are made of soft tissue walls cause of death. During an autopsy, the body is examined
(unless pathologically calcified) and contain blood (which is internally and externally as a prelude to microscopic
also of the soft tissue density). In contrast studies, examination and laboratory analysis. Organs can be
radiographic examination of certain viscera, cavities and examined with the naked eye; in situ, following excision
vessels can be achieved by utilising a contrast material. and then in cut section.
Sectional anatomy involves the appearance of the Dissection (L. apart + cut) provides a unique learning
body at a variety of levels and planes, particularly those of experience into the structure of the body. A dead human
clinical importance. It forms the basis for interpreting CT, body used for dissection is termed a cadaver (L. fallen).
MR and Ultrasound images. Cadavers are preserved by the infusion of embalming fluid
Computed Tomography (CT) is a technique displaying into the vascular system. Embalming fluid (typically
a cross-sectional image of a living body using X-rays (by including formaldehyde, phenol, ethanol and glycerol)
rotating the X-ray source and its detector around the long permeates the entire body, disinfecting, fixing and
axis of the body). As with radiographs, the images are moisturising tissues. In dissection, a regional approach is
based on the differing radiodensities of different types of generally adopted. Each region is dissected layer-by-layer,
anatomical structures. from superficial to deep.
Magnetic Resonance Imaging (MRI) is a multi-planar In authorised departments of anatomy, body parts and
technique displaying sectional images that does not involve organs may be utilised as predissected wet specimens.
the transmission of X-rays. MRI is based on recording radio These can be stored in tanks or mounted in pots for further
signals emitted from a living body placed within a strong study. Plastinated specimens can be obtained from
magnetic field following transmission of radio frequency special techniques that replace organic tissue with
pulses into it or with rapid magnetic field changes. synthetic material. Individual bones or even the whole
Ultrasound (US) imaging techniques use specific skeleton (G. dried up may be obtained when cartilage,
acoustic densities of different tissues to identify interfaces. periosteum and bone marrow has been removed.
The final image is a cross sectional image composed of In forensic osteology and odontology, skeletal and
many vertical lines, which together outline an image based dental remains as well as radiographs are examined to
on these acoustic interfaces. Different types of tissues are determine sex, age and possible causes of death.
characterised by an ultrasound scale.
182
Chapter 23: Surface and Functional Anatomy
SURFACE REGIONS
183
PRACTICAL PERSPECTIVES
1. - pectoral region
2. - axilla
3. - anterior compartment of arm
4. - cubital fossa
5. - anterior compartment of forearm
6. - carpal tunnel
7. - palm of hand
8. - palmar aspect of digits
9. - scapular region
10- deltoid region
11. - posterior compartment of arm
12. - posterior compartment of forearm
13. - anatomical snuffbox
14- dorsum of hand
15. - dorsal aspect of digits
184
23. Surface and Functional Anatomy
Bony landmarks
Fig.23.10
Fig.23.9
Fig.23.13
Fig.23.11
Fig.23.14
186
23. Surface and Functional Anatomy
187
PRACTICAL PERSPECTIVES
Fig.23.20
188
23. Surface and Functional Anatomy
Fig.23.24
Muscle function
Assessment of muscle function
Muscle function may be tested using active range or
resisted contraction. A movement at a joint is active when
it is directly due to contraction of its associated muscles.
Active movements may also be assisted (active
assistance) or resisted (active resistance) by an external
agent. In clinical assessment of muscle function, the active
range of movement (associated with muscle contraction) is
Fig.23.27 compared to the passive range (allowed by joint mobility),
189
PRACTICAL PERSPECTIVES
to determine which structures may limit movement (or Somatic and visceral reflexes
produce pain).
There are two major types of reflexes: somatic and
Muscle strength is gauged by the degree of active
visceral.
resistance required to prevent movement.
With somatic reflexes the effectors are skeletal
muscles, while with visceral reflexes the effectors are
Assessing muscle tone and wasting smooth muscle, cardiac muscle or glands. Somatic reflexes
may be subdivided into superficial and deep according to
Skeletal muscle tone and its assessment the afferent nerve fibre type. Superficial somatic
Skeletal muscle tone (G. tension) is measured as (cutaneous) reflexes (e.g. withdrawal reflexes) arise from
resistance to stretch. Muscle tone is under reflex control. It skin.
is dependent on a nerve supply (both motor and sensory) A special group of superficial reflexes (e.g. cough and
and is modulated by the recruitment of more or fewer motor swallow reflexes) arise from mucous membranes, although
units. they involve skeletal muscle effectors. Deep somatic
Skeletal muscle tone may be either increased or (proprioceptive) reflexes (e.g. stretch reflexes and tendon
decreased by certain lesions of the nervous system. jerks) arise from skeletal muscles and joints. Visceral
Assessment of skeletal muscle tone involves resistance to reflexes include pupillary, lacrimal, salivary, baroreceptor
stretch of a major muscle group ideally through its full and chemoreceptor reflexes.
range of movement (with increasing velocity). This is an
important step in a neurological examination.
Fig.23.
190
23. Surface and Functional Anatomy
BIPEDAL LOCOMOTION
In contrast to standing where muscular effort is
conserved, bipedal locomotion enlists the actions of
many muscles.
Walking on level ground involves cycles (between heel-
strike of the same foot) of swing (limb not in contact with
the ground) phase and stance (weight bearing) phase.
Muscles not only act to accelerate the swinging lower limb
(from the beginning of swing phase to mid-swing), but also
to decelerate it (from mid-swing to the end of swing phase).
191
Chapter 24: Radiographic Anatomy and Imaging
Recording media
On specially designed receptor materials (X-ray film
and image intensifier screens), X-rays produce a short, tiny
burst of light for every X-ray photon that is absorbed. This
flash of light is recorded as a single dot on the X-ray film, or
as a single impulse in a digital image. An X-ray image
comprises millions of such dots.
The X-ray film is still the most commonly used
recording medium in radiography. Once exposed, the X-ray
film is called a radiograph (or an X-ray image).
Unexposed film consists of a plastic sheet covered with an
emulsion sensitive to the visible light (photo-sensitivity) and
Fig. 24.1 Context for a plain radiograph X-rays (radio-sensitivity). The exposure to the X-ray
radiation, followed by the interaction with a developer,
X-rays results in chemical changes characterised by deposition of
X-rays are electromagnetic waves of radiation of a very the metallic silver in the emulsion, which produces
short wavelength (only about 1/10,000 the wavelength of blackness on the film.
visible light).
In the electromagnetic spectrum, the shorter the The intensity of blackness on a radiograph is directly
wavelength of radiation, the greater the energy of radiation. proportional to the intensity of radiation which reaches
the film.
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24. Radiographic Anatomy and Imaging
RADIODENSITIES OF TISSUES
Effects of X-rays on tissues
In living tissues, X-rays can either cause no effect (pass
through unchanged), or become absorbed or deflected.
When an X-ray (more specifically an X-ray photon to
differentiate it from colloquial uses of the word X-ray) is
absorbed or deflected, all or some of its energy
(respectively) is absorbed by tissue electrons, which in turn
are knocked out of their usual energy levels (orbitals or
shells). This knocking out can ionise atoms and
molecules (ionisation: loss of an electron by an atom, to
acquire an overall electrical charge). Most of the time,
ionisation reverses almost immediately, without any effects.
However, it potentially has biochemical consequences
via ionisation of living molecules. DNA in particular may be
affected. X-rays can have both cancer-killing and cancer-
promoting effects.
The gonads of both the patient and staff should be
shielded from X-ray exposure by an appropriate covering Fig. 24.3 Tissue radiodensities on a plain film
(e.g. a lead apron). An embryo is potentially vulnerable to
radiation, particularly during organ development and it is The air density includes gases (which are normally
important to be aware of the possibility of an unsuspected present in some hollow viscera) as well as air in air
pregnancy. For women of reproductive age, pelvic or sinuses.
abdominal radiography should be performed within two Soft tissues include all body fluids, muscles, water,
weeks of the onset of menstruation. cartilage, liquid bowel contents and parenchymal organs.
Bone density includes teeth.
Attenuation of X-ray beam A fifth non-anatomical density, often seen in
X-rays interact with different tissues of the body. As an radiographs, is that of metal, which is much denser than
X-ray beam penetrates through the body it progressively bone (e.g. total hip prostheses, fracture fixation plates,
loses X-ray photons (i.e. the beam becomes less intense). prosthetic heart valves, etc). Other commonly used
X-rays which are stopped (absorbed) or deflected prosthetic and medical device materials include plastics
(scattered) by the tissue they pass through are excluded and silicones, which have densities close to that of soft
from the beam. This reduction in intensity of the X-ray tissue (but often have a radiodense stripe or marker to
beam is termed attenuation. make identification easier).
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PRACTICAL PERSPECTIVES
RADIOGRAPHIC VIEWS
Images of the same structure from different angles are
termed radiographic views (or projections).
Radiographs are two-dimensional images of three-
dimensional structures positioned between the source of X-
rays (the X-ray tube) and the film. Not only is the anatomy
collapsed into a flat image on the film but structures are
superimposed on each other without indication of their
Fig. 24.4 How various densities appear on a film order.
Each view provides an image of an object from a
Radiological interfaces different angle.
An interface is created when different anatomical
structures lie in contact with each other. An object is usually radiographed in at least two
projections at right angles to each other.
A radiological interface is created when tissues of
different radiodensity lie adjacent to each other. This enables the viewer to construct a 3-dimensional
mental image from the complementary pair of flat (2-
Depending on the positioning relative to the path of the dimensional) radiographs. It also enables superimposed
x-rays, these radiological interfaces may or may not be (overlying) structures to be identified as separate entities.
visible on a radiograph.
Types of radiographic views
Lines on a radiograph The name of a projection (and its abbreviation) is
Lines (or edges) may be seen on a radiograph when derived either from the direction of the X-ray beam or from
radiological interfaces are parallel to the path of the X- the position of the object relative to the recording medium.
rays. The front-to-back view is known as anteroposterior (A-P)
and the back-to-front is posteroanterior (P-A). These
describe the direction of an X-ray beam, with the X-ray film
being always close to their exit from the body.
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24. Radiographic Anatomy and Imaging
An A-P view and a lateral view are standard Sharpness is a descriptive term that conveys the
radiographic views. They are sufficient for many success with which thin interfaces are depicted as thin on
radiological examinations, being at right angles to each the image. A sharp edge retains its pencil-thin quality (e.g.
other. bone cortex interface with muscle). An unsharp edge is
Sometimes, a particularly important structure can be where an interface appears smeared or blurred on the
visualised optimally only if an oblique view is obtained as image. Unsharpness is due to the inevitable blurring of thin
well. In those instances the oblique view becomes a interfaces and edges that occur on all films. When severe,
standard view in addition to the A-P view and a lateral view. unsharpness will limit the diagnostic interpretation of the
film.
Geometric unsharpness is the result of the X-ray tube
source being a finite size and not a true point source. This
produces half-shadows (penumbras) which lead to
blurring of otherwise sharp edges.
Looking at a radiograph
The image, whether an AP or PA view, is looked at as if
facing the patient. The patients right is on the observers Fig. 24.8 Geometric and motion unsharpness
left and vice versa. R and L are marked on a radiograph
Because of natural magnification of the image with
to indicate the respective side.
increasing object-film distance, geometric unsharpness is
For lateral and oblique projections, abbreviations
worst for structures furthest from the film (and, by corollary,
indicate which aspect of the body is adjacent to the film.
closest to the X-ray tube). For the same reasons, the
Right lateral (R lateral) view indicates that the right aspect
greater the source-object distance compared to the object-
of the imaged body part is placed against the film. Right
film distance, the less is the geometric unsharpness. In
anterior oblique (RAO) view indicates the positioning of
part, this is why chest X-rays are taken with a large source-
the right antero-lateral aspect of the body against the film.
object distance.
Motion unsharpness is the result of the edge moving
PROPERTIES OF PLAIN RADIOGRAPHS while the film is being exposed. Motion unsharpness
produces the X-ray equivalent of photographic blur when a
The quality of an image on a radiograph depends on fast moving object is photographed with a long exposure.
the ability to record closely placed objects (particularly if Therefore, radiographs of moving objects (such as the
they are of similar densities) as separate entities. heart and pulmonary vessels) are taken with as short an
Film penetration and sharpness exposure as possible. For the same reason, a patient may
be asked to keep still, not to breathe, or not to swallow
How black (or white) the overall film is and how sharp during certain exposures.
(or unsharp) the edges on it are will determine the ability to
interpret the image. Image resolution and noise
The degree of penetration of the film will limit the
Capacity of an imaging system to register very small,
viewers ability to tell different tissues from each other. A closely positioned objects as two separate objects and to
film that is overpenetrated is too black; a film that is present them as distinct images is known as the resolving
underpenetrated is too white. A correctly exposed film power or spatial resolution of the system. The greater the
(correctly penetrated) has a full range of white, grey, and resolution, the smaller are the objects that can be identified
black shades. A film that is underpenetrated will lose most as separate.
tissues other than the blackest (e.g. air in lungs). A film that Image noise describes the point-to-point variation in
is overpenetrated will lose all tissues other than the whitest image optical density, where a uniform image is expected.
(e.g. bones). While an image that is too black can be partly It is the visual equivalent of background noise produced by
compensated by bright light translumination, an image that an audio system in place of expected total silence. Image
is too white cannot be manipulated further. noise limits the contrast resolution of an imaging system
With the introduction of digital radiography the problem (i.e. the ability to distinguish radiographic density
of incorrect exposure leading to under or overpenetration of differences between two objects, particularly if the objects
the film will become largely overcome because of very wide are small). In radiographs or scans taken with progressively
optical latitude of the digital receptor, so that incorrect lower exposure, image noise makes up a progressively
exposure can be compensated by window and level greater proportion of the total imaging signal. Therefore,
manipulation of the resulting data set.
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PRACTICAL PERSPECTIVES
reducing X-ray exposure parameters (to reduce patient X- When the anterior aspect of the body (or a part of the
ray dose) will eventually produce a non-diagnostic image. body) needs to be least magnified and distorted on a
radiograph, a P-A view is chosen.
Magnification and distortion For example in a routine chest X-ray, the heart and lung
X-rays being divergent, will magnify the image of any hila (both nearer to the anterior thoracic wall) are of more
structure in their path in the same way as a point source of interest than the spine. The patient is positioned with the
light will magnify shadows. The closer an object is to the front of the chest leaning against the X-ray film (while the
film, the less will be its magnification. The further an X-ray source is located behind the middle of the patients
object is away from the film (and by corollary the closer it is back).
to the X-ray source), the greater will be its magnification.
The X-ray beam cone has a central ray, and peripheral Superimposition and summation
rays symmetrically distributed on either side. Because the An overlap (partial or total) of images of structures
peripheral rays have a longer path than the central rays, positioned in the path of the X-ray beam is termed
structures imaged by the peripheral rays will be magnified superimposition. The order of these structures is not
more than structures in the path of the central ray. evident from the X-ray image alone, but can be correctly
The combination of progressive magnification and mis- determined by combining the skill of thinking in layers
mapping of structures that lie progressively further away when looking a radiograph (enhanced by experience) with
from the central ray produces distortion. good knowledge of anatomy. This combination of skill with
knowledge is particularly required to interpret images of
Structures of most interest should be placed centrally complex structures (e.g. skull or vertebral column).
within the X-ray beam.
BONES ON RADIOGRAPHS
Bones, being very radiodense, are easily identifiable on
a plain X-ray film because of their contrast with surrounding
structures. Each type of bone has a particular radiographic
appearance.
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24. Radiographic Anatomy and Imaging
Compact bone (densely packed bone tissue infiltrated each other. Hence, a careful layer-by-layer approach is
with calcium) appears more opaque than cancellous necessary.
bone (containing many little compartments).
Short and irregular bones on images Fig. 24.15 Flat and pneumatic bones (skull)
In short and irregular bones, the thin compact layer Certain skull bones have air-filled cavities (the
present on the surface of bones is clearly seen only when paranasal sinuses), appearing as paired, clearly
the X-rays are parallel with these surfaces. demarcated lucent areas (air radiodensity) of variable size.
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PRACTICAL PERSPECTIVES
Margins of every normal bone on a radiograph A radiolucent gap seen on the radiograph of a growing
(regardless of size, shape and complexity) should appear bone between the primary and secondary ossification
as sharp, clear and continuous lines demarcating the edge centres (or between epiphysis and metaphysis in long
of the bone from the surrounding tissues. bones), represents the epiphysial (growth) plate. The
Trabecular patterns within cancellous bone should form radiolucency is due to soft tissue epiphysial cartilage that is
clear and continuous parallel lines where present. end-on to the X-ray beam.
Optimal bony alignment (and immobilisation to maintain Zones of calcified cartilage form thin but distinguishable
it) is crucial in fracture management. white (radiopaque) lines clearly demarcating the epiphysial
plate from surrounding bone tissue.
Ossification centres
In the developing skeleton, primary centres of Epiphysial lines
ossification (except for the short bones of the wrist and Growth of bones finishes with closure of the epiphysial
foot) appear well before birth. Further development and (growth) plates. Calcified cartilage from the margins of the
growth of certain bones occur until the end of adolescence. epiphysial plate extends into its middle converting it to
Secondary centres of ossification (epiphyses) appear bone. With time, this area becomes thinner and merges
at different ages in cartilaginous parts of developing with nearby trabeculae. However, a fine line of compact
skeletal elements. They appear on radiographs as small bone, termed the epiphysial line, usually persists
and irregular (often nodular) radiopacities representing throughout life.
calcified cartilage in the centre of cartilaginous bone ends.
These islands of calcification quickly become ossified,
expand in size and develop denser margins and trabecular
cores. As they grow they replace the hyaline cartilage of
the epiphysis (with hyaline cartilage remaining only on
articular surfaces).
the foot and hand. On radiographs they appear as discreet Being of soft tissue density, all these structures blend
round or oval bones with clearly defined margins. They into a uniform opacity filling the space between articular
should not be mistaken for abnormal calcification that may surfaces and cannot be distinguished from each other.
occur in tendons, for loose bodies in a joint cavity or for Some joints contain fat pads that push their synovial
bone fragments. lining against non-apposed articular cartilage. These can
be seen with care, and are important in the assessment of
JOINTS ON RADIOGRAPHS a joint.
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PRACTICAL PERSPECTIVES
200
24. Radiographic Anatomy and Imaging
Fluoroscopy systems
Often, the flow and distribution of the contrast material
has to be demonstrated in real time, so the design of the X-
ray machine reflects those needs (capacity for continuous
observation, quick successive image capture and video
recording).
A fluoroscopy system consists of an image intensifier
(which transforms X-rays into a flux of electrons in an
evacuated tube, and then into visible light) and a camera or
a solid state light deflector which converts this light to still
or video images.
201
PRACTICAL PERSPECTIVES
or stands to best demonstrate successive parts of the large invasive radiological approaches (e.g... ultrasound, contrast
intestine in turn. Double contrast barium enema optimally studies, CT and MRI) are not conclusive.
details the large intestinal mucosal lining. Appropriate
patient preparation in order to achieve a clean colon is an Urography and cystography
absolute prerequisite for this examination. Intravenous urography (intravenous pyelography),
retrograde pyelography and cystography are contrast
examinations of the urinary tract.
Intravenous urography involves intravenous
administration of a contrast medium followed by obtaining a
precisely timed sequence of radiographs. Several
radiographs taken within the first minute from the bolus
injection show the renal parenchyma (nephrogram phase),
while the radiographs at about 5 minute intervals post-
injection demonstrate calyces, renal pelvis, ureters and the
urinary bladder. Compression of the ureters where they
cross the pelvic brim (by a tight band) is often applied after
the first 5 minutes in order to distend the ureters and renal
pelvis. Following release of compression, the contrast
accumulates in the urinary bladder. A post-voiding
radiograph is obtained to check bladder emptying.
Retrograde pyelography is a contrast radiographic
examination in which the contrast material is injected
directly into the renal pelvis via a ureteral catheter passed
retrogradely (introduced with the aid of a cystoscope). The
calyces and renal pelvis are well displayed with this
examination.
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24. Radiographic Anatomy and Imaging
Peritoneography
Peritoneography is used occasionally to look at
location and distribution of peritoneal compartments, and to
diagnose difficult peritoneal hernias. Contrast material is
Fig. 24.33 Hysterosalpingogram
injected into the peritoneal cavity under fluoroscopic
This examination can also have a therapeutic effect on control.
female infertility by opening the uterine tubes previously
occluded by adhesions. CONTRAST STUDIES OF VESSELS
CONTRAST STUDIES OF CLOSED CAVITIES Angiography is a specialised radiological examination
utilising contrast media (organic iodine solutions) to directly
Certain closed cavities (spinal and cranial cavities, joint visualise vessels and indirectly visualise organs by
cavities and the abdominal cavity) can also be injected with opacifying their capillaries.
contrast media in order to visualise surrounding or Angiography may be performed to investigate primary
associated structures. However, these invasive contrast vascular diseases (e.g. aneurysms), bleeding, trauma and
studies have generally been superseded by modern non- neoplastic diseases.
invasive imaging techniques (e.g. CT or MRI).
Arteriography
Myelography Arteriography refers to the contrast examination of
Myelography is performed by injecting the contrast arteries in general. Specialised arteriography includes
media (usually opaque myelographic contrast material, angiocardiography, aortography, cerebral and coronary
rarely gas) into the spinal subarachnoid space. The angiography. These are concerned with contrast
contrast material is introduced either via a lumbar puncture examination of the heart chambers, thoracic and abdominal
or via a cervical lateral puncture under direct fluoroscopic aorta, intracranial and coronary arteries, respectively.
vision. The patient is carefully turned and tilted to distribute Contrast medium is injected via a catheter inserted into
the contrast through the CSF in a way that will show the a peripheral artery (e.g. femoral or brachial) and passed
suspected abnormality, and may then proceed onto CT retrogradely to the origin of the desired artery, or even into
scanning after a variable time delay. cardiac chambers. Arterial blood flow directs the
distribution of the contrast medium from the catheter tip.
Angiography of certain solid organs (e.g. kidney, liver)
includes three phases: arterial, capillary and venous. The
capillary phase enables visualisation of the organ
parenchyma. Associated veins are also commonly
sufficiently opacified in the last stage of arteriography (after
the contrast medium passes through the capillary system of
an organ whose arteries are opacified).
Contrast arthrography
Contrast arthrography utilises a gaseous medium
(pneumoarthrography), positive contrast medium (opaque Fig. 24.35 Arteriogram (abdominal aorta)
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PRACTICAL PERSPECTIVES
Interventional radiology A blue dye is injected into the tissues of the dorsum of
the foot or hand (depending on which part of the lymphatic
Arteriography is the prelude to radiologic intervention.
system needs to be viewed). The dye is taken-up by local
Therapeutic applications such as angioplasty, embolisation,
lymphatic vessels which are outlined enabling subsequent
thrombolysis and selective chemotherapy may be
cannulation and injection with a radiodense medium.
performed following diagnostic arteriography. The
The first set of radiographs, to demonstrate lymph
subspecialty of radiology that utilises radiological
vessels, is taken within one hour of the injection. A second
techniques for treatment is called interventional radiology.
set, to demonstrate lymph nodes, is taken about 24 hours
Venography later (allowing time for the contrast to accumulate in them).
Lymphography has been taken over by cross sectional
Venography is the contrast examination of veins imaging, in particular CT.
(peripheral and central).
A venous catheter is inserted (and positioned) into a
peripheral vein. The injected contrast medium is carried in DIGITAL SUBTRACTION ANGIOGRAPHY
the direction of venous blood flow towards the heart,
Digital Subtraction Angiography (DSA) involves
opacifying lumina of the veins along this path.
removing unwanted parts of an image by the use of digital
manipulation. It is widely used in angiography in order to
subtract bones, gas-filled organs and soft tissues from the
image, so that contrast filled blood vessels are not
obscured by them.
Lymphography
Lymphography includes the contrast examination of
lymph vessels (lymphangiography) and of lymph nodes
(lymphadenography).
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Chapter 25: Sectional Anatomy, CT and MRI
SECTIONAL ANATOMY
CT IMAGE PRODUCTION
TISSUE PROPERTIES IN CT
PROPERTIES OF CT IMAGES
ADDITIONAL CT TECHNIQUES
MR IMAGE PRODUCTION
PROPERTIES OF MR IMAGES
SPECIAL MR IMAGING
SECTIONAL ANATOMY
Images of sections may be correlated with those from Fig. 25.2 Sagittal section (left parasagittal)
CT and MR and are presented with the same left-right
orientation as plain film radiography. An image is viewed as Coronal sections of the body
if facing the patient; the patients right is on the viewers left
and the patients left is on the viewers right. Historically, for
axial images, this has been called the view from the feet.
The same convention applies to coronal slices (right on the
left and left on the right). However, no convention exists
with sagittal images.
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PRACTICAL PERSPECTIVES
CT image acquisition
The two major components of any CT scanner are the Fig. 25.6 A CT voxel
gantry (shaped like a donut) and the patient bed, which Each CT voxel has a value, traditionally displayed as a
slides through the middle of the gantry. The gantry contains shade of grey. The value in each voxel is a measure of
a mobile X-ray tube which continuously rotates around the tissue radiodensity in the corresponding voxel in the
gantry opening, and an array of many small digital X-ray patient. CT can measure radiodensity with exquisite
detectors lying opposite the X-ray tube. accuracy, and can detect extremely subtle radiodensity
The X-ray tube produces a thin, fan shaped X-ray differences in adjacent voxels.
beam. The width of the beam (also the width of the slice) is
controlled partly by physical tube collimators, and partly by
electronic detector masking. The beam traverses the
TISSUE PROPERTIES IN CT
patient and is read by the detectors on the other side of As in plain radiography, when a fan-shaped X-ray beam
the gantry opening. penetrates the body during Computed Tomography (CT)
examination, it interacts with different tissues.
Depending on the tissue radiodensity, some X-rays are
absorbed, some are scattered.
Tissue radiodensities in CT
While plain radiographs have four groups of
radiodensities, CT images provide a greater range of
shades that allow differentiation between many tissue
types.
206
25. Sectional Anatomy, CT and MRI
negative values are for structures with lower attenuation scanners, The third dimension ('Z' axis) of a voxel is usually
than water (fat and air). the thickness of the X-ray fan beam (i.e. the collimation).
The attenuation values for tissues of different On multi-slice CT scanners voxel depth and slice thickness
radiodensities expressed in Hounsfield Units are: is determined by physical and electronic collimation and
air -1000 HU, also by reconstruction parameters.
fat -100 to -60 HU,
water 0 HU Windowing in CT
soft tissues 40 to +60 HU, The limited capacity of the human eye to differentiate
bone +1000 HU or higher between different shades of grey limits the total number of
shades of grey that can be displayed on a CT monitor or on
CT film at any one time. The number of shades of grey that
can be usefully displayed is far smaller than the number of
different Hounsfield Unit values that are measured by a CT
scanner. In order to fit the large dynamic range of the
measured Hounsfield Units into the narrow dynamic range
of the human eye, only select portions of the dynamic
range are displayed, and may be stretched or
compressed into only a few steps of grey. The process of
displaying the HU range of interest is called windowing.
Window level refers to the mid-value of the HU range to
be displayed with the limited shades of grey, while window
width describes the extent of this range. In general, to
display a particular tissue optimally, the window level
should be comparable to that tissues usual HU number,
and the window width can then vary depending on how
many other structures need to be included.
A narrow window shows great detail in the structure
of interest, but everything above the window will be
presented as uniform white, and everything below as
uniform grey. A wide window displays many different
Fig. 25.8 Attenuation values (in HU) and grey scale tissues as grey, but there is little differentiation between
them.
A CT image is simply a tissue density map (expressed
Optimal window level and width vary for each tissue.
in HU) in that particular slice. Although CT images can be
For optimal display of mediastinal soft tissues, the window
displayed in any colour scale of the users choice, by
level is around 40 HU, and the width is 400 HU. For lungs,
tradition they are displayed in the same way as
however, the window level is around -700 HU and the width
radiographs: radiolucent tissues are black, and increasingly
is 1000 HU. These values are usually displayed on the
radiodense tissues are progressively white.
image.
PROPERTIES OF CT IMAGES
The images displayed on a monitor following CT
scanning consist of a matrix of picture elements (pixels).
Each individual pixel on the screen represents the HU
value of the corresponding tissue voxel in the patient.
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PRACTICAL PERSPECTIVES
ADDITIONAL CT TECHNIQUES
Rapid progress in digital technology and engineering,
as well as routine utilisation of contrast media, led to the Fig. 25.11 High resolution CT (of lungs)
refinement of routine CT techniques and development of
targeted CT techniques. Multislice CT
Use of oral and intravenous contrast media With the development of CT X-ray tubes, detector
technology and electronic collimation, detector arrays are
In abdominal CT examinations, the use of orally or evolving to allow acquisition of multiple slices with each
rectally administered contrast materials enables contrast- tube rotation. Four and 16 slice CT scanners may become
filled lumina of hollow organs to be more confidently superceded by new 64 slice machines.
distinguished from solid masses or cysts. Multislice CT dramatically decreases the total
Intravenously administered contrast material opacifies examination time, because fewer tube revolutions are
blood vessels, making identification easier, and also required to cover the same cranio-caudal distance. This is
opacifies vascular parenchymal organs, allowing better of particular use with patients who have difficulty holding
detection of abnormal areas within them (e.g. tumour still (e.g. short of breath, or children) and in trauma cases.
masses). Intravenous contrast is used routinely for imaging
all areas of the body where vessels need to be Helical CT
distinguished from non-vessels (e.g. in the neck, identifying Helical CT imaging involves constant advancement of a
vessels and lymph nodes). patient through the gantry with a continuously revolving X-
In children and thin patients with little intra abdominal ray tube. This is equivalent to helical motion of an X-ray
fat, the anatomical borders between soft tissue density tube around the patient. Helical CT images are of a
structures are often difficult to find, because these are continuous volume of tissue, rather than a single slice at a
usually outlined by fat. Oral and intravenous contrast time, hence the term volume scanning. It eliminates gaps
administration is particularly helpful in these cases. between slices in a conventional CT and allows multi-
planar and 3-D reconstructions (e.g... of the skull).
Because CT slices are continuously acquired, the total
data set is volumetric, and the reconstructed axial slices
can be reformatted into coronal, sagittal or oblique slices
with little information loss.
Almost all new CT scanners are helical and helical CT
is rapidly replacing conventional CT.
MR IMAGE PRODUCTION
Fig. 25.10 Contrast media in CT (abdomen) It is based on recording radiofrequency signals emitted
from within the body (rather than on the transmission of X-
Thin section CT rays through the body).
High-resolution computed tomography (HRCT)
refers to thin-section CT. In HRCT the beam collimation is
the thinnest possible, often as thin as 0.5 to 1.0mm. This
means that voxel depth (Z axis) is the thinnest possible,
and partial voluming artefact that degrades in-slice
resolution with thicker slices is minimised. However, it is
impossible to scan an entire body with 1.0mm slices (this
will produce at least 1000 images to look at the torso
alone), and of necessity such thin slices are taken with a
spacing, often 10mm. Hence, this is a sampling study that
is most frequently used to examine lung parenchyma in fine
detail for diffuse lung disease where only representative
tissue slices are sufficient. Fig. 25.12 Context for MR images
208
25. Sectional Anatomy, CT and MRI
Contraindications to MR Imaging
209
PRACTICAL PERSPECTIVES
show water and fluid as bright. Modern T2W sequences These include Cerebrospinal Fluid (CSF), mucus, urine
('fast spin echo T2W') also show fat as bright. and bile, or in case of a pathological process, oedematous
mucosa and non-clotted blood.
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25. Sectional Anatomy, CT and MRI
Proton movements
Dedicated MR sequences allow selective demonstration
of moving protons, and in particular of flowing blood. In
these dedicated sequences, moving blood can be either
bright (white blood sequences) or have no signal (black
blood sequences).
The vast majority of MR angiography (MRA) and MR
venography (MRV) is based on white-blood sequences,
sometimes following contrast material administration.
This imaging approach enables 3-D reconstruction of
vascular tree images.
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Chapter 26: Ultrasound Imaging
The transducer produces pulses of high frequency
sound which are sent to the body.
After each pulse of ultrasound is emitted, there is a
ULTRASOUND IMAGE PRODUCTION listening period, when the transducer detects US waves
returning from the body. Small electric pulses coming from
TISSUE PROPERTIES IN US IMAGING the transducer are amplified, decoded and placed into their
correct location in a cross sectional image.
PROPERTIES OF US IMAGES
TISSUE PROPERTIES IN US IMAGING
DOPPLER ULTRASOUND IMAGES
An ultrasound wave propagates through different
tissues at different speeds depending on their composition.
Solid soft tissue has grey appearance from internal concave apex that corresponds to the probe face. Linear
reflections, as well as its own granularity (echotexture), in probes produce a square or rectangular image. Some
the following order: (whiter) pancreas > liver, spleen > probes are designed to have a small footprint (for example,
kidneys (darker). to image the heart by scanning between ribs). These
Fat is very reflective, and looks bright white on sector scanners or vector arrays produce a triangular
ultrasound. image with a point apex. Intra-cavity probes (for endorectal
Gas absorbs sound and does not transmit it, and has and endovaginal ultrasound) are elongated and thin, with
the appearance of dirty shadowing on ultrasound. usually a curved semicircular transducer on their tip.
In contrast, bone (or calcification) does not transmit The operator can decide at any time to obtain a series
sound, but does give a sharp reflection, producing clean of characteristic frozen images for detailed studies of
shadowing. anatomy or pathology appearing on certain slices.
Colour Doppler
Colour Doppler imaging detects moving blood and its
direction but provides no information about its spectral
properties. The velocity of motion commonly presented as
an intensity map. By convention, flow towards the
transducer is coloured red, while flow away from the
transducer is coloured blue (although any colour scale
Fig. 26.3 Echocardiograms could be chosen).
Most ultrasound probes are either curved or linear.
Curved probes produce a wedge-shaped image but with a
213
PRACTICAL PERSPECTIVES
Pulsed Doppler
In pulsed Doppler imaging, a continuous narrow beam
of US is used to 'listen' along one chosen direction in a
small target volume. The reflected US beam carries
information about the flow velocity within the target volume
as a function of time as well as spectral information about
all its velocities (i.e. the spread of different velocities and
their relative prevalence within the target volume). The
sound equivalent of pulsed Doppler US is the familiar
arterial 'whoosh'. The visual image is a very accurate
representation of the flow waveform and is used for
vascular physiological analysis (e.g... to derive peak
systolic velocity, diastolic velocity etc.).
214
Chapter 27: Endoscopic Anatomy
Gastroscopy
LOOKING WITHIN HOLLOW VISCERA The upper gastrointestinal tract to the duodenum can
be viewed through a gastroscope passed via the mouth.
LOOKING WITHIN BODY CAVITIES Sphincteric function is also assessed.
An additional diagnostic and therapeutic procedure
such as ERCP can be performed where a tube is passed
LOOKING WITHIN JOINT CAVITIES into the bile duct. This enables investigation of the biliary
tract and removal of stones.
Bronchoscopy
The respiratory tract to the segmental bronchi can be
viewed through a bronchoscope passed via the nose.
Vocal cord function is also assessed.
Fig.27.3 Tract viewed at gastroscopy
1. Upper end of oesophagus with folds (from
surrounding cricopharyngeal sphincter)
2. Lower end of oesophagus (with folds from
surrounding functional sphincter) and line of
epithelial transition to gastric type
3. Body of stomach (with rugae)
Fig.27.1 Tract viewed at bronchoscopy 4. Pyloric antrum and canal with orifice (and
surrounding pyloric sphincter)
1. Inlet of larynx and vocal folds 5. Smooth part of first part of duodenum (duodenal
2. Trachea cap)
3. Tracheal bifurcation 6. Second part of duodenum with circular folds and
4. Right main bronchus duodenal papilla (for bile duct and main pancreatic
5. Right upper lobe bronchus duct)
6. A segmental bronchus
Fig.27.2 Internal views of respiratory tract Fig.27.4 Internal views of upper digestive tract
215
PRACTICAL PERSPECTIVES
Colonoscopy Cystoscopy
The lower gastrointestinal tract to the caecum and The lower urinary tract including the bladder (and
terminal ileum can be viewed through an endoscope ureteric orifices) can be viewed through a cystoscope
passed via the anus. Prior to the procedure, the large passed via the external urethral meatus. The urethra in a
intestine is cleared by oral ingestion of a special bowel male is much longer than that in a female. Particular care is
preparation. During the procedure, gas can be introduced taken to ensure the cystoscope negotiates the change in
to distend the lumen. Normal mucosal features are direction of the urethra at the bulb of the penis (to smoothly
visualised, abnormalities detected, biopsies of suspicious enter the narrow membranous urethra). This is achieved by
areas taken and polyps removed. manoeuvring the penis.
Fig.27.6 Internal views of lower digestive tract Fig.27.8 Internal views of lower urinary tract
216
27. Endoscopic Anatomy
Fig.27.10 Internal views of pleural cavities Fig.27.12 Internal views of peritoneal cavity (in female)
217
PRACTICAL PERSPECTIVES
Fig.27.13 Major joint cavities viewed at arthroscopy Fig.27.15 Internal views of major lower limb joints
Arthroscopy of upper limb joints
1. Articulation between head of right humerus and
glenoid cavity of scapula (with labrum)
2. Attachment of long head of biceps tendon (to
supraglenoid tubercle)
3. Anterior capsule of shoulder joint (with defect to
subscapular bursa)
4. Inferior capsule of shoulder joint
5. Right elbow joint (with annular ligament around
head of radius)
6. Left wrist joint (with articulation between distal end
of radius and proximal row of carpal bones)
218
Chapter 28: Clinical Procedures
INJECTIONS
NERVE BLOCKS
ARTERIAL PUNCTURE
VENEPUNCTURE
INTRAVENOUS CANNULATION
INCISIONS
An incision is a surgical cut through skin. Incisions are
made to remove skin lesions or to provide access to
deeper anatomical structures. For surgical exploration of
body cavities, incisions are also made through the other
layers of the body wall.
Skin characteristics of the region (including relaxed
skin tension lines) should be assessed with functional
and cosmetic implications considered. Fig.28.2 Incisions and skin creases
Relationship to skin tension lines Incisions in special areas
Special care should be taken for incisions in certain
Skin incisions made parallel to lines of tension heal areas, particularly on the face, to avoid disfigurement.
with a minimal scar, while those crossing lines of Special care should also be taken near cutaneous orifices
tension tend to produce a wider scar. (e.g... at the vermilion border of the lips).
Sites where incisions should be avoided
Incisions crossing joint lines should be avoided due to
subsequent restriction of movement even from normal
scar contraction.
219
PRACTICAL PERSPECTIVES
220
28. Clinical Procedures
221
PRACTICAL PERSPECTIVES
Fig.28.8 Eversion and alignment of wound edges Fig. 28.11 Optimal compression from dressings
Excess tension (e.g... sutures tied too tight) impairs Sutures should be left for a greater time in areas under
blood supply to the wound (especially its edges), causes tension with a poor blood supply (or other factors delaying
pain and delays healing. Impaired blood supply may even healing). If there is doubt, they can be removed in stages
result in the wound breaking down. rather than all at the one time (and risk wound disruption).
However, if sutures appear too tight (and causing
inadequate blood supply) they should be removed early.
222
28. Clinical Procedures
The wound is debrided by removing any foreign or Prior to the puncture, it is important to anaesthetize skin
dead tissue (particularly fat or deeply located tissue). Dead and synovial membrane as these layers are the most richly
tissue is more extensive with contusions and crush injuries. innervated by pain fibres.
Contaminated wounds are likely to become infected
particularly if time has elapsed. Infection results in wound Hazards of a joint puncture
breakdown. After inspecting, exploring and debriding, it In a joint cavity puncture, if the needle is pushed too
may be best to delay wound closure for 5 days (delayed firmly, its point may damage hyaline cartilage covering a
primary closure). bony articular surface within the joint.
For the lower approach in a knee joint puncture other
SYNOVIAL CAVITY PUNCTURE intra-articular structures (the menisci and cruciate
ligaments) are also endangered.
A synovial cavity includes a closed sac with a
potential space enclosed within the serous membrane.
BODY CAVITY PUNCTURE
The sac contains a small amount of fluid for lubrication.
Fluid, blood or pus may accumulate in it as a result of A body cavity includes a closed sac with a potential
trauma or disease. A synovial cavity may be drained by space located between the parietal and visceral layers of a
aspiration via a needle inserted through the layers serous membrane. The sac contains a small amount of
overlying the joint or associated bursa. fluid for lubrication. Fluid, air, blood or pus may
accumulate in it as a result of trauma or disease. A body
Sites for a joint puncture cavity may be drained by aspiration via a tube or needle
In a knee joint puncture, the needle may be inserted inserted through the layers of the overlying body wall.
from either side near the superior border (base) of the
patella, into the gap between the patella and the femur or Sites for a body cavity tap
into the suprapatellar bursa (which is continuous with the Appropriate sites for access are determined by
synovial cavity above the patella). Alternatively a lower relationships to anatomical landmarks and potential
approach may be adopted from either side of the hazards (e.g. vessels and nerves of the body wall and vital
ligamentum patellae near the inferior border (apex) of the structures in the body cavity).
patella. Prior to insertion of the needle, local anaesthetic is
injected to infiltrate each layer of the body wall that is pain
sensitive (particularly the overlying skin and underlying
parietal layer of serous membrane).
The site is determined by clinical examination and may
be confirmed by radiological imaging. The thickness of the
body wall is estimated as a guide to maximal safe depth of
needle insertion. Aspiration is attempted throughout
needle advancement. If fluid is not encountered at the
estimated depth, consideration should be given to the
possibility of the needle tip being blocked by a plug of
tissue (the needle may be flushed to unblock it, or rotated
to bring the bevel away from adjacent tissue).
223
PRACTICAL PERSPECTIVES
Layers pierced in a body cavity tap For an IM injection, the muscle should be relaxed (e.g.
arm loosely by side). The skin may be stretched just prior
For a body cavity puncture the following layers are
to rapidly inserting the needle with a dart-like action, to
pierced in sequence by the needle:
minimise pain.
- skin
- subcutaneous tissue Preventing inadvertent IV injection
- muscle/fascial layers
- parietal layer of serous membrane There is always the danger of inadvertently injecting
Drainage of a pleural effusion (accumulation of fluid in into a blood vessel (especially veins which are numerous
the pleural cavity) may be performed via a needle inserted and variable) within subcutaneous tissue or within muscle.
posteriorly through an appropriate intercostal space in the Aspiration, by drawing back the plunger of the syringe (and
lower part of the thoracic wall. observing that blood does not appear), immediately before
injecting, minimises this.
Hazards of a body cavity tap
Aspirating before injecting avoids inadvertent
The structures endangered by a needle inserted into a intravenous injection
body cavity are vessels and nerves of the body wall in
addition to vital organs within the body cavity. If blood is aspirated, the point of the needle should be
In a pleural tap, the needle is inserted near the lower moved. The tributaries of gluteal veins deep in the buttock
margin of the intercostal space to avoid injury to the main are particularly numerous and large.
intercostal neurovascular bundle that runs in a groove near
the inferior border of a rib.
The following viscera are endangered:
- lungs (by penetrating the visceral pleura)
- liver on the right (by penetrating the diaphragm)
- spleen on the left (by penetrating the diaphragm)
- kidneys (by penetrating or passing below diaphragm)
Assessment of lung status by physical examination is
mandatory after the procedure and a chest x-ray may also
be required.
INJECTIONS
Intradermal (ID) injections are given directly into the
dermis of the skin. Subcutaneous (SC) injections pass
through the skin into superficial fascia. Intramuscular (IM) Fig.28.16 Aspiration before injecting
injections penetrate into muscle.
Sites for IM injections
IM injections are commonly given in the upper arm
(deltoid muscle), buttock (gluteus maximus muscle) or
lateral aspect of thigh (vastus lateralis muscle).
224
28. Clinical Procedures
An IM injection into gluteus maximus should be given in the The area anaesthetized by a nerve block corresponds
upper-outer quadrant of the buttock (to avoid the sciatic to the sensory distribution of the nerve (distal to the
nerve). site of infiltration) minus the area of overlap from
IM injections into vastus lateralis endanger the descending adjacent nerves.
branches of the lateral circumflex femoral vessels.
For an intercostal nerve block, it is necessary to also
NERVE BLOCKS block the nerves above and below the level of injury (or
region requiring anaesthesia) due to the extensive overlap
A nerve block involves infiltrating local anaesthetic in sensory supply of adjacent spinal nerves (and
around a nerve to interrupt conduction (temporarily). dermatomes).
For a digital nerve block, each of the 4 digital nerves
Within a peripheral nerve, small fibres (mainly pain at the base of a finger (supplied by a palmar digital and a
fibres) are most affected by local anaesthetic agents. dorsal digital nerve on each side) may be blocked. An
alternative approach is to infiltrate around the common
Larger fibres are affected to a lesser degree (hence palmar digital nerve in a web space. It is often necessary to
touch sensation may remain). block more than one common digital nerve because each
Although anaesthesia may be achieved by infiltration provides digital nerves only to contiguous halves of
directly around certain structures (e.g. in a wound) much adjacent fingers.
more local anaesthetic agent is required than with a nerve
block. Directly injecting certain areas (e.g. palm or sole) Use of vasoconstrictors with nerve blocks
may be painful and injection of fluid into tight, confined Conditions that increase blood supply (inflammation,
compartments may also raise pressure in the compartment, exercise) decrease the duration of action. Vasoconstrictor
compromising vascular supply to its contents. drugs (e.g. adrenaline) may be used to prolong the action
Fine needles reduce the rate of injection and the of local anaesthetic agents (by slowing blood stream
volume required. Dental syringes have cartridges and fine removal of drug) and reduce local bleeding. However, they
needles, allowing easier control of the volume injected. must be used with caution and are forbidden for certain
However, they preclude aspiration and should only be used sites.
for superficial injections. The point of the needle must be
moved while injecting to avoid inadvertent intravenous Adrenaline must never be injected into terminal parts
injection of a large bolus. (particularly digits or penis) because they are
(collectively) supplied by end-arteries.
Sites for nerve blocks
Appropriate sites for access to nerves are determined It may produce intense arterial spasm resulting in death
by relationships to anatomical landmarks and potential of tissue distal to the injection site.
hazards (e.g. accompanying vessels and neighbouring vital
organs). Landmarks directly observed or palpated,
coupled with knowledge of anatomy and its variations, are
vital for correct placement.
225
PRACTICAL PERSPECTIVES
226
28. Clinical Procedures
Technique of venepuncture
The needle should be directed along the chosen vein at
a reasonably flat plane of entry (10 -15 degrees) through
the skin, bevel upwards. It is inserted to at least 5 mm. into
the interior of the vein.
Heart excised
The heart is removed by cutting all the great vessels at
the reflections of the serous pericardium.
230
29. Postmortem Examination of Organs
Fig.29.10 Excised hollow viscera in cut section Fig.29.12 Excised solid viscera in cut section
231
Chapter 30: Cadaver Dissection
Dissecting safely
DISSECTION PREPARATION As in surgery, all needles and blades are classified as
sharps and must be handled with care. They should only
SURGICAL INSTRUMENTS be discarded in specially designed and labelled containers
for safe disposal. Particular care is taken when changing
scalpel blades (attaching a blade to the scalpel handle or
SKIN INCISION detaching a blade from it). Artery forceps (instead of
fingers) are used for grasping the blade, to minimise risk of
SKIN REFLECTION injury.
Dissecting gloves are used to protect the hands.
SUBCUTANEOUS FAT REMOVAL Adequate lighting is not only essential for visualising the
structures encountered, but also for visualising instruments
and any other potential hazards (e.g. sharp cut ends of
DEEP FASCIA INCISION AND REFLECTION bones).
SURGICAL INSTRUMENTS
DISSECTION PREPARATION
Prior to dissection, (as in surgery on a living patient) the
cadaver is carefully placed in position on the table for
optimal access to the appropriate region. The body is
uncovered and relevant anatomical landmarks identified.
Dissection involves exposing anatomical structures by
separating them from surrounding tissue, which is then
removed. Connective tissue (fascia) keeps some structures
together and keeps others apart, but also tends to obscure
them from view (loose connective tissue contains a
variable amount of fat).
232
30. Cadaver Dissection
The scalpel should be held like a pen, with the index Retractors and probes
finger used to guide the blade for incisions. The little finger
During deep dissection, retractors are used to expose
can rest on the cadaver to steady the hand for fine work.
the field of view by maintaining separation of overlying
structures.
A cats paw retractor is usually held by an assistant.
Alternatively, a self-retaining retractor has two paws that
can be locked apart to maintain separation of structures,
without need for an assistant.
A blunt probe is used to explore avenues obscured
from view. A duct can be explored by inserting the probe
through its orifice.
Scissors
A pair of scissors can be activated by inserting the
distal phalanx of the thumb and of the ring finger into each
loop. The scissors may then be guided by the index finger,
which is positioned over the joint for fine control and Fig.30.6 Incising the skin (on leg)
steadied by the middle finger.
The epidermis and dermis (approximately 2mm deep)
are pierced. In thick skin, on the palm of the hand or sole
of the foot, the epidermis is greatly thickened and much
tougher. These areas require a more forceful incision, so
special care must be taken to avoid injury.
Once the blade enters the (fatty) subcutaneous tissue,
a reduced resistance is felt.
SKIN REFLECTION
Skin may be reflected after two incisions meeting at a
Fig.30.5 Holding tissue scissors correctly
right angle have been made.
Large scissors with round-tipped blades can be used to The skin at the junction of the incisions is gripped firmly
separate tissues by inserting their blades closed, then (using toothed forceps) and traction applied to it, while the
gradually opening them. Curved blades enable these blade of the scalpel progressively frees dermis from
scissors to be controlled from an angle (not in the plane of underlying subcutaneous tissue. This is done using small
dissection) so that they do not obscure the field of view. strokes, rotating the blade so it cuts parallel to the plane of
Small, pointed scissors should be used for very fine the subcutaneous tissue. Reflection along this plane avoids
dissection or trimming surfaces and edges of soft tissue. damage to structures in the subcutaneous tissue.
233
PRACTICAL PERSPECTIVES
Skin flaps are reflected, rather than removed, so that DEEP FASCIA INCISION AND REFLECTION
they can be replaced following dissection to keep
underlying tissue moist. A larger scalpel is required to incise the thin but tough
deep fascia.
Fig.30.7 Reflecting skin from underlying tissues Fig.30.9 Incising and reflecting deep fascia
Deep fascia is removed from the field of dissection and,
SUBCUTANEOUS FAT REMOVAL in this case, incised along its attachment to bone (where it
After the subcutaneous tissue is entered, dissection is becomes continuous with the periosteum). In general, deep
continued within this plane to preserve the structures fascia is easily removed from underlying muscles except
coursing in it. Plain forceps and a finer scalpel are used to where it merges with intermuscular septa.
free fatty tissue from them. At some sites, muscle may be attached to deep fascia
by its associated connective tissue (surrounding
epimysium, aponeurotic expansions or tendinous
prolongations).
235
Appendix 1: List of Principles
S
Seeccttiioonn 11:: TThhee H
Huum
maann B
Booddyy Synovial membrane lines the internal surface of the
capsule and all non-articular structures on the
IIIn
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n interior of a synovial joint.
The developmental history of an individual reflects Ligaments, within a joint or between two joints acting
the evolutionary history of its species. as a functional unit, are positioned along the axis of
The potentials (and limitations) of cells, tissues and movement.
organs are determined by the germ layers from which Collateral ligaments are important contributors to
they are derived. stability by preventing unwanted side-to-side
Only mesoderm derived structures are vascular movement.
C
Ch
C haaap
h pttteeerrr 111::: H
p Hu
H um
ummaaan
nA
n An
Annaaattto
om
o miiicccaaalll T
m Teeerrrm
T msss
m Children are more likely to fracture a bone before
tearing a ligament.
When describing the relationship between one
structure and another, the body is considered to be The weakest points of a ligament are at or near their
in the anatomical position. attachments, rather than between them.
C
C
Chh
haaap
pttteeerrr 222::: H
p Hu
H um
ummaaan
nF
n Fo
Foorrrm
m aaan
m nd
n dS
d Stttrrru
S uccctttu
u urrreee
u A ligament that is arranged in discrete parts rather
than a continuous band allows more joint mobility
Branchial arch derivatives retain their nerve supply
but is weaker and therefore more vulnerable.
despite migration.
Discs or menisci create compartments, allowing
The nerve supply to a muscle is retained even if the
different movements to occur simultaneously on
muscle migrates during development.
each side of the partition.
Each limb develops with a principal bone proximally,
Bursae tend to be more numerous at joints with
a pair of long bones distal to it, then short bones and
greater mobility.
five digits.
The contribution to joint stability from bones is
The most distinctive human characteristic is the
dependent on the congruence of their articular
habitual adoption of upright stance and locomotion
surfaces.
based solely on the two lower (hind) limbs.
Muscles are the most important stabilising factor for
mobile joints, providing the first line of defence
S
Seeccttiioonn 22:: B
Booddyy S
Syysstteem
mss aanndd S
Sttrruuccttuurree against dislocation.
C
Ch
C haaap
h pttteeerrr 444::: S
p Skkkeeellleeetttaaalll S
S Syyysssttteeem
S m aaan
m nd
n dB
d Bo
Boon
neeesss
n Nerves supplying muscles that produce movements
Bony trabeculae are oriented along lines of stress at a joint also typically supply the joint.
(both compressive and tensile). C
Ch
C haaap
h pttteeerrr 666::: M
p Mu
M ussscccu
u ulllaaarrr S
u Syyysssttteeem
S m aaan
m nd
n dM
d Mu
Muussscccllleeesss
Articular surfaces are the only external surfaces of a Tendinous attachments to bone, in contrast to those
bone not surrounded by periosteum. of fleshy muscle fibres, produce bony markings.
Bony elevations are produced at sites of traction A large tendon attaching to a developing bone is
Hyaline cartilage is avascular and aneural likely to be associated with a traction epiphysis (to
Unlike cartilage, bone requires a blood supply, as the allow for growth of the bone at the site of
calcified matrix does not allow diffusion. attachment).
Almost all secondary centres appear after birth In contrast to a ligament, a muscle tends to rupture at
(females generally at an earlier age than males). other sites in addition to its attachments.
Growth in length occurs at the metaphysial surface Muscles crossing more than one joint are particularly
of an epiphysial plate. prone to injury from over-stretching.
Epiphyseal fusion occurs after puberty (females Fleshy muscle fibres tend to be replaced by tendons
generally at an earlier age than males). at sites of pressure or friction.
The earlier an epiphysis appears the later it fuses. Deep fascia is not found as a continuous sheet
around parts of the body that expand significantly.
Epiphyses for larger long bones tend to appear
before (and fuse after) those for smaller long bones. Deep fascia is not found over the subcutaneous
surface of a bone
Damage to an epiphysial plate will impair subsequent
growth. Muscles with a common action are generally located
in the same fascial compartment.
Adults tend to have stronger bones than ligaments,
while children have the reverse. Where nerves and vessels have a common course
they tend to be enclosed within a common fascial
Healing, including of fractures is more rapid in sheath (as a neurovascular bundle).
children than in adults.
The active range of movement at a joint is
Weight bearing bones heal slower than non-weight proportional to the length of muscle belly.
bearing bones.
Strength is proportional to the cross-sectional area
C
Ch
C haaap
h pttteeerrr 555::: A
p Arrrtttiiicccu
A ulllaaarrr S
u Syyysssttteeem
S m aaan
m nd
n d JJJo
d oiiin
o ntttsss
n of the muscle.
The shape of the articular surfaces determines the
Muscles crossing more than one joint can generate
particular movements permitted.
extra force but are also prone to overstretch.
Bony articular surfaces do not come in direct contact
with each other unless the overlying articular Prime movers tend to be located superficially and
cartilage has worn away. fixators deep.
236
Appendix 1: List of Principles
Skeletal muscles with a common action often share a Vessels cross planes at sites (of least mobility)
common nerve supply and occupy a common where connective tissue is anchored.
compartment. Arteries course from fixed (concave) areas to mobile
A muscle located on the border between two (convex) areas.
compartments may receive a dual nerve supply (and Veins converge on fixed areas from mobile areas.
have dual prime mover actions).
The vast majority of muscles are part of more than
The nerve supply to a muscle reflects its one angiosome.
developmental origin (nerves remain faithful to their
muscles). Lymph capillaries are not present in epithelia
(including epidermis) but are abundant directly under
The segmental pattern of nerve supply in the trunk is an epithelial surface.
in a simple cranial to caudal sequence.
Lymph vessels tend to accompany veins.
An individual limb muscle typically receives its
supply from two consecutive spinal cord segments. Lymph normally passes through at least one set of
lymph nodes before reaching the venous system.
Proximal flexor muscle groups are supplied from
more cranial (pairs of) segments than those for distal The skin of almost the entire body drains first to a
flexor muscles. superficial lymph node group before draining to a
deep group.
The most caudal segment distributed via the limb
plexus supplies the most distal muscle group for the C
C
Chh
haaap
pttteeerrr 888::: V
p Viiisssccceeerrraaalll S
V Syyysssttteeem
S msss aaan
m nd
n dV
d Viiisssccceeerrraaa
V
upper limb and for the lower limb (intrinsic muscles Normal constrictions of the lumen tend to occur at
of palm and of sole, respectively). the beginning and end of a tubular viscus.
Where there is a major source artery (and principal Structures directly related to an organ tend to
vein) it enters as part of the neurovascular bundle at produce grooves or impressions on it.
the hilum, on the deep surface of the muscle. A duct opening into the lumen of a hollow viscus
The majority of anastomoses in the body are via tends to narrow as it traverses the wall.
skeletal muscles. Endocrine glands have a very rich blood supply.
C
C
Chh
haaap
pttteeerrr 777::: IIIn
p nttteeeg
n gu
g um
ummeeen
ntttaaalll S
n Syyysssttteeem
S m aaan
m nd
n dS
d Skkkiiin
S n
n A paired viscus receives a unilateral neurovascular
The dermis on extensor surfaces tends to be thicker supply and refers pain to the same side.
and tougher increasing protection from injury. Midline unpaired viscera receive nerve and vascular
Connective tissue in living skin is oriented along the supply lines from both sides
relaxed skin tension lines. Non-midline unpaired viscera have an arterial supply
In burns, fluid loss is proportional to the surface area from unpaired branches of the aorta (arteries of the
affected. foregut, midgut and hindgut) and venous drainage
Territories supplied by peripheral nerves derived into an unpaired system of veins (portal system).
from consecutive spinal segments overlap Unpaired viscera receive a bilateral nerve supply.
extensively (and their branches intermingle). Pain from an unpaired viscus is felt over the midline
Overlap for pain and temperature is more extensive of the body as impulses are simultaneously received
than that for touch. by the left and by the right side of the spinal cord.
Nerve branches do not cross the midline of the body. Sphincters are often located near an external orifice
Adjacent dermatomes that are consecutive overlap (particularly on the perineum).
extensively. The direction of the orifice is at right angles to the
The middle segment of a limb plexus is distributed to direction of apposition of the walls of the tubular
the most distal skin. viscus (or duct) immediately proximal to it.
Adjacent dermatomes that are not consecutive do The epithelial lining of viscera is avascular (as is the
not overlap. epithelium of skin).
Cutaneous nerve branches do not cross axial lines. The underlying connective tissue of the lamina
propria is highly vascular (as is the dermis of skin).
Pain from a deep source is referred to the same
neurosome. Arterial anastomoses, venous communications,
watershed areas of lymph drainage and inter-nervous
Unpaired viscera receive a bilateral nerve supply. lines (of sensory nerve supply) occur at
Pain from an unpaired viscus is referred to the mucocutaneous junctions.
midline. Visceral nerves supply smooth muscle sphincters,
Pain from a paired viscus is referred to the same and somatic nerves supply skeletal muscle
side. sphincters.
Vessels, being derived from mesoderm, develop only Transmucosal junctions tend to be located where
in mesoderm-derived tissues. territories of different developmental origin meet.
Continuous arteries supply continuous organs. Inter-nervous lines for reflexes particularly occur
where mucosa overlies skeletal muscle.
Arteries travel with connective tissue via fascial
There tends to be no arterial anastomosis across
planes particularly associated with muscles.
vascular segments although there may be some
Vessels do not cross mobile planes. venous communication.
237
Appendix 1: List of Principles
Visceral nerves supply smooth muscle and glands, Adjacent (branches of) arteries tend to anastomose
while somatic nerves supply skeletal muscle. with each other.
The body wall and the (parietal) layer of serous Skeletal muscles receive the most arterial branches
membrane lining it are supplied by somatic nerves, and contain the majority of anastomoses.
while the gut and the (visceral) layer of serous Anastomoses occur around joints but are only
membrane around it is supplied by visceral nerves. significant within muscle bellies that cross the joint.
C
Ch
C haaap
h pttteeerrr 999::: N
p Neeerrrvvvo
N ou
o usss S
u Syyysssttteeem
S m aaan
m nd
n dN
d Neeerrrvvveeesss
N End organs are particularly vulnerable to having their
Although some peripheral nerves are purely motor or arterial supply cut off.
purely sensory, the vast majority are mixed. End tissues within end organs are most vulnerable to
In contrast to a receptor, an effector is not in direct having their arterial supply interrupted.
continuity with a neuron. An embolus within an artery tends to lodge
The functional fibre type of a sensory nerve fibre immediately distal to a branch point, where the main
corresponds to the type of organ associated with the artery narrows.
receptor. C
Chaaap
Chh pttteeerrr 111111::: V
p Veeen
V no
n ou
o usss S
u Syyysssttteeem
S m aaan
m nd
n dV
d Veeeiiin
V nsss
n
The functional fibre type of a motor nerve fibre A portal system links two capillary beds at low
corresponds to the type of effector. pressure.
Sympathetics primarily control smooth muscle tone A valve is typically located at the termination of a
of arterioles. vein.
Most neural pathways in the CNS cross the midline. The veins of the vena caval systems traversing body
Posterior nerve roots are purely sensory while cavities of the trunk, together with the entire
anterior nerve roots are purely motor. vertebral and azygos systems of veins, are valveless.
Each branchial arch is supplied by a mixed cranial C
Ch
Chhaaap
pttteeerrr 111222::: L
p Lyyym
L mp
m ph
phhaaatttiiiccc S
Syyysssttteeem
S m aaan
m nd
n dL
d Lyyym
L mp
m ph
p hV
h Veeesssssseeelllsss
V
nerve. Lymph capillaries are present only in tissues derived
A ganglion, created by the collection of cell bodies of from mesoderm.
sensory neurons, is found on the posterior root of The termination of lymph ducts occurs where the
every spinal nerve. venous pressure is about zero, whether upright or
Each posterior root ganglion resides in an supine.
intervertebral foramen, regardless of the length of the Lymph drains from superficial nodes to deep nodes.
associated nerve root.
After puberty, the thymus in particular (together with
The sensory ganglia of cranial nerves are located in lymphoid tissue in general) involutes with age.
or near the associated foramina in the skull.
Each spinal nerve from T1-L2 is connected to the S
Seeccttiioonn 33:: B
Booddyy R
Reeggiioonnss aanndd P
Poossiittiioonn
sympathetic trunk by a white rami communicans. IIIn
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n
Every spinal nerve is connected to a sympathetic
Regional anatomy is concerned with the situational
trunk by a grey ramus communicans.
(extrinsic) properties of an organ its position and
Only anterior rami of spinal nerves take part in the relations.
formation of plexuses.
The first step in a clinical diagnosis is to determine
Peripheral nerves derived from anterior divisions of a the (anatomical) site of a lesion.
plexus are distributed to flexor compartments while C
Ch
C haaap
h pttteeerrr 111444::: A
p Arrrrrraaan
A ng
n geeem
g meeen
m nttt o
n offf B
o Bo
B od
o dyyy R
d Reeeg
R giiio
g on
o nsss
n
those derived from posterior divisions are distributed
to extensor compartments. The branching patterns of vessels tend to be
asymmetrical resembling the branching of a tree.
A nerve which supplies a muscle producing
movement at a joint also supplies sensation to the Flexor muscles with a richer nerve supply (for fine
joint and skin overlying (the insertion of) the muscle. control of movements) tend to occupy compartments
on the ventral aspect of the body and are covered by
The CNS receives blood supply from its periphery. delicate skin with a correspondingly richer nerve
There are no lymph vessels in the CNS. supply (for fine sensory discrimination).
Large nerve fibres within a peripheral nerve are the Course antigravity extensor muscles tend to occupy
most susceptible to pressure. compartments on the dorsal aspect covered by
A neuron influences the vitality of its connections. hairier skin with tougher dermis.
Posterior rami of spinal nerves directly supply the
C
Ch
C haaap
h pttteeerrr 111000::: A
p Arrrttteeerrriiiaaalll S
A Syyysssttteeem
S m aaan
m nd
n dA
d Arrrttteeerrriiieeesss
A dorsal aspect of the trunk (and also of the neck) with
The greatest drop in blood pressure occurs across their associated extensor regions containing skin,
arterioles. joints and (deeply located) intrinsic muscles.
Where arteries divide into terminal branches, the A limb plexus divides into anterior and posterior
larger branch tends to be more directly in line with divisions, with their nerve fibres distributed (via
the main trunk, with the smaller at a greater angle. associated peripheral nerves) to flexor regions and
The cardiovascular system is not only a closed extensor regions, respectively.
system but also a double system with two distinct C
Chaaap
Chh pttteeerrr 111555::: B
p Bo
B od
o dyyy C
d Co
C om
o mp
mppaaarrrtttm
meeen
m ntttsss aaan
n nd
n dF
d Faaasssccciiiaaalll P
F Plllaaan
P neeesss
n
blood circulations. Compartments tend to be in layers.
Systemic arteries transport oxygenated blood.
238
Appendix 1: List of Principles
While major vessels and nerves may course along C
Ch
C haaap
h pttteeerrr 222111::: A
p An
A naaattto
n om
o miiicccaaalll V
m Vaaarrriiiaaatttiiio
V on
o n iiin
n nP
n Po
Poosssiiitttiiio
on
o n
n
them, few cross mobile fascial planes as they would During development migration may occasionally fall
overstretch or have their own mobility restricted. short of the normal site.
Vessels tend to cross planes at sites of fusion, where During development migration may occasionally
connective tissue is anchored. overshoot the normal site or deviate to an abnormal
Vessels and nerves course from fixed to mobile site.
areas. Abnormal communications may occur from
Fluids (including blood and pus) tend to track along endothelial channels failing to close during
mobile fascial planes as they provide paths of least development.
resistance. Vessels develop from networks that have the
C
Ch
C haaap
h pttteeerrr 111777::: N
p Neeeu
N urrro
u ovvvaaassscccu
o ulllaaarrr P
u Paaattth
P hw
h waaayyysss
w potential for change, where preferred channels
Within a neurovascular bundle, the vein and lymph remain while others regress (providing scope for
vessels are located more peripherally. variation).
C
Chaaap
Chh pttteeerrr 222222::: P
p Paaattth
P ho
h olllo
o og
o giiicccaaalll V
g Vaaarrriiiaaatttiiio
V on
o n
n
The major limb arteries tend to run through flexor
regions and are generally located on the flexor In contrast to anatomical variation (with abnormal
aspect of joints. structure or position but no functional impairment)
The nerve supply to a structure remains constant pathological changes have impaired function, even if
even if the structure has migrated. not immediately evident.
Arterial pulsation is best detected by palpation at a Malformations occur when organ systems are
site where an artery is closely related to both skin forming (between the third to eighth weeks) and most
and bone. major malformations spontaneously abort.
Multiple minor malformations generally signify an
S
Seeccttiioonn 44:: D
Deevveellooppm
meenntt aanndd V
Vaarriiaattiioonn underlying major malformation.
IIIn
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n Understanding of normal and abnormal anatomy is
the basis for recognising clinical manifestations of
Anomalies found on physical examination or by disease processes.
imaging may be of clinical significance per se or
when misdiagnosed as being pathological. S
Seeccttiioonn 55:: P
Prraaccttiiccaall P
Peerrssppeeccttiivveess
Encountering anomalies, particularly when not
anticipated, can pose problems during invasive C
Ch
C haaap
h pttteeerrr 222333::: S
p Su
S urrrfffaaaccceee aaan
u nd
n dF
d Fu
F un
u nccctttiiio
n on
o naaalll A
n An
A naaattto
n om
o myyy
m
procedures or surgical operations. In burns, fluid loss is proportional to the surface area
It is vital for a clinician to distinguish typical from affected.
atypical, normal from abnormal, and health from The viscera that are most mobile are those
disease. suspended by a mesentery.
C
Ch
C haaap
h pttteeerrr 111888::: G
p Grrro
G ow
o wttth
w h aaan
h nd
n dD
d Deeevvveeelllo
D op
o pm
p meeen
m nttt
n C
Ch
C haaap
h pttteeerrr 222444::: R
p Raaad
R diiio
d og
o grrraaap
g ph
p hiiiccc A
h An
A naaattto
n om
o myyy aaan
m nd
n d IIIm
d maaag
m giiin
g ng
n g
g
During the early embryonic phase, features appear The intensity of blackness on a radiograph is directly
from more primitive ancestors. proportional to the intensity of radiation which
C
Ch
C haaap
h pttteeerrr 111999::: N
p No
N orrrm
o maaalll V
m Vaaarrriiiaaatttiiio
V on
o n
n reaches the film.
The lymphoid organs are the first organs to involute. The greater the tissue radiodensity, the greater the
attenuation of X-rays.
The part of the skeleton that best distinguishes
males from females is the bony pelvis. A radiological interface is created when tissues of
different radiodensity lie adjacent to each other.
The most mobile viscera are those suspended by a
mesentery. Lines (or edges) may be seen on a radiograph when
radiological interfaces are parallel to the path of the
C
Ch
C haaap
h pttteeerrr 222000::: A
p An
A naaattto
n om
o miiicccaaalll V
m Vaaarrriiiaaatttiiio
V on
o n iiin
n nS
n Stttrrru
S uccctttu
u urrreee
u
X-rays.
Multiple branches arising close to each other can An object is usually radiographed in at least two
have a common stem. projections at right angles to each other.
Variations in venous patterns are extremely common Structures of most interest should be placed
as veins develop from numerous endothelial centrally within the X-ray beam.
channels.
The X-ray film should be placed perpendicular to the
An arterial trunk arsing from a main artery and centre of the X-ray beam.
subsequently dividing can be absent, with its
branches arising independently. The organ or body part of most interest is positioned
as close as possible to the recording medium to
A large anastomosing branch of a neighbouring minimise magnification and loss of sharpness.
artery may replace an artery and take over its
territory. Compact bone (densely packed bone tissue
infiltrated with calcium) appears more opaque than
Abnormal fusion of vertebral elements tends to occur cancellous bone (containing many little
at transitional regions compartments).
Accessory bones are created by failure of a centre of Only fat has sufficient radiographic contrast
ossification to fuse with the rest of the bone. compared to all other types of soft tissues (and body
Anomalies of bony fusion and non-fusion may create fluids) to form visible interfaces on a plain film.
a domino effect along the spine.
239
Appendix 1: List of Principles
When an organ or a tissue of soft tissue density is Incisions should ideally be placed along prominent
adjacent to air or gas, the difference in radiodensity skin creases (particularly in the trunk, neck and face)
will form a clean and sharp edge provided the to disguise the scar.
interface is parallel to the x-ray beam. Incisions crossing joint lines should be avoided due
C
Ch
C haaap
h pttteeerrr 222555::: S
p Seeeccctttiiio
S on
o naaalll A
n An
A naaattto
n om
o myyy,,, C
m CT
C T aaan
T nd
n dM
d MR
MRRIII to subsequent restriction of movement even from
Radiographs display the entire body part or an organ normal scar contraction.
that is imaged, whereas CT images display slices of Incisions should be planned with an awareness of
body parts or organs. underlying structures (particularly nerves and
MRI (unlike radiography and CT) avoids using vessels) and special care must be taken to avoid
ionising radiation. damaging them.
Implanted electronic devices and potentially mobile Wounds should be closed layer by layer to prevent
ferromagnetic material are contraindications to MRI. dead space and maximise wound strength
On T1 weighted images tissues with a high fat Aspirating before injecting avoids inadvertent
content appear bright. intravenous injection
On T2 weighted images tissues with high water Within a peripheral nerve, small fibres (mainly pain
content appear bright. fibres) are most affected by local anaesthetic agents.
The most important advantage of MR over other Larger fibres are affected to a lesser degree (hence
imaging modalities is the ability to distinguish types touch sensation may remain).
of soft tissues from each other. The area anaesthetized by a nerve block corresponds
C
Ch
C haaap
h pttteeerrr 222666::: U
p Ullltttrrraaassso
U ou
o un
u nd
ndd IIIm
maaag
m giiin
g ng
n g
g to the sensory distribution of the nerve (distal to the
site of infiltration) minus the area of overlap from
Ultrasound allows real time cross-sectional imaging adjacent nerves.
without any ionizing radiation.
Adrenaline must never be injected into terminal parts
An acoustic interface exists at the junction of two (particularly digits or penis) because they are
tissues of different acoustic impedance. (collectively) supplied by end-arteries.
The larger the difference in density of adjacent Ideal sites for cannulation of veins are at an inverted
tissues, the larger the reflection, resulting in a 'V' junction point or where a vein pierces deep fascia.
brighter signal from their acoustic interface.
C
Ch
C haaap
h pttteeerrr 222888::: C
p Cllliiin
C niiicccaaalll P
n Prrro
P occceeed
o du
d urrreeesss
u
Skin incisions made parallel to lines of tension heal
with a minimal scar, while those crossing lines of
tension tend to produce a wider scar.
240
Appendix 2: List of Applications
SSeeccttiioonn 11:: TThhee H
Huum
maann B
Booddyy Effects of capsular or ligamentous injury
Effects of articular cartilage injury
C
Ch
C haaap
h pttteeerrr 222::: H
p Hu
H um
ummaaan
nF
n Fo
Foorrrm
m aaan
m nd
n dS
d Stttrrru
S uccctttu
u urrreee
u
C
Ch
C haaap
h pttteeerrr 666::: M
p Mu
M ussscccu
u ulllaaarrr S
u Syyysssttteeem
S m aaan
m nd
n dM
d Mu
Muussscccllleeesss
Site of most stress on spine
Grades of muscle injury
Risk of choking and protective reflexes
Sites of muscle tears
SSeeccttiioonn 22:: B
Booddyy SSyysstteem
mss aanndd SSttrruuccttuurree
Muscles prone to strain
C
Ch
C haaap
h pttteeerrr 444::: S
p Skkkeeellleeetttaaalll S
S Syyysssttteeem
S m aaan
m nd
n dB
d Bo
Boon
neeesss
n
Tenosynovitis
Marrow reversion after blood loss
Infection of a synovial sheath
Mistaking bones for fracture fragments
Effect of mesotendon injury
Mistaking epiphysial plates for fracture lines
Assessment of muscle function
Determination of skeletal age
Active insufficiency
Importance of imaging bones bilaterally
Passive insufficiency
Epiphysial judgement
Skeletal muscle tone and its assessment
Epiphysial damage
Muscle hypertrophy and atrophy
Perichondrial stripping
Muscle injuries and healing
Periosteal stripping C
Ch
C haaap
h pttteeerrr 777::: IIIn
p nttteeeg
n gu
g um
ummeeen
ntttaaalll S
n Syyysssttteeem
S m aaan
m nd
n dS
d Skkkiiin
S n
n
Interruption of blood supply to bone Direction of skin incisions and scarring
Fractures Fluid loss in burns and rule of nines
Fracture healing Regeneration of skin after burns
C
Ch
C haaap
h pttteeerrr 555 A
p Arrrtttiiicccu
A ulllaaarrr S
u Syyysssttteeem
S m aaan
m nd
n d JJJo
d oiiin
o ntttsss
n Effect of nail bed damage
Joint degeneration
Subungual haematoma
Osteophyte formation
Fingerprinting
Articular cartilage damage
Skin surgery
Synovial effusion
Area of anaesthesia in a nerve block
Haemarthrosis
Assessing skin sensory loss
Septic Arthritis
Shingles dermatomal distribution
Loose body
Effects of lacerating dermal vessels
Grades of ligament injury
Planning grafts based on angiosomes
Tears and avulsion at ligament attachments
Lymphangitis
Ligament vulnerability
Lymph spread from watershed areas
Ligament stress test C
Ch
C haaap
h pttteeerrr 888::: V
p Viiisssccceeerrraaalll S
V Syyysssttteeem
S msss aaan
m nd
n dV
d Viiisssccceeerrraaa
V
Masking of ligament tear by muscle spasm Obstruction of a tubular viscus
Masking of pain by nerve fibre rupture Types of duct obstruction
Laxity and loss of proprioception Torsion of a viscus
Labrum or meniscal tears Surgical removal of a segment
Bursitis Strangulation of a viscus
Joint cavity communication C
Ch
C haaap
h pttteeerrr 999::: N
p Neeerrrvvvo
N ou
o usss S
u Syyysssttteeem
S m aaan
m nd
n dN
d Neeerrrvvveeesss
N
Pinched fat pad Features of a segmental nerve lesion
Assessment of joint mobility Importance of testing visual fields
Joint dislocation and subluxation Pre-fixed and post-fixed plexus variants
Pain from degenerative arthritis Features of a peripheral nerve lesion
Sensory effects of ligamentous injury Reflex muscle spasm
Effects of injury on vascular joint tissues Barrier to spread of brain tumours
241
Appendix 2: List of Applications
Types of nerve injuries C
Ch
C haaap
h pttteeerrr 111555::: B
p Bo
B od
o dyyy C
d Co
C om
o mp
mppaaarrrtttm
meeen
m ntttsss aaan
n nd
n dF
d Faaasssccciiiaaalll P
F Plllaaan
P neeesss
n
Grades of nerve injury Compartment syndrome
Axonal degeneration Potential paths of tracking and direct spread
Axonal regeneration C
Ch
C haaap
h pttteeerrr 111666::: B
p Bo
B od
o dyyy W
d Waaallllllsss aaan
W nd
n dC
d Caaavvviiitttiiieeesss
C
Pain from meninges and dural sleeves Hernia
242
Appendix 2: List of Applications
Assessing joint congruence and alignment
Assessing soft tissue calcification
Interventional radiology
C
Ch
C haaap
h pttteeerrr 222555::: S
p Seeeccctttiiio
S on
o naaalll A
n An
A naaattto
n om
o myyy,,, C
m CT
C T aaan
T nd
n dM
d MR
MRRIII
Distinguishing soft tissues on MR images
C
Ch
C haaap
h pttteeerrr 222888::: C
p Cllliiin
C niiicccaaalll P
n Prrro
P occceeed
o du
d urrreeesss
u
Sites where incisions should be avoided
Structures endangered by incisions
Lacerations and their management
Hazards of a joint puncture
Hazards of a body cavity tap
Preventing inadvertent IV injection
Structures endangered by IM injections,
Hazards of nerve blocks
Assessment of collateral circulation
Hazards of an arterial puncture
Preventing inadvertent intra-arterial injection
Hazards of a venepuncture
Hazards of peripheral IV cannulation
243
Appendix 3: List of Terms
S Myomeres Chondrocytes
Seeccttiioonn 11 Metamerism Diaphysis
Ectoderm Somites Accessory
Mesoderm Sclerotome
Endoderm C
Ch
C haaap
h pttteeerrr 555
p
Dermamyotome
Ch Joint
C
Chhaap
a pttteeerrr 111
p Branchiomerism
Branchial arches Cavity
Anatomical Position Suture
Sagittal Branchial muscles
Polarity Syndesmosis
Coronal Gomphosis
Transverse Buccopharyngeal membrane
Cloacal membrane Synostosis
Anterior Primary cartilaginous joints
Posterior Pre-axial border
Post-axial border Secondary cartilaginous joints
Superior Symphyses
Inferior Dermatomes
Myotomes Plane
Medial Uni
Lateral Welcoming Position
Vertebrate Axial
Proximal Hinge
Distal Skeleton
Spinal cord Pivot
Superficial Bi-Axial
Deep Spinal nerves
Quadrupeds Condylar
External Ellipsoid
Internal Mammals
Appendages Saddle
Ventral Multi-Axial
Dorsal Mammary glands
Uterus Ball and Socket
Palmar Simple
Plantar Umbilical cord
Placenta Compound
Cranial Complex
Caudal Pulmonary
Systemic Fibrocartilage
Rostral Disc
Occipital Forebrain
Jawbone Menisci
Bilateral Articular
Midline Teeth
Ossicles Ovoid
Unilateral Sellar
Ipsilateral Primates
Brachiators Pit
Contralateral Fossa
Flexion Thermoregulation
Hominid Notch
Extension Fat Pad
Abduction Homo sapiens
Line of gravity Labrum
Adduction Discs
Medial Bipedal locomotion
Gluteus Maximus Menisci
Internal Osteophytes
Lateral Larynx
Vocal cords Mobility
External Fusion
Lateral flexion Soft palate
Nasopharynx Loose body
Pronation Fibrous capsule
Supination Oesophagus
Pharynx Intracapsular
Plantar flexion Bursa
Dorsiflexion Oropharynx
Annular ligament
Inversion C
Ch
C haaap
h pttteeerrr 333
p Synovial cavity
Eversion Internal Genital Organs Synovial membrane
Protraction External Genital Organs Synovial cavity
Retraction Synovial fluid
Elevation S
Seeccttiioonn 22 Hyaluronic Acid
Depression Synovial effusion
C IIIn
ntttrrro
n od
o du
d uuccctttiiio
on
o n
n
Ch
C haaap
h pttteeerrr 222
p Haemarthrosis
Animal Viscera Haemophiliac
Coelomate Cells Septic arthritis
Chordate CCChhhaaap pttteeerrr 444
p Loose body
Animal Extracellular matrix Locking
Coelom Osteoblasts Ligaments
Gut tube Osteoclasts Elastic Ligaments
Chordates Compressive Ligamenta Flava
Neural groove Tensile Intrinsic Ligaments
Notochord Calcium Extrinsic Ligaments
Pharyngeal pouches Collagen Cruciate Ligaments
Branchial clefts Hyaline Collateral Ligaments
Segmentation Fibro Accessory Ligaments
Polarity Elastic Grade I
Grade II
244
Appendix 3: List of Terms
Grade III Tendons C
Ch
C haaap
h pttteeerrr 888
p
Avulsed Aponeurosis Hollow
Stressing Raphe Solid
Laxity Deep Serosa
Proprioception Superficial Muscularis
Special structures Retinaculum Mucosa
Labrum Septa Orifices
Disc Sheets Folds
Menisci Sheaths Thickenings
Labrum Fascial Visceral obstruction
Loose body Intermuscular Impaired Passage
Intracapsular tendon Interosseous membrane Distension
Bursa Fibrous tendon sheaths Pain
Bursitis Fibro-osseous tunnels Constipation
Septic arthritis Synovial sheaths Abdominal distension
Fat Pads Tenosynovitis Pain
Mobility Tendinitis Bowel sounds
Stability Tenovaginitis Duct
Passive assistance Power Exocrine
Roll Fulcrum Orifice
Slide Load Endocrine
Spin Line of pull Hormones
Bony Parallel Midline
Ligamentous Obliquely Non-midline
Muscular Pennate Sac
Dynamic ligaments Uni Invaginate
Stretch reflexes Bi Mesenteries
Close packed Multi Posterior
Loose packed Isotonic Peritoneal
Dislocation Eccentric Subperitoneal
Subluxation Isometric Mobility
Vascular Circle Flexor Fixation
C Extensor Suspended on a mesentery
Chap
Chhaa pttteeerrr 666
p
Agonist Motility
Skeletal Muscle Antagonist
Striated Sphincter
Fixator Distal
Somatic Dynamic ligament
Non-Striated Reservoir
Synergists Functional sphincter
Autonomic Peripheral nerve
Cardiac Muscle Folds
Motor unit Junction zones
Collective unit Proprioceptive
Endomysium Fusion
Hypertrophy Mucocutaneous
Perimysium Disuse atrophy
Epimysium Junctions
Denervation atrophy Mucocutaneous junctions
Fleshy Myotome
Tendinous Strangulation
Pedicles
Roughening C
Ch
C haaap
h pttteeerrr 999
p
Line C
Ch
Chhaap
a pttteeerrr 777
p
Axon
Crest Striae Supporting cells
Tubercle Skin cleavage lines Axoplasm
Origin Mucocutaneous junctions Neurons
Insertion Alignment Schwann cell
Biceps Tension Neurilemma
Triceps Disfigurement Nerve
Adductor magnus Indirect Synapse
Muscle belly Direct Synaptic cleft
Tendon Inter-nervous line Sensory
Musculotendinous junction Midsagittal Motor
Fusiform Welcoming Position Receptor
Digastric Dermatome maps Effector
Tendinous intersections Herpes zoster Reflex
Flat Shingles Negative feedback
Circular Vesicles Somatic
Palmaris longus Unpaired Visceral
Plantaris Paired Neural crest
Vestigial Mobile Neuroglia
Regressive Fixed Cortex
Atavistic Lymphangitis Tracts
Avulsed Lymphotome Dermatome
Gastrocnemius
245
Appendix 3: List of Terms
Myotome Peripheral oedema Neurovascular hilum
Plexuses Pulmonary Boundaries
Branchial arches Oedema Apertures
Gill clefts Ascites Direct relations
Ganglion Portal hypertension External haemorrhage
Parasympathetic ganglia Oesophageal varices Internal haemorrhage
White rami communicans C Lacerations
Ch
C haaap
h pttteeerrr 111222
p
Grey ramus communicans Fracture
Splanchnic nerves Venom Dislocation
Thoracic pain line Lymphoedema Entrapment
Pelvic pain line Antigens External compression
Plexus Cervical
Axillary S
Coronal morphological plane
Inguinal
Seeccttiioonn 44
Peripheral
Accessory spleens IIIn
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n
Segmental
Muscular Normal variations
Cutaneous
S
Seeccttiioonn 33 Atypical
Articular IIIn Anatomical variations
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n
Vasomotor Abnormal
Region Normal
Muscular Position
Articular Function
Relations Anomaly
Cutaneous Module
Joint Partial
Dislocation C
Ch
C haaap
h pttteeerrr 111333
p Complete
Angiosome Paired Single
Choke vessels Unpaired Multiple
Blood brain barrier Bony Unilateral
Laceration Soft tissue Bilateral
Traction Apertures Reciprocal
Compression Compensatory
C
Ch
Chhaap
a pttteeerrr 111444
p
Meningitis Pathological changes
Unpaired Impaired function
Neurogenic pain
Ventral Congenital
Neuralgia
Dorsal Acquired
Herpes zoster
Thoracic
Shingles C
Ch
C haaap
h pttteeerrr 111888
p
Abdomino-pelvic
Varicella zoster Growth
Cranial
Phantom pain Development
Vertebral
Phantom limb Prenatal
Paired
C
Ch
C haaap
h pttteeerrr 111000
p Bilateral symmetry Embryonic
Rete mirabile Rotate Foetal
Pulmonary Boundaries Zygote
Systemic Apertures Morula
Haemorrhage Compartments Blastocyst
RICE Boundaries Embryoblast
Rest Trophoblast
C
Ch
C haaap
h pttteeerrr 111555
p
Ice Bilaminar germ disc
Prime movers Ectoderm
Compression
Fixators Endoderm
Elevation
Compartment syndrome Trilaminar germ disc
Arteriovenous
Laminectomy Mesoderm
End artery
Fibrous septa Organogenesis
Anatomical end artery
Hemiplegia C
Ch
C haaap
h pttteeerrr 111666
p Longitudinally
Cardiac arrhythmia Body wall Transversely
Vasoconstriction Parietal Neural tube
Thrombus Hernia Somites
Embolus Compression Crown-rump length
Thromboembolus Obstruction Amniotic fluid
Strangulation Gubernaculum
C
Ch
Chhaap
a pttteeerrr 111111
p
Serous sac Crown-heel length
Communicating veins Oxygenated
Mesothelium
Varicose vein Deoxygenated
Parietal
Emissary veins Ductus venosus
Visceral
Thrombosis Ductus arteriosus
Mobility
Thrombus Foramen ovale
Motility
Thromboembolus Ligamentum venosum
Prolapse
Tumour metastases Ligamentum arteriosum
Septicaemia C
Ch
C haaap
h pttteeerrr 111777
p Ligamentum teres
Prostate cancer Neurovascular bundle Medial umbilical ligaments
Septic thrombosis Axial artery Neonate
246
Appendix 3: List of Terms
Pre-term Dysphagia Endoscopic Anatomy
Premature Dysphagia lusoria Endoscopy
Fontanelles Ch Procedures
C
Chhaap
a pttteeerrr 222222
p
Sutures Autopsy
Primary curvatures Congenital malformations Postmortem
Infancy Anatomical variation Dissection
Primary dentition Pathological changes Cadaver
Secondary curvatures Malformation syndrome Predissected Wet Specimens
Childhood Down's Syndrome Plastinated Specimens
Early Trauma Bones
Late Ulceration Forensic Osteology
Secondary dentition Laceration Odontology
Adolescence Contusion
Strain C
Ch
Chhaap
a pttteeerrr 222333
p
Adulthood
Adolescent Sprain Stressing
Growth spurt Fracture-dislocation Passive assistance
First Degree Hypertrophy
C
Ch
C haaap
h pttteeerrr 111999
p Second Degree Disuse atrophy
Normal Third Degree Denervation atrophy
Variation Inflammation Somatic
Maturity Physical Visceral
Involution Chemical Gluteus Maximus
Old Age Organismal C
Chap
Chhaa pttteeerrr 222444
p
Menopause Autoimmune
Atrophy Acute Inflammation X-Rays
Postmenopausal Resolution X-Ray tube
Osteoporosis Spread X-Ray film
Hypertrophy Suppuration Radiograph
Spermatogenesis Fibrosis X-Ray image
Andropause Chronic Inflammation Digital Radiography
Senescence Abscess Image Intensifier tubes
Osteoporosis Scar Attenuation
Gingivitis Degeneration Tissue radiodensity
Arteriosclerosis Cell Damage Radiolucent
Genetic Necrosis Radio opaque
Hormonal Regeneration End-on effect
Environmental Calcification Views
Heavy Lysis Projections
Medium Gangrene Anteroposterior (A-P)
Light Apoptosis Posteroanterior (P-A)
Adipose Infiltrations Standard
Somatotyping Congestion Oblique
Mesomorphs Oedema Penetration
Endomorphs Haemorrhage Sharpness
Ectomorphs Shock Geometric Unsharpness
Obesity Haematoma Motion Unsharpness
Body Mass Index Aneurysm Spatial Resolution
Functional differences Thrombus Image Noise
Posture Embolus Contrast Resolution
Respiration Ischaemia Magnification
Pregnancy Infarction Distortion
Compression Superimposition
C
Chap
Chhaa pttteeerrr 222000
p Summation
Collapse
Mobile Obstruction Trabeculae
Expansile Dilatation Subchondral Bone
Exercise Hernia Compact Bony Tables
Contents Prolapse Diploe
Activation Primary centres
Vestigial S Secondary centres
Atavistic
Seeccttiioonn 44 Epiphysial line
Cranial IIIn
ntttrrro
n od
o du
d uccctttiiio
u on
o n
n Bony articular surfaces
Caudal Surface Anatomy Radiological joint space
Supernumerary Functional Anatomy Congruence
Accessory Radiographic Anatomy Alignment
C Plain Radiography Mammography
Ch
C haaap
h pttteeerrr 222111
p
Contrast Studies Contrast radiograph
Excessive mobility Contrast material
Direction Sectional Anatomy
Computed Tomography Positive
Aberrant Negative
Aberrant Accessory Magnetic Resonance Imaging
Ultrasound Imaging Direct
247
Appendix 3: List of Terms
Indirect Glue
Pharyngogram Clips
Barium Swallow Strips
Barium Meal Anatomical
Small bowel series Landmarks
Single contrast Lacerations
Double contrast Debrided
Barium Enema Synovial
Oral Cholecystography Cavity
Endoscopic Retrograde Synovial
Cholangiopancreatography Cavity
Intravenous Urography Puncture
Retrograde Pyelography Body
Cystography Cavity
Hysterosalpingography Body
Myelography CavityPuncture
Contrast Arthrography Intradermal
Peritoneography Subcutaneous
Angiography Intramuscular
Arteriography Nerve block
Arterial Intercostal nerve block
Capillary Digital nerve block
Venous Arterial puncture
Venography Radial artery
Lymphography Brachial artery
Digital Subtraction Angiography Femoral artery
C Venepuncture
Ch
C haaap
h pttteeerrr 222555
p
Tourniquet
Subtracted Image
Computed Tomography
Windowing
Narrow Window
Wide Window
Spatial Resolution
Contrast Resolution
High-Resolution Computed
Tomography
Multislice CT
Helical CT
Volume Scanning
Magnetic Resonance Imaging
MRCP
C
Ch
C haaap
h pttteeerrr 222666
p
Ultrasonography
Ultrasound
Transducer
Reflection
Absorption
Scatter
Acoustic Impedance
Echogenicity
Echotexture
Probes
Doppler effect
Colour Doppler
Duplex Scanning
Pulsed Doppler
C
Ch
C haaap
h pttteeerrr 222888
p
Incision
Relaxed skin tension lines
Keloid
Incisional hernia
Wound
Incision
Laceration
Interrupted
Continuous
Subcuticular
248
Appendix 4: List of Derivations
1 L. 'jointed') L. axis
Ectoderm G. outside skin L. 'dried up' L. tendons
Mesoderm G. middle skin L. four + footed G. nerve + husk
Endoderm G. inside skin L.'breast' L. string
L. area L. womb G. touch
L. 'wall' L. navel L. receive
L. rupture L. cake L. bend backwards
L. serum a watery fluid L. 'first' G. nerve + glue
L. thin skin L. arm L. shell
L. falling L. 'man form' G. gill
G. not + type L. 'man' G. swelling
L. away + rule L. 'wise man' G. viscus
G. irregular G. 'voice' L. braid
G. in + grow L. sticky G. nerve + pain
G. yolk G: bone + germ G. creep + girdle
L. mulberry G. bone + break L. net + wonderful
G. germ + bladder G. between growth L. lung
G. nutrition + germ L. seams G. blood + gush
L. rudder G. together + bone G. clot
L. new + birth G. together + band G. plug
G. month + beginning) G. bolt L. out + send
L. grown up G. together + grow G. bag
L. to wrap up L. to bend G. produce against
G. month + pause L. joint direct
G. man + pause L. egg-like G. disease
L. growing old L. saddle L. small fountains
G. bone + porous L. lip L. ring
L. fatty G. bone + growths G. absent + formation
G. body + form L. box reciprocal
L. ancestor L. with + egg endangered
L. above + number G. blood + joint compensatory
L. straying L. bind fail
G. bad + eat L. with + side defectively
L. a sport of nature L. tear away redness
L. with + born L. lip swelling
G. 'running together' L. little half-moons heat
L. 'to go away' L. purse pain
L. mouse direct
2 G. within muscle lymphatic
L. arrow around muscle blood
L. crown Upon muscle G. 'dropping off'
L. nearest G: two + heads G. new + moulding
L. distant L. spindle + shape L. 'crab'
L. belly G. double + stomach G. beyond + standings
L. back L. forefather G. 'cancer' + 'swelling'
G. skull L. tear away G. 'flesh' + 'swelling'
L. tail L. stretch out G. blood + swelling
L. beak L. from + tendon G. widening
L. begin as in born first L. seam G. clot
L. bend L: tether G. plug
L. stretch) L. partition G. keep back + blood
L. face down L feather L. stuffing
L. back down G. equal stretch L. rupture
'breath' equal length L. falling
G: hollow G. contest G. within+look
G outside skin G. with + work G. self + view
middle skin L. ones own receiver; L. after death
inside skin G. over-nourishment L. apart + cut
G. 'cord' G. muscle + cut L. fallen
(G. back + cord G. creep + girdle G. over-nourishment
G. 'throat' L. outside + secrete deltoid
G. 'gill' L. opening gluteus maximus
G. 'muscle parts' G. inside + secrete vastus lateralis
G. body G. rouse Ontogeny recapitulates
G. hard + cut L. serum Phylogeny'
G. skin + muscle cut G. middle intestine L. 'drum'
L. 'sewer' G. strangle) L. 'monthly'
G: 'skin' + cuts' L. slit L. build
G: 'muscle' + 'cuts' L. choke G. tool
249
Appendix 4: List of Derivations
L: organised whole L. nipples L. branch
L. body L. white L. beak
L: vessel L: hair + grease L. tail
G: dried up L. small bags G. lines
L: beams hair L. vessels of nerves
L: marrow sweat G. air + carry
G: around bone L. wax L. light
G. within bone L. breast G. within + nipple
G: blood + make L. under + nail L. minute hairs
G: air L. fat L. space-like
L. spaces G: skin + cut G. eat + cells
G: sesame seed-like L. sticky L. little balls of thread
L. joint L. light with + contract
L: thorn L. flask between + contract
G. knuckle L. acorn G. artery + hardness
Fr. little face L. shell gruel + hardness
L. ditch L. middle G. widening
L. pit L. lead G. through + mouth
L. furrow G. middle L. balls of thread
L. bore G. wall G. keep back + blood
L. passage L. slippery + thin skin L. stuffing
(L. aperture L. plate + special L. vessels of vessels)
G. glass L. nipples G. not yoked
G. around +cartilage L. sewer G. gateway + liver
changing growth G. visceral G. under + growth
upon growth G. marrow L. flaps
L. 'covering' G. within nerve L. veins + accompanying
L. break around nerve L. hollow
L. skin upon nerve L. tough mother)
L. vessel + body G. trees L. bring together
L. carry to G. swelling
3 G. self+ law L. clear fluid
L. yellow G. intestine L. milk
L. in + sheath G. membranes L. juice
L. middle + tendons L. hard + mother reservoir + juice
L. slit G. spider web-like + mother L. knots
G. tension L. tender + mo L. flat
G. skin G. circles L. middle + carry
G. upon + nipple L. furrows G. tension
L. scale L. nuts
G. black L. little cords
250
Index
251