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GENERAL ANATOMY

Principles and Applications


Norman Eizenberg, Craig Adams, Christopher Briggs and Gerard Ahern

www.anatomedia.com
Credits About the authors

Principal Authors Norman Eizenberg (MBBS)


Norman Eizenberg (MBBS) Project Leader of Anatomedia
Christopher Briggs (PhD) Coordinator and Senior Lecturer, Postgraduate (PG)
Craig Adams (MBBS MD) Surgical Anatomy ACB/University of Melbourne (U of M)
Gerard Ahern (MBBS) Member, Anatomy committee RACS
Contributor, RACS and RACDS Fellowship Courses
Contributing Authors General Practitioner and Member, RACGP
Priscilla Barker (PhD) Research: Medical Education, Anatomical Variation
Ivica Grkovic (MD) Universitas 21 Fellowship Award (2000)
Alex Pitman (FRANZCR) Meritorious Service Award RACDS (2006)
Craig Adams (BMedSci MBBS MD)
Prototype Contributors
Henoh Dolezal (MBBS) Professor, Clinical Skills (FSMed)
Zdenek Dubrava (MBBS) Examiner, (Australian Medical Council)
Education Consultant, (General Surgeons Australia)
Content Consultants Contributor, Emergency/Trauma Courses (RACS)
Marius Fahrer (FRACS) Recipient, Faculty Medicine Excellence in Teaching
Robert Marshall (FRACS) Awards (1998-2009)
John Furness (PhD) Research: Medical Education
Jenny Hayes (MBBS)
Christopher Briggs (PhD)
Educational Consultant: Deputy Head, ACB/U of M
Cyril Driver (Med) Coordinator & A/Professor, UG Anatomy ACB/U of M
Clinical Consultants
Contributor, Diploma of Surgical Anatomy Course
Christen Barras (MBBS) Contributor, PG Surgical Workshops
Maurice Brygel (FRACS) Contributor, PG Physiotherapy & Forensic Anthropology
Erica Fletcher (PhD) Consultant Forensic Anthropologist, VIFM
Robert Heng (FRANZCR) Research: Applied Anatomy, Forensic Anthropology
Justin Kelly (FRACS)
Gerard Ahern (MBBS)
Martin Richardson (FRACS)
Andrew Rotstein (FRANZCR) PG Co-ordinator, Lecturer, Prosector ACB Monash U.
Ramin Shayan (MBBS) Lecturer Southern Health Clinical School
G. Ian Taylor (FRACS) Senior Fellow in Anatomy U of M
Hon. Ass. Professor Oceania University
Photography Contributor, RACS Surgical Skills for GPs
Stuart Thyer (BAppSc) Contributor, Diploma of Surgical Anatomy Course U of M
Today), General Practitioner.
Dissections Priscilla Barker (PhD)
Priscilla Barker (PhD) Principal Prosector ACB/ U of M
Matt Jackson (BSc) Contributor, Physiotherapy and Science Anatomy Courses
Physiotherapist and Member, APA
Illustration and Images Research: Lumbar Spine, Anatomy and Biomechanics
Priscilla Barker (PhD) Young Investigator of the Year Award (2005)
Diana Keshtiar (BSc) Ivica Grkovic (MD)
Head, Department of Anatomy/University of Split, Croatia
Prototype Illustrations Coordinator & Professor, UG Anatomy Courses
Quang Minh Phan (MBBS) Contributor, PG Anatomy Courses
Yun Fan Lu (MBBS) Professional associations
Research:
Graphic Design Alexander Pitman (FRANZCR)
Gavin Leys Professor of Medical Imaging, University of Melbourne
Director of Medical Imaging, St Vincent's Hospital
Design Consultant Senior Fellow, Department of Anatomy U of M
Chris Hanger Generalist & Specialist Radiologist
Author Radiology Core Review
Design Consultant Councillor A & NZ Ass. of Physicians in Nuclear Medicine.
Michelle Gough (BAppSc)

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'

Chapter 1: Human Anatomical Terms


Chapter 2: Human Form and Structure
Chapter 3: Human Sexual Characteristics

1
Introduction: Anatomy accommodates ancestry

Evolutionary history of the human body


All animals evolved from a common ancestor. Humans
(Homo sapiens) share many features with other animals
on our family tree but may be categorised via a hierarchy of
progressively more specific characteristics.

The human 'identity card' is:

Kingdom: Animal
Superphylum: Coelomate
Phylum: Chordate
Subphylum: Vertebrate
Class: Mammal
Order: Primate
Family: Hominid
Genus: Homo
Species: Homo sapiens

Developmental history of the human body


During development from a single cell (itself the product
of fertilization of an ovum by a sperm) to an adult human
(male or female), features from each of the above
categories appear, at least transiently. For example, all
developing vertebrates acquire precursors of gills and a
tail, even though they may subsequently disappear or
become modified beyond recognition.
It is also no accident that this reflects the evolution from
unicellular organism to Homo sapiens, as at the earliest
stages of their development embryos of different animals
tend to resemble each other (a human embryo even up to
six weeks is almost indistinguishable from that of other
mammals). However, from then on they progressively
diverge, both in form (external appearance) and in structure
(internal construction). The respective genetic blueprint
(modified by mutations) predetermines this. According to
Haeckels Biogenetic Law: Ontogeny recapitulates
Phylogeny'.

The developmental history of an individual reflects the


evolutionary history of its species.

During development, an individual passes through the


ancestral stages of life forms that progressively acquired
modifications (due to gene mutations retained through a
succession of environments).

The potentials (and limitations) of cells, tissues and


organs are determined by the germ layers from which
they are derived.

The embryo develops from three germ layers:


ectoderm, mesoderm and endoderm.
1. Ectoderm (G. outside skin) forms epidermis (and
skin appendages) plus nerve cells.
2. Mesoderm (middle skin) forms all connective
tissues (including bone, muscle, fascia, dermis and the
sheaths of peripheral nerves). Mesoderm also forms
vessels.
3. Endoderm (inside skin) forms the epithelial lining
of the digestive tract (gut) and of the respiratory tract
(which buds out of the foregut)

Only mesoderm derived structures are vascular.

2
Chapter 1: Human Anatomical Terms

ANATOMICAL POSITION AND PLANES

TERMS OF RELATIONSHIP

TERMS OF COMPARISON

SPECIAL TERMS OF COMPARISON

TERMS OF LATERALITY

TERMS OF MOVEMENT

SPECIAL TERMS OF MOVEMENT

ANATOMICAL POSITION AND PLANES


To avoid confusion in describing the location of one
structure relative to another a standard reference position
has been adopted.
This arbitrary position is termed the anatomical
position, where the body is standing upright with arms by Fig.1.2 Planes at 90 degrees to each other
the sides and palms facing forwards. Other terms of
position include sitting, kneeling and lying.
TERMS OF RELATIONSHIP

When describing the relationship between one


structure and another, the body is considered to be in
the anatomical position.

Terms of relationship are in opposite pairs along the


three dimensions of depth, length and width. Superior is
above while inferior is below. Medial (L. middle) is closer
to the midline while lateral (L. side) is further from it.
Anterior is in front while posterior is behind.

Fig.1.1 The anatomical position


Three sets of planes associated with the anatomical
position are sagittal, coronal and transverse.
Sagittal and coronal planes are vertical but at 90
degrees to each other. Vertical slices parallel to the sagittal
(L. arrow) suture of the skull are in sagittal planes. The
midline of the body is in the mid-sagittal (or median) plane,
as it is directly along the sagittal suture.
Vertical slices parallel to the coronal (L. crown) suture
of the skull are in coronal planes. Horizontal slices are in Fig.1.3 The mid-sagittal plane
transverse planes.
3
THE HUMAN BODY

Fig.1.4 A coronal plane

Fig.1.6 Terms of comparison

SPECIAL TERMS OF COMPARISON


Special terms of comparison may be used for certain
specific regions.

Fig.1.5 A transverse plane

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

The palm of the hand is termed the palmar surface. Its


opposite surface is the dorsum of the hand. The sole of
the foot is the plantar surface. Its opposite surface is the
dorsum of the foot. In the anatomical position, the dorsum
of the hand is posterior to the palm while the dorsum of the
foot is superior to the sole.

Fig.1.10 Examples of movement pairs

SPECIAL TERMS OF MOVEMENT


Special terms may be used for certain movements.
For example, the cervical spine, with a series of joints
between its seven vertebrae, can (collectively) decrease
the angle between the head and the shoulder on each side.
The term for this pair of movements is lateral flexion of the
neck to the left and to the right.
Another example is the complementary rotatory
movements that occur at proximal and distal radio-ulnar
Fig.1.8 Terms of polarity joints between the two bones of the forearm. It is much
Cranial (G. skull) is closer to the head while caudal (L. simpler to use the terms pronation (L. face down) and
tail) is closer to the tail. Within the head, rostral (L. beak) supination (L. back down) of the hand.
is closer to the front while occipital (L. begin as in born
first) is closer to the back of the head.

Fig.1.9 Polarity within the head

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

ERECT POSTURE AND EXPANDED BRAIN


Fig.2.2 A coelomate
BIPEDAL LOCOMOTION
The gut tube is suspended in the coelom. Although
SPEECH VIA A LENGTHENED PHARYNX there is an opening at both ends of the gut tube (one
becoming a mouth, the other an anus) the coelom is a
closed body cavity which does not communicate with the
outside environment.

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).

Fig.2.4 Neural tube development

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).

Pharyngeal pouches of endoderm


At the cranial end of the gut tube, a series of
Fig.2.6 Segmentation in embryo at 3 weeks
endoderm bulges termed pharyngeal (G. 'throat') pouches
abut overlying ectoderm depressions termed branchial (G.
'gill') clefts. In certain caudates (water breathers) the
pouches communicate with the corresponding clefts via gill
slits.

Fig.2.7 Section through trunk of an embryo at 4 weeks


Sclerotomes form the vertebral skeleton, while derma-
myotomes form segments of skin and skeletal muscle that
become incorporated into the trunk and the limb buds.
These mesoderm segments are located lateral to the
notochord.
In the adult, segmentation is still seen in the short
muscles of the back and intercostal muscles, vertebrae and
ribs, spinal nerves and vessels of the trunk. It is also
reflected in the segmental nerve supply of skin (as
Fig.2.5 Endoderm pouches and ectoderm clefts dermatomes), even in the limbs.

7
THE HUMAN BODY

The nerve supply of branchial arch derivatives is from a


specific cranial nerve (designated for each arch) rather
than from a spinal nerve.

Fig.2.10 Paired branchial arches of mesoderm


Fig.2.8 Segments of the trunk in an adult
Although structurally identical to skeletal muscles and
Segmentation relies upon the differential expression of capable of voluntary movement (e.g. in speech), branchial
sets of genes in the long axis (about the fourth week of muscles develop from splanchnic (rather than somatic)
development). These are known as homeotic genes. They mesoderm. These muscles, which tend to be covered by
determine regional characteristics. These genes have a mucous membrane or located near a mucocutaneous
sudden onset of expression then fade out once their junction, are also functionally related to smooth muscle.
segmental job is done. This produces an acute onset of the They are effectors for a special group of superficial reflexes
next body segment and gradual loss of the previous (e.g. swallow and cough reflexes) arising from mucous
segment. Genetic variation can produce loss of segments, membranes (of upper digestive and respiratory tracts) and
extra segments, transposed segments or changes in often act in conjunction with visceral reflexes involving
segment number (e.g. with cranial or caudal shift of the glandular secretion (e.g. salivation).
vertebral column, common anatomical variations).

Branchial arches POLARITY


Head segmentation ('branchiomerism') is modified All chordates exhibit polarity with a cranial (head) end
from that in the trunk. Bones, cartilages and muscles of the and a caudal (tail) end. The cranial part of the neural tube
jaw, face, pharynx and larynx are derived from the expands to form the brain, while the remainder develops
branchial arches. These commence as six paired masses into the much narrower spinal cord, terminating caudally.
of mesoderm situated between branchial clefts (ectoderm
depressions overlying endoderm pouches). Branchial Pharyngeal pouches and cloaca
arches may also be termed pharyngeal arches as pouches At the head and tail ends of the gut tube endoderm
associated with them line the developing pharynx. abuts ectoderm at the buccopharyngeal membrane and
cloacal (L. 'sewer') membrane, respectively. These
Branchial arch derivatives retain their nerve supply membranes break down to create orifices (with endoderm
despite migration. becoming continuous with ectoderm).

Fig.2.9 Segmentation in an embryo at 5 weeks Fig.2.11 Longitudinal section through embryo

8
2. Human Form and Structure

The pharyngeal pouches arise from the cranial end of


the gut tube. In humans, the middle ear (tympanic) cavity
develops as an extension of the first pharyngeal pouch
(remaining in continuity with the pharynx via the
pharyngotympanic tube).

Fig.2.14 Axial borders on limbs in the anatomical position

Sequence of dermatomes and myotomes


The combination of segmentation with polarity is
Fig.2.12 Division of cloaca in the human reflected in how dermatomes and myotomes are
arranged.
In humans, the cloacal membrane becomes divided A dermatome (G: 'skin' + cut') is the area of skin
into urogenital and anal membranes, creating separate supplied by a particular spinal cord segment.
orifices. The segmental arrangement of dermatomes in an adult
is less disguised when the limbs are shifted from the
Axial borders anatomical position (to the 'welcoming position') by
abduction of both upper and lower limbs as well as lateral
rotation of the lower limbs. The pre-axial border of each
limb is then located cranially and the corresponding post-
axial border, caudally (like the original limb buds).

Fig. 2.13 Axial borders on limb buds of embryo (5 weeks)


In the embryo, a limb bud develops like a paddle (or
flipper) with a pre-axial border (along the radius/thumb
aspect of the upper limb and the tibia/big toe aspect of the
lower limb) and a post-axial border (along the ulna/little
finger aspect of the upper limb and the fibula/little toe
aspect of the lower limb).
During later development the limb buds lengthen
considerably and the lower limb buds rotate medially. In the
anatomical position the pre-axial border of the upper limb is
located laterally (and post-axial border medially), with flexor
compartments anteriorly and extensor compartments
Fig. 2.15 Axial borders and relation to dermatomes
posteriorly. The pre-axial border of the lower limb is located
medially (and the post-axial border laterally), with flexor A myotome (G: 'muscle' + 'cut') is the mass of muscle
compartments posteriorly and extensor compartments supplied by a particular spinal cord segment.
anteriorly.

9
THE HUMAN BODY

The segmental arrangement of muscles in the trunk


(particularly for intercostal muscles and short muscles of
the back) is easily seen, with myotomes oriented from
cranial to caudal. However, myotomes are oriented from
proximal to distal along a limb and are disguised by even
more overlap than occurs with dermatomes.

Fig.2.16 Segment in the trunk

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.

Spinal cord and spinal nerves


The spinal cord is enclosed within the vertebral Fig.2 18 Developing limb in quadrupeds and humans
(spinal) canal with an associated series of paired
segmental spinal nerves exiting on each side. The MAMMALIAN FEATURES
segmental arrangement of the trunk is also seen with the
vertebrae and ribs. It is less visible with the muscles, Humans are mammals. A young mammal (L. 'breast')
although still reflected in their nerve supply. is suckled by its mother.

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

ERECT POSTURE AND EXPANDED BRAIN

Fig 2.22 The peculiar human foot

Skull supported by S-shaped spine


The bones of the upper limb are shorter than those of
the lower limb, allowing manipulation rather than
locomotion. The hand has an elongated and fully
opposable thumb, and particularly sensitive fingertips. The
femur is angulated medially enabling the feet to be placed
together in upright stance. The short but broad pelvis,
created by the hipbones and sacrum, forms a complete
ring. In females, the enclosed cavity provides a birth canal
large enough for a foetal skull to pass through.
The adult vertebral column is aligned vertically but has
a series of four curves, which are alternately convex
forward (cervical and lumbar) and convex backward
(thoracic and sacral). This supports a large cranium (in turn
containing a particularly large brain) above it. The short, flat
face with a relatively small jaw (and associated reduction in
teeth) enables better balance of the vertically held head.
Thanks to our skeleton, we can literally hold our heads
up high.

Fig.2.21 Adult skeleton in erect posture


Upright stance is associated with evolution of the
largest cerebral hemispheres (and corresponding
intellectual capacity) within the animal kingdom.

The arched human foot


The principal feature associated with erect posture and
bipedal gait is our peculiar foot (which may be regarded as
the most distinctly human part of the body).
In non-human primates, feet are also used for grasping,
and resemble hands (particularly as the big toe is
opposable). The human foot is an arched platform
(supporting body weight) and has a non-opposable big toe
(sacrificing grasp for gait). It seems that humans owe their
highly developed intelligence to evolution of the foot and Fig.2.23 Features of the human skeleton
the domino effect of features associated with bipedalism
(all the way up to and including the head). Line of gravity and stable joints
Bipedalism complements the massive increase in In an adult standing upright, the line of gravity passes
cerebral hemisphere size and literally enables us to think between the mastoid processes of the skull, balancing the
on our feet. head.

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).

Fig.2.26 Phases of the walking cycle


The line of gravity moves forwards in the direction of
motion. At one phase of the cycle (mid-swing and mid-
stance) it passes through both limbs. At all other phases it
passes between the limbs.
Fig.2.24 Line of gravity in erect posture
Roles of the gluteal muscles
Thanks to stable joints the precarious evolution of The large gluteus maximus muscle is located
upright stance did not fall flat on its face. posteriorly (creating the unique form of the human buttock)
Site of most stress on spine producing powerful hip extension in running and jumping.

Fig.2.27 Stabilisation of the pelvis during locomotion


Fig.2.25 Weight-bearing stress at angulation of spine Gluteus medius and minimus muscles prevent
excessive tilting of the pelvis (supporting the trunk above it)
Due to angulation between the lumbar spine and
towards the unsupported side during locomotion.
sacrum, weight bearing creates shearing stress through the
lumbosacral disc (which is obliquely oriented) and through The gluteal muscles literally got us up off our backsides
the fifth lumbar vertebra. to move.

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.

Fig.2 28 High larynx in a chimpanzee


Other mammals (and human infants) have a high larynx
at the level of the soft palate and can only emit air from the
mouth in short bursts. However, they can breathe and
swallow simultaneously as their air and food pathways do
not cross. Air is breathed into the larynx via the
nasopharynx (situated behind the nose) and food from the
mouth swallowed (into the oesophagus) via channels
lateral to the larynx.
During human postnatal development (late infancy) the
pharynx lengthens as the larynx descends into the neck.
This creates a new part of the pharynx, termed the
oropharynx, situated between the soft palate and the
larynx.

Fig.2.29 Low larynx in an adult human

Risk of choking and protective reflexes


A potentially deadly risk is created by descent of the
larynx as the air and food pathways now intersect in this
region. Swallow and cough reflexes (elicited by stimulating
mucous membranes of the oropharynx and larynx,
respectively) as well as gag and vomit reflexes, protect the
airway.

14
Chapter 3: Human Sexual Characteristics

Male primary sexual characteristics


MALE Primary sexual characteristics are formed during pre-
natal development. In the male they are the testes,
FEMALE together with the male genital tract and external genitalia.

Male secondary sexual characteristics


Secondary sexual characteristics arise during puberty.
MALE These have widespread effects on the body and are due to
hormonal secretion initiated by the pituitary gland. They
Humans are typically either male or female. Although
include enlargement of the genital organs and the
ambiguous sexual development may occur, a genetic
appearance of pubic and axillary hair. Distinctive
male is characterised by the presence of a Y
masculine features are the extensive growth of facial and
chromosome. There is normally a single X chromosome
body hair together with that of the skeleton and skeletal
and a single Y chromosome. Males are conceived (and
muscles. Typically, males have a relatively narrow pelvis
born) in about equal proportions with females.
with broad shoulders. The larynx is also large (associated
with deepening of the voice).

Genital organs in the male


The internal genital organs of a male include the
testes, epididymes, deferent ducts, seminal vesicles,
prostate and bulbourethral glands, while the penis and
scrotum are regarded as external genital organs.

Fig. 3.2 Male genital organs

FEMALE
A genetic female is characterised by the absence of a
Y chromosome. There are normally two X chromosomes.

Female primary sexual characteristics


Female primary sexual characteristics are the ovaries,
together with the female genital tract and external genitalia.
These are formed during prenatal development.

Female secondary sexual characteristics


As with the male, female secondary sexual
characteristics have widespread effects on the body due to
hormonal secretion initiated by the pituitary gland.
They also include enlargement of the genital organs
and the appearance of pubic and axillary hair, in addition to
the onset of menstruation (L. 'monthly'). Distinctive female
features are the growth of the mammary glands (creating
the breast form) and preferential deposition of
Fig.3.1 Adult male characteristics subcutaneous fat, creating a more rounded body form.
15
THE HUMAN BODY

Typically, females have a relatively wide pelvis


compared to that of males. The female pelvis has more
capacious internal dimensions (although there is
considerable variation) enabling less restricted passage for
a foetus along the birth canal.

Fig 3.4 Female genital organs

Fig.3.3 Adult female characteristics

Genital organs in the female


The internal genital organs of a female include the
ovaries, uterine tubes, uterus and vagina while the clitoris
and vulva are regarded as external genital organs.

16
Section II
BODY SYSTEMS AND ORGAN STRUCTURE

Introduction: 'Structure mirrors function'

Chapter 4: Skeletal System and Bones


Chapter 5: Articular System and Joints
Chapter 6: Muscular System and Muscles
Chapter 7: Integumental System and Skin
Chapter 8: Visceral Systems and Viscera
Chapter 9: Nervous System and Nerves
Chapter 10: Arterial System and Arteries
Chapter 11: Venous System and Veins
Chapter 12: Lymphatic System and Lymph Vessels

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

Organs may be grouped according to a common


function into systems (L: organised whole). 2.

Systemic anatomy is concerned with the intrinsic


(organisational) properties of organs - their structure and
supply.

The body may be classified into twelve systems in three


groups of four.

Somatic systems:
- skeletal system
- articular system
- muscular system
- integumental system

Somatic (L. body) systems are collectively


responsible for the overall form and shape of the body.
They provide support, movement and protection. Somatic
systems are the musculoskeletal framework together with
3.
the covering skin. The skeletal, articular and muscular
systems may be grouped into a single musculoskeletal (or
locomotor) system.

Visceral systems:
- respiratory system
- digestive system
- urinary and male genital systems
- endocrine and female genital systems

Viscera (L. sticky) are collectively responsible for


internal regulation. They occupy cavities within the body
framework and are involved with secretion, excretion and
absorption. Visceral systems are made up of solid glands
and/or hollow tubes (of smooth muscle, lined by mucosa).
The urinary and genital (reproductive) systems may be
grouped into a single urogenital system.

Supply systems: 4.
- nervous system
- arterial system
- venous system
- lymphatic and haemopoietic systems

All organs, whether somatic or visceral, require


neurovascular supply (although supply of somatic organs
is by a separate set of nerves and vessels to that of
viscera). Organs receive their nerve supply via the nervous
system. Organs also receive a supply of arterial blood as
well as drainage of venous blood and lymph. Vascular (L:
vessel) refers to arteries, veins and lymph vessels.
Vascular systems are classified as arterial, venous and
lymphatic. The heart, together with arterial and venous
systems, may be grouped into a single cardiovascular (or
circulatory) system.

18
Chapter 4: Skeletal System and Bones

Bones are typically paired except for those in the


midline. Some bones that are paired during development
SKELETAL SYSTEM (e.g. the halves of the mandible and of the frontal bone)
unite in the midline to become unpaired.
COMPACT AND SPONGY BONE
Subdivisions of skeleton
PERIOSTEUM AND BONE MARROW The skeleton may be subdivided according to the
following modules:
Head 29 bones
BONES AND BONY FEATURES Neck 7 bones
Thorax 25 bones
CARTILAGE Back 19 bones
Upper limbs 64 bones
OSSIFICATION AND PRIMARY CENTRES Lower limbs 62 bones
Total 206 bones
SECONDARY CENTRES & GROWTH PLATES

EPIPHYSES AND EPIPHYSIAL LINES

LONG BONE GROWTH AND GROWING END

NEUROVASCULAR SUPPLY OF A BONE

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.

Fig.4.2 Axial and appendicular skeleton of an adult


The bony pelvis is made up of the paired hip bones (of
the lower limb) and the sacrum and coccyx (of the back).
The hyoid bone is included in the head (although it may be
classified in the neck). The cervical vertebrae are included
in the neck while the rest of the spine is included in the
back. Bones may also be arranged into the axial skeleton
(skull, spine and thoracic cage) and the appendicular
skeleton (limb bones including the pectoral and pelvic
girdles).

COMPACT AND SPONGY BONE


Functions of bone
Bone provides protection and support for the body as
well as levers for limb movements. Bone houses a major
site of blood cell production and is a vast calcium
reserve. Although a skeleton (G: dried up) is the bony
remnant of a dead body, in the living it has the capacity for
Fig.4.1 Disarticulated skeleton of a newborn remodelling and (up to maturity) for growth.
Short bones (e.g. carpal bones in the wrist and most Bone cells and matrix
tarsal bones in the foot) tend to be cartilaginous at birth.
One or both ends of long bones, together with parts of Bone is a dense connective tissue composed of cells
vertebrae, are also cartilaginous at birth. and extracellular matrix.

19
BODY SYSTEMS AND ORGAN STRUCTURE

The cells responsible for bone deposition are Medullary cavity


osteoblasts (G: bone + germ) and those responsible for
resorption are osteoclasts (G. bone + break). These cells Trabeculae are absent in the medullary cavity of a
require a rich blood supply to remain viable. The long bone (a cylinder is lighter and almost as strong as a
extracellular matrix is made up of mineralised ground solid rod). A long bone is characterised by a shaft between
substance (resisting compression) reinforced by collagen its proximal and distal ends. The shaft has a central
fibres (that resist it being pulled apart). Bone therefore medullary (L: marrow) cavity. There are no (net) forces in
possesses compressive strength coupled with tensile this part of the bone (where compressive and tensile forces
strength and is hard yet not brittle. About two thirds of the cancel each other).
dry weight of bone is calcium salts and one-third collagen. The shaft (particularly midway along it) has a thick shell
of compact bone where its perimeter is subject to
Trabeculae considerable forces. This rigid tube resists bending forces
in all directions without the need for a solid core. In dry
Compact bone forms the hard, protective outer shell
bone all fibrous tissue and cartilage have been stripped off.
while the inner spongy (cancellous) bone possesses
trabeculae (L: beams) that resemble scaffolding with
spaces between them. This trabecular arrangement
provides strength with lightness. Bony trabeculae in the
upper end of the femur form intersecting arches. Lines of
compressive stress are oriented more vertically along the
femoral neck while lines of tensile stress run across it.

Fig.4.5 Compressive and tensile forces on the shaft


Dry bone is also devoid of bone marrow (which during
life fills the medullary cavity and the spaces within spongy
bone).

PERIOSTEUM AND BONE MARROW


Outer and inner layers of periosteum
Periosteum (G: around bone) is the covering around
compact bone, except over joint surfaces (which are
4.3 Upper end of a dry femur covered by cartilage).
Bony trabeculae are oriented along lines of stress
(both compressive and tensile).

Fig.4.4 Trabeculae along stress lines Fig.4.6 Upper end of an embalmed femur.

20
4. Skeletal System and Bones

Periosteum has an outer (fibrous) layer. Ligaments Bony surfaces


and muscles attach to bone through the blending of their
The exterior of bones typically has flattened surfaces
collagen fibres with those around, and of, the bone.
separated by sharper borders. Articular (L. joint)
Periosteum also has the capacity to form new bone
surfaces are the areas of bone that articulate at synovial
(ossification) from its inner (osteogenic) layer. Both
joints.
layers of periosteum have a vascular supply and a nerve
supply Articular surfaces are the only external surfaces of a
bone not surrounded by periosteum.
Red and yellow bone marrow
The medullary cavity of a long bone has a fibrous tissue Articular surfaces are covered by hyaline articular
lining, termed the endosteum (G. within bone). Bone cartilage. Articular surfaces are smooth and may be in the
marrow fills the spaces of spongy bone and the medullary form of a small flat area (articular facet), a large rounded
cavity of a long bone. Red bone marrow is a prime site of area (head), a knuckle-shaped area (condyle) or a pulley
blood cell production. It consists of haemopoietic (G: (trochlea).
blood + make) tissue embedded in fat (adipose tissue).
Yellow bone marrow is almost entirely fat. In early life bone
marrow throughout the body is red. Red marrow remains in
the axial skeleton for life, but in the limbs becomes yellow
marrow during adolescence.

Marrow reversion after blood loss


Yellow marrow retains the capacity to revert to red
marrow, particularly after severe blood loss.

BONE TYPES AND BONY FEATURES


Classification of bones
Bones are primarily classified as long, short, flat or
irregular. Pneumatic (G: air) bones surround membrane-
lined spaces of the skull. These house the paranasal air
sinuses (L. spaces) and mastoid air cells. Sesamoid (G:
sesame seed-like) bones are found in tendons where they
articulate with bony facets. The patella is by far the largest
sesamoid bone. Accessory bones may also occur. They
are anatomical variants, created from bony parts that fail to
amalgamate with the parent bone.

Fig. 4.8 Bony features

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).

Bony elevations are produced at sites of traction

Attachments of fleshy muscle fibres tend not to produce


markings.

Fig.4.7 Major types of bones CARTILAGE


Mistaking bones for fracture fragments There are three types of cartilage (L. gristle):
Although smooth and regular, sesamoid and accessory - hyaline cartilage
bones may be mistaken by the unwary for fracture - fibrocartilage
fragments in radiographs. - elastic cartilage

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.

OSSIFICATION AND PRIMARY CENTRES


Ossification in cartilage and membrane
Bone development is termed ossification. The vast
majority of bones develop from a hyaline cartilage
precursor, by intracartilaginous (endochondral)
ossification where a cartilage model is progressively
replaced by bone. Some bones develop from a fibrous
tissue precursor, by intramembranous ossification. These
bones include the flat bones of the skull as well as parts of
the clavicle and mandible. Despite the different precursor
(and process), bone formed via intramembranous
ossification is identical with that formed via
intracartilaginous ossification.

Primary centres of ossification


Ossification commences at a primary centre. This
generally occurs in the middle of each cartilage (or
membranous) model. At about the sixth intrauterine week,
intramembranous ossification commences. At about the
eighth week hyaline cartilage starts being transformed into
bone at primary centres (those for the larger bones tending
to appear first). By birth the vast majority of primary centres
Fig.4.9 Types of cartilage have appeared (except for the short bones in the hand and
most of those in the foot).
Hyaline cartilage
Hyaline (G. glass) cartilage covers bony articular
surfaces. In addition, it is found in the chest wall (as costal
cartilages) and is also associated with the respiratory tract
(helping keep patent the nose, larynx, trachea and bronchi,
particularly during inspiration).
The model for the early foetal skeleton is primarily
hyaline cartilage. Hyaline cartilage is composed of a solid
matrix that can bear weight, resist compression and be
almost frictionless. The glassy appearance is due to the
collagen fibres in the matrix being arranged in parallel
bundles. A thin fibrous membrane, the perichondrium (G.
around + cartilage) surrounds non-articular cartilage.
There are no blood or lymph vessels and nerve fibres in
hyaline cartilage.

Hyaline cartilage is avascular and aneural

Vessels would otherwise be compressed and nerve


endings irritated by the pressures hyaline cartilage may be
subjected to.
Cartilage cells (chondrocytes) receive their nutrition
(from synovial fluid in joint cavities or from vessels in the
perichondrium) via diffusion through the cartilage matrix.

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

Fig.4.11 Endochondral ossification of diaphysis

SECONDARY CENTRES & GROWTH PLATES


Secondary centres of ossification Fig.4.13 Secondary centres in tibia of a 2 year old
Many bones have additional sites of growth allowing for The termination of the diaphysis is the metaphysis
the subsequent change in demands on them. Secondary (changing growth). An epiphysis (upon growth) is the
centres of ossification are growth centres typically located end of the developing bone, adjacent to a metaphysis. The
in the ends of the cartilage model for long bones. They primary centre of ossification commences near the middle
occur only at one end of a small long bone (e.g. digits and of the diaphysis then extends along it to reach each
ribs) but at both ends of the large long bones of the limbs. metaphysis. A secondary centre of ossification commences
near the middle of each epiphysis then invades the
Almost all secondary centres appear after birth cartilage model between the joint surface and the growth
(females generally at an earlier age than males). plate.
Although secondary centres tend to appear at different
times for different sites, the vast majority have appeared
well before puberty.
Blood vessels, together with osteoblasts, invade each
secondary centre.

Fig.4.14 Parts of mature and developing bones


Fig.4.12 Endochondral ossification of epiphyses
Epiphysial plate
The (epiphysial) arteries are derived from separate
sources to that of the primary centre (which is from the The epiphysial (growth) plate is a plate of hyaline
nutrient artery). Hyaline articular cartilage is retained at cartilage in the epiphysis, along its junction with the
joint surfaces after the bone has completed ossification. metaphysis.
The epiphysial plate produces new bone at its
Diaphysis, metaphysis and epiphysis metaphysial surface (where it is supplied by metaphysial
arteries).
A mature long bone is characterised by a shaft
(between its proximal and distal ends). The corresponding
Growth in length occurs at the metaphysial surface of
part in a developing long bone is the termed the diaphysis
an epiphysial plate.
(G. between growth).

23
BODY SYSTEMS AND ORGAN STRUCTURE

Mistaking epiphysial plates for fracture lines


An epiphysial plate undergoing fusion resembles a
fracture line. Awareness of the likely sites for epiphyses
helps avoid mistaking an epiphysial plate for a fracture line
on a radiograph.
An epiphysial plate may also be differentiated from a
fracture by obtaining an X-ray of the corresponding bone
on the other side of the body.

Fig.4.15 Zones in epiphysial plate

Fig.4.17 Epiphysial plates and lines


Fig.4.16 Relationship of epiphysial plate to metaphysis
Epiphysial line
The epiphysial plate disappears (along with the Fusion of an epiphysis to a metaphysis is associated
capacity for growth in length at this site) when the with disappearance of the epiphysial plate and cessation of
epiphysis fuses with the metaphysis. further growth in length at this site.
A thin layer of compact bone, termed the epiphysial
Epiphyseal fusion occurs after puberty (females line, is the only remnant of the plate in a mature bone.
generally at an earlier age than males). Although not visible on the external surface, an epiphysial
line can be seen at times in vertical sections and in
Although epiphyses at different sites tend to fuse at radiographs.
different times, the vast majority have fused by the end of
adolescence. Determination of skeletal age
Since epiphyses fuse in an ordered sequence, they can
EPIPHYSES AND EPIPHYSIAL LINES assist in determining the age of an individual from
radiographic images or forensic skeletal examination. In
Pressure and traction epiphyses the latter, a narrow cleft on the external surface of a bone
Epiphyses are located in the ends of developing long indicates an epiphysis undergoing fusion.
bones (adjacent to the metaphysis) and produce growth
corresponding with demands on the bone. The two major
Accessory bone formation
types of epiphyses are pressure and traction A bony part that was previously an epiphysis may exist
epiphyses. as a discrete bone, termed an accessory bone. This
Pressure epiphyses are associated with joints. They sometimes occurs for traction epiphyses associated with
enable growth of the apposed articular surfaces while bones of the foot and hand.
being subjected to compression.
Traction epiphyses associated with bony prominences Mistaking accessory bones for fragments
enable growth where strong attachments pull on them. An accessory bone can be mistaken for a fracture
Atavistic epiphyses are few and insignificant. They fragment, although accessory bones have regular rather
represent bones that have disappeared during evolution than jagged edges. If the accessory bone is bilateral it will
(becoming incorporated with another bone). show a similar appearance on x-ray of the corresponding

24
4. Skeletal System and Bones

bone on the other side of the body, excluding a fracture


(unless the injury is also bilateral).

LONG BONE GROWTH AND GROWING END


Growing end of a bone
A long bone grows in length at the metaphysial surface
of each growth plate. It also grows in width from the inner
(osteogenic) layer of the periosteum. An epiphysis is
located only at one end of a long bone that is of small size
(e.g. in a finger). This end (termed the growing end) is
responsible for all of its growth in length. Although
epiphyses (and growth in length) of a large long bone occur
at both ends, one end (also termed the growing end) is
responsible for more growth than the other.

Fig.4.19 The humerus in late adolescence

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).

The earlier an epiphysis appears the later it fuses.

Epiphyses for larger long bones tend to appear before


(and fuse after) those for smaller long bones.

Within a large long bone the epiphysis for one end


tends to appear before (and fuse after) that of the other
end. More growth therefore occurs at one end (the growing
end).
The first epiphyses to appear (at about birth) are for the
lower end of the femur and the upper end of the tibia (the
two longest bones in the body).

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

Blood vessels enter and leave a bone via numerous


Damage to an epiphysial plate will impair subsequent vascular foramina. Large vascular foramina (primarily for
growth. veins) are particularly numerous near the articular margin
(e.g. on neck of femur) and on parts of bones filled with red
Bone infections (spread from the blood stream) tend to bone marrow (e.g. body of a vertebra).
occur at the metaphysis (a site of vulnerable blood supply) Lymph vessels accompany the arteries and veins.
and may also lead to damage of the adjacent epiphysial Nerves also accompany them, providing sensory fibres to
plate. Interruption of blood supply to the adjacent epiphysis bone and motor fibres to vessels.
or metaphysis will similarly tend to impair normal growth. Vascular foramina are absent from articular surfaces of
bone because its covering articular cartilage has no
vessels or nerves. Bony articular surfaces therefore receive
their vascular and nerve supply via the underlying bone.

Nutrient and periosteal arteries


The shaft of a long bone receives a single large
nutrient (medullary) artery via a nutrient foramen
extending obliquely to the medullary cavity (directed away
from the growing end) to supply the bone marrow and inner
compact bone.

Fig.4.21 Impaired growth from epiphysial damage

NEUROVASCULAR SUPPLY OF A BONE


Supply to bone and cartilage
Bone tissue has a sensory nerve supply and a rich
blood supply. The periosteum also possesses vessels and
abundant sensory nerve (particularly pain) fibres. In a
developing bone the entire cartilage model (including Fig.4.23 Vessels supplying the shaft of a long bone
articular cartilage and the growth plate) is avascular and It divides into superior and inferior medullary branches
aneural except after conversion to bone at centres of (directed towards both ends). The shaft of a long bone also
ossification. In a mature bone, hyaline cartilage is retained receives multiple small periosteal arteries that supply the
only on articular surfaces. Cartilage that is not articular periosteum and outer compact bone.
(e.g. of nasal septum) receives its only nutrition from
perichondrial vessels. Periosteal stripping
Although these arteries link with branches of the
Perichondrial stripping nutrient artery, extensive stripping of the periosteum (e.g.
Extensive stripping of the perichondrium (e.g. from during surgery) may deprive directly underlying compact
bruising) endangers viability of the cartilage. bone of blood supply.
Vascular foramina Metaphysial and epiphysial arteries

Fig.4.24 End arteries in a developing long bone


The ends of developing long bones typically receive
sets of metaphysial and epiphysial arteries. These
arteries are end arteries because the cartilaginous plate
is avascular and forms a barrier preventing communication
Fig.4.22 Sites of vascular foramina between them (until epiphysial fusion).

26
4. Skeletal System and Bones

Interruption of blood supply to bone


Interruption of blood supply from metaphysial or
epiphysial arteries endangers the adjacent metaphysis or
epiphysis, respectively. This may impair normal growth
and/or result in death of bone (avascular necrosis)

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.

Fig.4.27 Upper end of adult femur after vascular injection

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.

Adults tend to have stronger bones than ligaments,


Fig.4.25 Arteries at the end of a developing bone while children have the reverse.
The vascular circle is typically located around the
attachment of the capsule to bone. It provides branches
both to the capsule and to bone. Early in development the
joint capsule attaches around the periphery of the
epiphysial plate. The vascular circle around the end of a
developing bone is initially located at this site and provides
both epiphysial and metaphysial branches.

Anastomoses in the end of a long bone


A mature long bone no longer possesses epiphyses,
metaphyses or a diaphysis (the parts of a developing long
bone).

Fig.4.28 Simple and compound fractures


If fractured bone is exposed to the air (by laceration of
overlying skin or mucous membrane, e.g. from sharp bone
fragments) it is termed a compound (open) fracture and
has a significant risk of bone infection.

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

Fig.4.29 Alignment and immobilisation in fracture healing

Healing, including of fractures is more rapid in


children.

Weight bearing bones heal slower than non-weight


bearing bones.

28
Chapter 5: Articular System and Joints

Other joints, particularly sutures (fibrous joints between


bones of the skull) tend to become obliterated with aging.
ARTICULAR SYSTEM Joints are typically paired. However, secondary
cartilaginous joints are unpaired and are located
FIBROUS AND CARTILAGINOUS JOINTS exclusively in the midline.

SYNOVIAL JOINTS

ARTICULAR SURFACES AND CARTILAGE

FIBROUS CAPSULE

SYNOVIAL MEMBRANE AND CAVITY

LIGAMENTS

SPECIAL JOINT STRUCTURES

JOINT STABILITY AND MOBILITY

NEUROVASCULAR SUPPLY OF JOINTS

ARTICULAR SYSTEM
The articular system is made up of joints including
associated ligaments. Bones and/or cartilages meet at
joints.

Types of joints Fig 5.2 Major joints of the articular system


Joints are classified as fibrous, cartilaginous and
synovial. The vast majority are synovial joints which are FIBROUS AND CARTILAGINOUS JOINTS
adapted for movement.
Some joints, particularly primary cartilaginous joints of Fibrous and cartilaginous joints are solid with no joint
developing long bones (epiphysial plates) are temporary, cavity.
fusing at various ages.

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.

Fig.5.6 Secondary cartilaginous joints in midline


Fig.5.4 Structure of a fibrous joint
Sutures (L. seams) occur between bones of the skull SYNOVIAL JOINTS
creating characteristic wavy lines occupied by sutural
ligaments. With age, skull bones tend to unite, forming a Synovial joints allow for extensive movement and are
synostosis (G. together + bone) as the fibrous joint characterised by a joint cavity (in addition to the hyaline
becomes obliterated. Sutures are not mobile but they allow cartilage that covers the bony articular surfaces).
for growth. A syndesmosis (G. together + band) holds the
The shape of the articular surfaces determines the
distal ends of the tibia and fibula together by a strong
particular movements permitted.
interosseous ligament. It permits only a small amount of
movement, enough to help absorb compressive forces and Shape, depth and size of articular surfaces (as well as
avoid fracture. A gomphosis (G. bolt) is a tooth socket
ligaments and muscles) contribute to the range of
lined by the periodontal membrane (ligament) anchoring
movement possible.
the tooth. It does not allow significant movement.
Types of synovial joints
Primary cartilaginous joints
The only movements that occur at plane joints are
In primary cartilaginous joints, two areas of bone are
simple gliding movements (e.g. joints between articular
bridged by hyaline cartilage. They do not allow movement
facets of adjacent vertebrae and some joints between
but allow for growth.
carpal bones). Plane joints are characterised by articular
surfaces that are almost flat and parallel.

Fig.5.5 Structure of a primary cartilaginous joint


An epiphysial (growth) plate is regarded as a primary
cartilaginous joint, even though it is temporary. At
epiphysial fusion this joint disappears, becoming a
synostosis. Other primary cartilaginous joints occur in the
thoracic cage associated with the costal cartilages
(particularly the costochondral and interchondral joints).

Secondary cartilaginous joints


Secondary cartilaginous joints consist of a thin layer
of hyaline cartilage lining each bony articular surface, with
thick fibrocartilage sandwiched between them. They allow
restricted movement yet can withstand considerable
pressure. Secondary cartilaginous joints are also termed
symphyses (G. together + grow). They are located
exclusively in the midline of the body. The pubic
symphysis, intervertebral discs and the manubriosternal
joint are all secondary cartilaginous joints. Fig.5.7 Types of synovial joints and associated movements

30
5. Articular System and Joints

Synovial joints may be classified according to the


number of axes of movement.
Uni-axial joints have a pair of movements around one
axis. These joints may be further classified as hinge for
flexion (L. to bend) and extension (e.g. elbow joint and
interphalangeal joints), and pivot for rotation (e.g.
radioulnar joints).
Bi-axial joints have a pair of movements
(flexion/extension and abduction/adduction) around each of
two axes (typically perpendicular to each other). These
joints may be further classified according to the shape of
their articular surfaces. Bi-axial joints are condylar (e.g.
metacarpo-phalangeal joints of the fingers and toes),
ellipsoid (wrist joint) and saddle (metacarpo-phalangeal
joint of the thumb).
Multi-axial joints have two pairs of movements
(flexion/extension and abduction/adduction) around two
horizontal axes perpendicular to each other and an
additional pair of movements (medial rotation/lateral
rotation) around a longitudinal axis. These are ball and
socket joints (e.g. shoulder and hip joints).
Combinations of movements may occur in bi-axial joints
(e.g. rotation in conjunction with flexion or extension) and in
multi-axial joints (e.g. circumduction).

Simple and compound joints


Synovial joints may be classified according to the
number of articular surfaces. Simple joints have one pair of
articular surfaces (the majority of synovial joints) while Fig.5.8 Articular surfaces and cartilage of hip joint
compound joints have more than one pair (e.g. elbow and
knee joints). The elbow joint involves the humerus, ulna Bony non-articular surfaces
and radius (in humero-ulnar and humero-radial Although articular surfaces are typically bony, the entire
articulations). The knee joint involves the femur, tibia and surface on the end of a bone is not necessarily articular.
patella (in femoro-tibial and femoro-patellar articulations). Bony non-articular areas occur in some joints (e.g. hip
Complex joints and knee). They may be in the form of a pit, fossa or
notch providing attachment for intra-articular ligaments
The vast majority of synovial joints have a single (e.g. ligament of head of femur and cruciate ligaments) or
synovial cavity. In complex joints the joint cavity is menisci.
subdivided into more than one compartment. This may be a A bony non-articular area may be covered by a fat pad
complete partition by fibrocartilage disc (e.g. (e.g. in the socket of the hip joint).
temporomandibular and sternoclavicular joints) or
incomplete by menisci (e.g. knee joint). Complex joints Non-bony articular surfaces
enable separate movements to occur simultaneously on Ligaments and fibrocartilage may contribute to articular
either side of the partition (e.g. gliding with rotation at the surfaces.
temporomandibular joint) whilst maintaining optimal Ligaments, particularly around pivot joints (e.g. proximal
stability. radioulnar) and associated with some weight bearing joints
(e.g. hip and ankle), may have a surface that is articular.
ARTICULAR SURFACES AND CARTILAGE This surface tends to be lined with cartilage (as it would
otherwise be rough).
The surfaces of structures meeting at a joint are termed A fibrocartilaginous labrum (L. lip) deepens the socket
articular (L. joint) surfaces. Typically, there is only one of a ball and socket joint. Fibrocartilaginous discs (e.g.
pair (simple joints) but some joints have more than one temporo-mandibular and sternoclavicular) and menisci
(compound joints). (e.g. knee) also tend to be articular.
Matching pairs of articular surfaces are smooth and
reciprocally shaped. Each is covered by articular cartilage Joint degeneration
(to bear weight, resist compression and be almost With aging and overuse there is a tendency for joint
frictionless). degeneration. With this degeneration (degenerative
arthritis) the articular cartilage becomes progressively
Bony articular surfaces do not come in direct contact thinner. This may be detected on a radiograph as a
with each other unless the overlying articular cartilage narrowing of the radiological joint space in contrast to the
has worn away. anatomical joint space (the synovial cavity).
Thinning of the articular cartilage causes the bony
All joint surfaces have some degree of curvature. This articular surfaces to come into closer proximity, eventually
may be convex, concave or both. Ovoid (L. egg-like) making contact with each other. This causes severe pain
surfaces are convex (male) or concave (female) in all due to exposure of underlying bone possessing a sensory
directions. Sellar (L. saddle) surfaces are concave in one nerve supply (in contrast to aneural hyaline articular
direction and convex in the other. cartilage).

31
BODY SYSTEMS AND ORGAN STRUCTURE

Fig.5.9 Thinning and loss of articular cartilage

Osteophyte formation Fig.5.11 Effects of articular cartilage damage


Degenerative arthritis is also associated with formation
of osteophytes (G. bone + growths) at the joint margins. FIBROUS CAPSULE
Description
The fibrous capsule (L. box) encloses a synovial
joint, defining its boundary. Structures located within the
joint are termed intracapsular (or intra-articular). The
fibrous capsule may also be termed the capsular ligament.
Like a ligament, it is dense connective tissue made up of
collagen fibres.
The fibrous capsule may be reinforced by ligaments or
receive muscle attachments at particular sites. It may also
have deficiencies (to allow exit for an intracapsular tendon
or for a bursa to communicate with the joint cavity).

Fig.5.10 Osteophytes and encroachment on a foramen


These are produced by proliferation of exposed bone
with a rich blood supply (in contrast to the avascular
hyaline articular cartilage). The progressive bony
proliferation tends to decrease joint mobility (and may
ultimately result in bony fusion). Osteophytes may also
encroach on adjacent structures, especially if bordering
confined spaces (e.g. spinal canal or an intervertebral
foramen).

Articular cartilage damage


Injury to an articular surface (particularly a fracture Fig.5.12 Elbow joint capsule and reinforcements
extending into it) is likely to be associated with damage of
the hyaline articular cartilage. If a fragment of cartilage Attachments of fibrous capsule
breaks off, a loose body (in the joint cavity) is created, The capsule generally attaches to the articular margins
together with the associated defect that may expose (where its collagen fibres merge with those of the
underlying bone. periosteum). At particular sites its attachment may deviate
Damage to articular cartilage triggers an early onset of along the bone. In certain joints part of the capsule may
degenerative arthritis at that joint. attach to a ligament rather than to bone.

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.

Fig.5.13 Migration of capsule during development

SYNOVIAL MEMBRANE AND CAVITY


Synovial cavity
The space within the interior of a joint is termed the
synovial cavity. The vast majority of joints have a single
and discrete joint cavity. For some (complex joints), the
joint cavity is either partly (e.g. knee joint) or completely
(e.g. temporomandibular joint) subdivided compartments.
For others, more than one joint may share the same joint
cavity (e.g. elbow joint with proximal radioulnar joint).

Fig.5.15 Section through the shoulder joint

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

Haemarthrosis capsule. They may be extracapsular or intra-capsular. Most


of them are extracapsular. The cruciate ligaments are an
Tearing the vascular synovial membrane produces
example of intracapsular ligaments. They are located near
bleeding into a synovial cavity. The accumulation of blood
the axis of movement at the knee joint, enabling them to
in a synovial cavity is termed a haemarthrosis (G. blood +
contribute to stability without impeding mobility. The same
joint). It is typically due to severe trauma, particularly when
applies for extrinsic ligaments situated between two joints
structures lined with synovial membrane are torn. However,
acting as a functional unit (e.g. the interosseous ligament
it may even occur with minimal trauma in a haemophiliac.
between the two joints under the talus and the interosseous
Blood progressively accumulates in the joint cavity (until
membrane between the two radioulnar joints). Such
limited by capsular expansion). A haemarthrosis produces
ligaments also tend to be located along the axis of
a swelling of the joint that tends to be warm to touch.
movement.
Septic Arthritis
Ligaments, within a joint or between two joints acting
Introduction of microbes into a synovial cavity (septic as a functional unit, are positioned along the axis of
arthritis) is a potentially serious event likely to produce an movement.
accumulation of pus. Septic arthritis, as with any
inflammatory arthritis, may lead to permanent joint
destruction due to erosion of articular surfaces. Collateral ligaments
Collateral (L. with + side) ligaments are typically
Loose body located on the medial and lateral sides of hinge joints (e.g.
A fragment of cartilage may survive as a loose body elbow, ankle, knee and interphalangeal joints of the fingers
in a joint cavity (or even grow) because it receives and toes) perpendicular to the axis of movement. They
adequate nutrition from the synovial fluid. A loose body tend to blend with the joint capsule, forming intrinsic
may produce locking of the joint if trapped between the ligaments.
articular surfaces. This interference with movement tends
to be episodic. Collateral ligaments are important contributors to
stability by preventing unwanted side-to-side
movement.

Some part of a collateral ligament tends to remain taut


throughout the full range of flexion/extension.

Fig.5.16 Loose body surviving in synovial fluid

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

Accessory ligaments are found in the spine (e.g.


ligaments of the vertebral arches and bodies) at a distance The weakest points of a ligament are at or near their
from the intervertebral joints. They are also found on the attachments, rather than between them.
clavicle (e.g. costoclavicular and coracoclavicular
ligaments) at a distance from the joints at each end of the Sometimes a fragment or flake of bone is avulsed (L.
bone (sternoclavicular and acromioclavicular joints, tear away) with (or even instead of) ligament rupture.
respectively). The interosseous membrane of the forearm
and the leg may be regarded as an accessory ligament of Ligament vulnerability
the radioulnar and tibiofibular joints, respectively. A ligament that is arranged in discrete parts rather
than a continuous band allows more joint mobility but
Grades of ligament injury is weaker and therefore more vulnerable.
Ligament injuries (sprains) are common, particularly in
adults (where bones are relatively much stronger than in
children).

Children are more likely to fracture a bone before


tearing a ligament.

Fig.5.20 Vulnerable bands of ankle joint lateral ligament

Ligament stress test


Extensive ligament damage produces great impairment
of function and increased potential for instability.

Fig.5.18 Grades of ligament injury


In ligament injuries there is damage to the collagen
fibres. Degrees range from microscopic sprain (grade I)
where a few fibres rupture to partial tear (grade II) and
complete tear (grade III), where all fibres rupture.

Fig.5.21 Stress test for cruciate ligaments of knee joint


Ligament integrity may be tested clinically by stressing
the ligament (putting it on stretch) and comparing the
observable movement between the injured and uninjured
sides. This can be confirmed on X-ray by performing stress
views for suspected complete rupture of a ligament. With a
ligament sprain, pain tends to be exacerbated by stressing
the ligament.

Masking of ligament tear by muscle spasm


Abnormal or excessive joint movement is an important
diagnostic feature in an acute ligament injury, particularly a
grade III injury. This may be masked initially by the other
stabilising structures at a joint, particularly muscles (due to
protective reflex muscle spasm).

Masking of pain by nerve fibre rupture


Stressing a ligament to elicit pain is also a diagnostic
Fig.5.19 Avulsion fracture feature in an acute ligament injury (particularly for grade I
or grade II sprains). This may be masked in grade III
Tears and avulsion at ligament attachments
injuries as sensory nerve fibres (including pain fibres)
Ligaments tend to tear at their weakest point. within the ligament are also likely to be severed.
35
BODY SYSTEMS AND ORGAN STRUCTURE

Laxity and loss of proprioception Flexion/extension occurs in the upper compartment of


the knee joint (between the femur and menisci) while
Laxity can predispose a ligament to future injury by
rotation occurs in the lower compartment (between the
allowing excessive range of normal movement and/ or
menisci and tibia). Discs and menisci are made of
abnormal movements.
fibrocartilage. Being articular, they are not covered by
Loss of proprioception also predisposes to future
synovial membrane (although they assist with spreading
injury by impairment of (voluntary and reflex) muscle
synovial fluid). They are able to resist compression and
control (that normally contribute to joint stability).
may be weight-bearing.
Discs and menisci tend to be thicker at their periphery
(increasing stability) where they attach to the fibrous
capsule and receive a vascular supply. The central parts of
these structures are avascular (receiving nutrition from the
synovial fluid).

Labrum or meniscal tears


A torn labrum tends not to heal, as it is avascular.

Fig.5.22 Predisposition to further injury

SPECIAL JOINT STRUCTURES


Additional components of certain joints are termed
special structures. These structures are made up of
fibrocartilage, tendon, serous membrane or fat.

Fig.5.24 Vascularity and healing of meniscal tears


Tears to discs or menisci tend not to heal, except
around the periphery (where they receive a blood supply
along their capsular attachment). A meniscus trapped
between bony condyles while weight bearing may split
longitudinally. A dislodged fragment of meniscus may
survive as a loose body in a joint cavity (since it receives
adequate nutrition from the synovial fluid).

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

Certain bursae (e.g. subscapular and suprapatellar) Fat pads


communicate with a synovial cavity (of shoulder and knee,
Fat pads are intracapsular but extra-synovial. They fill
respectively). The communication occurs via a deficiency in
unoccupied space in a joint (e.g. below the patella at the
the fibrous capsule. Synovial fluid may pass between the
knee joint and in the bony fossae of the humerus at the
synovial cavity and its communicating bursae.
elbow joint).
Fat pads help absorb compressive forces between
bones. They also contribute to the spread of synovial fluid
by acting as a swab and create extra folds of synovial
membrane to greatly increase its surface area.

Pinched fat pad


A fat pad may occasionally become trapped (pinched)
between bony surfaces (e.g. between the large femoral and
tibial condyles). This may produce pain associated with a
synovial effusion.

JOINT MOBILITY AND STABILITY


The dual joint properties of mobility (capacity for
movement) and stability (capacity to resist excessive or
unwanted movement) vary in degree for different joints.
Movements are described as occurring at a joint
(rather than of a joint). Movements may also refer to the
(distal) part or bone moved (e.g. movements at the
Fig.5.25 Types of bursae
shoulder joint may also be termed movements of the arm
Bursitis or humerus).
Irritation (e.g. by unaccustomed or repetitive movement) Passive and active movements
trauma or infection of a bursa may result in inflammation
Movements are either passive or active. A movement at
(bursitis) with associated accumulation of synovial fluid,
a joint is passive when it is not directly due to contraction of
blood or pus, respectively.
its associated muscles (e.g. purely via gravity).

Assessment of joint mobility


An external agent may also be utilised to assist a
passive movement throughout its full range of motion
(passive assistance).
This enables a clinical assessment of joint mobility (the
potential range for each movement at a joint) that may be
otherwise masked by muscle weakness or paralysis.

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).

Roll, slide and spin motions


There are three possible motions that may occur at joint
surfaces for any particular movement. Roll (like a wheel),
slide (like a ski) and spin (like a top) occur in varying
combinations and degrees.
Flexion/ extension and abduction/ adduction tend to
have a combination of roll and slide. This minimises the
necessary length of articular surfaces while maximising the
range of a movement. Normally, rotation is pure spin.

Factors responsible for joint stability


Joints represent a trade-off between mobility and stability
(e.g. the shoulder joint is the most mobile but least stable
Fig.5.27 Penetrating injury to a bursa and septic arthritis joint in the body).

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).

Muscles are the most important stabilising factor for


mobile joints, providing the first line of defence against
dislocation.

Muscle's role in joint support can be controlled


automatically by stretch reflexes (e.g. when part of a
capsule is on stretch the overlying muscles contract more
strongly).

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.

Fig.5.28 Factors stabilising the shoulder joint

The contribution to joint stability from bones is


dependent on the congruence of their articular
surfaces.

Fig.5.30 Close-packed position of a joint

Joint dislocation and subluxation


Dislocation of a joint means its articular surfaces are
completely separated. Subluxation is a partial dislocation
where there is still some contact between the articular
surfaces.
The vulnerability for dislocation and subluxation is
greatest when overlying muscles are relaxed (or
weakened).
Dislocation and subluxation may stretch (or tear) the
Fig.5.29 Types of joint stabilising factors joint capsule and ligaments; damage its associated
structures (e.g. synovial membrane, bone, articular
Ligaments (both intrinsic and extrinsic) act in addition to cartilage, menisci) or structures adjacent to the joint
the fibrous capsule to prevent unwanted movements and (particularly nerves and vessels). Reflex spasm of overlying
movements beyond normal range. They also resist muscles tends to protect the joint from further damage (but
distraction of articular surfaces. also makes reduction of a dislocation more difficult).
Muscles (and tendons) surrounding the joint give it Dislocation or subluxation may result in subsequent
support. Around the most mobile joints (shoulder and hip) ligamentous laxity, which predisposes to future injury.

38
5. Articular System and Joints

Sensory effects of ligamentous injury


Capsular and/ or ligamentous injury tends to be painful
and results in significant loss of proprioception, particularly
joint position sense. This loss of proprioception
predisposes to future injury by impairment in both voluntary
and reflex control of muscles contributing to joint stability.

Articular branches of nerves


Nerves supplying muscles that produce movements at
a joint also typically supply the joint.

Nerve supply is via articular branches that convey


sensation (particularly proprioception and pain).
When capsule on the flexor aspect of a joint is stretched
it stimulates proprioceptive sensory fibres in articular
branches of the associated nerve. This leads (via reflex
control involving the spinal cord then motor fibres in
muscular branches of the same nerve) to increased
contraction of the overlying flexor muscle group, helping to
Fig.5.31 Complete and partial joint separation
protect it from further stretch. Similarly, stretch of the
capsule on the opposite aspect of the joint leads (via reflex
NEUROVASCULAR SUPPLY OF JOINTS control involving articular, then muscular branches of a
different nerve) to increased contraction of its overlying
Certain joint structures possess a rich nerve supply, (extensor) muscle group.
while in others it is poor or absent. The same applies for
blood supply. Vascular synovium and bone
Innervated underlying bone The synovial membrane and the bone beneath articular
surfaces receive a rich blood supply (from branches of
The bony articular surfaces receive pain fibres, but articular arteries). Numerous vascular foramina are located
these are normally protected from exposure and excessive on all non-articular parts of the bone, but hyaline cartilage
pressure by the overlying hyaline articular cartilage (which covering articular surfaces is avascular (receiving its
is aneural). nutrition from the synovial fluid).
Pain from degenerative arthritis Effects of injury on vascular joint tissues
Degeneration of articular cartilage may lead to the Mild injury of the synovial membrane produces an
progressive exposure of underlying bone, resulting in effusion of synovial fluid.
severe pain (especially with movement or weight bearing). A severe injury tearing the synovial membrane
produces bleeding into the joint cavity. Intracapsular bone
fractures are also associated with bleeding into the synovial
cavity.
When degeneration of articular cartilage exposes
vascular bony surfaces, bone proliferation tends to occur
(creating osteophytes).

Poorly vascular capsule and ligaments


Although the fibrous capsule and ligaments receive a
blood supply, it is poor, particularly compared to that of the
highly vascular surrounding muscles.

Effects of capsular or ligamentous injury


Injuries to capsule and ligaments tend not to bleed
much compared to injured muscles or bones. They repair
slowly and often inadequately, with resultant ligamentous
weakness, lengthening and loss of proprioception.

Aneural and avascular hyaline cartilage


Hyaline articular cartilage does not possess blood
vessels, lymph vessels or nerve fibres
Fig.5.32 Bone exposure with cartilage loss
Effects of articular cartilage injury
Innervated capsule and ligaments Injury to hyaline cartilage does not directly produce pain
The main fibrous tissue elements of a joint (capsule and but may expose (or be accompanied by injury to) bone that
ligaments) receive a rich supply of proprioceptive fibres does produce pain. Although a fragment of hyaline
conveying deep somatic sensation such as stretch and joint cartilage may survive in the synovial cavity as a loose
position. They also receive a rich supply of pain fibres body, the defect on the articular surface where it was
(together with associated periosteum). previously located tends not to undergo normal healing.

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).

Fig.5.33 Anastomosis around the hip joint


The anastomosis around a joint also provides articular
branches to the joint forming a vascular circle located at
the capsular attachment. Arteries to the capsule (also
supplying the synovial membrane) and arteries to the
associated bone arise from the vascular circle. Joint
structures receiving an arterial supply have a
corresponding venous drainage. Many of the vascular
foramina in bone, particularly those near the articular
margin, are for veins.

Fig.5.34 Vascular supply to a joint

40
Chapter 6: Muscular System and Muscles

MUSCULAR SYSTEM

MUSCLE STRUCTURE AND ATTACHMENTS

TENDON, APONEUROSIS AND RAPHE

DEEP FASCIA AND RETINACULA

FASCIAL SEPTA, SHEETS AND SHEATHS

FIBROUS & SYNOVIAL TENDON SHEATHS

MOVEMENT AND SKELETAL MUSCLE FORM

MUSCLE CONTRACTION AND ACTION

NEUROVASCULAR SUPPLY & MYOTOMES

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.

Fig. 6.3 Types of muscles


Fig.6.1 Muscular system within body modules

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.

Connective tissue in skeletal muscles


A skeletal muscle is composed of bundles of large
striated muscle fibres (the contractile elements) surrounded
by collagen and elastic fibres (the connective tissue
elements). A thin tubular sheath of connective tissue
termed endomysium (G. within muscle) surrounds each
individual skeletal muscle fibre.
Bundles of skeletal muscle fibres are surrounded by
connective tissue termed perimysium (around muscle).
The whole skeletal muscle is wrapped in a layer of
connective tissue termed the epimysium (upon muscle).

Fig.6.5 Parts of a skeletal muscle

Fig.6.4 Bundling of skeletal muscle fibres

Bony markings from muscle attachments


Skeletal muscle attachments to bone may be fleshy
(directly from the muscle belly) or tendinous (via a tendon
or aponeurosis). In each case their collagen fibres blend
with those of the bone (via the periosteum).

Tendinous attachments to bone, in contrast to those of


fleshy muscle fibres, produce bony markings.

The attachment of a tendon occupies much less area


on a bone. The force generated by the muscle pulls on the
periosteum with correspondingly greater pressure leading
to prominent bone markings. These may be in the form of a
roughening, a line, a crest or a tubercle.

A large tendon attaching to a developing bone is likely


to be associated with a traction epiphysis (to allow for
growth of the bone at the site of attachment).

Origins and insertions


A skeletal muscle has at least one attachment at each
end. Generally muscle attachments are to bone but may be Fig.6.6 Muscle attachments
to skin, fascia, ligament or even other muscles. The origin
is typically fixed and more proximal while the insertion is Muscle belly
typically mobile and more distal. Skeletal muscles have a variety of shapes determined
There may be one or more heads of origin. Biceps (G: by the arrangement of their components. A muscle belly
two + heads) muscle and triceps muscle have two and lies between the attachments of a skeletal muscle. In many
three heads of origin, respectively (although each of these cases there is also a tendon connecting a muscle belly to
muscles inserts via a single tendon). the site of attachment.

42
6. Muscular System and Muscles

The site where a muscle belly becomes continuous with


a tendon is termed the musculotendinous junction.
A fusiform (L. spindle + shape) muscle has a single
muscle belly with a tendon at each end.
A few muscles have more than one belly. Digastric (G.
double + stomach) muscle has two bellies, with a tendon
between them. Rectus abdominis has a series of muscle
bellies joined by tendinous intersections.
Triangular, rhomboid or quadrate shaped muscles have
a flat muscle belly.
A circular muscle (e.g. orbicularis oris around the lips)
has a continuous muscle belly with its fibres arranged
concentrically. Muscular contraction narrows the opening,
while relaxation widens it.

Fig.6.9 Regressive variations


A muscle attachment (e.g. of adductor magnus) that
has retreated from one bone to another (e.g. tibia to femur)
during evolution may remain as a ligament between them
(e.g. medial ligament of knee joint). Occasionally, some
muscle fibres may also remain. This type of variation is
termed an atavistic (L. forefather) variation.

Fig.6.7 Forms of muscle bellies

Fig.6.10 Atavistic variations

Grades of muscle injury


In muscle injuries (strains) there is damage to the
Fig.6.8 Shapes of flat muscle bellies muscle and/or collagen fibres.
Degrees range from microscopic strain (grade I) where
Regressive and atavistic variations a few fibres rupture to partial tear (grade II) and complete
Skeletal muscles are subject to considerable tear (grade III), where all fibres rupture. Each grade
anatomical variation. generally produces different results on testing. Grade I
A few muscles (e.g. palmaris longus in the forearm tears may be painful with strength testing (but do not
and plantaris in the leg) have evolved a small belly in reduce strength). Grade II strains are more extensive,
conjunction with a very long tendon. They are becoming producing pain with strength testing (and reduced strength)
vestigial, being no longer functionally important and may as well as pain when the muscle is stretched. Grade III
even be absent. This type of variation is termed a possess a visible and palpable defect, together with a total
regressive variation. loss of function.

43
BODY SYSTEMS AND ORGAN STRUCTURE

A tear is particularly likely to occur at a previous scar


(which is a site of weakness).
Sometimes a fragment of bone is avulsed (L. tear
away) as well as (or even instead of) muscle or tendon
rupture at an attachment.

Muscles prone to strain


Muscles crossing more than one joint are particularly
prone to injury from over-stretching.

The muscles are more easily stretched beyond their


limit by the collective movements at the (two) joints.
However, these muscles enable extra force to be
generated (as stretching unto a critical point creates
stronger contraction).

Fig.6.11 Degrees of muscle injury

Sites of muscle tears


In contrast to a ligament, a muscle tends to rupture at
other sites in addition to its attachments.

This typically occurs within the muscle belly, at the


musculotendinous junction or through its tendon.

Fig.6.14 Extra stretch by crossing 2 joints


Contracting gastrocnemius with an extended knee and
dorsiflexed ankle permits a strong contraction, but
increases vulnerability of the muscle to injury from
overstretching. This also occurs in contracting the
hamstrings with a flexed hip and extended knee.

TENDON, APONEUROSIS AND RAPHE

Fig.6.12 Sites of muscle injury

Fig.6.13 Avulsion fracture Fig.6.15 Fibrous condensations in muscles

44
6. Muscular System and Muscles

Condensations of fibrous tissue associated with a DEEP FASCIA AND RETINACULA


skeletal muscle may be in the form of tendons, an
aponeurosis or a raphe. Deep fascia
Tendon Fascia (L. bandage) keeps certain structures together
and keeps others apart.
A tendon (L. stretch out) is a prolongation of Deep fascia is a thin, tough sheet primarily made of
connective tissue linking a muscle belly to its attachment collagen fibres (dense connective tissue). It is found deep
site(s). to the looser subcutaneous tissue (superficial fascia)
Tendons enable force to be concentrated over a smaller under the skin of the limbs, neck, back and perineum.
area and/ or transmitted over a longer distance. Deep fascia is strong and non-expansile. It gives
Tendons are found at many sites throughout the body, protection and support to underlying structures while
particularly where muscles compete for space (e.g. in the providing an extensive surface area for muscle attachment.
peripheral parts of the limbs). A tendon is much less bulky Deep fascia is thickened in the palm (as the palmar
than a muscle belly. Some muscles (e.g. long flexors and aponeurosis) and in the sole (as the plantar aponeurosis)
extensors to fingers and toes) have multiple tendons. where it is bound to the overlying skin by numerous fibrous
Aponeurosis connections. Deep fascia is also thickened over muscles
requiring power (e.g. calf muscles) restricting their (radial)
An aponeurosis (L. from + tendon) is a broad, flat expansion and increasing their (longitudinal) efficiency.
sheet of connective tissue linking a muscle belly to the site Deep fascia is usually in one layer. However, in the
of attachment. Aponeuroses enable force to be spread over neck it forms concentric layers, including one deep to the
a greater area and may enclose other muscles to increase skin (investing fascia) and one around the cervical spine
their efficiency of contraction (e.g. rectus abdominis in the (prevertebral fascia). This enables structures (e.g.
rectus sheath). trachea, oesophagus and major vessels) to glide between
Aponeuroses are found at many sites throughout the the two layers during neck movements.
body. The most extensive aponeuroses are found in the
trunk (e.g. associated with anterior abdominal wall Sites where deep fascia is absent
muscles). An aponeurosis is much thinner than either a Deep fascia is absent from the face (where muscles of
muscle belly or a tendon. Some muscles (e.g. biceps facial expression are in the subcutaneous tissue, inserting
brachii) insert via both a tendon and an aponeurosis. directly to skin).
Raphe The thoracic and abdominal walls are able to expand
without the restriction of a continuous layer of non-yielding
A raphe (L. seam) is a line of fibrous tissue where one deep fascia. Their muscles insert into extensive
muscle joins another. Raphes are often located in the aponeuroses, which provide support while permitting
midline of the body, uniting a muscle with its fellow from the distension of underlying viscera (stretching the muscles).
other side.
A raphe provides a relatively long attachment, utilising Deep fascia is not found as a continuous sheet around
minimal connective tissue and occupying little space. parts of the body that expand significantly.
A raphe enables its associated muscles to provide
greater support, while maintaining flexibility. The deep fascia of the leg is absent over the subcutaneous
The floor of the mouth (formed by the mylohyoid surface of the tibia. It attaches to the bony edges by
muscles and their raphe) supports the tongue while the blending with periosteum.
pelvic floor (formed by the levator ani muscles and their
raphe) supports the pelvic viscera (while enabling them to Deep fascia is not found over the subcutaneous
expand). surface of a bone
Sites where muscle fibres are substituted
Retinacula
A retinaculum (L: tether) is a thickening of deep fascia
that holds down tendons. Retinacula are located near
major peripheral joints where long tendons cross en route
to more distal joints (to exert their primary action).
Retinacula are found near the wrist and ankle joints,
particularly associated with the many long flexor and
extensor tendons destined for the digits. Retinacula prevent
tendons from bow-stringing and can create a pulley
mechanism that enhances movement of the joints distally
(e.g. In the fingers and toes).
Being maintained close to the axis of motion at the wrist
and ankle joints, the digital tendons do not have much
influence on movement at these joints. In contrast, the
Fig.6.16 Substitution of muscle fibres at pressure site tendo calcaneus (Achilles tendon) crosses the ankle joint
but is not covered by a retinaculum as the tendon inserts
Fleshy muscle fibres tend to be replaced by tendons at immediately distal to the joint rather than to the toes.
sites of pressure or friction. The absence of a retinaculum allows tendo calcaneus
to bowstring and to exert great leverage at the ankle joint
Fleshy muscle fibres tend to be replaced by (by being located at a distance from the axis of motion).
aponeuroses at sites of increased tensile loading or where This leverage would otherwise be reduced by a
enclosed muscles benefit from a mechanical advantage. retinaculum.

45
BODY SYSTEMS AND ORGAN STRUCTURE

Retinacula are generally regarded as flexor or extensor,


according to the tendons transmitted. The space beneath a
retinaculum may be subdivided into compartments (for one
or more tendons) by fibrous partitions.

Fig.6.19 Septum separating compartments


They also may subdivide the space under a retinaculum
into separate compartments for tendons.
Intermuscular septa are fascial extensions forming
partitions between muscles, providing them with additional
area for attachment as well as routes for the passage of
vessels and nerves (along the septa).

Muscles with a common action are generally located in


the same fascial compartment.

Fig.6.17 Deep fascia and its thickenings

FASCIAL SEPTA, SHEETS AND SHEATHS


Fascia may be arranged in perpendicular septa,
parallel sheets or in cylindrical sheaths.

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).

Fig. 6.18 Fascial compartments in calf Fig.6.21 Types of fascial sheets

46
6. Muscular System and Muscles

An interosseous membrane is a fibrous sheet Synovial tendon sheaths


between parallel bones, connecting the periosteum of one
Synovial sheaths surround tendons that are enclosed
with that of the other and providing increased area for
by fibrous sheaths or pass under a retinaculum (e.g. the
muscle attachment. It creates a major partition between
long flexor and extensor tendons to the digits). A synovial
muscle groups and contributes to the formation of
sheath may also surround a tendon that lies in a bony
compartments. Flexor muscles are located on (and gain
groove (e.g. tendon of long head of biceps in the bicipital
attachment to) one side of an interosseous membrane with
groove of the humerus). The role of a synovial sheath is to
extensor muscles on the other.
minimise friction between moving parts in a confined
Fascial sheaths space.
Fascial sheaths surround glands. They also surround
nerves and vessels.

Where nerves and vessels have a common course they


tend to be enclosed within a common fascial sheath
(as a neurovascular bundle).

Fascial sheaths are not as tough as septa or sheets of


deep fascia. They provide support, yet allow some
movement or expansion.

Fig.6.22 Sheath of a neurovascular bundle


Where more expansion occurs (e.g. around large veins)
the fascial sheath is thinner or even absent. Fig.6.24 Fibrous and synovial tendon sheaths
A synovial sheath is an elongated pouch made up of
FIBROUS & SYNOVIAL TENDON SHEATHS two layers of serous membrane. Each serous membrane
consists of a layer of flattened cells (mesothelium) on a
Fibrous tendon sheaths thin vascular bed of loose connective tissue. One layer of
The long flexor tendons in the digits are covered by the serous membrane pouch lines the internal surface of a
dense connective tissue, termed fibrous tendon sheaths. fibrous tendon sheath, while the other layer covers the
Fibrous tendon sheaths form the roof of fibro-osseous tendon.
tunnels for long tendons passing over (the flexor aspect) of
a succession of bones (in the digits).

Fig.6.23 Fibro-osseous tunnels for a tendon


Tendons are bound down by fibrous tendon sheaths to
prevent them from bow-stringing. A pulley mechanism
created may enhance movement (e.g. on the fingers and
toes). The sheath is thicker (with its fibres aligned) along
lines of stress. Fig.6.25 Development of a synovial tendon sheath

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).

Infection of a synovial sheath


Infection introduced into a synovial sheath (e.g. by a
penetrating injury to a digit) may spread long distances by
tracking along the fluid-filled conduit provided in the sheath.
The long flexor tendon to the little finger is surrounded
by a synovial sheath that is continuous with the large
common sheath (at the wrist) for all long flexors of the
fingers. Infection introduced into the synovial sheath for the Fig.6.28 Mesotendon formation
little finger is likely to spread proximally to the palm and
wrist. MOVEMENT AND SKELETAL MUSCLE FORM
Skeletal muscles have a dual role. They move bones,
but also hold bones together. Complementing the dual role
of joints in mobility (capacity for movement) and stability
(capacity to resist excessive or unwanted movement) they
vary in degree for different muscles. A particular movement
may be described as occurring at its fulcrum (e.g. flexion at
the elbow joint). Alternatively, it may be described as a
movement of the lever distal to the joint (e.g. flexion of the
forearm).

Third order levers


Three types of levers occur in the body. The vast
majority of muscles (e.g. flexors at the elbow joint) act on
third order levers to move a load through the greatest
range of movement (along a wider arc and at more speed).
The power (P) via the muscle attachment is applied
between the fulcrum (F), or axis of the joint, and the load
(L) at the end of the bony lever.

Fig.6.26 Spread of infection along synovial sheaths

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

Second order levers Distance of line of pull


Second order levers provide greatest power. The load Leverage of a muscle acting at a joint is determined by
(e.g. body weight transmitted through the ankle) is between the distance of the line of pull from the axis of that joint.
the fulcrum (e.g. the joints of the toes) and the power (e.g. The line of pull is (represented by) a line connecting the
via the Achilles tendon). muscles origin and insertion. The axis of the joint is
located at the centre of the arc of movement.

Fig.6.32 Leverage determined by distance from line of pull

Trade-off between power and range


Fig.6.30 Second order levers (for power) The active range of movement at a joint is dependent
on muscle shortening. There is a trade-off between power
First order levers and range of movement.
A powerful movement requires a strong contraction
First order levers provide greatest stability. The fulcrum
acting at a distance along a lever (creating great leverage).
(e.g. the joint above the atlas) is between the load (e.g. the
A large range of movement requires shortening of a muscle
head) and the power (e.g. via neck muscles).
that inserts close to the fulcrum (creating a wide arc of
movement of the distal lever). The power and range of a
particular movement may be deduced by considering the
sites of skeletal muscle attachments (for determining
leverage versus lever arc) and muscle form (for
determining strength of contraction versus degree of
shortening).

Muscle form
The form of a skeletal muscle is determined by the
arrangement of its fibres.

Fig.6.31 First order levers (for balance)

Rotatory and translatory motion


Rotatory (angular) motion consists of a bony lever
moving around a fixed axis. Translatory (linear) motion
consists of a bony lever being pulled directly away from or
pushed directly towards a joint. Skeletal muscle contraction
generally results in a combination of rotatory and
translatory motion, which vary for different stages of a
movement. There tends to be a trade-off between rotatory
and translatory motion (depending on the line of pull of the
muscle). The rotatory component typically produces the
visible movement of a lever. Fig.6.33 Types of fibre orientation

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.

MUSCLE CONTRACTION AND ACTIONS


Types of muscle contractions
Usually, when muscle fibres contract the muscle as a
Fig.6.34 Pennate muscles whole shortens (a concentric contraction). This may be an
The active range of movement at a joint is proportional isotonic (G. equal stretch) contraction where the muscle
to the length of muscle fibres. This is reflected in the length as a whole shortens (while contracting) to move a load. In
of the muscle belly (its contractile part), rather than the an eccentric or paradoxical contraction the muscle as a
whole muscle (which may include a non-contractile whole lengthens (due to further stretching of its elastic
tendon). elements, despite the contractile mechanism operating)
while resisting the load. This occurs when slowly lowering a
The active range of movement at a joint is proportional load against gravity.
to the length of muscle belly. In an isometric (equal length) contraction, the muscle
as a whole maintains the same length (while the muscle
The orientation of fibres is also important as muscles fibres contract) without movement (due to simultaneous
with parallel fibres shorten more than those with oblique stretching of the elastic elements). This occurs when
fibres. If a muscle is purely fleshy with parallel fibres, the attempting to lift a load that cannot be overcome.
shortening of the whole muscle will equal the degree of
contraction of its individual fibres. If a muscle contains a
tendon (non-contractile element) and/ or obliquely oriented
muscle fibres, the shortening of the whole muscle will equal
only the longitudinal component of the contraction of its
individual fibres.

Cross-sectional area of muscles

Fig.6.35 Strength and cross-sectional area Fig.6.36 Isometric and eccentric contractions

50
6. Muscular System and Muscles

Length/tension relationship Flexor and extensor muscles tend to be located on their


respective (flexor or extensor) aspect of a joint, separated
At rest, muscles are generally in a state of mild stretch.
by a fascial intermuscular septum, on each side. Not only
Stretching a muscle (to a degree) before contraction
do flexors and extensors occupy separate compartments
produces a stronger contraction (generating more tension).
but they also have a separate nerve supply.

Prime movers and antagonists


A muscle acts as a prime mover or agonist (G.
contest) when its contraction produces a particular
movement.
In order to contract effectively a prime mover needs to
contract from a position with an optimal degree of stretch.
Movement results when the antagonist muscles relax
and lengthen.
The degree of stretch of antagonist muscles is often the
major factor limiting range of motion for a particular
movement.

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).

Muscles crossing more than one joint can generate


extra force but are also prone to overstretch.

Flexor and extensor musculature


Although skeletal muscles produce individual
movements they usually do so as part of a group. Although
they may also be involved in other pairs of movements,
skeletal muscles are considered as being either flexor
musculature or extensor musculature. The major pair of
movements (even at biaxial or multi-axial joints) is flexion
and extension.

Fig.6.39 Types of muscle action

Fixators as dynamic ligaments


Certain muscles are designed to provide stability at a
joint. A fixator muscle is located close to the axis of
movement at a joint. It is characteristically a short muscle
that stabilises by acting as a dynamic ligament. Muscles
(and tendons) surrounding the joint give it support. Those
that blend with the capsule around the most mobile joints
(shoulder and hip) form a cuff. This arrangement prevents
distraction of the ball from its socket (without impeding
Fig.6.38 Flexor and extensor compartments mobility).

51
BODY SYSTEMS AND ORGAN STRUCTURE

However, the same muscle may act as prime mover,


antagonist, fixator or synergist for different movements.

NEUROVASCULAR SUPPLY & MYOTOMES


Neurovascular hilum and motor point
A skeletal muscle receives its nerve supply via
muscular branches from a peripheral nerve. A nerve
typically enters a muscle accompanied by vessels. This
site, the neurovascular hilum (L. slit) is where the
muscle moves least in relation to the major artery of the
limb. This is often near the middle of the muscle belly and
on its deep surface. Clinically the neurovascular hilum may
be identified as the motor point (where electrical
stimulation of the nerve most easily elicits contraction of the
Fig.6.40 Fixator muscles positioned close to a joint muscle).
Fixator muscles tend to be the most important
stabilising factor and the first line of defence (against
dislocating forces). Their tone can be controlled
automatically by stretch reflexes (when part of a capsule is
on stretch, the overlying muscles contract more strongly).

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.

Fig.6.42 Neurovascular hilum in a muscle

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.

Fig.6.41 Prime mover enlisting a synergist


Opposing flexion at the wrist joint (which is crossed by
the long flexor tendons to the fingers) enables the wrist
extensors to act as synergists for finger flexion. Biceps and
triceps are prime movers for flexion and extension at the Fig.6.43 A motor unit
elbow joint, respectively. In addition, the long head of
biceps and of triceps cross the shoulder joint. A motor unit (within a particular muscle) is the total
The long head of triceps acts as a synergist for elbow number of muscle fibres innervated by a single motor nerve
flexion by opposing the flexor action of the long head of fibre (from a peripheral nerve).
biceps (at the shoulder joint). Their roles are reversed for A motor unit is the functional neuromuscular unit. Gross
elbow extension. movements are possible using a few large motor units
(each with many muscle fibres). More precise movements
Prime movers tend to be located superficially and require many small motor units (each with fewer muscle
fixators deep. fibres).

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.

Skeletal muscle tone and its assessment


Skeletal muscle tone (G. tension) is measured as
resistance to stretch. Muscle tone is under reflex control. It
is dependent on a nerve supply (both motor and sensory)
and is modulated by the recruitment of more or fewer motor
units.
Skeletal muscle tone may be either increased or
decreased by certain lesions of the nervous system.
Assessment of skeletal muscle tone involves resistance to
stretch of a major muscle group ideally through its full Fig.6.44 Dual nerve supply of muscle on a border
range of movement (with increasing velocity). This is an
important step in a neurological examination. Nerve supply to muscles
Muscles that migrate during development retain their
Muscle hypertrophy and atrophy original nerve supply.
Muscle is a very highly specialised tissue. Even though
mature muscle cells have lost the capacity to replicate they The nerve supply to a muscle reflects its
respond to changes in demand. Muscle fibres undergo developmental origin (nerves remain faithful to their
progressive enlargement, termed hypertrophy (G. over- muscles).
nourishment) with increased demand. Muscle fibres
progressively waste away with inactivity (disuse atrophy) The two parts of adductor magnus developed as
and particularly after loss of their motor nerve supply separate muscles becoming incorporated into one. Each
(denervation atrophy). part retains its original nerve supply. The diaphragm
Being structural changes, muscle hypertrophy and developed as separate parts (with separate sensory nerve
atrophy are not evident immediately but only after a supplies) initially far from each other. The central part of the
variable period of time. Assessment of skeletal muscle diaphragm commenced development in the neck. It then
wasting involves comparing both sides of the body and, migrated inferiorly retaining its original nerve supply, the
where possible, measurement of circumference. This is phrenic nerves (derived from cervical spinal cord
also an important step in a neurological examination. segments) which explains their long course.

Reciprocal innervation Myotomes


A myotome (G. muscle + cut) is the mass of muscle
Skeletal muscles with a common action often share a supplied by a particular spinal cord segment.
common nerve supply (as well as occupying a
common compartment). The segmental pattern of nerve supply in the trunk is in
a simple cranial to caudal sequence.
Muscular branches (containing both sensory and motor
nerve fibres) from particular peripheral nerves supply flexor Each intercostal nerve (the continuation of a single
muscles. Extensor muscles receive their branches from thoracic spinal nerve) supplies the muscles in its
different peripheral nerves to those supplying the flexor corresponding intercostal space. The peripheral pattern of
muscles. motor distribution therefore matches the segmental pattern.
Contraction of a prime mover (whether flexor or
extensor) is associated with relaxation and stretch of the Two consecutive spinal segments
antagonist group. Stimulating motor nerves to a prime In the limbs (where there are 50 muscles in each), the
mover is therefore associated with a subsequent arrangement of myotomes (involving primarily 5 segments)
stimulation of proprioceptive fibres from the antagonist. is much less apparent than in the trunk. A major peripheral
This reciprocal innervation enables coordination between nerve (having emerged from a plexus) therefore contains
prime movers and antagonists during normal movements. motor fibres derived from a number of spinal cord
segments. As a result, the peripheral pattern obscures the
Dual nerve supply segmental pattern of distribution.
A muscle located on the border between two
compartments may receive a dual nerve supply (and An individual limb muscle typically receives its supply
have dual prime mover actions). from two consecutive spinal cord segments.

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).

Cranial myotomes are proximal Anastomoses provide potential alternative pathways


(collateral circulations) if a major artery is occluded. Within
Proximal flexor muscle groups are supplied from more muscles there is typically a continuous network of vessels
cranial (pairs of) segments than those for distal flexor rather than end arteries. However, at the boundaries of the
muscles. vascular territories arteries are usually linked by
anastomoses via reduced calibre (choke) arteries. Veins
The same applies for extensor muscle groups (although also link territorial boundaries within muscles. However,
they receive the two segments more caudal than those for unlike arteries they are not of reduced calibre. These veins
the corresponding flexors at a particular joint). (oscillating veins) do not have valves and permit flow in
either direction.
The most caudal segment distributed via the limb The concept of vascular territories within muscles
plexus supplies the most distal muscle group for the (together with the knowledge of the sites of vascular
upper limb and for the lower limb (intrinsic muscles of pedicles for particular muscles) is applied when planning
palm and of sole, respectively). grafts in reconstructive surgery.

Muscle injuries and healing


With a muscle injury there may be considerable
bleeding due to the rich blood supply of muscle fibres
(although tendon has a poor blood supply).
Subsequent healing tends to be problematic as
completely torn muscle fibres do not regenerate, but heal
with fibrous scar tissue. In addition, inactive muscle wastes
away and extensive bruising may even calcify. The degree
of fibrous (scar) tissue is minimised by appropriate first aid
management (to reduce bleeding) followed by rehabilitation
(including graded stretching and exercise). Scar tissue is
inherently weaker than normal muscle and shortens the
muscle, predisposing it to future injury.

Fig.6.45 Upper limb myotomes and associated movements

Muscular branches of arteries


Skeletal muscles normally make up well over one third
of body weight and are highly metabolic when exercising.
They possess a rich blood supply with the capacity to
dramatically increase it on demand. Skeletal muscles
receive their (potentially) considerable blood supply via
muscular branches from adjacent major arteries and are
drained via tributaries of associated veins. Muscles are
typically supplied by more than one artery via vascular
pedicles (stalks containing vessels and providing the
avenues of supply). However, a few muscles have only one
major vascular pedicle. These are typically muscles with
fleshy bellies, which may possess a long tendon (e.g.
gastrocnemius), or a tendon at each end (e.g. biceps
brachii). Segmental muscles may have two pedicles of
similar size (e.g. rectus abdominis) or multiple pedicles of
similar size (e.g. external oblique) arising from separate
arteries. Other muscles have a dominant pedicle at one or
other end and several small accessory vessels along the
belly (e.g. rectus femoris) or a dominant pedicle to the belly
and several small accessory vessels peripherally.

Where there is a major source artery (and principal


vein) it enters as part of the neurovascular bundle at
the hilum, on the deep surface of the muscle.

54
Chapter 7: Integumental System and Skin

Body temperature is controlled primarily by regulating


blood flow to skin and by sweating. An additional role is in
INTEGUMENTAL SYSTEM vitamin D synthesis (required for normal bone formation)
via absorption of ultraviolet rays, from exposure of the skin
SKIN STRUCTURE AND TENSION LINES to sunlight.

SKIN APPENDAGES AND SPECIALISATIONS

SUBCUTANEOUS TISSUE AND FAT

CUTANEOUS NERVES AND OVERLAP

NEUROSOMES AND REFERRED PAIN

ANGIOSOMES AND SKIN BLOOD SUPPLY


Fig.7.2 Skin functions
LYMPHOTOMES AND WATERSHED AREAS Epidermis
Skin is made up of two components. A connective
tissue layer, the dermis (G. skin) is covered by an
INTEGUMENTAL SYSTEM epithelium (G. upon + nipple, i.e. a surface lining) termed
the epidermis.
The integumental (L. 'covering') system consists of skin
Epidermis is primarily a stratified squamous (L.
and skin appendages (including hair and nails),
scale) epithelium. It contains many layers of cells that
subcutaneous tissue and the breasts.
become progressively flatter towards the exterior. The
outermost horny layer (stratum corneum) is dead and
forms a protective layer composed mainly of the protein
keratin, preventing fluid loss and acting as an additional
barrier. The innermost basal layer (stratum basalis) is a
single layer of cells resting on the dermis. Some of these
cells, the melanocytes, produce melanin (G. black)
pigment.

Fig.7.3 Epidermis and its major layers

Dermis

Fig.7.1 Modules of the integumental system

SKIN STRUCTURE AND TENSION LINES


Skin covers the body and is its largest organ.

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.

Fig.7.6 Relaxed skin tension lines on the back

Connective tissue in living skin is oriented along the


relaxed skin tension lines.

Body surface area


Skin (including its specialisations) covers the entire
Fig.7.5 Relative thicknesses of dermis external surface of the body. The surface area of an
average adult male is approximately two square meters.
The dermis on extensor surfaces tends to be thicker Fluid loss in burns and rule of nines
and tougher increasing protection from injury.
In burns, fluid loss is proportional to the surface area
affected.
The dermis on flexor surfaces is more adapted for
discriminative sensation. This is calculated to determine the amount of fluid
Skin pigmentation replacement required.
According to the rule of 9s:
A readily visible characteristic of skin is pigmentation. trunk = 4x9%
The melanocytes in the basal layer of the epidermis lower limbs = 4x9%,
produce melanin pigment and transfer it to overlying cells upper limbs = 2x9%,
protecting against ultraviolet damage to their nuclei. Skin head & neck = 1x9%
pigmentation decreases the risk of sunburn and skin Total = 99% (+ genitals the remaining 1%).
cancer.
Intrinsic pigmentation is determined by genetic factors.
An albino (L. white) has a genetic lack of melanin pigment
in the skin, hair and eyes. Environmental pigmentation,
produced by exposure to ultraviolet light, is reversible.
Environmental pigmentation may also be due to
hormones. In pregnancy there tends to be increased skin
pigmentation, particularly of nipples and areolae.

Relaxed skin tension lines


General skin characteristics also include mobility,
elasticity and tension. These are primarily determined by
the attachments, composition and alignment of dermal
connective tissue fibres. They vary in different areas and
with aging.

Direction of skin incisions and scarring


Incisions made parallel to lines of tension heal with a
fine scar, while those at right angles to lines of tension tend
to produce a wide scar. Fig.7.7 'Rule of nines for adult body surface area
56
7. Integumental System and Skin

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.

Nails and nail beds

Fig.7.8 A pilosebaceous unit


Hairs are modified in various locations. These include
hairs of the scalp (capilli), eyebrows, eyelashes, nostril
hairs (vibrissae), axillary and pubic hairs. Hairs are absent
from thick skin (palms and soles), lips (and labia minora) Fig.7.11 Section through distal phalanx of a finger
and glans penis (and clitoris). Nails are primarily composed of keratin and are derived
Sebaceous glands are also located in the dermis. A
from an outer layer (the stratum lucidum) of the epidermis.
duct from each opens into an associated hair follicle. A nail is made up of a nail root (deep to the proximal fold
Sebum is the oily secretion that helps make skin
of skin), lunule and nail plate (between the lateral fold of
waterproof. Arrector pili (L. hair) muscles are small
skin on each side) projecting towards the distal margin of
bundles of smooth muscle in the dermis attaching to hair the digit. A nail bed lies under the nail plate and is derived
follicles and when stimulated, make hairs stand on end.
from the epidermis (deep to the stratum lucidum). The
Contraction of smooth muscle associated with the nipple
thickened part of the nail bed deep to the nail root and
can make it become erect. lunule is termed the matrix.

Effect of nail bed damage


Damage to the matrix may result in permanently
deformed nails.
The underlying subungual (L. under + nail) dermis is
thick and vascular with numerous fibrous attachments
directly to the periosteum of the distal phalanx. There is no
intervening subcutaneous layer.
Fig.7.9 Pilosebaceous units around eye and nipple
Subungual haematoma
Sudoriferous and odoriferous glands
Even a small degree of swelling from a bruise under a
Sudoriferous (L. sweat) glands are located in the nail (subungual haematoma) causes considerable pain.
dermis. Their ducts pass through the epidermis to open on Drainage (e.g. using a hot paper clip) suddenly releases
its external surface. The bases of some sweat glands the pressure bringing rapid relief.
extend through the dermis into the underlying
subcutaneous tissue.

Fig.7.12 Drainage of a subungual haematoma


Nail beds and associated dermis have migrated dorsally
from tips of the digits. This is reflected in the neurovascular
supply (from palmar/plantar digital nerves and vessels),
Fig.7.10 Site of sweat gland and associated duct which is retained.
57
BODY SYSTEMS AND ORGAN STRUCTURES

These interfaces are termed mucocutaneous


junctions and are located near openings to the respiratory
and digestive tracts (nares and oral fissure) and to the
terminations of the urogenital and digestive tracts (urethral,
vaginal and anal orifices).

Fig.7.13 Ventral supply for nail bed

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).

Fig.7.15 Cutaneous openings on female perineum


Other openings involving skin are for the external
auditory meatus (of the ear) and the palpebral fissure (of
the eyelids). Associated epidermal modifications form the
epithelia of the eardrum (tympanic membrane), conjunctiva
and cornea.

Fig.7.14 Sites of thick skin


Sweat glands are numerous but hair follicles (with Fig.7.16 Cutaneous openings for mouth and eye
sebaceous glands and arrector pili muscles) and
Specialised areas of skin occur on the breast (nipples
pigmentation are absent. Paradoxically thick skin has a
and areolae) and on the genitals (penis and scrotum,
thinner dermis than thin skin.
clitoris and labia).
Friction ridges Skin surgery
Thick skin has prominent surface ridges termed friction
Extra care is required with incisions and in surgical
(or papillary) ridges. These epidermal ridges are
repair of wounds to areas with skin specialisations. This is
associated with the dermal papillae in the palms and soles.
to ensure accurate alignment, minimise tension and
They help increase grip and also enhance sensation.
prevent disfigurement (most important on the face,
The pattern of friction ridges is permanent and unique.
particularly with lips and eyelids). Wounds tend to be under
Fingerprinting greater tension where skin is tightly bound down (e.g. to
cartilage of the ears and the nose). Incisions across flexure
Fingerprints, being unique, unchanging and accessible, lines and hairlines (particularly eyebrows) should be
can be used for identification of individuals. avoided. Where possible, incisions (particularly in the face
Flexure lines and skin creases and neck) should be placed along skin creases.
Specialised areas of skin and mucocutaneous junctions
Flexure lines occur where the skin is bound down over also tend to have a particularly rich blood supply and
joints to form prominent creases. These are found sensory nerve supply.
particularly over the joints of the fingers (and toes) and in
the palm of the hand. In the face and neck, skin creases
become permanent wrinkles when elasticity is lost due to SUBCUTANEOUS TISSUE AND FAT
aging. They tend to become aligned perpendicular to the
direction of contraction of underlying muscles. Subcutaneous fat
Subcutaneous tissue (also known as superficial fascia)
Cutaneous openings and special areas is a loose connective tissue layer, of variable thickness.
Cutaneous openings are typically associated with Subcutaneous tissue contains a variable amount of
interfaces between skin and mucous membrane. adipose (L. fat) tissue.

58
7. Integumental System and Skin

Sites of subcutaneous muscles


Muscles are found in the subcutaneous tissue of the
face, neck, palm and scrotum. Muscles of facial expression
are located in the subcutaneous tissue of the face (where
there is no deep fascia). They insert directly into the skin.
Platysma is a sheet of skeletal muscle that extends into
the subcutaneous tissue of the neck. Palmaris brevis
corrugates the skin over the medial aspect of the palm.
Dartos is a sheet of smooth muscle that wrinkles the
scrotum.

Superficial nerves and vessels


Cutaneous nerves and vessels are transmitted to the
skin via subcutaneous tissue. Superficial veins
(accompanied by lymphatics) and cutaneous nerves run for
considerable distances in subcutaneous tissue. They tend
to be located close to the underlying deep fascia.

Fig.7.17 Thick layer of subcutaneous tissue in thigh


Fat is deposited in preferential sites depending on
genetics, age and gender (typically abdomen in males,
buttocks and thighs in females). Fat is not present in the
subcutaneous tissue of the eyelids, ear, scrotum, penis and
clitoris.

Fig.7.20 Location of cutaneous nerves and vessels


Fixed skin is supplied by short (indirect) arteries
running along the fibrous septa after passing through and
supplying underlying muscle. In contrast, mobile skin tends
to be supplied by longer (direct) arteries that pass
between rather than through underlying muscles.

CUTANEOUS NERVES AND OVERLAP


Fig.7.18 Layers of skin and underlying tissue Superficial somatic afferents
Sites of subcutaneous septa Even though the epidermis does not possess nerve
fibres, the underlying dermis receives a particularly rich
nerve supply via cutaneous (L. skin) branches of
peripheral nerves. Skin is a superficial somatic structure.
Cutaneous sensory nerve fibres are superficial somatic
afferents (in contrast to deep somatic afferents which
supply bones, joints and muscles).

Fig.7.19 Compartments within subcutaneous tissue


Fibrous strands in subcutaneous tissue bind the
overlying skin to the underlying dense connective tissue.
These occur particularly in the palms, soles and scalp
where they are thickened as septa.
Fibrous septa form boundaries of numerous small
compartments within the subcutaneous tissue. In the breast
prominent fibrous septa radiate from beneath the nipple,
demarcating lobes of the mammary gland within the
subcutaneous tissue. The upper septa are termed
suspensory ligaments. Fig.7.21 Major types of dermal receptors

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).

Nerve branches do not cross the midline of the body.

Fig.7.22 Types of motor fibres to skin


Visceral motor nerve fibres (sympathetics) are particularly
important for thermoregulation, being distributed to the Fig.7.25 The major Internervous line of non-overlap
smooth muscle of dermal blood vessels (vasomotor
The cutaneous branches of a particular peripheral
fibres), sweat glands (sudomotor fibres) and even to the
nerve do not cross the midsagittal plane to intermingle
arrector pili muscles (pilomotor fibres).
with those from the opposite side of the body.
Cutaneous nerve territories and overlap
The skin of the body may be mapped into territories
(peripheral cutaneous neurosomes) supplied by the
cutaneous branches of peripheral nerves.

Fig.7.26 Internervous line through a body segment

Area of anaesthesia in a nerve block


Fig.7.23 Peripheral cutaneous neurosomes

Territories supplied by peripheral nerves derived from


consecutive spinal segments overlap extensively (and
their branches intermingle).

Fig.7.27 More than one nerve may need to be blocked


The area of skin anaesthetised by injection of local
anaesthetic around a peripheral nerve corresponds to the
cutaneous sensory distribution of the nerve (distal to the
site of infiltration) minus the area of overlap from adjacent
Fig.7.24 Sensory overlap for different modalities nerves.

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.

NEUROSOMES AND REFERRED PAIN


A neurosome (L. nerve + body) is the total sensory
territory (a 3-dimensional block of tissue) supplied by a
particular peripheral nerve (peripheral neurosome) or spinal
cord segment (segmental neurosome).
Fig.7.30 Spinal cord segment distribution
Dermatomes and overlap
Cranial spinal cord segments are distributed
A dermatome (G: skin + cut) is the area of skin progressively along the skin of the pre-axial border of a
supplied by a particular spinal cord segment. It is better limb (from proximal to distal) while caudal spinal cord
termed a segmental cutaneous neurosome. segments progressively supply the post-axial border (from
distal to proximal).

Middle segment to distal skin


The middle segment of a limb plexus is distributed to
the most distal skin.

Fig.7.28 Segmental cutaneous neurosomes


Adjacent dermatomes that are consecutive overlap
extensively.

Damage to a single spinal cord segment (or posterior


nerve root) may produce only a small (or even no) zone of Fig.7.31 Distribution of middle segment of brachial plexus
complete cutaneous sensory loss.
As for peripheral nerves, overlap for pain and
temperature is more extensive than that for touch across
consecutive dermatomes that are adjacent to each other.

Fig.7.29 Consecutive dermatomes overlap extensively

Pre-axial and post-axial borders


In the embryo a limb bud develops with a pre-axial
border (along the radius/thumb of the upper limb and the
tibia/big toe of the lower limb) and a post-axial border Fig.7.32 Distribution of middle segment of sacral plexus
(along the ulna/little finger of the upper limb and fibula/little In the upper limb C7 is the middle segment of the
toe of the lower limb). brachial plexus (C5, 6, 7, 8 and T1) and is distributed to the
The pre-axial border of the upper limb is located skin of the hand including both palmar and dorsal aspects
laterally (and post-axial border medially) in the anatomical of the middle finger. In the lower limb S1 is the middle
position, with flexor compartments anteriorly and extensor segment of the sacral plexus (L4, 5 and S1, 2, 3) and is
compartments posteriorly. The pre-axial border of the lower distributed to the skin of the foot including both plantar and
limb is located medially (and the post-axial border laterally) dorsal aspects of the middle toe.

61
BODY SYSTEMS AND ORGAN STRUCTURES

Axial lines therefore correspond to inter-nervous lines


(of non-overlap). They represent buried areas of skin
during development of the limb buds. Each limb has an
anterior and a posterior axial line (midway between the pre-
and post-axial borders) continuing proximally onto the
trunk. However, development of the lower limb is
complicated by medial rotation with the anterior axial line
spiralling medially around to the posterior aspect when
viewed in the anatomical position.
Since the lower limb buds rotate medially during
development, their dermatomes also spiral in the same
direction. The anterior axial line of the lower limb and the
arrangement of dermatomes in an adult untwist when the
lower limbs are shifted from the anatomical position (to the
'welcoming position') by abduction and lateral rotation.
Fig.7.33 Incorporation of middle dermatome in limb buds
The upper limbs are simply abducted to adopt this position.
Anterior and posterior axial lines
Axial lines are imaginary lines located where non-
consecutive dermatomes are adjacent to each other.

Adjacent dermatomes that are not consecutive do not


overlap.

Fig 7.36 Anterior axial lines in the welcoming position


The pre-axial border of each limb is then located
cranially and the corresponding post-axial border, caudally
(like the original limb buds).

Assessing skin sensory loss


Clinical testing for diminished cutaneous sensation (due
to a specific lesion involving either a spinal cord segment or
a peripheral nerve) is best performed across axial lines. It
is recommended to commence from an area of normal
sensation and proceed across the axial line to the
suspected area of sensory loss.

Differing dermatome maps


Dermatome maps are not only artificial constructs but
Fig.7.34 Development of an axial line they show sharp lines of demarcation between each strip
Cutaneous nerve branches do not cross axial lines. (which should be blurred where there is overlap).
They also depend on results from testing living people
and may be mapped differently with different modalities
(e.g. overlap for pain is greater than that for touch). Two
types of maps have been constructed.

Fig.7.37 Map based on sensory loss (Foerster)


One type of map (according to Foerster) is based on
the area of sensation remaining after nerve roots from
segments above and below a single segment were
Fig.7.35 Axial lines in the anatomical position severed. These have both anterior and posterior axial lines
62
7. Integumental System and Skin

(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.7.38 Map based on pain radiation (Keegan & Garrett)

Another type of map (according to Keegan and Garrett)


is based on loss of pain sensation due to compression of a
particular nerve root. These have continuous strips Fig.7.40 Sites of referred pain from heart
radiating along a limb and no posterior axial line. This map
is preferred for identifying spinal segments involved in pain Deep somatic pain and visceral pain are dull and ill-
referral. defined (especially visceral pain which is particularly poorly
localised). Deep pain is also often accompanied by referred
Shingles dermatomal distribution pain. The site of referred pain tends to be in a pattern that
The skin of the body can be mapped into territories has an anatomical basis. Thus, there can be two sets of
(dermatomes) of cutaneous supply derived from each pain. The first is the actual deep (somatic or visceral) pain
from the source, experienced deeply (but often poorly
spinal cord segment (via its associated spinal nerve).
Herpes zoster (G. creep + girdle) also known as localised). The second is the associated pain that is
shingles is due to reactivation of Varicella zoster (deceptively) referred elsewhere (referred pain).
(chicken pox) virus in the sensory ganglion of a spinal or Referred pain may mask pain directly from the source,
cranial nerve. This condition is characterised by vesicles making diagnosis difficult. However, awareness of the
and pain along the cutaneous distribution of the affected anatomical basis of referred pain can overcome this.
nerve.
Pain from a deep source is referred to the same
The pain may precede the rash and can be severe. The
neurosome.
rash does not extend across the mid-sagittal plane
because branches of cutaneous nerves do not cross the This can be territory supplied by the same spinal cord
midline of the body (being the major line of fusion). For segment (segmental neurosome) or the same peripheral
example, the rash for shingles affecting a thoracic spinal nerve (peripheral neurosome). An example of the former is
nerve appears as a band around left or right half of the pain referred to the umbilicus from an inflamed appendix.
trunk, mapping the territory supplied by it. This, in turn, An example of the latter is pain referred to the ear from an
corresponds to the associated dermatome (including the impacted wisdom tooth.
area of overlap with adjacent dermatomes).

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

Afferents from a 3 dimensional block of somatic


structures (both superficial and deep) converge on the
same part of a spinal cord segment as those arising from
certain deep organs (particularly viscera). This common
area of the spinal cord can be excited by impulses along
neighbouring neurons conveying pain from these organs.
The brain seems to interpret impulses arriving at a
particular spinal cord segment as originating from a source
mapped on the body surface even though experienced
deep to it. The deep source may be a viscus (visceral
referred pain) or a somatic structure (somatic referred
pain).

Migration and referred pain


Although referred pain generally overlies the associated Fig.7.43 Unpaired organs and midline pain referral
deep structure, it is often experienced at a site distant from
the source. This phenomenon occurs when viscera have The bladder is an unpaired viscus located in the
migrated (with their nerves) during development or when midline. Pain is referred from it to the midline (suprapubic
somatic structures have migrated (with their nerves), during region of the abdomen) because it also receives a bilateral
development. nerve supply.

Referred pain to same side


Paired viscera develop and are subsequently located
on both sides of the body. Only visceral nerves from the
same side of the body supply a paired viscus.

Pain from a paired viscus is referred to the same side.

Fig.7.42 Migration and referred pain to neurosomes


The three locations of referred pain relative to its (deep) Fig.7.44 Paired organ and ipsilateral pain referral
source are: The kidneys are paired viscera located on each side of
- the neurosome overlies a deep organ supplied by the the posterior abdominal wall. Pain from the left kidney is
same spinal cord segment (e.g. joint capsule) referred to its own side of the body (the left loin) while pain
- the neurosome remains but the deep organ has from the right kidney is referred to the right loin.
migrated (e.g. appendix, diaphragm)
- the deep organ remains but the neurosome has
migrated (e.g. limb buds). ANGIOSOMES AND SKIN BLOOD SUPPLY
Referred pain to midline The epidermis does not have blood vessels. Its cells
receive their nutrition by diffusion from the underlying
Viscera have different patterns of pain referral dermis.
depending on whether they are unpaired or paired.
Vessels, being derived from mesoderm, develop only
Unpaired viscera receive a bilateral nerve supply. within mesoderm-derived tissues.
This is retained even if they have migrated away from The dermis (together with connective tissue in general)
the midline. contains vessels because it is also derived from
mesoderm. Epidermis is not derived from mesoderm and
Pain from an unpaired viscus is referred to the midline.
therefore cannot develop vessels.
This occurs because impulses are received Superficial and deep dermal plexuses
simultaneously in both left and right sides of the associated
spinal cord segments. The stomach is an unpaired viscus The dermis receives a rich blood supply at two levels. A
that has migrated to the left during its development. Pain is superficial (papillary) plexus of arterioles (and venules)
referred from it to the midline (epigastric region of located adjacent to the epidermis communicates with a
abdomen) because its sensory nerve fibres enter both deep (reticular) plexus located adjacent to the
sides of the spinal cord. subcutaneous tissue.

64
7. Integumental System and Skin

Vascular planes
Arteries travel with connective tissue via fascial planes
particularly associated with muscles.

Connective tissue is derived from the mesoderm


surrounding specialised structures (bones, muscles, fat,
vessels and fibrous nerve sheaths) that have developed
from it.
Vessels run within the connective tissue mesh along
mobile planes where muscles slide under deep fascia and
where skin glides over deep fascia or bone.

Vessels do not cross mobile planes.

Fig.7.45 Dermal plexuses


Communications (arteriovenous anastomoses) also
occur directly between arterioles and venules of the deep
plexus, particularly in terminal areas exposed to cold (e.g.
digits, ears and nose). Blood may be diverted from one set
of vessels to another in thermoregulation.
Skin, being a continuous sheet, is supplied by sets of
anastomoses (linking arterioles lumen to lumen). There are
no end-arteries in skin

Continuous arteries supply continuous organs.

Effects of lacerating dermal vessels


Fig.7.47 Arteries pass along mobile planes
Skin lacerations extending through the dermis bleed
due to the rich blood supply. For this reason they also tend Vessels cross planes at sites (of least mobility) where
to heal rapidly (after the wound is closed). connective tissue is anchored.

Angiosomes This occurs particularly at the periphery of muscles,


Cutaneous arterial supply may be mapped into over intermuscular septa, under flexure lines (and skin
territories that represent the surface of a block of tissue creases) and where deep fascia attaches to bone.
(which includes bone, muscle and skin) supplied by a
Arteries course from fixed (concave) areas to mobile
primary source artery. An angiosome (L. vessel + body)
(convex) areas.
is the 3-dimensional block of territory supplied by a
particular (named) artery and associated vein. It consists of
a matching arteriosome and a venosome. Arteries and Direct and indirect arteries to skin
veins follow the connective tissue framework of the body, a There are two types of arteries to the skin. Direct
continuous mesh between the outer dermis and inner cutaneous branches tend to course at the periphery of a
skeleton (where it is calcified). muscle (piercing the deep fascia where it is anchored).
Indirect musculocutaneous branches pierce muscles and
supply them before reaching the skin.
Direct arteries are associated with mobile skin because
vessels do not cross mobile planes (otherwise they would
be ruptured or would restrict mobility). Indirect arteries are
associated with fixed skin (e.g. bound by septa overlying
the muscles). These tend to be shorter and more
perpendicular than direct arteries. Branches of direct and
indirect arteries communicate with each other within
muscles and within skin.

Directional and oscillating veins


The venous drainage of skin is by two sets of veins
communicating with each other:
Fig.7.46 Angiosomes - Directional veins converge (with valves directing
blood flow) towards the centre of a venosome. They are
Planning grafts based on angiosomes longer and are associated with direct arteries (and with
The concept of an angiosome, coupled with knowledge mobile skin).
of specific vascular territories, is vital when planning grafts - Oscillating veins (without valves, hence flow in either
in plastic and reconstructive surgery. A block of skin, with direction) are shorter and associated with indirect arteries
or without deeper structures, can be successfully (and with fixed skin). They occupy the territory between the
transplanted to another site provided it is done so with the directional veins (equilibrating flow and pressure).
primary source artery and is within the boundaries of the
Veins converge on fixed areas from mobile areas.
associated angiosome.

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 AND WATERSHED AREAS


Dermal lymph capillary networks
The epidermis does not contain vessels. The dermis
contains blood vessels and lymph vessels, because unlike
epidermis it is derived from mesoderm.

Lymph capillaries are not present in epithelia


(including epidermis) but are abundant directly under
an epithelial surface.

The dermis has an abundance of lymph capillaries and


although most have a blind origin they link freely to form
extensive communicating networks.

Fig.7.49 Lymph flows from superficial to deep


The skin of almost the entire body drains first to a
superficial lymph node group before draining to a deep
group.

Two areas of skin are peculiar in their lymph drainage.


Skin on the front of the thorax and skin of the glans penis
(and clitoris) drain directly to deeply located lymph nodes
without first draining to a superficial lymph node.
Lymphatics draining skin of the front of the thorax, including
part of the breast, accompany tributaries of the internal
thoracic vein (which perforate the intercostal spaces) to the
deeply located parasternal nodes. Lymphatics draining the
glans accompany tributaries of the deep external pudendal
vein to the deep group of inguinal nodes (along the femoral
vein).

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).

Subcutaneous afferent lymphatics


Lymph vessels tend to accompany veins.

Superficial veins run in the subcutaneous tissue


accompanied by lymph vessels directed towards the major
superficial lymph node groups. These groups (cervical,
axillary and inguinal), located at the junction of the head
with the neck and the trunk with the limbs, are readily
palpable on clinical examination. Fig.7.50 Lymphotomes

66
7. Integumental System and Skin

Watershed areas of lymph drainage

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

Vertical and horizontal watersheds Lymph spread from watershed areas


Watershed areas are located at sites of extensive
communicating networks of lymph capillaries. These
correspond to zones of more than one direction of venous
drainage. Cutaneous watershed areas may be classified
into two groups: vertical (along developmental lines of
fusion) and horizontal (between the most important
superficial lymph node groups).

Fig.7.54 Tumour spreads in more than one direction


Watershed areas of lymph drainage are clinically
important in the spread of cancer or of infection. Tumour
cells or microbes may be carried in different directions to
more than one group of lymph nodes.
If the alternative routes are not anticipated, early
detection/treatment is more likely to be incomplete and the
venous system entered (with further dissemination). This is
particularly important regarding the spread of cancer,
including skin cancers and breast cancer.

Fig.7.52 Vertical watershed


The major vertical cutaneous watershed area is centred
along the midline of the body where lymph drains to the
corresponding lymph nodes on both sides of the body.
There is also a vertical cutaneous watershed area centred
on the nipple lines over the thorax. There are two major
horizontal cutaneous watershed areas, one across the level
of the clavicles (where lymph drains to both cervical and
axillary lymph nodes) and the other across the level of the
umbilicus (where lymph drains to both axillary and inguinal
lymph nodes).

67
Chapter 8: Visceral Systems and Viscera

bronchial tree. It is shared with the digestive tract where the


pathways for air and for food intersect.
VISCERAL SYSTEMS
Digestive system
HOLLOW VISCERA The digestive system consists of hollow tubes, the
digestive (alimentary) tract, together with solid viscera
EXOCRINE GLANDS AND DUCTS (the associated glands). The tract extends from the mouth
to the anus. It is made up of the pharynx (oral and
laryngeal parts), oesophagus, stomach, small intestine and
ENDOCRINE GLANDS large intestine. The associated glands are the (paired)
salivary glands and the unpaired pancreas. The digestive
PAIRED AND UNPAIRED VISCERA system also includes the biliary system, made up of the
liver, gall bladder and biliary tree.
SEROUS MEMBRANE AND MESENTERIES

MUSCLE COATS AND SPHINCTERS

MUCOUS MEMBRANE AND JUNCTION ZONE

HILUM AND VASCULAR SEGMENTS

NEUROVASCULAR SUPPLY OF A VISCUS

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

Urinary and male genital systems

Fig.8.1 Respiratory system


The respiratory system consists of the respiratory tract
and the lungs. The tract is made up of the nasal cavity,
pharynx (nasal and oral parts), larynx, trachea and Fig.8.3 Urinary and male genital system

68
8. Visceral Systems and Viscera

The urinary system consists of a pair of solid organs


(the kidneys) together with the hollow urinary tract
(ureters, bladder and urethra).
The male genital system also consists of solid internal
genital organs (testes, epididymes, seminal vesicles,
prostate and bulbourethral glands) together with a hollow
tract (ductus deferens and ejaculatory ducts). The external
genital organs are the penis and scrotum.
Part of the urinary tract (the urethra) is shared with the
male genital tract. This combined system may also be
regarded as the male urogenital system.

Fig.8.5 A typical hollow viscus (small intestine)

Fig.8.4 Endocrine and female genital systems

Endocrine and female genital systems


Fig.8.6 Layers of the wall of a hollow viscus
The endocrine system consists of discrete endocrine
glands together with endocrine tissues in other organs. A serosa typically covers all or part of the external
The endocrine glands are the pituitary, pineal, thyroid, surface of a hollow viscus (and may be continuous with a
parathyroids and suprarenals. Clusters of endocrine tissue mesentery attaching to the body wall). It consists of a
occur as the islets in the pancreas. The ovaries in the single layer of flat cells (mesothelium) covering vascular
female (and testes in the male) also have an endocrine connective tissue.
function. A serous membrane minimises friction from movement
The female genital system consists of internal genital due to extrinsic changes in position (mobility), intrinsic
organs, the paired ovaries and uterine tubes together with propulsive contractions (motility) or expansion. The
the unpaired uterus and vagina, and external genital muscularis consists of at least one muscle coat. Visceral
organs (the clitoris and vulva). smooth muscle can produce waves of contraction (termed
peristalsis) to propel its contents. The mucosa consists of
HOLLOW VISCERA epithelium covering vascular connective tissue. Mucous
membranes may have numerous folds to increase their
A hollow viscus is typically tubular, characterised by a surface area for absorption (e.g. small intestine).
cylindrical wall surrounding a central channel, termed the
lumen (L. light, as at the end of a tunnel). Some hollow Sites of normal constrictions
viscera are saccular, being more spherical in shape. A The lumen of a tubular viscus may have a dilatation
duct (itself a tubular viscus) conveying secretions from an termed an ampulla (L. flask) or constrictions at particular
exocrine gland may pass through the wall of a hollow sites.
viscus.
Normal constrictions of the lumen tend to occur at the
Structure of a hollow viscus beginning and end of a tubular viscus.
The wall of a hollow viscus consists of three principal
layers from external to internal: the serosa (serous These are often associated with orifices, mucosal
membrane), the muscularis (muscle wall) and the folds or thickenings of the muscle wall to control passage
mucosa (mucous membrane). through the lumen.

69
BODY SYSTEMS AND ORGAN STRUCTURE

Obstruction of a tubular viscus causes impaired


passage of luminal contents. This, in turn, tends to
produce distension (proximal to the obstruction), pain
(due to stretching of the distended viscus) and altered
peristalsis (to overcome the obstruction, initially). As an
example, intestinal obstruction typically produces the triad
of constipation (reduced passage of faeces and flatus),
abdominal distension and pain. These symptoms may be
accompanied by altered bowel sounds (from peristalsis),
detected on auscultation.

EXOCRINE GLANDS AND DUCT


A gland (L. acorn) is made up of clusters of secretory
cells. Glands may be organised into an outer cortex (L.
shell) and an inner medulla (L. middle).
Glands may also be subdivided into lobes, then
lobules (which contain the secretory units). Although
typically enveloped by a capsule, glands tend to be
surrounded by an additional covering.

Fig.8.7 Normal constrictions of urinary tract


The beginnings and ends of the ureters and the urethra
have normal constrictions of the lumen. Normal
constrictions may also occur where adjacent structures
compress a tubular viscus at particular sites along its
course. Such normal constrictions occur where the ureter
crosses the pelvic brim and where the urethra (in the male)
passes through the urogenital diaphragm.

Obstruction of a tubular viscus


Impairment of propulsion through a tubular viscus is
termed visceral obstruction. This may occur directly by
mechanical factors or indirectly by interfering with its
neurovascular supply (affecting wall function and/or
vitality). Obstruction of a tubular viscus may be classified
anatomically into three types (according to its relationship
with the wall).
Extramural (external) obstruction is from outside
compression of a tubular viscus (e.g. by a tight hernial
orifice, fibrous adhesions).
Intramural obstruction arises from within the wall of a
tubular viscus (e.g. by a mucosal tumour, spasm of smooth Fig.8.9 Exocrine gland (kidney) and its duct (ureter)
muscle, occlusion of arteries supplying the wall).
Although the kidney excretes rather than secretes urine,
Intraluminal (internal) obstruction is from a blockage in
it may be regarded as an exocrine gland, with the ureter its
the lumen of a tubular viscus (e.g. by a foreign body).
duct.

Serosal covering or fascial sheath

Fig.8.10 Serosa around organs in the peritoneal cavity


Some glands are enclosed by fascia that splits to form
Fig.8.8 Types of visceral obstruction an investing sheath.

70
8. Visceral Systems and Viscera

Fig.8.13 Exocrine gland and duct


A duct (L. lead) is formed from a system of internal
collecting channels and emerges from the hilum of an
Fig.8.11 Fascial sheath around a gland exocrine gland. The duct transmits secretions towards its
These fascial sheaths occur particularly in the head and orifice opening into the lumen of a hollow viscus (e.g. bile
neck (e.g. around salivary glands and the thyroid gland) duct into duodenum) or onto an external surface (e.g.
where they provide both support and protection. lacrimal ducts onto conjunctiva).
Glands associated with a body cavity (e.g. liver, At the hilum of the kidney the ureter arises from the
ovaries) are covered almost entirely, or at least in part, by a renal pelvis, formed by the union of its collecting channels
serosa, which reduces friction. (calyces).

Shape, grooves and impressions Orifice of a duct


The shape of an organ (together with its borders and A duct opening into the lumen of a hollow viscus tends
surfaces) may be determined by the structures adjacent to to narrow as it traverses the wall.
it. The left suprarenal gland is a crescent shape while the
right is a triangular pyramid (wedged between the liver, The narrowest part of a duct is its orifice (L. opening).
inferior vena cava and right kidney). A calculus (stone) will most likely lodge at the orifice of a
duct. The narrowest part of the ureter is its orifice in the
bladder (the most likely site for a ureteric calculus to lodge).

Fig.8.12 Organ shaped by its direct relations

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

ENDOCRINE GLANDS microscopic collections of endocrine tissue. The


pancreatic islets are particularly important collections of
Glands secreting directly into the blood stream are endocrine tissue which secrete both insulin and glucagon
termed endocrine (G. inside + secrete). Hormones (G. to regulate blood glucose. The testes and ovaries contain
rouse) are chemicals produced in one part of the body that cells that secrete sex hormones. These are responsible for
regulate cells in another part of the body. Certain hormones secondary sexual characteristics. The thymus is a
(e.g. growth hormone) have widespread effects on many lymphoid organ but also has an endocrine role.
tissues throughout the body.
PAIRED AND UNPAIRED VISCERA

Fig.8.15 Endocrine gland (suprarenal)

Ductless glandular organs


Fig.8.17 Paired and unpaired viscera
Endocrine glands do not have ducts (hence they may
also be termed ductless glands). Their secretions Paired viscera and unilateral supply
(hormones) are conveyed directly into the blood stream
The lungs (and bronchi) and most exocrine glands
carrying them to their target organs.
(lacrimal and salivary glands, kidneys, ovaries, testes and
seminal vesicles) are paired viscera. Similarly, their
respective ducts (including ureter, uterine tube and ductus
deferens) are paired. The suprarenal and parathyroid
glands are paired endocrine glands.
A paired viscus develops and is subsequently located
on one side of the body. Its nerve and vascular supply lines
are directed to that same side of the body.

A paired viscus receives a unilateral neurovascular


supply and refers pain to the same side.

For example, right kidney pain is felt in the right loin.

Fig.8.16 Blood flow through an endocrine gland


Endocrine glands have a very rich blood supply.

Purely endocrine glands are the pituitary gland and


pineal gland (in the head), the thyroid gland and
parathyroid glands (in the neck) and the suprarenal
glands (in the abdomen). However, endocrine glandular
tissue is not only clustered into discrete organs.

Sites of endocrine tissue


Some solid viscera (e.g. pancreas, kidneys and
gonads) have both exocrine and endocrine roles. While
primarily regarded as exocrine glands they contain Fig.8.18 Ipsilateral supply of paired kidneys
72
8. Visceral Systems and Viscera

Unpaired viscera Unpaired vascular supply to gut


There are two types of unpaired viscera, midline and Non-midline unpaired viscera have an arterial supply
non-midline. This also has implications regarding their from unpaired branches of the aorta (arteries of the
neurovascular supply. Some hollow viscera (trachea, foregut, midgut and hindgut) and venous drainage into
bladder, urethra, uterus and vagina) an exocrine gland an unpaired system of veins (the portal system).
(prostate) and most endocrine glands (pituitary, pineal and
thyroid) are unpaired viscera located in the midline.

Midline viscera and bilateral supply


Midline unpaired viscera develop by fusion from each
side of the body.

Fig.8.21 Unpaired arteries supplying the gut


Unpaired branches (coeliac, superior mesenteric and
inferior mesenteric arteries) arising from the front of the
aorta supply the stomach, small intestine and large
Fig.8.19 Bilateral blood supply to the uterus intestine. The venous drainage is to the liver via the portal
vein.
Midline unpaired viscera receive nerve and vascular Bilateral nerve supply to gut
supply lines from both sides
Unpaired viscera receive a bilateral nerve supply.
These subsequently form a broad band of overlap
across the wall of the viscus. This applies for all unpaired viscera (midline and non-
midline). Although the nerves to a non-midline unpaired
Non-midline unpaired viscera viscus are derived from both sides of the body they
The digestive system developed from the primitive gut, converge to accompany the unpaired arteries (which
originally in the midline of the body. This includes the originate from the front of the aorta).
gastrointestinal and biliary tracts, with their associated
glands (liver and pancreas) and ducts. These viscera
subsequently migrate to one side of the body, or are
located asymmetrically across the midline. However, the
uppermost end of the digestive tract (mouth and pharynx)
and lowermost end (anal canal) remain in the midline, as
do their orifices.

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.

SEROUS MEMBRANES AND MESENTERIES


Serous membranes
A serous membrane typically covers most of, the
external surface of a viscus within a body cavity. The
interior of a body cavity is lined by serous (L. serum)
membrane forming a closed sac.

Fig.8.25 Supply lines to serous membranes

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).

Fig.8.23 The mesentery and its contents


A serous membrane consists of a single continuous
sheet of flat cells that secrete a small amount of fluid (into
the enclosed potential space) minimising friction between
structures. This mesothelium (G. middle + nipple, i.e. a
surface lining) is on a thin bed of vascular connective
tissue.

Parietal and visceral serous membranes

Fig.8.26 Development of a mesentery

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

Posterior and subperitoneal viscera


The paired abdominal viscera (suprarenal glands,
kidneys and ureters) are located on the posterior
abdominal wall and are covered by the unpaired viscera
(which project much further into the peritoneal cavity).

Fig.8.27 Roles of a mesentery

Viscera suspended in body cavities


Viscera projecting into body cavities (pleural and Fig.8.30 Posterior peritoneal viscera
peritoneal) are usually suspended by a mesentery.
Most unpaired pelvic viscera (bladder, prostate gland,
vagina and rectum) are partly located below the level of the
peritoneum, in the pelvic cavity, without a mesentery.

Fig.8.28 An intraperitoneal viscus Fig.8.31 Subperitoneal viscera


The lungs are suspended in the pleural cavities (of the Viscera associated with a body cavity, but without a
thorax) and (intraperitoneal) segments of the mesentery, still tend to be partly covered by a serous
gastrointestinal tract in the peritoneal cavity (of the membrane. This applies both to posterior peritoneal and
abdomen and pelvis). The ovaries and the uterus also have to subperitoneal viscera.
mesenteries as they are suspended in the peritoneal cavity
(of the pelvis). Retroperitoneal viscera

Fig.8.32 Retroperitoneal abdomino-pelvic viscera


Fig.8.29 Intraperitoneal abdomino-pelvic viscera
The gut tube (foregut, midgut and hindgut), forming the
Typically, a viscus has a single mesentery. However, gastrointestinal tract and associated glands, commences
some viscera have more than one (e.g. stomach and liver). development with a dorsal mesentery throughout its length.

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.

Mobility and fixation trade-off


The gastrointestinal tract (GIT) has fixed segments
(which have fused their mesentery with the parietal
peritoneum) alternating with free segments (which have
retained their mesentery).

Fig.8.35 Torsion of the testis

MUSCLE COATS AND SPHINCTERS


Circular and longitudinal coats
The wall of a tubular viscus consists of smooth muscle
coats (the muscularis) between serous membrane (the
serosa), externally and mucous membrane (the mucosa),
Fig.8.33 Parts of gut alternately fixed and free internally. Concentric rings of smooth muscle, organised
into a circular coat, surround the mucosa in a tubular
For a very long tube such as the gut there is a trade-off viscus. A complete or partial longitudinal coat (around the
between mobility and fixation. The parts of the circular coat) is also present in many tubular viscera. In the
gastrointestinal tract are alternately free (intraperitoneal) stomach there is an oblique muscle coat in addition to the
and fixed (retroperitoneal) to enable mobility while circular and longitudinal. This (incomplete) coat is located
maintaining stability, respectively. In addition to altering internal to the other two.
their relative position (by mobility) those segments
suspended by a mesentery have more capacity to distend
(by expansion).

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.

Fig.8.36 The stomach wall


Fig.8.34 Torsion and compromise of blood supply Motility and expansion
A loop of intestine may also become twisted by Motility refers to the process by which luminal contents
adhesions or by protrusion through a hernial orifice. are transmitted along tubular viscera (and ducts). This is

76
8. Visceral Systems and Viscera

due to the wave of visceral smooth muscle contraction,


termed peristalsis.
Peristalsis typically involves alternate contractions of
longitudinal and circular muscle coats (the former
expanding the lumen ahead of a bolus, the latter
constricting the lumen behind it).

Fig.8.37 Intrinsic movement of a viscus


Solids, liquids and gas are ingested at the proximal end
of the gastrointestinal tract and propelled to its distal end,
where the remnants are expelled.
Visceral smooth muscle fibres (unlike skeletal muscle Fig.8.39 Voluntary and involuntary anal sphincters
fibres) may be stretched without increasing their force of
contraction.
Sites of sphincters
The property of stretch without increased force of Sphincters are found at the distal end of viscera that
contraction is termed plasticity and is particularly act as a reservoir (e.g. bladder, stomach).
important in organs that may expand to store large volumes
(e.g. stomach, bladder and rectum). The bladder and
rectum gradually accumulate urine and faeces,
respectively. At a critical point of stretch (micturition and
defecation) reflexes are elicited, with expulsion of the
contents. The stomach expands to accommodate a meal
then gradually releases its contents.

Voluntary and involuntary sphincters


A sphincter (G. strangle) is a localised muscular
thickening of, or around, the wall of a tubular viscus
controlling passage of contents through its lumen.
A sphincter may be smooth muscle (an internal
sphincter) of the visceral wall itself or skeletal muscle (an
external sphincter) around the viscus. Visceral nerves Fig.8.40 Sphincter at distal end of a reservoir
supply the former, also termed involuntary sphincters
(under reflex control), while somatic nerves supply the Sphincters may also be located at the distal end of a
latter, also termed voluntary sphincters (under voluntary duct (e.g. bile duct and pancreatic duct).
control).

Fig.8.41 Sphincters at distal end of ducts


Sphincters are often located near an external orifice
Fig.8.38 Skeletal and smooth muscle sphincters (particularly on the perineum).

77
BODY SYSTEMS AND ORGAN STRUCTURE

Mucosal functional sphincters


A fold of mucosa can create a functional sphincter.
The ileocaecal valve has two folds of mucosa helping
maintain one-way passage from the small intestine to the
large intestine. The spiral valve in the cystic duct is a raised
fold of mucosa, helping control passage of bile to and from
the gallbladder. This special mechanism can allow flow in
both directions (but at different times).

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).

Muscular functional sphincters


Passage can also be controlled without an anatomical
sphincter. A sphincteric mechanism without any localised
muscular thickening is a functional sphincter.
Sphincteric mechanisms can arise from muscle
contraction around (extrinsic) or within (intrinsic) a viscus.
A functional sphincter may be created from extrinsic
muscle contraction by the oblique path of a tube through a
gap in a muscle (e.g. the termination of the ureter through
the bladder wall). Contraction of the (extrinsic) muscle
presses against the tube from two directions creating a
shutter-valve without need for an anatomical sphincter.

Fig.8.45 Direction of orifices on perineum


A functional sphincter may also be created at an orifice.

The direction of the orifice is at right angles to the


direction of apposition of the walls of the tubular
viscus (or duct) immediately proximal to it.

This is particularly important for orifices opening onto


the exterior of the body at the termination of the urethra,
the vagina and the anal canal. The external urethral,
vaginal and anal orifices are aligned in the mid-sagittal
plane, while the walls of the urethra, vagina and anal canal
are apposed antero-posteriorly. The anal canal is
particularly well guarded. It has an involuntary sphincter (of
smooth muscle) surrounded by three voluntary sphincters
(of skeletal muscle) and an additional external sling of
skeletal muscle (from levator ani). In addition, (although
Fig.8.43 Functional sphincter of ureter created by the anatomical sphincters) the orientation of the
orifice (relative to that of the walls of the canal) may be
A functional sphincter may be created by intrinsic
regarded as a functional sphincter.
muscle contraction by a localised increase of muscle tone
in the wall of a viscus. The functional sphincter at the
junction of the lower end of the oesophagus with the cardia MUCOUS MEMBRANE AND JUNCTION ZONE
of the stomach (cardiac sphincter) may be contrasted with
A mucous membrane (L. slippery + thin skin) forms
the distinct muscular thickening at the distal end of the
the inner component of the wall of a tubular viscus.
stomach (pyloric sphincter).

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).

Fig.8.46 The major layers of a mucous membrane


The epithelial lining of viscera is avascular (as is the
epithelium of skin). Fig.8.47 Horizontal and vertical junctions of supply
Mucus is secreted onto the epithelium of respiratory Developmental interfaces
and digestive tracts. This may be directly from surface cells
or from microscopic exocrine glands deep to the Vertical junction zones typically correspond to lines of
epithelium. fusion. Horizontal junction zones typically correspond with
tissues of differing embryological derivation (e.g. endoderm
The underlying connective tissue of the lamina propria or ectoderm derived epithelium).
is highly vascular (as is the dermal layer of skin).

In particular, there are numerous lymph capillaries


strategically located directly under a surface lining where
they contribute to the first line of defence (by draining
invaders to a lymph node). Although most have a blind
origin they link freely to form extensive communicating
networks.

Mucosal folds and papillae


The internal features on a mucous membrane are
usually created by the pattern of mucosal folds, projecting
into the lumen. Numerous small folds (e.g. circular folds of
small intestine) increase surface area, particularly when
coupled with microscopic projections (villi and microvilli)
for absorption. Large folds of mucosa may help create a
functional sphincter (e.g. ileocecal valve, rectal valves).
Mucosal folds within a duct (e.g. spiral fold of cystic duct)
may also create a functional sphincter. Elevations, termed
mucosal papillae (L. nipples) may have openings of ducts
on their summits. These ducts are derived from associated
exocrine glands. The bile and pancreatic ducts enter the Fig.8.48 Major developmental interfaces of gut
duodenum on a raised fold on the mucosa, termed the Endoderm forms the epithelial lining of the digestive
duodenal papilla. tract (derived from the primitive gut tube) as well as the
respiratory tract and part of the lower urogenital tract
Horizontal and vertical junctions (which develop as an outpouching associated with the
Junction zones are mucosal interfaces where supply foregut and hindgut, respectively).
lines approach each other from different directions to meet During development, endoderm meets ectoderm at the
or overlap. oropharyngeal membrane and at the cloacal (L. sewer)
Junction zones may be classified into two groups. At a membrane, which break down, forming openings at each
horizontal junction, nerves and/or vessels approach each end of the gut tube.
other from above and from below. Horizontal junctions may Additional interfaces occur between the pharyngeal
be mucocutaneous (between skin and mucous membrane) pouches and the foregut, foregut and midgut, midgut and
or transmucosal (between different mucosal territories). At hindgut and between the hindgut and the cloaca. The
a vertical junction, nerves and/or vessels approach each upper end of the digestive and respiratory tracts (with
other from each side. A midline tubular viscus (e.g. bladder, epithelia derived from pharyngeal pouches) and the lower
uterus and vagina) may be regarded as a vertical junction, end of the digestive and urogenital tracts (with epithelia
possessing a bilateral neurovascular supply overlapping derived from the cloaca) form special zones where mucous
across the width of the mucosa. This is in contrast to skin, membrane covers skeletal muscle.

79
BODY SYSTEMS AND ORGAN STRUCTURE

At these zones skeletal muscles (derived from Mucocutaneous junctions


pharyngeal arches and cloacal sphincter, respectively) are
The most prominent junction zones occur at
involved in important reflexes (particularly swallowing and
mucocutaneous junctions. These are located at the
coughing, micturition and defecation), which are coupled
openings to the respiratory and digestive tracts (nostrils
with voluntary control.
and lips) and the terminations of the urogenital and
digestive tracts (near urethral, vaginal and anal orifices).
There are three types of transitions that particularly
occur in relation to mucocutaneous junctions:
- the epithelial lining (the transition between epithelium
of mucous membrane and epidermis)
- the mucosal and cutaneous neurovascular territories
in the underlying connective tissue (at the transition
between lamina propria and dermis)
- the type of underlying muscle (the transition between
smooth and skeletal muscle coats and/or sphincters).
These transitions in epithelium, neurovascular territories
and muscle type are usually located at or near the same
site.

Fig.8.49 Derivation of the gut in an adult

Fig.8.52 Transition of lining and wall at a junction zone

Epithelial interfaces

Fig.8.50 Developmental interface at distal gut


The reflexes coordinated by motor nerves to particular
muscles are elicited by stimulation of corresponding
sensory nerves that supply the overlying mucosa.

Fig.8.53 Epithelial interface in anal canal


At mucocutaneous junctions, the epithelium changes
from a moist, delicate lining of the mucous membrane into
epidermis, characterised by an outermost dead and dry
layer (stratum corneum). A line in the anal canal (the
dentate line) is created by remnants of the anal membrane
and demarcates the change in epithelium. It represents the
Fig.8.51 Common segments of nerve supply site of the endoderm/ectoderm interface.

80
8. Visceral Systems and Viscera

muscle sphincter are found around the anal canal; similar


arrangements occur for the urethra and vagina).

Fig.8.54 Mucosa of rectum and anal canal

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).

Fig.8.55 Neural and vascular interfaces at a junction zone

Muscular interfaces Fig.8.57 Mucosal and muscular interfaces in oesophagus


These mucocutaneous junctions usually overlie a
Other transitions associated with the oesophagus in its
change of muscle tissue and particularly involve sphincters
lower half include arterial supply together with venous and
(e.g. an internal smooth muscle and an external skeletal
lymphatic drainage (in the lamina propria).

81
BODY SYSTEMS AND ORGAN STRUCTURE

Fig.8.60 Reflex territories along upper airway


At the upper end of the digestive tract, stimulating touch
Fig.8.58 Vascular interface along oesophagus and taste receptors of oral mucosa elicits chewing and
salivation reflexes (via cranial nerves V3 and VII,
The type of underlying muscle (from skeletal to smooth) respectively), while stimulating touch receptors of
coats is also in transition, together with the associated type pharyngeal mucosa elicits the swallowing reflex (via cranial
of nerve fibres. nerve IX).
At the upper end of the respiratory tract, stimulating
touch receptors of nasal mucosa elicits the sneeze reflex
(via cranial nerve V2) and touch of laryngeal mucosa (e.g.
by inadvertent entry of food or fluid) elicits the cough reflex
(via cranial nerve X). Internervous lines for reflexes (e.g.
defaecation and micturition) also occur at the lower end of
the digestive and urinary tracts.

Internervous pain lines


Between the oesophagus and the rectum, visceral pain
fibres accompany sympathetic nerves (bilaterally) to spinal
cord segments T4-L1. Pain is referred to associated
neurosomes in the midline, from the sternal (T4-6),
epigastric (T7-9), umbilical (T10-11) and suprapubic
regions (T12-L1), represented on the surface by the
corresponding dermatomes.

Fig.8.59 Vascular interfaces along gut

Transmucosal junctions tend to be located where


territories of different developmental origin meet.

Transmucosal junctions correspond with neurovascular


interfaces (associated with the respective foregut, midgut
or hindgut artery and with the visceral afferent pain fibres
that pass along them).

Internervous reflex lines


Sensory nerve interfaces at transmucosal junctions in
long visceral tracts have major significance regarding
reflexes and referred pain.

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.

HILUM AND VASCULAR SEGMENTS Surgical removal of a segment


The concept of a vascular segment, together with
Hilum knowledge of the specific territories, is applied in the
A hilum (L. slit) of a viscus is the site where nerves and surgical removal of part of a solid viscus. It is also
vessels typically enter and leave it. The hilum is also the important in considering the consequences of ligating a
site where a duct exits from an exocrine gland. particular artery (e.g. ligating a segmental branch of a renal
The site of the hilum is usually associated with an artery is likely to result in infarction of that kidney segment).
indentation. The cavity in the hollow of the kidney (renal
sinus) contains the renal pelvis (which gives origin to the NEUROVASCULAR SUPPLY OF VISCERA
ureter) together with the neurovascular supply lines.
Viscera receive an entirely separate nerve supply to
Vascular segments that of somatic structures.

Visceral nerves supply smooth muscle and glands,


while somatic nerves supply skeletal muscle.

Derivation of visceral muscle and its supply

Fig.8.63 Hilum and vascular segments of kidney


Solid viscera (e.g. liver, kidney and lung) are often
subdivided into discrete segments termed vascular Fig.8.65 Gut smooth muscle from splanchnic mesoderm
segments.
83
BODY SYSTEMS AND ORGAN STRUCTURE

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).

Fig.8.66 Differing paths of visceral and somatic nerves

Fig.8.69 Dual motor supply of glands

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).

Visceral afferents and efferents Highly vascular endocrine glands


Hollow viscera generally receive a single sensory
supply of visceral afferents. Clinically, the most important
are pain fibres normally stimulated by stretch but also by
tissue damage (e.g. associated with inflammation) or
deprivation of blood supply.

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).

Fig.8.71 The multiple vessels of the thyroid gland

Arterial links along tubular viscera


Tubular viscera, being continuous organs, have a
continuous series of links between adjacent arteries
(anastomoses). A long tube (e.g. large intestine) however,
may be vulnerable at particular sites (between the vascular
reinforcements).

Dual vascular supply of lungs and liver


The lungs and the liver not only possess a dual blood Fig.8.73 Strangulation of a herniated gut loop
supply but this supply is from different vascular systems.
One (public) supply is primarily for the benefit of the rest
of the body, while the other (private) supply is primarily
nutritional for the organ itself.
The lungs receive a huge pulmonary circulation (via
pulmonary vessels) for gas exchange and a small systemic
supply (via bronchial vessels) to keep the airways viable.

Fig.8.72 Public and private vascular supplies to lung


The liver receives the hepatic artery and the portal vein
(carrying blood to it from the gut via the portal venous

85
Chapter 9: Nervous System and Nerves

The visceral nervous system consists of the


sympathetic nervous system, the parasympathetic
NERVOUS SYSTEM nervous system, visceral afferent fibres and the enteric
nervous system.
NERVE FIBRES AND REFLEX ARCS

BRAIN AND SPINAL CORD STRUCTURE

SPINAL NERVES AND FIBRE TYPES

CRANIAL NERVES AND FIBRE TYPES

NERVE GANGLIA

SYMPATHETIC TRUNKS AND FIBRE PATHS

NERVE PLEXUSES

NERVE DISTRIBUTION AND BRANCHES

VASCULAR SUPPLY OF A NERVE

NERVE INJURIES AND NEUROGENIC PAIN

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.

Components of a nerve fibre


A nerve fibre is made up of a centrally located axon (L.
axis) and surrounding supporting cells (with or without a
myelin sheath, between them). An axon is a major
prolongation of cell membrane and enclosed cytoplasm
(axoplasm) from a nerve cell. Nerve cells are termed
neurons (L. tendons i.e. stretched out). The supporting
cell (termed the Schwann cell) is in the form of a sheath,
the neurilemma (G. nerve + husk).

Fig.9.1 Nervous system within body modules


The brainstem is the (unpaired) midbrain, pons and
medulla. The PNS is made up of the somatic and visceral
(autonomic) nervous systems that are distributed via 12
pairs of cranial nerves and 31 pairs of spinal nerves. Fig.9.3 Nerve fibres and speed of conduction

86
9. Nervous System and Nerves

Myelin (G. marrow) is a fatty insulator (derived from


the Schwann cell) around the axon and internal to the
neurilemma, enabling rapid conduction. The wave of
excitation jumps between gaps (nodes) that occur at
regular intervals in the myelin, bypassing intervening
segments of the axon. Conduction velocity is also
proportional to the diameter of the nerve fibre. Large
myelinated nerve fibres (e.g. motor fibres to skeletal
muscle) are the most rapidly conducting, while small non-
myelinated nerve fibres (e.g. pain fibres from viscera) are
the slowest conducting (but occupy much less space).

Connective tissue of a peripheral nerve


A nerve (L. string) is made up of nerve fibres (derived
from ectoderm) and connective tissue (derived from
mesoderm).
A tubular sheath of connective tissue termed
endoneurium (G. within nerve) surrounds each individual
nerve fibre. Bundles of nerve fibres are surrounded by
connective tissue termed perineurium (around nerve).
The whole nerve is wrapped in a connective tissue sheath
termed the epineurium (upon nerve). The connective Fig.9.6 Sites of synapses
tissue associated with nerves is primarily made of collagen
fibres, although it may include some fat between the Cell membranes of synapsing neurons are separated
epineurium and perineurium. This occurs particularly at by a gap, the synaptic cleft. A chemical transmitter
sites where nerves are subjected to stretch or to released by arrival of electrical impulses at the pre-synaptic
compression (e.g. the median nerve in the carpal tunnel). membrane diffuses across the synaptic cleft to affect the
excitability of the post-synaptic membrane.

Fig.9.7 Components of a synapse


Fig.9.4 Connective tissue sheaths of nerve fibres
Typically, synapses with dendrites are excitatory, while
Synapses those with the cell body are inhibitory
The central nervous system consists of the brain and
spinal cord. The peripheral nervous system and ganglia
Sensory and motor nerve fibres
are derived from cranial and spinal nerves (arising from the Nerve fibres within a peripheral nerve are classified into
brain and spinal cord, respectively). two types. Sensory fibres conduct impulses from organs
An axon of one neuron meets another via a synapse that are sensitive to stimuli, while motor fibres conduct
(G. touch) impulses to organs that may respond actively. Sensory and
motor fibres are also termed afferent (L. carry to) and
efferent (L. carry from) being directed to and from the
central nervous system, respectively.

Fig.9.5 Major components of a neuron


Although a neuron possesses only one axon, it may
receive numerous synapses from axons of other neurons.
These typically occur with the cell body (which surrounds
the nucleus) and with prolongations of cell membrane
termed dendrites (G. trees) near the cell body. Fig.9.8 Afferent and efferent nerve fibres

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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.

Autonomic nervous system


The nervous system can be subdivided functionally into
somatic and visceral components. The visceral component
is the Autonomic (G. self+ law i.e. automatic) Nervous
System (ANS). It continuously controls vessels and
viscera, including glands (both exocrine and endocrine),
without relying on conscious awareness. The ANS is
subdivided into sympathetic, parasympathetic and enteric
divisions.
Sympathetics and parasympathetics generally have
complementary actions (e.g. parasympathetic erection
followed by sympathetic ejaculation).
Fig.9.9 Components of a neuromuscular junction
Some of their activities are independent as a few
viscera and almost all vessels (except for arteries supplying
In contrast to a receptor, an effector is not in direct the brain and erectile tissue) receive sympathetics only.
continuity with a neuron. Other actions can be opposite (e.g. on heart rate and
pupil size) as many organs receive supply from both.
A motor neuron meets an effector at the neuro-effector However, even for organs with dual innervation,
junction. There is a gap (the junctional cleft) between the sympathetics tend to supply different components from
cell membrane of the neuron (exposed by local loss of those supplied by parasympathetics. For example,
endoneurium, neurilemma and myelin sheath) and that of sympathetics supply smooth muscle sphincters of hollow
the effector. The neuro-effector junction for skeletal muscle viscera as well as blood vessels of both hollow and
is termed a neuromuscular junction. At a neuromuscular glandular viscera (with stimulation generally increasing
junction, a chemical transmitter released by arrival of vasoconstrictor tone). In contrast, parasympathetics supply
electrical impulses at the nerve terminal diffuses across the the smooth muscle wall of hollow viscera as well as their
junctional cleft to excite a specialised area of skeletal associated exocrine glands (with stimulation producing
muscle cell membrane (the motor end-plate). secretion).

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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).

Parasympathetic nervous system


Parasympathetic nerve fibres (craniosacral outflow)
emerge from the brain (associated with cranial nerves III,
VII, IX and X) and as pelvic splanchnic nerves (nervi
erigentes) from sacral spinal cord segments (S2-4).
Parasympathetic fibres are distributed to the intervening
thorax and abdomen via the continuation of the vagus
nerve (cranial nerve X) on each side.
Parasympathetic outflow is more convergent and
targeted than sympathetic. For example it is directed to
Fig.9.11 Reciprocal autonomic activation specific sets of arterioles (in the brain and erectile tissues).
Sympathetic nervous system Parasympathetic activity maintains a slow heart rate
and activates reflexes associated with glandular secretion
Sympathetic nerve fibres (thoracolumbar outflow) (e.g. salivation and lacrimation). Parasympathetic
emerge from thoracolumbar spinal cord segments (T1-L2). stimulation constricts pupils and accommodates the lens of
They radiate to the rest of the body via a long sympathetic the eye (enhancing visual acuity). Parasympathetics also
trunk (situated between the base of the skull and the tip of form the efferent pathway for the erection reflex (via dilation
the coccyx) on each side of the vertebral column. of arteries supplying erectile tissue).

Fig.9.13 An example of parasympathetic activation

Fig.9.12 An example of sympathetic activation


Enteric nervous system
The enteric (G. intestine) nervous system is a special
Sympathetic outflow is more divergent and diffuse than division of the ANS that contains more neurons than either
parasympathetic. For example, it is directed to almost all the sympathetic or parasympathetic divisions. The enteric
arterioles throughout the body, particularly those in skin nervous system includes all nerve cells found within walls
and skeletal muscle (including of the limbs). of the gastrointestinal and biliary tracts, as well as in the
pancreas. It contains complete circuits that can operate in
Sympathetics primarily control smooth muscle tone of the absence of connections with the CNS.
arterioles. Extrinsic nerves provide the primary innervation of the
digestive tract only near its proximal end and at its distal
Blood can be diverted to active organs according to end (associated with skeletal muscle derived from
need while blood pressure is maintained (ensuring branchial arches and cloacal sphincter, respectively). For
adequate cerebral blood flow). the vast majority of the digestive tract (associated with
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BODY SYSTEMS AND ORGAN STRUCTURE

smooth muscle, glands and mucosa of the foregut, midgut


and hindgut), there are numerous intrinsic nerve cells,
warranting the special classification. Neurons of the enteric
nervous system tend to synapse with each other, rather
than take part in reflex arcs that pass through the CNS.
Their numerous local circuits provide the prime neural
control mechanism for gut motility, secretion and
absorption.
Enteric neurons also have connections with certain
extrinsic visceral nerves (sympathetic post-ganglionic fibres
and parasympathetic pre-ganglionic fibres) which can
modulate their actions (e.g. on peristalsis).

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

90
9. Nervous System and Nerves

However, motor neurons that have their cell bodies in


the CNS (all somatic and all preganglionic autonomic motor
neurons) are not derived from neural crest.

Meninges and Cerebrospinal fluid


The brain and spinal cord are soft, protected by the
surrounding meninges (G. membranes) and
cerebrospinal fluid.
The meninges consist of three connective tissue layers.
The outer layer is the dura mater (L. hard + mother) a
tough fibrous covering derived from mesoderm. The middle
layer is the arachnoid mater (G. spider web-like +
mother) lining the dura. The inner layer is the pia mater
(L. tender + mother) a delicate covering, directly investing
the brain and spinal cord (as well as the blood vessels that
supply them). The pia and arachnoid are derived from
ectoderm.
Cerebrospinal fluid (CSF) is formed in the ventricles of
the brain. The ventricular system communicates with the
subarachnoid space (located between the arachnoid and
Fig.9.17 Visceral reflexes pia), where CSF circulates, acting as a shock absorber for
the brain and spinal cord. CSF is in equilibrium with
BRAIN AND SPINAL CORD extracellular fluid surrounding neurons and neuroglia,
which it maintains (e.g. by removing potentially harmful
Neural tube metabolites).
The central nervous system is made up of the brain and CSF is returned to the venous system (via arachnoid
spinal cord with a common derivation (from ectoderm). A granulations projecting into the superior sagittal venous
longitudinal midline thickening of ectoderm (the neural sinus) within the cranial cavity.
plate) along the dorsum of the embryo forms a groove.
This neural groove has folds that meet and become buried
Neuroglia
as the neural tube. The brain and spinal cord consists of nerve cells plus
supporting cells.
Blood vessels (being derived from mesoderm) supply
the brain and spinal cord from the exterior and must
penetrate them to reach deep parts.
Neuroglia (G. nerve + glue) supports neurons in the
brain and spinal cord. The majority of neuroglial cells
(which also outnumber neurons in the CNS) are the
astrocytes. These star-shaped cells have processes with
foot plates that surround blood vessels. Some neuroglial
cells are more like the Schwann cells that support
peripheral nerve fibres. These myelin-forming cells are the
oligodendrocytes.

Grey matter cortex and nuclei


The brain and spinal cord are composed of grey matter
and white matter. Grey matter is made of cells, white
matter of fibres.
Components have a precise anatomical localisation
coupled with a representation of associated body areas (or
even of basic mental activities). Grey matter consists
primarily of cell bodies of neurons. It also contains non-
myelinated axons.
Grey matter is primarily located around the periphery of
Fig.9.18 Development of neural tube the cerebral and cerebellar hemispheres, where it is termed
cortex (L. shell). This is in contrast to the spinal cord
The brain develops from the expanded cranial end of where all grey matter is centrally located, with white matter
the neural tube, while the spinal cord develops from its around the periphery.
narrow caudal part. The cavity of the neural tube remains The grey matter of the cerebral cortex is in folds,
relatively wide throughout most of the brain (as its termed gyri (G. circles) with intervening crevices, termed
ventricles), but becomes very narrow in the spinal cord (as sulci (L. furrows) greatly increasing its surface area.
its central canal). Collections of cell bodies of neurons centrally located in the
Islands of ectoderm (neural crest) break away from the brain (particularly around the ventricular system) or at least
neural folds to form all of the sensory neurons in the PNS. submerged in its white matter are termed nuclei (L. nuts).
Ganglia and Schwann cells are also derived from neural These include the basal nuclei (in the cerebrum), nuclei of
crest, as well as the suprarenal medulla (a modified the thalamus and hypothalamus (in the diencephalon),
sympathetic ganglion) and the inner two membranes cranial nerve nuclei (in the brainstem) and cerebellar
covering the CNS. nuclei.

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BODY SYSTEMS AND ORGAN STRUCTURE

Fig.9.21 Upper and lower motor neurons

White matter tracts


White matter consists of axons surrounded by a myelin
sheath (derived from neuroglia) and appears white
Fig.9.19 CNS grey matter and white matter because of the fatty content of the myelin.
Within white matter, nerve fibres are grouped into
Spinal cord columns pathways (tracts). In the brain, tracts of white matter
Grey matter within each side of the spinal cord is contain fibres that are classified according to their
arranged as two major columns (previously called horns orientation. Projection fibres pass up (ascending fibres) or
when seen in transverse sections), posterior and anterior. down (descending fibres). Association fibres pass
The posterior column is continuous with the posterior nerve forwards or backwards (on the one side of the brain).
root (for entering sensory fibres). The anterior column Commissural fibres pass from one side of the brain to the
contains the cell bodies of somatic motor neurons. Their other (a band purely of fibres that cross the midline is a
axons exit via the anterior nerve roots. Anterior column commissure).
cells are also called lower motor neurons and are the final Spinal cord funiculi
common path for skeletal muscle stimulation.
Each half of the spinal cord is divided into three funiculi
(L. little cords) posterior, lateral and anterior.
These funiculi consist of white matter tracts with
descending fibres (to motor neurons) and ascending
fibres (from sensory neurons).

Fig.9.22 Descending fibres to motor neurons

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).

92
9. Nervous System and Nerves

Posterior nerve roots are purely sensory while anterior


nerve roots are purely motor.

They contain only afferent fibres and efferent fibres


respectively.

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.

Most neural pathways in the CNS cross the midline.

SPINAL NERVES AND FIBRE TYPES


Posterior and anterior nerve roots
There are 31 pairs of spinal nerves (8 cervical, 12
thoracic, 5 lumbar, 5 sacral and 1 coccygeal). Each is
attached to the corresponding spinal cord segment via
nerve roots arising as a series of rootlets from the posterior
and the anterior aspects of the spinal cord.
Fig.9.26 Somatic afferent fibre paths
In addition, posterior roots from T1 to L2 convey some
visceral afferent fibres (which accompanied the visceral
efferents but passed through a sympathetic ganglion
without synapsing). These fibres convey visceral (slowly
conducting) pain from thoracic, abdominal and upper pelvic
viscera. Posterior roots from S2 to S4 convey visceral
afferents from lower pelvic viscera.

Fig.9.24 Spinal nerve roots Fig.9.27 Visceral afferent fibre paths

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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).

Posterior and anterior nerve rami


The spinal nerve proper is very short (only a few
millimetres in length) because it divides almost
immediately.
Every spinal nerve receives a connection from the
sympathetic trunk and some spinal nerves (T1-L2) give a
connection to the sympathetic trunk as well. These
Fig.9.28 Somatic efferent fibre paths connections (rami communicantes) are located at, or just
distal to the division of a spinal nerve into its rami.
In addition, anterior roots from T1 to L2 convey (pre-
Each spinal nerve divides into a posterior and an
ganglionic) sympathetic fibres and anterior roots from S2 to
anterior ramus (L. branch). The posterior ramus turns
S4 convey (pre-ganglionic) parasympathetic fibres.
sharply backwards, while the anterior ramus is a direct
continuation of the spinal nerve.

Fig.9.29 Visceral efferent fibre paths

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.

Recurrent meningeal branch


The recurrent meningeal (or sinuvertebral) nerve is a
small branch that arises immediately from each spinal
nerve and re-enters the associated intervertebral foramen.

Fig.9.30 Recurrent meningeal nerve and its branches Fig.9.32 A thoracic spinal nerve

94
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.

Fig.9.33 Distribution of a thoracic spinal nerve


The segmental pattern of distribution from cervical, Fig.9.34 Levels of cranial nerve origin
lumbar and sacral spinal nerves is disguised by their
anterior rami linking to form plexuses. Branchial arches and associated nerves
The mixed cranial nerves supply special muscles that
Features of a segmental nerve lesion
possess certain properties of somatic and visceral muscle.
A lesion of a spinal nerve produces a segmental pattern
of loss of function. This is reflected in loss of power and
muscle tone affecting the myotome, sensation affecting the
dermatome (minus overlap from adjacent dermatomes),
reflexes and (if long term) muscle wasting. A lesion of
anterior nerve roots produces a segmental pattern of loss
of motor function, while a lesion of posterior nerve roots
produces a segmental pattern of loss of sensory function.
However, a lesion to any component of its reflex arc will
diminish a reflex.

CRANIAL NERVES AND FIBRE TYPES


Cranial nerves
Fig.9.35 Branchial arches
All vertebrates have 12 pairs of cranial nerves
numbered from rostral (L. beak) to caudal (L. tail). The Muscles of the jaw, face, pharynx and larynx are
first two are atypical, being direct outgrowths from the derived from the branchial (G. gill) arches (first, second,
brain. The remaining ten arise from the brain stem. third and fourth/sixth respectively). These are paired
I olfactory (for smell) masses of mesoderm situated between gill clefts
II optic (for vision) (ectoderm depressions overlying endoderm pouches).
III oculomotor (for most eye movements and to pupil) Branchial arches may also be termed pharyngeal
IV trochlear (to one eye muscle) arches as their associated pouches line the developing
V trigeminal (for most head sensation and chewing) pharynx.

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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 branchial arch is supplied by a mixed cranial


nerve.

The cranial nerves with both motor and sensory fibres


are peculiar in that their supply includes branchial arch
muscles (as well as skin or mucosa of associated clefts
and pouches) to pathways for a special set of reflexes.
Although structurally identical to skeletal muscles and
capable of voluntary movement (e.g. in speech), branchial
muscles develop from splanchnic mesoderm. These
muscles, which tend to be covered by mucous membrane
or located near a mucocutaneous junction, are also
functionally related to smooth muscle.
They are effectors for a special group of superficial
reflexes (e.g. swallow and cough reflexes) arising from
mucous membranes (of upper digestive and respiratory
tracts) and often act in conjunction with visceral reflexes
involving glandular secretion (e.g. salivation).

Fig.9.37 Visual pathways to left visual cortex

Importance of testing visual fields


The visual pathway travels from the front to the back of
the brain (hence the importance of visual field examination
for identifying the site of a lesion within the brain).

Columns of cranial nerve nuclei


The cell bodies of cranial nerves are clustered in groups
termed nuclei.
Cranial nerve nuclei within the brain stem are arranged
in columns associated with particular fibre types. Seven of
the cranial nerves (I, II, IV, VI, VIII, XI and XII) contain only
one fibre type, while the remainder contains multiple fibre
types. There are three groups of motor fibre types special
Fig.9.36 Protective airway reflex territories (branchial) efferents in addition to somatic and visceral.
There are also three groups of sensory fibre types: special
Special sense organs and receptors afferents in addition to general and visceral.
Certain cranial nerves (particularly those that are purely
sensory) are involved with special senses. The special
senses are smell, vision, taste, hearing and balance.
Receptors for the special senses are located at the
peripheral end of each of the following cranial nerves:
I (smell)
II (vision)
VIII (hearing and balance)
VII, IX and X (taste)
Some special receptors create discrete organs or parts
of organs (e.g. retina of the eye as well as cochlea and
vestibular apparatus of the inner ear) while others are
microscopic collections on mucous membranes (e.g. taste
buds of the tongue and olfactory receptors of the nose).
The optic nerves join in the midline at the optic chiasm
(G. lines that cross) prior to diverging as optic tracts.
Fibres conveying impulses from the medial half of the
retina in each eye (stimulated by light from the lateral half
of both left and right visual fields) cross the midline at the
optic chiasm. Fibres conveying impulses from the lateral Fig.9.38 Columns of cranial nerve nuclei in brainstem
96
9. Nervous System and Nerves

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.

A ganglion, created by the collection of cell bodies of


sensory neurons, is found on the posterior root of
every spinal nerve.

The ganglion is located on the posterior root just before


it unites with the anterior root (to form the spinal nerve).

Fig.9.41 Sensory ganglia at exit foramina


Ganglia are located on cranial nerves conveying
general sensation (V, VII, IX and X) and/or visceral
sensation (VII, IX, X).

The sensory ganglia of cranial nerves are located in or


near the associated foramina in the skull.

The location of sensory ganglia is similar to the sensory


ganglion of a spinal nerve in an intervertebral foramen.

Features of an autonomic ganglion


Motor ganglia are associated with autonomic nerves
(not somatic nerves). An autonomic ganglion is a swelling
created by clusters of cell bodies of visceral motor neurons
and is distinguished from a sensory ganglion by the
presence of synapses. Each synapse receives the axonal
termination of a preganglionic neuron. Each cell body in
an autonomic ganglion is of a postganglionic neuron.

Fig.9.39 Posterior root ganglia


Each posterior root ganglion resides in an
intervertebral foramen, regardless of the length of the
associated nerve root.

Fig.9.42 Sympathetic ganglion and associated fibres

Autonomic ganglia involve sympathetics and/or


parasympathetics.
Preganglionic fibres are myelinated, while
postganglionic fibres are nonmyelinated (and of smaller
diameter). Additional fibres may pass through an
autonomic ganglion without synapsing in it. This applies to
all visceral afferent fibres and even applies to some
visceral efferent fibres. The latter may be postganglionic
(having already synapsed in a more proximal ganglion) or
Fig.9.40 Site of posterior root ganglia in exit foramina preganglionic (to synapse in a more distal ganglion).

97
BODY SYSTEMS AND ORGAN STRUCTURE

Paravertebral sympathetic ganglia Suprarenal medulla and paraganglia


The suprarenal (adrenal) medulla is a modified
sympathetic ganglion (having also developed from the
neural crest). It is supplied by (pre-ganglionic) sympathetic
fibres and secretes adrenaline and noradrenaline directly
into the blood stream. Clumps of (chromaffin) tissue
similar in composition to suprarenal medulla (and neural
crest derived) may be found nearby, along the abdominal
aorta. These paraganglia can also secrete adrenaline. The
largest are known as the para-aortic bodies.

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.

Prevertebral sympathetic ganglia


A series of ganglia, termed prevertebral ganglia, is
found in front of the vertebral column. They are located at
the origins of major arteries arising from the abdominal
aorta and have synapses that are primarily for
sympathetics. Postganglionic fibres are distributed along
the associated arterial branches to abdominal and pelvic
viscera. Fig.9.45 Parasympathetic ganglion and associated fibres

SYMPATHETIC TRUNKS AND FIBRE PATHS


Sympathetic trunks are paired chains, linking a series
of sympathetic ganglia. These ganglia are primarily
segmental, although some have fused. A sympathetic trunk
runs vertically (along each side of the vertebral column)
from the base of the skull to the tip of the coccyx.

Lateral column of spinal cord

Fig.9.44 Types of sympathetic ganglia


Preganglionic parasympathetic fibres (from branches of
the vagus nerve) also pass through these ganglia. They
tend to synapse in (parasympathetic) ganglia located
Fig.9.46 Peripheral sympathetic path and its origin
adjacent to the viscera.

98
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.

Splanchnic nerves to abdomen and pelvis


The splanchnic (G. viscus) nerves distribute
sympathetic fibres to abdominal and pelvic viscera.

Fig.9.47 White ramus communicans

Grey ramus communicans


Every spinal nerve is connected to a sympathetic trunk Fig.9.49 Sympathetic trunk and connections
by a grey ramus communicans. These fibres are preganglionic, synapsing in
prevertebral ganglia well prior to the viscera. The thoracic
splanchnic nerves (greater, lesser, least) arise from
paravertebral ganglia of the sympathetic trunk in the thorax.
They pierce the diaphragm to join prevertebral ganglia
(coeliac, aorticorenal and mesenteric) located in front of
the abdominal aorta, where their fibres synapse.
Postganglionic fibres are distributed to abdominal (and
pelvic) viscera along the unpaired branches of the aorta.
The lumbar splanchnic nerves arise from paravertebral
ganglia of the sympathetic trunk in the abdomen and join
prevertebral ganglia (primarily inferior mesenteric) where
their fibres synapse. Postganglionic fibres are distributed to
the pelvic viscera along arteries.

Visceral pain fibre paths


Pain is conveyed from thoracic, abdominal and upper
pelvic viscera (between the thoracic pain line and the
pelvic pain line) via visceral afferent fibres to spinal cord
segments T1-L2. Until they enter posterior nerve roots,
these fibres transmitting visceral pain accompany
sympathetic motor fibres along their peripheral paths. This
includes passing through sympathetic ganglia (without
Fig.9.48 Grey ramus communicans synapsing).
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BODY SYSTEMS AND ORGAN STRUCTURE

Anterior rami of spinal nerves primarily consist of


somatic nerve fibres (although they also contain
postganglionic sympathetic fibres). The majority link up to
form somatic plexuses from which many peripheral
nerves arise. The somatic plexuses are cervical (derived
from segments C1-C5), brachial (derived from segments
C5-T1) and lumbosacral (derived from segments L1-S4).

Only anterior rami of spinal nerves take part in the


formation of plexuses.

Each thoracic anterior ramus from T2-T12 does not


unite with any other anterior ramus (although T2 and T12
usually have a small connection to the brachial plexus and
lumbosacral plexus, respectively). Typical intercostal
nerves (the continuation of almost all thoracic anterior rami)
retain their obvious segmental arrangement rather than
arise from a nerve plexus.

Limb buds and associated plexuses


With the exception of the cervical plexus, somatic
Fig.9.50 Thoracic and pelvic pain lines plexuses are associated with the development of a limb
bud. The brachial plexus supplies the upper limb, while the
In contrast, pain is conveyed from lower pelvic viscera
lumbosacral plexus supplies the lower limb.
(below the pelvic pain line) via visceral afferent fibres to
spinal cord segments S2-4. Until they enter posterior nerve
roots, these fibres transmitting visceral pain accompany
parasympathetic motor fibres along their peripheral paths.
This includes passing through parasympathetic ganglia
(without synapsing).

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

100
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.

Peripheral nerves derived from anterior divisions of a


plexus are distributed to flexor compartments while
those derived from posterior divisions are distributed
to extensor compartments.

Fig.9.54 Divisions of plexus and supply of compartments


Fig.9.55 Nerve fibre types and their distribution
The anterior rami of the brachial plexus unite to form
trunks, each dividing into two divisions, the anterior for Somatic efferent fibres are distributed to skeletal
distribution to flexor compartments and the posterior for muscles. Visceral efferent fibres are sympathetic and
distribution to extensor compartments. The divisions (after primarily vasomotor. These fibres are distributed to blood
reuniting to form cords) provide the major peripheral vessels in muscles, bones, joints and skin. Sudomotor
nerves to the limb as terminal branches of the plexus. fibres (to sweat glands) and pilomotor fibres (to arrector pili
Branches to proximal muscles (surrounding the plexus) muscles) are also distributed to skin.
may arise directly from components of the plexus (anterior
rami, trunks or cords). Features of a peripheral nerve lesion
It is important to distinguish a peripheral pattern from a
Pre-fixed and post-fixed plexus variants segmental pattern in deducing the site of a nerve lesion. A
Occasionally the segments of origin can vary by a lesion of a peripheral nerve may affect each of the
cranial shift of one segment up (a pre-fixed plexus) or by functional fibre types in it. The features are primarily
a caudal shift of one segment down (a post-fixed determined by the distribution of the particular nerve distal
plexus). This may be associated with bony variants (e.g. a to the site of the lesion. A lesion of a peripheral nerve
cranial shift or a caudal shift) of the vertebral column. produces a peripheral (in contrast to a segmental) pattern
Awareness of the possibility for anatomical variation is of loss of function.
important in interpreting the findings from a neurological There is loss of power and tone of muscles supplied by
examination and may account for atypical patterns of nerve motor branches arising distal to the lesion. This is coupled
distribution. with loss of sensation of the skin supplied by sensory
branches arising distal to the lesion (minus overlap from
Autonomic plexuses adjacent peripheral nerves). Reflexes (e.g. tendon jerks)
Viscera are supplied by sympathetics and may also be affected and (if long term) there may be
parasympathetics (including visceral afferent fibres associated muscle wasting.
accompanying either of them). These fibres tend to
converge, forming plexuses near the viscera. Peripheral nerve branches
The major autonomic plexuses in the thorax (cardiac, A typical peripheral nerve distributes its fibres via
pulmonary and oesophageal), the abdomen (coeliac and muscular, cutaneous, articular and vasomotor
mesenteric) and the pelvis (hypogastric) contain all of the branches.
above visceral nerve fibre types. In the abdomen and pelvis
these plexuses surround major arteries supplying the
viscera. In addition, purely sympathetic plexuses occur
along arteries in the head, neck and limbs.

NERVE DISTRIBUTION AND BRANCHES


Peripheral nerve distribution
Peripheral nerves supply their target organs (e.g.
territories of skin and muscle) by branches. The structures
Fig.9.56 Types of peripheral nerve branches
supplied by branches of a particular nerve are regarded as
its distribution. Muscular branches are generally the most important
The distribution of a peripheral nerve depends on the branches. They are mixed, containing both motor and
functional fibre types within it. There are generally three sensory fibres.
fibre types in a typical peripheral nerve. Cutaneous branches are primarily sensory (except for
Somatic afferent fibres are distributed to skin, bones, some sympathetic fibres). The terminal branch of a
joints and muscles. Those arising from receptors in the skin peripheral nerve is typically cutaneous.
101
BODY SYSTEMS AND ORGAN STRUCTURE

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.

Protective somatic reflexes


The shared nerve supply for muscles, their underlying
joints and overlying skin may provide reflex arcs linking
them. Protective reflexes for joints or skin utilise associated
skeletal muscles. This may be regarded as an application
of Hiltons Law. Stretch on a joint capsule, or associated
ligaments, tends to trigger a reflex contraction of the
overlying muscle.

Fig.9.57 Branches of the musculocutaneous nerve

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).

A nerve which supplies a muscle producing movement


at a joint also supplies sensation to the joint and skin
overlying (the insertion of) the muscle.

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).

Reflex muscle spasm


Reflex muscle spasm is a protective mechanism that
usually occurs after injury to deep structures (e.g. joints
and ligaments). Continuous involuntary contraction
(spasm) of overlying muscle, which has a common nerve
supply to the underlying structures, tends to protect them
from further injury.
Injury to joints of the spine is associated with reflex
muscle spasm of overlying back muscles (erector spinae),
which have a common nerve supply (via dorsal rami of
Fig.9.58 Sequence of peripheral nerve branches spinal nerves).
The musculocutaneous nerve in the arm supplies a While reflex muscle spasm tends to be protective it may
muscular branch to biceps brachii (a flexor at the elbow), create further problems (e.g. via a positive feedback cycle
then an articular branch (to the flexor aspect of the elbow with pain escalation). Reflex muscle spasm also needs to
102
9. Nervous System and Nerves

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.

Fig.9.60 Protective back muscle spasm


Inflammation of the meninges (meningitis) is
accompanied by neck stiffness due to reflex spasm
involving extensor muscles of the cervical spine as well as
referral of pain (headache). Guarding and rigidity of the
anterior abdominal wall protects underlying viscera when Fig.9.62 Vasa nervorum
inflammation has spread to involve the parietal peritoneum
(peritonitis). Blood-brain barrier
The CNS receives blood supply from its periphery.

The cerebral and the spinal arteries run on the surface


of the brain and the spinal cord invested in pia mater. Their
branches penetrate the white and grey matter,
progressively getting smaller.
The deepest areas of the CNS tend to have the most
precarious arterial supply (particularly as these branches
do not link with each other).
Capillaries in the brain and spinal cord allow water to
pass freely across the endothelial membrane with ease.
However, their endothelium is impermeable to many
substances, while others cross slowly. In addition, these
capillaries are peculiar in being almost completely
surrounded by the footplates of astrocytes (star-shaped
neuroglial cells). This unique permeability barrier of
cerebral capillaries has been termed the blood-brain
barrier by physiologists and tends to protect the brain from
toxic substances.
A few areas of the brain are outside the blood-brain
barrier. These small zones either have chemoreceptors
(monitoring chemical changes in the plasma) or secrete
Fig.9.61 Protective abdominal muscle rigidity hormones. The blood-brain barrier does not fully develop
until early childhood. It also may be affected by brain
disease (e.g. infection or tumours) and certain drugs may
VASCULAR SUPPLY OF A NERVE enter it (e.g. a few antibiotics), while others do not.
Vasa nervorum There are no lymph vessels in the CNS.
Although nerve cells are derived from ectoderm, the
surrounding connective tissue within a peripheral nerve is Barrier to spread of brain tumours
derived from mesoderm (as are vessels) and provides an The presence of the blood-brain barrier, coupled with
avenue for a peripheral nerve to receive its blood supply. the absence of lymph vessels, may explain why tumours
Peripheral nerves obtain their blood supply by a succession arising within the CNS tend not to spread outside it.

103
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).

Neuralgia and phantom pain


Direct irritation of fibres within a peripheral nerve or a
posterior nerve root may produce neurogenic pain (arising
from the nerve) and/or abnormal sensation along the
distribution of that nerve. Neurogenic pain is also known as
neuralgia (G. nerve + pain).
Herpes zoster (G. creep + girdle) also known as
shingles is due to reactivation of Varicella zoster
(chicken pox) virus from the sensory ganglion of a spinal
Fig.9.63 Complete nerve disruption or cranial nerve. This condition is characterised by pain
(and vesicles) along the cutaneous distribution of the
Axonal degeneration affected nerve.
Interruption of an axon results in degeneration of the
entire axon distally (including associated degeneration of
its myelin sheath) and (for motor neurons) is coupled with
subsequent muscle atrophy. This is termed antegrade
degeneration. There is also a variable degree (depending
on severity) of degeneration proximally. This ranges from a
short distance of axon, to the cell body itself and (for
severe injuries) may even include neurons that synapse
with its cell body. This is termed retrograde degeneration.
This is demonstrated in both antegrade and retrograde
degeneration.

A neuron influences the vitality of its connections.


Fig.9.64 Neuralgic pain
Axonal regeneration
With limb amputation, inadvertent stimulation of fibres
Nerve cells are highly specialised and have lost the
associated with the stump may result in pain (phantom
capacity to divide.
pain), and/or abnormal sensation (phantom limb),
Although the cell bodies of neurons in the CNS or PNS
attributed to the absent extremity
may not be replaced, axons in peripheral nerves may
The anatomical causes of pain (based on its possible
regenerate. This is provided they have a track to
sources) are somatic, visceral and neurogenic.
regenerate along (created by the endoneurium). In
Somatic and visceral pain directly arise from pain
contrast, axons in the CNS do not have tubes of connective
receptors within their respective tissues, while neurogenic
tissue and do not tend to regenerate. In a peripheral nerve,
pain arises indirectly from abnormal activity in nerve fibres
gradual regeneration can occur (at a rate of approximately
that transmit pain.
2 mm/day) provided the endoneurium is intact.
Disruption of the endoneurium, with or without
perineurium and epineurium (in addition to the axons),
results in variable degrees of permanent impairment. Even
104
Chapter 10: Arterial System and Arteries

The systemic arterial system arises from the left


ARTERIAL SYSTEM ventricle of the heart and consists of the aorta and its
branches (and their branches in turn).
ARTERIES AND BRANCHES

ANASTOMOSES

END ARTERIES

NEUROVASCULAR SUPPLY OF A VESSEL

ARTERIAL SYSTEM
The arterial system arises from the ventricles of the
heart. It is divided into two separate systems.

Fig.10.3 Systemic arterial system

ARTERIES AND BRANCHES


Arteries are vascular tubes that carry blood towards
the tissues. Their branches become progressively smaller,
with the direction of flow away from the heart. The term
artery (G. air + carry) is a misnomer. Arteries were so
named because, prior to Harveys concept of blood
circulation, they were mistakenly thought to contain air.
Blood is made up of cells (red blood cells, white blood
cells and platelets) and plasma. Arterial blood is typically
oxygenated (with oxygen transported principally by red
blood cells).

Pulmonary arterial blood

Fig.10.1 Arterial system within trunk modules


The pulmonary arterial system arises from the right
ventricle of the heart and consists of the pulmonary trunk
and pulmonary arteries.

Fig.10.2 Pulmonary arterial system Fig.10.4 Pulmonary arterial blood is deoxygenated

105
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).

Fig.10.5 Foetal umbilical artery blood is deoxygenated


Arteries throughout the foetus have deoxygenated
blood mixed with oxygenated blood.

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.

The greatest drop in blood pressure occurs across


arterioles.

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.

106
10. Arterial System and Arteries

Although mesoderm derived, articular cartilage is


subject to continuous compression.

Fig.10.8 Capillary microcirculation

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

The arterial component of the pulmonary circulation is


made up of the pulmonary trunk (arising from the right
ventricle of the heart), right and left pulmonary arteries and
their branches in the lungs. Pulmonary arteries transport
deoxygenated blood. The blood pressure in pulmonary
capillaries is much lower than in systemic capillaries
preventing fluid escape into the lung alveoli with
impairment of gaseous exchange (particularly as oxygen
has very poor solubility in water). The arterial component of
the systemic circulation is made up of the aorta (arising
from the left ventricle of the heart) together with all of its
branches.

Fig.10.11 Types of arterial branches

Potential and preferred channels


Vessels develop from mesoderm, commencing in the
embryo as capillary networks with interconnecting lumens.

Fig.10.13 Systemic pressure is higher than pulmonary


Almost all the arteries in the body (other than
pulmonary arteries) are derived from the aorta (and even
include bronchial arteries supplying walls of the airways,
lymph nodes and visceral pleura).

Systemic arteries transport oxygenated blood.

The lung has two circulations: pulmonary (via


pulmonary arteries) and systemic (via bronchial arteries).
Fig.10.12 Development of arteries from networks Systemic arterial blood pressure is higher than pulmonary
arterial blood pressure (and much higher than venous
Many of these narrow, while others remain as the blood pressure).
preferred channels and subsequently become the major
arterial pathways. However, the capacity to open narrower Arterial blood pressure
paths (e.g. after occlusion of the preferred channel) Blood pressure is the pressure exerted radially on the
remains. There is also the capacity for considerable vessel wall by the contained blood.
anatomical variation of arterial patterns as there is often Arterial blood pressure is primarily produced by the
more than one avenue that may become a preferred pressure wave created by contraction of the heart.
channel. Variations of arteries or their branches include However, hydrostatic pressure (of the column of blood) due
origin, number, course and distribution. to gravity adds to it. This hydrostatic component
(particularly in the lower limbs) is accentuated by standing
Pulmonary and systemic arteries
upright as it increases the length of the column of blood
The cardiovascular system is not only a closed system above the specified level. There are two elements to
but also a double system with two distinct blood arterial blood pressure: systolic and diastolic. Systolic
circulations. (G. with + contract) pressure is produced by forward
expulsion of blood during ventricular contraction. Diastolic
The pulmonary (L. lung) circulation enables gaseous (between + contract) pressure is produced by forward
exchange between air and blood (via the lungs), while the expulsion of blood by elastic arteries (between ventricular
systemic circulation enables gaseous (and metabolic) contractions) while the heart refills with blood from venous
exchange between blood and all tissues of the body. return.

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).

Fig.10.14 Mechanism of flow during systole and diastole

Pulsatile arterial blood flow


Blood flows down a pressure gradient. Blood flow in
elastic and muscular arteries is pulsatile (reflecting systole
and diastole) as well as being at high pressure relative to
that in other types of vessels. This may be contrasted with
the continuous low-pressure blood flow in capillaries.
Pulsation of arteries is termed expansile pulsation (and
occurs in all directions). Pulsation through a structure
overlying an artery is termed transmitted pulsation.
Features of the arterial pulse include pulse rate and rhythm
as well as pulse pressure (the difference between systolic
and diastolic pressures).
Fig.10.15 Contrast between arterial and venous bleeding
Clinical examination of the pulse Haemorrhage can be external (and visible) or internal
Pulse rate and rhythm may be detected clinically by (hidden in a body cavity, compartment or space).Although
palpation of any accessible artery. The radial artery at the blood tends to spurt from elastic and muscular arteries due
wrist is usually chosen because at this site it is easily felt to the pulsatile flow at higher pressure, large thin-walled
between skin and bone (the distal end of the radius). Pulse veins oozing at lower pressure can cause equally severe
volume and character may be detected clinically by blood loss.
palpation of the common carotid artery in the neck against Blood loss and drop in blood pressure may cause
the carotid tubercle (on the transverse process of C6). symptoms (e.g. fainting). Internal haemorrhage may also
Palpation should not be performed near the carotid sinus cause pain due to pressure in the surrounding
(at the level of C3/4) where compression of baroreceptors compartment. However, large compartments (e.g. muscle
may cause reflex bradycardia and subsequent compartments of the thigh) or body cavities can
hypotension). accumulate dangerous volumes of blood without a
significant rise in local pressure (and pain).
Arteriosclerosis
Changes tend to occur in arteries as they age. First aid management of haemorrhage
Arteriosclerosis (G. artery + hardness) is hardening of RICE is an acronym for the first aid management of
the arteries due to increased fibrous tissue and even haemorrhage. Rest (e.g. immobilizing the part and the
calcification in the wall. Aging is accompanied by a patient) minimizes the rise in systolic blood pressure which

109
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.

Fig.10.16 External and internal haemorrhage


Compression may need to be applied upstream from
the damaged vessel at strategic sites (e.g. where it runs
over bone and can be compressed). Elevation, when
possible (e.g. of a limb) will reduce hydrostatic pressure. Fig.10.18 Arterial and A-V anastomoses in the hand
The definitive treatment of a damaged vessel (particularly a True anastomoses
large artery or vein) may involve ligation or surgical repair.
In severe haemorrhage, fluid replacement or blood Links directly between branches of muscular arteries
transfusion (via a major vein) may also be required to are typically of large calibre. These are termed true
prevent shock (inadequate perfusion of tissues) and anastomoses.
maintain blood pressure.

Fig.10.19 True anastomosis


Adjacent (branches of) arteries tend to anastomose
with each other.

The more branches the greater the potential for


anastomoses.
The labial branches of the facial artery are continuous
with their counterparts from the other side of the body,
forming a true anastomosis around the lips. A midline
incision through the lips tends to result in arterial blood
spurting from both sides.
Fig.10.17 Rest, ice, compression and elevation Other examples of anastomoses include the cerebral
arterial circle (of Willis) at the base of the brain, the palmar
ANASTOMOSES arches in the hand and the plantar arch in the foot.

An anastomosis (G. through + mouth) is a linking of Potential anastomoses


tubular structures, such as blood vessels (lumen to lumen, Links directly between arterioles are typically of small
i.e. mouth to mouth). When it occurs without an intervening calibre. These are termed potential anastomoses as they
capillary bed, it offers an alternative (collateral) route. have the capacity to enlarge their calibre.

110
10. Arterial System and Arteries

Anastomoses occur around joints but are only


significant within muscle bellies that cross the joint.

Branches from the main artery provide alternative


pathways of flow when the artery is kinked by joint flexion.
The anastomoses around joints occur primarily within the
surrounding muscles rather than as true anastomoses
independent of the muscles.

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

Anastomoses in continuous organs


Arteriolar anastomoses are extensively located
throughout most organs and regions of the body.

Skeletal muscles receive the most arterial branches


and contain the majority of anastomoses.

Continuous arterial arcades (via anastomoses between


contributing arteries) supply continuous organs (e.g.
muscles, bones and skin). These structures are in
continuity via their connective tissue framework (which like
vessels is mesoderm-derived).

Fig.10.23 AV anastomoses and temperature regulation


Arteriovenous anastomoses are involved in temperature
regulation, enabling blood to be shunted between
superficial and deeper cutaneous vessels.
Fig.10.21 Anastomoses within a muscle
Glomus tissue
Anastomoses around joints At special sites arteriovenous anastomoses occur in the
form of tiny clusters of interconnecting vessels termed
glomera (L. balls of thread). They are most numerous in
the skin of the fingers and toes, particularly digital pads and
nail beds. A localised collection of glomus tissue also
occurs at the origin of the internal carotid artery (carotid
body), at the origin of the internal jugular vein (jugular
body) and at the tip of the coccyx (coccygeal body). The
carotid body has a high blood flow enabling it to function as
a chemoreceptor monitoring the partial pressure of
dissolved gases in the plasma. The roles, if any, of the
other two are unknown.

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

Arterial vasodilatation (of dorsal and deep arteries of


the penis, stimulated by parasympathetic nerve fibres)
coupled with restriction of venous drainage (via the deep
dorsal vein, compressed against the penile fascia) may
create considerable turgor. The penis thus elongates and
becomes rigid prior to coitus.

Fig.10.26 Retina with central artery branches and optic disc

Functional end arteries


Functional end arteries take part in potential (small
calibre) anastomoses with each other at the arteriolar level.
Part of their territory of distribution will not remain viable if
Fig.10.24 AV anastomoses in erectile tissue of penis one is suddenly occluded. However, gradual occlusion may
enable time for existing anastomotic branches (collaterals)
to dilate. This creates a collateral avenue of supply (without
END ARTERIES development of new branches). Coronary arteries are
functional end arteries. Although terminal branches of the
An end artery is an artery isolated from others. Its
right and left coronary arteries anastomose with each other,
branches do not appear to link with those of another artery.
these are only at the arteriolar level.
The territory it supplies is dependent on that single vessel.

Anatomical end artery


An anatomical end artery is a single artery, which
does not form anastomoses with another artery. The entire
territory of distribution for an anatomical end artery is
compromised by its occlusion. Branches of cerebral
arteries are anatomical end arteries. These supply the
brain by pushing into its substance from the exterior.
Arterial branches to individual segments of the kidneys
and of the liver are also anatomical end arteries.
The retina may be regarded as an outgrowth from the
brain. The sole arterial supply to the critical layers of the
retina is from its central artery, a long slender vessel that is
the classic example of an anatomical end artery. Its
branches radiate from the optic disc.

Fig.10.27 Coronary arteries are functional end-arteries

Effect of sudden coronary artery occlusion


Because occlusion of a coronary artery is usually
sudden, the majority of its territory of distribution typically
undergoes infarction unless the occlusion is cleared
rapidly.

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.

End organs are particularly vulnerable to having their


arterial supply cut off.

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.

112
10. Arterial System and Arteries

pericardial cavity. Although each receives more than one


artery of supply they may collectively be regarded as end
arteries, because there are only arteriolar anastomoses
between branches within their substance. The retina, as an
outpouching of the brain, is an end organs end organ.

Organs with avascular barriers


The arteries supplying the epiphyses and metaphyses
of growing long bones are end arteries. Epiphysial and
metaphysial arteries are end arteries because the
cartilaginous epiphysial (growth) plate is avascular and
forms a barrier preventing communication between them
(until epiphysial fusion occurs).

Fig.10.28 Terminal body parts are supplied by end-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).

Danger of ligating a segmental artery


Ligation of a segmental artery compromises the
arterial supply to that segment. A triangular wedge of dead
tissue with its apex towards the hilum typically results.
Fig.10.29 Contraindicated sites for vasoconstrictors

Arteries to blind ending organs


Blind ending organs typically project into or are
suspended within a cavity.
The appendix and the gall bladder are hollow viscera
protruding into the abdominal cavity. Each is an
outpouching from the gastrointestinal and the biliary tract,
respectively and is supplied by an end artery (unlike other
hollow viscera of these tracts). The appendicular artery
runs to the tip of the appendix and the cystic artery runs to
the fundus of the gall bladder.

Fig.10.32 Segments of the kidney and their end arteries

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

113
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.

Effects of functional end artery occlusion


Sudden occlusion of a functional end artery
compromises part of its territory of supply. Not all of the
area is affected because there are peripheral anastomoses
(although these are limited to arterioles). Gradual occlusion
of a functional end artery may allow time for an adequate
collateral circulation to develop. This can only occur by
dilation of existing avenues (potential anastomoses which
increase their calibre) and not by formation of new vessels.

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

Fig.10.36 Paths of systemic emboli from left side of heart

NEUROVASCULAR SUPPLY OF A VESSEL


Fig.10.34 Paths of pulmonary emboli from a systemic vein Vessels have both a nerve supply and a vascular supply.
Pulmonary emboli are life threatening if large, occluding Vascular tone
a major branch of a pulmonary artery, or multiple, involving Vascular smooth muscle tends to be in a state of
many branches. Pulmonary emboli tend to cause continuous partial contraction (tone), modulated by
breathlessness and chest pain (due to the associated area (visceral) motor nerves. This is most significant in
of pulmonary infarction). However, symptoms range from arterioles, the vessels primarily involved in the regulation of
none to sudden death. blood flow and blood pressure.
An area of lung affected from a large embolus typically
appears red (a haemorrhagic infarct) due to the Vasomotor nerve fibres
continued arterial supply from bronchial arteries, which
Motor nerve fibres supplying blood vessels are termed
bleed because they are not able to keep the lung tissue
vasomotor nerve fibres. These are almost exclusively part
alive on their own. Typical infarcts elsewhere are white (a
of the sympathetic nervous system (although arterioles
pale infarct) due to absence of blood.
associated with erectile tissue also receive fibres from the
parasympathetic nervous system that result in
vasodilatation).

Fig.10.35 Paths of emboli through and from right atrium

Systemic arterial embolus


Emboli originating from the left atrium or ventricle (or Fig.10.37 Vasomotor fibres to media of a blood vessel
associated valves) may occlude systemic arteries (e.g. a
cerebral artery via the common carotid artery and a femoral Sympathetic (postganglionic) fibres enter the ventral
artery via the descending aorta). ramus of each spinal nerve (via a grey ramus
Emboli may also arise from within systemic arteries communicans from the sympathetic trunk).
(e.g. from a plaque of atheroma at the origin of internal Many of these fibres then pass through the major limb
carotid artery). Its effects are potentially much more plexuses to be distributed (via associated peripheral
harmful if they involve end-arteries (e.g. even a small nerves) to arteries in the limbs. These arteries receive their
embolus in the central artery of the retina may produce vasomotor nerve fibres at multiple levels as tiny branches
sudden blindness in one eye). from the neighbouring peripheral nerves. In addition to

115
BODY SYSTEMS AND ORGAN STRUCTURE

supplying arteries, sympathetic postganglionic fibres may


also form plexuses along certain arteries (e.g. arteries to
the head and to abdominal viscera) and are distributed with
their branches.

Vasa vasorum

Fig.10.38 Vasa vasorum of aorta


The endothelium and intima receive nutrition directly by
diffusion from blood in the lumen of a vessel.
However, the media and adventitia (particularly of
elastic and muscular arteries) require a blood supply from
vessels of their own, termed vasa vasorum (L. vessels of
vessels). Vasa vasorum include arteriae vasorum as well
as venae vasorum.

116
Chapter 11: Venous System and Veins

The azygos vein drains into the superior vena cava


(SVC). It also links the superior vena caval system and
VENOUS SYSTEM the inferior vena caval system, although its connection to
the latter is usually minor. The azygos system drains the
VEINS AND TRIBUTARIES vertebral system (via lumbar and posterior intercostal
veins).
VENOUS VALVES AND VENAE COMITANTES

VENOUS SINUSES AND COMMUNICATIONS

VENOUS SYSTEM
The venous system comprises three separate major
systems.

Fig. 11.3 Components of systemic venous system


The portal venous system drains blood from the gut
into the liver where it branches into a capillary bed, then
forms the hepatic veins. These veins, in turn, drain into the
inferior vena cava (IVC).

Fig.11.1 Venous system within major trunk modules


The pulmonary venous system drains into the left
atrium of the heart and is made up of pulmonary veins.

Fig. 11.4 Components of portal venous system

VEINS AND TRIBUTARIES


Veins are vascular tubes that carry blood away from
the tissues. This occurs by a progression of larger
Fig. 11.2 Components of pulmonary venous system tributaries, with the direction of flow towards the heart.
The systemic venous system drains into the right Venous blood is typically deoxygenated (oxygen
atrium of the heart. It has four sub-systems: superior vena transported by red blood cells having been mostly taken up
caval, inferior vena caval, azygos and vertebral. by the tissues after diffusing through capillaries).

117
BODY SYSTEMS AND ORGAN STRUCTURE

Fig.11.7 Foetal umbilical vein blood is oxygenated

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.

Fig.11.5 Venous tree and changes in its dimensions

Pulmonary venous blood


Throughout postnatal life, blood in the pulmonary veins
(from the lungs) is oxygenated. This process occurs in
pulmonary capillaries by diffusion of oxygen from air in lung
alveoli.

Fig.11.8 Layers of venous wall


Veins have thinner walls and larger lumens than
arteries, correlating with their lower pressure (and slower
rate of flow) and greater volume.
Veins act as capacitance vessels. They contain most
of the blood volume.

Venules and venous tributaries


The smallest venous tributaries are termed venules.
These vessels directly drain the capillary bed. They
correspond to arterioles (which directly supply the capillary
bed) but have much thinner walls and, in particular, much
less smooth muscle. Unlike arterioles, the direction of flow
in venules is from smaller to larger vessels.
Fig.11.6 Pulmonary venous blood is oxygenated
However, blood in pulmonary veins (and subsequently
systemic arteries) is not quite fully saturated with oxygen,
as tributaries of bronchial veins do not extend to the
peripheral parts of the bronchial tree, lung parenchyma and
visceral pleura. Venous blood from these areas drains into
tributaries of the pulmonary veins. This phenomenon has
been termed the physiological shunt.

Blood in foetal umbilical vein


Prior to birth, a foetus receives oxygenated blood via
the umbilical vein (from the placenta). This blood enters the
inferior vena cava (after bypassing the liver) where it
becomes mixed with deoxygenated blood. It then enters
the heart and exits via the aorta (after bypassing the lungs). Fig.11.9 Superficial abdominal veins and tributaries

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).

Managing venous bleeding in surgery


Numerous veins are encountered during surgical
procedures. Venous tributaries can usually be diathermied,
clamped or ligated without adverse effect. There are many
alternative pathways for venous return.

Pulmonary venous system


The venous component of the pulmonary circulation
comprises tributaries of the pulmonary veins (in the lungs).
These drain into two right and two left pulmonary veins
that empty directly into the left atrium of the heart.
Pulmonary veins transport oxygenated blood (which is
almost fully saturated with oxygen) towards the heart.

Systemic venous system


The venous component of the systemic circulation
comprises tributaries of the superior vena cava and
inferior vena cava. These empty deoxygenated blood
directly into the right atrium of the heart.

Fig.11.11 Hepatic portal venous system


The portal system drains the gastrointestinal tract,
pancreas and spleen. Although portal venous blood is
deoxygenated, it transports absorbed nutrients from the
small intestine and hormones (secreted from the pancreas)
to the liver. The liver also filters absorbed toxins. Veins of
the hepatic portal system are characterised by their
branching and subsequent termination in another capillary
bed (the hepatic sinusoids). Tributaries of hepatic veins
(belonging to the inferior vena caval system), in turn, drain
the hepatic sinusoids.

Hypophyseal portal venous system


The hypophyseal portal system consists of tiny veins
linking capillary beds between the hypothalamus (at the
base of the brain) and the hypophysis (G. under +
growth, i.e. the pituitary gland suspended from the brain).

Fig.11.10 Systemic venous systems


The azygos (G. not yoked i.e. unpaired) vein is a
partial bypass between the superior and inferior vena cava
(helping equilibrate pressure between them). It is primarily
located in the thorax. In addition to draining the posterior
abdominal and thoracic wall, azygos vein tributaries receive
vertebral veins. Vertebral veins include internal and
external vertebral venous plexuses (networks located
inside and outside the vertebral canal). Blood cells
produced in the vertebral column enter the circulation via
them.

Hepatic portal venous system


A portal venous system begins as well as ends in
capillaries.

A portal system of veins links two capillary beds at low


pressure. Fig.11.12 Hypophyseal portal venous system

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.11.15 Numerous valves in long veins of limbs


Valves are particularly numerous in long veins. They
break up what would otherwise be a continuous column of
blood into shorter units. Each valve in the series takes a
share of the hydrostatic pressure (which is considerable
when standing upright). Valves are also present in veins
(termed perforating veins) connecting superficial and deep
Fig.11.13 Venous valves allow flow in one direction only systems. Their valves direct flow from the superficial veins
to the deep veins and are most important in the calf where
Sites of venous valves blood is pumped upwards against gravity by muscles
A valve in a vein is also often located just distal to the surrounding the deep veins.
entry of a major tributary (as well as at the termination of
Venae comitantes
the tributary)
Venae comitantes (L. veins + accompanying) are a
A valve is typically located at the termination of a vein. pair of companion veins wrapped around an artery. These
veins also intercommunicate.

Fig.11.14 Valves located near entry of a major tributary Fig.11.16 Venae comitantes

120
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.

Fig.11.17 Heat conservation by venae comitantes

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.

Fig.11.20 Thoracic venous pump


Descent of the diaphragm during inspiration, in addition
to creating a negative intrathoracic pressure, shortens the
inferior vena cava emptying it (into the right atrium of the
Fig.11.18 Vascular venous pump heart from below) while the superior vena cava lengthens
and fills. During expiration the converse occurs as the
The connective tissue around the vascular bundle tends
superior vena cava shortens and empties (into the right
to resist the expansion associated with each arterial
atrium from above), while the inferior vena cava lengthens
pulsation, compressing blood within the pair of veins.
and fills. The thoracic pump therefore augments venous
Venous flow is directed proximally due to the presence
return from both caval systems (if not from below in
of venous valves (even though the arterial flow is in the
inspiration, then from above in expiration).
opposite direction).
121
BODY SYSTEMS AND ORGAN STRUCTURE

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.11.21 Blood trapped in trunk by valves above and


below
Fig.11.23 Haemorrhoids and prolapse with straining
Thus, raising intrathoracic and intra-abdominal pressure
(coughing, straining) shunts blood into the vertebral system Venous valve incompetence
(via the azygos system from the caval systems). Structural damage to valve cusps (e.g. from venous
Conversely, inspiration creates a suction that shunts blood thrombosis) may result in venous valve incompetence.
from the vertebral system to the caval systems. The cusps fail to close adequately allowing flow in the
Varicose veins and haemorrhoids reverse direction.

A varicose vein (or varix) is an abnormal dilatation of a


vein, which also may become elongated and tortuous.

Fig.11.22 Features of a varicose vein Fig.11.24 An incompetent venous valve and effect on flow
122
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.

Fig.11.27 Calf muscle venous pump


Fig.11.25 Effect of incompetent valve in perforating vein Repeated contraction of the calf muscles (e.g. by
A dilatation of a vein at the site of a venous valve may raising the heel and flexing the toes) promotes venous
also result in impairment of valve function with the potential return by enlisting the muscular venous pump and
for a domino effect further along the vein. This occurs minimises pooling of blood.
particularly with long veins subjected to periods of high Dural venous sinuses
hydrostatic pressure (e.g. superficial veins of the lower limb
in prolonged standing). Varicose veins may therefore be Dural venous sinuses are endothelial-lined spaces
both cause and effect of valve incompetence. within the cranial cavity between the outer and inner layers
of dura mater (L. tough mother) surrounding the brain.
VENOUS SINUSES AND COMMUNICATIONS
Venous sinuses (L. hollow) are normal dilatations of
veins. These occur in special sites, including the mesh of
minute venous sinuses capable of expansion in cavernous
(erectile) tissue.

Fig.11.28 Venous sinus between the two layers of dura


These venous sinuses are unique in that they are
enclosed by dense connective tissue. Tension in the
fibrous walls keeps the sinuses open despite the negative
intracranial venous pressure, which would otherwise
collapse them when standing upright.

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.

123
BODY SYSTEMS AND ORGAN STRUCTURE

The azygos system links the inferior vena caval system


with the superior vena caval system, drains the vertebral
system and communicates with the portal system. The
azygos venous system is valveless so flow may occur in
either direction and through its communications with the
other systems equilibrates pressure between them.

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.

Fig.11.29 Perforators link superficial to deep veins

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.11.32 Major site of portal systemic anastomosis


The two major sites of portal-systemic anastomosis are
at the lower end of the oesophagus (with the azygos
system) and at the anal canal (with the inferior vena caval
system).

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.

Fig.11.33 Venous plexus in spinal canal


Many venous plexuses are found around pelvic viscera
(e.g. bladder, rectum and vagina) accommodating to
changes in shape of these organs. They are also extensive
as a cushion in the sole of the foot and within the vertebral
Fig.11.31 Valveless azygos venous system canal (where they help cushion the spinal cord).

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.

Alternative routes of venous return


There are numerous communications between
tributaries of neighbouring veins. Venous occlusion, unless
very extensive or of a major large vein, is usually not a
problem as blood may return via many possible venous
routes.
Unlike certain arteries (end arteries) or their branches, it
is generally safe to ligate a vein or tributary.

Venous spread of tumours and infections


Tumours and infections in organs can spread via the
veins that drain them. Venous blood with cancer cells or
microbes may be carried to larger veins within the
associated system and to veins of a communicating
system. Ultimately they may pass to the liver (via the portal
venous system) or to the lungs (via the vena caval systems
and right side of the heart). The liver and lungs are
common sites of tumour metastases. Proliferation of
microbes within the blood stream (septicaemia) and
passage through pulmonary capillaries results in spread of
infection throughout the body via the arterial system.
Prostate cancer commonly spreads via veins to
vertebral bodies. Communications between the prostatic
venous plexus and the internal vertebral venous plexus
provide the pathway, while the absence of valves allows
retrograde flow to the vertebral column.

125
Chapter 12: Lymphatic System and Lymph Vessels

The lymphatic system consists of lymph vessels,


lymph nodes, lymphoid organs and lymphoid tissues
LYMPHATIC AND HAEMOPOIETIC SYSTEMS (in other organs). The haemopoietic system consists of
haemopoietic tissue in bone marrow.
LYMPH VESSELS
Roles of lymphatic system
LYMPH RETURN The roles of the lymphatic system are fluid return and
defence.
Lymph (L. clear fluid) is fluid within lymph vessels.
LYMPH NODES Lymph vessels return lymph to the circulation (via the
venous system). More than five litres of fluid per day
LYMPHOID ORGANS AND TISSUES (containing plasma protein), escapes from arteriovenous
capillaries. This would otherwise accumulate in the
interstitial fluid compartment (between intracellular and
intravascular fluid compartments).
LYMPHATIC AND HAEMOPOIETIC SYSTEMS

Fig.12.3 Interstitial fluid filtered via lymph nodes


The volume and the protein content of lymph vary from
site to site. They are particularly high where capillaries are
most permeable (e.g. from sinusoids of the liver). Lymph
carrying foreign material is transmitted via lymph vessels to
Fig.12.1 Lymphatic and haemopoietic systems in modules lymph nodes, where it is filtered and brought in contact with
defence cells.

Roles of haemopoietic tissue


Active bone marrow is red. It is the site where red blood
cells, certain white blood cells and platelets are produced.
Red marrow remains in the axial skeleton, but in the limbs
becomes yellow marrow during adolescence. Yellow
marrow has the potential to revert to red marrow in certain
circumstances (particularly after major haemorrhage).

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.

Fig.12.6 Tissues where lymph capillaries are absent

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.

Fig.12.5 Lymph capillary plexuses in dermis

Tissues without lymph capillaries


Lymph capillaries are present only in tissues derived
from mesoderm.

Tissues that do not possess lymph capillaries include


epidermis (ectoderm derived) and other surface epithelia Fig.12.7 A lymph node and associated lymphatics

127
BODY SYSTEMS AND ORGAN STRUCTURE

Lymph from a particular organ or body area normally Lacteals


drains through at least one set of lymph nodes before
Intestinal lymphatics are termed lacteals (L. milk). This
reaching the venous system.
is because they contain chyle (L. juice), lymph rich in lipid
Lymph nodes lie in the course of lymph vessels.
molecules absorbed after a meal. Lacteals do not
Afferent lymphatics enter lymph nodes, while efferent
accompany veins (as intestinal veins are part of the portal
lymphatics leave them. Afferent lymphatics tend to be
venous system to the liver). Instead, they accompany the
multiple (several entering a lymph node around its
artery of the midgut (an unpaired branch of the aorta). As a
periphery), while efferent lymphatics are typically single
result, large lipid molecules (primarily triglycerides in the
(leaving a lymph node via its hilum).
form of chylomicrons) are conveyed to systemic veins via
a large lymph collecting duct. The other nutrients, in
contrast, are absorbed from the small intestine directly into
portal venous blood.

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.

Fig.12.8 Excised inguinal lymph node with its lymphatics

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.

Fig.12.10 Relationship of lymph vessels to blood vessels

Thoracic duct and right lymphatic duct


Lymph trunks typically drain into a lymph duct. On the
left, jugular, subclavian and bronchomediastinal lymph
trunks typically enter the termination of the thoracic duct.
On the right they typically unite to form a short common
channel, termed the right lymphatic duct. However, the
terminations of these lymph trunks are variable and each
often enters the venous system independently. When this
occurs on the right, the right lymphatic duct is absent.
The thoracic duct is the largest single avenue of lymph
Fig.12.9 Relationship between lymphatics and veins
return to the venous system.
Although superficial lymphatics accompany superficial The thoracic duct traverses the entire length of the
veins, deep lymphatics do not always accompany deep thorax (from aortic opening in the diaphragm to the root of
veins. the neck). The thoracic duct has thin walls, with valves, that
In the abdominal cavity, lymphatics accompany arteries give it a beaded appearance. Its flow is dependent on the
to their origins from the front of the aorta (rather than thoracic pump (variations in intrathoracic pressure with
accompany the portal vein to the liver). phases of respiration).
128
12. Lymphatic System and Lymph Vessels

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).

Lymph return to venous system


All lymph is normally returned to the venous system

Fig.12.11 Lymph ducts drain into the venous system

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.

Territory drained by thoracic duct

Fig.12.13 Major direct path of lymph to the venous system


Lymph is directly returned to the venous system via the
thoracic duct (on the left) and the right lymphatic duct.
These empty into large central veins (typically the origin of
the brachiocephalic veins) at the junction of the neck and
thorax.

Fig.12.12 Quadrants of body drained by thoracic duct


At its origin the thoracic duct drains lymph from almost
the entire body below the diaphragm (from intestinal and
lumbar lymph trunks via cisterna chyli).
At its termination it typically receives lymph from the
left upper quadrant (after collecting the associated jugular,
subclavian and bronchomediastinal lymph trunks). The
thoracic duct (or the origin of the left brachiocephalic vein)
is therefore the major direct pathway for lymph from three
quadrants of the body. The right lymphatic duct (or the
origin of the right brachiocephalic vein) is the major direct
pathway for the right upper quadrant, of the body. Fig.12.14 Sites of zero pressure in erect or supine posture

129
BODY SYSTEMS AND ORGAN STRUCTURE

The termination of lymph ducts occurs where the


venous pressure is about zero, whether upright or
supine.

This site is located near the front of the thoracic inlet


just above the level of the heart. Lymph therefore tends to
flow freely into the central venous system without backflow
of blood into the lymphatic system. The thoracic and right
lymphatic ducts also have valves and arch up into the root
of the neck just prior to their entry into the venous system
(this helps prevent blood inadvertently entering them).
Between two to three litres of lymph per day is returned via
the thoracic duct. The thoracic duct is of sufficient diameter
to carry cells (e.g. lymphocytes) as well as large molecules
(e.g. plasma proteins and chylomicrons).
Fig.12.16 Stages of lymphatic spread
Lymphovenous communications
There are numerous small communications between Predicting the path of tumour cells carried by lymphatics
the lymphatic system and the venous system. These are is complicated by the possibility of:
via peripheral connections between some lymphatics and 1. Occlusion of some lymphatics by tumour cells
veins, as well as via veins that emerge from the hila of (altering the direction of spread)
lymph nodes. There are also numerous communications 2. Variation in, as well as overlap of, lymph drainage
between the thoracic duct and tributaries of the azygos territories
veins in the thorax. A significant proportion of fluid return is 3. Posture and external compression influencing lymph
by these routes. flow (being at low pressure)
4. Lymphovenous communications via direct peripheral
connections and via veins emerging from lymph node hila
(providing potential avenues for short circuit)
5. Certain tumours producing growth factors generating
new lymph capillaries which subsequently link with existing
capillaries

First aid for venomous bites


Venom from a bite tends to be located initially in tissue
fluid (unless the bite is directly into a blood vessel) and is
taken up by local lymph capillaries (rather than by blood
capillaries). However, venom carried in the lymph may
ultimately reach the venous system with potentially serious
consequences. First-aid management for most venomous
bites involves applying a compression bandage to collapse
lymph vessels. A tourniquet is contraindicated, as it may
totally occlude arterial (and venous) flow, compromising the
viability of the body part distal to it. Dissemination of venom
is particularly accelerated by muscle contraction.
Immobilising an affected part (e.g. by splinting the
appropriate limb) retards venom carriage in the lymph.

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

Lymphoid tissue contains lymphocytes and associated


cells on a supporting framework of reticular (L. little net)
fibres. Lymph nodes resemble small glands and are
typically kidney shaped with a hilum. Several afferent
lymphatics enter lymph nodes around their periphery, while
a single efferent lymphatic emerges from the hilum (where
an artery and vein also enter and leave, respectively).

Fig.12.18 The final sentinel lymph node


Fig.12.17 Lymph nodes Major lymph node groups
Lymph filter and antigen response roles The major lymph node groups of the body (cervical,
axillary and inguinal) are located at the gateways of the
Lymph nodes function as mechanical filters of lymph.
trunk. These key sites are at the junctions of the trunk with
Those in the lung appear black due to the presence of
the head, upper limb and lower limb (in the neck, armpits
inhaled carbon particles.
and groins, respectively). The cervical, axillary and inguinal
Antigens (G. produce against) are generally foreign
lymph nodes are readily palpable in a physical
substances that trigger the formation of antibodies
examination.
specifically acting against them. Antigens carried in lymph
from the tissues to lymph nodes (via afferent lymphatics) Superficial and deep groups of nodes
are brought in contact with certain defence cells, which
respond to them. Lymph nodes also release lymphocytes
into the venous system (directly via veins that drain them
and indirectly in lymph via efferent lymphatics).

Sentinel lymph nodes


Lymph from each part of the body normally drains
through at least one set of lymph nodes before reaching
the venous system. The first lymph nodes encountered in
the path of lymph drainage from a particular organ or area
of the body may be regarded as sentinel nodes, guarding
the rest of the body from dissemination of tumour cells or
microbes.

Sentinel nodes in tumour spread


Sentinel lymph node involvement is particularly
significant not only as the first potential barrier to lymphatic
spread of tumours, but also in their clinical assessment.
Staging of tumour spread influences treatment and
indicates prognosis.

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.

Significance of signal node enlargement


Enlargement of this left supraclavicular lymph node may
signal lymph spread of cancer from a structure within the
territory drained by the thoracic duct. It may even be the
first (although late) sign of cancer in a thoracic organ (e.g.
lung) or abdominal organ (e.g. stomach or testis), since the
thoracic and abdominal lymph nodes are all deeply located
and none are readily palpable.
Palpation of both left and right supraclavicular (groups
of cervical) lymph nodes should be performed in the routine
examination of the thorax. Palpation of the left
supraclavicular lymph nodes should be performed in the Fig.12.20 Drainage of lymph from superficial to deep
routine examination of the abdomen (and is mandatory if
there is suspicion of cancer in an abdominal organ). Lymph drains from superficial nodes to deep nodes.
131
BODY SYSTEMS AND ORGAN STRUCTURE

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.

LYMPHOID ORGANS AND TISSUES Mucosa Associated Lymphoid Tissue


Lymphoid tissue is present diffusely in the mucous
In addition to multiple, discrete, collections of lymphoid membranes of the digestive, respiratory and urinary tracts.
tissue (lymph nodes), there are single discrete organs of This Mucosa Associated Lymphoid Tissue ('MALT') is
lymphoid tissue (lymphoid organs) and collections of subepithelial (in the lamina propria) where it is well placed
lymphoid tissue within other organs (lymphoid tissues). to respond to antigens that penetrate the delicate surface
lining.
Thymus
Tonsils

Fig.12.21 Thymus with its lobes


The thymus is a lymphoid organ, which reaches its
greatest absolute size at puberty (although its greatest
relative size is at birth). It is located primarily in the thorax Fig.12.23 Waldeyer's ring (of tonsillar tissue)
(extending up into the neck) and receives a blood supply The (palatine) tonsils plus other collections of tonsillar
from neighbouring vessels. Special immature lymphocytes tissue (nasopharyngeal and lingual) encircle the pharynx
(T cell precursors) from the bone marrow are transported (as Waldeyers ring) in the mucosa at the junction of the
via the blood stream to the thymus where they develop and upper digestive and respiratory tracts. Lymph vessels drain
differentiate. Those that would otherwise attack host cells them to deep cervical lymph nodes (particularly the tonsillar
are recognised and removed there. The particular lymph node, palpable just below the angle of the mandible).
lymphocytes (T cells) released from the thymus into the
circulation are involved in mobilising certain defence cells Peyers patches
against a foreign agent (cell mediated immunity). Lymphoid tissue in the terminal small intestine forms
aggregates termed Peyers patches. These tend to be
After puberty, the thymus in particular (together with
arranged longitudinally in the ileum (along the anti-
lymphoid tissue in general) involutes with age.
mesenteric border), while the lymphatics draining them
pass transversely.
Spleen

Fig.12.22 Spleen with its blood vessels


Fig.12.24 Peyer's patches in small intestine
The spleen has a rich blood supply, large vascular
spaces and sinusoids. The spleen filters blood picking up
antigens, responds to them and releases lymphocytes into .
the blood stream. The spleen also removes old red blood
cells from the circulation and is a store of red blood cells.
132
Section III
BODY REGIONS AND ORGAN POSITION

Introduction: 'Everything is somewhere'

Chapter 13: Regions of the Human Body


Chapter 14: Arrangement of Body Regions
Chapter 15: Body Compartments and Fascial Planes
Chapter 16: Body Wall and Cavities
Chapter 17: Neurovascular Pathways

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

The majority of regions are paired, including all regions


of the limbs with some additional regions of the trunk, head
and neck. The remaining regions being along the midline of
the body are unpaired.
From a geographic perspective, a module is like a
country while regions are like its states.

Regional anatomy is concerned with the situational


(extrinsic) properties of an organ its position and
relations.

Position refers to spatial relationships of an organ to


the body as a whole, while relations are those to its
immediate neighbours.

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.

Although arbitrary, regions (with clearly defined


borders) are necessary for precise localisation of any
specific organ. Regional anatomy also enables accurate
description of the course for a structure (e.g. a nerve or a
vessel) passing from one region to another, as well as
relations at any point along a pathway.

The first step in a clinical diagnosis is to determine the


(anatomical) site of a lesion.

This is typically expressed in terms of the region it is


situated in and its proximity to a key bony or soft tissue
landmark contributing to a boundary of the region.
Landmarks can also be apertures (through or across
boundaries) allowing pathways between one region and
another.

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 UPPER LIMB


Fig.13.2 Cranial regions of head
REGIONS OF LOWER LIMB 6. - face
7. - parotid region
8. - deep styloid region
REGIONS OF HEAD 9. - infratemporal region
10. - pterygopalatine fossa
The head may be divided into 15 regions arranged in
three groups of five.
The cranial regions surround or are enclosed by cranial
bones of the skull.
The facial regions cover the facial skeleton.
The upper airway regions are the proximal parts of the
respiratory and digestive tracts.
The pharynx and larynx are regarded as regions of the
head, although they extend into the neck (covered by the
anterior triangle of the neck).

Fig.13.3 Facial regions of head


11. - mouth
12. - tongue
13. - nose
14. - pharynx
15. - larynx

Fig.13.1 Regions of head


1. - scalp
2. - temporal region
3, - cranial cavity
4. - orbit
5. - ear Fig.13.4 Upper airway regions of head
135
BODY REGIONS AND ORGAN POSITION

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

Fig.13.7 Regions of neck and modules adjacent to them

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

Fig.13.5 Regions of neck


The anterior triangle surrounds the larynx and lower
part of the pharynx, which although extending into the neck
are regarded as regions of the head.

Fig.13.6 Triangles of neck


Their continuations (trachea and oesophagus, Fig.13.8 Regions of back
respectively) are located in the root of the neck. The root of
the neck is covered by the lower third of sternomastoid The superficial compartment includes the skin of the
muscle while the sternomastoid region is covered by its back and extends further laterally than the deep
upper two thirds. compartment, which in turn overlaps the much narrower
The vertebral region of the neck includes the cervical vertebral region. The superficial compartment contains
vertebral column as well as the enclosed vertebral canal extrinsic back muscles while the deep compartment
(and associated pairs of intervertebral foramina). contains intrinsic back muscles.

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.

Fig.13.9 Deep compartment of back and vertebral region

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.

Fig. 13.13 Subdivisions of mediastinum


The pericardial sac occupies most of the middle
mediastinum. A lung is located in each pleural sac while
Fig.13.10 Regions of thorax
the heart is in the pericardial sac.
1. - anterior thoracic wall
2. - posterior thoracic wall
3. - the diaphragm
4. - pleural sacs
5. - anterior mediastinum
6. - middle mediastinum
7. - posterior mediastinum
8. - superior mediastinum

Fig.13.14 Pleural sacs

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

part of the anterior abdominal wall and, in the male, it is


continuous with the scrotum.
The abdominal cavity is enclosed by the abdominal
walls. Its contents include the abdominal viscera and the
peritoneal cavity.

Fig.13.17 Regions of pelvis


1. - posterior pelvic wall
2. - lateral pelvic wall
3. - pelvic floor
4. - pelvic cavity
5. - anal triangle of perineum
6. - urogenital triangle of perineum

Fig.13.15 Regions of abdomen


1. - posterior abdominal wall
2. - anterior abdominal wall
3. - inguinal canal (and scrotum)
4. - abdominal cavity.

Fig.13.18 Position of pelvic floor

Fig.13.16 Position of abdominal cavity within trunk


The abdominal cavity is separated from the thoracic
cavity by the diaphragm but is continuous with the pelvic Fig.13.19 Pelvic wall regions
cavity below the pelvic brim.

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

REGIONS OF UPPER LIMB REGIONS OF LOWER LIMB


The upper limb may be divided into 15 regions, (all The lower limb can also be divided into 15 regions,
covered by skin) arranged in (8) anterior regions and (7) (covered by skin) arranged in (8) anterior regions and (7)
posterior regions. posterior regions.

Fig.13.21 Regions of upper limb


Fig.13.23 Regions of lower limb
1. - pectoral region
2. - axilla 1. - femoral triangle
3. - anterior compartment of arm 2. - sub sartorial canal
4. - cubital fossa 3. - anterior compartment of thigh
5. - anterior compartment of forearm 4. - medial compartment of thigh
6. - carpal tunnel 5. - anterior compartment of leg
7. - palm of hand 6. - lateral compartment of leg
8. - palmar aspect of digits 7. - dorsum of foot
9. - scapular region 8. - dorsal aspect of digits
10. - deltoid region 9. - gluteal region
11. - posterior compartment of arm 10. - posterior compartment of thigh
12. - posterior compartment of forearm 11. - popliteal fossa
13. - anatomical snuffbox 12. - posterior compartment of leg
14. - dorsum of hand 13. - tarsal tunnel
15. - dorsal aspect of digits 14. - sole of foot
15. - plantar aspect of toes

Fig.13.24 Major parts of lower limb


Fig.13.22 Major parts of upper limb

139
Chapter 14: Arrangement of Body Regions

These also are not empty spaces, being occupied


mainly by the brain and spinal cord, respectively (as well as
UNPAIRED REGIONS & MIDLINE OF BODY their surrounding membranes and fluid).

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.

Ventral and dorsal cavities of body

Fig.14.2 Bilateral symmetry in a coronal section


Even within the head, neck and trunk unpaired regions
have bilateral symmetry, being divided into two halves by
the midline.

Asymmetrical regions and structures


The major exceptions to bilateral symmetry are serous
sacs within the thoracic and abdomino-pelvic cavities,
Fig.14.1 Major body cavities in a mid-sagittal section together with their contained unpaired organs (heart,
digestive system and spleen) and associated unpaired
The body contains two main cavities, both of which are vessels.
in the midline. The two main cavities in the body are the
ventral cavity and the dorsal cavity. The branching patterns of vessels tend to be
The ventral cavity is partitioned by the diaphragm into: asymmetrical resembling the branching of a tree.
-.a thoracic cavity, above it
- an abdomino-pelvic cavity, below it Even paired viscera are not perfectly symmetrical.
These are not empty spaces, being occupied mainly by Left and right lungs are of slightly different sizes and are
thoracic and abdomino-pelvic viscera, respectively (as well shaped differently by adjacent structures. The same
as their surrounding membranes and fluid). applies to the kidneys and suprarenal glands.
The dorsal cavity is divided into: One side of the face is not a mirror image of the other,
- a cranial part (the cranial cavity, in the head), limbs may not be exactly the same length and even certain
- a vertebral part (the vertebral canal, in the neck and individual limb muscles may be larger on the dominant side
the back continuous with the cranial part) of the body.
140
14. Arrangement of Body Regions

FLEXOR AND EXTENSOR REGIONS Rami of spinal nerves


Certain characteristics of the ventral aspect of the body
Posterior rami of spinal nerves directly supply the
are different to those on the dorsal aspect (which, in
dorsal aspect of the trunk (and also of the neck) with
quadrupeds, is more exposed to the elements).
their associated extensor regions containing skin,
joints and (deeply located) intrinsic muscles.
Flexor muscles with a richer nerve supply (for fine
control of movements) tend to occupy compartments
on the ventral aspect of the body and are covered by
delicate skin with a correspondingly richer nerve
supply (for fine sensory discrimination).

Fig.14.5 Territories within a segment of the trunk


The exception is the (superficially located) extrinsic
muscles. They have migrated onto the dorsal aspect (and
retain their nerve supply from ventral rami).

Fig.14.3 Flexor and extensor regions in the trunk and limbs

Course antigravity extensor muscles tend to occupy


compartments on the dorsal aspect covered by hairier
skin with tougher dermis.

Coronal morphological plane


The coronal morphological plane of the trunk separates Fig.14.6 Spinal nerve rami
flexor from extensor territory. It passes through the
vertebral column and its transverse processes, bisecting Anterior rami of thoracic spinal nerves directly supply
each intervertebral foramen (passing between rami of each the ventral aspect of the trunk with its associated regions
emerging spinal nerve). (regarded as flexor regions).

Fig.14.7 Supply of limb buds from anterior rami


Anterior rami of cervical and lumbosacral spinal nerves
supply the upper and lower limbs, respectively (although
Fig.14.4 The coronal morphological plane indirectly via peripheral nerves derived from plexuses).

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.

Fig.14.8 Supply of musculature within a limb bud


Flexor and extensor regions therefore become situated
on opposite aspects of the respective limbs, (flexor regions
are anterior in the upper limb but posterior in the lower
limb)
The nerve supply for both flexor and extensor regions in
the limbs are derived from anterior rami of spinal nerves.

A limb plexus divides into anterior and posterior


divisions, with their nerve fibres distributed (via
associated peripheral nerves) to flexor regions and
extensor regions, respectively.
Fig.14.10 Imaginary lines between bony borders in thorax
In view of the rotation of the limb buds, anterior
divisions of the lumbosacral plexus supply posterior Soft tissue boundaries
compartments of the lower limb and posterior divisions Soft tissue boundaries of regions may include borders
supply anterior compartments. of muscles. The distal border of teres major muscle
demarcates the base of the axilla. Pronator teres muscle is
BOUNDARIES OF REGIONS the boundary between the cubital fossa and the anterior
compartment of the forearm.
Regions are demarcated from each other by their
boundaries. These may be bony or soft tissue or a
combination of both.

Bony boundaries

Fig.14.11 Key soft tissue boundaries in upper limb

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.

Fig.14.12 Key structures exiting from spinal apertures


Apertures may be major or minor. Major apertures are Fig.14.15 Major and minor apertures in the diaphragm
clearly defined openings (e.g. between or within bones),
while minor apertures are avenues across boundaries (e.g.
over or under a muscle) or through a boundary (e.g. by
piercing a muscle) where an opening is not readily
apparent. Many structures may pass through a major
aperture

Fig.14.13 Major apertures from neck


For example, the superior aperture of the thorax
transmits many viscera, vessels and nerves to and from the
root of the neck. Generally only one or two structures pass
through a minor aperture. For example, the radial artery,
median nerve and ulnar artery each leave the cubital fossa
to enter the forearm via a different avenue (passing over,
through or under pronator teres muscle, respectively).

Fig.14.14 Minor apertures associated with a muscle

143
Chapter 15: Body Compartments and Fascial Planes

COMPARTMENTS AND LAYERS

MOBILE AND FIXED FASCIAL PLANES

COMPARTMENTS AND LAYERS


Regions are typically in the form of compartments with
clearly defined boundaries.

Fig.15.2 Layers within compartments of arm


The roof of a compartment is composed of superficial
structures (skin, subcutaneous tissue and deep fascia) that
can be in the form of concentric layers (e.g. around a limb).
The floor is composed of deep structures (bones and
joints). The contents of compartments (between the roof
and the floor) provide the intermediate group of structures
and may also be in layers. This particularly applies to
muscle compartments.
Muscles in a superficial layer tend to be prime movers.
They tend to span greater distances between their
attachments (moving levers through greater arcs) or at
least exert greater leverage.
Muscles in a deep layer are usually shorter and tend to
be fixators. Their role is more for stabilising rather than for
generating power and range of movement. The key supply
lines (major nerves and vessels) tend to run in the
intermediate layer. Branches from them are well placed to
pass superficially (cutaneous branches), deeply (articular
branches) and to adjacent structures (muscular branches).
Fig.15.1 Compartments and layers of leg Flexor and extensor compartments
Compartments have boundaries (composed of walls, a Muscle compartments are either flexor or extensor,
roof and a floor) and contents. typically being situated on ventral or dorsal aspects of the
body, respectively.
Boundaries and contents of a compartment
Compartment walls are typically fascial (e.g. inter-
muscular septa and retinacula) but may also be bony or
muscular. A roof typically includes overlying skin,
subcutaneous tissue and deep fascia. A floor typically
includes underlying bone (covered by periosteum) or a joint
(demarcated by its fibrous capsule). If there is a pair of
bones (e.g. radius and ulna or tibia and fibula) the floor
may also include an associated interosseus membrane
(separating anterior from posterior compartments of the
forearm or leg).
Apertures in certain boundaries allow passage of
structures between a compartment and neighbouring Fig.15.3 Plexus divisions and type of compartment supplied
regions.
The contents of a compartment may be grouped into The deep muscle compartment (for intrinsic back
those structures that enter or exit the region (e.g. tendons, muscles) on the dorsal aspect of the trunk, is an extensor
ducts, nerves and vessels) and those structures that reside compartment, and is supplied by posterior rami of spinal
solely in the region (e.g. muscles and glands). nerves. In the limbs, flexor compartment muscles are
Remaining space within a compartment tends to be located anteriorly in the upper limb and posteriorly in the
occupied by fat. lower limb. They are supplied by anterior divisions of the
associated nerve plexuses. Conversely, extensor
Layers of structures within a compartment compartment muscles are located posteriorly in the upper
limb and anteriorly in the lower limb. They are supplied by
Compartments tend to be in layers. posterior divisions of the associated nerve plexuses.

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).

Fig.15.6 Disc bulging into intervertebral foramen


Swelling in rigid compartments increases the pressure
and ultimately leads to compression of its contents. Even a
small degree of swelling tends to give considerable pain.
Further increase of compartment pressure compresses
vessels (initially veins then arteries) and nerves.
An emergency surgical operation to decompress the
compartment may need to be performed (e.g. a
laminectomy, to relieve spinal cord or spinal nerve root
Fig.15.4 Rigid compartments in the spine compression).
Major vessels tend not to run through a rigid Swelling (in 'mini-compartments') where skin is bound
compartment (e.g. carpal tunnel). down to underlying structures (e.g. palm, nail bed, ear,
nose and anus) may also be extremely painful. Drainage
Compartment syndrome (e.g. by an appropriate incision) suddenly releases the
A compartment with rigid walls is a confined space and pressure and typically brings rapid relief.
a potential site for compartment syndrome.

Fig.15.7 Bruised nail bed

MOBILE AND FIXED FASCIAL PLANES


Fascial planes (L. flat) are created by flat layers of
fascia and may be mobile or fixed.

Mobile fascial planes


Mobile planes occur between parallel sheets of fascia
Fig.15.5 Anterior compartment syndrome in leg and tend not to be pierced by vessels or nerves.

145
BODY REGIONS AND ORGAN POSITION

aponeurosis is fixed by muscles (frontalis and occipitalis) to


the supraorbital margin and superior nuchal line, at the
front and back of the skull, respectively. The loose
connective tissue between the epicranial aponeurosis and
the periosteum of the skull is a mobile fascial plane.
Vessels and nerves tend not to cross this plane. Similarly,
on the side of the head (in the temporal region) the
subcutaneous tissue glides over the tough deep (temporal)
Fig.15.8 Mobile plane between fascial sheets fascia.

While major vessels and nerves may course along


them, few cross mobile fascial planes as they would
otherwise overstretch or have their own mobility
restricted.

Fig.15.10 Paths of vessels and nerves in fascial planes


Vessels and nerves also course from fixed (concave)
Fig.15.9 Vessels parallel to a mobile fascial plane areas to mobile (convex) areas across the face. The facial
artery enters the face from the neck by passing across the
Vessels and nerves may course parallel to mobile lower border of the body of the mandible (to which the
planes for long distances (e.g. where fascial coverings of investing deep fascia of the neck attaches). Branches of
muscles slide against each other and where subcutaneous the facial nerve emerge from within the parotid gland (fixed
tissue glides over deep fascia or periosteum). by the parotid deep fascia which encloses it) prior to
Mobile fascial planes are exploited in anatomical radiating across the face (in the subcutaneous tissue).
dissection and in surgical operations as they are easier to
separate and there is less chance of damaging vessels or Potential paths of tracking and direct spread
nerves. Fluids (including blood and pus) tend to track along
mobile fascial planes as they provide paths of least
Fixed fascial planes
resistance.
Fixed planes occur within fibrous septa. They tend to
transmit vessels and nerves from deep to superficial.
Arteries travel with connective tissue particularly via the
fascia associated with muscles. Arteries (being derived
from mesoderm) are retained within the connective tissue
mesh that develops from mesoderm.

Vessels tend to cross planes at sites of fusion, where


connective tissue is anchored.

This occurs particularly at the periphery of muscles,


over intermuscular septa, under flexure lines (and skin
creases) and where deep fascia attaches to bone. Nerves
may also pass from deep to superficial via canals within
bones (e.g. cranial nerves).

Courses from fixed to mobile areas


Fig.15.11 Tracking of blood along a mobile fascial plane
Vessels and nerves course from fixed to mobile areas.
Bruising may appear or an abscess may discharge
This particularly applies to the scalp where vessels and considerable distances from their source.
nerves (e.g... supratrochlear, supraorbital, superficial Direct spread of infection or tumours may also occur
temporal, posterior auricular and occipital) course from more easily along mobile planes, while fixed fascial planes
peripherally (arising deep to sites where fascia is fixed), provide a barrier.
converging on the vertex. The scalp is arranged in layers
(skin, subcutaneous tissue, epicranial aponeurosis, loose
areolar tissue layer and pericranium). The epicranial

146
Chapter 16: Body Walls and Cavities

Somatic nerves and parietal vessels


BODY WALL AND PARIETAL STRUCTURES The key supply lines to the walls are somatic nerves
and parietal vessels. They arise from their sources (e.g.
spinal cord and aorta) posteriorly and run forwards around
SEROUS SACS AND BODY CAVITIES the body wall on each side to supply the parietal structures
particularly skin, muscles and parietal layer of the serous
membrane (e.g. parietal pleura or peritoneum).
BODY WALL AND PARIETAL STRUCTURES
The body wall is made of parietal (L. 'wall') structures.

Fig.16.3 Supply lines to abdominal wall and cavity


In contrast, visceral nerves and vessels supply the
viscera (and are directed towards them in the cavity). They
also supply the visceral layer of an associated serous
membrane (e.g... visceral pleura or peritoneum).

Apertures in body wall


Fig.16.1 Lateral and posterior walls of thorax & abdomen Apertures occur in the body wall at certain sites to allow
passage of structures from one region to another (e.g. the
The trunk includes large cavities surrounded by walls. spermatic cord through the inguinal rings in the anterior
Each wall and cavity is regarded as a discrete region. abdominal wall).

Layers of body wall in trunk Hernia


A hernia (L. rupture) is an abnormal protrusion of an
anatomical structure through an opening, defect or area of
weakness (in its containing walls).

Fig.16.2 Layers of anterior abdominal wall


The body wall in the trunk is arranged in layers.
The anterior thoracic and abdominal walls have skin on
a layer of subcutaneous tissue, in turn, on layers of
muscles or aponeuroses (rather than an unyielding layer of
deep fascia). The anterior thoracic wall even has bones
(sternum and ribs) and associated joints, in addition to
muscles (the intercostals).
The parietal layer of a serous membrane lines the
interior of the body wall. Viscera are located internal to the
body wall where they are more protected, occupying the
cavity enclosed by the wall. Fig.16.4 Avenues of herniation

147
BODY REGIONS AND ORGAN POSITION

Herniation may occur through a normal opening (e.g.


of stomach through oesophageal opening in diaphragm,
intestine through deep inguinal ring) a defect (e.g. nucleus
of intervertebral disc through a split in its peripheral part) or
a weakness (e.g. intestine directly pushing through
posterior wall of inguinal canal).
Herniation is commonly precipitated by raised pressure
inside a cavity (e.g. raised intra-abdominal pressure
through coughing or straining).

Fig.16.7 Herniation through a rigid opening


Strangulation is more likely to occur if the opening has
rigid edges.

Fig.16.5 Herniation from straining


Rarely, but importantly, a sudden change in pressure
gradient by performing a lumbar puncture in raised intra-
cranial pressure may cause (potentially fatal) herniation of
part of the brain through the (rigid) foramen magnum into
the spinal canal.
Serious complications from herniation include direct
compression (of a vital structure), obstruction (of a
hollow viscus) and strangulation (choking of vascular
supply).
Fig.16.8 Strangulation of a herniated loop of gut

SEROUS SACS WITH BODY CAVITIES


A serous (L. serum a watery fluid) sac consists of a
serous membrane (L. thin skin), an enclosed body cavity
and the structures surrounded by the serous sac.

Fig.16.6 Iatrogenic herniation of brain stem Fig.16.9 Types of surface linings

148
16. Body Wall and Cavities

Mesothelium Serous sacs are also associated with joints (synovial


cavities and bursae) and synovial tendon sheaths. A
A serous membrane is composed of connective tissue
serous sac is a closed body cavity. A potential space
covered by mesothelium.
(normally occupied by only a thin film of fluid) is between
parietal and visceral layers of the serous sac.
With the exception of the peritoneal cavity in females
(through the abdominal opening of the uterine tube) a body
cavity does not communicate with any other type of cavity
nor does the mesothelium become continuous with any
other type of surface. However, such a cavity may be
divided into compartments with a communication between
them. The mesothelium lining one cavity is continuous with
that of another (e.g. where certain bursae communicate
with a synovial joint cavity).
With the exception of articular cartilage, discs or
menisci in a joint cavity, the serous fluid secreted into a
body cavity does not come in contact directly with
structures enclosed within the serous sac (they are covered
by the serous membrane).

Drainage of accumulations in a body cavity


Fluid, air, blood or pus may track along and accumulate
within a body cavity as a result of trauma or disease. This
may need drainage through the body wall by needle
aspiration or by insertion of a drain tube (which usually
remains present for a number of days).

Pleural, pericardial and peritoneal sacs


Fig.16.10 Peritoneum and peritoneal cavity The diaphragm partitions the large ventral cavity of the
trunk into a thoracic cavity above and an abdomino-pelvic
A mesothelium consists of a (mesoderm-derived) single cavity below. The superior aperture of the pelvis, in turn,
layer of flat cells that secrete a small amount of lubricating divides the abdomino-pelvic cavity into abdominal cavity
fluid (into an enclosed potential space) minimising friction. and pelvic cavity. These cavities are not empty spaces as
A mesothelium may be contrasted with an endothelium they are fully occupied by their contents (e.g. viscera,
(also a single layer of mesoderm-derived cells but lining the nerves and vessels). They include serous sacs with
interior of vessels) and with an epithelium (ectoderm- potential spaces (pleural, pericardial and peritoneal
derived epidermis or endoderm-derived lining of a mucous cavities) located between parietal and visceral layers of the
membrane). serous membrane.
A serous membrane has a parietal layer lining the wall
of the sac and a visceral layer covering structures
contained in the sac.
These two layers are continuous via a mesentery (L.
middle + carry) that suspends the structures projecting
into the sac.

Fig.16.12 Subdivisions of the ventral cavity of the body


The two pleural cavities and the pericardial cavity are
separate closed cavities within the pleural sacs and
Fig.16.11 Parietal & visceral layers of a serous membrane pericardial sac, respectively. The peritoneal cavity is a
single cavity within the peritoneal sac of the abdomino-
Closed body cavity pelvic 'cavity' (providing continuity between the abdominal
Serous sacs contain structures that have considerable 'cavity' and the pelvic 'cavity'). The peritoneal sac is
mobility or motility, in particular many viscera within the subdivided into greater and lesser sacs (communicating
large ventral cavities of the trunk. via the omental foramen).

149
BODY REGIONS AND ORGAN POSITION

Fig.16.13 Pleural and pericardial sacs


In males, the scrotal cavities are extensions of the
peritoneal cavity (via the inguinal canal on each side) that
normally become separate from it just prior to birth (by
closure of the processus vaginalis).

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.

Fig.16.14 Prolapse of uterus into vagina

150
Chapter 17: Neurovascular Pathways

NEUROVASCULAR BUNDLE

COURSE THROUGH A REGION

RELATIONS WITHIN A REGION

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.17.3 The major neurovascular bundle of the neck

Venae comitantes in limbs


In smaller neurovascular bundles, a single vein is often
replaced by venae comitantes. These are a pair of
intercommunicating veins wrapped around an artery. They
conserve heat by its transfer from warm arterial blood to
cool venous blood returning from the periphery.

Fig.17.1 Components of a neurovascular bundle


Smaller vessels and nerves also tend to be surrounded
by connective tissue, although this may not be in the form Fig.17.4 Venae comitantes and heat conservation
of a tubular sheath when passing via fixed fascial planes
(e.g. within intermuscular septa). Venae comitantes are located in the limbs, particularly
distally.

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).

Course of superficial veins in limbs


Major arteries develop along the axis of a limb and do
not run superficially for long distances, thus conserving
heat. In contrast, the major superficial veins of limbs follow
the pre-axial and post-axial borders. Cutaneous nerves
(which also run along these borders) and lymph vessels
accompany the superficial veins within the subcutaneous
tissue and make up the other components of the major
superficial neurovascular bundles.

Fig.17.6 Course of popliteal artery behind knee


A course is described from origin to termination
according to convention. Thus, arteries and their branches
course from proximal to distal, while veins and their
tributaries course from distal to proximal. Nerves and their
branches course from proximal to distal (even those that
contain only afferent fibres).

Position of major arteries relative to joints


The major limb arteries tend to run through flexor
regions and are generally located on the flexor aspect
of joints.

Fig.17.8 Veins coursing along axial borders of limbs

Changed course of a nerve


Generally nerves and vessels take a direct course
within a region. However, certain nerves change direction
or even loop around a structure (e.g. left recurrent
laryngeal nerve around the ligamentum arteriosum under
the aortic arch) due to migration of the organ of supply
during development.

The nerve supply to a structure remains constant even


if the structure has migrated.

In contrast, vessels, having the capacity for alternative


channels, may be acquired along the way and take more
Fig.17.7 Position of major arteries adjacent to joints direct paths (e.g. renal arteries usually arise from the aorta

152
17. Neurovascular Pathways

at the level where the kidney completes its ascent). Nerves


may even temporarily change compartments (e.g. radial
and ulnar nerves in the arm) if the septa bordering them
have shifted in development.

Tortuous arteries
Many arteries are tortuous and accommodate
movement (e.g. facial, splenic), protrusion (lingual) or
expansion (uterine) of the organs supplied.

Fig.17.9 Arterial tortuosity from mobility of face

Fig.17.11 Boundaries and key contents of femoral triangle


The boundaries of a (3-dimensional) region have the
following pairs of relations to its contents:
- anterior/posterior
- superior/inferior
- medial/lateral
In typical regions, one pair of boundaries form the roof
and floor, the remainder form the walls. However,
boundaries may receive different terms for regions of a
different shape. The femoral triangle has a (anterior) roof
and (posterior) floor, a (superior) base and (inferior) apex,
medial and lateral borders.

Relations of contents within a region


The following types of contents within a region may be
related to each other:
- muscles (and tendons)
- fascia (and fibrous tendon sheaths)
Fig.17.10 Tortuosity of uterine and lingual arteries
- glands and hollow viscera (including ducts)
However, any artery may ultimately become tortuous - serous membranes (including synovial membrane,
because of loss of elasticity through aging. bursae and synovial tendon sheaths) with associated
body cavities
Convergence of paths at neurovascular hila - nerves (and branches)
Nerves and vessels tend to enter their organ of supply - arteries (and branches)
(e.g... a muscle or a viscus) at a common neurovascular - veins (and tributaries)
hilum. - lymph nodes (and lymph vessels).
The most important relationships (direct relations)
are where structures are in direct contact.
RELATIONS WITHIN A REGION This is applicable to nerves and vessels where they
Regions have boundaries (typically walls, roof and course alongside each other or where they intersect. A
floor) with apertures. The contents of a region may be gland is often enclosed by fascia that splits to form a
classified into those that course to or from another region sheath around it. A tendon (surrounded by a synovial
(via apertures in the boundaries) and those that are tendon sheath) may occupy a fibrous tendon sheath. Major
situated in that region only. nerves and vessels typically accompany each other in a
neurovascular bundle enclosed by a fascial sheath.
Relations to boundaries of a region
Detecting arterial pulsation
Structures forming the boundaries of a region include
skin, subcutaneous tissue, deep fascia, retinacula, septa, Arterial pulsation is best detected by palpation at a site
muscles, tendons, ligaments, joint capsules and bones. where an artery is closely related to both skin and
Gaps between them create apertures in the boundaries. bone.

153
BODY REGIONS AND ORGAN POSITION

The usual site for clinical examination of an arterial


pulse is where the radial artery lies on the distal end of the
radius just deep to skin of the wrist.

Fig.17.12 Palpating the radial artery against bone

Predicting vascular endangerment


Vessels closely related to skin are prone to be severed
by lacerations, resulting in external haemorrhage. Vessels
closely related to bones or joints may be severed by
fracture or dislocation, respectively and result in internal
haemorrhage.
This is particularly significant when hidden in large
compartments or body cavities, which may accumulate
dangerous volumes of blood without significant initial Fig.17.14 Vulnerability to nerve severance or entrapment
symptoms.
In addition, nerves may be endangered by external
compression from tight or inappropriate splints and casts.
This is applicable to nerves closely related to both skin and
bone (e.g... common fibular nerve around neck of fibula).
Although compression may directly damage nerve
fibres (e.g... from a crush injury) it primarily compromises
blood supply to the nerve.

Fig.17.13 Endangerment of vessels near skin or bone

Predicting nerve endangerment


Nerves closely related to skin are prone to be severed Fig.17.15 Vulnerability to external nerve compression
by lacerations. Those closely related to bones or joints
may be injured by fracture and dislocation, respectively.
Nerves are endangered by compression from
entrapment in confined spaces with rigid walls (e.g. an
intervertebral foramen, carpal tunnel). They are also
endangered by compression from entrapment where they
pierce certain muscles or dense fascia.

154
Section IV
HUMAN DEVELOPMENT AND VARIATION

Introduction: 'Derivation determines destiny'

Chapter 18: Growth and Development


Chapter 19: Normal Variation
Chapter 20: Anatomical Variation in Structure
Chapter 21: Anatomical Variation in Position
Chapter 22: Pathological Changes

155
Introduction: Derivation determines destiny

Even in so-called identical twins, no human body is


exactly the same as another. Bodies vary within a wide
range of normality (as well as beyond that range) resulting
in observed differences from the typical case described in
anatomy textbooks.
Normal variations are atypical (G. not + type) in
that they do not conform to a standard model (e.g. an adult
male of medium build) but their structure and function are
both within the normal range.
Normal variation for somatic structures is primarily in
external form due to constitutional factors (age, sex and
body build) and there is no alteration of structure other
than the normal stages of development (e.g. epiphyses in
growing bones). Viscera may also vary in size or shape
(for expansible organs) and in position (for mobile organs)
due to physiological factors (e.g. posture, phase of
respiration and pregnancy).
Anatomical variations have a significant structural or
positional modification that is abnormal (L. away + rule),
meaning a deviation away from the norm (i.e. beyond the
range of normal). However, normal function is retained.
An anatomical variant may also be termed an anomaly (G.
Although anomalies are not normal they are not
irregular). Anomalies tend to have a developmental basis
diseased. However, certain anomalies may have a
and may reflect features from ancestral life forms.
decreased functional reserve, or a predisposition to
disease. Others may impinge on or compress neighbouring
structures.

Encountering anomalies, particularly when not


anticipated, can pose problems during invasive
procedures or surgical operations.

Some are also associated with the presence of other


anomalies. Anatomical variation is not uncommon,
although for certain anomalies there is a different incidence
across different population groups (e.g. sex, race). Careful
dissection of an entire body on average uncovers about 50
anomalies. With closer examination (e.g. by tracing fine
branches of vessels) the number detected is potentially Pathological (G. disease) changes have impaired
much greater (e.g. as vascular patterns, like fingerprints, function in addition to abnormal structure. Pathological
are unique for each individual). Thus, each human body variation may be congenital or acquired. Congenital
should be regarded as special and assessed on its own malformations have a genetic and/or developmental basis,
merits. while acquired disorders are more likely to be caused
Anatomical variants may be partial or complete, primarily by environmental factors (e.g. physical, chemical,
single or multiple and, if affecting a paired structure, organisms), although genetic factors often contribute.
unilateral or bilateral. If multiple, they may be reciprocal Either way there is abnormal structure with abnormal
and even compensatory. function that is not healthy (health being the state of
optimal physical wellbeing with the absence of disease).
Anomalies found on physical examination or by It is vital for a clinician to distinguish typical from
imaging may be of clinical significance per se or when atypical, normal from abnormal, and health from
misdiagnosed as being pathological. disease.

156
Chapter 18: Growth and Development

Trilaminar disc and organ development


PRENATAL GROWTH AND DEVELOPMENT During the third week, a trilaminar germ disc is formed
with the development of mesoderm between the ectoderm
and the endoderm.
POSTNATAL GROWTH AND DEVELOPMENT

PRENATAL GROWTH AND DEVELOPMENT


From an anatomical perspective, growth is increase in
physical size while development refers to other structural
changes that occur until maturity.
Prenatal growth and development occur from
conception to birth, typically lasting for about 38 weeks.
This corresponds to about 40 weeks from the first day of
the last menstrual period (as ovulation usually occurs two
weeks later, just prior to fertilization of the ovum).
The embryonic (G. in + grow) phase is the first eight
weeks from conception while the foetal phase continues
until full term.

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).

Fig.18.1 Development in 1st week


A fluid-filled cavity develops, creating a blastocyst (G.
germ + bladder). This has an inner cell mass, the
embryoblast and an outer cell mass, the trophoblast (G.
nutrition + germ). The latter implants into the uterine wall
at the end of the first week.
During the second week a bilaminar germ disc, the
dorsal lamina becoming ectoderm and ventral lamina
becoming endoderm, develops from the inner cell mass.
Ectoderm subsequently forms epidermis (and skin
appendages) and nerve cells. Endoderm forms the
epithelial lining of the digestive tract (gut) and of the
respiratory tract (which buds out of the foregut).
Fig.18.4 Longitudinal folding due to neural tube
rd th
In the 3 to 8 weeks, all the major organ systems start to
develop (organogenesis). During this period of dramatic
structural change, birth defects tend to occur. The embryo
folds both longitudinally and transversely. Cephalo-
caudal folding occurs due to development of the neural
tube while lateral folding occurs due to development of
somites.

During the early embryonic phase, features appear


from more primitive ancestors.

Early human embryos appear almost identical to those


of other vertebrates. Further modifications, including
disappearance of certain features, occur progressively with
the embryo becoming more recognizably human by the end
nd
Fig.18.2 Two-layered germ disc in 2 week of the embryonic phase.

157
HUMAN DEVELOPMENT AND VARIATION

At the beginning of the third month a foetus is about 3


grams in weight and 3 cm in crown-rump length (CRL). In
the foetal phase there is further growth and maturation of
the organ systems created during the embryonic phase,
with dramatic increase in size. The foetus is bathed in
amniotic fluid with the lungs being un-inflated and
receiving minimal pulmonary circulation.
The lungs are not developed sufficiently to enable
th
survival of a premature baby prior to about the 28 week.
The rib cage is relatively small with the ribs and heart
horizontal. The large thymus (which attains its maximal
relative size at birth) extends out of the thoracic cavity and
into the neck. The abdomen is large, primarily due to the
size of the liver. The spleen and suprarenal glands are also
large and the kidneys are lobulated. The umbilicus is
prominent and transmits the umbilical vessels and the
urachus (a projection from the apex of the bladder).
The pelvis is relatively small with the bladder extending
beyond the pelvic brim into the abdomen. In a male the
th
Fig.18.5 Transverse folding due to somite development scrotum is empty until about the 8 month. The testes are
located in the abdominal cavity and gradually descend
Development of the upper lip, nostrils, external ears and
towards the scrotum guided by a fibrous band, the
eyelids make the face more human looking. The limbs have
gubernaculum (L. rudder). The external genital organs
elongated and fully formed hands and feet are present. th
are large enough at about the 12 week for sex to be
Primary centres of ossification appear in long bones and
determined on ultrasound examination. The spine of a
during this time the limbs rotate to the foetal position
foetus is C-shaped. In the foetal position the spine and
(elbows pointing backwards, knees forward).
limbs are all flexed.

Fig.18.6 Embryo at 6 weeks

Features of a foetus

Fig.18.8 Position of limbs and spine in a foetus

Moulding of cranium during birth


At birth a full term foetus is about 3 kg in weight and 50
cm in crown-heel length (CHL).

Fig.18.9 Least dimensions presented by skull at birth


The skull has the largest circumference of any part of
the foetus and presents the major obstacle to passage
along the birth canal. The foetal skull is elongated in an
antero-posterior direction. During childbirth the foetal head
normally rotates and flexes to present its smallest
diameters as it negotiates the changing dimensions of the
Fig.18.7 Embryo at 5 weeks (7mm) and foetus at 6 months maternal bony pelvis between its inlet and outlet. The

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.

Fig.18.10 Umbilical vessels and bypass channels


Before birth, oxygenated blood is received from the
placenta via the umbilical vein and deoxygenated blood
returned to it via the umbilical arteries. Fig.18.12 Changes in body dimensions
The immature liver and lungs are bypassed by
temporary vascular channels (ductus venosus and A neonate has a relatively larger head and shorter
ductus arteriosus, respectively). Blood is also shunted lower limbs than an adult. This is also reflected in surface
from the right atrium of the heart to the left via a temporary area. The head is about 18% of a neonates surface area
opening (foramen ovale) between them. while only 9% of an adult's.

Circulatory changes at birth Calculating fluid loss from burns in neonates


Fluid loss from burns depends on surface area and may
be calculated from the rule of 9s.

Fig.18.11 Remnants after closure of vascular channels


At birth, respiration via the lungs occurs with the very
first breath. Also at birth (with oxygen supplied by
respiration from the lungs), the foramen ovale closes and
the bypass channels are obliterated, becoming ligamentous
remnants (ligamentum venosum and ligamentum
arteriosum, respectively). The umbilical vein and arteries
are also obliterated, becoming ligamentous remnants
(ligamentum teres and medial umbilical ligaments,
respectively). Fig.18.13 Changes in body surface area

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).

Fig.18.15 High larynx in a neonate


The tongue is short and broad and is located entirely in
the oral cavity. The larynx lies much higher than in the adult
(enabling the newborn to simultaneously swallow while
continuing to breathe).

Neonatal trunk and limbs


The bony thorax and pelvis are small relative to the size
of the abdominal viscera. The liver extends well below the
costal margin and even the spleen may be palpable. The
suprarenal glands (primarily due to the cortex) are also
large. Pelvic viscera (particularly the bladder) project
upwards into the abdomen beyond the pelvic brim.
Primary curvatures of the vertebral column (thoracic
and sacral) develop first (with the heart and lungs and
pelvic viscera, respectively).
Primary (diaphysial) centres of ossification are present
in all limb long bones. One or two secondary (epiphysial)
centres have appeared at the knee. A secondary centre in
the distal end of the femur is the key forensic index of foetal
maturity.
At birth the head of the femur is much larger than the
acetabulum (predisposing it to dislocation). Fig.18.16 Changes to skeleton from birth to childhood

160
18. Growth and Development

The skull vault almost reaches adult size by mid-


childhood. The skull base (with bones formed in cartilage
rather than membrane) continues to grow enabling the face
to move anteriorly. This accommodates future development
of the secondary (permanent) dentition. The bones of
the face and mandible grow as new teeth appear. At about
6 years the first permanent molar appears, followed soon
after by the lower, then upper, incisors.

Fig.18.19 Lymphoid organs reach maturity first

Growth of genital organs


The external and internal genital organs are immature
in both male and female children. They enlarge
dramatically following the end of childhood and in females
there is also mammary gland development.

Fig.18.17 Body of mandible sectioned in a child


Paranasal sinuses start to develop at the beginning of
the second year keeping pace with progressive eruption of
the maxillary teeth, contributing to changes in the shape
and size of the face. Fig.18.20 Genital organs start maturing last
Development of the pelvis allows the bladder and Changes at puberty include ossification of the
intestines to sink into it. This is associated with a flattening remaining secondary centres and maturation of secondary
of the anterior abdominal wall. sexual characteristics, including the external genitalia. Sex
Growth of nervous system differences in the skeleton become more apparent. In
males there is increased growth in width of the shoulders
In the newborn the brain is relatively large although the while in females the pelvis widens. In the male, onset of
cerebral cortex is only about half its adult thickness. secondary sexual characteristics is associated with
The neonatal cord terminates at about the level of the changes in the larynx (and deepening of the voice), in the
third lumbar vertebra. The adult level is higher (between L1 skin and distribution of hair on the body. In females the
and L2) due to the differential growth between the nervous menarche (G. month + beginning) marks the time of the
system and skeletal system. Myelination of nerve tracts is first menstrual period.
incomplete at birth, but occurs rapidly from about 6 months. Adolescence is associated with a sudden and rapid
A number of reflexes are present at birth, the most increase in growth in height. The adolescent growth
important (for survival) including sucking and swallowing. spurt is earlier in girls than boys, but in both sexes lasts
for approximately 2 years, after which increases in height
continue, although at a slower rate. In girls, most growth in
height is completed by the age of 18 years and in boys by
20 years. Typically, the earlier puberty begins the more
rapidly it develops and the earlier it finishes.

Epiphysial closure and adulthood


The end of the adolescence is associated with
adulthood (L. grown up) when the individual is physically
mature. Growth in height ceases and all epiphyses close.
Fig.18.18 Nervous system starts maturing first The centre of gravity of the body shifts downwards to about
the level of the pubic symphysis (due to accelerated growth
Growth of lymphoid organs in the length of the trunk during adolescence).
The thymus reaches its largest relative size at birth and
increases in absolute size until puberty (when it starts to Forensic determination of age
regress). Lymphoid tissue in general and the thymus in In forensic determination of age or gauging maturity the
particular are very active during childhood, releasing stage of reproductive, skeletal and dental development can
lymphocytes into the circulation to establish the immune be assessed from a combination of external features, X-
response. rays and dental records (providing reproductive, skeletal
Tonsillar tissue reaches its maximum development at and dental age, respectively).
about 6 years (and normally begins to involute afterwards).

Puberty and adolescence


Adolescence is the phase between the end of
childhood (about year 13) and the beginning of adulthood
(about year 20).

161
Chapter 19: Normal Variation

This occurs even before maturity is reached by many


other organs. The thymus is largely replaced by fibrous
AGE DIFFERENCES AND AGING tissue before the end of adulthood (having reached its
maximum size by puberty).
SEX AND BODY BUILD DIFFERENCES Lymphoid tissue in the spleen begins to decrease at
puberty and lymph nodes and tonsillar tissue also regress.
FUNCTIONAL DIFFERENCES Changes to bone marrow in adolescence
During adolescence red marrow in spongy bone of the
limbs is gradually replaced by fat, becoming yellow marrow
AGE DIFFERENCES AND AGING (except for the upper ends of the humerus and femur).
From adulthood red marrow is almost exclusively
confined to the axial skeleton (although yellow marrow can
revert to red marrow in response to severe blood loss).

Fig.19.1 Age changes in the mandible


Normal variation due to age differences parallels the
stages of normal (prenatal and postnatal) growth and Fig.19.3 Distribution of bone marrow types in an adult
development until maturity (which for most organ systems
is reached by adulthood). Humans tend to survive beyond Menopause
adulthood unlike wild animals, which are often killed by The menopause (G. month + pause) is the cessation
younger and healthier ones before effects of aging have of ovarian and uterine cycles. Although occurring at a
time to develop. variable time in different women, a normal ovarian cycle is
Reduction in organ size termed involution (L. to wrap rare beyond the age of 50. Diminution in the secretion of
up) may occur prior to the onset of old age. oestrogen leads to atrophy of the ovaries, shrinkage of the
uterus and atrophy of the breasts. A reduction in fat
Involution of lymphoid organs surrounding the breast causes the skin to wrinkle and sag.
The lymphoid organs are the first organs to involute. Post-menopausal osteoporosis occurs rapidly due to
lower oestrogen levels, which results in bone removal
exceeding bone deposition. At a critical level, post-
menopausal osteoporosis is associated with a high risk of
fracture.

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

androgens in men may be termed the andropause (G.


man + pause).

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.

Forensic determination of sex


. In forensic anthropology, identification from individual
bones is much less certain and often inconclusive.
However, sex can usually be confidently identified from
examination of complete adult skeletal remains.

The part of the skeleton that best distinguishes males


from females is the bony pelvis.

Typical male or female pelvis


There are identifiable differences in the shape and
dimensions of the typical male bony pelvis in comparison to
the typical female bony pelvis although the considerable
range of variation may obscure this. The pelvic type in the
male is typically android and in addition, the true pelvis is
small relative to the false pelvis. The inlet is heart shaped
and the mid-pelvis funnels to the small pelvic outlet, which
has a narrow sub-pubic angle. The pelvic type in the
female is typically gynaecoid, and in addition the false
pelvis is small relative to the true pelvis (which accentuates
its curve). The inlet is oval (wider transversely) and the
mid-pelvis remains wide to the large pelvic outlet, which
has a wide sub-pubic angle. Fig.19.5 Sex and body build differences in the humerus.

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

Prominent bone markings


Bones of heavily built males tend to be large and have
prominent bony markings produced by the pull of
correspondingly large muscles, tendons and ligaments.
This may in part be related to occupation. A manual worker
or an athlete is likely to have general or local muscular
hypertrophy (associated with larger bones).

Central and peripheral fat deposits


Body build is not only dependent on musculoskeletal
size but also on the amount of adipose (L. fatty) tissue.
While fat tends to be deposited in the subcutaneous tissue
there are also certain areas of preferential deposition and
these vary according to sex.
In males fat tends to be deposited within and around
the abdomen (producing a lemon-shaped body form) while
in females fat tends to be deposited around the buttocks Fig.19.6 Postural variation in position of organs
and thighs (producing a pear-shaped body form).
The surface markings and vertebral levels for organs
Fat distribution and cardiovascular risk based on anatomical descriptions of a recumbent cadaver
The central distribution of fat typically seen in males is may be vastly different to those in a living person standing
more likely to be associated with cardiovascular risk than upright.
the peripheral distribution, typically seen in females. The curvatures of the spine and the arches of the foot
are affected by lying, sitting or standing. Other effects of
Somatotyping posture include distension and pooling of blood in veins.
Somatotyping (G. body + form) is a method of
describing adult physique.
Normal variation with respiration
Mesomorphs are muscular with little subcutaneous fat,
while endomorphs and ectomorphs are at opposite ends
of a continuum possessing greater to lesser amounts of fat.
Excess body fat is termed obesity. It is common in many
western societies.

Body Mass Index


A measure of obesity may be derived from the Body
Mass Index (BMI).
2
BMI = weight (kg)/stature (m ).
A person with a BMI of 30 or more is regarded as
obese. A person with a BMI of 25-30 is regarded as
overweight.

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

Normal variation with pregnancy


In pregnancy, there is enlargement of the uterus (which
rises above the pelvic inlet after the first trimester).
Abdominal viscera (in particular those that are more
mobile) tend to be displaced upwards (e.g. the appendix
rises from its typical position in the right iliac fossa). Breast
enlargement (due to mammary gland proliferation) occurs
during pregnancy and beyond (until weaning or no longer
required).

Fig.19.10 This one I just did because Im a prick

Fig.19.8 Functional differences in a woman near full term

Fig.19.9 Bloody Norm made me put this in when I was


totally fucked

165
Chapter 20: Anatomical Variation in Structure

SIZE OR SHAPE

FEATURES OR ATTACHMENT

PRESENCE OR PERSISTENCE

ABSENCE AND DISAPPEARANCE

FUSION OR SEPARATION

NUMBER OR DUPLICATION
Fig.20.2 Variation in size of arterial branches

SIZE OR SHAPE Abnormally shaped viscera


The kidney is normally a paired organ that commences
Abnormally long or short organs development in the pelvis and migrates into the abdominal
The appendix in humans, although vestigial, is highly cavity during prenatal life. A horseshoe kidney (incidence:
variable in size (as well as orientation). In certain animals about 0.2%) is the product of two kidneys that have united
(e.g. ruminants that can digest cellulose) it can be even at their lower poles during migration, resulting in a
comparable in size to the large intestine. characteristic horseshoe-shape. Although without overt
functional impairment (hence regarded as an anatomical
anomaly rather than a congenital malformation), functional
reserve is decreased.

Fig.20.1 Abnormally long appendix


The size of muscle bellies relative to their associated
tendons is also variable. Palmaris longus has evolved a
small belly in conjunction with a long tendon. It is now
vestigial, with considerable variation in the degree of
disappearance of the belly (and even its position along the
tendon). Another example of a regressive variation is
plantaris in the leg, which also has a small belly relative to
the length of the tendon. Peroneus tertius is becoming
more developed in humans (a progressive variation).
Length of a duct (e.g. the cystic duct) is also variable. The Fig.20.3 Horseshoe kidney
cystic duct may be longer than normal (joining the common
hepatic duct at a lower level) or shorter than normal. The A horseshoe kidney may be endangered, particularly if
12th rib may be abnormally long or short. encountered unexpectedly during surgical procedures.
An abnormally long appendix produces no functional Part of the head of the pancreas may encircle the
impairment. However, it may be of clinical significance duodenum, creating an annular (L. ring) pancreas.
when inflamed, making diagnosis more difficult (especially
if it comes to lie adjacent to other structures and irritates
them).

Large or small vascular branches


Variations in size often affect branches of vessels and
tend to be reciprocal. Thus if one branch is larger (and
supplies a greater territory) another branch is reciprocally
smaller (and supplies a correspondingly lesser territory).
During development a vessel ultimately becomes the
preferred channel from a number of possible alternative
pathways. The vertebral arteries may vary in size, with one Fig.20.4 Annular pancreas
being larger than the other. The circle of Willis, an arterial Pelvic type in females
anastomosis at the base of the brain, may have only small
posterior communicating arteries connecting the internal The shape of the pelvis in a female can vary from the
carotid and vertebral systems. classic gynaecoid type (about 50%).

166
20. Anatomical Variation in Structure

incidence of other spinal anomalies (cranial shift of the


th
vertebral column) including a short 12 rib. A lumbar rib
may form from the (costal element of the) transverse
process of the 1st lumbar vertebra. This anomaly is also
associated with a higher incidence of other spinal
anomalies (caudal shift of the vertebral column) including
th
a long 12 rib. These anomalies may be unilateral or
bilateral, complete or partial.
A supracondylar process or spur (about 0.8%) and a
supratrochlear foramen (about 4%) are anatomical variants
in humans, although normal in certain animals. A spur may
be associated with a fibrous band (ligament of Struthers)
and even with other anomalies (e.g. muscular slips from
biceps and coracobrachialis, or high division of the brachial
artery).
The sternum ossifies from multiple centres on each
side. Occasionally a gap may remain between adjacent
centres leaving a sternal foramen (which may be confused
with a bullet hole).

Abnormal features of viscera


Abnormal features of viscera include those that appear
during development but usually disappear before birth. An
Fig.20.5 Gynaecoid pelvic type and variants in females ileal (Meckels) diverticulum (about 2%) may remain as an
outpouching at the midpoint of the midgut. Duodenal
The android (about 30%), anthropoid (about 20%) and diverticuli may also occur. Foetal lobulation of the kidney
platypelloid (about 2%) types, have obstetric significance. may persist as surface features demarcating each lobe. A
Being of different internal dimensions, labour can be developmental remnant associated with the thyroglossal
delayed or obstructed. duct is the pyramidal lobe of the thyroid gland (about 50%).
Extra or absent fissures on the surface of a lung may result
FEATURES OR ATTACHMENT in three lobes on the left or two on the right (a reversal of
the normal arrangement).
Abnormal processes and foramina The arch of the azygos vein may segregate part of the
lung, creating a lobe of the azygos vein (incidence: about
1%) although it is a normal feature of quadrupeds. This can
create a shadow on X-ray.

Fig.20.7 Azygos lobe of right lung


Variations in the lobes of the liver also occur (a multi-
lobed liver is normal in many animals). The uterus can be
Fig.20.6 Anomalous bony features bi-cornuate may also occur (multiple horns are normal in
the uterus of animals with litters). Deep notches of the
Although rib elements are present in cervical and spleen (creating multiple lobes) are associated with early
lumbar vertebrae, ribs normally occur only in the thoracic branching of the splenic artery.
spine.
A cervical rib (about 1%) may arise from the (costal Abnormal muscle attachments
element of the) transverse process of the seventh cervical Attachments of certain muscles or tendons also vary.
vertebra. This anomaly is associated with a higher Pectoralis minor may have a slip of origin up to the second

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).

Abnormal ligamentous attachments


A partial cervical rib tends to be completed by a fibrous
band (invisible on a plain radiograph). Although there is no
functional impairment, it is of clinical significance if the
cervical rib (or associated fibrous band) impinges on or
compresses neighbouring structures (subclavian artery
and/or lower trunk of brachial plexus).
Although a supracondylar spur produces no functional Fig.20.9 Presence of fabella in a radiograph of the knee
impairment, it tends to be attached by a fibrous band,
termed the ligament of Struthers (to the medial A sesamoid bone may also be present in the tendon of
epicondyle). A ligament of Struthers may encircle and peroneus longus (about 25%) and in the tendon of tibialis
compress neighbouring structures (brachial artery and/or posterior (about 22%).
median nerve). The persistent frontal (metopic) suture (about 8%,
although more common in certain races) may be complete
PRESENCE OR PERSISTENCE or partial. It is normally present during development
(generally disappearing by the age of 8 years) and has no
Muscles not normally present functional significance (but may have clinical significance if
confused with a fracture).
An extensor digitorum brevis manus is rare. It has no
functional significance but may have clinical significance if
it is misdiagnosed as a tumour.

Fig.20.10 Persistent frontal suture

Arteries not normally present


The thyroid ima artery (about 3%) arises from the arch
Fig.20.8 Presence of extensor digitorum brevis manus of the aorta and passes in front of the trachea, where it is
endangered by tracheotomy.
The axillary arch (about 7%) across the base of the A persistent superficial brachial artery (about 5%) may
axilla, sternalis (about 5%) on the front of the sternum and remain from an earlier stage of development, in addition to
rectalis of the anterior abdominal wall are all examples of the normal brachial artery. The median artery (about 8%)
muscles not normally present in humans but present in remains on the median nerve. The lateral costal artery
some other animals. Rarely a remnant of the tail may be (about 25%) arises from the internal thoracic artery (and
present in addition to the coccyx. Vestigial muscular tissue links to the upper six intercostal arteries).
on the pelvic floor represents the levator and depressor
caudae of tailed animals. Multiple branches arising close to each other can have
Scalenus minimus is an additional muscle of the neck a common stem.
(to scalenus anterior, medius and posterior) attaching to
the first rib. This particularly applies to the arch of the aorta. A
common trunk for the left common carotid artery and
Bones not normally present brachiocephalic trunk (about 22%) may occur. A common
Abnormal presence of sesamoid bones may occur. trunk for the left subclavian and left common carotid
The fabella (about 20%) occurs in the tendon of origin arteries (about 1%) may also occur. A common trunk from
of the lateral head of gastrocnemius and can be mistaken the external carotid artery for the lingual and facial arteries
for a loose body in the knee joint. (about 20%) may occur.

168
20. Anatomical Variation in Structure

Veins not normally present Absent vessels


A persistent left inferior vena cava may remain between A large anastomosing branch of a neighbouring artery
the left common iliac veins and the left renal vein, in may replace an artery and take over its territory.
addition to the normal inferior vena cava.
The dorsalis pedis artery may be absent (about 10%)
Variations in venous patterns are extremely common with its territory taken over by the perforating branch of the
as veins develop from numerous endothelial channels. peroneal artery. The lateral thoracic artery may be absent
and its territory taken over by neighbouring branches of the
These are too common to be considered anomalies. axillary artery. Posterior communicating branches of the
Many veins (and their tributaries) are un-named. arterial circle of Willis (at the base of the brain) may be
absent. The median cubital vein (linking the cephalic with
ABSENCE OR DISAPPEARANCE the basilic vein) may be absent it is replaced by a median
cephalic and a median basilic vein, which join forming a V.

Fig. 20.12 Absent median cubital vein (on left)

Unilateral agenesis of an organ


Agenesis (G. absent + formation) of an organ is
regarded as an anomaly rather than a congenital
malformation, provided there is no functional impairment.
This applies only to certain viscera that are normally paired,
Fig.20.11 Absent palmaris longus (on right)
as absence of an unpaired viscus cannot be compensated.
Absent muscles and tendons One kidney may be absent (about 0.2%) without
functional impairment, although there is diminished
Complete absence of one or both palmaris longus functional reserve despite compensatory enlargement.
muscles and associated tendons is common (about 15%). Before a paired organ is surgically removed the
This has no functional significance but the otherwise presence of its counterpart on the opposite side should be
underlying median nerve may be confused with this tendon. confirmed. Bilateral renal agenesis is a congenital
It is also more vulnerable to laceration, being directly under malformation that is incompatible with life (at least soon
the skin. after birth). Unilateral testicular or ovarian agenesis may
Complete absence of plantaris is less common (about also occur.
6%). The sternocostal head of pectoralis major may also be
absent. Peroneus tertius may be absent (about 6%).
FUSION OR SEPARATION
Absent vascular trunks
Fused bones
An arterial trunk arsing from a main artery and
subsequently dividing can be absent, with its branches
arising independently.

The brachiocephalic trunk may be absent (about 2%)


with the right subclavian and right common carotid arteries
arising independently from the aortic arch.
The common interosseous artery is an arterial trunk that
may be absent (about 10%). When this occurs the anterior
and posterior interosseous arteries arise independently
from the ulnar artery.
The right bronchomediastinal, subclavian and jugular
lymph trunks may join to form the right lymphatic duct,
which is the classic anatomical description. However, the
right lymphatic duct is much more commonly absent (about
80%) and the lymph trunks enter the venous system
independently. Fig.20.13 Partial sacralisation of L5

169
HUMAN DEVELOPMENT AND VARIATION

Abnormal fusion of vertebral elements tends to occur


at transitional regions

Partial or complete fusion of the fifth lumbar vertebra to the


sacrum (about 5%) is termed sacralisation of L5. If
complete, there is a reduction of lumbar vertebrae from five
to four (about 1%).
Occipitalisation of the atlas may occur, where the first
cervical vertebra is incorporated into the occipital bone of
the skull.
The lunate of the wrist may fuse with the adjacent
triquetrum. Fusion of phalanges may occur, particularly in
the little toe. A fractured biphalangeal little toe may be
overlooked.

Incomplete fusion of bones


Fig.20.16 Os tibiale externum in a radiograph of the foot
The patella develops from multiple centres of
ossification. One of these may remain unfused, creating a
bipartite patella. Small accessory bones may occur within
the sutures of the skull. These are termed sutural (or
wormian) bones. The zygomatic bone may ossify in two
parts, creating the os japonium (about 0.2%). The occipital
bone may also ossify in two parts, creating the inter-parietal
bone or os incae. These accessory bones are more
common in certain races. The os odontoideum is a
nd
separate tip of the odontoid process of the 2 cervical
vertebra.
Accessory bones cause no functional impairment but
have clinical significance if mistaken for a fracture on X-ray.
As they may be bilateral in about one in three individuals
Fig.20.14 Sacralisation of L5 and lumbarisation of S1 with the anomaly, X-ray of the corresponding part on the
opposite side provides confirmation in such cases.
Partial or complete separation of the first sacral
vertebra from the rest of the sacrum (about 5%) is termed Cranial or caudal shift of spinal elements
lumbarisation of S1. If complete, there is an additional Genetic variation can produce changes in
lumbar vertebra (from five to six). segmentation, which relies upon the differential expression
Accessory bones of sets of genes in the long axis of the body about the
fourth week of development.
Accessory bones are created by failure of a centre of
ossification to fuse with the rest of the bone. Anomalies of bony fusion and non-fusion may create a
domino effect along the spine.
The os acromiale (about 8%) is an atavistic (L.
ancestor) epiphysis. This is a phylogenetic remnant of a
discrete bone in certain animals. The epiphysis for the tip of
the acromion remains separate from the rest of the
scapula.

Fig. 20.15 Os acromiale


Accessory bones in the foot include the os trigonum
(about 8%), a separate lateral tubercle of the talus bone
and the os tibiale externum (about 4%), a separate
tuberosity of the navicular bone. The os trigonum is the
homologue of the lunate bone in the hand (representing the
phylogenetic os intermedium seen in certain animals). Fig.20.17 Clusters of associated spinal anomalies

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.

Fig.20.18 Accessory renal arteries

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

This has clinical significance if not recognised as


ectopic thyroid tissue (particularly if this is the only site of
SITE OR ORIENTATION thyroid tissue) and is surgically removed.

SIDE OR COMMUNICATION Ectopic organs and tissue


During development migration may occasionally
ORIGIN OR BRANCHING overshoot the normal site or deviate to an abnormal
site.
COURSE OR RELATIONSHIP Anatomical variation in position of parathyroid glands
may be due to migration overshooting its descent to the
DIVISION OR DEPTH normal site adjacent to the thyroid gland. This has clinical
significance in thyroid surgery if an ectopic parathyroid
gland is inadvertently removed.
ENDING OR DISTRIBUTION Ectopic pancreatic tissue (about 2%) may be found in a
persistent ileal diverticulum, as may ectopic gastric tissue.

SITE OR ORIENTATION Abnormally mobile viscera


The position of certain abdominal viscera can vary
Incomplete ascent or descent considerably due to due to excessive mobility from an
abnormally long mesentery. In such cases the stomach or
During development migration may occasionally fall
large intestine may even lie in the pelvis.
short of the normal site.
The retention of a mesentery that normally disappears
can create an excessively mobile caecum (about 10%),
The kidney ascends from the pelvic cavity during
predisposed to twisting (caecal volvulus). This may lead to
development and migrates to its normal position on the
strangulation and subsequent gangrene.
posterior abdominal wall, adjacent to the suprarenal glands
(which develop separately). Its vascular supply changes as Abnormally oriented viscera
it ascends by progressively receiving (and losing) vessels
from the nearest major arteries and veins. A pelvic kidney The orientation of the appendix is highly variable.
(about 0.1%) falls well short in its ascent. Its (segmental) Although the position of its base at the caecum is constant
arteries arise primarily from the adjacent part of the aorta the rest of the appendix may point in any direction. The
(or common iliac arteries) and its veins drain primarily to normal orientation is retrocaecal (about 64%). The most
the adjacent part of the inferior vena cava (or common iliac common anomaly is a pelvic appendix (about 32%).
veins). In contrast, the suprarenal gland remains in the
normal position.

Fig. 21.2 Variations in orientation of appendix


Other anomalies include transverse (about 2.5%), pre-
ileal (about 1%) and retro-ileal appendix (about 0.5%).
The uterus is normally anteverted as the long axis of
the cervix is directed more anteriorly than the long axis of
the vagina. A retroverted uterus is a common variant.

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.

Fig.21.3 Left-sided inferior vena cava


There is also an association with some degree of
visceral transposition (e.g. the heart being situated on the
right side of the body) or vascular transposition (e.g.
reversal of the azygos venous system with the azygos vein
on the left, the hemiazygos and accessory hemiazygos
veins on the right). These have clinical significance as
unexpected findings on physical examination, imaging or at
surgery.

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.

Origin on abnormal arterial trunk


Whenever multiple branches lie close to each other,
they may arise from a common stem rather than
independently. This particularly applies to the arch of the
aorta. The left common carotid artery may arise in common
with the brachiocephalic trunk (about 22%). The left
subclavian and left common carotid arteries may arise by a
common trunk (about 1%). The lingual and facial arteries
Fig.21.6 A normal and an aberrant obturator artery
may arise from a common trunk (about 20%) rather than
independently from the external carotid. Both anterior and A few classic' patterns (described in textbooks as the
posterior circumflex humeral arteries may arise from a standard) are themselves atypical or present in less than
common trunk (about 20%) rather than independently from 50% of cases. It is contentious as to which pattern is
the axillary artery. The profunda brachii artery may arise anomalous. For example, a complete superficial palmar
from a common trunk with the posterior circumflex humeral arch in the hand (linked to the superficial palmar branch of
artery (about 14%). the radial artery) occurs in fewer than 30% of cases. A
classic thyrocervical trunk is present in fewer than 50% of
Abnormal arterial branching cases. A classic branching pattern of the axillary artery
Vessels develop from networks that have the potential occurs in only about 10% of cases. Even a classic circle of
for change, where preferred channels remain while Willis (at the base of the brain) is present in just over 50%
others regress (providing scope for variation). of cases.

Abnormal nerve branching


Branching patterns of nerves are also variable
(although less so than vessels), particularly those arising
from a nerve plexus and associated components (including
roots and branches).
Although axons in a nerve plexus do not directly
communicate with each other (in contrast to vascular
anastomoses that intercommunicate via lumens) they are
wrapped in common connective tissue sheaths. Axons
therefore tend to be bundled in a variety of ways, leading to
variation in the origin of a nerve from a plexus or branches
arising from a particular nerve (depending on the
epineurium they finally get wrapped in).
The musculocutaneous nerve and the median nerve
both arise from anterior divisions of the brachial plexus and
can contain branches from each other (incidence: about
20%). The brachial plexus may arise from more cranial
spinal nerve roots (pre-fixed) or more caudal (post-fixed).
These may be associated with vertebral column anomalies
(e.g. cranial and caudal shift), particularly those affecting
Fig.21.5 Scope for variation during arterial development the number of vertebrae.

The pattern of preferred channels produces alternative COURSE OR RELATIONSHIP


pathways (e.g. where the same set of arteries may supply
a particular territory but via different routes). These Abnormal course of an artery
variations tend to be reciprocal (i.e. if one branch is
smaller, another is larger to compensate). Branches may An artery may take an abnormal course, even though it
also arise at a more proximal or more distal site along an has a normal site of origin.
artery. Ultimately every individual has a unique branching The vertebral artery may enter the foramen
pattern for each vessel, as there is no requirement at this transversarium of the fifth cervical vertebra (about 5%) or
level for symmetry. Like fingerprints, even the branches of less commonly the seventh, fourth or third rather than its
the central artery of the retina (as seen in examination of normal course into the sixth.
the optic fundus) are peculiar to each individual.
Abnormal course of aberrant artery
Branching patterns often vary, particularly for arteries
that anastomose with other arteries. Any alternative path A retro-oesophageal right subclavian artery (about 1%)
may become the preferred channel. The inferior epigastric arises aberrantly from the arch of the aorta (to the left of
and obturator arteries normally anastomose via their pubic the left subclavian artery) instead of from the
branches. An aberrant obturator artery arises from the brachiocephalic trunk (which is absent). It takes an
epigastric artery (about 30%) where a large pubic branch abnormal path behind the oesophagus and may compress
replaces the normal origin from the internal iliac artery or is it, causing dysphagia (G. bad + eat; i.e. difficulty in
additional to a normal obturator artery (i.e. an aberrant swallowing). The special case of dysphagia due to
accessory obturator artery). compression by an anomaly is termed dysphagia lusoria

174
21. Anatomical Variation in Position

(L. a sport of nature). The anomaly itself has no functional


impairment of blood flow, but may have clinical impact on
an adjacent structure (in this case, the oesophagus).

Fig.21.8 Superficial ulnar artery from a high division


A high division of the axillary artery (about 4%) or of the
Fig.21.7 Retro-oesophageal right subclavian artery brachial artery (about 6%) can occur. The high division may
either be due to persistence of the superficial brachial
10% of aberrant obturator arteries pass medial to the artery (the brachial artery dividing subsequently into radial
femoral canal rather than lateral to it and are regarded as and ulnar arteries) or division directly into radial and ulnar
endangered aberrant obturator arteries (about 3% overall). arteries.
Because it lies along the free margin of the lacunar The roots of the median nerve normally pass in front of
ligament, the artery is potentially endangered in femoral the axillary artery, however with a high division of the
hernia surgery (where the lacunar ligament is cut). axillary artery one branch passes in front of them. The
median nerve normally passes in front of the brachial artery
Abnormal relations of an artery in the arm. If the brachial artery disappears, instead of the
The inferior thyroid artery has a variable relationship to superficial brachial artery, the median nerve remains
branches of the recurrent laryngeal nerve adjacent to the deeply located (about 12%). Where there is a pair of
thyroid gland. The artery (in about equal proportions) may brachial arteries in the arm (about 10%) the median nerve
run superficial to, deep to or through the nerve branches passes between them. The popliteal artery normally divides
(which are therefore endangered in thyroid surgery). at the distal border of popliteus however it may divide at its
The right hepatic artery passes in front of the common proximal border (about 2%).
hepatic duct (about 24%) and behind the portal vein (about
9%). Abnormally superficial artery
The cystic artery passes in front of the common hepatic The ulnar artery normally passes deep to the common
duct (about 24%). It is endangered in gall bladder surgery. origin of the forearm flexor muscles however; it may pass
superficial to them (about 3%) particularly if associated with
Abnormal course of a nerve a high division of the brachial artery. A superficial ulnar
In coursing from the axilla to the anterior compartment artery can be endangered by inadvertent injection (as it
of the arm the musculocutaneous nerve may pass tends to be mistaken for a superficial vein). Intra-arterial
superficial to coracobrachialis rather than through it. injection of certain drugs may produce intense
A non-recurrent right recurrent laryngeal nerve occurs vasoconstriction causing death of forearm and hand
in association with an aberrant right subclavian artery. musculature. Injection of anaesthetic agents should not be
Instead of looping under the right subclavian artery it given in the cubital fossa for this reason.
passes from the right vagus nerve directly to the larynx and
is endangered in thyroid surgery. Abnormally deep artery
The maxillary artery normally passes superficial to the
DIVISION OR DEPTH lateral pterygoid muscle but may pass deep to it (about
30%).
Abnormally high division of artery Abnormally high division of a nerve
During development, the axillary artery divides into a
The sciatic nerve normally passes below piriformis,
pair of arteries (brachial artery and superficial brachial
however with a high division (about 12%) the common
artery). The latter normally disappears and the brachial
peroneal portion of the nerve pierces piriformis or may
artery divides into two branches: radial and ulnar, at the
even pass above it (about 0.5%).
level of the cubital fossa.

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.

Fig.21.10 Normal coronary arteries (right dominance)


The left coronary artery may provide the posterior
interventricular branch/PDA (about 10%), termed left
dominance. When both coronary arteries contribute
equally to the PDA, it is termed balanced (about 5%).

Fig.21.11 Angiogram of dominant left coronary artery


Other variations even include a single coronary artery,
which provides all branches. The sino-atrial nodal branch
Fig.21.9 Asymmetrical distribution of cerebral arteries may arise from the left coronary artery (about 45%) and the
Generally blood from the two arterial systems: internal atrio-ventricular nodal branch from the left coronary artery
carotid and vertebro-basilar) does not mix, but the (about 10%).
anastomosis provided by the communicating arteries The area of myocardial infarction from a coronary
enables the potential for alternative paths in occlusion occlusion in a particular individual is dependant on the
affecting one or more of them. The clinical features of a pattern of distribution and degree of coronary artery
stroke from such occlusion are therefore influenced by the dominance. This is of particular significance regarding
anatomical arrangement of the circle of Willis. supply of the conducting system and the associated risk of
a life-threatening arrhythmia.
Abnormal lymph trunk or vein ending
Terminations of the lymph trunks (jugular, subclavian,
bronchomediastinal) may enter veins independently of the
thoracic duct or right lymphatic duct. The inferior
mesenteric vein typically terminates in the splenic vein but
may terminate in the superior mesenteric vein (about 10%)
or at the junction of the splenic and superior mesenteric
veins (about 30%). Tributaries of the great saphenous vein
176
Chapter 22: Pathological Changes

About 25% of newborns with a major malformation have


other major malformations and generally do not survive for
CONGENITAL MALFORMATIONS long.
There are associations between certain birth defects.
ACQUIRED DISORDERS The specific malformations produced depend on the critical
stage of development reached by organs at the time of
influence from the causative factors.
The most common major malformations involve the:
CONGENITAL MALFORMATIONS - central nervous system (about 30%)
- cardiovascular system (about 30%)
Congenital (L. with + born) malformations, also - digestive system (about 10%)
termed birth defects, are pathological structural changes - urogenital system (about 10%)
that arise before birth. However, certain abnormalities from - musculoskeletal system (about 10%)
defective prenatal growth and development may not be A malformation syndrome (G. 'running together') is a
diagnosed until later. Major malformations are recognised cluster of certain birth defects, particularly due to
in 2- 3% of live newborn babies and an additional 2- 3% chromosomal abnormalities.
during infancy. Single minor malformations occur in about Down's syndrome (e.g. from an extra chromosome
15%. 21) typically includes cardiac, craniofacial and many other
Functional impairment defects, both major and minor, along with mental
retardation.
There is a fine line between the anatomical variation
of anomalies and the pathological changes of congenital Defective closure or migration
malformations. Defective closure of the inter-ventricular septum or
inter-atrial septum of the heart results in ventricular septal
In contrast to anatomical variation (with abnormal defects (incidence: about 0.4% of live births) and atrial
structure or position but no functional impairment) septal defects (incidence: about 0.2%), respectively.
pathological changes have impaired function, even if Ventricular septal defects may be isolated or part of Fallot's
not immediately evident. tetralogy.
The abnormalities most difficult to classify are those
present at birth without functional impairment, but with a
diminished functional reserve. A structural abnormality (e.g.
a patent foramen ovale or horseshoe kidney) that remains
symptomless throughout life as an incidental finding (e.g.
on imaging or at post-mortem) is considered to be an
anatomical anomaly. In contrast, a structural abnormality
(e.g. an atrial septal defect or polycystic kidney) that is
symptomless at birth but later manifests functional
impairment is considered to be a congenital malformation.

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.

Malformations occur when organ systems are forming


(between the third to eighth weeks) and most major
malformations spontaneously abort.

About 20% of perinatal deaths are also due to


congenital malformations. Genetic mutations and
chromosomal abnormalities are solely responsible for
about 15% of malformations. Environmental causes are
solely responsible for about 10% and include physical
agents (e.g. radiation), chemical agents (e.g. drugs) or
organisms (e.g. certain viruses). The remainder (about
75%) are from multifactorial or unknown causes.

Major and multiple minor malformations


Multiple minor malformations generally signify an
underlying major malformation.

This is important in the routine examination of a


newborn child. Fig. 22.2 Tetralogy of Fallot

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.

Fig.22.3 Spina bifida


However, spina bifida occulta (about 2%) is minor
affecting the neural arch of one or more vertebrae and Fig.22.5 Polycystic kidney
often not detected.
Aqueductal stenosis in the brain may cause congenital
hydrocephalus, with accumulation of cerebrospinal fluid
and enlargement of the cranium. Stenosis of the pulmonary
or aortic valves in the heart may occur and in coarctation of
aorta (about 0.1%) a constriction is located near the ductus
arteriosus.
Certain structures may fail to form.
These include digits and even limbs. An absent or
rudimentary brain is known as anencephaly (about 0.1%)
and in bilateral renal agenesis (about 0.03%) both kidneys
are absent. Congenital absence of lymph vessels in a lower
limb (Milroy's disease) results in lymphoedema. An absent
uterus (about 0.02%) and even vagina may occur.
Certain structures may form defectively.
Chest deformities (about 0.1%) may result in funnel
chest (depressed sternum) or pigeon chest (protruding
sternum). Congenital dislocation of hip may be due to
defective formation of the acetabulum of the hipbone. It
requires recognition (and splinting) prior to weight bearing
to prevent long-term effects. Talipes (club foot) results in a
Fig.22.4 Tracheo-oesophageal fistula deformity. In polydactyly there is an extra digit or digits and
in syndactyly two or more digits are fused.
An abnormal passage may remain from defective Failure of development of a centre of ossification in the
closure of the trachea from the oesophagus as a serious body of a vertebra results in hemivertebra with associated
tracheo-oesophageal fistula (about 0.05%). An auricular pit, scoliosis of the spine.

178
22. Pathological Changes

The degree of the inflammatory response depends on the


anatomical site and local blood supply, as well as on
general health and immunity.

Fig.22.8 Acute lobar pneumonia


Fig.22.6 Scoliosis due to a hemivertebra
The two types of inflammation are acute and chronic.
Failure of development of epiphyses of long bones Acute inflammation is characterised by the cardinal
produces an achondroplastic dwarf. Microcephaly of the signs of redness (rubor), swelling (tumor), heat (calor)
head and micrognathia of the jaw may occur. Certain and pain (dolor). This response is due to increased blood
genetic disorders (e.g. adrenogenital syndrome from flow from vasodilatation (hyperaemia), leakage of fluids
congenital adrenal hyperplasia) and chromosomal and plasma proteins from increased vascular permeability
disorders (e.g. Down's syndrome, Turner's syndrome and (exudation) and passage of certain white blood cells from
Klinefelters syndrome) also produce defective formation of the blood to surrounding tissues through the vessel wall
organs as secondary effects. (emigration).
The possible sequelae of acute inflammation are
restoration to normal (resolution), passage along
ACQUIRED DISORDERS anatomical pathways (spread), abscess formation
There is a fine line between normal variation and (suppuration), scar formation (fibrosis) or procedure to
pathological variation regarding acquired disorders. The chronic inflammation.
normal variations most difficult to classify are those due to Spread may be direct (e.g. along fascial planes),
aging. The normal changes associated with senescence lymphatic (via local lymph vessels to regional lymph nodes
merge with certain degenerative disorders. There is even a (containing collections of defence cells that filter lymph
fine line between congenital malformations and acquired prior to its return into the venous system) or blood (via local
disorders. The most difficult to classify are those birth veins prior to circulating around the body).
defects that do not manifest themselves until later in life, An abscess (L. 'to go away') is a localised collection of
and those acquired conditions that have a primarily genetic pus (dead tissue, defence cells and micro-organisms) due
basis. to massive emigration of certain white blood cells. A scar is
due to the production of collagen fibres from connective
Traumatic disorders tissue cells that proliferate after damage associated with
Trauma is the disruption of tissues by physical injury. acute inflammation. Chronic inflammation may follow acute
inflammation if the causative agent remains (e.g.
The nature of the traumatic condition is dependent on the
persistence of a foreign body) or may occur from the outset
type of anatomical structure involved: skin or mucous
with an organism of low virulence. There is infiltration of
membrane ulceration (loss of epithelial continuity), soft
tissue laceration (tearing) or contusion (crushing), muscle certain defence cells together with the proliferation of
or tendon strain, ligament sprain, bone fracture or joint connective tissue.
dislocation. For certain of these (e.g... muscle strains or Degenerative disorders
ligament sprains) the degree of disruption may be classified
as microscopic (first degree), partial (second degree) or Degeneration is the effect on living cells by injury. The
complete (third degree). cells primarily affected are those embedded in the vascular
and connective tissues of an organ. These specific cells
(parenchymal cells) are most sensitive to direct harm from
the injury while the vascular and connective tissues react to
the injury (via an inflammatory response). The cause of the
injury may be direct (e.g. by a physical, chemical or
organism agent) as well as indirect (from associated
inflammation). Parenchymal cells are also sensitive to
injury from lack of oxygen. Effects on cells range from
injury of the cytoplasm (cell damage) that is reversible
(e.g. hydropic swelling, fatty change) through to injury of
Fig.22.7 Spinal injury with associated cord damage the nucleus, resulting in cell death (necrosis) that is
Inflammatory disorders irreversible. The sequel of necrosis is generally repair,
involving surviving parenchymatous cells (via
Inflammation is the response of living tissues to injury. regeneration) and the connective tissues (via fibrosis).
The cause of the injury may be physical, chemical, Certain highly specialised cells (e.g. nerve and muscle)
organismal or autoimmune. The inflammatory response have lost the capacity to divide (and thus replace necrotic
is produced by vascular and connective tissues, directed cells). Other possible sequelae are deposition of calcium in
towards protection. However, it may result in some damaged tissue (calcification), dissolving dead tissue
collateral damage (and in autoimmune conditions the body (lysis) with cyst formation and infection of a necrotic part
is tricked into attacking a particular normal host tissue). (gangrene).

179
HUMAN DEVELOPMENT AND VARIATION

A mass formed from blood elements within the vascular


system during life is termed a thrombus (G. clot) while a
substance that is carried in the blood stream and lodges in
a vessel is termed an embolus (G. plug).
Arterial occlusion may produce a restriction of blood
flow, termed ischaemia (G. keep back + blood), through
to tissue death from interruption of supply, termed
infarction (L. stuffing).

Fig.22.9 Cirrhosis of the liver


Where continuous damage occurs, some necrosis and
repair may even take place simultaneously (although
associated with a degree of disruption of normal
architecture) in the organ (e.g. cirrhosis of the liver from
chronic alcoholism).
Apoptosis (G. 'dropping off') is programmed cell death,
particularly associated with aging.
Other degenerative conditions involve extracellular
infiltrations into surrounding tissues including protein Fig.22.11 Cerebrovascular accident from hypertension
deposition (e.g. amyloid) around blood vessels of certain
Mechanical disorders
organs and pigmentation from products of red blood cell
breakdown (e.g. haemosiderin, bilirubin) or from inhalation Mechanical disorders, as distinct from traumatic (where
of particles (e.g. carbon, silicone) into the lungs. there is tissue disruption from physical injury), involve a
physical cause altering structure and/or impairing function.
Neoplastic & growth disorders These include compression from the outside (e.g. by a
A neoplasm (G. new + moulding) is an abnormal surrounding structure) and collapse from the inside (e.g. of
mass of tissue capable of progressive growth. A neoplasm a lung). Other mechanical disorders include obstruction of
may be either benign or malignant. A malignant neoplasm a hollow viscus. This may be associated with an abnormal
is often called cancer (L. 'crab') tending to spread by local dilatation (of the wall and lumen) proximal to the
invasion (direct spread) and/or dissemination via obstruction.
lymphatics, blood vessels or even across a body cavity. Hernia (L. rupture) is an abnormal protrusion of an
Malignant neoplasms include those in the host tissue (a anatomical structure through an opening, defect or
primary) or those spread to distant sites (secondaries). weakness. Prolapse (L. falling) is the dropping of an
organ from its normal position (e.g. due to weakness of its
supports, coupled with gravity).

Fig.22.10 Carcinoma of the colon


Secondary neoplasms are also termed metastases (G.
beyond + standings). A carcinoma (G. 'cancer' + Fig.22.12 Hydronephrosis of kidney
'swelling') is a malignant neoplasm derived from epithelial
cells (whether of a surface lining or of a gland), while a The cause of a disorder may be the consequence of
sarcoma (G. 'flesh' + 'swelling') is derived from connective another. A mechanical disorder may be a sequel of a
tissue or muscle cells. Other disorders of growth include traumatic disorder (e.g. injury to one organ may produce
atrophy (a decrease in size from wasting), hypertrophy compression of an adjacent organ) or of a neoplastic
(an increase in cell size), hyperplasia (an increase in cell disorder (e.g. a carcinoma may obstruct a hollow viscus
number), dysplasia (abnormal cellular development) and producing a dilatation proximal to it). In each of these cases
metaplasia (transformation of mature cells into an the normal anatomy is altered.
abnormal form).
Understanding of normal and abnormal anatomy is the
Circulatory disorders basis for recognising clinical manifestations of disease
Circulatory disorders include an accumulation of blood processes.
within the vessels of an organ (congestion), an
accumulation of extravascular fluid (oedema), bleeding
from vessels (haemorrhage) and an inadequate perfusion
of tissues throughout the body (shock)
A haematoma (G. blood + swelling) is a localised
extravascular collection of blood. A localised dilatation of
an artery due to a weakness in its wall is termed an
aneurysm (G. widening).

180
Section V
PRACTICAL PERSPECTIVES

Introduction: 'Anatomy involves exploration'

Chapter 23: Surface and Functional Anatomy


Chapter 24: Radiographic Anatomy and Imaging
Chapter 25: Sectional Anatomy, CT and MRI
Chapter 26: Ultrasound Imaging
Chapter 27: Endoscopic Anatomy
Chapter 28: Clinical Procedures
Chapter 29: Postmortem Examination of Organs
Chapter 30: Cadaver Dissection

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

The borders of these may be mapped on the skin by


imaginary lines representing the surface projections of their
SURFACE REGIONS underlying bony and soft tissue boundaries.
Two in three (48 of 72) regions of the body include
SURFACE MARKINGS AND EXAMINATION some external surface. Their borders may also be mapped
on the skin by imaginary lines. They include more than half
SURFACE MAPS OF SUPPLY TERRITORIES of the head and neck regions, some trunk regions, but all of
the limb regions. The remaining (24) regions are deeply
located without any direct skin covering.
FUNCTIONAL ANATOMY AND TESTING
Surface regions of head and neck

SURFACE REGIONS

Fig.23.2 Surface regions of head

Fig.23.3 Surface regions of neck

Surface regions of trunk

Fig.23.1 Surface of modules


Each body module includes some external surface. Fig.23.4 Surface region on back of trunk

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

Surface regions of lower limb

Fig.23.5 Surface regions on front of trunk

Fig.23.6 Surface regions on perineum

Surface regions of upper limb

Fig.23.8 Surface regions of lower limb


1. - femoral triangle
2. - subsartorial canal
3. - anterior compartment of thigh
4. - medial compartment of thigh
5. - anterior compartment of leg
6. - lateral compartment of leg
7. - dorsum of foot
8. - dorsal aspect of digits
9. - gluteal region
10. - posterior compartment of thigh
11. - popliteal fossa
12. - posterior compartment of leg
13. - tarsal tunnel
14. - sole of foot
Fig.23.7 Surface regions of upper limb 15. - plantar aspect of toes

184
23. Surface and Functional Anatomy

SURFACE MARKINGS AND EXAMINATION lower limbs = 4x9%,


upper limbs = 2x9%,
Skin features and body build head and neck = 1x9%
Total = 99% (+ genitals the remaining 1%).

Fig.7.7 'Rule of nines for adult body surface area

Bony landmarks

Fig.23.10

Fig.23.9

Body surface area


Skin (including its specialisations) covers the entire
external surface of the body. The surface area of an
average adult male is approximately two square meters.

Fluid loss in burns and rule of nines


In burns, fluid loss is proportional to the surface area
affected.

This is calculated to determine the amount of fluid


replacement required.
According to the rule of 9s:
the trunk = 4x9%
185
PRACTICAL PERSPECTIVES

Surface projections of viscera

Fig.23.13
Fig.23.11

Soft tissue landmarks

Fig.23.14

Normal variation with posture


When standing, due to gravity, all abdominal viscera
descend, particularly those that are more mobile.
Fig.23.12
The viscera that are most mobile are those suspended
by a mesentery.

The stomach and transverse colon are especially


mobile, each having two mesenteries (which may be of
considerable length). In certain individuals the stomach or
transverse colon may even descend to the pelvis.

186
23. Surface and Functional Anatomy

Sites where motor nerves are superficial

Fig.23.15 Postural variation in position of organs


The surface markings and vertebral levels for organs
based on anatomical descriptions of a recumbent cadaver
may be vastly different to those in a living person standing
upright.
The curvatures of the spine and the arches of the foot Fig.23.17
are affected by lying, sitting or standing. Other effects of
posture include distension and pooling of blood in veins. Sites where arteries are palpable
Arterial pulsation is best detected by palpation at a site
Normal variation with respiration where an artery is closely related to both skin and bone.

Fig.23.16 Movement of organs during breathing


During inspiration the lungs expand and viscera directly
below the diaphragm, particularly the liver (and gall
bladder), spleen and kidneys, are pushed downwards as it
descends.
Physical examination of abdominal organs includes
attempting to palpate them on full inspiration.

Fig.23.18 Sites for palpation of arteries against bone


The usual site for clinical examination of an arterial
pulse is where the radial artery lies on the distal end of the
radius just deep to skin of the wrist.

187
PRACTICAL PERSPECTIVES

Sites where lymph node groups are palpable

Fig.23.19 Palpating the radial artery against bone


Other sites where arteries may be pressed against
bone include the common carotid artery on the carotid
th
tubercle (of the 6 cervical vertebra) and the facial artery
on the body of the mandible. Although the femoral artery is
not directly related to bone, it is large and is close to skin
just below the mid-inguinal point (at the base of the femoral
triangle) where its pulsation may also be palpated.

Measurement of blood pressure


Systolic and diastolic blood pressure can both be
measured clinically (utilising a sphygmomanometer and
cuff) by auscultation (with a stethoscope). The cuff is
wrapped around the arm to overlie and (when pumped up)
compress the brachial artery. This site is selected because
it is at the approximate level of the heart (thus without Fig.23.22
additional hydrostatic pressure). The diaphragm of the Significance of signal node enlargement
stethoscope is placed over the brachial artery near its
termination. Tapping sounds are produced when flow Enlargement of this left supraclavicular lymph node may
becomes intermittent (between systolic and diastolic blood signal lymph spread of cancer from a structure within the
pressures) as pressure in the cuff is gradually released. territory drained by the thoracic duct. It may even be the
first (although late) sign of cancer in a thoracic organ (e.g.
Clinical examination of the pulse lung) or abdominal organ (e.g. stomach or testis), since the
Pulse rate and rhythm may be detected clinically by thoracic and abdominal lymph nodes are all deeply located
palpation of any accessible artery. The radial artery at the and none are readily palpable.
wrist is usually chosen because at this site it is easily felt
between skin and bone (the distal end of the radius). Pulse
volume and character may be detected clinically by
palpation of the common carotid artery in the neck against
the carotid tubercle (on the transverse process of C6).
Palpation should not be performed near the carotid sinus
(at the level of C3/4) where compression of baroreceptors
may cause reflex bradycardia and subsequent
hypotension).

Sites where veins are accessible

Fig.12.17 The final sentinel lymph node


Palpation of both left and right supraclavicular (groups
of cervical) lymph nodes should be performed in the routine
examination of the thorax. Palpation of the left
supraclavicular lymph nodes should be performed in the
routine examination of the abdomen (and is mandatory if
there is suspicion of cancer in an abdominal organ).

Examination of major lymph node groups


The cervical, axillary and inguinal lymph nodes are
readily palpable in a physical examination.

Fig.23.20
188
23. Surface and Functional Anatomy

SURFACE MAPS OF SUPPLY TERRITORIES FUNCTIONAL ANATOMY AND TESTING


Cutaneous nerve supply
Ligament integrity
Ligament stress test
Extensive ligament damage produces great impairment
of function and increased potential for instability.

Fig.23.24

Assessing skin sensory loss


Clinical testing for diminished cutaneous sensation (due
to a specific lesion involving either a spinal cord segment or
a peripheral nerve) is best performed across axial lines. It
is recommended to commence from an area of normal Fig.5.21 Stress test for cruciate ligaments of knee joint
sensation and proceed across the axial line to the
suspected area of sensory loss. Ligament integrity may be tested clinically by stressing
the ligament (putting it on stretch) and comparing the
Segmental nerve supply observable movement between the injured and uninjured
sides. With a ligament sprain, pain tends to be exacerbated
by stressing the ligament.

Reflex muscle spasm


Abnormal or excessive joint movement is an important
diagnostic feature in an acute ligament injury, particularly a
grade III injury. This may be masked initially by the other
stabilising structures at a joint, particularly muscles (due to
protective reflex muscle spasm).

Nerve fibre rupture


Stressing a ligament to elicit pain is also a diagnostic
Fig.23.25 feature in an acute ligament injury (particularly for grade I
or grade II sprains). This may be masked in grade III
Arterial supply
injuries as sensory nerve fibres (including pain fibres)
within the ligament are also likely to be severed.

Range of joint movement


Passive and active movements
Movements are either passive or active. A movement at
a joint is passive when it is not directly due to contraction of
its associated muscles (e.g... purely via gravity).
An external agent may also be utilised to assist a
passive movement throughout its full range of motion
(passive assistance). This enables a clinical assessment
Fig.23.26 of joint mobility (the potential range for each movement at a
joint) that may be otherwise masked by muscle weakness
Lymph drainage or paralysis.

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.

Muscle hypertrophy and atrophy Importance of testing visual fields


Muscle is a very highly specialised tissue. Even though The visual pathway travels from the front to the back of
mature muscle cells have lost the capacity to replicate they the brain (hence the importance of visual field examination
respond to changes in demand. Muscle fibres undergo for identifying the site of a lesion within the brain).
progressive enlargement, termed hypertrophy (G. over-
nourishment) with increased demand. Muscle fibres Assessing posture and gait
progressively waste away with inactivity (disuse atrophy)
and particularly after loss of their motor nerve supply Line of gravity and stable joints
(denervation atrophy).
In an adult standing upright, the line of gravity passes
Being structural changes, muscle hypertrophy and
between the mastoid processes of the skull, balancing the
atrophy are not evident immediately but only after a
head. It continues through the S-shaped vertebral column
variable period of time. Assessment of skeletal muscle
behind the centres of the cervical and lumbar spine and in
wasting involves comparing both sides of the body and,
front of the centres of the thoracic and sacral spine. It then
where possible, measurement of circumference. This is
passes behind the centre of the hip joints and in front of the
also an important step in a neurological examination.
centre of each of the knee and ankle joints.
While standing (with hips and knees extended and
Testing reflexes ankles dorsi-flexed) the weight bearing joints are in the
position of maximal stability. Articular surfaces are apposed
and associated ligaments taut (to conserve muscular
effort). Minimal skeletal muscle tone is therefore required to
maintain upright posture, other than to correct for body
sway.

Fig.23.

Fig.23. Line of gravity in erect posture

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).

Fig.23. Phases of the walking cycle


The line of gravity moves forwards in the direction of
motion. At one phase of the cycle (mid-swing and mid-
stance) it passes through both limbs. At all other phases it
passes between the limbs.

Roles of the gluteal muscles


The large gluteus maximus muscle is located
posteriorly (creating the unique form of the human buttock)
producing powerful hip extension in running and jumping.

Fig.23. Stabilisation of the pelvis during locomotion


Gluteus medius and minimus muscles prevent
excessive tilting of the pelvis (supporting the trunk above it)
towards the unsupported side during locomotion.

191
Chapter 24: Radiographic Anatomy and Imaging

Radiation at the low end of the spectrum (e.g. visible


light) does not penetrate through human tissues. Radiation
PLAIN RADIOGRAPH PRODUCTION at the high end of the spectrum (e.g. cosmic rays) is not
absorbed in human tissues, and passes through
RADIODENSITIES OF TISSUES unchanged.
Energy of X-rays is optimal when some is absorbed by,
RADIOGRAPHIC VIEWS and some passes through human tissues (with greater
amounts absorbed by more electron dense tissue than by
PROPERTIES OF PLAIN RADIOGRAPHS less electron dense tissue). The non-uniform beam that
emerges from the patient carries within it information about
the location and size of structures of different electron
BONES ON RADIOGRAPHS density in the patient (i.e. a tissue density map).

JOINTS ON RADIOGRAPHS X-ray source


X-rays are produced in an X-ray tube, which is the
OTHER STRUCTURES ON RADIOGRAPHS central component of every X-ray machine. It consists of an
air-evacuated glass cylinder in which a tungsten filament
(cathode) and anode are located. A high potential (voltage)
CONTRAST RADIOGRAPH PRODUCTION difference (up to several hundred kV) is applied between
the cathode (which is also heated) and the anode.
CONTRAST STUDIES OF VISCERA Electrons are ejected from the cathode and are attracted to
the anode.
CONTRAST STUDIES OF CLOSED CAVITIES

CONTRAST STUDIES OF VESSELS

DIGITAL SUBTRACTION ANGIOGRAPHY

PLAIN RADIOGRAPH PRODUCTION


The production of a plain radiograph involves beaming
X-rays through an object onto a recording medium.

Fig. 24.2 An X-ray tube


When these highly accelerated electrons collide with
the anode, their kinetic energy is transformed to heat and
radiation, including X-rays. The X-ray beam exits through a
window (usually rectangular) bounded by lead collimators.

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.
192
24. Radiographic Anatomy and Imaging

Digital radiography is progressively replacing film Tissue radiodensities


based radiography. Digital X-ray receptors are large solid-
Capacity of a tissue to absorb or scatter X-rays
state plates which convert the photon energy directly to
depends on its electron density, because X-ray photons are
electrical signals that can be read out electronically. The
absorbed or deflected primarily by electrons. The closest
advantage of digital radiography is that the image is a
easily measurable physical parameter to electron density is
dataset and not dependent on a physical carrier. A digital
physical density (i.e. mass per unit volume, usually
radiograph can be manipulated, copied and sent like any 3
expressed as grams/cm ), which is not only related to the
other digital image.
physical state of the tissue but also to the atomic number of
Image intensifier tubes are still in use. These are
the elements which form it. When describing degrees of X-
highly evacuated tubes which convert incoming X-ray
ray attenuation, density of living tissue is termed tissue
photons into electrons accelerated towards a photocathode
radiodensity.
converting them into light photons. The light photons are in
turn recorded with a (digital) video camera that generates The greater the tissue radiodensity the greater the
the final image. Image intensifier tubes are part of X-ray attenuation of X-rays.
equipment used for real-time procedural imaging.
All CT scanners already collect their information in This results in fewer X-rays reaching and interacting
digital form, as do nearly all procedural X-ray machines with the X-ray film (or other recording medium).
(angiography and fluoroscopy machines, and operating
theatre mobile image intensifiers). Radiodensity spectrum
Steps in radiograph production On the basis of their (plain film) radiodensities, tissues
can be classified into four groups from the least to the most
Production of a radiograph includes: dense:
1 - proper patient positioning - air
2 - protecting the patient from unnecessary radiation - fat
3 - correct placing of film, X-ray source and the patient - soft tissues
4 - selecting optimal settings on the X-ray machine - bone
(voltage, tube current, exposure time, focal spot)
5 - exposure of the film or digital receptor
6 - development, fixing, washing and drying the film
The film or digital image is interpreted and reported.

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

Degrees of lucency or opacity A radiological interface viewed end-on is seen as a


distinct line on the radiograph while a radiological interface
Images of different tissues appear on X-rays as
face-on to the x-ray beam is never seen. A line seen on a
different shades of grey, from almost black (least dense) to
radiograph implies two absolute conditions have been met.
almost white (most dense).
The first condition is that two tissues of sufficiently different
When referring to the appearance of different densities
radiodensity lie next to each other (i.e. form an interface).
on the X-ray film, the terms lucency and opacity used. Dark
The second condition is that the interface is parallel to the
structures on the film are referred as radiolucent (e.g. air)
X-ray beam.
while light or white structures (e.g. bones) are called radio
The difference in density of the two structures has to be
opaque.
sufficient to produce a noticeable difference in X-ray
attenuation. A relatively radiodense but small structure will
produce a visible edge (e.g. a sesamoid bone) when
surrounded by less radiodense tissue (e.g. muscle).Even
tissue which has little difference in radiodensity to its
surroundings can still produce an edge if the radiological
interface is long and straight enough.
In the chest, a thin structure such as a blood vessel or a
bronchial wall, will produce a visible edge against air-filled
lung parenchyma for as long as it runs parallel with the X-
ray beam. This is called the end-on effect. The same
blood vessel or bronchial wall may be invisible if it runs at
an angle to the X-ray beam.

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.

Fig. 24.6 Views from beam via back and front


Fig. 24.5 How a line is formed on an image Side-on projections are known as lateral views.

194
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.

Fig. 24.7 Standard views of lumbar spine


In addition to these, a number of oblique projections
can also be used enabling certain features of a body part to
be visualised.
The X-ray tube is always perpendicular to the middle of
the film. The optimal degree of required obliquity varies for
different structures.

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.

When the central ray is not perpendicular to the film,


distortion is particularly severe for any structures not
located immediately against the film. This is particularly
significant for a mobile film cassette.

The X-ray film should be placed perpendicular to the


centre of the X-ray beam.

Fig. 24.11 Summation from superimposed structures


The combined optical density (as seen on the final
image) of several superimposed structures is the sum of
the optical densities produced by each structure
Fig. 24.9 Magnification individually, because the X-ray beam is attenuated by each
structure independently and in turn. The increase in optical
Positioning of the patient density on the film produced by several overlapping
Being three-dimensional, the body will naturally have structures is termed summation. For example, the
some of its parts closer to the film than others. vertebral column and mediastinal soft tissue structures are
superimposed on a frontal chest X-ray, and where
The organ or body part of most interest is positioned superimposed they produce a whiter area (i.e. summation
as close as possible to the recording medium to takes place).
minimise magnification and loss of sharpness. In order to avoid interpretation difficulties resulting from
the superimposition and summation phenomena, multiple
projections are routinely used with the object often
radiographed in at least two projections commonly at right
angles to each other.

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.

Long bones on images


The differences between compact and cancellous bone
Fig. 24.10 Positioning chosen part near film are particularly visible on radiographs of long bones.

196
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).

Compact bone is particularly thick in the shaft of a long


bone where it forms weight-bearing walls surrounding the
medullary cavity.
Compartments within cancellous bone and the entire
medullary cavity are filled with radiolucent bone marrow.

Fig. 24.14 Irregular bones on an image (spine)

Flat and pneumatic bones on images


In flat bones, the cancellous bone (containing bone
marrow) is usually reduced to a thin layer between two
compact layers. Its interface with cortical bone is only
visible when parallel with the X-ray beam.
Flat bones of the cranium have a typical appearance.
Two parallel densities (representing internal and external
compact bony tables) sandwich a reticular opacity
representing diploe.

Fig. 24.12 Long bones on an image (elbow)


Parts of the shaft circumference are parallel and other
parts are perpendicular to the X-ray beam. Four interfaces
are visible, two with soft tissues surrounding the shaft and
two with the medullary cavity filled with soft tissue (bone
marrow).
The ends of a long bone are predominantly cancellous
bone organised into groups of parallel struts (representing
weight bearing paths) known as trabeculae. Compact
bone is reduced to a thin superficial covering
(subchondral bone) that usually supports the articular
cartilage.

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.

Assessing bony integrity

Fig. 24.13 Short bones on an image (wrist)


Underlying cancellous bone is organised into a system
of weight bearing trabeculae.
Irregular bones often have a complex radiographic
appearance, with their parts and surfaces superimposed on Fig. 24.16 Bony integrity (hip)

197
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).

Fig. 24.19 Epiphysial line on tibia (adult)

Accessory and sesamoid bones on images


An accessory (supernumerary) bone appears when an
ossification centre fails to fuse with the main bony mass.
Fig. 24.17 Epiphyses of knee (age 3) Accessory bones are relatively common, and on
radiographs should not be mistaken for a bone fragment
Epiphysial plates produced by a fracture.

Fig. 24.20 Sesamoids and accessory bone (foot)


Sesamoid bones occur in certain tendons, where they
pass across bony convexities. In addition to the patella (the
Fig. 24.18 Growth plates of knee (age 10) largest sesamoid bone), they are found most frequently in
198
24. Radiographic Anatomy and Imaging

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.

Bony articular surfaces may be directly observed on a


plain X-ray film of a joint. Other joint components of soft
tissue radiodensity are indistinguishable from each other.
However, articular fat pads (fat radiodensity) can be seen.

Radiological joint space


The radiolucent gap between opposing bony articular
surfaces visible on plain radiographs is termed the
radiological joint space. In a normal synovial joint, this
space is occupied by articular cartilage covering each
bony articular surface as well as the thin layer of synovial
fluid between them. The space is visible because the
apposed cartilage layers are end on to the X-ray beam.

Fig. 24.23 Plain film of knee joint

Assessing radiological joint space width


The width of the radiological joint space should be
assessed. Changes (widening, narrowing or
disappearance) are all signs of joint abnormality. Cartilage
degeneration narrows the space. An abnormal
accumulation of fluid inside a joint (e.g. due to bleeding) will
widen the space.

Bony articular surfaces


Fig. 24.21 Plain film of hip joint
Bony articular surfaces are clearly observable on plain
In certain joints, the radiological joint space contains radiographs.
intra-articular fibrocartilage (e.g. intervertebral discs, The continuity of each surface (including the edges
menisci of the knee) or ligaments (e.g. cruciate ligaments where it is continuous with the thin nonarticular compact
of the knee). bone) is carefully examined. The line(s) representing an
articular surface should be sharp and smooth (without pits
or bumps).
The bone adjacent to an articular surface should not
display excessive opacity or lucency and its trabecular
pattern should be regular (oriented according to forces
transmitted through the supported articular surface).

Assessing joint congruence and alignment


Joint congruence is assessed by following the
opposing articular surfaces. These should be parallel and
equidistant in all projections.
Joint alignment is of course dependent on joint position
at the time of the radiograph. The conventional way to
measure alignment is by measuring the angle between the
long axes of the two articulating bones. For complete
assessment of alignment, more than one view is required.
Obtaining optimal joint congruence and alignment is
crucial in management of dislocations. Laxity of the joint
capsule, ligaments or surrounding tendons can also result
in joint malalignment that is also seen radiographically.

Joint soft tissues


Although not visible separately on plain radiographs,
Fig. 24.22 Plain film of lumbar spine individual soft tissue components of synovial joints should

199
PRACTICAL PERSPECTIVES

be considered. Soft tissue structures around a joint that


typically present as uniform soft tissue density are the joint
capsule, surrounding tendons, bursae and muscles, and
also any overlapping neurovascular bundles. Only joint fat
pads will be visible as fat density structures (if large
enough, and if the interface with other soft tissue structures
is parallel to the beam).

Assessing soft tissue calcification


Calcification of articular soft tissues can occur with
degeneration, following injury and in certain diseases. This
may become visible on a plain radiograph and should be Fig. 24.26 Mammogram of a fatty breast
distinguished from calcification in tissues not associated
with the joint. Air-soft tissue interfaces

When an organ or a tissue of soft tissue density is


OTHER STRUCTURES ON RADIOGRAPHS
adjacent to air or gas, the difference in radiodensity
Certain structures other than bones and joints may be will form a clean and sharp edge provided the interface
distinguished on a plain radiograph. is parallel to the x-ray beam.
Anatomical soft tissues include many different types
(e.g. muscle, cartilage, fascia, tendon, glands and fat). In This is best seen on a plain chest X-ray where blood
addition, body fluids (e.g. water, blood bile, urine, vessels in the lung can be recognised and clearly outlined
cerebrospinal fluid) can not be distinguished from by air contained within the lung parenchyma.
radiographic soft tissue on plain film.
Fat-soft tissue interfaces
Only fat has sufficient radiographic contrast compared
to all other types of soft tissues (and body fluids) to
form visible interfaces on a plain film.

Kidneys and lateral borders of psoas muscles are


surrounded with extraperitoneal fat on the posterior
abdominal wall. Therefore, they can be easily outlined as
well defined radiopacities on the background of the more
radiolucent adipose tissue.

Fig. 24.27 Air-soft tissue interfaces (chest)

Intralumenal air or gas


Fig. 24.24 Abdominal fat-soft tissue interfaces In viscera which contain air or gas the interface
The breast is composed of glandular tissue supported between the air filled lumen and mucosa becomes visible.
by ligamentous suspensory elements (of soft tissue On a plain chest radiograph air is seen in the trachea and
density) and clumps of fat dispersed through it. In principal bronchi and as well as in the stomach. On a plain
mammography, the fibro-glandular tissue of the breast radiograph of the abdomen air is seen in the stomach and
can be distinguished and visualised on the breast fat gas (produced by microbial fermentation as well as
background (although this varies with age and hormonal swallowed air) is seen in the intestine.
status). Significance of extralumenal air or gas
Air of gas seen outside the lumen of a viscus may
indicate perforation. If this occurs to an intraperitoneal
viscus (e.g. stomach, large intestine) gas enters the
peritoneal cavity and may accumulate under the
diaphragm.

CONTRAST RADIOGRAPH PRODUCTION


The production of a contrast radiograph involves
beaming X-rays through an object following the
administration of contrast material (contrast medium) to
Fig. 24.25 Mammogram of a dense breast change the radiodensity of certain structures.

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.

CONTRAST STUDIES OF VISCERA


The lumen of a viscus can be outlined using contrast
material introduced either directly or indirectly. The direct
approach involves filling a lumen with contrast media
introduced via normal body openings (e.g. swallowed, or
utilising an endoscope). The indirect approach involves
ingestion or injection of a contrast medium that gets
Fig. 24.28 Context for a contrast radiograph concentrated and excreted into the lumen of a different
The passage of contrast material is often followed in organ than what it entered.
real time during the duration of contrast examination to The viscera most commonly examined by contrast
observe the patterns of its distribution. studies are of the digestive and urogenital systems.
Certain hollow viscera may also be outlined indirectly
Contrast enhancement after excretion of contrast media through them.
Since body fluids (and non-gaseous contents of hollow Upper GI studies
organs) cannot be distinguished from their surrounding
walls on a plain radiograph, administration of contrast Several different studies examine the upper digestive
material is required to see them. This is achieved by filling tract, each tailored to one specific part. Fluoroscopy is used
body cavities or lumina of viscera and of vessels with to demonstrate the pharynx (pharyngogram), oesophagus
materials of different radiodensity. The resulting change in (barium swallow), stomach (barium meal) and small
radiographic density between the lumen and walls of the intestine (small bowel series) with only liquid barium as
imaged organs (or body parts) allows their visualisation. contrast (for single contrast study), or liquid barium and
Contrast material can be introduced into just about any gas-producing crystals or liquid or even injected air (for a
body cavity or potential space. double contrast study).
Intravenously administered contrast material, (different
to that for non-vascular administration), is concentrated in
various parenchymal body organs depending on its
biochemical properties, and so may opacify these organs,
making them more visible against adjacent soft tissue. The
most common example is contrast opacification of the
kidneys, making the renal parenchyma and collecting
systems visible in turn (intravenous pyelogram or
intravenous urogram).

Positive and negative contrast media


Any compound introduced into the body in order to
change the radiodensity of soft tissues is called contrast
material (or contrast medium).
Certain contrast media are denser than the organ or
tissue imaged (positive contrast media) like iodinated
injectable compounds for intravascular administration or
barium sulphate suspensions for oral or rectal
administration.
Other contrast media are less dense (negative
contrast media) like air, oxygen and carbon dioxide for
gastrointestinal or body cavity administration.

Avenues of contrast administration


Contrast material can be introduced into the body Fig. 24.29 Barium meal
through normal body orifices. Contrast material can also be
injected through needles or catheters into various body Lower GI series
cavities, spaces or structures (e.g. joint cavity, The large intestine is examined (in single or double
subarachnoid space, blood vessels). contrast) using a barium enema. Liquid barium is run into
Contrast material may even be injected into loose the colon via a rectal tube (under fluoroscopic vision). To
connective tissues (to subsequently highlight lymph vessels obtain double contrast, extra barium is then evacuated and
and nodes) as it is gradually included in the lymph flow. air insufflated into the colon to distend it. The patient turns

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.

Fig. 24.30 Barium enema

Oral cholecystography and ERCP


Oral cholecystography is a contrast examination of
the gall bladder following the oral administration of a
special iodine medium, which is resorbed in the intestine
and delivered to the liver via the portal system. In the liver it
is metabolised and excreted into the biliary tract and finally
concentrated in the gall bladder, where the material
increases radiodensity of the lumen making it visible. Oral
cholecystography has now been superseded by
intravenous CT cholecystography (CT-IVC), where the
contrast material is injected intravenously and images
acquired on a CT scanner.

Fig. 24.32 Retrograde pyelogram


Cystography is an examination of the urinary bladder
and it is often performed with urethrography in males to
assess the functional anatomy of the lower urinary tract.
Following catheterisation, the bladder is filled with contrast
material and examined using fluoroscopy. The second part
of the examination involves removal of the catheter
followed by fluoroscopic examination of micturition.

Fig. 24.31 Oral cholecystogram


Hysterosalpingography
Hysterosalpingography is a contrast radiographic
Endoscopic Retrograde Cholangiopancreatography examination of the uterus and uterine (Fallopian) tubes. A
(ERCP) is a contrast radiographic examination in which the vacuum cup device (with a small cannula) or a specially
contrast material is injected directly (and retrogradely) into designed catheter is attached to the vaginal opening of the
the biliary and pancreatic ducts by use of a fiberoptic cervix and contrast material is directly introduced into the
endoscope. Although, this examination offers excellent uterine cavity. The contrast medium then fills the tubes and
demonstration of ducts, it is performed only when less spills into the peritoneal cavity.

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24. Radiographic Anatomy and Imaging

arthrography) or combination of two (double-contrast


arthrography) to examine synovial joint cavities (joint
space, also outlining any contained soft tissue structures
such as menisci, ligaments, cartilage and bursae). Single
contrast arthrography is commonly performed under local
anaesthesia. The contrast is injected into the synovial
cavity, the joint is manipulated to achieve optimal
distribution of media and then examined with radiography,
CT or MR.

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).

Fig. 24.34 Lumbar myelogram

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.

Masking unwanted structures


Before contrast is given to opacify blood vessels, an
initial image (termed a mask) is taken in exactly the same
position as the subsequent images. As contrast is being
injected, several images in rapid succession are taken. The
mask film is subtracted from the run films, hence the terms
'subtracted image' for the final product and 'subtraction
angiography' for the technique. However, any movement by
the patient will lead to differences between the mask and
the run images not caused by vascular opacification. Such
confusing artefacts on the subtracted images may render
them useless for diagnosis.

Fig. 24.36 Venogram (inferior vena cava)

Lymphography
Lymphography includes the contrast examination of
lymph vessels (lymphangiography) and of lymph nodes
(lymphadenography).

Fig. 24.38 Digital subtraction aortogram

Fig. 24.37 Lymphogram


Both the media and the application approach are
unique. Oily iodine contrast media are utilised because of
their longer retention by the lymphatic system.

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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

TISSUE PROPERTIES IN MRI

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.

Axial sections of the body


Sections in axial planes are oriented transversely, being
perpendicular to the long axis of the body (or specific body
part). When the body is standing erect (e.g. in the
anatomical position) axial planes are horizontal.

Fig. 25.3 Coronal section


Fig. 25.1 Axial section (mid-thoracic level)
Sections in coronal planes pass between the right and
Sagittal sections of the body left sides of the body, parallel to the coronal suture of the
skull. They are also oriented longitudinally but are
Sections in sagittal planes pass between the front of the
perpendicular to sagittal planes.
body and the back, parallel to the sagittal suture of the
skull. They are oriented longitudinally, being parallel to the
long axis of the body (and are vertical when standing CT IMAGE PRODUCTION
erect).
Computed tomography (CT) is a radiologic technique
The midline of the body is in the mid-sagittal (or
which utilises X-rays to produce cross-sectional images of
median) plane, as it is directly along the sagittal suture.
the patient.

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PRACTICAL PERSPECTIVES

Each reconstructed slice consists of voxels (3


dimensional brick-shaped pixels). The size of the digital X-
ray detectors and the number of angular projections
determine the smallest possible size of the voxel within
each axial slice (dimensions in the X and Y directions, i.e.
the short sides of the brick). The size of the voxel in the Z
direction (craniocaudal direction, the long side of the brick)
is the width of the X-ray beam.

Fig. 25.4 Context for CT images


The formation of CT images is a multi-step process with
the equipment design reflecting the order in which this
takes place.

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.

Fig. 25.5 Components for CT image production


The X-ray tube continuously rotates around the patient
(at the speed of 1 revolution per second, or faster), and
images from many angular projections are collected during
any one revolution. These images are analogous to
multiple overlapping photographs in panoramic
photography, but are only slice-thick.
The patient bed (with the patient lying as still as
possible) is moved through the gantry, presenting
successive parts of the patient to the X-ray beam, so that Fig. 25.7 Tissue radiodensities in CT imaging
contiguous slices are acquired.
Traditionally, tissue radiodensity as measured by CT is
CT image reconstruction expressed in Hounsfield Units (HU) or CT units.
The resulting huge volume of data from the image On the HU scale, the attenuation value for water is
acquisition process is passed to the CT computer for image zero. Positive values are for structures with higher
construction. attenuation than water (soft tissues and bones) while

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.

Body slices in CT images


Radiographs display the entire body part or an organ
that is imaged, whereas CT images display slices of
body parts or organs.

The recording medium in radiography is traditionally the


X-ray film whereas in CT, signals from detectors are
transformed into digital images. However, these may
subsequently be recorded on film.
CT images can be presented in all the ways than any
other digital images can. They can be viewed on a
computer monitor, television screen, be printed to reflective
paper or transparent film. Conventionally, to allow side-by-
side hanging of radiographs and CT scans on the same
light box, hardcopy CT is printed to transparent film.

Pixels from voxels in CT


A CT image is displayed for interpretation as a flat, two
dimensional picture composed of small picture elements Fig. 25.9 Windows in CT (of thorax)
(pixels). The slice it represents is composed of small brick-
shaped volumes of tissue termed voxels. The voxel depth CT resolution
is not evident from the flat display, but can be read from the In-slice CT spatial resolution is limited by the size of
information provided with the image. On single-slice CT individual X-ray detectors, and the number of angular

207
PRACTICAL PERSPECTIVES

projections that are collected. CT spatial resolution in the


cranio-caudal (Z axis) is limited by slice collimation
(whether physical or electronic). CT spatial resolution,
although impressive, is much coarser than of plain film.
CT contrast resolution (the ability to tell different
tissue radiodensities apart) is extremely high, and well
above that of plain film. Similar to plain radiography, it is
limited by image noise.

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

Magnetic Resonance Imaging (MRI) produces high


quality cross-sectional images of the patient in any plane
(horizontal, sagittal, coronal and/or oblique).

MRI (unlike radiography and CT) avoids using ionising


radiation.

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

Magnetization of body MR control processing and storage


In MR imaging, the body is placed into a strong, The control console of an MR scanner works
permanent magnetic field. Superimposed on this is a much analogously to the control console of a CT scanner. It is a
weaker, rapidly variable magnetic field, produced either by high powered computer, running specialised software to
transmitting specific radio frequency (RF) electromagnetic drive the magnet and to rapidly reconstruct the read out
waves into the body, or by rapidly switching magnetic coils. signal into anatomical images.
Once reconstructed, the images are handled the same
way as any other cross sectional computerised images,
and can be printed to paper or film, read on the screen (soft
copy reading), recorded on a CD or a backup tape.

Contraindications to MR Imaging

Implanted electronic devices and potentially mobile


ferromagnetic material are contraindications to MRI.

Any implanted electronic device can either be disabled


by the magnetic field of an MR scanner or generate current
loops which can cause burns. In particular, pacemakers
usually stop functioning in an MR scanner, potentially
leading to asystole and death. Pacemakers,
neurostimulators and bionic ear implants are absolutely
contraindicated in MR scanning. No electronic implant
should even enter the MR scanning room.
Metallic implants can be ferromagnetic (i.e. move in a
Fig. 25.13 Emission of RF signals from body
magnetic field) or not. Generally, firmly implanted joint
The variable magnetic field leads to radiofrequency prostheses and other orthopaedic hardware will degrade
electromagnetic waves being emitted from the body. These the MR image to useless in their vicinity, but can enter the
are recorded by receiver coils, the location of their source magnet. However, freely mobile metallic implants must be
is decoded, and spatial maps of several magnetic considered ferromagnetic till proven otherwise. In
properties of the body are slowly built up with successive particular, cerebral aneurysmal clips or coils can not enter
pulse-receive cycles. the MR scanning room until cleared as MR compatible.
Metallic intraocular foreign bodies can cause severe
RF application and detection damage if they move in the magnetic field. These can be
The formation of an MR image is not an instant event, detected with a plain X-ray.
but occurs after many repetitive cycles. These pulse- Ferromagnetic objects (e.g. oxygen cylinders, hand
receive cycles consist of sending RF wave pulses into the tools) may be drawn into the magnet and become
body, followed by detecting RF signals that are emitted unintended projectiles.
from the tissues. The number of repetitions depends on the In MR examination, the patient is placed on the
field of view (i.e. how large a volume is being imaged), the moveable table, which slides inside a narrow tunnel barely
matrix size (i.e. how many voxels this volume is broken up large enough to contain an average human body. Patients
into) and how much signal is wanted above system noise with claustrophobia may not cope with the procedure and
(desired signal to noise ratio). The larger the volume, the obese patients may not even fit in the tunnel.
finer the matrix, and the better the signal to noise, the
longer it will take for a particular imaging sequence to run. TISSUE PROPERTIES IN MRI
Most imaging sequences last between one and 10 minutes,
with most common being around 3 to 5 minutes long. To be When placed within a strong magnetic field and
sufficiently thorough, most examinations consist of at least exposed to electromagnetic radiation of specific frequency,
several imaging sequences. tissues emit the absorbed energy in the form of RF signals.
Properties of these signals reflect certain physical and
Magnet and coils chemical properties of the tissue. The collected RF signals
The main part of an MRI machine is a very large carry interpretable information about the spatial location of
magnet with a long and narrow tunnel or bore in which the various tissues within the body.
patient is placed during the MR examination. This is the
most obviously visible part of the MR machine.
Magnetic properties
The transmitter RF coils (and coils to create magnetic Just like with CT, MR imaging creates volume maps of
field gradients) are no less important, but hidden in the several physical properties of the tissues being imaged. CT
machine housing. creates a map of only one such property: tissue
The receiver coils (used for reading the emitted RF radiodensity (which in turn reflects electron density in the
waves) are placed as close as possible to the area being tissue).
imaged, and so are quite obvious. The birdcage placed in MR imaging can image three fundamental tissue
front of a patients face when imaging the brain is the head properties: proton density, and two others, called T1 and
receiver coil. The coil for imaging the spine is usually built T2 constants.
into the patient table. Coils for imaging joints and other All tissues have the properties of T1 and T2 constants,
body parts are usually placed around, or applied directly which relate to how quickly magnetization returns to steady
on, the body part to be imaged. To obtain the best possible state after being altered by the RF pulses sent in by the
image, the body part is placed in the centre of the main transmitter coils. T1 weighted sequences show fatty tissues
magnet bore. as bright and fluids as dark, while T2 weighted sequences

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.

Fig. 25.15 MR images (mid-sagittal) weighted differently

Distinguishing soft tissues on MR images


The most important advantage of MR over other
imaging modalities is the ability to distinguish types of
soft tissues from each other.
Fig. 25.14 MR images (axial) weighted differently
MR imaging distinguishes white matter from grey matter
PROPERTIES OF MR IMAGES in the CNS.
The ability to distinguish tissues on MR images applies
The image occurring on a video monitor following MR not only to normal tissues, but also to pathological changes
imaging consists of a matrix of picture elements (pixels). in them. Because many disease processes lead to local
Each individual pixel on the screen represents the degree oedema (e.g... inflammation), the increased water content
of signal intensity for the corresponding voxel in the body of oedema becomes visible as an area of increased signal
translated into a different shade of grey scale. on T2 weighted images.
Modern T2 weighted sequences also image fat and
Pixels from voxels in MR very fatty tissues as bright. This leads to occasional
The slab of tissue imaged with MR is broken up into confusion between fat and water if only the T2W
voxels the same way as in CT. The resulting voxel map of sequences are studied. In general, to begin deciding on the
proton density, T1 weighting or T2 weighting in the imaged composition of a particular tissue, both T1 and T2 weighted
volume is presented as a series of 2-D slices made up of 2- images need to be reviewed.
D pixels. Conventionally, these PD, T1W or T2W maps are A quick way to recognise a sectional image as being
displayed as shades of grey (although any other colour MR rather than CT, is to look at the subcutaneous fat layer.
scheme could be used). Fat on MR appears bright (T1W) or less bright (T2W) but
Tissue magnetic properties displayed with MR images on CT fat typically appears black (subject to windowing).
(proton density, T1W and T2W) reflect the different
chemical composition of different tissues. Compact bone SPECIAL MR IMAGING
and air appear black on all sequences (no signal emitted).
By using contrast media that have magnetic properties,
Appearances on T1 weighted images the MR images of blood vessels and vascular organs can
On T1 weighted images tissues with a high fat content be enhanced. Alternatively, manipulation of MRI data can
appear bright. display only the structures that move quickly. This enables
imaging of blood vessels without an application of any
These include: contrast media.
- adipose tissue
- yellow bone marrow
Gadolinium based material
- white matter in the CNS Gadolinium is a toxic rare metal. However, when firmly
In contrast, tissues with a high water content and fluids bound to organic chelates, it produces a chemical
(e.g. CSF) appear dark. compound with distinct magnetic properties. Following an
Muscle is of intermediate brightness, but this depends intravenous injection, gadolinium based contrast materials
on the amount of fat infiltration and fluid content of the circulate within the vascular system, and enter the
muscle. extracellular tissues but do not cross the intact blood-brain
barrier. Gadolinium based contrast material is excreted via
Appearances on T2 weighted images the kidneys and accumulates in the urine. On T1 weighted
On T2 weighted images tissues with high water content images gadolinium contrast agents lead to tissue
appear bright. brightening (enhancement) in a comparable way to how

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25. Sectional Anatomy, CT and MRI

iodinated contrast material behaves in CT. There is no


effect on T2 weighted images.

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.

Heavily T2 weighted sequence


On heavily T2 weighted sequences fluid has very bright
signal. A number of MR applications which image normal
fluid spaces within the body utilise this phenomenon. One
of these is MR Cholangiopancreatography (MRCP)
which produces a map of the biliary tree and pancreatic
ducts.
Other sequences have been used to image ureters,
fluid filled loops of intestine, and even dilated lymphatic
vessels.

Fig. 25.16 MRCP

211
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.

ULTRASOUND IMAGE PRODUCTION Reflection, absorption and scatter


Ultrasound is a high frequency vibration transmitted as
Ultrasound imaging or ultrasonography is an imaging
a series of longitudinal waves. When they travel through
technique which produces cross-sectional multiplanar
the patients body, these waves can be reflected, absorbed,
images of the patients body by using ultra high frequency
or scattered, and a combination of these three interactions
sound or ultrasound (US).
of sound with tissues forms its ultrasound appearance.
Ultrasound allows real time cross-sectional imaging Reflection produces weak US waves which travel back to
without any ionizing radiation. the transducer.
Absorption and scatter (like in radiography) lead to
Ultrasound reflection the reduction of the US beam energy. This depends on the
tissue composition and thickness as well as on the
Ultrasound is a high frequency vibration transmitted as
transducer frequency. These factors affect the ability of
a series of longitudinal waves through the body. When it
tissue interfaces to reflect the sound in order to be
travels through the tissues, the vibration interacts with
interpreted as a signal in the US machine.
them. The most important form of interaction for creation of
US images is reflection, which occurs when the US waves Acoustic impedance and echogenicity
cross boundaries of tissues which are of different acoustic
Acoustic impedance is a property of material
densities. The reflected US wave is picked up by the
transducer, and the location and distance of the boundary determined by its density coupled with the velocity of
is calculated. These boundaries (interfaces) form the ultrasound (and may be regarded as the 'elastic resistance'
ultrasound image are built up by an ultrasound machine. to US wave propagation).

An acoustic interface exists at the junction of two


tissues of different acoustic impedance.

At each acoustic interface, an incident ultrasound wave


is partly refracted (changes direction) and partly reflected
(leading to image production). The amount of sound
reflected depends on the difference in tissue acoustic
impedance between the two tissues.

The larger the difference in density of adjacent tissues,


the larger the reflection, resulting in a brighter signal
from their acoustic interface.

Tissues can be classified into different groups based on


their tendency to uniformly reflect sound. In ultrasound this
tendency to reflect ultrasound is referred to as
Fig. 26.1 Context for US images
echogenicity.
Ultrasound formation and detection
Both formation and detection of ultrasound is done in a PROPERTIES OF US IMAGES
transducer. The transducer contains a piezoelectric
Ultrasound images can be printed to paper or film, or
material (crystal) which has an intrinsic ability to change
displayed in real time on a monitor. By convention, US data
shape when voltage is applied to it, and rapid oscillation of
is displayed as shades of grey, while flowing blood is
the piezoelectric crystal shape produces ultrasound waves.
colour-coded.
The most convenient material used in US transducers is
ceramic because it has large charged atoms which are Ultrasound tissue scale
loosely held in a complex crystal structure. When placed in
On the basis of their echogenicity the appearance of
an electric field, these atoms move and change the shape
of crystal. This in turn produces high frequency sound or tissues can be classified (and is conventionally presented
on a grey scale) as follows:
ultrasound.
Fluid (water, urine, cyst fluid, bile, non-clotted blood)
The piezoelectric effect is symmetrical, so the crystal
has very few reflections and appears black. Fluid with
shape change will produce a small electric signal when the
crystal is struck by the reflected ultrasound wave. Thus, the internal debris and particles (intestinal content) has an
irregular reflecting (patchy white) appearance. Debris and
transmitter is also used as the receiver.
other floating reflectors move gently in real time.
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26: Ultrasound Imaging

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.

Fig. 26.2 US image of gall bladder (bile-filled)

Real time sector scans


All modern ultrasound machines produce real-time
images, which change constantly with tissue movement.
The frame refresh rate is sufficiently high to demonstrate
normal cardiac, diaphragmatic, tendinous and other
movements as continuous and smooth.
Ultrasound probes are the detachable scan heads that Fig.26.4. Routine US at 18 weeks of pregnancy
carry the transducer on their end, and are applied directly
to the patient (through an acoustic coupling gel). Ultrasound examination during pregnancy may be
obtained by moving the transducer across the abdomen. It
is performed to assess the foetus as well as the position of
the placenta.

DOPPLER ULTRASOUND IMAGES


Doppler ultrasound detects and analyses rapidly
moving objects. Specifically, this applies to flowing blood.

The Doppler effect


When an emergency vehicle with a siren is travelling
towards a listener, the frequency of sound (the pitch) is
higher than when it is travelling away from the listener. This
phenomenon is an example of the Doppler effect. The
Doppler effect is produced when the effective frequency of
a longitudinal sound wave is changed because its source is
also moving (in the same direction or in the opposite
direction to the sound wave).

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

Fig. 26.5 Colour Doppler images (right kidney)


Colour Doppler information can be superimposed on
real-time grey scale structural imaging to provide a
composite image ('duplex scanning').

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.

LOOKING WITHIN HOLLOW VISCERA


The mucosal features of most tubular viscera can be
examined endoscopically. Such (intralumenal) endoscopy
is typically performed via a normal opening on the exterior
of the body. As well as looking at normal anatomy and for
abnormalities (e.g. tumours, ulcers), function (e.g. of
sphincters) can be assessed, biopsies of suspicious areas
taken and treatment performed (e.g. removal of polyps,
stones or foreign bodies).

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.27.5 Tract viewed at colonoscopy


1. Rectum (with superior, middle and inferior rectal
Fig.27.7 Tract viewed at cystoscopy (male and female)
valves) lined by a characteristically thin mucosa
2. Sigmoid colon 1. Penile urethra
3. Splenic flexure of colon (with shadow of spleen 2. Bulbar fossa in urethra (and opening to
seen through the wall) membranous urethra)
4. Transverse colon 3. Prostatic urethra (with urethral crest and seminal
5. Ascending colon and caecum (with ileocaecal colliculus)
valve) 4. Internal urethral meatus (and uvula of bladder
6. Caecal pole (with mucosal folds and orifice of projecting into lumen)
appendix)) 5. Trigone of bladder
6. Right ureteric orifice

Fig.27.6 Internal views of lower digestive tract Fig.27.8 Internal views of lower urinary tract

216
27. Endoscopic Anatomy

LOOKING WITHIN BODY CAVITIES Laparoscopy


The peritoneal cavity and abdominopelvic organs can
The interior of major body cavities and external features
of contained organs can be examined endoscopically. A be viewed through a laparoscope introduced via a small
portal of entry is created by a small incision through the incision through the anterior abdominal wall, typically at the
umbilicus.
body wall allowing passage of the endoscope (which is
The peritoneal cavity is a potential space normally
then manoeuvred around the cavity).
occupied by only a thin film of fluid (between parietal and
Thoracoscopy visceral layers of the peritoneum). The viscera separate
from the anterior abdominal wall when gas is introduced to
The pleural cavity, lung and mediastinal structures can
distend the space.
be viewed through the relevant side of the thoracic wall.
At the beginning of the procedure, the lung is partially
collapsed by entry of air into the pleural cavity. This
potential space is normally occupied by only a thin film of
fluid (between parietal and visceral layers of the pleura). As
it collapses, the lung separates from the thoracic wall. The
lung is re-inflated after the thoracoscope has been
removed.

Fig.27.11 Body cavity viewed at laparoscopy


1. Left lobe of liver (lifted, showing left subhepatic
space), stomach (with greater omentum) and
spleen, diaphragm and left subphrenic space
2. Diaphragm and right subphrenic space, right lobe
of liver and fundus of gall bladder
Fig.27.9 Body cavities viewed at thoracoscopy 3. Anterior abdominal wall and small intestine
4. Uterovesical pouch of peritoneal cavity (between
1. Right sympathetic trunk descending on the uterus and bladder), uterine tubes and ovaries
posterior thoracic wall (crossing intercostal veins) (with follicles)
2. Right lung (middle and lower lobes) and anterior 5. Rectouterine pouch of peritoneal cavity (between
costodiaphragmatic recess rectum and upper part of vagina) and fundus of
3. Right dome of diaphragm and posterior uterus
costodiaphragmatic recess
4. Upper lobe of left lung and lateral thoracic wall
5. Left phrenic nerve on pericardium over left ventricle

Fig.27.10 Internal views of pleural cavities Fig.27.12 Internal views of peritoneal cavity (in female)

217
PRACTICAL PERSPECTIVES

LOOKING WITHIN JOINT CAVITIES Arthroscopy of lower limb joints


7. Right hip joint (with articulation between head of
Joint cavities can be examined through an arthroscope
introduced via a portal of entry created by a small incision femur and acetabulum of hip bone)
into the joint capsule. Normal intra-articular structures can 8. Patella and suprapatellar bursa of right knee joint
9. Medial femoral and tibial condyles with medial
be identified, abnormalities detected and therapeutic
meniscus
procedures performed (e.g. trimming a torn meniscus).
10. Anterior cruciate ligament in intercondylar notch
11. Lateral femoral and tibial condyles with lateral
meniscus
12. Left ankle joint (with articulation between dome of
talus and distal end of tibia)

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)

Fig.27.14 Internal views of major upper limb joints

218
Chapter 28: Clinical Procedures

This may be even more critical for patients with a


INCISIONS tendency to form a nodular mass of scar tissue (termed a
keloid) along a skin wound.

WOUND CLOSURE Incisions should ideally be placed along prominent


skin creases (particularly in the trunk, neck and face)
SYNOVIAL CAVITY PUNCTURE to disguise the scar.

BODY CAVITY PUNCTURE

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.

Similarly, incisions crossing facial expression lines


(including eyebrows) should be avoided as normal scar
contraction may result in an altered appearance. In
addition, with hairlines, scar tissue does not form hair
follicles.
Incisions crossing mucocutaneous junction lines should
be avoided where possible.
Pressure areas (e.g... behind elbow or heel, over
patella or on the sole) should also be avoided because of
wound tension coupled with restricted blood supply when
bearing pressure.

Bleeding from incisions and healing


Incisions (particularly if deep) pass through vascular
structures (dermis, subcutaneous tissue and muscle) and
will bleed (particularly where hydrostatic pressure is
increased). Certain regions tend to possess a richer arterial
supply than others and are more likely to bleed profusely.
They will also heal rapidly where there is a low venous
Fig 28.1 Relaxed skin tension lines pressure (e.g... scalp, face and neck) as the arteriovenous

219
PRACTICAL PERSPECTIVES

pressure difference enables effective circulation at the


tissue level.

Fig.28.3 Elevation to reduce bleeding


Fig.28.4 Incision via layers (anterior abdominal wall)
Those with high venous pressure (e.g. legs and feet)
heal slower due to a more sluggish microcirculation. Areas Structures endangered by incisions
with a poor arterial supply (e.g. skin over the tibia) do not
tend to heal well. This is accentuated in patients with Incisions should be planned with an awareness of
impaired arterial flow (e.g. from arterial occlusion) or underlying structures (particularly nerves and vessels)
impaired venous flow (e.g. from varicose veins). and special care must be taken to avoid damaging
them.
Pain and need for prior anaesthesia
Many structures are supplied by sensory nerves with
significant numbers of pain receptors and some (e.g. skin)
produce extremely severe pain while being cut. It is most
important to provide adequate anaesthesia (whether
general, nerve block or local) for any incision.
The dermis of skin has a particularly rich supply of
superficial somatic pain fibres.
Deep fascia, aponeurosis and muscle are supplied with
deep somatic pain fibres and serous membranes (parietal
layer) are particularly richly supplied.
If local anaesthesia is adopted, each of the pain
sensitive layers needs to be adequately injected. If a nerve
block is adopted, infiltration around the appropriate nerve
(or nerves) needs to be achieved (noting that adjacent
sensory nerve supply territories may overlap).

Layers traversed by incisions


Layers traversed from superficial to deep may include
skin, subcutaneous tissue, deep fascia and muscle.
Incisions to open a joint cavity may additionally include,
ligament, fibrous capsule and synovial membrane.
Incisions to open a body cavity typically involve
Fig.28.5 Sites where vital nerves are superficial
traversing body wall layers in the following sequence:
- skin Nerves that are superficial and vulnerable at specific
- subcutaneous tissue sites include the:
- aponeurosis and/or muscle layers - facial nerve branches (on face)
- parietal layer of serous membrane - accessory nerve (in posterior triangle of neck)
In abdominal incisions, where possible, muscles are - ulnar nerve (behind elbow and at wrist)
split parallel to the direction of fibres (rather than incised) to - median nerve (at wrist)
minimise damage (with pain and bleeding) and avoid nerve - recurrent thenar branch of median nerve (in palm)
injury (e.g. to the ilioinguinal nerve). This also enables - common fibular nerve (behind knee)
more rapid healing and less chance of the postoperative All of the above nerves contain motor fibres, with
complication of a protrusion through the area of weakness significant functional impairment to muscle action resulting
from the incision (an incisional hernia). if inadvertently severed.

220
28. Clinical Procedures

Sensory nerves that are superficial and vulnerable


include the:
- great auricular nerve (in neck)
- palmar cutaneous branch of median nerve (at wrist)
- saphenous nerve (in leg)
Incisions in the thoracic wall endanger intercostal
neurovascular bundles. Anterior abdominal wall incisions
endanger epigastric vessels (superficial, inferior and
superior).
Lateral abdominal incisions may divide nerves to the
rectus abdominis muscle as they approach it from laterally.
They may also endanger branches of the circumflex iliac
vessels (superficial and deep).

Fig.28.7 Closure in layers (anterior abdominal wall)

Wound layers sutured


Interrupted sutures or a continuous suture may be
used for a particular layer where appropriate. Layers are
closed in the reverse order to those traversed by an
incision and may include muscle, deep fascia,
subcutaneous tissue and skin. Subcutaneous tissue is
generally closed with the skin as fat does not hold sutures
well.
Closing wounds from incisions into a body cavity
typically involve the following layers of the body wall:
- parietal layer of serous membrane
- aponeurosis and/or muscle layers
Fig.28.6 Vessels and nerves endangered on abdomen - subcutaneous tissue with skin
Internal organs (e.g... abdominal viscera) may even be In abdominal incisions, where more than one layer of
endangered if an incision is made too deeply. muscles are split parallel to the direction of fibres (rather
than incised) and the fibre direction for these layers cross
each other, they may spring back together (and overlap
WOUND CLOSURE sufficiently) without need for suturing.
A wound is an injury involving a break in the skin, Sutures and other options for skin
produced by either an incision or a laceration (traumatic
tear). For skin interrupted sutures may be used for most
regions. They also tend to stop bleeding even in highly
Prevention of dead space vascular areas (e.g. scalp, face and neck). These areas
tend to bleed more readily but heal more rapidly (with
Wounds should be closed layer by layer to prevent sutures removed in about 5 days). Less scarring is
dead space and maximise wound strength obtained by using a larger number of fine sutures rather
than fewer, heavier sutures more widely spread.
Closing wounds in layers prevents dead space that A subcuticular suture heals with minimal scarring and
otherwise tends to accumulate blood and is prone to may be used for cosmetically important sites particularly in
subsequent infection. Closing in layers also maximises females and children. However, it directly apposes only the
wound strength (although fat does not hold sutures well) epidermis and dermis, with more sutures probably being
and minimises risk of disruption. required in a deeper layer to compensate.
Muscles also tend to pull apart with contraction of their Glue or clips may be helpful in certain circumstances.
fibres and the most critical layer (e.g. an aponeurosis or a External adherent strips may be used to close
fascial wall of a compartment) should be closed without superficial wounds (except across joints, where movement
creation of any weakness or gap. disrupts them) and are of particular value in children.
Adherence of skin to deeper structures is avoided by
closing in layers, otherwise the scar tends to retract and
Wound edge alignment and suture tension
move with underlying muscle contraction (e.g. a scar from Wound edges require precise alignment with
thyroid surgery moving on swallowing). anatomical landmarks (e.g... borders of lips or eyelids) to

221
PRACTICAL PERSPECTIVES

prevent disfigurement. Edges heal better when they are


slighted everted. Sutures should be tied away from the
wound edge.

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.

Lacerations and their management


Lacerations are wounds produced by trauma rather
than by controlled surgical incisions. In addition to skin,
fascial and muscle layers, the laceration should be
systematically inspected for injury to each of the following
types of structures where applicable:
- vessels
- nerves
Fig.28.9 Suture tension and tissue blood supply - tendons
- bones and/or joints
Although many areas can tolerate some tension to - internal organs
bring wound edges together, in certain regions (e.g. lower Damage to deeper vital structures may be concealed.
leg, foot, palm and fingers) only minimal tension is
permissible. Areas already under considerable tension
(e.g. over the tibia) require particular care. Excessive
tension may require mobilization of a skin flap or even skin
grafting.

Fig.28.12 Layers of a laceration and associated injuries


Bleeding from wounds, even in highly vascular areas
(e.g... scalp) is usually controlled by pressure applied to
each side of the wound. Small spurting arteries can be
clamped (with artery forceps) for a couple of minutes and
larger spurters ligated, if necessary. Bleeding will tend to
Fig.28.10 Postoperative elevation to minimise swelling stop from compression by the sutures when the wound is
closed.
Post-operative swelling will further increase wound
The wound should be explored by searching for any
tension. Swelling can be minimized by elevation (which
foreign bodies. The site, number and depth are assessed
reduces hydrostatic pressure). Tension from muscle action
(including by x-ray where appropriate) before attempting
can be minimized by immobilization from a splint. Firm
removal. Use of a tourniquet may be considered to provide
dressings may reduce wound tension and swelling, but if
a bloodless field.
too tight will impair blood supply.

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).

Fig.28.13 Drainage of knee joint synovial cavity

Layers pierced in a joint puncture


For a synovial cavity puncture the following layers
are pierced in sequence by the needle:
- skin
- subcutaneous tissue
- deep fascia (with or without underlying muscle)
- fibrous capsule (with or without overlying ligament)
- synovial membrane Fig.28.14 Drainage of pleural cavity

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).

Layers pierced by an IM injection


For an IM injection the following layers are pierced in
sequence by the needle:
- skin (epidermis and dermis)
- subcutaneous tissue
- deep fascia
- muscle

Structures endangered by IM injections,


The structures endangered by an IM injection are
primarily vessels and nerves coursing deep to the muscle.
The arteries are accompanied by venae comitantes (a pair
of intercommunicating veins that surround the artery).
Inadvertent intravenous injection may occur if the needle
tip enters them.
IM injections into deltoid endanger the:
- axillary nerve and circumflex humeral vessels (deep to
deltoid running transversely around the surgical neck of the
humerus)
- cephalic vein (along the anterior border of the muscle
Fig.28.15 Depth and optimal angle of injections within the subcutaneous tissue)
The more superficial the injection, the flatter the plane - radial nerve and profunda brachii vessels (behind the
of entry, to prevent the needle from penetrating too deeply. posterior border of deltoid deeply within triceps)
For an ID injection, the needle is of narrower bore and the IM injections into gluteus maximus endanger the:
volume injected to raise a small bleb within the skin is - sciatic nerve (deep to the inner-medial quadrant of the
much smaller. For a SC injection in a thin person, the skin buttock)
and subcutaneous tissue may be pinched to ensure the - superior and inferior gluteal vessels (deep to the
correct layer is injected. gluteal muscles)

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.

Fig.28.18 Vasoconstriction of end arteries from adrenaline

Hazards of nerve blocks


The structures endangered by a nerve block are
accompanying vessels in addition to the nerves
themselves:
- veins (with direct vessel damage and/or intravenous
injection)
- arteries (with direct vessel damage and/or arterial
spasm)
- nerve (with direct damage by intraneural injection)
Damage indirectly due to compartment syndrome may
also occur with a nerve block (particularly if large volumes
of agent are given).
Aspirating before injecting avoids inadvertent
intravenous injection.
Ideally, nerve blocks should only be performed on
patients who are awake. If a nerve is hit, reporting of
paraesthesia enables the operator to reposition the needle
prior to injection. If direct injection into a nerve occurs,
reporting of paraesthesia or pain enables the operator to
immediately stop injecting and reposition the needle to
Fig.28.17 A digital nerve block prevent further damage.

225
PRACTICAL PERSPECTIVES

ARTERIAL PUNCTURE Layers pierced in an arterial puncture


An arterial puncture may be performed to provide a The procedure is painful unless a local anaesthetic
sample of arterial blood for analysis of blood gases (partial injection is given (particularly into the skin).
pressures of oxygen and carbon dioxide). An arterial Tension may be put on the artery to immobilise it. This
cannulation may be performed for direct measurement of prevents the artery moving away from the needle, when it
arterial blood pressure during surgery and for radiological is inserted. The layers then pierced are skin, subcutaneous
procedures. Punctures are not performed on end-arteries. tissue and deep fascia. The artery is penetrated by the
needle, until blood is seen pulsating into the syringe.
Accessible and palpable sites of arteries
The radial artery is commonly chosen for an arterial
puncture and is readily palpable between skin and bone at
the distal end of the radius on the front of the wrist (lateral
to the tendon of flexor carpi radialis).
The brachial artery and the femoral artery are
alternatives for arterial puncture. They are readily palpable
in the cubital fossa (medial to the tendon of biceps) and in
the femoral triangle (below the mid-inguinal point),
respectively.

Assessment of collateral circulation


Adequate collateral circulation should be tested for prior
to an arterial procedure.

Fig. 28.21 Radial artery puncture


Fig.28.19 Compressing circulation to hand
Compression of the artery immediately after removal of
Adequate collateral circulation to the hand is tested by the needle or cannula is mandatory to minimise bleeding.
compressing both the radial and ulnar arteries at the wrist Firm pressure is maintained (through a gauze swab) for at
until the skin of the palm has blanched. One artery is least 5 minutes.
released with blushing in the entire palm indicating
adequate collateral supply from that artery. The test can be
repeated for the other artery to assess adequacy of
collateral supply from it.

Fig.28.22 Minimising bleeding after arterial puncture

Hazards of an arterial puncture


The needle tip may hit underlying periosteum and bone
(with resultant pain). A neighbouring vein, nerve or tendon
may also be damaged.
The artery itself is vulnerable to damage with bleeding
and subsequent haematoma (which may be large and
painful). Potential hazards are arterial spasm or
Fig.28.20 Releasing compression of ulnar artery thrombosis.

226
28. Clinical Procedures

VENEPUNCTURE fossa because of the risk of inadvertent intra-arterial


injection into an anomalous artery (e.g. a superficial ulnar
A venepuncture is used for obtaining a venous blood artery, which occurs in about 3% of cases). This may result
sample or for giving an intravenous injection. in intense vascular spasm compromising supply of the
forearm and hand.
Sites for a venepuncture For other intravenous injections, a superficial vein
The procedure is best performed on a distended vein situated laterally in the cubital fossa, such as the cephalic
and it is far more convenient to choose a superficial vein of vein, may be chosen. The cephalic vein is located further
the upper limb. However, in emergency situations, the away from the brachial artery than the median cubital vein
femoral vein may be used, as more peripheral veins may (which is separated from the artery only by the thin bicipital
be difficult to access (particularly with shocked, obese or aponeurosis).
very young patients).
Superficial veins are highly variable (and have Tourniquet to distend veins
numerous unnamed tributaries). Although any prominent Application of a tourniquet (e.g. around the arm)
vein in the upper limb may be used, the cubital fossa is the distends the veins distal to the tourniquet. The tourniquet
most satisfactory site for a venepuncture as large should be at a pressure less than diastolic arterial pressure
superficial veins meet in the roof of this region. A median to enable sufficient blood flow.
cubital vein typically connects the cephalic vein to the Veins are often best felt, not just seen. If a vein is not
basilic vein in the subcutaneous tissue. However, a median very prominent, gently tapping over it may help the vein to
cephalic vein and a median basilic vein (rather than a dilate. Veins tend to constrict in the cold and dilate with
single median cubital vein) may be present instead. warmth (e.g. from a hot towel). They also tend to dilate
when hydrostatic pressure is increased (e.g. utilising
gravity, by placing the limb in a dependent position).

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.

Fig.28. 23 Superficial venous patterns in cubital fossa


Being a flexor region, the skin is not as tough as on the
extensor aspect of the limb and after the procedure
compression of the vein can be easily assisted by elbow
flexion.

Preventing inadvertent intra-arterial injection


Anatomical variations associated with the brachial
artery or its branches may be potential hazards.

Fig.28.25 Venepuncture in the cubital fossa


For obtaining a venous blood sample, aspiration should
be performed gently; otherwise the vein (being at low
pressure) will tend to collapse. Failure of the procedure
may occur because the needle has missed the vein (the
needle can be withdrawn slightly and the procedure
reattempted) or penetrated right through the vein (the
needle can be slowly withdrawn while gently aspirating,
until the vein is re-entered).
After the sample is obtained, the tourniquet is released
Fig.28.24 Inadvertent injection into an arterial variant and the needle withdrawn. Compression of the vein
(through a swab) immediately after removal of the needle
Intravenous injection of a general anaesthetic agent or will minimise bleeding and bruising. Gentle pressure is
vasoconstrictor should not be administered at the cubital usually required for only a short time.
227
PRACTICAL PERSPECTIVES

Hazards of a venepuncture subcutaneous tissue) at a reasonably flat plane of entry


(10-15 degrees) through the skin, bevel upwards. It is
The vein itself (being thin walled) may be nicked or
inserted up the vein far enough to ensure that the cannula
even lacerated, resulting in bleeding and a subsequent
is also within the vein (when blood begins passing up the
haematoma.
needle, it is pushed a bit further up the vein). The cannula
A neighbouring artery or nerve may also be damaged.
is then slid forwards off the inside needle until it is as far as
In the cubital fossa the brachial artery, or a variant of it, is
possible within the vein, prior to withdrawing the needle
endangered. The median nerve is medial to the artery and
and releasing the tourniquet.
the lateral cutaneous nerve of the forearm runs near the
lateral border of the cubital fossa (on the brachioradialis Hazards of peripheral IV cannulation
muscle).
With a cannulation, the vein itself (being thin walled)
may be nicked or even lacerated, resulting in bleeding and
INTRAVENOUS CANNULATION a subsequent haematoma.
Intravenous cannulation is performed to infuse fluid, Infusion fluid may leak into the surrounding tissues.
transfuse blood and administer drugs. Typically a An additional hazard is thrombosis. This is more likely
peripheral vein is chosen, but a central vein (e.g. internal with immobilisation, hence splints are not ideal.
jugular or subclavian) should be utilised to monitor central
venous pressure, infuse certain drugs or supply parental
nutrition.

Sites for peripheral IV cannulation


It is far better to choose a superficial vein of the upper
limb (to avoid risk of thrombosis in the lower limb). The
chosen vein should be as distal as possible along the limb
(which preferably should be the non-dominant upper limb).
Indwelling cannulae should not overlie a joint (to avoid
kinking by flexion) unless the joint is splinted.
The veins are distended by application of a tourniquet
proximal to the selected site for entry. If a vein is not very
prominent, gently tapping over it may help the vein to dilate
(which is also helped by warmth and dependency).

Ideal sites for cannulation of veins are at an inverted


'V' junction point or where a vein pierces deep fascia.

Veins tend to be more fixed at these sites, which helps


anchor them so that they do not move away from the tip of
the needle.

Technique of peripheral IV cannulation

Fig.28.26 Intravenous cannulation on dorsum of hand


The needle (with surrounding cannula) should be
directed along the chosen vein (located in the
228
Chapter 29: Postmortem Examination of Organs

The transverse colon is lifted, revealing its mesentery


and that of the small intestine (the mesentery).
POSTMORTEM EFFECTS ON TISSUES
ORGANS IN-SITU AT AUTOPSY

EXCISED VISCERA AT AUTOPSY

POSTMORTEM EFFECTS ON TISSUES


The colour, texture and shape of organs at postmortem
more closely represent their living state than in embalmed
cadavers (due to the effects of embalming fluid). However,
postmortem tissues are more friable and may be obscured
by blood. They are also not disinfected and tend to
deteriorate (particularly at room temperature).
During autopsy, organs are first examined in-situ.
Viscera are also examined following excision and in cut
section (demonstrating their external and their internal Fig.29.2 Intestines with mesenteries revealed
appearance, respectively).
Anterior thoracic wall removed
ORGANS IN-SITU AT AUTOPSY The ribs are cut laterally and the front of the rib cage
removed, by cutting it from the diaphragm. This opens the
Skin and abdominal wall incised pleural cavities and reveals the lungs. The pericardium
After the body is placed in the supine position, a line of (located between the pleural sacs) is also exposed.
incision to expose contents of the thoracic and abdominal
cavities is planned.
The skin and muscles covering the anterior thoracic
wall and those of the anterior abdominal wall are incised
and reflected. This reveals the sternum and rib cage (with
intercostal muscles) in the thorax and opens the peritoneal
cavity below the costal margin.
Within the abdomen, the liver and stomach are
exposed, together with the fatty membrane (greater
omentum) covering most of the intestines.

Fig.29.3 Intestines with mesenteries removed


The transverse colon and most of the small intestine
(jejunum and ileum) are excised along with their
mesenteries. This reveals the duodenum and descending
colon.

Lungs excised and pericardium opened


The lungs are excised. The pericardial sac is opened
anteriorly and reflected downwards, exposing the
pericardial cavity and serous pericardium (its parietal layer,
which lines the interior of the fibrous pericardium). The
Fig.29.1 Thoracic wall and abdominal cavity exposed surface of the heart is also revealed. It is partly covered by
epicardial fat (particularly over the right atrium).
Transverse colon lifted Within the pericardial sac, the pulmonary trunk and
The greater omentum is excised from the transverse ascending aorta can be seen arising from the ventricles of
colon to uncover the small intestine and ascending colon. the heart. The auricles (ear-shaped appendages) of the
atria can also be seen.
229
PRACTICAL PERSPECTIVES

The pericardium is removed, revealing other structures


located in the mediastinum. The mediastinum is the region
of the thoracic cavity between the pleural sacs. The first
two parts of the aorta (ascending and arch) are visible, with
the third part (descending aorta) obscured by the
oesophagus. Pulmonary veins are also seen passing
horizontally.
The diaphragm is lifted, revealing the superior surface
of the liver and the upper part of the stomach. The
ascending colon has also been displaced upwards, to
reveal the caecum and appendix.

Liver, stomach and spleen excised


Fig.29.4 Heart within pericardial sac

Heart excised
The heart is removed by cutting all the great vessels at
the reflections of the serous pericardium.

Fig.29.7 Retroperitoneal unpaired viscera


All remaining contents of the thoracic cavity are
removed, revealing the thoracic vertebral column. The liver
(with the gall bladder), stomach and spleen are excised,
revealing the duodenum and pancreas. The ascending
Fig.29.5 Parietal layer of serous pericardium colon, descending colon, duodenum and pancreas are
The parietal layer of the serous pericardium is reflected retroperitoneal as their (dorsal) mesentery became
onto the heart (to become the visceral layer) via two absorbed during development.
connecting roots for the great vessels. One set of
Retroperitoneal unpaired viscera excised
reflections is for the arteries (pulmonary trunk and
ascending aorta) while the other set is for the veins
(superior vena cava, inferior vena cava and the pulmonary
veins). The right pulmonary veins are demonstrated while
the left pulmonary veins have been removed.

Pericardium removed and diaphragm lifted

Fig.29.8 Paired viscera on posterior abdominal wall


The diaphragm, ascending colon (with caecum and
appendix), duodenum and pancreas are all excised. The
paired viscera (kidneys, suprarenal glands and ureters) on
the posterior abdominal wall are exposed, together with the
inferior vena cava.
The left renal vein is seen passing across the
abdominal aorta before draining into the inferior vena cava.
The descending colon is displaced laterally and is seen
crossing the pelvic brim to become the sigmoid (pelvic)
colon. The peritoneal cavity of the pelvis is continuous with
Fig.29.6 Mediastinum and abdominal viscera revealed that of the abdomen.

230
29. Postmortem Examination of Organs

EXCISED VISCERA AT AUTOPSY


Hollow viscera excised and in cut section Solid viscera excised and in cut section

Fig.29.9 Excised hollow viscera


Fig.29.11 Excised solid viscera
1. Oesophagus
2. Trachea and main bronchi 1. Thyroid gland
3. Heart 2. Lungs
4. Stomach 3. Liver
5. Gallbladder 4. Spleen
6. Duodenum 5. Pancreas
7. Jejunum and ileum 6. Suprarenal glands
8. Caecum (with appendix) and abdominal colon 7. Kidneys
9. Bladder (with ureters) and deferent ducts 8. Ovaries
10. Vagina and uterus (with uterine tubes) 9. Testes (with epididymes)
11. Sigmoid colon, rectum and anal canal 10. Prostate gland (with seminal vesicles)

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).

MUSCLE & FASCIAL PLANE SEPARATION Maintaining the cadaver


The cadaver can be maintained in good condition by
covering when not in use, to prevent parts from drying up
NEUROVASCULAR BUNDLE DISSECTION and hardening. Once dissected, spraying the region with a
special wetting and disinfecting solution and wrapping it in
EXPOSURE OF DEEP STRUCTURES plastic also helps to keep it moist.

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).

Fig.30.2 Surgical instruments used for dissection


Fig.30.1 Cadaver supine on a dissecting table
Scalpels
Dissection utilises surgical instruments to manipulate
tissues and is performed layer-by-layer (from superficial to Scalpels are used to make incisions and to clean visible
deep) commencing with a skin incision. surfaces (e.g. muscles) by piecemeal removal of fat. They
have a handle and a blade, each of which come in various
Fixation by embalming fluid sizes. The larger blades are more useful for incisions and
removal of skin or of deep fascia, while the smaller blades
Embalming fluid fixes tissues of the cadaver so that
are more useful for very fine dissection (e.g. clearing
connective tissue becomes firmer and fat is solidified, in
connective tissue from a small vessel).
contrast to living or unembalmed tissue. Embalming
Scalpel blades become blunt with use and need to be
provides the advantage of a bloodless field and less friable
changed regularly (with great care). The scalpel handle is
tissues (in addition to the benefits of disinfection and
notched obliquely on one side; which abuts the oblique end
moisturisation). However, organs appear drained of colour.
of the blade and the two may only be correctly fitted on that
Viscera are particularly affected and hollow viscera tend to
side.
deflate.

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.

Fig.30.3 Holding a scalpel correctly SKIN INCISION


Forceps A fresh, sharp blade is applied to the scalpel handle to
There are a variety of forceps. Plain (non-toothed) begin dissection. Larger scalpels are generally chosen for
forceps are used for grasping tissues other than skin and skin incisions on an embalmed cadaver, due to the force
may be used in fine dissection to separate tissues. required to penetrate the skin (which might snap a small
scalpel blade).
An incision is made with the scalpel blade held
perpendicular to the plane of the skin, contacting it along
the blades edge (rather than just with the point).

Fig.30.4 Holding tissue forceps correctly


Toothed forceps are used for grasping cadaver skin,
(that has been fixed by embalming fluid). However, toothed
forceps should not be used on living skin to avoid localised
trauma.
Other special types of forceps are artery forceps, used
for clamping vessels (and for changing scalpel blades).
They have a ratchet, enabling the joints to be locked at
various tensions. Bone forceps are strong and heavy, used
for fragmenting and removing bone.
Plain and toothed tissue forceps should be held like a
pen, but controlled between the thumb and middle finger
for optimum ease and accuracy.

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).

MUSCLE & FASCIAL PLANE SEPARATION

Fig.30.8 Detaching subcutaneous tissue


Cutaneous nerves and superficial veins receive their
fine branches (or tributaries) from the skin. The main
nerves and veins are preserved and may be followed until
they pierce the deep fascia. The remaining fat is reflected Fig.30.10 Blunt dissection along a fascial plane
and removed.
234
30. Cadaver Dissection

Individual muscles may be separated from each other


by blunt dissection. This is the parting of structures without
using a scalpel blade. It is best performed along fascial
planes, particularly mobile fascial planes, where tissues are
only loosely connected to one another.
Several instruments can be used for blunt dissection,
including plain forceps, large round-tipped scissors (with
blades closed), or even the tip of the finger.

NEUROVASCULAR BUNDLE DISSECTION

Fig.30.12 Exposing and displaying a deep structure

Locating nerves and vessels at dissection


During dissection, a nerve or vessel can be located by
backtracking after finding the neurovascular hilum of their
target organ. Even if nerves and vessels take separate
paths or one has an anomalous course, they eventually
converge near their destination.

Fig.30.11 Opening scissor blades to separate structures


Neurovascular bundles tend to course along mobile
fascial planes, in parallel with them. Branches tend to pass
along fixed fascial planes (e.g. intermuscular septa). The
fascial sheath of a neurovascular bundle is thinner around
veins, enabling them to expand. This may be removed
(usually using a fine scalpel and forceps) and structures
within the bundle separated by inserting closed scissors,
then gradually opening the blades.
Deep arteries in the periphery are surrounded by venae
comitantes (pairs of veins with numerous
intercommunicating branches). These in turn also
communicate with superficial veins by communicating
veins, which pierce the deep fascia.

EXPOSURE OF DEEP STRUCTURES


Major nerves and vessels tend to run deeply between
muscles. A retractor may be required to help expose these
structures.
Veins are much more numerous and variable than
arteries and many smaller veins (together with their
tributaries) may need to be removed for adequate
exposure of an accompanying artery or nerve.

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

Neuralgia and phantom pain Drainage of accumulations in a body cavity


C
Ch
C haaap
h pttteeerrr 111000::: A
p Arrrttteeerrriiiaaalll S
A Syyysssttteeem
S m aaan
m nd
n dA
d Arrrttteeerrriiieeesss
A Prolapse
Measurement of blood pressure C
Ch
C haaap
h pttteeerrr 111777::: N
p Neeeu
N urrro
u ovvvaaassscccu
o ulllaaarrr P
u Paaattth
P hw
h waaayyysss
w
Clinical examination of the pulse Detecting arterial pulsation
Arteriosclerosis Predicting vascular endangerment
Atherosclerosis and arterial aneurysm Predicting nerve endangerment
Haemorrhage SSeeccttiioonn 44:: H
Huum
maann D
Deevveellooppm
meenntt &
& VVaarriiaattiioonn
First aid management of haemorrhage
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
Effect of central retinal artery occlusion
Calculating fluid loss from burns in neonates
Effect of sudden coronary artery occlusion
Forensic determination of age
Vulnerability to vasoconstrictors
C
Ch
C haaap
h pttteeerrr 111999::: N
p No
N orrrm
o maaalll V
m Vaaarrriiiaaatttiiio
V on
o n
n
Danger of ligating a segmental artery
Forensic determination of sex
Types of arterial occlusion
Obstetric assessment of pelvic dimensions
Effects of anatomical end artery occlusion
Vulnerability to fractures from a fall
Effects of functional end artery occlusion
Arterial occlusion to vital areas Fat distribution and cardiovascular risk

Inadvertent ligation or injection Body Mass Index

Thrombosis and embolism Palpating abdominal organs on inspiration

Pulmonary embolus SSeeccttiioonn 55:: PPrraaccttiiccaall PPeerrssppeeccttiivveess


Systemic arterial embolus 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
C
Ch
C haaap
h 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
Fluid loss in burns and rule of nines
Managing venous bleeding in surgery
Sites where arteries are palpable
Varicose veins and haemorrhoids
Measurement of blood pressure
Venous valve incompetence
Clinical examination of the pulse
Deep vein thrombosis in the calf
Significance of signal node enlargement
Alternative routes of venous return
Examination of major lymph node groups
Venous spread of tumours and infections
Assessing skin sensory loss
Venous congestion and oedema
Ligament stress test
C
Ch
C haaap
h 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
Reflex muscle spasm
Lymph vessel ligation
Nerve fibre rupture
Effect of thoracic duct laceration
Assessment of muscle function
Lymphatic spread
Skeletal muscle tone and its assessment
First aid for venomous bites
Muscle hypertrophy and atrophy
Lymphoedema
Importance of testing visual fields
Sentinel nodes in tumour spread
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
Significance of signal node enlargement
Steps in radiograph production
Accessory spleens and splenectomy effect
Assessing bony integrity
SSeeccttiioonn 33:: B
Booddyy R
Reeggiioonnss aanndd O
Orrggaann PPoossiittiioonn Assessing radiological joint space width

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

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