GILROY Atlas of Anatomy

Table of Contents
Back Thorax
, Bones, Ligaments & Joints 5 Thoracic Wall

Vertebra l Colum n: Overv iew 2 Thor acic Skeleto n 44
Vert ebral Colum n: Elem ent s 4 Ste rn um & Ribs 46
Cervical Vert ebrae 6 j o int s ofthe Thor acic Cage 48
Tho racic & Lumba r Vert ebrae 8 Thoracic Wall Muscle Facts 50
Sacrum & Coccyx 10 Diaphragm 52
Int ervert ebral Disks 12 Neuro vasculatu re of t he Diaphr agm 54
j oint s of th e Vert ebr al Colum n: Overv iew 14 Arter ies & Veins of th e Tho racic Wall 56
j oint s of t he Verteb ral Colum n: Craniovertebra l Region 16 Nerves of the Tho racic Wall 58
Vertebr al Ligame nts: Overview & Cerv ical Spine 18 Neurovascular Topography of th e Thoracic Wall 60
Vertebral Ligamen ts: Tho racolumba r Spi ne 20 Fema le Breast 62
Lym phat ics of the Fema le Breast 64
2 Muscles
6 Thoracic Cavity
Muscles of the Back: Overview 22
Int rinsic Mu scles of th e Cervical Spi ne 24 Divisio ns of th e Thoracic Cavit y 66
Int rinsic Muscles of th e Back 26 Arte ries of t he Thoracic Cavity 68
Muscle Facts (I) 28 Vein s of t he Thoracic Cavity 70
Muscle Facts (II) 30 Lym phat ics of th e Thor acic Cavit y 72
Muscle Facts (III) 32 Nerves of the Tho racic Cavity 74
3 Neurovasculature 7 Mediastinum
Art eries & Veins of t he Back 34 Mediast inum : Overv iew 76
Nerves of th e Back 36 Mediastinum : Stru ctures 78
Neur ovascular Top ogr aphy of th e Back 38 Thym us & Pericardium 80
Heart in Situ 82
4 Surface Anatomy Heart : Surfaces & Cham bers 84
Heart : Valves 86
Surface Anato my 40
Arteries & Vein s of t he Heart 88
Condu cti on & Innervat ion of t he Heart 90
Heart: Radio log y 92
Pre- & Postn ata l Circulatio n 94
Esoph agus 96
Neurovasculatu re of th e Esop hagu s 98
Lymp hat ics of th e Mediastinum 100
XI
8 Pleural Cavity Jej unum & Ileum 162
Cecum , Appendix & Colon 164
Pleura l Cavity 102
Rectum & Ana l Canal 166
Lungs in Situ 104
Liver : Overview 168
Lun g: Radio lo gy 106
Liver: Segments & Lobes 170
Bronchopulmonary Seg m ents of the Lung s 108
Gallb ladder & Bile Ducts 172
Trachea & Bronc hia l Tree 110
Pancreas & Spleen 174
Respirat ory Mechan ics 112
Kidneys & Supra renal Gland s: Overview 176
Pulmonary Arteries & Veins 114
Kidneys & Suprarena l Gland s: Feature s 178
Neurovascul at ure of t he Tracheobron chial Tree 116
Ureter 180
Lymp hatics of t he Pleura l Cavity 118
Urinary Bladd er 182
Urinary Bladder & Urethra 184
9 Surface Anatomy
Surface Anato my 120 14 Reproductive Organs
Overview of the Genital Orga ns 186

Ut erus & Ovari es 188
Vagi na 190
Fema le Externa l Genitalia 192
Neurovasculature of t he Fema le Genita lia 194
Penis, Scrotum & Sperm at ic Cord 196
Test is & Epididymi s 19 8
Male Accessory Sex Glands 200
Neurovasculatu re of the Male Genita lia 20 2
Development of the Genita lia 204
Abdomen
& Pelvis 15 Arteries & Veins
Ar ter ies of t he Abd omen 206

Abdomina l Aorta & Renal Arteries 208
10 Bones, Ligaments & Joints
Celiac Trunk 210
Pelvi c Gird le
124 Superior & Inferior Me senteric Ar te ries 212
Male & Fem ale Pelvis
126 Vein s of the Abd omen 2 14
Pelvic Ligam ents
128 Inferior Vena Cava & Renal Veins 2 16
Porta l Vein 218
11 Abdominal Wall Superio r & Inferior Mesente ric Veins 220
Arterie s & Vein s of t he Pelvis 22 2
Mu scles of t he Ab dominal Wall 130
Arterie s & Veins of t he Rectum & Genita lia 224
Ing uinal Regio n & Canal 132
Abdom inal Wa ll & Inguinal Hern ias 134
16 Lymphatics
Perineal Region 136
Abdom ina l Wa ll Muscle Facts 138 Lym ph Nod es of th e Abdomen & Pelvi s 226
Pelvic Floor Muscle Facts 140 Ly m ph Nod es of the Posterio r Abdominal Wa ll 228
Lymph Nodes of the Anterior Abdominal Organs 230
12 Spaces Lymph Nodes of t he Int esti nes 232
Lym ph Node s of the Genita lia 234
Div ision s of the Abdominop elvic Cavity 14 2
Peritoneal Cavity & Greater Sac 144
17 Nerves
Lesser Sac 146
Me senterie s & Posterior Wall 14 8 Autonomi c Plexuses 236
Contents of t he Pelvi s 150 Inn ervation of the Abdomina l Org an s 23 8
Peritonea l Relation ship s 152 Innervat ion of th e Int est ines 240
Pelvis & Perineum 154 Innervat ion of the Pelvi s 242
Transverse Section s 156 Autonom ic Innervat ion : Overview 244
Autonom ic Innervation: Urina ry & Genita l Organ s 246
13 Internal Organs
18 Surface Anatomy
Stomach
158
Duo de num
160 Surfa ce Anatom y 24 8
XII
Supraclavicular Branche s & Posteri or Cord 322
Posterior Cord: Axillary & Radial Nerve s 324
Medi al & Lat eral Cord s 32 6
Median & Ulnar Nerv es 32 8
Superfi cial Veins & Nerves of the Upper Limb 330
Post erio r Should er & Axilla 332
Anterior Should er 334
Top ography of the Axil la 336
Topog raph y of the Brachial & Cubita l Region s 338
Upper Limb Topography of the Forearm 340
Topography of the Carpal Region 342
Top og raph y of the Palm of t he Hand 344
19 Shoulder & Arm

Topography of t he Dor sum of th e Hand 346
Bon es of t he Upper Limb

252 Tran sverse Secti o ns 348
Clavicle & Scapula

254
Hu merus
256 23 Surface Anatomy
joints of the Shou lder

258
Surface Anatomy (I) 35 0

j oint s of th e Shou lder: Glenohume ral joint
260
Surface Anatomy (II) 352
Subacromia l Space & Bursae

262
Ant erior Mu scles of th e Sho ulder & Arm (I)

264
Anterior Mu scles of th e Sho ulder & Arm (II)

26 6
Post erior Muscl es of th e Sho ulder & Arm (I)

268
Posterior Mu scles of t he Sho ulder & Arm (II)

270
Muscle Fa ct s (I)
272
Mu scle Facts (II)

274
Muscle Facts (III)

276
Muscle Facts (IV)

27 8
20 Elbow & Forearm
Radiu s & Ulna

280
lower Limb
Elbow j oint
282
Ligam ents of th e Elbow j oint

284
Radiou lnar j oint s

286 24 Hip & Thigh
Mu scles of th e Forearm (I)

288
Bones of t he Lower Limb 356
Muscles of t he Forearm (II)

290
Pelvic Girdle & Hip Bone 358
Mu scle Fact s (I)

292
Femur 360
Mu scle Facts (II)

294
Hip j oint: Overvi ew 36 2
Mu scle Fa cts (III)

296
Hip j oint: Ligam ent s & Capsule 364
Anteri or Muscles of the Thigh , Hip & Glut eal Region (I) 36 6
21 Wrist & Hand

Anteri or Muscl es of the Thigh , Hip & Glut eal Reg ion (II) 368
Bon es of th e Wri st & Hand 29 8 Poster ior Muscl es of the Thigh , Hip & Glutea l Regi on (I) 37 0
j oints of t he Wrist & Hand 300 Posteri or Mu scles of t he Thigh, Hip & Glutea l Regi on (II) 372
Ligame nt s of t he Wrist & Hand 302 Muscle Facts (I) 374
Ligaments of the Fingers 304 Mu scle Facts (II) 376
Mu scles of th e Hand: Superfic ial & Midd le Layers 306 Muscl e Fa cts (III) 378
Mu scles of th e Hand: Midd le & Deep Layers 30 8
Dor sum of th e Hand 3 10 25 Knee & leg
Mu scle Fact s (I) 3 12
Tibia & Fibula 38 0
Mu scle Fa ct s (II) 3 14
Knee j oint: Overvi ew 382
Knee j oint: Capsule, Ligam ent s & Bursae 384
22 Neurovasculature
Knee j oint: Ligam ents & Meni sci 38 6
Arteri es of th e Upp er Limb

3 16 Cruci ate Ligam ents 388
Veins & Lymphatics of th e Upp er Limb

3 18 Knee j oint Cavity 390
Nerves of th e Brachi al Plexus

32 0 Mu scles of the Leg: Anterior & Lateral Views 392
XIII
Mu scles ofthe Leg: Posterior View 394
Mu scle Fact s (I) 396
Mu scle Fact s (II) 398
26 Ankle & Foot
Bon es of t he Foot 400
Joints of t he Foot (I) 402
Joints of th e Foot (II) 404
Join t s of th e Foot (III) 40 6

Head & Neck
Ligam ent s of th e Ank le & Foot 40 8
Plant ar Vault & Arches of th e Foot 4 10
Mu scles of t he Sole of th e Foo t 4 12

29 Bones of the Head
Muscles & Tendo n Sheat hs of th e Foot 4 14
Ant erio r & Lat eral Skull 454
Muscle Facts (I) 4 16
Post eri or Skull & Calvaria 4 56
Muscle Facts (II) 4 18
Base of th e Skull 45 8
Et hmo id & Spheno id Bon es 4 60
27 Neurovasculature
Ar t eries oft he Lower Lim b 420

30 Muscles of the Skull & Face
Vein s & Lympha t ics of th e Low er Lim b 422
Mu scles of Facial Expr ession & of Mast icat ion 462
Lum bosacral Plexus 424
Muscle Origins & Insertions on th e Skull 464
Nerves of t he Lumb ar Plexus 426
Mu scle Fact s (I) 46 6
Nerves of th e Lum bar Plexus: Obt urato r & Fem oral Nerves .. 428
Muscle Facts (II) 468
Nerves of t he Sacral Plexus 430
Nerves of th e Sacral Plexus: Sciat ic Nerv e 432
31 Cranial Nerves
Superfic ial Nerves & Vessels of t he Low er Limb 434
Top ogr aphy oft he Ingu inal Regi on 436

Cranial Ner ves: Overv iew 470
Topography of t he Glut eal Regi on 438

CN I & II: Olfacto ry & Opti c Ner ves 472
Topography of t he Ant erior & Post erior Thig h 440

CN III, IV & VI: Oculo mo tor, Tro chlear & Abduce nt Ner ves .. 474
Topography of th e Post erior & Medial Leg 44 2

CN V: Trig em inal Nerve 47 6
Top ograp hy of th e Lat eral & Anterior Leg 44 4

CN VII: Fa cial Nerve 47 8
Topog raphy oft he Sole oft he Foot 446

CN VIII: Vestib ulocochlear Nerve 4 80
Transverse Sect io ns 44 8
CN IX: Glossopha ryng eal Nerv e 482
CN X: Vagu s Nerve 484
28 Surface Anatomy CN XI & XII: Accessory & Hyp oglossal Nerve s 4 86
Surface Anatom y 450
32 Neurovasculature of the Skull & Face
Innervati o n of th e Face 488
Arte ries of t he Head & Neck 490
Ext ernal Carot id Art ery:

Ante rio r, Medi al & Posteri or Branches 49 2
Ext ernal Carotid Arter y: Term inal Branches 494
Veins of th e Head & Neck 496
Top ography ofthe Superfi cial Face 498
Topography of t he Parot id Regio n & Tem po ral Fossa 500
Top ography of th e Inf rat em poral Fossa 502
Top ography of t he Pt er yg opalatin e Fossa 504
33 Orbit & Eye
Bones of th e Orbit 506
Muscles of t he Orbit 50 8
Neurovasculat ure of th e Orbit 510
XIV
Topog raphy ofthe Orbit 512
Orbit & Eyelid 514
Eyeball 516
Corn ea. Iris & Lens 5 18
34 Nasal Cavity & Nose
Bones of t he Nasal Cavity 520

Paranasal Air Sinuses 522
Neurovascu lat ure of t he Nasal Cavity 524 Neuroanatomy
35 Temporal Bone & Ear
39 Brain & Spinal Cord
Tempora l Bone 526
Ext erna l Ear & Auditory Canal 528 Nervous System : Overview 592
Middl e Ear: Tympanic Cavity 530 Telencep halo n 594
Middle Ear: Ossicular Chain & Tympani c Memb rane 532 Telencepha lon & Diencephalon 596
Art eries ofth e Middle Ear 534 Dienc ephalon. Brainstem & Cerebellum 598
Inner Ear 536 Spinal Cord 600
Mening es 602
36 Oral Cavity & Pharynx Ventr icl es & CSF Spaces 604
Bones of th e Oral Cavity 538

Tem po romandibular Joint 540 40 Blood Vessels of the Brain & Spinal Cord
Teeth 542 Du ral Sinuses & Veins of t he Brain 606
Ora l Cavity Muscle Facts 544 Arteri es of t he Brain 608
Inne rvation of th e Ora l Cavity 546 Art eries & Vein s oft he Spina l Cord 610
Tongu e 548
Topog raphy of th e Ora l Cavity & Salivary Glands 550 41 Functional Systems
Tonsils & Pharyn x 552
Pharyng eal Muscl es 554 Circuitry 6 12
Neurova sculatu re of t he Pharynx 556 Sensory & Motor Pathway s 6 14

Senso ry Systems (I) 616
37 Neck Sensory Syst em s (II) 618

Sensory Systems (III) 620
Bones & Ligaments of th e Neck 558
Muscle Facts (I) 560 42 Autonomic Nervous System
Muscl e Facts (II) 562
Muscle Facts (III) 564 Auton omic Nervo us System 622
Arteri es & Veins of t he Neck 566

Innervat io n of th e Neck 56 8
Laryn x: Carti lage & Struc ture 570
Larynx: Muscl es & Levels 572
Neurova sculature of the Larynx. Thyroid & Parathyroid s 574
Topography of t he Neck: Regions & Fascia 576
Appendix
Topography of th e Anterior Cervica l Region 578
Topography of th e Ant erior & Lat eral Cervi cal Reg ions 580
Topog raphy of t he Lat eral Cervical Region 582 Answers to Surface Anatomy Questions 626
Topography of th e Post erior Cervica l Region 584
Lymphatics of th e Neck 586 Index 628
38 Surface Anatomy
Surfac e Anatomy 588
xv
Bacl<
1 Bones, liga ments & Joints
Vertebra l Co lum n: Overview 2
Vertebra l Colum n: Eleme nts 4
Cervical Vertebrae 6
Thoracic & Lumba r Vertebrae 8
Sacru m & Coccyx 10
Intervertebral Disks 12
Joints of th e Vertebra l Column: Overview 14
Joint s of the Vert ebral Column: Cranioverteb ral Region 16
Vert ebral Ligament s: Overview & Cervical Spine 18
Vert ebr al Ligame nts: Thoraco lumbar Spine 20
2 Muscles
Muscles of t he Back: Overv iew 22
Int rin sic Muscles of t he Cervica l Spine 24
Intrinsic Mu scles ofthe Back 26
Muscle Facts (I) 28
Muscle Facts (11) 30
Muscle Facts (11 1) 32
3 Neurovasculature
Arteries & Veins of the Back 34
Nerves of t he Back 36
Neurovascular To pography ofthe Back 38
4 Surface Anatomy
Surface Anatomy 40
Vertebral Column: Overview
~ The vertebral colum n (spi ne) is divided int o four regio ns: t he and lumbar spines demon strate lo rd osis (inward curvat ure); the thoracic
IiIriiiiiII cerv ical, tho racic, lumbar, and sacral spi nes. Both the cerv ical and sacral spines demonstrate kypho sis (outward curvature).
Fig. 1.1 Vertebral column

Left latera l vi ew .
C1 - (7
Craniocervical junction vertebrae
Cervical spine
Cervicothoracic junction
t':t.~ii=;::.}---- Spinous
process
Thoracic spine
Thoracolumbarjunction
l,...d~i::::~ Costal
Lumbar spine
facets
T1-T1 2
Lumbosacral junction vertebrae
Articular
Sacrum (sacral spine)
processes
A Region s of t he spine.
~ ·PP'...-----'o. Interverte
bral foramina
~ Clinical
Spinal development L1- L5

The characteristi c curvatures of the adult spine appear over the course vertebrae
of postnatal development, being only partially present in a newborn. The ~~~~i'<i;j--- Interverte
newborn has a "kyphotic" spinal curvature (A); lumbar lordosis develops bral disk
later and becomes stable at puberty (C).
Adult spinal
column
~~~~"l'!'I--- Sacral
Kyphotic
Transitional
phase ~
W
F- Cervical
Sacrum
(51-55
promontor y
~
spine lordosis
of the vertebrae)
newborn
- Thoracic
kyphosis
Coccyx [
[l.: Lumbar
\)~ lordosis B Bony vertebral col umn.
<~ Sacral
~)) kyphosis
A B c
2
Fig. 1.2 Normal anatomical position ofthe spine
Left lat eral view.
1-- - - External
Dens of axis (C2) - - - --;---c aud it o ry canal Dens of axis (C2)
Ton gu e
Laryn x
Spinous process of
vert ebr a pro m inens (C7)
Trachea
Line of gr avity - -- ---I Inflect ion point s
Spinal cord
Ascendi ng
aor t a
Vert ebral canal
Heart
Esophagus
Int ervert ebra l di sk
Diaphr agm
Spino us proce ss
'ilii.~~- Whol e-body Liver
center of gravit y
Sto ma ch Body of L1
Conus m edullari s
Abdom inal
aort a
A Line of gravit y. The line of gravit y passes

through cert ain anato mical landmarks, Caud a eq uina
including th e infl ecti on points at th e cervi
cot horacic and t horacolumb ar jun cti ons. Sacral pro mo nto ry
It cont inues t hrough th e center of gravity
(anterior to th e sacral pro montory) before
passing th rough th e hip joint, knee, and
ankle. Bladder
. ~~~- Coccyx
Rectum
B Midsagittal sect ion t hrough an adult male.
3
Vertebral Column: Elements
~ Fig. 1.3 Bones of the vertebral column

e
'Xl
At las (C1) Jootiiilll<!~~~- Dens of axis (C2)
Axis(C2)
C1-(7
verte brae
Fig. 1.4 Palpable spinous processes

as landmarks
Verte bra -~~."""J Posterior view. The easily palpated spinous
prom inens processes provid e important landmarks dur
(C7)
Transverse
ing physical exami nati on.
pro cess
~C;~ii~..J~~ Scapular spine (13)
Tl -Tl 2
verte brae
Ver tebral \~~~~~~- Inferio r scapular
body ang le (17)
12t h rib (T12)
Invert ebral .. ~....,....-::'b!r'i-:::-:::<:="loo:-- Iliac crest (L4)

d isk
L1 - - ---iIf,--J,1
Ll - L5
verteb rae
Sacrum [ Posterio r
(fused sacral
Sacrum
51- 55 foramin a
ver te brae) Anterior
sacral
for am ina
Coccyx [ Coccyx [
A Ant erior view. B Poste rior view.
4
Fig. 1.5 Structural elements of a vertebra Fig. 1.6 Typical vertebrae
Left posterosuperior view . With th e exception of th e at las (C1) and axis Superior view.
(C2), all vertebra e consist of th e same struc tura l elem ent s.
Superior
articu lar Verte bral
Verteb ral -1'----- pro cess for am en
body
Superio r arti cular facet
Pedicle Transverse Pedicle
Verte proc ess ..-........_ ~ Posterior tubercle
bral Transverse process wit h
arch
1
Lamin a Spino us
pro cess
sulcus for spinal n.
Body Ant erior
Transverse foram en
tub ercle
Inferior
articu lar proce ss
A Cervica l vertebra (C4).

Spin ous pro cess
Costa l facet
Transverse process
"';""v~- Superio r art icular facet
Inferior cost al facet

_
Superior costa l facet

--'-J'---- Body
B Thoracic vertebra (T6).

Median
sacral crest
Superior art icular proc ess Sacral canal
Spinous process
Accessory process Transverse pro cess ~ --cr\-- Lateral part

/ of sacrum
Vert ebral arch
Supe rior arti cular process
Vert ebral for am en
Superior verte bral

not ch
Base of Promontory Wing of
sacrum sacrum
C Lumbar vert ebra (L4). D Sacrum .
Structural elements of vertebrae

Verteb rae Body Vertebral foramen Transverse processes Articular processes Spinous process
Small (may be absent in

Superopo sterio rlyand
Cervical vert ebrae Small 0); anterior and posterior Short (C3-C5); bifid (C3-C6);
Large (triangu lar) inferoanteriorly; obliq ue facet s:
C3 '-0 (kid ney-shaped) t ubercles enclo se lon g (0)
most nearly ho rizonta l
tr ansverse foramen
Medium (heart- Large and st ro ng; lengt h Poster iorly (slig ht ly laterally) and Long, sloping poste ro-
Thoracic vertebrae
shaped); includes Small (circular) decreases 11-T12; costa l anteriorly (slightly m edially) ; inferiorly; tip extends to level
T1- 11 2
costal facets facets (T1-11 0) facets in coro nal plane of vertebral bod y below
Posteromedially (or med ially)

and anterolatera lly (or laterally);
Long and slender;
Lum bar vert ebrae Large facet s nearly in sagitta l plane;
Medium (tria ng ular) accessory process on Short and broad
L1- L5 (kidney-shaped) mammi llary process on poster ior
poster ior surface
surface of each superior articu lar
proce ss
Superoposte riorly (SI) superior
Sacralverteb rae (sacrum) Decreases from Fused to rudimentary rib
Sacral canal surface of lateral sacrum Median sacral crest
S1-S5 (fused) base to apex (rib s, see pp. 44-47)
auricu lar surface
' C1 (atlas) and C2 (axis) are considered atyp ical (see pp. 6-7).
5
Cervical Vertebrae
~ The seve n verte brae of th e cervica l spine di ffe r most conspicu all di rect ions. ( 1 and (2 are known as t he at las and axis, respective ly.
~ ously fr om t he com mo n verte bral m orphology. They are special C7 is called the vertebra prominens for its long, palpab le spinous process.
ized t o bear th e weigh t of t he head and allow th e neck t o m ove in
Fig. 1.7 Cervical spine

Left lateral view.
Posterio r
arch of at las
Fig. 7.8 Atlas (C1)
Superior Groove for

C2(axis) -
art icular facet ~ verteb ral a.
Spinous
process Posterior
Anterior
t ubercle
t ubercle -
Posterior
Transverse arch of at las
'-------~,r-- Zygapo
Transverse
Anterior ------,-L,f physeal j oi nt fo rame n process
Inferior
tu bercle
b ---':llr--- - Inferior art icular
articu lar facet
Posterior
process
tu bercle
Superior art icular

A Left lateral view.
process
Sulcus fo r
spinal n.
Fig. 7.9 Axis (C2)

Uncinate process - ----,---- 7""'l ... J Spinous
process Anterio r
C7 (verte bra -
prom inens)
I articu lar facet -
Superior

articular facet
Transverse
Transverse - 'l/n;c--.ilI
- - Spinous
process process
foramen
Transverse fo ramen
Body
A Bones of th e cervica l spi ne, left lateral view.

Transverse Inferior Vertebral
process art icular facet arch
A Left lateral view.
Fig. 7.10 Typical cervical vertebra (C4)
Transverse Supe rio r

foramen articular process
Transverse process
<:"'~--- Superio r articu lar facet
- ,",---~
c----"'~-- Inferio r articular

process
Sulcus fo r Inferior Spinous

spinal n. articular facet process
B Radiograph of t he cervica l spine, left lateral view. A Left lateral view.
6
~ Clinical
Injuriesin the cervicalspine

The cervical spine is pro ne t o hyperexten sion inju ries, such as Thi s pati ent hit t he dashboard of his car wh ile not
" w hiplash: w hich can occu r w hen th e head extends back m uch farth er wearing a seat belt . The result ing hyperext ension
t han it normally wo uld, The most common inju ries of t he cervica l spine caused th e traumatic spo ndylolist hesis of (2 (axis)
are fractures of th e dens of t he axis, traumati c spo ndylolist hesis (vent ral wi t h fr act ure of t he verte bral arch of (2 , as w ell as
slippage of a verte bral body ), and atlas fract ures. Patient prognosis is t earing of th e ligaments between C2 and (3 . This
largely dependent on th e spinal level of t he injuries (see p. 600). inj ury is of ten referred to as "hangma n' s fract ure."
Superior Ante rior

art icular facet arch Posterior arch - - - . , . . ~--- Post erior t ub ercle
Superio r
art icular
facet
Transverse process
Transverse Inferio r Ant erior Transverse

_ 1""-- - - Ante rior arch
forame n art icular tubercle process
Ant erior
facet
tubercle
B Anterior view . C Su p erio r vi ew.
. ~~-- Spinous process
Vert ebral
Vert ebral arch
for am en
Inferior
art icular
Transverse
process
process
Inferior Superio r Transverse

art icular facet art icular fo ram en
Body
facet
Ante rior art icular facet
B Anterior vi ew . C Superior v iew.
Superior
artic ular
Uncinate Vertebral foram en ~ Spinous pro cess
process process
Vert ebr al arch
Posterior Lam ina /
/ ' t ube rcle Trans Superior
Sulcus for
verse Pedicle ----,_ ---,.4'11. art icular facet
spinal n.
Ant erior process
tubercle Posterior tubercle
Transverse
Bod y process with Transverse
sulcus for foramen
Spinous spinal n. Body Ant erior
process tu bercle
B Anterior vi ew. C Sup eri or v iew .
7
Thoracic & lumbar Vertebrae
Fig. 1.11 Thoracic spine Fig. 1.12 Typical thoracic vertebra (TG)
Lef t lat eral vi ew.
Superior Superior
vertebral not ch art icular facet
Superio r \ Transverse
~
~
cost al facet process
1st thora cic X

Spinou s process
+- Costal facet on
t ransverse
vertebra (Tl) l.-~~
Body - ---;-- pro cess
-!!!l..,.---:=-'tr - ----=-- - - Inferior art icular
process
Inferior
vert ebral notch
l~~~~g~t~~:,- process
Superior art icular
Inferior Spinous
art icular facet pro cess
~---1r--- Transverse
proc ess
A Left lat er al v iew.
-r-.------ - Costal facet
on tran sverse
process Superior Transverse
art icular process Body process
~~~--- Zygapo
physeal j oint
Superior
cost al facet
Vertebral - ------!-
bod y I nfer i o r ~ Cost al facet
cost al facet on tr ansverse
pro cess
Inferior
Spinous proc ess - - articu lar facet
v~~~~~
B A nterior v iew.
Inter_ !
vertebral
for am en Superior - ---f--='-'--=- ,....,- Cost al facet on
vertebra l
tr ansverse pro cess
notc h
,,-----.l~- Transverse
process
12th tho racic - - 7--
Pedicle "':o ...,~.,..--- Superior
vert ebra (T12 )
articular facet
Inferior --........., Superior
costal facet vertebral not ch
Inferior
art icu lar facet Superior ~---+------- Body
cost al facet
C Superior vi ew.
8
Fig. 1.13 lumbar spine
Left lateral view.
Fig. 1.14 Typical lumbar vertebra (l4)

Transverse proc ess
1st lum bar
vertebra (L1)
Supe rior
art icular process
Inferior
vert ebra l
-----.J-~~~~~~",.II"'l'\
Spinou s
1... . - Mammillaryprocess
Transverse
-~ii;;;iiii~iJ~
Inter- {
process
verteb ral notch
proce ss
foram en
Superior
Body !--- -
vertebral
notch Spinous
Zygapophyseal ~~:::~~~~ process
jo int Inferior
verte bral notch
Vert ebral
Inferior
body
art icular facet

Inferior
art icular pro cess
A Left lat eral view.

5t h lumbar
vert ebra (L5)
Superior
art icular
Inferior Inferior
Body proc ess
articular process arti cular facet
I
~ Clinical
Osteoporosis
The spine is t he structure mo st aff ected by degenerative diseases of t he
skelet on, such as art hrosis and osteoporosis. In ost eoporosis, m ore bone
mate rial get s reabsorbed tha n buil t up, resulting in a loss of bone mass.
Symptoms include compression frac ture s and resulting back pain. Inferior - -
art icular facet
Inferior Spinous
articular process process
B Ant erior view.
Spinous process - -
Mammillar y
process
Accessory Transverse process
process
I.
Vert ebral - ---'....'----'l.
Superior artic u
arch
lar process
Vert ebral
- -----.----1- ----/
Superior
forame n
verteb ral
Body -----\~-----'--____,- notch
A Radiogra ph of a norma l B Radiograph of an osteoporotic spine. C Superior view.

lumbar spine, lef t latera l The vert ebra l bod ies are decreased in
view. densit y, and th e int ernal trab ecular
st ruct ure is coarse. Lower and upper
end plates are fractured .
9
Sacrum & Coccyx
~ The sacrum is fo rmed fro m five postnata lly fused sacral vert e vert ebra. and th e apex artic ulates w it h th e coccyx, a series of t hree or
~ brae. The base of the sacrum art iculates w it h th e fift h lum bar four rudimenta ry verte brae.
Fig. 1.15 Sacrum and coccyx

Superio r
art icular Wing of
Promo nt ory pro cess sacrum
Lat eral
part
Ant erior sacral . 2:-? - ---::o!J- - Transverse

forami na lines
Apex of Superio r
sacrum art icular Sacral
~~:::::;:=iiifii9Gr--- Sacrococ cyg eal
j oi nt facet t ubero sit y
Sacral
canal
A Ant eriorview .
Auricular
surface
Lat eral
sacral crest
Post erior sacral - --=;-:,-,.--Z '-$'-- - - Me dian

foram ina sacral crest
~",,",,"r-~-- Medial sacral crest
~~=::~~:..--- Sacral hiatu s
:="'l~--- Sacral cornua

Coccyge al cornu -----~
......-~"'!l'-f""+--- Sacrococcyg eal
j oint
B Posterior view.
10
Base of
sacrum
.3l_ - - Superior
articu lar pro cess
Promon
tory
Auricu lar - - -H- - Sacral

surface t uberosity
Poster io r
surface
Ant erior (pelvic) surface
o Radiograph of sacrum, anteroposterior view.
C Left lateral view.
Fig. 1.16 Sacrum

Superior view.
Med ian
sacral crest
Superior Sacral
art icular proc ess canal
Median
sacral crest
Sacral
canal
- - r ll-- Lat eral

part of
sacrum
Promontory Wing of ; ii'-:~-- Lat eral part

sacrum
A Baseof sacrum , superio r view.
Coccyx
B Transverse section t hro ug h second sacral vert ebra demon strating

anteri or and posteri or sacral forami na, superio r view.
t
Intervertebral Disks
Fig. 1.17 Intervertebral disk Vert ebral canal

in the vertebral column
Sagittal sect ion of Tl1-Tl 2. left lat eral view. Vert ebral body l.-----J-t-- - - - Supe rior
The intervertebral disks occupy th e spaces

art icular
between vertebrae (int ervertebral joints. facet
see p. 14). Anulu s ~m,"'+;""'l+--- Verteb ral

Inter-
vert ebral
disk
1
r fibro sus
Nucleus - -r..,*":-t-i':-
arch
~~' ~~i+-- Spin ous process

pul posus
ligame ntum
flava
Inter spinous
ligament
Anulus Nucleus Superior Transverse

Fig. 1.18 Structure of fib rosus pulpo sus articular process process
intervertebral disk
Anteros uperior view with t he anterior half of
t he di sk and t he right half of th e end plate
rem oved. The intervertebral disk consists of
an external fibrous ring (anulus fibrosus) and a
gelatinous core (nucleus pulposu s).
Hyaline
cartila ge
end plate
Intervertebral Marginal ridge

surface Body (epiphyseal ring )
Fig. 1.19 Relation of intervertebral Fig. 1.20 Outer zone of the anulus fibrosus
disk to vertebral canal Ant erior view of L3-L 4 w it h int ervertebral disk.
Four t h lumbar vert ebra . superio r view.
Marginal ridge Superior

(epiphyseal ri ng) art icular process
Spino us process
Vert ebral Superior art icular

foram en pro cess
Transverse
~....~::;;;>-- Transverse pro cess
process
Superior - - --"!!!'-- :;'--::=~~~~~ __
ver te bral Int ervertebral
Vert ebral _ --J<-----/'
notc h fora m en
bodi es -r----,;..,..e,=- - Crossing fiber

--~'fff!:~f-- Nucleus pu lp osus systems of th e
anulu s fib rosus
Anul us { Inner zone
fibros us Outer zone --...::s.~~3~'"
Inferior --~~,.-iir"llllll.r
artic ular
process
Spino us pro cess
2
~ Clinical
Disk hern iat ion in t he lumbar spine

As t he stress resist ance of t he anulus fibrosus declines w it h age, the tis sue t he spinal nerve is affec ted. t he muscl es served by t hat spina l nerv e w ill show
of t he nucl eus pul posus may protrude t hrou gh w eak spots und er loadi ng. w eakeni ng. It is an importa nt di ag nosti c step to test t he mu scles inne rvated by
If the fibrou s ring of th e anulus ruptu res complete ly. the hern iat ed m aterial a nerve fro m a certain spinal segment, as well as t he sensit ivity in t he specific
m ay com press t he con tent s of t he intervert ebral foram en (n erve roots and dermatome. Example: The fi rst sacral nerve roo t innerva tes the gastro cnemi us
blood vessels). These pat ient s ofte n suf fer from severe local back pain. Pain and soleus muscles; t hus. st andi ng or wa lki ng on t oes can be affecte d (see
is also felt in t he associat ed dermatome (see p. 600 ). Wh en t he motor part of p. 398).
Cauda Fat in t he
equina epidural
space
L3
~ Herniat ed
Dural sleeve
disk
with spinal n.
L4 Cauda
equina in
Cent ral CSF'-filled
herniation dural sac
Nucleus =:.-'X~»-- Sacrum

pulposus
A Superio r view.
B Mid sagittal T2-w eig ht ed MRI (m agne ti c
reson ance image).
Posterior herniation (A. B) In t he MRI. a co nspicuo usly hern iated disk at th e

sac is deepl y indente d at t hat level. ' CSF (cerebrospina l flu id ).
. level of L3-L 4 protrud es po st er ior ly (t ran sligame nt ous hern iati on ). The du ral
Spinal
dura mater
- ;l..:z>=;J-- Dural , ac
Spondylophyte
Dural sleeve
wit h spinal n.
Compressed
Posterolateral
nerve root s
herniat ion
Posterolat eral
herniation
Nucleus
pulposus \ .F""'_~ Intervert ebral disk
Vertebral arch
(pedicle divided)
Dural sleeve wit h spinal n.
C Superior view . D Post erior view. vertebral arches rem oved .
Post erolat eral herniat ion (C. D) A post erol at eral hern iation may compress m edi ally posit ion ed . t he herni at io n m ay spare the nerv e at t hat level. but
t he spinal nerve as it passes t hro ug h th e int ervert ebral foram en. If more im pact nerves at inf erior levels.
13
Joints of the Vertebral Column: Overview
Joints of the vertebral column

Fig. 1.21 Joints of
G)- -----,K the vertebral column
Craniovertebral joints
: CD : Atlanto-occipita l joints : Occiput-C1
:0 : Atlantoaxial j oint s • C1- C2
• Joint s of t he vertebral bodie s
, Q) : Uncovertebr al joints • (3-C7

~ @) : Interv ertebral joint s : C1- S1
: Joints of the vertebral arch

:® ~ Zygapophyseal joint s , C1-S1
Fig. 1.22 Zygapophyseal (intervertebral facet) joints

Th e o rient at io n of th e zyg apo p hyse al j oints d iffer s between the sp ina l
regi on s, inf lue nc ing th e d egree and directi on o f m ov em ent.
"'c-- - - - - Superior art icular
process
Il
Anterior
Transverse tub ercle

Spinous process
process Posterior
tub ercle
Zygapophyseal
joint
Sulcus for
spinal n.
Transverse Inferior art icular

Superior
foramen process
art icular facet
A Cervi cal reg ion, lef t lat eral vi ew. Th e zyga po p hysea l joints lie -\-- - Costal facet
4 5 d egrees from th e horizontal.
Vertebral foramen
Superior
art icular process
Tranverse
process
.:6Ii1.....-t- Tranverse
Zygapophyseal process
join t
Spinous process - - -'-1-- ;4-';
B Tho racic regi on , lef t lat eral v iew. The j oints lie in th e coro nal p lane.
Inferior --"'::::;-0.1"' , "'~
articular process
C LUlIIUdl reql on, post er lor vie w . The j oints lie In th e sag ittal plan e.
4
Fig. 1.23 Uncovertebral joints
~ Clinical
Anterior vie w . Uncoverteb ra l j oints form during childhood between the
uncinate processes of (3-(6 and the verteb ra l bodies im m ed iate ly su pe
ri or. Th e joints may res ult from fi ssures in the cartilag e o f the di sk s that
Proximity of spinal nerve and vertebral artery
to the uncinate process
....
assume an arti cul ar charac te r. If the f issures b ecom e co m p let e t ear s, The spinal nerve and vert ebral artery pass throug h th e int ervertebral and
th e ris k of pu lp osu s hernia ti on is increased (see p. 13). t ransverse foramina, respect ively. Bony outgrowt hs (osteophytes) result ing
fro m uncoverteb ral art hrosis may comp ressboth the nerve and the arte ry
and can lead to chroni c pain in t he neck.
Dens
Vertebral a.
in t ransverse
foramen
Lateral 1IIo."'i~- Axis (CZ)
atlantoa xial
joint
C1 spinal n. At las(Cl)
Axis (C2)
Uncinate - - ----'r 'iI
processes
Vertebral a.
=".....- - Verte bral body
Uncinate
process
Post erior <, -='\i-- - Intervertebral
Trans- t ubercle disk
verse
..'",~- Transverse
1
process Ant erior
process
t ubercle
Sulcus for
Spinal n.
spinal n.
in sulcus
Vertebral body (( 7)
A Cervical spine, ante rior view.
A Uncovertebra l joints in the cervi cal spine of an , 8-year-old m an,

anterior vi ew. Spinous
process
Lamina Vertebral
foramen
Spinal
cord
Spinal n.
Posterior root -~'7""''''~~
(spinal) ganglion
Transverse
process
B Un cov ertebra l j oint (en larg ed ) , anterior vi ew o f corona l sect io n .
Transverse Uncinate
foramen process
B Fourth cervical verte bra, superior view.
C Split intervertebra l di sk. anteri or vi ew of co ronal sec t io n.
15
Joints of the Vertebral Column: Craniovertebral Region
5 Fig. 1.24 Craniovertebral joints

::J
::l
Superior External occipit al
nuchal line protuberance
Occipital condyle
Mastoid process ---\.~"'• •
(temporal bone)
...:110..--:-- - - - Dens of axis (C2)

Median
Styloid process - Atl as(C1) atlantoaxial joi nt
(te mporal bone)
- - - - Axis (C2) Dens of axis (C2) Superior articu lar
facet (lateral mass
of axis)
A Post erior v iew.
Groove for
Transverse
verteb ral a.
process
Spinous process
B At las and axis , posteros uperio r v iew.
Fig. 1.25 Dissection of the craniovertebral joint ligaments

Posterior view .
Externa l occipita l
/ N
",""'.
protub erance
Nuchal I.
Atlanto-occipital
Styloid process joint
Posterior at Ianto Posterior arch

occipital membr ane At las (C1) of at las
0 - =1---- - Tectori al memb rane
Zygapophyseal .---------1 (posterior
joint (capsule) Axis (C2) longitudi nal I.)
Ligamenta flava Vertebral arch
• A Nuchal li gam ent and po st eri or at lan to B Posterio r long itud ina l lig am ent. Removed:
oc ci p it al m emb ran e. Spina l co rd ; verteb ral can al windowed .
16
~ The at lanto -occipita l joi nt s are th e t w o art iculat ion s between th e axial jo int s are t he t wo lat eral and one medial art iculat ions bet ween t he
IIIriiiiII convex occipita l condyles of th e occipita l bone and th e slight ly atla s (C1) and axis (C2).
concave superior art icu lar facets of t he at las (C1). The at lanto-
.....
Fig. 1.26 ligaments of the craniovertebral joints
Med ian Apical I.

Anterior
at lantoaxia I Alar II.
tube rcle Alar II.
joi nt
Superio r Apical I. Superio r Tectorial me mb rane
art icular facet of t he dens articu lar
facet Transverse I.
Transverse I. of at las
Transver se Capsule of _~~-Y
process of at las
lat eral at lanto
occip ita l jo int
~--- Transverse process
Int ertransverse I.
Groove for
Lateral mass
vertebral a.
of t he at las Posterio r arch
Lo ngit udin al fascicles Post erio r of at las
Posterior tubercle at lanto-occipital

Spinous process mem brane
of the at las
of axis
Spino us process
A Ligament s of t he median at lanto axial jo int.
superio r view. The fovea of t he at las is hid

B Ligament s of th e cranioverte bral joint s,
den by t he j oint capsule.

post erosuperior view. The dens of t he axis
is hidden by t he t ect orial mem brane.
~ ..... . . , .... ~ ....... ............. ... ......................... . .. . . . ............. ,... ...
Tect ori al Lon gitu dina l Apical I.

Alar II. m em brane fascicles of dens
Atia nto
occipita l
capsule Lon gitudinal
Alar I.
fascicles ' Lat eral
mass of C1
.-~~-- Transverse I. Dens. poste rio r
of at las' art icular surface
Lo ngit udi nal

Posterior longit udinal I. fascicles
C Cruciform ligament of at las ( *) . Removed: D Alar and apical ligament s. Removed: Transverse
Tect orial membra ne. ligam ent of atlas, longit udinal fascicles.
~ ..
17
Vertebral ligaments: Overview & Cervical Spine
~ The ligam en t s of t he spina l co lumn bind t he vertebrae and enab le st resses and lim it t he ra nge of m o t io n. Th e lig am ent s ar e su bd ivid ed
IiIIiiiiII t he sp ine to wit hsta nd high m echanical lo ad s and shearing into vertebra l body ligam ent s and vertebral arch liga m ents.
Fig. 1.27 Vertebral ligaments Vertebral ligaments

View ed ob liquely from the left po sterior vi ew .
Ligament Location
Vertebral body ligaments

Along anterior surface of
® Anterior longitudinal ligament
vert ebral body
®
Along posterior surface of
® Posterior longit udinal ligament
vertebral body
- Inter @
tra nsverse Vertebral arch ligaments
ligament CD Ligamenta flava Between laminae
0 Interspinous ligament s Between spinous process
Along posterior ridge of

0 Supraspinous ligament s
spinous processes
8) Intertr ansverse ligaments Between transverse processes
CD
Between external occipita l
Nuchal ligament ' protubera nce and spinous
process of 0
. 1:.
toa , > t hat is broadened superior ly.
Fig. 1.28 Anterior longitudinal ligament Fig. 1.29 Posterior longitudinal ligament
Anterior lo ng it ud inal ligament. Anterior view with ba se of sku ll rem oved. Posterior v iew wit h verteb ra l cana l w indowed an d spinal co rd removed.
The tectoria l membra ne is a broaden ed expansion of th e posterior
lon g it ud inal ligament.
Int ernal Occipital External occipital

occipita l bone. protub erance
prot uberance basilar
part
At lanto-o ccipital
joint (atlanto
occipital capsule)
Anterior
I
atlant o
occipit al
membrane
Transverse
Transverse process
foramin a
Lateral At lanto-o ccipit al
Axis ((2) »->: at lantoaxial capsule
joint (capsule) Posterior atlanto
Anterior occipital mem brane
Zygapophyseal
longitudina l
joint (capsule)
ligament
Vert ebral arch
Sulcus for
spinal nerve
Ant erior
t ubercle
IntervertebraI Posterior longitu dinal

disk "'{r;<-""""i}--- Verteb ra ligament
prom inens
(0)
8
Fig. 1.30 Ligaments ofthe cervical spine
Sella Apical ligam ent Hypoglossal Tector ial
t urcica of th e dens canal memb rane
Spheno id sinus
Occipital bon e,
basilar part
~~l!ii;i;!l!l!!!!':;;;t;~~r+-- Dens of axis (C2)

Anterior arch ---=--=~--ii
of atla s (Cl)
~,
Maxil la
Poste rio r arch of atlas,

poster ior tubercle
Facet join t
.....~~3r----+--- Ligament a f lava
capsule 1L---'.!lIo-:":'-'-----,-,- -'-:-+-- - Verte bral arch
Int ervert ebral disk - ---\;-;'- S\"-;:;:- .,----'-_ _ Intervert ebral fo rame n
I:c-" --"-'-- - - Spinous process
'-+T."":::--:---- - Int erspinou s ligament
Posterior longi tu dinal ---"""~i1*~,""",,". 'Il

ligament
A Midsagitta l sectio n, left lat eral view. The nuchal ligament is th e

broadened, sagit t ally oriente d part of t he supraspinous ligam ent th at
exte nds fro m t he vert ebra prominens (C7) to t he exte rnal occipit al
prot uberance.
Cerebellomedu llary
Apex of dens cistern
Posterior t ubercle
Body of axis of atlas
Nuchal ligament
Posterior longit u
dinal ligame nt
Vertebral body
Int ervert ebral

disk
Supraspino us ligam ent
Verte bra
promi nens (0) Spinal cord
Ante rio r ~ ."!!i~~~~'=~+-- Subarachno id space

longitudin al
ligamen t
B Midsagittal T2-weighte d MRI, left lateral view.
19
Vertebral Ligaments: Thoracolumbar Spine
Fig. 1.31 ligaments of the vertebral Vert ebral canal

column: Thoracolumbar junction
Left lateral view ofTl1 -L3 . wit h T11- Tl2 - - - -- Superior art icular
sect ioned in t he midsagitta l plane. facet
Posterior longit udinal

ligam ent
Intervertebral
disk ~nw&-::-=-f+---- Vert ebr al arch
)=4 "'9c':'r-- - Ligam ent a f1ava
Superior art icular

Ant erior process
longitudinal
ligam ent ( ),!f--- - Spino us processes
Interspinous ligament s
Vert ebra l bod y - ---Bc--.,.,----!-

~-~t----- Intert ransverse ligam ent s
Facet j oint capsuIe - - ---.:;"-----HCH--'''7i::'-'7--''--:
. +.--~- Supraspinous
ligament
~-.-----¥'il-- Inferior art icular

facet
Fig. 1.32 Anterior longitudinal

ligament
Ant erior view of L3-LS.
Int ervertebral Transverse

disk proc ess
- - - - - Verte bral bod y
Anterior longitudina l ligam ent

Fig. 1.33 Ligamentum flavum and
intertransverse ligament
Anterior vi ew of open ed v ertebra l canal at
lev el of L2- L5. Removed: L2- L4 vertebra l
bodies.
-"=,.---- - - - - Superior
artic ular
process
Lamina
Inter
tran sverse Ligamenta
ligament s flava
Posterior -----"~--;;-~ ~~-+-'l-- Superior

longitudin al art icular
ligament process
Fig. 1.34 Posterior longitudinal
ligament
Posterior view of opened vertebral canal at
Ant erior ------"~....-~-T.-I+-+ I lev el of L2-L5 . Removed: L2-L 4 vertebra l
longitud inal
arc he s at pedic ular level.
ligament
Spinous process
Nutri ent ----+-~

foramina
Pedicles of
Posterior --~,-< , vertebral arches
longit udinal
ligam ent
Intervertebral
Intervertebral ------,~~~.~-:
foram en
disk
~-- Vert ebral
Gap in
body
ligamentous
reinfo rcement
Superior
of th e disk
arti cular facet
Transverse
process
Inferior arti cular

process
21
Muscles of the Back: Overview
~ The mu scle s of the ba ck are divid ed in t o two gro ups. t he ext rin sic mu scles are co nsid ered m uscles of t he up per lim b t hat have m ig rated to
~ and t he intrinsic mu scle s. wh ich are separat ed by th e supe rfi cial th e back ; these muscle s are d iscu ssed in Unit 4 .
layer of t he t ho raco lumbar fascia. Th e supe rfici al extri nsic
Fig.2.1 Superficial (extrinsic) muscles ofthe back

Po st er io r vi ew . Removed: Trapezius and lati ssimu s d or si (r ight) . Revealed:
Th oraco lumbar fa scia. Note: The su pe rf ici al layer of th e th o raco lumbar
fascia is rein fo rced by the apo ne urotic or igi n of the lat issim us d orsi.
m f -- Sternocleido
mastoid
I+;l'----- - - Thoracolumba r fascia

(= deep layer of nuchal fascia)
Trapezius. - -- ¥.6''r Rhomboideus mi nor

descending part
Trapezius.
tran sverse part

Clavicle
- -- - Acromion
Sca pular spine - - - ----f.1Wi'r;-;--;-- - - - Supraspinat us
Deltoid
Scapula. medial border

Teres major
Teres major
Trapezius.
Serrat us anterior
ascending part
Triceps brachii --d!-~r+-"-i Lati ssimus dorsi
Latissim us dorsi - --¥.- -*-- ---,:
Serratus
posterior inferior
Thoracolumbar - --i!1;CT---f,
fascia. superficial
layer
Exte rnal
oblique
Olecranon ---lH+fT'l*"~"
Aponeurot ic -----!!'!HK~~~f---
origin of
- - - N -,rriilHW ilf.II--- Int ernal
latissimus
obliqu e
dorsi
Lumbar
t riangle.
internal
oblique
Iliac crest
Gluteal
aponeurosis
22
Fig. 2.2 Thoracolumbar fascia
Transverse sect ion, superior view . The intrinsic back mu scles are seques layer that unite at the lateral marg in of t he intrinsic back m uscles. In t he
tered in an osseof ibrous canal, formed by the thora columbar fascia, t he neck, t he superficial layer blend s w ith the nucha l fascia (deep layer),
vertebra l arches, and t he spinous and tran sverse processes of associated beco ming cont inuous with th e cervica l fascia (prevertebral layer).
vertebrae. The thoracolumbar fascia consist s of a superfi cial and a deep
Infrahyoid Visceral
m uscles Trachea Esoph agu s fascia
Thyroid glan d
Sternoc leidom asto id
Int ernal
j ug ular v.
Carot id sheat h - - - --!,

~;:-:----- Pretracheallayer
l f
Cerv ical
fascia
Prevert ebrallayer
B
Vagus n. ---~~~~
Com m on
carot id a.
---7J~r;~i~~~~~~ ""'="""': ¥:-- - Lon gu s co lli
Brachial plexus - --f------,/'iil !5~~l-- Scalene mu scles

C6 vertebra ~f.+:-t':--- Spinal co rd
Levat or --'!~"''''
scapulae
Int rinsic back ---4'<~

mu scles
~
Trapeziu s - -- ----'-: ~~~~
V~- Deep layer 1 .
....~~;v:0I'l _
, Superficia l JNuc hal fascia
layer
A Transverse sect ion at level of C6 verteb ra, superior view.
Psoas fascia
Abd ominal Inferior Pariet al Renal fascia,

aorta vena cava periton eum Kidn ey ante rio r layer
Lateral
abd om inal
wa ll m uscles
~/--- Transversali s fascia
+.ffi -- - Fibrou s capsu le

L3 verte bra --}~~ltI~~g~~1
'1:-1- - - Renal fascia.
Psoas m ajo r - ---'1-£ ..... ,...., post erior layer
~r~~~~u--- Latissim us do rsi

Vertebr al arch
Transver se pro cess ~~~#'T,L----- Serrat us

posterior inferi or
Spino us process --~~Riii'
Quadratus
Int rin sic - - ......~!----,,---'--=== lum borum
back m uscles
Thoracolumba r
} fascia
B Transverse sect ion at level of L3, superior view.

Removed: Cauda equina and anterior trun k wall.
23
Intrinsic Muscles of the Cervical Spine
Fig. 2.3 Muscles in the nuchal region

Posteri or view. Removed: Trapezius, sternocleido mastoid, splenius, and
sem ispinalis mu scles (right). Revealed: Nuchal muscles (right).
Parieta l bon e ----;-:='"~~-
Occipita l bon e ---h:-+i~~~~~~------ Ext ernaI occipita I
protuberance
Semis pi nalis
capitis
Superior -----~~#.!.t~~~~~-:7'- Ste rno cleido

mastoid
nuchal line
Splenius capit is
Semis pinalis --------,,-'-'-~-:-!-:.'"::;'

Mastoid process
capit is
+- - - - - - Ob liqu us cap it is
Stern ocleid o superior
mast oi d
:=--- - - - Atl as (C1), tran sverse pro cess
Rectu s capit is
posterior min or
~_'-------- Ob liquus cap it is
Rectu s capit is
inferior
poster ior maj or
- --'-- - - - Longi ssimu s capitis

Splenius capitis
Axis (C2), spino us process - - - -- - Sem ispinalis capit is
Sem ispinalis - - - - - - Splenius capitis

cervicis
Trapezius - -- __cot'.! - - -- - - Splenius cervicis
24
Fig. 2.4 Short nuchal muscles
Posterior view. See Fig . 2.6.
Trapezius Superior nuchal lin e
Rect us capitis Ext ernal occipit al
post erio r m inor protub erance
Semispina lis
capit is
'~::f.;,~-- Rect us capiti s
Ste rnocleido
posterior major
ma st oid
Spleni us capit is --D M - - - Ob liq uus
capit is superio r
Obliquu s ---~:.!
Masto id proc ess

capit is superio r
Longi ssimu s - - - - ..:....:tr
capit is Poste rio r at lant o- occip ita l
m emb rane (pierced by
Transverse / "
vert ebral a.)
pro cess of at las (C1)
Rectu s cap it is Posterior arch
posterio r major of at las (C1)
Obl iquu s Spino us process
capit is inferio r
of axis (C2)
~~--- Int erspinales
Int ertran sversarii cervicis
cerv icis
Transverse
Spino us ----'i"l~=-----ll'"""'
process of C7
proc ess of C7
A Course of th e short nuchal mu scles.
Sem ispinalis Rectu s capi ti s Rectu s capit is

capiti s posterior minor posterior maj or
--"_'!I"_,,,,",,,,",,~~---f-- Trapezius
St ernocleido
Spleniu s - ---1;; mastoid
cap iti s
Longissim us ---~'ftI
capiti s
Obliqu us
capitis inferior
"J=;:~---- Int er spinales

cervicis
Int ert ransversarii
cervicis
B Origi ns (red) and insertions (b lue) in t he suboccipita l region .
25
Intrinsic Muscles of the Back
~ The extrinsic musclesof the back (trapezius, latissim us dorsi, serratus posterior, considered an intermediate extrinsic back muscle, has
~ levator scapulae, and rhomboids) are discussed in Unit 4. The been includedwith the superficial intrinsic muscles in this unit.
Fig.2.5 Intrinsicmuscles of the back

Posteriorview. Sequentialdissection of the thoracolumbar fascia, super
ficia l intrinsicmuscles, intermediate intri nsic muscles, and deep intrinsic
muscles of the back.
---'! --!-c----;!!I----'o.- - Thoracolumbar fascia

(= deep layer of
nuchal fascia)
Rhom boi deus ----='-::.1+.-<\ ~--- Serr atu s
major and mi nor posterior
superio r
Semispinalis -~~\-,;-l
capit is
External
Trapezius ---fL-=f;{;ff.j~~-=------+'!
intercostal
mu scles
Splenius Thora columbar
capit is fascia (= deep layer
of nuchal fascia)
Spleniu s ----l~
cervici s
Thoraco
lum bar
fascia
Serrat us
posterior
inferio r
Inte rnal -~~\
oblique Lat issimus Exte rnal
dor si int ercost aI
apon euro sis m uscles
Ext ern al -~, . ,"" "~ Ext ern al
ob liqu e oblique
lIio - - -,lJh "..;;.4 -+-\":;
costalis
Iliac crest
Longi ssi --~~~~-!rl~
mu s
Exte rnal
o blique
Int ernal
Gluteu s
obliq ue
maximu s Iliac crest
A Thoracolumbar fascia . Removed: Shoulder girdlesand extrinsic back

muscles (except serrat us posterior and aponeurotic originof latis
simus dorsi). Revealed: Superficial layer of thoracolumbar fascia.
Thor acolumba r fascia.

superficial layer
B Superficia l and intermediate intrinsic back muscles. Removed: Thora

columbar fascia (left). Revealed: Erector spinae and spleniusmuscles.
26
Splenius capit is --~. Semispinalis
(cut edge) capiti s
Iliocostalis
th oracis External
intercost al
Levatores - -r.iF---=r--hbi rnuscles
costarum
Superior
nuchal line
SpinaIis - --iI!'-:T.: R-+ Lon
gissimus Splenius capit is Rectus capitis
th oracis posterior min or
Obliquus
capit is superior
Iliocostalis ---'l~~ Rectus capiti s - -- ---. Y - - - Obliquus
lumb orum posterior major capit is inferior
Internal
obliqu e Longi ssimus - - - -----t1ll,liI Interspinales
Transversus capiti s cervicis
abdomini s
Spinalis - -- - -4ttJiiJlf
cervicis
Iliac crest ~~--- Rotato res

t horacis longi
Levatores ------cl~-=~~II II Rot ato res

costarum t horacis breves
longi
External
Spinalis -M"'---::",,",~~('/J_/~ , int ercostal
Gluteus Mult ifidus Thoracolumb ar
th oracis mu scles
maximu s fascia. deep layer
C Interm ed iate and deep intrin sic ba ck muscl es. Removed: Longissimus
th ora ci s and cerv icis, sple nius mu scles (left); ili o co st ali s (right). Note:
Th e d eep lay er of th e th ora columbar fas cia gives o ri g in t o the internal
o b li q ue and transver sus abd o m inus. Revealed: Deep mu scles of th e 12th rib
back .
-==--- Inter
Interspinales tra nsversarii
lumbo rum laterales
lumb orum
Transversus Transverse
abdomini s processes
Iliac crest
Thoracolum bar Multifidu s Quadrat us

fascia. deep layer lurnb orum
D Deep intrin sic back muscl es. Removed: Superficial and inte rmedi ate
intrin sic ba ck mu scle s (all); d eep fa scial layer and multifidu s (right) .
Revealed: Intertransversari i and quadratus lumborum (r ig h t ).
27
Muscle Facts (I)
15 Fig. 2.6 Short nuchal and craniovertebral joint muscles

o
CQ
Superior Inferio r
nuchal line nuchal line
\ Obliq uus
capit is superior
~-- Masto id process
-f-- - - Rectu s capit is

Post erior - - -+ poster ior major
tu bercle of atlas Transverse
Spino us - - ----:11 process of atlas
process of axis
Obliqu us
capit is inferior
A Post erior view. B Suboccipita l m uscles, posterior view.
Transverse Masto id External occip ita l

process of atlas process protube rance
Iiiii/''----- - Obliq uus

capiti s superior
At las (C1) - -----!!"--- - - - I-'t:!'
= !'__ - - Rect us capit is
Axis (C2) - - - - - - --:lH :!:" W-:.1II posterior m inor
Rectu s capit is
post erior maj or
Obliq uus Spinou s proce ss

capiti s inferior of axis
C Suboccipita l mu scles, left lateral view.
Short nuchal and craniovertebral joint muscles

M uscle Origin Insertion Innervation Action
, CD Rect us capit is , C2 (spinou s ! Occipital bone (inferior nuchal line. mi ddle
: Rect us capit is ..........................................
posterior major : process) ! th ird)

: Bilateral: Extends head
: poste rior ! 0 Rect us capiti s : Occipit al bo ne (i nferio r nuchal line. inner ! Unilateral: Rotates head t o same side
: t hird) : C1
posteri or min or
........",.""" .,., ,.,.,'..""," , ",.", ",.."..".., ,.,": (posterior ..... .... .. ... ... ... .. ... ... .. ..... . .. ... ........... ....•.... .... ...
: Bilateral: Ext end s head
! C1 (t ransverse : Occipital bo ne (inferior nuchal line. m idd le ! ram us =
: Unilateral: Tilts head t o same side; rotates t o
: Obliquus : process) : t hird ; above rect us capit is posterior major) : subo ccipit al n.)
! opposite side
.....•. .••...•.••.•.• .. .•......... ...• .......••••.. •••• •. .• • •
! capit is
:, @ Obliquus capit is: C2 (spinous : Bilateral: Ext end s head
, : C1 (t ransverse process)
infer ior : process) : Unilateral: Rot ates head to same side
Fig. 2.7 Prevertebral muscles Basilar part of Rectus
occipital bone capitis anterior
Basilarpart of
occipital bone
Atlas - -----::: Mastoi d -----X::1IJ"Mp:;'f~;1I! '''l1I~~:.JI~~;.f4 Rectus
process capitis lateralis
Axis - - - ,,*=
""",1,,,,-- '~,.;---- Transverse
process of atlas
Longus - - --f-
capitis
Axis Superior
C7 vertebra - - --7.- obli que
part
Lo ngus
colli
A Anterior view. C7 vertebra
1st rib
13 vertebra
B Prevert ebral mu scles, ant erio r view,

Removed: Longus capit is (left); cervical
viscera.
Prevertebral muscles
Muscle Origin Insertion Innervation Action
Direct branches Bilateral: Flexes head

0 -C6 (transverse processes,
CD Lo ngus capitis Occipital bone (basilar part) from cervical plexus Unilateral: Tilts and slightlyrotates head
anteriortubercles)
(Cl -0) to same side
Vertical(medial) C5- 13 (anterior sides of C2-C4 (anterior sides of
part vertebral bodies) vertebral bodies)
Direct branches Bilateral: Fl exes cervicalspine
@ Longus coll i Superior oblique 0 - C5 (transverse processes, Cl (transverse process,
from cervical plexus Unilateral: Tilts and rotates cervicalspine
(cervicis) part anterior tubercles) anteriortubercle)
(C2-C6) to same side
Inferior obli que T1- 13 (anterior sides of C5-C6 (transverse processes,
part verteb ral bodies) anteriortubercles)
Q) Rectus capitis
C1 (lateral mass) Occi pital bone (basilar part) Bilateral: Flexion at atlanto-occipltaljoint
anterior
Rectus capitis Cl (anterior ramus) Unilateral: Lateral flexion at atlanto
@) Rectus capitis Occipital bone (basilar part, occipitaljoint
C1 (transverse process)
lateralis lateralto occipitalcondyles)
29
M uscle Facts (II)
~ The intrin sic back mu scles are divided into supe rficial, inte rme di nerves. not th e do rsa l ram i, which innervat e th e intrinsi c back muscl es.
~ at e, and deep layers. The posterior se rrat us muscl es are ext rinsic They are included here as th ey are encountered in dissec tion of th e ba ck
back muscl es, innervated by t he ven tral rami of inter cost a l mu sculature.
Superficial intrinsic backmuscles

Mu scle Origin Insertion Innervation Acti on
.• CD Posteriorserratus '. Ligamentum nuchae; , 2nd-5th intercostal

. 2nd-4th ribs (superiorborders) • Elevatesribs
superior
: Posterior ............................. ' C7-T3(spinous processes) • nn.
................. ................................................................. ................................. . ,
: serratus : 0 Posterior serratus • 8th- 12th ribs (inferior borders. : Spinal nn. T9- T1 2
• T11-L2(spinous processes) . . : Depresses ribs
inferior • nearangles) • (anterior rami)
................................................................................................................ .................................................................... . .
. : Ligamentum nuchae;
, Occipitalbone (lateralsuperior '. Spinal nn. Cl -C6 ''. Bilateral: Extends cervical spineand head
: <» Splenius capitis
: Splenius uu u uu. u..u.u u . ~? :::T~ ~s~ i ~.?~s ~~?C~Ss~s l. ~ ~~~a l li ~e ; rnast? i d pro~ess ) .......• (posterior rami. lateral • Unilateral: Flexesand rotates head to the
: @ Splenius cervicis • T3- T6(spinousprocesses) • C1-C2 (transverseprocesses) . branches) ...... ......... ... •.~a~ ~ side
Fig. 2.8 Superficial intrinsic back Fig.2.9 Intermediate intrinsic back muscles (schematic)
muscles (schematic) Right side. posterior view. These muscles are co llectively known as t he e re cto r spina e.
Right side, posterior view.
®
®
~ CD
® @
0
(])
A Post erior B Splenius A Il iocostalis B Longissimus C Spinalis
ser rat us.

muscles. mu scles. muscl es. muscles.
Intermediate intrinsic backmuscles

M uscle Origin Insertion Inner vation Action
® Il iocostalis cervicis 3rd-7th ribs C4-C6 (transverse processes)

® Iliocostalis thoracis 7th-12th ribs 1st-6th ribs Spinal nn. C8-L1 Bilateral: Extends spine
Il iocostalis (posteriorrami. Unilateral: Bends spine laterally
6th-12th ribs; thoracolumbarfascia
Sacrum; iliac crest; lateral branches) to same side
o Il iocostalis lumborum thoracolumbar fascia
(deep layer); upper lumbarvertebrae
(transverseprocesses)
Tl - T3(transverseprocesses); Bilateral: Extends head
® Longissimus capitis C4-C7 (transverse and articular Temporal bone (mastoid process) Unilateral: Flexes and rotates
processes) head to same side
® Longissimus cervicis Tl-T6(transverse processes) C2-C5 (transverse processes) Spinal nn. Cl - L5
Longissimus (posteriorrami,
Sacrum; iliac crest; lumbar lateral branches) Bilateral: Extends spine
2nd-12th ribs; lumbarvertebrae Unilateral: Bends spine laterall y
vertebrae (spinousprocesses);
@ Longissimusthoracis (costal processes); thoracic vertebrae to same side
lower thoracicvertebrae
(transverse processes)
(transverse processes)
® Spinalis cervicis C5-T2(spinous processes) C2-C5(spinous processes) Bilateral: Extends cervical

Spinal nn. and thoracicspine
Spinalis T1 O-L3 (spinous processes, T2- T8(spinousprocesses. lateral
@ Spinalis thoracis (posteriorrami) Unilateral: Bends cervical and
lateralsurfaces) surfaces) thoracic spine to same side
•
Fig. 2.10 Superficial and intermediateintrinsic back muscles
Posterior view.
Superior ---7"-----
nuchal line
Spino us process of C7 ~.L..., Splenius

cervicis
Posterior - - - - 3
serrat us
superio r
Lon gissim us capit us
Iliocost alis cervicis

Posterior -""".-e_~ Spinalis
serrat us cervicis
Longissim us cervicis
inferior
Iliocost alis
t hor acis
Spinalis
th oracis
Lon gissimu s
th oracis
A Splenius and poste rior serrat us mu scles.

Iliocostalis
lum borum
B Ere ct or sp inae : Ili o co st ali s. lon g issimu s. and spi n alis mu scl e s.
Muscle Facts (III)
~ The deep intrinsic back muscles are divided into two groups: spinalis muscles pass between the transverse and spinou s processes of
IIIiiiII transversospinal and deep segmenta l muscles. The transverso - the vertebrae.
Transversospinalis muscles

Tl - Tl2 (between transverse and spinous processesof
CD Rotatoresbrevis adjacentvertebrae) Bilateral: Extends throacicspine
Rotatores
Tl- Tl2 (between transverseand spinous processes, skipping Unilateral: Rotatesspineto opposite side
o Rotatores longi one vertebra)
Bilateral: Extends spine
C2-sacrum (between transverse and spinous processes, Spinal nn.
Multifidus 0 Unilatera l: Flexes spineto same side, rotates
skippi ng two to fourvertebrae) (posterior to opposite side
rami)
Occipital bone (between
C4-T7(transverse and Bilateral: Extends thoracicand cervicalspines
o Semispi nalis capitis articular processes)
superior and inferior nuchal
and head (stabilizes craniovertebraljoints)
lines)
Semispinalis
® cervicis T1 T6 (transverse processes) C2 C5(spinousprocesses) Unilateral: Bends head, cervica land thoracic
spinesto same side,rotates to opposite side
® Semispinalis thoracis T6-Tl2 (transverse processes) C6-T4 (spinousprocesses)
Fig. 2.11 Transversospinalis muscles (schematic) Fig.2.12 Deep segmental muscles

Posterio r view. (schematic)
Posterio r view.
@
@- --"Iloe-
@
A Rotatores
m uscles , B Multifidus. C Semispinal is.
Deep segmental back muscles

o Interspinales cervicis C1-C7 (between spinous processesof adjacent vertebrae) Spinal nn. Extends cervical and lumbarspines
Interspinales' (posterior
® Interspinales lumborum L1-L5 (between spinous processesof adjacent vertebrae) rami)
Intertransversarii anteriores Spinal nn.
C2-C7 (between anterior tuberclesof adjacent vertebrae)
cervicis (anterior rami)
Bilateral: Stabilizes and extends the
® Intertransversarii cervicaland lumbar spines
C2-C7 (between posterior tubercles of adjacent vertebrae)
posteriorescervicis
Inter
transversarii ' Unilateral: Bends the cervica land
@ Intertransversarii mediales lumbar spineslaterally to same side
L1- L5 (between mammillary processesof adjacent vertebrae)
lumborum
Spinal nn.
(posterior
® Intertransversarii laterales
L1- L5 (between transverseprocessesof adjacent vertebrae) rami)
lumborum
@ Levatores costarum breves Costalangle of next lower rib Bilateral: Extends thoracicspine
10 " " " '0 <
C7- T11 (transverse processes) Costalangle of ribtwo Unilateral: Bends thoracicspine to
costarum @ Levatores costarum longi
vertebrae below same side, rotates to opposite side
",'
•Boththe interspinales and intertransversarii musclestraverse the entirespine; onlytheir clinically releva nt components have been included.
Superior Fig. 2.13 Deep intrinsic back muscles
nuchal line Post eri or view.
Inferior -4~0iiI~~
nuchal line Semispinalis
capit is
Semispinalis
cervicis
Spinous process of (7 -------o~7\ \
Semispinalis
t horacis
Transverse
process
Spinous process --~~=~::"'!III!l"~~
Rot at ores -----,l;.,----:;~--"'Ilt::::;;~~'1

longi
~-- Int erspinalis cervicis

Rot atores ----ilr-==-~~F--#,!"i
breves /i1i':l"i£lI"lIf:-----;;-~- Inte rtransversarii
posteri or es
cervicis
~~:~~~,~~~~~~~~- costa
Levat orures
lo ngi
m
Levat or es
costa rum
breves
Sacrum - - ---';-- --'1'1'''''''':.....".....
A Transversosp inal is mu scles: Rot atores.

mu ltifidus. and sem ispinalis.
B Deep seg m ent al mu scles: Int ersp inales.

in tertra nsver sarii, and levat or es cos t aru m .
Arteries & Veins of the Back
Internal External
carot id a. carot id a.
Fig. 3.1 Arteries of the back
The structures of t he back are supplied by branches of th e pos terior
intercostal arteries. which arise from the t horacic aorta or di rectly from
th e subc lavian ar t er y.
- Comm on carotid a. Vert ebral a.

Subclavian a. ~=v.l~" - ,...--- Brachiocephalic t runk
Common carotid a.
Aort ic arch
Thyrocervical tru nk
- Posterior intercostal aa. Costocervical
t runk Right subclavian a.
Anterior intercostal aa.
1st posterior
Thoracic intercostal a.
aort a Internal
thoracic a.
2nd posterior
Abdomin al ----<1IIO'IiC1iIIiL.
intercostal a.
aorta
""\,a..t.r --.......-'c".-- SubcostaI a.
B Vascular su p p ly t o th e nuc hal reg io n. pos

A Arteri es of t he terol ateral view. Note: Th e first and second
t runk. righ t lat eral posterior intercostal arteries arise from
view. t he costo -cer vical trunk. a branch of the
sub clav ian arter y.
Sternal Lateral
branches cutaneous
branch
Spinal
Internal branch
t horacic a.
Anterior - -1M
ramus
Medial
cutaneous
branch
Thoracic
aorta
E=:,-- - - - Abdominal
aorta
Median
sacral a.
'..."1- .:--- - External iliac a.

Lateral cutaneous Lateral Int ernal iliac a.
branch sacral a.
C Po st erior intercos t al arteries. o b liq ue po s

t ero superior view. The post er ior intercostal
ar teries gi ve rise t o cutaneous and m uscu
lar br an ches. as w ell as sp ina l br an ch es th at
su p p ly th e spinal cor d .
o Vascu lar sup p ly to t he Sd U U Ill . ante rior view.
34
Fig. 3.2 Veins of the back
Th e vein s of th e back dr ain into th e azyg os vein via t he superio r interco s
ta l vei ns, hemia zygos veins , and ascend ing lumba r vein s. Th e interi or of
th e spinal co lum n is d rain ed by th e vertebral venou s plexus t hat run s t he
length of t he spine.
'i,J:·I1--- - lnternal jugular v.

Superior
Subclavian v. sagitt al sinus
~~ ~~......,..-_ Right brachiocephalic v.
1~ft~~~~= Azyg o S v.
... Superior venacava Transverse sinus
Sigmoid sinus
~~ ~~~~~l-- Posterior intercost al w .
External vertebral Internal jugular v.

venous plexus
Left
~~~ .!--==-~-+- Inferior vena cava brachiocephalic v.
Superior
{'_=--::-'-'+ - Subcostal v. vena cava
Accessory
hemiazygosv.
Azygosv.
Posterior
A Vein s of th e intercostal vv.
trunk , rig ht lat eral
vi ew. Hemiazygosv.
External vertebral
venous plexus
Posterior internal
vertebral venous plexus
Posterior internal ---¥-<-7

Lumbarv.
vertebral venous plexus
Ascending lumb ar v.
Anterior internal
vert ebral
venous plexus
Azygosv. -~~~~~~l~"
Anterior
intercost al v. Anterior ~~---,"--"'i-1
internal External
Anterior ext ernal
Hemiazygasv. vertebral
iliac v.
Internal vertebral
t horacicvv. venous plexus venous
Internal
plexus
iliac v.
B Ver t ebral venou s pl exu s, posteri or vi ew w it h vertebral canal w in

dow ed in t he lumbar and sacral spine. The ext ern al vertebral ven ou s
pl exu s co m m unicates w it h t he sig m o id sinus throu gh em issary veins
in th e skull. The external vertebral venou s pl exu s is d ivi ded into an an
t eri or and a posteri o r porti on tha t run alo ng t he ext erio r of th e spinal
co lum n. Th e anter ior and post erior internal vertebral veno us pl exu s
C Int erco st al veins and anterio r verteb ral veno us pl exu s, anterosupe rio r run in th e vertebral foram en and d rain th e spinal cor d .
vi ew . The inte rcosta l veins foll ow a simi lar co urse as th e intercost al
nerv es and arteries (see pp . 34 , 36). Not e: Th e ant eri or exte rn al verte
bral ven ous pl exu s can be seen co m m unicati ng with th e azygos vein.
35
Nerves of the Back
~ The back receives its inner vation from branches of th e spinal intrinsic mu scles of th e back. The ext rinsic mu scles of th e back are sup
-.iiiiiII nerves. The posterior rami of th e spinal nerves supply m ost of th e plied by th e anterior rami of th e spinal nerves.
Fig. 3.3 Nerves of the back

The ant erior rami of spinal nerves Tl-Tll form the int ercostal nerves,
which course along th e ribs and giv e rise to lateral and anteri or cut ane
ous bran ches.
Post erior
Lat eral cuta ramu s T1
neous bra nch
Int ercost o
brachial nn.
___--foi~- Ant erior cuta
neous bra nch
Posterior
ramu s
Intercost al nn.
Anasto mosis
with medi al
brachial
cut aneous n.
Meningeal ramus
cuta neous
branch
Ante rior
Subcostal n. -
ram us
(12th int ercost al n.)
<,
A Cour se of th e int ercostal nerves.
B Spinal nerve branches, superior view. The posterior rami of th e spinal

Ante rio r Ante rio r ramu s nerves giv e rise t o mu scular and cut aneous branches, as well as
Ante rio r sacral (t o sacral plexus)
arti cular bran ches to th e zygapophyseal joints. The anterior rami of
roo t foram en
/ spinal nerves Tl - Tll produce t he int ercostal nerves (T12 produ ces
th e subcost al nerve).
Posteri or
ramu s
Branchesof a spinal nerve

Branches Territory
ramu s Spinal of spinal colum n

Posterior Post eri or Lat eral branc h Art icular branch Zygapophyseal joint s
Cauda roo t sacral (to th e cluneal
Medial branches Mu scular branch Intr insic back muscle s
eq uina fo ramen nerves)
Posterior
Cutaneous bran ch
ramu s Skin of posterior head, neck , back, and buttocks
C Spinal nerve branches in th e sacral foram
Cut aneous branch
ina. Superior view of tran sverse sect io n Lateral branches
Muscular branch Intrinsic back mu scles
through right half of sacrum .
Ante rior Lateral cutan eou s branch es Skin of lateral chest w all
ram us Ante rio r cutaneous branch es Skin of anterior chest wall
" The white and gray rami communicans carry pre- and postganglionic fibers bet ween the sym pat hetic trunk
and spinal nerve. Thcy arc show n on p. 622 .
36
Fig.3.4 Nerves of the nuchal region
Rig ht side, posteri or view. Like th e back, th e nu chal regi o n receives m ost
of its m otor and sensor y innervat io n fr om th e posterior rami of th e spinal
nerv es. The poste rio r rami of C1-C3 have spec if ic nam es: subocci pit al
nerve (C1), grea ter occipital nerv e (C2), and t hi rd occi pit al nerv e (C3).
The lesser occi pita l and gr eat auric ular nerves arise f rom th e anterior
rami of th e C1-C4 spinal nerves and inn er vat e t he skin of th e ant ero lat
eral head and neck. The anterio r ram i of C1-C4 also g ive rise t o th e ansa
-r-- -----,f=.= '"7"-- Lesser
cervicalis, wh ich in ner vates t he inf rahyoid m uscles (see p. 562). .liIlIllr~l\ occipital n.
!!:"''------ - Suboccipital n. (C1)
I ~------ Greatauricular n.
Greater occipital n. (C2)
3rd occipital n. (C3)
Supraclavicular nn.
C5 spinal n.,
Fig. 3.5 Cutaneous innervation of the back posterior ramus
~ C2
-...,--- - Supraclavicular nn.

~: == (
T1 ~
(3
~C5
Medial
cutaneous
branches
\
Spinal nn.,
(posterior
rami)
C6
Lateral --"'c----"-i~
cutaneous
branches +-:;>- Intercostal nn.,
(lateral cutaneous Tl
branch)
Superior _~-:--...
cluneal nn.
Middle cluneal nn. Iliohypogastric n.
A Periph eral senso ry cu ta neous inn ervat ion of t he back. B Derma tomes: Segme nta l (rad icu lar) cut aneou s inn er vat ion of th e
back. Note: The posterior ram us of C1 is purely m otor : th ere is co nse
qu ently no C1 derm at om e.
37
Neurovascular Topography of the Back
Fig. 3.6 Neurovasculature of t he

nuchal region
Post erio r view. Removed:Trapezius,
sterno cleidomastoid , splenius capit is. and
sem ispinalis capit is. Revealed: Subo ccip i
t al regio n. See p. 60 for th e course of th e
int ercostal vessels.
Obliq uus capit is
superior
Occipital a.
Rectu s capit is Greater occipital n.

posterior min or
Verteb ral a.
Rect us capitis
posterior major
Suboccipita l n.
3rd occipita l n. ~'-----;T------- At las,

transverse process
Obliquu s capit is
inferior
Lesser occipita l n.
Axis, spinous process Great auricular n.
Sternocleido masto id
Deep cervical a.
Splenius capitis
Longissim us
/ capitis
Sem ispinalis Sem ispinalis

cervicis capitis
38
Fig. 3.7 Neurovasculature of the back
Posterior view. Removed: Muscle fascia (except
superficial layer of thoracolumbar fascia); lati s
sim us do rsi (righ t). Reflected: Trapezius (rig ht) .
Revealed: Transverse cervical artery in th e deep
scapular region .
3rd
occip it al n.
Splenius capiti s ----~

Spinal accessory n.
Rhomboid major
Trapezius
Spinal nn.,
poste rior ram i
Deltoid
(m edial
cut aneous
branches)
Thoracolumb ar fascia
~~~~J--- Serrat us posterior inferior
Int ercostal nn. and

posterior inte rcosta l -'i-;;;--A~~~+.T-\U--- Lati ssimu s do rsi
aa. and vv., lateral
cuta neous branches
Fibro us lum bar tr iangle
(of Gry nfelt t )
External oblique
Iliol umbar t riangle Internal oblique

(of Pet it)
Iliac crest
Superior --~~FI--'"S~'+-:ir:t-~
clunea l nn.
Midd le -----,~~-~f___c,__---i!%~~
clun eal nn.
Inferior cluneal nn.
39
Surface Anatomy
-0 Fig.4.1 Palpable structuresin the back

~ Posterior view.
Vertebra
prom inens (Cl)
/ --,:;,---- - Acrom ion

Scapular
~ Greater
spine
tuberosity
Medial
bord er
Inferior
angle
6t h through
12th ribs
Iliac crest
}-- -- - - Anterior
superior
Posterior - - - - - - - :
iliac spine
superior
il iac spine Id E. -..-- .----- - - - - - Sacrum
...-- - - - Greate r
tr ochanter
.....,.=----- - - - - - - - Ischial
tub erosity
Trapezius
A Bony prominences.
~~==f- Teres
min or
Ter e s_-!----_~
major
Triceps
brachii
Lati ssimus - - - - - +-

dorsi
Exte rnal _
oblique Thoracolumba r
fascia
Glute us -+-_
mediu s
Gluteus
maximu s
B Musculatur e.
40
Fig. 4.2 Surface anatomy of the back
Posterior view.
Ql: Mi chaelis' rho mboid can be used as an

indicat or of th e w idth of t he fem ale pelvis.
Wh at are its bound aries?
SPinal _-----7------«
furrow
lJ Michaelis'
rhomboid
Anal _ _ ~----__;_;;::_____.....z
cleft
a:~~~1f------- Gluteal
fold
A Fem ale back.
Q2: The lim b girdl es are reliab le indi cat o rs Erector /

of specific vert ebr al levels. Wh at level
spinae
correspo nds t o t he inferior angle of t he
scapula? Wh at level co rrespo nds to t he
ili ac crest?
Sacral
] t riangle
Gluteal _ _--;~----'~~.
fold
See answers beginning on p. 626. B Male back.
41
Thorax
5 Thoracic Wall Heart in Situ 82

Heart: Sur faces & Cham bers 84
Thoracic Skeleton
44
Heart: Valves 86
Sternum & Ribs
46
Art eries & Veins of t he Heart 88
Joints of the Thoracic Cage
4g
Conduct io n & Inn ervat ion of t he Heart 90
I horac ic Wall Muscle Fact s 50
Heart: Radiol og y 92
Diaphragm ,2
Pre- & Post nata l Circulation 94
Neurovascu lat ure of t he Diaphragm 54
Esophagus 96
Arteries & Vein s ofthe Thoracic Wall 56
Neurovascu lat ure of th e Esophagu s 98
Ner ves of t he Thoracic Wall 58
Lympha t ics ofthe Mediasti num 100
Neurova scular Topography of t he Tho racic Wall 60
Female Breast 62
8 Pleural Cavity
Lymph ati cs of the Femal e Breast 64
Pleural Cavity 102
6 Thoracic Cavity Lungs in Situ i 04
Lung: Radiol oqy 106
Divisions of the Thoracic Cavity
66
Bronchop ulmo nary Segment s of th e Lungs 108
Arteri es of the Thoracic Cavity
68
Trachea & Bronchia l Tree 110
Veins of the Thoracic Cavity
70
Respi rat ory Mechani cs 112
Lymph at ics of t he Thoracic Cavit y
72
Pulmo nary Ar t eries & Veins 114
Nerves of the Thorac ic Cavit y
74
Neurovascul at ure of t he Tracheobronchial Tree 116
Lymphatics of t he Pleural Cavit y 118
7 Mediastinum
Media stinum: Overview
76 9 Surface Anatomy
Med iastinu m: St ruct ures
78
Surfa ce Anatomy 120
Thym us & Pericardiu m
80
Thoracic Skeleton
~ The th oracic skeleto n consists of 12 th oracic verte brae (p. 8). 12 prot ecti on to vit al organs. The female th orax is generally narrower and
~ pairs of ribs wit h costa l cart ilages, and th e ste rnum . In addition to shor ter t han th e male equiva lent.
participatin g in respirat or y m ovement s, it provides a measure of
Fig. 5.1 Thoracic skeleton
Clavicular
notch ~~~:I;~~~-- tSuperior
.~ horacic apert ure
~~~~JI~~~~~~__ Jugular notch

--r--=="-;~""'~-- Manubrium sterni
--<iiiiiiIiii1P77~~I- Sternal angle

Sternum
,---------;.,.........!!!!!!l~"'\_- Xi phoid process
. . . - ..a..~~,- Costa l
cartilage
Tl verte bral
body
l:1li;;3 -- Spinous process
.~·~--".=-",",=,d~~:\-- Costal margin

(arch)
Sternum Intervertebral
disk
Inferior
thorac ic aperture
A Ante rior view.
"'~tJ...M~O£""o~- Tl spinous process
~==ro-=-- T1 2 verteb ral

body
:I"'~- 12th rib
Costa l margin ----"-----"""::::~y
(arch) L1 vertebral
body
B Left lateral view.
~~~~I-- Costal angle
=---=---==~t--
Transverse
process
~~!'S:9II!!::~~~_ Costo
t ransverse
joint
Tl 2 spinous
process
....lr-~......= - L1 spinous process
C Posterior view.
44
Fig. 5.2 Structure of a thoracic segment
Superior view of 6th rib pair.
Costal Spinous Tra nsverse Costal

angle process process tubercle
Vertebral
foramen
Costal
cartilage
Sternum
Elements of a thoracic segment

: Vertebra
: Head
: Neck
: Bony part (costal bone)
Rib : Costaltubercle
....................................................................
: Body (includingcostalangle)
: : • • • •• • • • •• • • •• • • • • • • • • • • • •• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • n • • • • : • • ••• • • • • • • •• • • •• • • • •• • • •• • • • • • • • • • • • • • •• • • • • • • • • • • • •• • • • •• • •• • • • • •
.. . J~?~~~ I p.~ r.t (~?~~~ I ~~ r~i la~.~ ! .HH H

: Sternum (articulates
.. ., with costalcartilage of true ribs only;
,................................... .
see Fig. 5.3) .
Fig. 5.3 Types of ribs

Left late ral view.
: Ribtype Ribs Anterior articulation

Trueribs 1-7 Sternum (costal notches)
.. ... .... ... ....... ....... . .
False ribs : 8-10 : Rib above
.............................. . " ..
....r>-'' --- - - : Floating ribs ' 11, 12 : None
: ~ . .: .
45
Sternum & Ribs
e
o
Fig. 5.4 Sternum
The sternum is a bladelike bone consist ing of th e manub rium, body, and
t: xipho id process. The j unct io n of th e manubrium and body (t he ste rnal
angle) is ty pically elevate d and marks t he articulat io n of th e second rib.
The sterna l angle is an important landm ark for int ernal st ruct ures.
Jugular ---~ ~ Clavicul ar

notch / notch
- +- - 1st costal
notch
Manubrium - -T--- - Manu bri um - - -+
Ste rnal Sternal - --l: p..o.... M
angl e ang le
Body - - --+- - Body - - -7
-If------ot- - 2nd th rough

7t h cost al
notches
Xiphoid - - - - ---':- Xiphoid - - ---'-':.\

proce ss pro cess
A Ant erior view. B Left lateral view. The costa l not ches are
site s of art iculatio n wit h the costa l carti lage
of th e t rue rib s (see Fig. 5.3 ).
46
12th Fig. 5.5 Ribs
rib Right ribs. superior view. See pp. 258-259 for
joints of th e shoulder.
Scapular
notch
Acrom ion
Acro m io ~..---""7--:l.
-1i10'-;-- - Dens of axis (C2)
clavicular j oint
- - - At las (C1)
,::==""''--- - Ste rnoclav icular

j oint
Costa l Crest
t ubercle of neck
5t h rib
2nd rib Manubrium
~ N"k
A Variat ion s in rib size and shape. sterni
- - Head
Costa l
t ubercle
Costal
t ube rcle
Neck
Head
Head
Groove for
- - -- subclavian a.
Tubercle for
scalenus ante rior _ _ _ _ _ 2nd rib
Groove for
~ subclavian v.
- - Bod y
(shaft)
B 1st rib. Note: Most ribs have a costa l groove

along th e inferior bord er (not show n).
w hich protect s t he int ercostal vessels and
nerves. .iL- - - - - 11th rib
- - - - - - 5t h rib
C Right ribs. superior view.
47
Joints of the Thoracic Cage
~ The diaphragm is t he chief mu scle for quiet respirat ion (see

IIiiiiII p. 52) . The mu scles of th e t horacic wall (see p. 50) co nt ribute to
deep (for ced) in spiration .
Fig. 5.6 Rib cage movement

Full inspiration (red); fu ll expirat ion (b lue). In deep inspir ati on. th ere is infrasterna l ang le. The descent of the diaphragm furth er increases th e
an increase in tran sverse and sagittal t hor acic diameters. as well as th e volum e of the thoracic cavit y.
Inspiration
Infrasternal
angle
Transverse thoracic Sagitta l thorac ic
diameter diameter
Expirat ion
A Anterior view. B Left lateral view . C Position of diaphragm during respiration .
Axisof
movement Axis of
movement
Increase in
transverse
diameter
..
Increase in
sagitta l diameter
D Ax es of rib m ovem ent, superior view .
48
Fig. 5.7 Sternocostal joints
Anterior view with right half of sternu m sect ioned fronta lly. True joints
are generally fo und on ly at ribs 2 to 5; ribs 1, 6, and 7 attach to th e ster
num by synchondroses.
rI . ] ;;+-;;:::7-= - - Radiate Fig. 5.8 Costovertebral joints

sternocost al II. Two synovial jo int s make up t he costov ert ebral articu lation of each rib .
The cost al tub ercle of each rib arti culates w it h the costal facet of it s
1W~f'~=:::;~- Joint space accompanying vert ebra (A) . The head of most rib s articulates with the
vertebra of it s ow n number and th e vertebra immediately superior. Ribs
XcT=--==T..-:-- Costoxiphoid I. 1, 11, and 12 t ypically articulate only w ith their ow n vertebrae.
Costo t ransverse
Superior Costal facet j oint
art icular facet (tra nsverse pro cess)
Late ral costot rans Costal t ubercle,

verse I. arti cular surface
Superior costot rans- ~ ~¥ii(jj,: ll=iiiiii~ Costa l t ubercle

verse I.
Costotransverse I. Neck of 8t h ri b
Radiate I.
jo int of head of rib
Int ervert ebral

di sk
T8
--"'l~-- Transverse process A Costotran sverse jo int. Superior view with

Costotransverse I. jo ints of t he left rib tran sversely sect ion ed.
Ts
Superior - -i -- --.-- 7""C Costa l facet
costa l facet ~ (o n tran sverse process)
Inferior -~-==:-;o---.--rt- + - -
1""... Lateral costotr ans
cost al facet verse I.
Spinous process
Int ra-art icular I. --r:-===~;;1l~?Sbe::..----~~r-- Articular facet s

(on head of 7t h rib)
Crest of
rib head
Superior
costot ransverse I.
Int ervert ebral ---f~~-::::~D~ "
disk
~-- Costal t ub ercle
Radiate I. ----l>------:~~~~
~_~_If/_
8th rib (neck)
_ ...
T8
B Costovertebral joints. Left lateral view with t he joi nt head of t he 7th

rib op ened.
49
Thoracic Wall Muscle Facts
~ The muscl es of t he th o raci c wa ll are primarily resp on sibl e fo r w ith th e sho ulder (see pp . 264-267), an d th e serrat us p o st er ior is d is
~ chest respirati on , alt ho ug h ot he r mu scles aid in deep inspi ratio n: cu ssed with th e ba c k (see p. 30).
th e pectora lis major and serrat us anterio r ar e di scu ssed
Fig. 5.9 Muscles of the thoracic wall
A Scale ne muscles, anterior v iew . B Inter co st al muscl es, anterior view. C Tra nsve rsus th oraci s, p o st eri or v iew.
Muscles of the thoraci c wall
Muscle Origin Insertion Innervation Acti on
C3- C6 (transverse processes,

CD Ante rio r scalene 1st rib (scalene tub ercle) With ribs mobile: Raises uppe r ribs
anterior tu bercles) Direct branches
(inspiration)
from cervical and
Scalene 1st rib (poste rior t o groove With ribs fixed: Bends cervical spi ne
o Middle scalene C4- C6 (tra nsverse processes, for subclavian a.)
brachial plexus
to same side (unilateral); fl exes neck
posterior tubercles) (C3-C6)
(bil ateral)
@ Posterior scalene 2nd rib (outer surface)
Lower margin of rib to upper margin of next lower rib (courses

Raises ribs (inspirat ion); supports
@) Ext ernal intercostal obliquely fo rwa rd and downward from cost al t ubercle to
intercost al spaces; stabilizeschest wall
chondro -osseous jun cti on )
1stto l l t h
Int ercostal
~ Int ernal intercosta l int ercost al nn.
Lower margin of rib to lowe r m argi n of next lowe r rib (courses Lowers ribs (expiration); suppo rts
® Innerm ost obliquely forward and upward fr om costa l angle t o sternu m) intercosta l spaces, stabilizes chest wall
intercost al
Lower margin of lower ribs to inner surface of ribs t wo to t hree Variable lower
Subcosta l Raises ribs (inspiration)
ribs below int ercost al nn.
Ste rnum and xiphoid process ' 2nd to 6t h ribs (costal 2nd to 7th
IJ) Transversus t horacis Weakly lowe rs ribs (expirat ion)
(inner surface) carti lage, inner surface) intercostal nn.
50
----"1<,.--- - Atl as (Cl) Fig. 5.10 Muscles of the thoracic wall
Anterio r view. The exte rna l intercosta l m uscles
I -::~--- Axis (C2)
are rep laced anteriorly by the externa l int er
costa l membrane. The inte rna l intercostal
mu scles are replaced po ste rio rly by the interna l
Anterior longitu intercosta l membra ne (removed in Fig. 5.1 1).
dinal ligament
Posterior
scalene
:~~~--- Anterior
1st rib scalene
Manubrium
sterni External
int ercost als
Radiate
ste rnocost al ligaments
Ext ernal
Internal int er int ercostal
costals membrane
Ste rnum
External
inte rcostals
Costal
cart ilage
Ante rior longit u

dinalligament
Fig. 5.11 Transversus thoracis Posterior scalene

Anterior view with thoracic cage opened to
expose posterior surface of anterior wall. Middl e scalene
Ant erior scalene
Manubr ium
ste rni
Int ernal
Exte rnal
int ercostals
intercost als
Transversus
th oracis Int ernal
int ercostals
Xiphoid
pro cess
Cost al - -'\,--('
cartilag e
Chondro-osseous jun cti on

Diaphragm
Fig. 5.12 Diaphragm

The diaphragm. which separates the thorax from the abdomen, has two
asymmetric domes and three apertures (for the aorta , vena cava. and
esophagus; see Fig. 5.138).
Clavicle
_~L-_ Scapula ----""-----'-----::-~'!IIIlti~"----.._.I~- Cent ral

tendon
Diaphragm ---7li<-~,- --;:",L.",-:# - - Diaphragm
(right dome ) (left dom e)
Xiphoid
,..--e~ Caval process
apert ure
L1.
tra nverse
process
10t h rib
(1)
Right Left
crus crus
Lum bocost al A Anterior view.

t riangle L1. t ranverse process
Esophageal Caval
Cent ral
apert ure apert ure
te ndon
B Poste ri or view.
Right
do me
Left dome
Median
arcuate
ligament
Right crus
Latera l
arcuate
ligament
Aortic
aperture
Quadrat us
~!-!"!-- Transversus
lum borum
abdomini s
Psoas
m ajor
C Coronalsection wit h diaphragm in Medial arcuate
intermediate position. Psoas min or ligament
Diaphragm
Muscle Origin Insertion Innervatio n Act ion
: CD Costa
.......... l part .......·..!. ~ ~
....................... t? l .~ t ~..ri~ s. . ~in~ e ~ s.u rfac ~ ; lo~~rrna ~~ i~. ofc ? s.ta I a. ~ch)
~ Medial part: L1- L3 vert ebral bodies. intervert ebral disks. Princi pal muscle of respiratio n
, 0 Lumb ar part : and ante rior longit udinal ligament as right and left cru ra : Cent ral : Phrenic n. (C3- C5, (diaphra gmat ic and th oracic
. Diaphragm
Lat~ r. ~l p~r ts : .I ~~ ~r~ I ~~ ~ F.~ ~ i ~ I .~ ~ ~ ~ ~te ligament s
: cervical plexus) breathing); aids in comp ressing
....................... .................. tendon abdominal viscera (abdominal press)
: Q) Sterna l part • Xiphoid process (posterior surface)
52
Ste rnumDiaphragm
Fig. 5.13 Diaphragm in situ
_ _~I _ _~ (sternal part )
Centra l
tendon
Caval
aperture
;~"r--- Int ercostal

Diaphragm - - ----rTf;
(costal part) muscles
-'-'iI<-\-- Esophageal
Aort ic apert ure -----l~!'\ !!!!!.-~~-----~ apertu re
---f+.~- T 8
~Mr--- R i b
Endothora cic
Intrinsic fascia
back muscles
A Su pe rior v iew.
Sternum
Sterno costal Rectus
Caval tria ngle
aperture
Central
te ndo n
Median "-"'~-- Diaphragm

arcuat e ligament (costal par t)
Aortic apert ure

Esophageal
aperture
External
obliqu e .~~-- Left crus
"0#-"--- Lumbocostal
Int ernal triang le
oblique (Bochdalek's
Transversus ~ tr iangle)
abdo mini s Lat issim us
do rsi
Quadratu s
lumborum
Lateral arcuate
ligam ent
Psoas Verteb ral Erector Medial arcuat e ligament

major body spinae
B Inferio r view.
. , J" 1r--~'-'-:'i~-- Esophagus
no
.........----"le...::..-- - T12
Aor ta
C D iaph ragm at ic ape rtu res, left lat eral vi ew .
53
Neurovasculature of the Diaphragm
Fig.5.14 Neurovasculature ofthe diaphragm

Ante rior view of ope ned th oracic cage. Left int ernal jug ular v.
Left ext erna l j ug ular v.
Lef t subclavian a. and v.
:;-jfi-- - - - Left brachiocephalic v.

2<-:i-T- - - Left phrenic n.
Super ior vena cava -r-r-r-ri-r-x
Int ernal t hora cic a. - - - ---"'-'-',1

~-- Posterio r int ercostal vv,
Azygo sv. ---~
Perica rd iacop hreni c a.
Hemiazygos v.
Mu sculop hrenic a.
Superior phren ic aa. Phren ic n.
Inf erior phren ic aa. - - -+1'1
Celiac tr un k
'>/oil
Inferio r vena cava
Fig. 5.15 Innervation of C3

the diaphragm C4
Ante rior view. The phrenic nerve lies on t he C5
lat eral surface of th e fib rous pericardium
toget her with t he pericardiacophren ic art eries
and veins. Note: The ph renic nerve also inner
vates t he pericardium . ~
-f
Rib -
I
To pariet al pleur a.
mediast inal part
Int ercost al -
Pericard ial bra nches

mu scles
To parieta l pleur a.
diap hragmatic part
Inte rcost al nn .
Diaphragm
- Efferent fibers - Afferentfibers
54
Blood vessels of the diaphragm
Arte ry Origi n Vein Drainage
Inferior phrenic aa. (chief blood supply) Abdominal aorta; occasionally fr om celiac trunk Posterior int ercostal w .
Superior phr enic aa. Thor acic aorta Superior phrenic w. Right side: Azygos v.; Left side:
Pericardiacophr enic aa. Hemiazygos v,
Int ernal thora cic a. Right superior int ercostal v.
Musculoph renic aa.
Fig. 5.16 Arteries and nerves of the diaphragm

Note: Th e margin s of th e diaphragm receive sen so ry inn ervati on from
th e lowest inter co st al n er ve s.
Spinal cord
Sympathetic t runk Thoracic aort a Hemiazygos v.

Int ercostal n.
Parietal pleura.
costa l part
Azygos v. Parietal pleura,

diaphragm atic part
't.~~~~d~~~i'~m-- Left superior

phrenic a.
(fr om th or acic aor t a)
ci'T - Parietal pleura,

m ediastinal part
Inferior vena cava - - -T\iirni
Esophagus
'-i'- - - Phrenic n.,

pericardiacophrenic
Parieta l pleura, - - - --"=_ a. and v.
cost al part
:.-=- - - - - Pericardium
Musculophr enic a. ------"--2'~.::.
(fr om int ernal ::;s,..-!-=-- - - - - - Internal t horacic
A Sup eri or v iew. tho racic a.) ---.......... ---~ a. and vv.
Rect us -------=-~-7O'='
abdo mi nis Diaphragm ,
centra l te ndon
Diaphragm ,
costa l part Left
phrenic n.
Caval
hiat us
Esophageal
Right phr enic n. hiatus
!ill--"-- - Celiac tr unk

Right infe rior - - --;'--;iijlJ:
phrenic a. n- - - Left inferior
phrenic a.
Right superior - - ---,-,
suprarenal a.
Left superior
Common
suprarenal a.
hepat ic a.
Splenic a.
Externa l and internal
ob lique, tranver sus Greater
abdo minis splanchnic n.
Diaphragm,
lumbar part Left ascending
lumb ar v.
Quadratu s Psoas Abdo minal Spinal Lumbar Erector

B Inferio r vi ew. Removed: lumborum major aor t a vertebra
cord spinae
Pari etal pe rito n eu m .
55
Arteries & Veins of the Thoracic Wall
~ The post eri or interco st al arteries anosto mose wit h th e an t eri o r ao rta , w it h t he exce pt io n of th e 1st and 2 nd . w hic h ar ise f ro m t he su pe
~ inter co st al arte ries t o su p p ly t he st r uc t u res of the t horacic w all. rior interco st al artery (a br an ch of t he cos toce rvi ca l trunk).
Th e po sterio r interco st al arteri es b ran ch fr om t he t ho racic
Fig. 5.17 Arteries of the thoracic wall Com mo n

Anteri o r view. carotid a.
Superior
Thyrocervical
th oracic a.
Arteries of the
t runk
thoracic wall
Thoracoacrom ial a.
Subclavian a.
Origin Branch
:..~~~ e. r i?r ~~?r.~~.i ~ ~. Internal thoracic a.

: Lateral t horacic a.
........, .
2nd intercost aI a.
! Subclavian a. : Thoracoacrom ial a.
.................................... , .
. Posterior intercostal aa.

: (1st and 2nd; see p. 34)
Thoracic aorta
.........................................................
~ ~ Posterior
~
: Thoracic . Posterior intercostal aa.
"'" Intercostal a.
• aorta ! (3rd t hrough 12t h)
.................................. , .., .
Dorsal ~~
; Internal
: Anterio r intercostal aa,
................................................ ramus J~ ~~~~:~ ra l
: Musculo phrenic a.
: tho racic a.
Lateral
; Superior epigastr ic a.
cut aneous
branch
'\ ~ Medial mamma ry

t horacic a. \ branch
Anterior intercostal a.
Anter ior - -+'-"a- - -<
,------ Abdominal aorta
int ercost al aa.
~~- Superior epigast ric a.
Musculoph renic a. --~~b--~~'
!..=..--- 2nd and 3rd lum bar aa.
'------ - - Aortic bifurcation
Fig.5.18 Branches ofthe posterior

intercostal arteries
Supe rior view. Branches of the intercostal arteries
Medial cuta neo us
br anch Artery Branches Supplies
Spinal branch Spinal cord
Dorsal branch Medial cutaneous branch Posterior th oracic
Posterior
Lateral cuta neous branch wall
Lat eral intercostal aa.
cuta neo us Collateral branch LateraI t horacic
branch wall
Spi nal branch Ant erior Lateral cuta neous branch ' Anterio r t horacic
intercost al aa. wall
Anterio r Dorsa l ramu s
radicul ar a. ' The lateral mamm ary branch from t he lateral cutaneou s branch supplies th e
breast along wit h t he medial mam mary branch from t he internal t horacic
art ery.
56
~ The int ercostal veins drain prima rily into th e azygos system . but follow a sim ilar cour se to th eir art erial counterparts. However. th e veins
IIIiiiiII also int o th e int ernal thora cic vein. This blood ultimately return s of the vertebra l column fo rm an exte rnal vertebral venou s plexus that
to th e heart via th e superior vena cava. The inte rcost al veins trav erses th e enti re length of the spine (see p. 35).
Fig. 5.19 Veins of the thoracic wall

Int ernal Anteri or view.
jug ular v.
Ant erio r and post erior

Right internal verte bral venou s plexus
br achiocephalic v.
Sub clavian v.
Int ern al
t ho racic v. Posterior
intercost al vv.
Superior
vena cava
Accessory Ante rio r

hemi azygos v. int ercostal vv. Azygo s v.
Ante rio r
exte rnal
Azygo s v. Int ernal venou s
t horac ic vv. plexus
B Vert ebra l venou s plexus.
Hem iazygo s v.
Posterio r
int ercosta l vv.
Inferior
vena cava
Subco stal v.
( 12t h intercostal v.)
1st lum bar v.
A Anteri orvi ew with rib cage op ened. Int ern al jugu lar v. Exte rnal ju gu lar v.
Fig. 5.20 Superficial veins

Anterior view. The thoracoepigastr ic veins are
a potential superficial collate ral venou s drain Ceph alic v.
age route in th e event of superior or infe rior
vena cava ob structi on .
Sup erio r vena cava
Azygo s v. """"-----\:l.
Inferior vena cava --L
.9\?---"';...-----::;~--- Periu mb ilical vv.

Com mo n iliac v. - - ----\e--
Exte rnal iliac v.
~------ Ext ernal pud endal v.

Fem oral v.
- - - - - - Lon g sapheno us v.
57
Nerves of the Thoracic Wall
Fig.5.21 Intercostal nerves

Ant erior view . The 1st rib has been removed t o reveal t he 1st and 2nd
int ercost al nerves.
Posterio r
(dorsal)
ramu s
Tl
Int ercost o
brachial nn. Anter ior cut a
neous branch
3rd and 4t h
inte rcosta l nn.
Anastomosis St ernal
wit h m edial branches
brachial
cuta neou s n.
Subcost al n.
( 12t h intercost al n.)
Fig. 5.22 Thoracic wall: Peripheral sensory cutaneous

innervation
Supraclavicular nn.
Supraclavicu lar nn.
Medial
Anter ior cut aneous
cutaneous branches
branches Spinal nn.,
dorsal rami
Int ercost al nn. Lateral
cuta neous Intercost al nn.,
Lateral branches lateral cut aneou s
cut aneous Superior branches
branches cluneal nn.
Iliohypogastri c n.,
latera l cut aneous branch
A Ante rior view. B Posterior view.
58
Neurovascular Topography of the Thoracic Wall
Fig. 5.26 Anterior structures Axillary a. and v. External jugular v.

Anterio r view (see pp. 34-39 Deltoid
for neurovasculat ure
of th e back).
La te ralt horacic
a. and v.
Thoracoepigast ric v.
Internal thoracic
a. and v. Anterior cutaneous}
branches
Intercostal aa..
Intercostal a.. Lateral cuta neous vv., and nn.
v.. and n. branches
- - Superior epigast ric

a. and v.
Internal
oblique
Rectus
abdominis
~ Clinical
Insertio n of a chest tube

Abnormal fluid collection in the pleural space (e.g.• pleural effusion due to intercostal space on the posterior axillary line. The drainsh ouldal ways be
bronchial carcinoma) may necessitate t he insertion of a chest tube. Generally. introd uced at the upper margin of a rib to avoid injuring t he inte rcostal vein.
the opt imalpuncture site in a sitting patient isat the level of the 7t h or 8t h artery. and nerve. See p. 113 for details on collapsed lungs.
Pectoralis
major
Pleuraleffusion
1 " 'I~~!2---"-~-- Costal groove
Parietalpleura
"7-~f:'--;---'i:---- I ntercostaI
v.. a.. and n.
Visceral pleura
Endothoracic
fascia B Drainage tube is inserted C At ribs. the tub e is angled and
perpendicular to chest wall. advanced parallelto the chest
wallin the subcutaneous plane.
Rib
~~~- Chest tube
Pleuralspace
Puncture site
In nermost - - -- "';i &.-:--~-- Internaland D At the superior margin of the rib.
intercostal
external the tube is passed th rough the
intercostals intercostal muscles and advanced
A Coronal section. anterior view. into the pleural cavity.
60
Fig. 5.27 Intercostal structures in cross section
Transverse section, ant erosuperior view.
Intercostal n.,
posterior (dorsal) ramus
Right superior Intrinsic
phrenica. Costal Lateral branch Medial branch back muscles
groove
Latissimus
dorsi
Intercostal a.,
posterior
(dorsal) ramus
External
intercostals
Spinal cord (with
spinal ganglion)
Internal
intercosta ls !'!'!!!!=-- - - Intercostal nn.,
anterior
Innermost --~~~~?!L-.4~ (vent ral) rami
intercostals Posterior
intercostal aa.
Endothoracic -----'::;.;:~~-+-.!I andw.
fascia
Azygos v.
Central tendon
Thoracicaort a
~----- Esophagus
Serratus anterior ----i~ '\1l
Diaphragm Inferior vena cava

'rlr - - - - - - - - - -- - - - - Phrenic n.,
pericardiaco
phrenica. and v.
Pericardium
Parieta l pleura, - - --i

costa l part Musculophrenic a.
(from internal
thoracica.)
Internal
t horacic a. and vv.
Intercosta l n.,
lateral cutaneous - - Ante rior
branch perforating branch
Sternum
External oblique - - - - -
Intercostal n.,
anterior cutaneous branch
61
Female Breast
~ The female breast, a modified sweat gland in the subcutaneous byconnective tissue. The breast is additionally supported by suspensory
~ tissue layer, consists of glandulartissue, fibrous stroma, and fat. ligaments. An extension of the breast tissue into the axil la,the axillary
The breast exte nds from the 2nd to the 6th riband is loosely at tail, is often present.
tached to the pectoral, axi llary, and superficialabdominalfascia
Fig.5.28 Female breast Fig. 5.29 Mammary ridges

Right breast, anterior view. Rudimentary mammary glands form in both sexes along the mammary
ridges. Occasionally, these may persist in humans to form accessory
nipples (polythelia ), although only the thoracic pair normallyremains.
Nipple - - - --
~"----- Areola
Areolar
glands
Fig. 5.30 Blood supply

t o the breast
Subclavian
a. and v.
Axillarya .
and v.
Inte rnalth oracic

a. and v.
Lateral t horacic
a. and v.
Medial mammary Perforating Fig.5.31 Sensory innervation

branches branches
of the breast
Lateral mamma ry
branches
Mammar y
branches
Supraclavicular nn.
Intercostal nn.,
medial mamm ary
branches
Intercostal nn.,
lateral mammary
branches
62
~ The glandu lar t issue is com posed of 10 to 20 individua l lobes, sinus. Areolar elevations are t he open ings of t he areolar glands
~ each with its own lact iferou s duct. The gland ducts open on the (sebaceous). The glands and lacti ferous ducts are surrou nded by firm ,
elevate d nipple at the center of t he pigm ented areo la. Just pro xi fibrofatty tissue with a rich blood supply.
mal to th e duct opening is a dilated po rt ion called t he lact iferous
Fig. 5.32 Structures of the breast
Pect oral fascia
._+_~~ _ _ Suspensor y
(Cooper's) ligam ent s
Pecto ralis m inor
Mamma ry
Intercostal
lobes
mu scles
Nipple
Pectoralis m ajor
Lact iferous
Int ercostal
sinus
V., a., and n.
Lact iferou s du ct
Superfic ial
abdomin al fascia
Int erlobular
connect ive ti ssue
A Sagitta l sect ion along midclavicular line.
Lobules
Lact iferous duct
Lact iferou s sinus
Acini Term inal du ct

~------y------~
Mamma ry Termin al duct

lob es lobular unit (TDLU)
B Duct system and portion s of a lobe, sagittal section . In the nonla ctat C Termi nal duc t lobular unit (TDLU). The clustered acini composing the
ing breast (shown here), t he lob ules contain clusters of rudimentary lobu le empty into a termina l ductu le; these str uctures are collectively
acini. known as the TDLU.
63
lymphatics of the Female Breast
~ The lym phat ic vessels of t he breast (not show n) are divided into on t heir relat io nship to t he pect oralis m inor (Table 5.7). The medial por
I5iiII t hree syste ms: superficial, subcut aneo us, and deep. These drain t ion of th e breast is drained by t he parasternal lym ph nodes, w hich are
primarily into t he axillary lym ph nodes, w hich are classified based associated w it h t he int ernal t horac ic vessels.
Fig.5.33 Axillary lymph Level II Level III

nodes
A Lymphatic drain age of t he breast. Supraclavicular Ln.
Axillarya.
Cent ral
axillary I.n. Cervical Ln.
Pect oralis major
Brachial v.
Biceps brachii
--==---,,:~-- Clavicle
~_~~_---- Apical axillary I.n.
Basilic v. ;;:::::=-=-=..c~=:;;".----_ _ Pecto ralis minor
Brachial a.
lZ~=--=~~~~----- Interpectoral
axillary Ln.
Cubita l Ln. - ""=i;i;;::- - - - Pectoralis majo r
,)-7~~~~~~---:::-':':"""--- Pect oral axillary I.n.
e---'1~"",,~'="~="''-''--------cc'---- Lat eral tho racic v.

Hum eral
axillary I.n.
Supratroch lear Ln. Lat issim us dors i
B Ant erior view.
Levels of axillary lymphnodes

Level Position Lymph nodes(I.n.)
Pe c~?r~ I ~~ i llary Ln.

, .
•I
~ u ?scap~ l~ r axillary I.n: ... H .
• Lower axillar y gr oup : Lateral to pect oralis minor

:. ~ ~ fTl er~ l a x i li ary l.n H
• •••••••••••••••••
, Centra l l.n.
........................................................................., .....
~ II
... . j
Midd le axillary group : Along pecto ralis minor
.. • • • • • • • • • • • .• • H • • •• • • • • • • H " •• •• • H • . .•• • .• H ••••••••• H" •••• • • ••• H • • • • • • • H"': . I ~ ~ ~ r p. ~ ~ ~?ra l ~Xi lla. ~y I.n.
! III' : "'l.Jpper infraclavicu lar grou p ; Medial to pectora lis mi nor • Apical axillary Ln.
64
~ Clinical
Breast cancer
...Stem cells in th e int ralob ular connectiv e t issue give rise to t remendous cell makes the te rmin al duct lobu lar unit (TDLU) the mo st common site of origin of
growth. n ecessary for duct system proliferat ion and acini different iation . This maligna nt breast tumors .
Lobules
Lactiferousduct
Lactif erous sinus

~ 60%
~ 1O%
Acini Terminal duct

~ 1 0%
Terminal duct
lobular unit (TDLU )
A Termina l duct lobular unit. B Origin of malig nant t umo rs by quadrant .
Tumors originating in t hebreast spread via t he lym phat ic vessels. The deep colloids (techn etium [Tc] 99m sulfur rnkrocollotd). The downstream sent inel
system of lymphatic drainage (level III) is of parti cular importance . alt houg h node is th e fir st t o receive lymphatic drainage from the t um or and .is the refore
. th e parasternal lymph nodes provide a route by whic h tumorcells may spread the fir st to be visualized with radiolabeling. Once identified. it can then be
.across th e m idline. The survival rate in breast cancer correlates most strongl y · rem oved (via sentinel lymphadenectomy) and histologically exami ned for t umor
w it h t he number of lymph nodes involved at t he axil lary nodal level. Metastat ic cells. This m eth od is'98%accurate in predict ing the level of axillary nodal
involvement is gauged t hroug h scintigraphic mappingwith radiolabe led involvement .
~ M et astat ic involvement S-year survival rate
Levell 65%
.................. .................... .........................
~ Level II 31%
, Level III - 0%
C Norm al mamm ogr am . D Mammogram of invasive duct al carcinoma. The large lesion has changed t he
archite cture of the neighb oring breast tissue.
65
Divisions of the Thoracic Cavity
~ The tho racic cavity is divided into t hree large spaces: t he medias
a.iiIII t inum (p. 76) and t he t wo pleural cavit ies (p. 102).
Fig. 6.1 Thoracic cavity

Coronal sect ion. anterio r view.
Major structures of the tho racic cavit}''-~ ...
Thymu s. great vessels. trac hea.
-t1------"~,_____-- Superior Superior mediast inum
and t horacic duct
m ediast inum
Anterio r Thym us
Rig ht pleural - -I-!iII'---- -~O\-- Left pleural Heart . pericar diu m . and roots of
Mediastinum Middle
cavity cavity (left lung) Inferio r great vessels
(rig ht lung) m ediastinum
Thor acic aorta. t ho racic duct .
Inferior -lYIf::::::="':L-\I\- Posterior esophagus. and azygos venous
mediastinum
syste m
~ ",---;r.+-- Diaphragm
Pleural Right
cavitie s
Left pleural cavity Left
A Division s of th e th oracic cavity.
Thyro id gland, Thyro id Interna l

rig ht lobe carti lage jugular v.
I Trachea
Common carot id a.
Brachial plexus -------:.;;~b' Jn
Subclavian a. and v. - - --'--.fF-<.
Inferior thyro id v. -----,,r----T'=---..=~ ~=-~~-:,----- Internal t horacic a. and v.
~:2\~p,.----- Thymu s
~~<---- Left vagus n.
Superior vena cava - - - - - :'"=,_____----""---'-""" ~'-,'-------::;or---- Aorta. descendi ng part
Pericardiacophrenic --....,......--",ll~
a. and v.. phr enic n. Left recurr ent
laryngeal n.
Parieta l pleura.
- --.---"7';;---./ Left pulmonary a.
costal part
Parieta l pleura.
Right lung (wi t h
------.----;;;8'----~
med iastinal part
visceral pleura)
Left lung
Pericardium
Parieta l pleura, Diaphragm Atta chm ent between Sto mach

diaphragmatic part fibrou s pericardium and
diaphrag matic fascia
B Opened t ho racic cavity. Removed: Thoracic wall;

connecti ve tissue of anterior mediastinum .
66
Thoracic Fig. 6.2 Divisions of the mediastinum
inlet
Right pleural It .......jj--~'tr---- Superior

med iastinum
Left pleural
L
cavity cavity Esophagus,
cervical part
Inferior --w.!!------=::----\1~
mediastinum Thoracic inlet Cervical part }
Trachea
Diaphragm Thoracic part
Thoracic outle t Esophagus,

th oracic part
- \--'\:""\-- - - Superior
A Anterio r view (coro nal sectio n).

mediastinum
Sternu m \ -\-1---- - Sternum (body)

Anterior
",,\ .-\--\- l,--- Anterior
mediastinum
mediast inum
Posterior ----'t--'i7i'i~:::::""~- _;Jii.=;:::;~1J Middle

Midd le mediastinum mediastinum
mediastinum
Posterior
mediast inum Esophagus
Diaphragm
Right lung - ----\:lIIt-
Left lung
B Lat eral view (midsagittal sectio n).
Thoracic Descending
vertebra aorta
C Inferior view (transve rse sect ion).
Fig. 6.3 Transverse sections of the thorax

Comp ut ed tom ography (CT) scan of th orax. inferior view.
Superior vena cava Ascending aorta Inferior vena cava Esophagus
Right and left Esophagus Descending Azygos v. Descending

main bron chii aorta aorta
A Superior mediast inum . B Inferior mediastinum .
67
Arteries of the Thoracic Cavity
~ The arch of the aorta has three major branches: the brachioce tho racicaorta at the level of the sternalangle and the abdominalaorta
~ phalictrunk. left common carotid artery. and left subclavian artery. once it passes through the aortic hiatus inthe diaphragm.
After the aortic arch.the aorta begins its descent, becoming the
Fig. 6.4 Thoracic aorta

Trachea - - I-- -\-- - Esoph agu s
+--+- - - Lef t com mon

carotid a.
...-M-\-- - Left subclavian a.

Brachiocephalic - -+
t runk -----'>..,--- - Aort ic arch
Ascending aorta --+-
Left main - - t ----I-------Ci +-+ - Left pulm onary a.

bron chus
A Parts of the aorta. left lateral view. Note:
Pulmonary - -- Descending
The aortic arch begins and ends at the level
t runk aorta
of the ste rnalangle (see p. 46).
Thyr oid cart ilage
Right com m on carot id a. Left com mo n carot id a.
Trachea
Thyrocervi cal t run k
Left subclavian a.
Int ernal th oracic a. Esoph agus
-,;-"';-- - Aortic arch
Ascend ing aort a
Bronchial a.
Left main bro nchus
Esophag eal branch
Post erior int ercostal aa. --~

-'-7 - Thoracic aorta
Diaphrag m
Inferior phrenic a. Aor t ic hiat us
Celiac t runk
rr-'-F--;;:- - ""'-"""--';Ji- - Abdo min al aorta
Lumbar a.
-s.a
B Thoracic aorta in situ. anterior view. Removed: Heart. lungs. portions of diaphragm.
68
Branches of the thoracicaorta
The thoracic org ans are supplied by dir ect branche s from the th oracic aor ta, as well as indirect branches f rom the subclavian art eries.
Branches Region supplied

• Right subclavian a. See left subclavian a.
Brachiocephali c trun k
: Right com mo n carotid a.
Left com mon carotid a. Head and neck
Vert ebral a.
Ant erior intercostal aa. Anteri or chest w all
Thym ic branch es Thymu s
Int ernal thoracic a.
Left subclavian a. Mediastin al branch es Poste rior m ediastinum
Pericardi acophrenic a. Pericardium , diaphragm
Thyrocervical trunk Inferior thyroid a. trach ea, th yroid gland
Costocervical trunk Superior intercostal a. Chest w all
Visceral branch es Heart, bron chi. tra chea,

Descending t ho racic aorta • Posterior interco stal aa. Posteri or chest w all
Parietal branch es
• Superior phrenic aa.
~ Clinical
Aorticdissection
A t ear in t he inner w all (intima) of th e aorta allow s blood to separate t he aor t ic dissect ion s may be t reated conservatively, provided t here are no
layers of t he aortlc wall. creatin g a "false lumen" and pot ent ially result ing in com plications (e.g., obst ruc t ion of bloo d supply to the organs, in wh ich case a
life-t hreat ening aorti c rupture. Symptoms are dyspnea (short ness of bloo d) stent may be inserted to restore perf usion) . Aor ti c dissect ions occurring at t he
and sudd eno nset of excruciati ng pain. Acute .aortic dissect ion s occur mo st base of a corona ry artery m ay cause myocardial inf arction.
ofte n in the ascending aorta and generally require surgery. More dist al
"Fa lselumen"
Ascending Intim a
aorta
"Fa lse lumen"
Decending
aorta
A Aortic dissecti on . Parts of t he inti ma are st ill attached to th e connect ive B The flow in th e coronary arter ies is int act (arrow ).
t issue in th e wall of th e aorta (arrow) .
69
Veinsof the Thoracic Cavity
~ The superior vena cava is for me d by t he union of t he two brachio drained by th e azygos syste m (t he inferior vena cava has no t ributaries in
~ cephalic veins at t he level of t he 12-13 j unct io n. It receives blood t he th orax).
Fig. 6.5 Superior vena cava and azygos system

Right interna l ~ Left brachio
jugu lar v. ---------... cephalic v.
~ = \.#,7."-
Righ t subclavian v. ...... .6'-'~------- Superior vena cava
~------- Left pu lmonary vv .
Iil=,....,.--=-- - - - - - Inferio r vena cava

/
A Proj ecti on of venae cavae onto chest.
ante rior view.
Left int ernal jugular v.
Right supreme int ercost al v. Anterior scalene
Middle scalene
Left ext ernal jugu lar v.
Left subclavian v.
Rig ht int ernal th o racic v. --_---,---'~~ Inferior thyroid v.
-:-~:---- Left brachiocephalic v.
Righ t brach ioc ephalic v. - -",---=.--- - - Superio r vena cava
Azygos v. - - ----,!!.f,
m :--- - - Accessor y hemia zygos v.
Posterio r inte rcosta l vv . - - - ---7-::
Hemi azygos v.
Diaph ragm , centra l t endon - ----;i-;!
~--- Caval hiatu s
-'+-- - Esophageal hiat us
Right ascend ing lum bar v. - - - ....
Left ascend ing lum bar v.

Aort ic hiat us
Inferior vena cava - ----.1+
r-=.-..:1t~~~;:----=~---L--- Lum bar vv .
B Veins of th e th oracic cavity , ant erior view of ope ned th orax.
70
Thoracic tributariesof the superior venacava
Major vein Tributaries Region drained
Inferi or thyroid v. Esophagus, trachea , t hyro id gland
Externa l j ug ular vv.
Brachiocep halic w . Subclavian w .

Head, neck, upp er limb
Supreme intercostal vv.
Pericardia l vv.
Left , up'" l UI v.
Visceral branch es Trachea, bronchi, esophagus

Azyg os syste m Posterior intercosta l vv.
(left side: accessory hemia zygo s v.:
right side: azygos v.) Parieta l branches Superior phreni c vv. Inner chest w all and di aphr agm
Right superior interco stal v.
Thym ic vv. Thymu s
Mediastinal tributaries Posteri or mediastinum
Int ernal t horacic v. Ant erior intercostal vv. Ant erior chest w all
Pericardium
v.
Note: Structures of the superio r med iasti num may also drain "'" ~ ~ " ,u th e brachioce phalic veins via t he tra cheal, and media stinal veins.
Fig. 6.6 Azygos system

Ant erior view.
Right int ernal - - -- - - i!:i
jugu larv. ~~~iiii"I-- Inferior thyroid v.
Right subclavian v. Left br achio

cephalic v.
Superior vena cava
Azygos v. L>- - - - Accessory

I~, -"t""--..::;;jl--- hemia zygo s v.
Posterior inter - -Z
costal vv. Hemia zygos v.
Hepatic vv. Diaphr agm
I
Left renaI v.
Right t estic ularJ
ovarian v. * }f-- - - -- - Lumbar w .
Righ t ascending - - - - -41 Left ascendin g

lu mbarv. lumbar v.
Left com mo n
ili ac v.
Inferior vena cava
'T he left test icular/ovarian vein arisesfrom th e left renal vein.
71
lymphatics of the Thoracic Cavity
~ The body' s chief lymph vessel is t he thora cic duct. Beginning jug ular and subclavian vein s. The rig ht lymphatic duct drains to
IIIIiiiiII in the abdomen at th e level of L1 as t he cisterna chyli. t he t he right junctio n of t he interna l jugu lar and subclavian veins.
thoracic duct empties into the j unction of the left interna l
Fig. 6.7 Lymphatic trunks in the thorax

Anterior view of opened thorax.
Comm on carotid a.
Internal j ugu lar v.
Jugular t runk
Subclavian a.
Right lym phati c duct
Subclavian tr unk
Left subclavian v.
Left brachio
ceph alic v.
Bron chom ediastinal

trunk
Superior vena cava Ascendi ng aorta
Broncho mediast inal - - - --j----..,.

~c---- Thoracic aorta
t runk
Accessory
hemia zygo s v.
Thor acic du ct -r-r-r-r-i-rr
~r--- Intercostal
Diaphragm - - --.-:'i; lymphatics
Azygos v. - - -'-1i:
Hemia zygo s v.
Cisterna chyli - - -++
H~~H--f~~-~---~=-ic"':---- Left lumbar trunk

Right lumbar trunk -----------1i~=-~-,...,.-l~-7
72
Head and neck - - -- ) Fig. 6.8 Lymphatic pathways in
( the thorax
Right j ugular
Left j ugular
trunk
Thoracic tru nk
duct
Left int ernal
Right lymphat ic ~ jugular v.
duct
Right subclavian _ Left subclavian
t runk t runk
Left subclavian v.
Right broncho- _ _
Left bron cho
mediast inal tru nk
m ediastinal t runk
Ant erior m ediastinum Paraverteb ral l.n. ~.-----~----

( Posterior thora cic wall
Ante rior int ercost al -+_ _-rr-_ _
Parasternal Ln.
~--- Posterior intercostal spaces
spaces
Paramammary Ln. Superior mediastinum
Ante rior th or acic
wall
Mammary gland - - - -- /
Brachiocepha lic Ln.
Pre-pericardiaIL n.
Lateral pericardialLn.
?
Paraesophageal Ln.
Paratracheal Ln.
Tracheobronchial Ln.
Bronchopu lmonary L:. - = = C

Int rapulmonary Ln.
Superior phrenic Ln.

- - - - Pleura
! \
Abdom en, pelvis, and lower limb Fig. 6.10 Thoracic lymph nodes
Transverse sectio n at level of tra cheal bif urca
t ion (T4), inf erior view. The thora cic lymph
Fig. 6.9 Lymphatic drainage nodes can be divid ed int o three broad groups:
by quadrants nod es of t he t horacic wa ll (pink), pulmonary
node s (b lue), and mediasti nal nodes (gr een).
Parasternal Ln. Trachiob ron chiall .n.
For detail s of lymphatics of t he mediast inum ,
see pp. 100- 101.
--:--7.:- Right lym phat ic duct Lymphati cs in
t runk wall
Bronchopulmo nary Ln.
Thoracic duct
Intrapulmonary Ln.
Int ercostal l.n. Paraesophag eall.n. Paratrach eall .n.

73
Nerves of the Thoracic Cavity
~ Thoracic inn ervati on is m ostly auto no mic, arising from th e para pericardium and di aphragm (p. 54), and t he inte rcosta l nerves inn ervat e
IIIiiiiII verte bral sym pat het ic t runks and parasympat heti c vagus nerves, t he t horacic wa ll (p. 58).
There are t w o exceptions: t he phren ic nerves in nervat e t he
Fig. 6.11 Nerves in the thorax

Ante rior view of ope ned t horax.
Right vagus n. Left vagus n.
Sym pat het ic t runk,

tho racic ganglion
Right Lef t ph renic n.
phr enic n.
Posterio r ----.-.:
int ercost al nn.
A Thoracic innervat ion.
Esoph agus,
Trachea cerv ical part Commo n carotid a.
Sym path et ic t runk,

m idd le cervical gang lion Scalene mu scles
Right subclavian a.
loc, ,-v.,------ - - Brachial plexus
Right vagus n.
.~..; - - - Left subclavian a.
Right recur rent laryngeal n.
'~'---.,---- 1st rib
;::::"" '-----,.,--- - Left vagus n.
""',,-,- - Left recurrent laryngeal n.
,.----:r-- - Aortic arch
Esophagus, t horacic part - ---+,.,..

Thora cic aorta
Sympat heti c tr un k
Ante rior vagal trunk (with ---------:f

esophageal plexus) t Sympat hetic tru nk
Greater splanchnic n. Innerm ost intercostal s
Diaphragm
Ante rior Stom ach

gast ric plexus
B Nerves of t he th orax in situ . Note: The recurrent laryngeal nerves have bet ween t he t rachea and the esophagus, m aking th em vulnerable du r
been slight ly ante rior ly retr act ed; norm ally, the y occupy t he groove ing th yroid gland surgery.
74
~ The a uto nom ic ne r vou s system innervates smooth muscle. car (red) a nd parasympathetic (b lue) ne r vo us systems. w hich toget her
IIIiiiII diac m uscle, a nd g la nds. It is subdivided into the sympathetic reg u lates b lood f low. secretions, and organ f unction .
Fig. 6.12 Sympathetic and parasympathetic nervous systems in the thorax

Sympathetic Parasympathetic
nervous system nervous system
Midd le cervica l ganglion
C8
\-_.;---~,,-- Stellate gang lion
T1 Vagu s n. (CN X)
12
13 Cervica l
cardiac nn .
T4
T5
T6
T7
Pharyngea l plexus
T8
T9 Ext ernal
carotid plexus
T10 ~-.....
Tll 1--"" Int ernal

T12 f--- " carotid plexus
Recurrent
L1 laryn geal n.
L2 Commo n carotid plexus
Esophageal plexus
Sympathetic Vertebral plexus

tr unk
Greater and lesser -------<.CY

splanch nic nn. Subclavian plexus
Tho racic aortic plexus
Pulmo nary plexus
Pulm o nary plex us
Cardiac plexus
tt
Peripheralsympathetic nervous system Peripheral parasympathetic nervous system

Origin of Ganglion Course of Origin of Course of presynaptic
pres ynapt ic fibers' cells postsynaptic fibe rs Target pre synap tic fibe rs mo to r axon s ' Target
· Blood vessels Cardiac branches Cardiac plexus
: Follow inte rcosta l nn. · and glands in
Esophageal
: chest wa ll
Esophageal plexus
: Sympathetic . branches
• Spinal cord . : Accompany Vagus n.
• Visceral
Brainst em Tracheal branches Trachea
: t runk ! intrath oracic aa.
! t arget s (CNX)
... .. .. . ... .. ..... . ...... .... . , - .
Pulmonary plexus
'., Gathe r in greate r and .
· Abdomen
Bronch ial branches (b ronchi, pulm on ary
. .... ...... . . lesser splanchnic nn.
vessels)
' The axons of presynapt ic neuron s exit t he spinal cord via t he anterior roots and '
' The gang lion cells of the parasympathetic nervous system are scattered in
synapse w it h post synapt ic neuro ns in t he sympa~ he tic~a n~lia: .
m icrosco pic groups in their t arget orga ns. The vagus nerve t hus carries the
presynaptic motor axons t o t hese ta rgets.
eN - cranial nerve.
75
Mediastinum: Overview
~ The medi astinum is th e space in th e th orax between the ple ural The inferior mediastinum is furth er divided into anterior, middl e, and
~ sacs of th e lungs. It is divided into two parts: superior and infer ior. posterior portion s.
Fig. 7.1 Divisions of the mediastinum
Contents of the mediastinum
Superior Inferi or med iastinum

med iastinum Anterior Middle Posterior
• Thymus • Thymus • Heart • Eso phagus
• Trachea (inchildren. • Pericardium
cerVi Cal } Organs
part • Esophagus see Fig . 7.5)
. Trachea • Thoracic duct
Thoracic inlet - ---:f-{;..f/..hS:: Thor acic
part • Smallervessels • Thoracicaorta
• Aort ic arch • Ascending aorta
Esophagus. --~~~~ a ----1;-\\ - Superior • Brachiocephalic • Pulmonarytrunk and branches
thoracic part mediastinum trunk and branches • Thoracic duct
Arteries
Sternum • Left common • Pericardiacophrenic
carotid a. aa. andw.
Anterior
mediastinum • Leftsubclavian a.
Posterior ----f-7'*-\b~-~.....~~J Middle • Superior vena • Smallervessels. • Superiorvena cava • Azygos v.
mediastinum mediastinum Veinsand cava lymphatics. and • Azygos v. • Hemiazygos v.
lymph • Brachiocephalic lymph nodes • Pulmonary w. • Thoracic duct
Diaphragm vessels vv. • Pericardiacophrenic
• Thoracicduct aa. and vv.
A Schematic.
• Vagus nn. • None • Phrenic nn. • Vagus nn.
• Leftrecurrent
Nerves laryngeal n.
• Cardiacnn.
• Phrenic nn.
Eso phagealinlet -------df,---,h---,.-7---~ . ,

- - - Thyroid cartilage
Esophagus. cervical part -----':,..,-flf-fHc=,,~'_j!',f J .1 ''If-- - - - Trachea
Pretracheallayer }
Cervical
fascia
- - - - Investing layer
- - Left brachiocephalic v.
&-i - -
':;- - - Ma nubrium
\---'---cl":;;;,---- - Ascending aorta
.""""~--- Thymus (retrosternalfat pad)
Esophagus. thoracic part ---cr -----'." "'-l+-* ;-;c- .,...;--'- '-~--"<"<-:'L---_ Aortic valve
Left atrium -----.--~tt-JW--,.;=_4c-:1 ";-;-,---- - Ste rnum
l'-'- - - Pericardialcavity
Superiorphrenic lymph node --+--;-""Yi\'.---'!~~;Y/;i-:'-\---e . _

~iiiiii:;~:§~~-;,_.____- Site of attachment between
Diaphragm ----+-------2'\',----\\~.,_'\_"<£_::+_\~- ,
liver and diaphragm (bare area)
B Midsagitta l sec t ion. right lateral view.
76
Thyroid gland, Thyroid Fig. 7.2 Contents of the mediastinum
rig ht lobe cart ilage
Scalenus ante rio r ________
muscle
Phrenic n. J\ I
Trachea
Common carot id a.
Vagus n. (CN X)
Left recurrent laryngeal n.
~=~--- Internal t horacic a.

Inferior and v.
t hyroid v.
Thymu s Left vagus n.
Superior Aor ta
vena cava
Pericardiaco Left recurrent
phr enic laryngeal n.
a. and v.,
phrenic n. Left pulm onary a. Brachial plexus
Pariet al pleura,
mediastin al
part Left subclavian
a. and v.
Parietal pleura, / Left brachio

diaphragmatic Pariet al _ cephalic v.
part pleura, Aortic arch
cervical part
Superior Ligament um
vena cava art eriosum
Left pulm onary a.
Diaphragm Atta chme nt bet ween Fibr ous Superior and
fibrous pericardium and pericardium inferior loba r
diaphragm at ic fascia Right bronchi
pulmo nary w .
Left pleural cavit y
A Anterior view of mediastinum.
Pulm onary Thor acic
t runk aorta
Parietal pleura,
Righ t pleural
mediast inal part
cavity
Inferior pharyngeal --rtJI~ Thyroid gland,

constrict or right lobe - - Parietal pleura,
diaphragm at ic
Esophagus,
cervi cal part part
Left com mo n carot id a.
Left internal ju gu lar v. - - - ---I

Pericardiacoph renic Caval Esopha gus, Fibrous
Left subclavian a. and v.
a. and v.. phrenic n. aperture th or acic part pericardi um
.. . . .- -- Superior vena cava B Anteriorviewwith heart, pericardium, and

Aortic arch ----~IS·.. . ....1-- - - Trachea thym us removed,
Left pulmonary a. --~_o

Fibrou s pericardiu m,
left atri um
--~;;;
.. -1,l","-,"!rl;---
Azygos v.
Right mai n bro nchus
Re=-<~li.&>-=--- Right pulmon ary a.
Left pulm onary vv. -_~rl oJ.
Thoracic aorta - - - - - - -=-.....

}I-- - Fibrous pericardi um,
-
Fibrous pericardium , - -
righ t at rium
left vent ricle
.!!!!!!I!!!!!~--
"'"--- Inferior vena cava
(in caval apert ure)
Esophageal apertu re - - -,) 'll= ==
.~-------- Posterior
Diaphragm - -- int ercostal aa.
C Posterior view,
77
Mediastinum: Structures
E Fig. 7.3 Mediastinum

o
~
l st rib ---------~~~~~~~
Right subclavian a. and v.
Inte rcostal a., v., and n.
Brachiocep halic
lym ph nodes
Right vagus n. ------.L1~
Azygos v.
:-";~;'_;';,___--- Trachea
Sympathet ic tr unk, - - - - ---' ~~T---- Superior vena cava

t horac ic gangl ion
~~----':---- Right phrenic n.
Superior lobar - - -- - ---:!rr.
bronchus
-'i~----',---- Thymus
Righ t pulmo nary a. - - --'- -"-4 (ret roste rnal fat pad)
:=-.--'~~--- Fibrou s
pericardium
Common tr unk of - - ----.- S
mi ddle and inferior ~~--- Right pulm onary vv.
lobar bro nchi
Esophagus ----+---,---~~ ---T.~---T--- Phrenic n.,

pericardiacop hrenic
Greate r - -----i'---'-T-::ili:--,'
a. and v.
splanchnic n.
Pariet al pleura, -------'-'-----M'~
costal part
Intercost al a., - - -',--,---'li&'!S
v., and n.
.,...:-7'---- - - Diaphragm
Intercost al mu scles
A Rig ht lateral view, parasagittal sect io n. Not e th e many st ruct ures

passing bet ween th e superio r and inferior (middle and posterior)
mediastinum .
78
Clavicle ------+-------:c,.-;7."~ 1st rib
Brachial plexus --------,l-~--- -. . ~~~~~

Left subclavian ----~::::---F~_ff_~
a. and v,
Int ercost al a.,
Esophagus v., and n.
E~~-'-'------- Tho racic duct
;-'-- - - - Aort ic arch
Ligam entum Lef t recurrent

arteriosum laryngeal n.
Left phr enic n.
Sym pat hetic t ru nk
Left pul m onary a.

1-'-- - - - Accessory
hem iazygos v.
Lef t pulmo nary vv.

Left main bron chus
Fibrous -----:!~~+'f_;¥_
pericardium
1W,;.H-'~--- Thoraci c aort a

(descending aort a)
Lateral pericardial
lym ph node
Left vagu s n. Pariet al pleura,

costal part
Phrenic n.,
pericarcliaco
phrenic a. and v.
Hem iazygos v.
Superior phrenic ------!1~--s-'-
lym ph node
Diaphragm - - - 1--..-----;-';;
Int ercost al a.,

v., and n.
B Left lat eral view, parasagittal sect ion. Removed: Left lung and pariet al
pleura. Revealed: Posterior mediastin al st ruct ures.
79
Thymus & Pericardium
Fig. 7.4 Thymus and pericardium in situ Thyroid Inferior

Anteri or vi ew of corona l sect io n. Th e thymu s lies in t he Internal gland t hyroid v. Left recurrent
sup eri or m edia stinum . jugular v. ~ ~ laryngeal n.
Subclavian a. and v.
Vagusn . __~~~~~
(CNX)
""""~~_-,----_ _ Internal th oracic a.

Phrenic n. - --;;-'''S--'-'== = and v.
Superior vena cava ---'=~:'!'
Thymus
=--"l!!:-'--..........f=- Phrenic n.,
pericardiacophrenic
a. and v
Fig. 7.5 Thymus
Anteri or view o f op en ed thora x of a 2-year- o ld
child. Th e t hy m us is w el l d eveloped at thi s
ag e, exte ndi ng inferi orl y into the anteri or
m edi asti n um (compare with Fig. 7.4) . Th e thy
mu s g ro ws t h ro ug ho ut child ho o d; at pubert y,
high level s of circulating sex hormones cause
th e thymu s to atrophy. Parietal pleura, Parietal pleura, Fibrous
diaphragmatic part mediastinal part pericardium
Common carot id a.
Subclavian
a. and v,
Trachea - - - i'=
....,.·+ - - Left
Brachio- - - - '- brachio
cephalic t runk cephalic v.
Right brachio- ~
cephalic v.
Superior - --"'''lllio-=c ~","",,===r--- Left
vena cava pulm onary a.
Thymus, -~"" "'''''h ~";~:o:!'l~- Thymu s,
right lobe left lobe
Fig. 7.6 Pericardium

Anteri or view of opened thorax with flap s of
fibrous pericard ium reflect ed .
Superior
vena cava
Fibrous
pericardium
Parietal pleura,
(~ external
mediast inal
layer)
part
Cardiac surface
Serous Diaphragm
pericardium,
visceral layer
80
'// ~";;";'----;;-;----.---- Trachea
Fig. 7.7 Serous pericardial reflections
Ante rior view. The parietal and visceral serous peri
Esophagu s ----;~~ cardium are continuous wi t h one anoth er around
=~~~- Lef t brachiocephal ic v. th e great vessels of th e heart. The passage bet ween
th e art erial- and venous-associated reflections is th e
F'--'-7.~rr-+- Ascending aor ta trans verse pericardial sinus (see B).
Right
pulmonary a.
Transverse -7."s;,::;-,-,n - Pericardial cavity
pericardial
sinus
Left at rium
Serous
pericardium
Superior ~'+\;;'¥',-1<-----:
phrenic
lymph
nod e
Attachme nt of liver
Lef t com mo n ----~ ~--- Left subclavian a.
to diaphr agm (bare area)
carot id a.
Brachiocephali c
A Sagittal section through th e mediastinum .
t runk
Not e the continuity of the parietal serous
- - - - , - - Left pulm onary a. and v.

and visceral serous pericardia .
Ascending aorta ----\---0;
Transverse - - --'----: Pulmon ary trunk

pericardial sinus
Superior vena cava
.------ - Oblique pericardial
Right pulmon ary vv. - --+ sinus
Serous pericardium ,
parietal layer
Inferior vena cava - - - -f- Fibrou s
Left com mon pericardium
carot id a.
Left subclavian a. At tac hme nt

of fib rou s
per icardium to
~--- Aor t ic arch
diaphr agm ati c
fascia
Left pulmonary a. - -
Superior vena cava
B Pericardium with heart remo ved. ant erior
Left pulm onar y vv. Righ t pulm onary a.
view.
Left auricle - -
(at rial appendage)
~II-- Right pulmonary vv.
Left atri um - -----;'E--""''''\' Right at rium
Serous pericardium,
visceral layer
Reflect ed edge
(cont inuous wit h
parietal layer of serous
pericardium)
Coronary Inferio r vena cava

sinus
C Heart remo ved from fibrous pericardium ,

posterior view. Not e th e reflection of th e
visceral layer of serous pericardium (cut
edges). 81
I Heart in Situ
~ The heart is locat ed post erior to th e ste rnu m in th e m idd le por
~ ti on of th e inferior mediast inum . The heart proje ct s int o t he left
side of th e th oracic cavity .
Fig. 7.8 Topographical relations of
the heart
Right comm on carot id a. Left inte rnal jugular v.
Righ t brachio Fig. 7.9 Circulation

cephalic v.
Red: Oxygenated blood . Blue: Deoxygenat ed
blood . See p. 94 for prenata l circulat ion.
Upper bod y
circulat ion
}
Diaphragm -----*~~><::-::':::'\;
~-......::!toZ;;;;::;;;;;::t_- - - - Cardiac apex
Pulmonary
circu lat ion
A Projection of heart and great vessels o nto Pulmona ry v.

chest, anterior view .
Pulmonary w .
Superior vena cava
Trachea - - -'r- ~~~~-- Left atriu m

Left com mon Ascending aorta
carot id a.
" "'-- - Aorta
Brachiocephalic
trun k
Right at rium
Left subclavian a. l:\'iiiiH---=--- Left vent ricle
Ste rnum
(rnanubrium )
Aortic arch
Superior - - - +---r.;;:ll
- +--+-- ---!! !-- Right vent ricle
--.......:;;;:;;~y
vena cava Left main Hepaticw.
2nd rib - - + -h-I bro nchus
Pulmon ary ___----/l:.~ Por tal v.

{iI!!iri"---!==!-- -==--==!'r-- - Left Inferior
t run k vena cava
pulm onary
vv.
Sternum Port al
Thoracic circulat ion
(body)
aor ta }
Esophagus
Pericardium
Diaphragm
Abdom inaI -----I'-------\H;;~
aorta
} Lower body
circulat ion
B Left lateral view.
82
Fig. 7.10 Heart in situ
Ant erior view.
Right brachlo Brachlo

cephalic v. cephalic t runk
Right phreni c n. Left brac hio

cephalic v.
Right lung Left vagus n.
Aortic arch
Superior
vena cava
Left pulm onary a.
Ascending
aort a
Pulm onary
Parietal pleura. tru nk
mediasti nal part --li~~~~~~ Left auricle
(at rial app endage)
Right auricle
(atrial appe ndage) Left coron ary a.
(ant erior
int erventri c-
ular branch)
Left
vent ricle
Card iac
apex
Diaph ragm
Fibro us
pericardium
Right
vent ricle
\
Stomach
83
Heart: Surfaces & Chambers
>< ~ Not e the reflection of visceral serous pericard iu m to becom e

~ IIIIiiiIiII parieta l serou s pericardium .
i!:
Fig. 7.11 Surfaces of the heart Left subclavian a.
The heart has t hree surfaces: anterior Left commo n Aor ti c arch
carot id a.
(sternocost al), post erio r (base), and inferior Ligamentu m arteriosum
(diaphragmat ic). Brachio- - - ----,:ll
cephalic trunk Left pulmo nary a.
Right -~......
Left pulm onary vv.
pulmo nary a.
':.1,---- - Pulmonary
trun k
~!::a.~-- Left
auricle
Right -------I-~~=
auricle Right - ---1- Pericardium
atri um (reflecte d edge)
Coron ary --~~0ii3" Anteri or inter

sulcus ventricu lar
sulcus
Rig ht
Left
Left commo n vent ricle
vent ricle
carot id a.
Left subclavian a. - -----j "!"Q-- - Brachiocephalic

Cardiac apex
tr unk
- - - Aort ic arch A Anterior (sternocosta l) surface.
Left pulm onary a.

Superior vena cava
Left pulm onary vv. Right pulm onary a.
~=---- Right pulm onary vv.
Left atrium -----i~-=.. Right atri um
Left
ventr icle
Pericardium Aortic arch
(reflect ed edge)
Superior vena cava
Coronary
sinus
Inferior vena cava
Left pulmon ary a. --J:~i!!! ... Right pulm onar y a.
B Posterior surface (base). Left ;;:)ll:k- - Right

pulm onary vv. pulmon ary vv.
Left atrium - - -----;;-- - -

Right
atr ium
Coronary ------~~:"'I
sinus Inferior
vena cava
Left - + -
vent ricle
==--------" - Posterior
inter vent ricular
sulcus
84 C Inferior (diaph ragmatic) surface .

Aort ic arch Fig. 7.12 Chambers of the heart
Ligame ntum
arteriosu m
Pulmonary
tr unk
Right pu lmonary a. ::---r- - Lef t pulmona ry vv.
Super io r vena cava -------l- 1. '

k-:::......=-- - Valve of
Conus arteriosus pu lmona ry tru nk
Right atrium
Left ventricle
Coronary sulcus _ --'liiiii'iOiilli
Right at riovent ric Intervent ricular

ular valve. sept um
anterior cusp
Trabeculae
Inferior vena cava carneae
Chordae
tendineae ~-""'~iIIIIl~i:J~-- Cardiac apex
Ant erior
papil lary mu scle Posterio r Septomarginal
pap illary m uscle t rabecula
Ascending
A Right ventri cle. anterior view. Not e th e aor ta
supravent ricular crest. whic h marks th e Superior
adult boundary betwee n th e em bryo nic vena cava
ventr icle and the bulbus cordis (now conus Right pulmonary a. -----.....-.... " .----e-.,._ ==__----::_ Right
arterios us). auricle
Left atri um Crista termi nalis
Right Pectinat e m uscles

pulm onary vv,
~a--- Right ventricle
Int erat rial
septu m
Right atrioventric
Limbu s of ular orifice w it h
fossa ovalis at riovent ricular
valve
Fossa ovalis
Inferior
vena cava
Valved or ifi ce of Valved orifi ce of
inferior vena cava coronary sinus
B Rig ht atri um . right lateral view.
Lef t pulmonary a. - - '-"'!r -- - Aortic

arch
.-7- - - Right pulmo nary a.
Pect inals muscle s ~-- Lef t auricle
Left superior pu lmona ry v.

Ante rior
papillary m uscle Valve of fora me n ovale
Trabeculae carneae Left atriu m

of int erven
Int erat rial sept um
tricula r sept um
Chordae
t end ineae ":l!!!_ - Inferior
......",--r"'~ '
vena cava
Cardiac - j ..rlflliII;..,
apex
Post erior Left atrioventric
pap illary m uscle ular valve
C Left atrium and vent ricle. left lateral view.

Note th e i 'reqular tr abeculae carneae char
act eristi c of th e vent ricular wall. 85
Heart : Valves
~ The cardi ac valves are divid ed into t wo groups: semi lunar and passage of blood from t he ventricle s t o t he aorta and pu lmonary trunk.
~ atrioventricu lar. The two sem ilunar valves (aorti c and pu lmonary) The two at riove ntricu lar valves (left and righ t ) lie at t he interface be
locat ed at the base of th e two g reat arterie s of the heart reg ulate twe en t he at ria and ventricle s.
Fig. 7.13 Cardiac valves Left cusp }

Plane of card iac valve s, superio r view. Right cusp Aort ic valve
Removed: Atria and great arteries. Posterior cusp
1ii1lIk-- Right coronary a.
Left coronary a. ---7A~-:' Anterior

cusp
Right at rio
Left atrio Ant~:~~ ~~+If-- Sept al

cusp
ventr icular
(t ricuspid)
vent ricular valve
(bicuspid or { Posterior -~~~!!: -~'A'--- Posterior
mitral) valve cusp cusp
A Ventricu lar diastole (re laxatio n of th e ventricles). Closed: Semilunar

va lves. Open: Atrioventricu lar valv es. Coronary sinus
Left cusp }
Right cusp Aort ic valve
Posterior cusp
.... .- Right coronary a.
Left coronary a. ----E-,~... ~-- Anterior

cusp
Righ t atrio
Left atr io Ant ~~ ~~ .......~--"'=:;;----;HlJ-- Septal

cusp
ventricular
valve
vent ricular
valve { Posterior ---'li~ -~;#--- Posterior
cusp cusp
Fibrous ring
of pulmonary valve
Coronary sinus
B Ventricular syst o le (contraction of th e ventricles) . Closed: Atrioven

tricu lar valves. Open: Sem il unar valves. ;.- - Fibrous ring
of aort ic valve
Right fibrous -i---------''el~~...--illlI
tr igone
Left fibrous
anulus
Opening for the Rig ht fibrous
bundle of His anulus
C Cardia c skeleton . The card iac skelet o n is fo rm ed by dense fibrou s con

nect ive ti ssue. The fibrou s anu li (ring s) and int er vening trigon es sepa
rat e t he atria from th e ven tricles. Thi s provides m echanica l stab ility,
elect rical insu lation (see p. 90 fo r cardiac cond uction syst em), and an
atta chm ent po int for th e cardiac mu scles and valve cusps.
86
Fig. 7.14 Semilunar valves Fig. 7.15 Atrioventricular valves
Va lves have been lo ng it ud inall y sect ioned and o pe ned . Anterior vi ew during ve nt ric u lar systo le.
Commissural Left Posterior

Ascending aorta Nodule Lunule
cusp at rium cusp
Right
Opening
coronary a.
of left
Aort ic - - - --; Anterio r cusp ~
coro narya .
sinus
Left cusp
Right Int eratrial --+
cusp sept um Chordae
Mem branous part tendineae
Inter- Posterior
vent ricular papillary
sept um { m uscle
Muscular part ---~F
Ant erior
papillary
Posterior cusp Posterior mu scle
A Aorti c valve. papillary m uscle A Left atrioventricu lar valv e. Cardiac apex
Nodule Pulmo nary t runk

Anterior cusp Sept al cusp
~, 'T-':i-- Sept al papillary

Lunule Posterior
muscle
cusp
Interventri cular
Right cusp -----i; ;. Left cusp Chordae sept um
tendineae Anterior
Posterior papillary mu scle
Anterior
papillary
cusp ~~'---- Septomarginal
mu scle
t rabecula
B Pulmon ary valve. B Right atriov entricul ar va lve .
~ Clinical
Auscultation of the cardiac valves

Heart sounds. pro duced by closure of t he
semilunar and at riovent ricular valves. are
carried by t he blood flowing t hrough t he valve.
The resulti ng sounds are t herefore best heard
"downst ream: at defined auscultat ion sit es
(dark circles). Valvular heart disease causes
Aortic valve -i--"'-- .,.c....;- - - - Pulmonary valve
t urbulent blood flow through t he valve; this
produ ces a murm ur t hat may be dete cted in t he
Right atrioventric - - - - - ----.,. = ,-f't#t/
colo red regions. ular valve Left atriovent ric
ular valve
Position and auscultation sites of cardiac valves

Valve Anatomical projection Auscultation site
...................................... .................................................................................. .... ..............................................~ i~ht 2n~ .in~~~~~~~ ~lspa~e (atsterna l . l11ar9. i~)
, Aort ic valve : Left sternal border (at level of 3rd rib)
.
~~ lfll?n~r y' ~~ lve • Lef.t sternal border (at level of 3rd costal cartilage) .... .L ~ft~n~i~t~r.~~~t~l sp.~~~..( ~t..s~~r~~ II11~r~i ~) . . .
: Left atrioventr icular valve : Lef t 4t h/5th cost al cart ilage : Left 5t h int ercost al space (at midclavicular line) or cardiac apex
.. .... ..... ... : . . .
, Right atrio ventr icular valve : Sternum (at level of 3rd costal cartilage) • Left 5th intercost al space (at sternal margin)
87
Arteries & Veins of the Heart
Fig. 7.16 Coronary arteries and cardiac veins Pulm on ary Superio r left
Superior valve pulm on ary v.
vena cava At rial branches
Lef t auricle (at rial appendage)
Left coro nary a.

Ascending aorta
with aortic sinus Circumflex a.
Branch to sinoat rial nod e --~ !II!II'!!~_ _ Left margin al a. and v.
Right coronary a. ------,b~~ ,
Conus bran ch - - t \ -' .lc Great cardiac v.
At rial branch --~iO!!"~ Ant erior inter

Rig ht aur icle (at rial app endage) - - ----'\= : vent ricular
(left anterior
Small cardiac v. - - descending) a.
Righ t ma rgina l
Lateral a.
a. and v.
Ant eri or vv. of

right ventr icle
Left Super ior

Atrial bran ches atri um vena cava
Oblique v. of Cardiac apex
Right ventri cle
left at rium
A Anterior view.
Left pulm onary vv. ---,iitt__..,/-<f - - - Branch to
sinoat rial node
Right pu lmonary vv.
Circum flex a.
Great cardiac v.
Posterior left -------,1:;1
ventricular branch
Coronar y sinus
Inferior vena cava
Right coronar y a.
Post erior v.
of left ventri cle
Sma ll cardiac v.
Right post erol ateral a.
~ Rightventri cle
B Posteroinferiorview. Note: The right and
Posterior intervent ricular left coronary arte ries t ypically anastomose
(descend ing) a. and v. posteriorly at the left atri um and ventr icle.
Branches of the coronary arteries Divisionsof t he cardiacveins

l eft coronary art ery Right coronar y art ery Vein Tributaries Drainage
Branch to SA node Ant erior cardiac vv. (not shown) Right atrium
Circum f lex a.
• Atr ial branch Conus branch Anteri or interventricular v.
• Left marg inal a. Atria l branch Great cardiac v. Left margi nal v.
• Posterio r left ventricular a.
Right margi nal a. Oblique v. of left atri um
Ante rior interventricu lar a. Posterior interventricula r (descending) a. Lef t poste rior vent ricular v, Corona ry sinus
(left anter ior descending a.) • Inte rventricula r septal branche s
Posterior intervent ricular v. (m idd le cardiac v. )
• Conus branch Branch to AV nod e
• Lateral branch : Anterior vv. of righ t vent ricle
Small cardiac v.
• Int ervent ricular sept al branches Right postero lateral a. Right ma rginal v.
AV = atriov entricular; SA = sinoatrial.
88
Fig. 7.17 Distribution of the coronary arteries ~ Clinical
An t er ior and po ste rior views of th e heart, w it h su perio r views o f tran s
ver se sect io ns th rough t he ven t ricl es. The d ist rib utio n of t he co ro nary
Disturbed coronary blood flow
ar te ries d iffers f rom per son t o per son . Right co ro ne ry art er y and
Alt hough t he coronary arte ries are connect ed
br an ch es (green) ; lef t coro na ry artery and br an ch es (red). by st ruct ural anastom oses, th ey are end
art eries from a funct ional st andpoint . The "
most frequent cause of deficient blood flow
Intervent ricular
Left coro nary a. is atherosclero~is ,~ narrowing of t he coronary

sept um
Left
Right lumen due to plaque-like deposits on the
vent ricle vent ricle vesselwall. When the decrease in luminal size
a
(stenosis) reaches crit ical point , coronary '
blood flow is restricted, causing chest pain
(angina pecto ris). Initially , t his pain is induced
by physical effort . but event ually it persist s
at rest. often radiati ng to characterist ic sites
(e.g., left arm , left side of head and neck). A
Circumf lex branch myocardial infarcti on occursw hen deficient
blood supply causes myocardial tissue to die
Posterior left (necrosis). The locatio n and extent of t he
Right ventri cular branch Right infarctio n depends on t he stenosed vessel
corona ry a. coron arya . (see A- E, after Heinecker).
Posterior inte r Posterior inter

vent ricular branch vent ricular branch
A Lef t coro nary domina nc e (- 15%).
A A Supra-apical anterior infarcti on.

t
L -- - R
Left
coronary
a.
~ Areaof
P deficient
Circumflex branch blood flow
B Apical anterior inf arcti on.

Posterior left
vent ricular
branch
Post erior inter
Posterior int er
ventric ular branch
vent ricular branch
B Balan ced d istribu ti on (-7 0%).
C Anterior lat eral infarct ion.
D Posterior lat eral infarction.
Right
coronarya.
Post erior int er

vent ricular branch
E Posterior infarct ion.
C Righ t coro na ry d om inan ce (- 15%).
89
Conduction & Innervation of the Heart
~ Contraction of ca rdiac mu scle is modu lated by th e ca rdi ac co nd uct io n syst em co nt ains t w o no d es, both lo cat ed in th e atri a: t he
~ conduction sy ste m . Thi s syst em of specia lized myocardial ce lls sinoa t rial (SA) node, kn own as the pac em aker, and th e atrioventricular
gen erates and conducts excit ato ry impul ses in t he heart. The (AV) nod e.
Fig. 7.18 Cardiac conduction system

Superior Int erat rial Aort ic arch --+~
vena cava bund le
Superior ~ "'~-,, I - - - Pulmo nary

Sinoat rial (SA) --j~~~?1
L
vena cava ~ t runk

node
Sinoat rial (SA) ~ Intervent ricular
Ante rior, midd le, - -HeM At rioventricu lar node _ ..... _~,
sept um
and posteri or bundle (of His)
int ernodal bundles Left bund le Right bund le
branch branch
Atr ioventri c
'&---h-1l- - + - Left bu ndle branch ~~L-~---';~, Right
ular (AV) node
Right atri um ventr icle
Right bundl e -\t:-\\-¥-+ - Interventri cular
branch septum Atrio ven Septomarginal
tr abecula
t ricular (AV)
node Anterio r
A A nteri or view. Opened: papillary
A ll four cham bers . mu scle
Purkinje's
fibers
B Right lat er al v iew. Opened: Right atrium and

ventricl e.
Pulmonary - - - -
t runk
Left at rium
Left bundl e branch - - - - ,
Anterior fascicle
Interventri cular ---~
sept um Middle fascicle
Poster ior fascicle
Left vent ricle
C Left lat eral vie w . Opened:

Left atriu m and ve ntricl e. Cardiac apex
Electrocardiogram (ECG)
The cardiac impu lse (a physical dipole)
t ravels across t he heart and may be
detect ed wit h electrod es. The use of t hree Pwave Rwave T wave
elect rodes that separately record electr ical
Lead vectors --~T--7
acti vity of the heart along t hree axesor
in Eint hoven's
vect ors (Eintho ven lim b leads) generates an triangle
elect rocardiog ram (ECG). The ECG graphs
th e cardiac cycle ("heartbeat") , reducing
it to ase ries of waves, segments, and
intervals. These ECG comp onents can be
Recording
used to determ ine w het her cardiac impulses electrodes
are nor mal or abnormal (e.g.• myocardial
infarct ion. chamb er enlargement ). Note:
Alth oug h only t hree leads are required, a Q wave Swave STsegment
st andard ECG exam inat ion includ es at least
.' two others (Goldberger, Wilson leads). A ECG recording elect rodes. B ECG.
90
~ Sympath eti c innervati on : Presynapti c neuron s from T1 to T6 cont ribute to th e cardiac plexus. Parasymp ath eti c inn ervation : Presyn
~ spinal cord segments send fib ers to synapse on post synapti c neu apt ic neurons and fib ers reach t he heart via cardiac branches, some of
ron s in th e cervical and upp er thoracic sym pat het ic gang lia. The w hich also arise in th e cervical region. They synapse on postsynapti c
three cervical cardiac nerves and t horacic cardiac branches neur ons near t he SA nod e and along the coro nary art eries.
Fig. 7.19 Autonomic innervation of the heart
Dorsal vagal - --tt---t7i-- ,-- - - - - --...
nucleus
Superior, mi ddle,
~------+- and inf erior cervical
Midd le cardiac nn. Cervical cardiac nn.

cervical gang lion
___-+-1---- Superior and Aort ic arch wit h
Tl spinal inferior cervical thoracic aortic plexus
co rd segme nt cardiac branches
Sympath etic
t runk
-~~1=t-7-"'\-H++t------,---+- Thoracic
cardiac branches Cardiac plexus -----'~::,..L';r-r'\
~
:1---
J
Pulmo nary a. and
pulm onary vv. with
pulm onary plexus
'-----+- Cardiac plexus

"",.---'7-- Cardiac plexus (along
p,~~~~~-j- Sinoatr ial (SA) th e coro nary aa.)
node
B Auton om ic plexuses of th e heart, right lateral view. Not e th e cont inu

it y bet ween the cardiac, aortic, and pulm onar y plexuses.
A Schemat ic.
Superior laryngeal n. ~ Thyroid cart ilage
Rig ht vagus n. ~
Sym pathet ic t runk, ~
mid dle cervical I
ganglion
Brachial plexus Left commo n carot id a.
Subclavian a.
Trachea
Right recurrent -------,.r------c~
laryngeal n.
"""~--- Sympat het ic

tr unk, th oracic
ganglion
Left
phre nic n.
Pulmonary
plexus
Pulm onary
trunk
Cardiac
plexus
Phrenic n.
(on diaphrag m)
C Aut onomi c nerves of th e heart. Fibrous Gastric plexus
Ant erior view of opened th orax. pericardium (ope ned)

91
Heart: Radiology
Fig. 7.20 Cardiac borders and configurations
Bordersof the heart

Borde r Definin g struc tures
Right at rium
Right cardiac border Length of aorta ---------,"""--'-::~+.i~,
Superior vena cava
Apex Long-axis --------!-!'-----'--~"'----~
Left vent ricle
diameter
Aortic arch ("aor tic knob")
Pulmo nary tru nk Maximu m widt h
Left cardiac border on right side
Left atrium
Left ventricle Short-axis
diameter
Left vent ricle
Inferior cardiac border
Right vent ricle
Anterior Maximum widt h
midline on left side
Fig. 7.21 Radiographic appearance ofthe heart
Aortic arch
("aort ic knob ")
Superior + - - - - -! Pulmona ry

vena cava tr unk
Aorta, -+-- - - - ;-- ;'-- - 1-- Left atri um

ascending
part
----",;- - ; -- Left ventr icle
Right Right Cardiac

atrium vent ricle apex
A Ant erio r vi ew . B A nt ero pos ter io r chest radi ograph .
Trachea Aort ic arch
Right lung,
horizont al
fissure
Right lung,
Sternum
oblique fissure
(body)
Anterior Posterior
mediastinu m mediastin um
Cardiac apex Left and right

diaphragm
leaflets
C Lat eral v iew. Visible: Diaph ragm leaf let s and lun gs. Th e aortic arc h
form s a sling over the left m ain b ron chu s. Note th e na rrowness of the
anterior me dias ti n um relative t o the poste ri o r medi ast inum . D Left lat eral chest rad io g raph .
92
Fig. 7.22 Heart in transverse section
Sternum Pulmonary
outf low tract
(t unnel betwee n right
vent ricle and pulmo nary a.
Right lung
Left lung
Right at rium
Ascending
aorta
Left auricle
Left atrium
Descending
aorta
A Hea rt in norma l chest magnetic reso nance ima g ing (MR I) . The cardiac
cha mbers are clearly displayed owing to the high signal in te nsi ty. and
the lungs are not vis ua lized .
Internal thora cic Right

a. and v. Sternum ventricl e Costom ediastinal
Rig ht lung . recess
superior lobe
Intervent ricular
Horizontal sept um
fissure of right lung
Left lung.
superior lob e
Right lung.
midd le lobe Phrenic n.
(between fibrou s
pericardium and
parietal pleura.
~~!~;A~~~~ij~~L-=m e d iast i na l part )

Oblique
fissure of
left lung
Thoracic
Esophagus duct
Thoracic
(descending)
aort a
Azygos v.
Right lung. Left vagus n. Sym pathetic Hemiazygos v. Left lung.

inferior lobe (anterior vagal trunk) trunk s inferior lobe
B Tran sverse section through T8. inferi o r view.
93
Pre- & Postnatal Circulation
Fig. 7.23 Prenatal circulation

Afte r Fritsc h and Kuhnel,
CD Oxygenate d and nutrient-rich fet al blood fr om th e placent a passes t o ® Blood fro m th e superior vena cava ente rs t he rig ht at rium, passes to
t he fet us via th e um bilical vein . the righ t ventricle, and moves into the pulmona ry t runk . Most of th is
blood ente rs t he aorta via t he duct us arteriosus, a rig ht-to -Ieft shunt.
eD Approx imate ly half of t his blood bypassesth e liver (via th e ductu s
venosus) and ente rs th e inferior vena cava. The rem aind er ente rs th e Gl The part ially oxygenate d blood in t he aorta return s to t he placent a via
po rta l vein to supply t he liver w it h nutri ent s and oxygen. t he paired um bilical arteries that arise fro m t he int ernal iliac arte ries.
Q) Bloo d ente ring t he righ t at rium fr om th e in ferior vena cava bypasses

t he right vent ricle (as t he lun gs are not yet funct io ning) to enter t he
left at riu m via th e foramen ovale, a riq ht-to -Ieft shunt.
Ao rt ic arch - - - -----:
@ Ductu s arte riosus - - - ;::;~~---- Pulmonaryaa .

(p atent) (very little blood flow)
- - - Left pu lmonary vv.

(very littl e blood flow )
- - - Lef t atr ium

Supe rior vena cava - - - """
® Forame n ovale ---+;;;~...

- - - Pulmonary trunk
(patent)
Right atr ium - ---'c -+--- Left ventricle
::;"':''::;'-:~/--- Right vent ricle
Hepatic vv. - -------;1--- - - - --...
Liver - - -----!'---
Duct us venosus --I---,~V't_---=_:jlJ~~'-'
Anastom osis Porta l v.

between um bilical
v. and porta I v.
- - - - Abdo mi nal
CD Umbil ical v. - - -If aorta
Inferior
vena cava
Um bilical aa.
__- - Com mo n iliac a.
:""111. . . . .- Int ernal iliac a.
Um bilical aa.
Placenta - - \-\-
94
G) As pulmonary respiration begins at birth. Fig. 7.24 Postnatal circulation
pulmonary blood pressure falls. causing After Fritsch and Kuhnel,
blood from the right pulmonary t runk to
enter the pulmonary veins. Aortic arch
CIl The foramen ovale and ductus arte riosus

close. eli minating the fetal rlqht-to-left
shunts. The pulmonary and systemic circu
lations in the heart are now separate.
(2) Ligam entu m arter iosum - - - - - - - - :-If!.
- -- - Pulm onary aa.
G) As the infant
is separated from the placenta. (obl iterat ed duct us
(perfused)
the umbilicalarteries occlude (except for arte riosus)
the proximal portions), along with the Left pu lmo nary

umbilical vein and ductus venosus. vv. (perfu sed)
@) Blood to be
metabolized now passes Superior vena cava ------++- \ Left atr ium
through the liver.
(2) Foramen ovale ------!f-~._---,.'l\
(closed) Pulmo nary t runk
Right at rium Left vent ricle
Right ventricle
Hepatic vv. - - - -f-- - -- - -,
Liver - - -+- /
Ligamentum venosum
(ob literated ductu s venosus)
I
~lTc':oT---iiiiii~---- Porta l v.
Rou nd ligament of liver - -+-- - --;7"'''-------------1'1
(oblit erat ed umb ilical v.)
+ - - - - Abdominal
aorta
Umbilical cord 4---!<~----- Inferior

vena cava
Umbi licus
Septal defects
Sept al defects. th e most common t ype of
congenita l heart defect . allow bloo d from Obliter ated um bilical aa.
t he left chamb ers of t he heart to improperly (med ial um bilical ligam ent s)
passinto t he right chambers during systol e.
Ventr ical sept al defect (VSD. shown below)
is th e most common form. Patent foramen
ovale, t he most prevalent form of atrial septal
defect (ASD), results fro m im proper closure
ofthe fet al shunt.
Derivatives of fetal circulatory structures
Fetal structure Adult remnant
Ductu s arter iosus Ligament um art eriosum

Foramen ovale Fossa ovalis
Ductu s venosus Ligamentum venosum
Umbi lical v. Round ligam ent of th e liver (ligam entum teres)

Umbilical a. Medial um bilical ligament
95
Esophagus
~ The esophagus is divid ed into three parts: cervical (C6-T1), It descends slightly to the right of the thoracicaorta and pierces the
~ thoracic (T1 to the esophageal hiatus of t he diaphragm), and diaphragm slightly to the left, just below the xiphoid process of the
abdominal (the diaphragm to the cardiac orifice of the sto mach). ste rnum.
Fig. 7.25 Esophagus: location and constrictions C6
Cricoid cart ilage Upper esophageal

Cervical part - - - - - [ (pharyngo
Esophageal inlet ---(-~*-+,,t. 11I esophageal)
constri ct ion
Trachea, - - -+-r"'-H -=-T-f-H-I
Thoracic part {
t horacic part
~~-- Ste rnum
T4 - -+---/-;1-+
Abdominal part --[
I+-- - - - I -+ + - - Middl e esophageal
(t horacic)
const ricti on
A Projection of esophagus onto chest wall. Esophagealconstrictions are

indicated with arrows.
B Esophageal constrictions, right lateralview.
Fig. 7.26 Esophagus in situ Trachea, Esophagus,

Anterior view. cervical part cervical part
Left int ernal jugular v.
Brachial plexus

Brachiocephalic trunk
Rig ht brachiocephalic v. Left brachiocephalic v.
Pariet al pleura,
cervica l part
Aort ic arch
Ligamentum art eriosum

Superior vena cava
Left pulm onary a.
Right pulm onary a.
Superio r and inferior

Right pulmo nary w. lob ar bro nchi
Thoracic aort a
Pulmonary t ru nk
Parietal pleura,
m ediastin al part
Parietal pleura, Esophagus, Fibrous

\
Sto mach
diaphragmat ic part t ho racic part pericardium
96
Mucosa (longitudinal fold s)
Media stina l part }

· h . Parietal pleura
Circular Dlap raqrnatrc part
Fig. 7.27 Structure of the esophagus
Muscularis layer
{ Long it udina l
layer
Esophageal apert ure
Junct ion of Gastr ic

esophageal and fundu s
~:7; '-'--'!I~-- Phary ng eal gastric mu cosae
raph e (Z li ne) r-"'1i~~L_ Gast ric
Thyroid Parietal
Inferior pharyn geal cardia
carti lage periton eum
constricto r, thyro
Killian' s phar yng eal part Peritonea l
tr iang le cavity
Inferior pharyngea l
- - - - ----"""-- - Gastri c
const rictor, crico
Visceral _ _ -----'
fold s (ru gae)
pharyng eal part
perit oneum
Muscular coat B Esophagogast ric ju nction , an t eri o r view. A t r ue sp hincter is n o t

(circular layer) id entifiabl e at t his jun ct ion ; in stead, the d iaph rag matic mu scle o f the
eso p hag eal apertu re function s as a sp hi ncter. It is often referred to as
t he "Z line" because of its zigzag form .
Esophagus Muscular coat
(longitudina l layer)
Muscular coat
,
(circular layer)
"
~-.--- Muco sa
Sub m ucosa
(i"~
: )
A Esop hagea l wa ll, o b liq u e left posterior view. Pharyn x (p. 552); C Functiona l architect ure of e sophageal m uscle.
t ra chea (p. 1 10 ).
~ Clinical
Esophageal diverticula
Inferior pharyngeal constrictor Diverticula (abnorma l outpouchings or sacs) generally develop at weak
spot s in t he esophageal wa ll. There are three mai n ty pes of esophageal
Zenker's divert iculum dive rticula :
• Hypopharyngeal (pharynqo-esopheqeal) diverticula: Outpouchings

Trachea occurring at the j uncti on of t he pharynx and the esophagus. These
include Zenker's divert icula (70%of cases).
• "True" traction diverticula: Protrusion of all wall layers, not typically

Parabronchial diverticulum occurri ng at characteristic weak spots. How ever, they gen erally result
from an inflam m ato ry process (e.g. , lymphangitis) and are t hus com
Rig ht main bronchus

Left main bronchus mo n at sites whe re the esophagus closely approaches t he bro nchi and
bronchial lym ph nodes (thoracic or parab ronchial diverticula).
Esophagus, tho racic part • "False" pulsion divert icula: Herniations of the m ucosa and subm ucosa
t hrough weak spots in t he muscular coat due to a rise in esophageal
pressure (e.q., during norma l swallow ing) . These includ e parahiata l and
Epiphrenic divert iculum
epiphrenic diverticula occurring above t he esophageal apertu re of t he
diaphragm (10%of cases).
="-""=~~~==",.....- Diaphragm
+ - - - - Esop hagus, abdominal part
97
Neurovasculature of the Esophagus
~ Sympath etic inn ervation: Presynaptic fib ers ari se from th e T2- T6 and travel in th e vagu s nerves to form t he exten sive esophageal plexu s.
~ spi nal cord seg me nts. Postsynaptic fib ers arise from t he sym Note: The po stsyn aptic neurons are in th e wal l of th e eso phagus. Fibe rs
path eti c chain to j oi n th e esop hagea l plexu s. Parasympath et ic to the cervical portion of the eso phag us travel in the recurrent laryng eal
innervation: Presynapti c fibers arise from the dor sal vag al nucl eus nerves.
Fig. 7.28 Autonomic innervation Vagus n. (eN X)

of the esophagus
Dorsal vagal nucleus tf-......+----.l-_ _. Esophagus
(cervical part )
I
Sympathetic
trunk
"-..-L-+--+-- Recurrent laryngeal n.
T2 spinal cord segment Eso phagus (tho racic part)
-++---1 - Eso phageal plexus

T6 spinal cord segment
Esophagus (abdominal part )
n
Fig. 7.29 Esophageal plexus
The lef t and rig ht vag us nerves initia lly descend on th e lef t and rig ht Right recurrent
Left recurrent
laryngeal n.
laryngeal n.
sides of th e esophagus . As they begin to co nt ribute to th e eso phageal
pl exu s, th ey shif t to ant erio r and po st eri or po sition s, resp ectively. As t he Right vagus n. - -ft--li r+-Jri-- Left vagus n.
vagu s nerves continu e into th e abdom en , th ey are nam ed t he anterior
and po sterior vaga l trunks.
3rd t hrough
Left vagusn. 6th thoracic
ganglia
Eso phageal ----!~,~
plexus
Right - -
Right recurrent
sympathetic \
laryngeal n. t runk
Righ t - ------'1 Anterior
vagus n. Left recurrent vagal t runk
laryngeal n.
Left vagus n.
Post erior
intercostal a., B Anterior vi ew . Note t he po st
intercostal n. sy napt ic sy m pat het ic co nt ribu Left
Eso phagus - ---;:::= vagus n.
Anterior tion to the esop hag eal plexu s.
(t horacic part) vagal trunk
~~~~- Thoracic
aort a
Esophageal
Sympathetic plexus
trunk
Greater - - - =
splanchnic n.
Posterior
vagal
trunk
C Posteri or Posterior
98 A Esophag eal pl exus in sit u. Anterior view . vi ew . gastric plexus
Fig. 7.30 Esophageal arteries Lef t com mon
Inferior carot id a.
Anterior view. Ant erior scalene
t hyroid a.
Thyrocervical Esoph ageal

t run k branches
Intern al thoracic a. -~;=;.=- ~'!!_~-- Left subclavian a.
Verteb ral a.
Trachea
Aor tic arch
~""'~rr-- Left main

bronchu s
-..:;~-- Posteri or
Esophageal branches int ercostal aa.
(fr om thora cic aorta)
~~-- Thor acic aorta
- - Diaphr agm
Gastr ic fu ndu s
Esophagea l branch
Lef t inf erior phreni c a.
Celiac t run k
r-:.E""'- - - Lef t gastric a.
Com m on
Fig. 7.31 Esophageal veins hepati c a.
Ant erior view. Abdomina l aorta
Inferior
t hyroi d v. Int ernal
Ante rio r j ugu lar v.

scalene
Esophageal vv.
Ext ernal
j ugu lar v.
"~"'----- Subclavian v.
Right brachi o
cephalic v.
Superior
vena cava
~~#:~-- Accessory
hem iazygos v.
Esophageal vv. ~;.--- Posterior Blood vessels of the esophagus

int ercost al vv.
Origin of Dra inage of
Part esophageal arteries esophageal veins
Azygos v.
:.==;~- Hem iazygos v.
, Inferior th yroid a. : Inferior th yroid v.
.............................................. . ... ..... .. ... .. ... ... ... .. ... ..... ... .. ........ ... ..... ... ....
j Cervica l : Rarely dir ect branches

: fr om th yr ocervical tr unk or : Left brachiocephalic v.
, com mo n carot id a.
Esophageal vv. ..................... . . .
: Upper left: Accessory
. hem iazygos v. or lef t
Left
gastri c v. j Thoracic
: Aorta (four or five esophageal ?ra.c~ i?ce?~a. lic v,
• aa.)
L Lo.~~r. l:ft : ~ e.~ ia.~yg os v.
.................................. L R i~~t s.id~ : ~~yg o.s. ~ .
j Abdom inal j Left gast ric a. : Left gast ric v.
99
lymphatics of the Mediastinum
~ The superio r phrenic lymph nodes d rain lymph from t he dla found in t he abdomen, co llect lymph from the diaph ragm and low er
~ phragm, pericardium . lower esop hagus . lun g , and liver into t he lo bes of t he lung and convey it to t he lum bar t ru nk. Note: The perica r
bronchom ed iastina l trunk. Th e infer ior ph renic lym ph nodes . dium may also drain superio rly to the brach iocephalic lym ph nodes.
Fig. 7.32 Lymph nodes of the Esophagus

mediastinum and thoracic cavity Left jugu lar t runk
Trachea
Left anter ior ob liqu e vi ew .
'iJ..."""'i_ - - - Thoracic duct (at junc tion of left
Right brachio
subclavian and int ernal jugular vv.)
cephalic v.
1#1f.~::Q::""~~--- Left brachiocephalic v.
Brachiocep halic I.n. - - -+'/'=41
rl~~-'---'-~-- Paratracheal l.n.
Superior vena cava - - - f -./
=Ii*::;;;;;=---fr- - - Thoracic du ct
Tracheobronc hiall .n.
----7l~'-----4~
1F3'J""""~.';\----- Intercost al lymphat ics
i;f-~~::-'--T--- PrevertebralLn .
Fib rou 5 - -+-Jf--
pericardium - --"'\1-- Superior phrenic Ln.
Diaphragm - -----r:- / :;----
~lk~~"it~-~w- Celiac Ln.
Abdo mi nal --+-~:I'-t

aorta
- - --;-- - Sto mach
Fig. 7.33 Lymphatic drainage

of the heart
A uniq ue "crossed" dra inage pattern exist s
- \ - - Aortic arch
in the heart: lymph f ro m the lef t atrium and Superior vena cava - - - f-
ventricle d rains to t he rig ht venous junctio n.
w hereas lym ph f ro m t he righ t atrium and
Bronchopulmonary Ln.
ventricle dra ins to the lef t venous junctio n.
Left ventricle
Right coronary - - -+--F\..
~- Trachea t runk k- - ------\- - Right ventricle
Superior venacava - - -----1 B Lym ph at ic d rainage of t he rig ht chambers,

ante rior view.
Inferior ---+-~~,
tr acheobronchial Ln.
Left coronary
trun k ~-+-~--- Trachea
Rightventricle - - -\--+- Left ventricle Inferior tracheo

bronchial Ln. -+- - Superior vena cava
A Lymp hatic dra inage of t he lef t cham bers, Bronchopulmonary Ln. -_~:'A.i"=- Bronchopulmonary I.n.
anterior view.
Left atrium Right atrium

Left coronary tr unk r-4f'=-'1- - - Right coronary trunk
C Posterio r view.
100
~ The paraesophageal nod es drain t he esophagus. Lymphatic drain trun ks in t wo part s: th e upp er half drains cranially, and t he lower half
~ age of th e cervical part of th e esophagus is prim arily cranial, to drain s inferiorly via the superior phr enic lym ph node s. The bron chopul
the deep cervical lymph nod es and th en to th e jugular t runk . The monary and paratracheal nodes drain lymph from th e lung s. bron chi.
th or acic part of t he esophagus drains t o th e bronch om ediastinal and tra chea int o th e bron chom ediastinal trun k (see p. 118).
Fig. 7.34 Mediastinal lymph nodes
W.1!~~\j"' ~'\.,,~- Esophagus

Paraesophageall.n. -------.~Icq'!-c
~-- Tr a c h e a
Paratrachea l l.n.
Right main
bronchus
Inferior trach eo
bronchiall.n .
~ Paraesophageal l.n.
Diaphragm - - - -
Cardiac lymph at ic
ring (inconst ant) Stomach Left com mon
carot id a.
Left internaI
A Ant erior view of ope ned t ho rax. j ugu larv. . +-- - - Trachea
Left subclavian
a. and v.
- - - - Paraesophageall.n.
- - - - Superior vena cava
- - -- Aortic arch
Bronchopulm onary I.n.
:.:ill~-- Azygos v.
Left pulm onary a. - ----'I
Left main bronchus - - -"7"'7:
Tracheobronchial l.n. Bronchopulm onary I.n.
=.0:1--- - Paraesophageall. n.
Inferior vena cava

Fibrous ----:~-
pericardium
Diaph ragm - -- -
B Posterior view of medi astinal lym ph node s.
101
Pleural Cavity
~ The paired pleural cavities contain the left and right lungs. They and are under negative atmospheric pressure (see respiratory mechan
~ are completely separated from each other by the mediastinum ics,pp.112-113).
Fig.8.l Pleural cavity

Pleural cavitie s and lung s projected onto thoracic skelet on.
Right brachio Left brachio

cephalic v. cephalic v.
Superior Aort ic arch Left lung --~J.ij~~Tj~~~~~p~~Jt-----:- Right lung
vena cava / P1JI\·<MIt:-I : -A,-.-I--\-f----;r-- Parietal
A!t~~-<t--- Left lung
pleura
~at JJA-6-~'k-----'~- Pulmonary
-===l~i~~~~~~Q
trunk
Heart Diaphragm ~-+--- Li v e r
Spleen -
Left --~---ro~~~~Ct~~~~
suprarenal
gland
Liver. right lobe
T12
vert ebra
Stomach Transverse Transverse

colon colon
A Anterio r view. B Posterior view .
Fig. 8.2 Boundaries of the pleural cavities and lungs
MA
MC St PV MC
A Anterior view . B Right lateral view. C Posterior view . D Left lateral view .
Pleural cavity boundaries and reference points

Reference line Right parietal pleura Right lung Left lung Left parietal pleura
Sternal line (St) 7th rib 6th rib 4th rib 4th rib
Midclavicular line (Me) 8th costal cartilage 6th rib 6th rib 8th rib
Midaxillary line (MA) lath rib 8th rib 8th rib lath rib
Paravertebral line (PV) T12 vertebra lOth rib lOth rib T12 vertebra
102
Fig, 8.3 Parietal pleura
The p leur al cavit y is bound ed by t w o sero us layers. The vi sceral (pu l surfa ce of th e t horaci c cavi t y. Th e fou r parts of th e par ieta l pleu ra (cost al,
m on ary) p leur a co vers t he lu ng s, and t he parietal pleu ra lin es th e in ner diaph ragmat ic, m edi astin al, and cerv ical) are continu ou s.
8t h rib
K. .:': - - -- - Right lung
' ,' Visceral pleura

Cervical part
\
I
"
' Pa rietal pleura,
diaphragmati c part
Diaphragm
Pa rietal pleura, ------'!--l~!\';fr--III I
Pariet al peritoneum
costal part
Costal part
Visceral perito neum
Costodiaphragmatic
recess
Costal --T--+'~':-;'i
groove
Endotho racic fascia
Diaphragmat ic
Ext ernal - - ;,-- Liver
part
- - - Fibrous intercost al
pericardium ::'v- - Innermost
Internal
intercostal
intercost al
A Par t s of t he parietal pl eura. Opened: Rig ht B Costo dia p h rag ma t ic recess, co ro na l sec
pl eural cav ity, anterior view . ti on, anterio r vi ew . Ref lection of th e d ia
p h ragmati c p leura o nt o th e inn er th o racic
wa ll (becom ing t he costa l pl eu ra) fo rm s t he
costo diap h rag ma t ic recess.
Costom ediastinal Serous Parietal pleura,

recess mediastinal part
Right lung. Left lung,
superior lobe superior lobe
Horizont al
fissure
Visceral pleura
Right lung,
middle lobe
Pa rietal pleura,
costal part
Oblique
Oblique
fissure
fissure
Left
main
broncus
Right lung,
inferior lobe
Left lung,
inferior lobe
Pa rietal pleura,
costal part
Phrenic n. Right Sympat hetic Spinal Azygosv., Hemiazygosv. Thoracic
main trunk cord aorta
thoracic duct ,
bronchus and left vagus n.
C Transver se sect io n, inferi o r view. Ref lect ion
of t he costa l pl eu ra o nto th e per icard ium
form s t he co st o m edia stina l recess.
103
lungs in Situ
Fig. 8.4 lungs in situ Mediastin um

The left and right lungs occupy the ful l volume
---h~~ii~f::~~~
of th e pleural cavity. Not e that the left lung
is slight ly smaller than the right d ue to the Superio r lobe
~~-- Superior lobe
asymmetrica l position of th e heart . Hori zonta l fi ssure - -f:if.f'=l,,
Right Middl e lobe Left
44<.n"'--'1Iitt- Obliqu e fissure
lung Obliqu e fi ssure lung
Inferior lobe
Inferior lobe
Esophagus Descending
A Topographica l relations of t he lungs, aort a
tran sverse sect ion, inferior view .
Brachiocephalic
trunk
Left brachio
cephalic v.
Parietal pleura, -----.J-~~~~~

cervical part
Pulmonary apex ---T----.;;;m~F-,:;-;;'"'

Right lung (superior lob e) ----=='=~
Superior vena cava -------'----~
Left pu lmonar y a.
Right pulm onary a. - - - - --'!;ii

Superior and
inferio r lobar
bron chi
Right pulm onary vv. ---r7iJtJF,@~~~ Left lung
Right lung (superio r lobe)
(hori zont al fissure)
Pulmo nary -----f--;!i~~\--='~~~~ ~~-- Thoracic
t run k aort a
Right lung --~:.!:: Pariet al pleura.

(middle lobe) mediast inal part
Right lun g --~ Left lung

(obl iqu e fissure) (ob lique fi ssure)
Parieta l pleura.
costal part
Right lun g Lef t lung

(inferior lob e) (inferio r lobe)
Diaphragm Parietal pleura, Esophagus, Fibrous

diaphr agmatic part th oracic part pericardium
B Anterior view with lungs retracted .
104
~ Th e obliqu e and ho rizonta l fi ssur es divid e th e rig ht lung into three lu ng ex te nds into th e roo t of th e neck . Th e hilu m is th e lo cat io n at wh ich
IIIiiiJiII lo bes: su perio r, midd le, and inferior. The o bliq ue fissu re divid es the b ron chi and neu rova scu lar struct ures co nnec t t o t he lung .
the left lung int o t w o lo bes: su pe rio r and inferi o r. Th e apex of eac h
Fig. 8.5 Gross anatomy of the lungs

Apex
Superior
lobe
Anterio r Oblique
Horizontal border fissure
Cost al - ---!!c-+- - ----'...----' fissure
surface
Middle Costal -~~-=<..
lobe surface
Inferior - --=::=--:=---"'-~I .:JI.

lobe Inferior
lobe
Lingula -----.:lIlI~fIIii~
Oblique fissure
Inferior border
Inferior border
A Righ t lu ng , lat era l v iew. B Left lun g , lat eral vie w .
Apex Apex
Branchesof right
Superior lobe
pulmonarya.
Anterior
Superior lobar
bronchus border
Mediastinal ~ J ..
Branches of
surface J~
Oblique fissure
left pulmo nary a.
Anterior
Inferior and
border
middle lobar Obliqu e ----!--.>.~
Superior and
bronchi fissure
inferior lobar
Hilum (commo n origi n) bronchi
Branches
Horizontal - --'!,-,:r;" ;
Hilum -~"-~-"-"I: Branches
of right
fissure
of left
pulmonary vv.
pulmo nary vv.
Inferior lobe Mediast inal --f""-~'-;;
surface
Cardiac Cardiac
Costal surface,
imp ression Inferior lobe -+~~-= im pression
vertebra l part
Costa l surface, Cardiac
Pulmo nary
vertebral part notch
ligament
Middle lobe
Inferior
border
Lingula
Inferior border Pulmonary ligament
C Rig ht lu ng , m edi al view. D Lef t lu ng , media l v iew .
105
lung: Radiology
~ The reg ion s of the lungs show varying degrees of lucency in chest and segme nta l bron chi. The perihilar lung region is also covered by the
~ rad iograph s. The perihilar region where the main bronchi and heart. These "s hadows" app ear as white or bright areas on t he radio
vessels ent er and exit the lung is less radiol ucent than the periph graph (radi ograph s are negatives : areas that are imperm eable to
eral region , which conta ins small -caliber vascular branche s light wil l appear bright).
Fig. 8.6 Radiographic appearance of the lungs
Pleural
dome
Clavicle
Aort ic
arch
Superior Left
venacava hilum
Ascending Left Aort ic

aorta at rium arch
Right Left
Middle
at rium ventricle
esophageal
Apexof (t horacic)
Right heart const ruction
diaphragm
leaflet Left Left
diaphragm ventricle
leaflet
A Norma l anteroposterior chest rad iog raph .
Ri ght
diaphragm
leaflet
Left
diaphragm
leaflet
B Norm al lat eral chest radiograph.
Fig. 8.7 Opacity in lung diseases

Lateral and anterior view s of the right and left lun gs. Opacity (decreased of th e lung , which is inherently more rad iolucent. Note: Opacities that
radi ol ucency) may be ob served in di seased lung areas. Increased opac it y confo rm to seg me nt al lung bou ndari es are almost inva riably due to
may be due to f luid infi ltration (inflammation) or tis sue pro liferation pulmonary inflammation .
(neoplasia) . These opaciti es are easier to detect in t he peripheral part
A Apical segm ent opa city. B Upper lobe opacity.
C M idd le lobe opacity.

Note: The left lung has
no middle lobe. D Lower lobe opacity.
106
~ Clinical
Diseases of the lung

lncreasedopacit y in th e lungs does not necessarly correspond to segment al boundaries. Flu id accumu lation
in th e lungs also creates characterist ic "shadows" in pulm onary radiographs.
A Lingular pneumonia. The horizont al fissure can be seen (arrow). Note: The B Pulrnonary emphysema. The chest radiograph revealsdiaphragmatic depres
heart is much more diffi cult to visualize here due to increased opacity of sion (flattening of t he domes of t he diaphragm. arrows) wit h corresponding
segments IV and V. changesin t he orient at ion of t he cardiacshadow. The heart assumesa vert i
cal orientat ion due to t he low diaphragm (a lateral radiograph wo uld reveal
an increased retrosternal space). The cent ral pulmonary arteriesare dilated
but taper drarnatically at t he segmental level.
C Pulmonary edema complicating acute myocardial infarction. Dilation of ves D Tuberculosis. Note t he t hickening of t he pleura and th e radiat ing fi brous
sels increases the number of visible vascu lar st ruct ures.Thisimage shows a bands.This image does not contain the small pulmonary nodules (t ubercu
butt erfly pattern of edema and bilateral pleural effusion. lom as) ofte n found in th e upper zonesof th e lung.
107
Bronchopulmonary Segments of the lungs
~ The lung lobes are subdivided into bro nchop ulmonary segment s.
IIIiii3I each supplied by a tertia ry (segmenta l) bron chus. Note: These
subd ivision s are not defi ned by surfa ce bou ndaries but by or igi n.
Fig. 8.8 Segmentation ofthe lung

Anterior view. See pp. 110- 111 for detail s of
the tra chea and bron chial tree .
Right lung Trachea and bronc hial tre e
Hori zonta l ----:~--"....

fissure
Obliqu e
VII,VIII
fissure
Oblique
fissur e
Fig. 8.9 Posteroanterior bronchogram

Ante rior view of right lung.
Segmental archit ectu re of the lungs

Each segment is supplied by a segmenta l bronchus of t he same nam e (e.g., t he apical segmental bronc hus
supplies the apical segment). Seepp. , ' 0- , , , for details of the trachea and bro nchial t ree.
Right lung left lung
Superior lobe
: Apical segme nt ' I

................................................. .......... . . : Apicoposterior segme nt
: II : Posterior segment ' II
. . . . . ...... .............. .......... .... ... .. .... ... ..........
III Ante rio r segme nt • III
Middle lobe lingula

, IV • Lat eral segme nt , Superior lingular segme nt : IV
••• . . .•• ..• . . .• . . ..•. . . . . . . . . . .. . . . . .. . . . . . ...• •..•••••.••
V : Media l segment • Inferior ling ular segme nt V
Inferior lobe
VI Superio r segment ' VI

....................................... ................ . .
, VII Media l basal segment • VII
................................................ .................................................................................. ........ ,.... . , .
: VIII Ante rio r basal segm ent
.. ... ... ... ... ...... ... ....... .. ............ .......... ....•.yul .
IX Later al basal segment • IX
...... ... .................. .... ............ .......... .... . .... ... .... .... ... .... ..... .... ..... ..... .. .... ..... ..... .. .. ........ .. . ..... ........ .... ... ...... .. .. ........ .. ... .... ..
:X Posterior basal segme nt X
108
Fig. 8.10 Right lung: Bronchopulmonary segments
Horizonta l
fissure
Oblique
fissure
A Medial view. B Posterior view. C La teral view.
Fig.8.11 left lung: Bronchopulmonary segments
A Medial view. B Posterior view. C Lateral view.
~ Clinical
Lung resect ions

Lung cancer. emphysema. or t uberculosis may necessit ate t he surgical rem oval of damaged por tion s of t he lung.
Surgeons exploit th e anatom ical subdivision of the lung s into lobes and segme nts when excising dam aged tis sue.
Trachea
Segment I
of right lung
Superior lobe of - -
right lung
Left
lung
A Segme ntect omy (wedge resection): Rem oval of one or B Lob ectomy: Rem oval of lobe. C Pneum on ectomy: Rem oval of
more segm ents. ent ire lung.
109
Trachea & Bronchial Tree
~ Ator near the levelof the sternalangle, the lowest tracheal carti bifurcates at the carina into the right and left main bronchi. Each bron
~ lage extends anteroposter iorly, forming t he carina. The trachea chus givesoff lobar branches to the corresponding lung.
Fig. 8.12 Trachea

See p. 574 forthe st ructures of the thyroid.
Tracheal
bifurcat ion
Cervical part
Thoracic
part
I
Trachea
Right main ----Jp$::~~~~2:~f----- Left m ain
bronchus
bronchus
Thyroid ----"=~
cart ilage
_-J~I---_ _ Median
Cricoid - -:;- cricot hyroid
cart ilage ligam ent
A Projection of t rachea onto chest. Tracheal }
cart ilages ~
Thyroid cart ilage
-~::.-- Annul ar
ligam ent s
Arytenoid ----'c:~"'"
cart ilage Right
main
Cricoid - ----'0"-'- bronchus

cart ilage
Membranous - - i"-;-'Tracheal
posterior wall (with cart ilages
tra cheal glands) Right - -----"""'!!""'=t
L ii -- - - Left
superior lo bar
superior
bron chus -. IV lob ar
i"SHI- - Muco sa bro nchus
IV
Right -~7~,jI . _ J
midd le lobar
bron chu s ... . r ............ VIII
Right/ left
Right inferior loba r
m ain bron chi
bronchus
B Anteriorview.
II
~ Clinical
IV
Foreign body aspiration
IV
Toddlers are at particu larly high risk of potentially fatal aspirat ion of foreign
main
bod ies. In general. foreig n bodies are mor e likely to becom e lodged in th e
VIII ~' '''''- U bronchus
right main bron chus than the left: th e left bronc hus diverge s mor e sharply
at the t racheal bifur cation, whi le t he right bronchus is relativ ely st raight .
X IX
C Posteriorview with opened posteriorwall.

110
~ The conduct ing portion ofthe bronchial tr ee ext ends from th e respirato ry por t ion consists of th e respirato ry bronchio le, alveolar du ct s,
a.iiiJI t racheal bifu rcat ion t o t he t erm inal bron chiole, inclusive. The alveolar sacs, and alveoli.
Fig.8.13 Bronchial tree
Smooth mu scle
Segment al
bronchus
j ...:;1- - - Cart ilaginous
Elastic --=~'Il
(lattice arrangeme nt )
plate fibers
+ - Pulm onary
alveo lus
Large
subsegmenta l
bronchus
Respiratory
bronchioles
Sm all
subsegment al
bron chus
Interalveolar
sept um
Alveolar
Alveo lar du ct
sac Acinus
Alveolus
~ 111_'------""~- Pul monary

Bronchio le alveo li
Term inal \- - - - - -
(cart ilage -free
bronchiole _ ,-----H--, w all)
Respirato ry
bronc hiole
l see B B Respiratory po rt ion of the bro nchial t ree.
Alveolar f-
sacs L
~ Clinical
A Divisions of th e bronchial tree .
Respiratory compromise
The most com mon cause of respiratory com pro m ise at th e bronch ial level
Capillary Type II
Surfact ant is asthma. Com promise at t he alveolar level may result fro m increased
lum en pneum ocyt e
diffusion distance, decreased aerat ion (em physema) , or flui d infi ltra tio n
(e.g., pneumonia).
Diffusion distance: Gaseous exchange t akes place between t he alveo lar

and capillary lum ens in th e alveoli (see Fig. 8.13C). At t hese sites, t he
basem ent membranes of capil lary endothelial cells are fu sed w it h t hose
of type I alveolar epithe lial cells, lowering t he exchange distance to 0.5
Alveolar urn, Diseases th at increase th is diffusion di stance (e.g ., edema to us flu id
Eryt hrocy te
lumen collectio n or infl ammati on) result in compromised respirat ion.
Condition of alveoli: In diseases like em phy sema, which occurs in chro nic
obst ructive pulm onary disease (COPD), alveo li are destr oyed or dam aged.
Thi s reduces t he surface area available fo r gaseous exchange.
Production of surfactant: Surfactant is a protein-ph ospholi pid film t hat

low ers the surface te nsion of t he alveo li, maki ng it easier for th e lung to
Alveolar Type I Elast ic fibers Fusion of th e expand. The immature lungs of a preter m inf ant of ten fail to prod uce
macro pneumocyt e in t he basem ent suffic ient surfacta nt, leading t o respiratory prob lem s. Surfacta nt is
phage int eralveolar membranes produ ced and absorbed by alveolar epit helial cells (pneurnocytes). Type I
sept um alveo lar epit helial cells absor b surfactan t: ty pe II produce and distri bute it.
C Epit helial lining of th e alveoli.
111
Respiratory Mechanics
~ The m echanics of respirat ion are based on a rhyth m ic incr ease evident in th e pleural recesses: at funct ional residual capacity (rest ing po
~ and decrease in t horacic volume. with an associated expansion sit ion bet w een inspi rat io n and expirat ion). t he lung does not full y occ upy
and cont ract io n of th e lungs. Inspiration (red) : Cont racti on of th e t he pleural cavit y. As t he pleural cavity expands, a negat ive int rapleur al
diaphragm leaflet s low ers th e diaphragm into the inspiratory posi pressure is generated. The air pressure diff erent ial results in an influ x of
t ion, increasing t he volume of th e pleura l cavity along t he vert ical air (inspirat io n). Expiration (blue): During passive expirat io n. t he mu scles
axis. Contracti on of t he t horaci c mu scles (ext ernal intercost als w it h of t he t horacic cage relax and th e diaphragm returns to it s expiratory
t he scalene, int ercarti laginous. and post erior serrat us mu scles) el posit ion . Cont ract io n of t he lu ngs increases t he pulm onary pressure and
evates th e ribs, expanding th e pleural cavity along th e sagittal and expels airfro m th e lungs. Forforcible expirat ion. th e interna l int ercost al
t ransverse axes (Fig. 8.15A, B). Surface tension in t he pleural space mu scles (w ith th e t ransverse t hora cic and subco sta l m ucosa) can act ively
causest he visceral and pariet al pleura to adhere; t hus, changes in lower t he rib cage m ore rapidly and to a greater extent t han t hro ugh pas
t horacic volum e alter t he vo lume of t he lungs. This is part icularly sive elastic reco il.
Fig.8.14 Respiratory changes in thoracic volume ~------;r-- 1st rib

Inspirat or y positi on (red ); expiratory posit ion (blu e).
--+;=::~~~~- Sternum
Expiratory position ----,&'>I-\--~
Diaphragm
Inspiratory position -l'1-fj~
Fig. 8.15 Inspiration: Pleural cavity expansion

T1 2 vertebra
Expansion
E
Inspirat ion
1st rib - _ ?=>

Thoracic
inlet
I
Diaphragm
Fig. 8.17 Respiratory changes in lung
volume
Expansion Expansion
(t ransverse axis) (sag itta l axis)
A Anterior vi ew. B Left lateral view. C Ant erolateral view .
Fig. 8.16 Expiration: Pleural cavity contraction
Contraction
(vertical axis)
Expiration
Inferior border of lung (full inspiration)
Contractio n Cont raction

(transverse axis) (sagittal axis)
A Anterior view . B Left lat eral view . C Antero lat eral view .
112
Fig. 8.18 Inspiration: lung expansion Fig. 8.19 Expiration: lung contract ion Fig. 8.20 Movements of the lung and
bronchial tree
Rig ht lung (full inspirat ion) Right lu ng (full expirat ion) As the vo lume of t he lu ng ch ang es with th e
I
p~;;:~; t .
I
t horacic cav it y, t he ent ire bron chia l tree moves
within th e lung . Th ese st ructu ral movements
are more prono u nc ed in portion s of t he bron
chial tree d istant from the pu lmonary hilum.
Diaphragm
k
Diaphragm
Trachea
Lung
(full expirat ion)
Costodiaphragmat ic recess Costod iaphragmatic recess
Lung
(full inspirati on)
~ Clinical
Pneumothorax
The pleural space is normally sealed from th e outside environment. Injur y occurs w hen traumatically detached and displaced t issure covers t he defect
to t he parietal pleura, visceral pleura. or lung allows air to ente r t he pleural in the th oracic wall from th e inside. This mobile flap allow s air to enter, but
cavity (pneumothorax). The lung collapsesdue to it s inherent elasticity, and not escape, th e pleural cavity, causing a pressure buildup . The med iastinum
the patient' s ability to breath e is compromised. The uninjured lung continu es shifts to the normal side, w hich may cause kinking of th e great vessels and
to funct ion under normal pressure variation s, result ing in " mediast inal prevent th e return of venou s blood to the heart . With out treatment, ten sion
flutter": the mediast inum shifts toward the normal side during inspirati on pneumothorax is invariably fatal.
and return s to th e midline during expirat ion. Tension (valve) pneum oth orax
Normal airflow during Pleural

inspiration defect during
inspiration
Right Left
lung
lung
Inspiration
Positive pressure
in pleural cavit y
Normal airflow during Collapsed

expiration lung
Airflow out
of pleural
defect
Expirat ion
"Empty' pleural
cavity at
atmospheric
pressure
Cardiac shift
A Norm al respirat ion. B Pneumothor ax. C Tension pneumot horax.
113
Pulmonary Arteries & Veins
~ The pulmonary t runk arises from the rig ht ventricle and divides pulmo nary arteries accompany and follo w th e branch ing of the bron
IIriiiiII into a left and right pulmonary arte ry for each lung. The paired chial tree , w hereas the pu lmonary veins do not , being located at th e
pu lmona ry veins open into th e left atrium on each side. The margin s of the pulmonary lobules.
Fig.8.21 Pulmonary arteries and veins

Ant erior view.
Rig ht internal Left int ernal
~
Right .u g U l a r v. - : jugu larv.
pulm onarya . ""'/ left pulm onary
Right Left
subclavianv. ~~ subclavian v.
Right brachio- ~ - Left brachio
cephalic v. I / cephalic v.
~
c ava ~. - ~
(jf---'-- - - - - - Pulmonary
tr unk Superior vena Left
Right pulmonar yw.

A
=-
C l i-=C-'-~~-----
pulm onary vv.
Inferior
vena cava
A Project ion of pulmonary arter ies on chest wa ll. B Projection of pu lmona ry veins on chest wa ll.
Trachea
Right lung Left lung
Superior lobe Superior lobe
Right main
bronchus
Left main
bronchus
~J:",-_-",,~_--";!b\-- Left pulmonar y a.

Superior right
pulm onary v.
"'l;;i''-------'-"''= = r - - Superio r left

Inferior rig ht
pulmonary v.
---t----------::~~=i=! pulmon ary v.
--.-"--~~- Inferior left

Superior pulm onary v.
vena cava
Ascending aorta Pulmonary trunk
Right atri um :l---- :-----"--~~1!_- Left ventricle
Middle lobe
Inferior Right
Inferior lobe vena cava vent ricle Cardiac apex Inferior lobe
C Distribution of t he pulmonary arte ries and veins, anterior view .

114
Fig. 8.22 Pulmonary arteries Fig. 8.23 Pulmonary veins
Left co m m on
Brachio caro t id a. Left subclavian a.
cepha lic trunk
Aor t ic arch
Right
pu lrnonary a,
'--- - - Ligament um
Right /l eft
arteriosurn
superio r
Middl e
pu lm o nary v.
lobe a.
Left Right Jlef t
pu lrn onar y a. inferior
pulm on ary v.
@
A Sc hem ati c. A Sche m at ic.
Pulmonary arteries and their branches

Right pulmonary artery Left pulmonary artery veins and their tributaries
Superior lobe arteries Right pulmonary v ei n Left pulmonary vein
, Apica l segm ent al a. ® Superior pulmonary veins

... ..... " . .................... .........................
: Posterior segm ent al a. @ : CD : Apica l v.
.. . . .. . .. .. . .. . . . . .. . . . .. . . . . . . • . ••••. ,- .
.......................................................... , Apicoposteri or v. • @J
, Ante rior segmenta l a. :@ : Posterior v.
...............................................
Middle lobe arteries , Anterior v. , Ant erior v.

...................................................................... ... ........................... ............................ .................................
, @) : Later al segmental a. • @) • Midd le lobe v. • Ling ular v. :@

.......................................................................... ....: Linqu lar a.
• CIl : Media l segmenta l a. Inferior pulmonary veins
Inferior lobe arteries : Superior v. ® •. . . .•. . .. . . .. . •. . .. . .•. . ... .. .
® : Commo n basal v. @
. . .. . ................... ................. ...... ................. ..........................
(2) •@ : Inferior basal v. @
.. ....... .... .................... .... .
'@ ® Superior basal v. @

................................
® ..........................................................., Ante rior basal v. ®
.
, . .......... ....... .... . ................... .... ... ... ,: ,, ;
• @J : Med ial basal segmental a.
B Pulm onary arte ri o B Pu lmon arya r te rio

g ram , a r teria l p ha se, g ram, v en o us pha se ,
a nterio r vi ew. a n te rio r view.
~ Clinical
, Pulmonary embolism
Pot ent ially lif e-t hreateni ng pu lm onary emb olism occurs w hen blood ori ginate fr om st ag nant blood in the vein s of th e lowe r limb 'and pelvis
clot s m igrat e throug h t he venou s system a nd become lodged in on e of (venous throm boembo li). Causes include im m obilizat ion, diso rdered blo od
t he arte ries supplying t he lu ngs. Sym pt oms include dyspn ea (diffi cult y coaq ulat ion , and trau ma . Note: A th romboem bolus is a t hro m bus (bloo d clot)
breat hing) and ta chycardia (increased heart rate). M ost pulm ona ry em bol i t hat has mig rated (em bo lised).
115
Neurovasculature of the Tracheobronchial Tree
e
o
Fig. 8.24 Pulmonary vasculature
The pulmonary syst em is respon sib le for
Bronchial a. - - -----."""'1
Branch of - - - ';;;:,H
c:: gaseous exchang e within th e lu ng . Pulmonary pulmonary a.
arteri es (shown in blu e) carry deoxygenated (deoxygenated
blood and follow the bronchial tree. The pu l

blood)
monary vein (red ) is th e only vein in th e body
carrying oxygenated bl ood, which it receive s
fr om th e alveolar capilla ries at th e periphery

Respiratory ------,J'*-----.~
of t he lobu le. bronchiole
\~--- Branch of
pulmonary v.
(oxygenated
blood)
'l'--L-_ _~ Capillary bed

on an alveolus
' ~--=='7"''''';'-------\1--- Pulmonary

alveolus
Fibrous sept um - -
between
pulmonary
lobules
Pulmonary -----H:--;i:~~--;i
alveolus
- -- - - Subpleural
connective
tissue
Fig. 8.25 Arteries of the tracheobron Trachea
chial tree
The bron chia l tree receiv es it s nutrients via

th e bron chial arteries, found in th e adv entitia
of th e airways. Typ ically, th ere are o ne to Brachio

Left subclavian a.
cephalic t runk
t hr ee bronchial arterie s arising d irectly from
Ascen ding
t he aorta . Origin from a p ost erior interco sta l

aorta
artery m ay also occur.
Posterior
intercostal a.
Bronchial
Right main branches (fro m
bronchus th e thoracic aort a)
Left main
bronchus
~,-o;-- Superior lobe

bronchus
~.----- Inferior lobe
bronchus
'>---Nl~~~- Posterior
intercost al aa.
116
Fig. 8.26 Veins of the tracheobron Trachea
chial tree
Inferior - ----!.....,il!!!!lr---'.--+....
"""'=-- - Left brachio
cephalic v.
t hyroid v.
Righ t brachio ------'Il~

cephalic v.
Lef t main
Superior vena cava ---1~- bro nchus
Bron chial vv.

(opening into
th e accessory
hemi azygos v.)
Superior lob e --~~!!=ii;.
bro nchus
~--- Superior lobe
bronc hus
' ---4=- - - Inferior lobe

bron chus
Inferior lob e --------'.......,~~-,

bro nchus
Azygos v. ----r-.~H-_l".I
[r-
- Hem iazygos v.
Fig. 8.27 Autonomic innervation of Vagus n. (CN X)

the tracheobronchial tree
Sympat hetic innervation (red);
parasympath etic innervation (blue).
Dor sal vagal
nucle us
I Larynx,
t hyroid carti lage
Postga nglio nic
fibers (to
Middlecervical ca rdiac plexus)
ganglion
~-\----'='--f-- Superior
Cerv icot horacic laryngeal n.
ganglion
""7"=;'~""-+--- Recurr ent
T1 spinal laryngeal n.
cord segme nt
,L -_ _ +-_-+_ _ Laryngopharyn
geal branch
2nd t hrough -i::~~~t--
5t h th oracic
ganglia
Aut ono mic

branches to
t rachea
Great er splanchnic n. Pulm onar y
(t o abdomen) plexus
Bron chial branches in

pu lm onar y plexus
Right main Lef t main

bron chus bronchus
117
lymphatics of the Pleural Cavity
~ The lungs and bronchi are dr ained by two lym phati c drainage subpleural network collect s lym ph from t he perip heral lung and visceral
~ syste ms. The peribron chial net work follows th e bronchial tr ee, pleura.
draini ng lym ph from t he bro nchi and m ost of th e lungs. The
Fig. 8.28 lymphatic drainage of the pleural cavity

Transverse sectio n, inferior view.
Trachea
To right broncho- - - - - -" ,,-- -- - To left bro ncho

m ediasti nal tru nk m ediastinal tr unk
Right lung ----,LH,"--- -~~-- Left lung
Paratracheal l.n.
Superio r t racheo ~\-,;--i-c--------%,------ Inferior t racheo

A Peribronchial network, coronal sect ion. bronchial l.n. bronc hial l.n .
(Int ra)pulmo nary nodes along th e bron
chial t ree drain lym ph fro m t he lungs into To inferior - - 1-ii--- -----''-----¥ti- -\\--"''--'- -----'- ' d
th e bronchopulmo nary (hilar) nodes. trac heobronchiall. n.
Lymp h t hen passes sequentia lly throu gh
th e inferi or and superio r t racheobron chial > - - - - - ----H-\'- - Drainage thro ugh
nod es, paratracheal nod es, bron chome diaphragm
diastin al t run k, and finally t o th e right Diaphragm - - +iiiI-- J
lym phat ic or thora cic duct. Note: Signifi cant

am ount s of lym ph from th e left lower lobe
drain t o th e right superior tr acheobronchial Inferior phrenic I.n.
nod es.
Parasternall.n . Sternum Bronchop ulmo nary I.n.
Int rapulm onary I.n.

Tracheobro nchiall. n.
Paratr acheall.n.
IH-\-+-- Lymp hatics
in t he tru nk
wall
Peribro nchial
net work
B Subp leural net work, tr ansverse sect io n, Subpleural Trachea Int ercost al l.n.
superior view. net work
118
Fig. 8.29 lymph nodes of the pleural cavity
Anterior view of pulmonary nodes.
Right int ernal Left
jugular v. jugular trunk
Right Trachea Deep cervicall.n .

jugu lar trunk
ft...--- - - - - - Thoracic duct
': i."~~~~--- Left subclavian trunk
Right bronc ho- - - -- - ---i-'- 'ci- --"----+''--''<...

mediastinal trunk Md--',------,----';-- "--------';-,----'''-o-- - - Left bronc ho
mediastinal trunk
ParatracheaI l.n. - - - - - -;----,-O---";------;':--=;----+-:'---
Left main
Superior t racheo
bro nchus
bronchial l.n.
VAii~-':--':--~-+---'':;;'-~-- Broncho
Rig ht main -----/-:iJ~~:-=====--~~~;;;~~~;1\ pulmona ry I.n.
bronc hu s_-~~~~2:::::-;:("--c:-~~~=]:~t;,,~
Inferior trac heo ,'r'o.)-------:===~~=-'<--- Intr a
bronchia l l.n. pulmona ry I.n.
rn=7----iliii-\~~---;------:--o---T-'"""'i-- Thoracic
aorta
Riaht lung ------;'----:-- - - - -+--"c+-- - Left lung
..I
119
Surface Anatomy
Fig.9.1 Palpable structures in the thorax

Ant erior view. Seepp. 40-41 for structures of the back.
Midclavicul ar
line (MCL)
Suprajugu lar
not ch
Coracoid
process
Clavicle. -----------,~ T~---- Greater and

m edial head lesser t uberosit ies
Ste rnal - -- - - - - - - - -
angle
Xiphoid ------~_-~..___o:__:
process
- - - ----ir--------::---f-=<------- Subcost al
plane
Ant erior _
superio r
iliac spine
Ste rnocleidom asto id _---,~~

Thyroid cart ilage
A Bony prom inences.
Delti od --~
Deltopectoral - -1-- - -
gro ove
Pectoralis m ajor --I' ~--~~---
Serrat us ant erior - -t-- - ----,]i
Semil unar line

Rectus _ _ + __~
abdominus Linea alba
Iliac crest
\ Um bilicus
B M u scul at u re.
120
Fig. 9.2 Surface anatomy of the thorax
Ant erior view. See pp. 40-4 1 for st ruct ures of t he back.
Ql: A fem ale pati ent has giv en a histor y of

detect ing a " lump" during a self-exam ina
t ion . How w ould you proceed? Wh ere
wo uld you palpate for lymph nodes?
Nipp le - - - ---'---- ..
' - - -- Areola
Breast - - -- --'T-- ___
l"----=o~~~n_---- Umb ilicus
A Female t horax.
Q2: You are present ed w it h th e ante rior chest

of your fir st hospit al pat ient. How wo uld
you formu late a plan t o opti mally examine
t he four valves of t he heart?
See answers beginning on p. 626. B Male t horax.
121
Abdomen & Pelvis
Vagina 190
10 Bones, ligaments & Joints

Female External Genitalia 192
Pelvic Girdle 124

Neurovas culature of th e Femal e Genitalia 194
Male & Femal e Pelvis 126

Penis, Scrotum & Spermatic Cord 196
Pelvic Ligam ent s 128

Testis & Epididymis 198
Male Acce ssory Sex Glands 200
11 Abdominal Wall Neurovasculatu re of the Male Genit alia 202
Muscles ofthe Abd ominal Wall 130

Development of the Genitalia 204
Ingu inal Region & Canal 132
Abdomi nal Wall & Inguinal Hernia s 134

15 Arteries & Veins
Perin eal Region 136
Arteries of t he Abdomen 206
Abd ominal Wall Mu scle Facts 138
Abdominal Aorta & Renal Arteries 20 8
Pelvic Floor Mu scle Facts 140
Celiac Trunk 210
Superior & Inferior Mesenteric Arteries 212
12 Spaces Vein s of the Abd omen 214
Divisi on s of the Abd ominopelvic Cavity 142

Inferior Vena Cava & Renal Vein s 216
Peritoneal Cavity & Greater SiJC 144

Portal Vein 218
Lesser Sac 146

Superior & Inferio r Mesenteric Veins 220
Mesent eries & Posterior Wall 148

Arteries & Vein s of the Pelvis 222
Contents of the Pelvis 150

Arteries & Veins of the Rectum & Genitalia 224
Periton eal Relati on ship s 152
Pelvis & Perineum 154

16 Lymphatics
Transverse Sections 156
Lymph Node s of the Abd omen & Pelvis 226
Lymph Node s of the Posterior Abdo m inal Wall 228
13 Internal Organs
Lymph Nodes of the Anterior Abd ominal Organs 230
Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 58
Lymph Nod es ofthe Intestines 232
Du od enum 160
Lymph Nod es of the Genitalia 234
Jejunum & Ileum 162
Cecum, Appendix & Colon 164

17 Nerves
Rectum & Anal Canal 166
Autonomi c Plexuses 236
Liver: Overview 168
Innervation of th e Abdominal Organs 238
Liver: Segm ents & Lobes 170
Innervation of the Intestine s 240
Gallbladder & Bile Ducts 172
Inn ervati on of th e Pelvis 242
Pancreas & Spleen 174
Autonomic Innervation: Overview 244
Kidneys & Suprarena l Gland s: Overview 176
Auton omic Inn ervation : Urinary & Genital Organ s 246
Kidneys & Suprarenal Glands : l-eatures 178
Ureter 180
18 Surface Anatomy
Urinary Bladder 182
Urinary Bladd er & Urethra 184

Surfac e Anatomy 24 8
14 Reproductive Organs
Overvi ew of th e Genital Organ s 186
Uterus & Ovaries 188
Pelvic Girdle
.~
::.
~
~
Fig. 10.1 Pelvic girdle
Anterosuperior view. The pe lv ic g ird le consists
of t h e two hip bo nes and the sacrum (see
Fig. 10.2 Hip bone
Rig ht hip bone (ma le) .
p.358).
c:
~
E
0
"0 Sacroiliac Hip bone
.Q joint Iliac crest
o::c
Iliac fossa Iliac

tub erosit y
Anterior Auricular
superior surface of
iliac spine ilium
Arcuate
line
Pubic Anterior
sym physis Sacrum inferior
iliac spine
Ischial
Acetabular spine
rim
Symphyseal
Obt urator sur face
foram en
Iliac crest - - - -E Iliac
tu berosity Ischial
tub erosity
Iliac fossa - - -f - - - - - - Posterior A Anter ior view.

superior
iliac spine
Ant erior
superior -=----:-'---;;OC~--- Auricular
iliac spine surface
of ilium
Post erior inferio r

Ant erio r - - - - - -----;,
iliac spine
inferior
iliac spine
Ilium (body)
Arcuate line
Superior U
pubi c ramu s ~ Ischial spine
Pectinea l - - - - - - ".
line Ischium (body)
Symp hyseal Ischial

surface tub erosity
Ischial
Inferior Obtu rator ramu s
B M ed ial view. pubi c ramus for amen
124
Fig. 10.3 Triradiate cartilage of the hip bone
Rig ht h ip bon e, lateral view. Th e h ip b on e co nsists of t he ili u m, isc hi u m,
Iliac crest ---~"
Iliac wing
and pubi s.
-
<::I
txl
0
:J
~
Iliu m
....
Ilium (body) IQ'
Acetabu lum Q
3
Pubi s (bo dy) scr
-
Ischium Triradia te
cart ilage l(o
Superior
pubic ram us Acet ab-
ulum
-0:J,
Inferior
cr
pubic ram us
Ischial Obtu rator
t ub erosit y foram en
A Junctio n o f t he t riradiate cartilage. B Rad io g ra ph o f a child ' s ace ta b u lu m . Right h ip b one, later al v iew .
Fig, 10.4 Hip bone: lateral view

Right hip b on e (mal e) .
Iliac crest
Poste rior
gluteal line
Gluteal surface
Ant erior superior

Posterior
iliac spine
superior
iliac spine ~---~~---- Inferior

glut eal line
li- - - - - Ant erior inferior

iliac spine
Posterior - -""'"
~
inf erior
iliac spine ~~------ Acetab ular rim
Greater ~c-------- Lunate surface

sciat ic not ch
Aceta bular fossa
Acetabu lar notch
Pubic
tubercle
Obtu rator
foramen
Ischial - - -h
tuberosity
125
Male & Female Pelvis
Fig. 10.5 Female pelvis
Iliac
Sacroiliac Pubic crest
Iliac crest joint t ubercle

Sacral canal
Anter ior superio r

iliac spine
Iliac wi ng
Posterior
~~----Yi1 Median
Anterior inferior
superior
)..lo~~~(l,- -4-- sacral crest
Superio r
iliac spine
iliac spine
Greate r
and inferior
pub ic ram i
Poste rior
sciatic notch
infer ior
Ischial spine - -----";t-J='

Obt urator
_ _ + _ _ i l iaC SP ine ~
Pubic sym physis
for amen
Superior
r--,,..J-- - Lesser
pubic ram us
I sciatic notch
Ischial ramu s
Coccyx Ischial spine Ischial
tu berosit y
Inferior Sacral
A Anterior view. pubi c ram us hiat us
B Post erior view.
Fig. 10.6 Male pelvis
Sacru m
IIliac
Superior
I
Iliac crest Pelvic
Iliac crest tub erosit y Glut eal surface
Ala art icu lar proce ss
Sacral
canal Iliac
Ant erior Poster ior
superior \ t ube rcle

superior
and inferior and inf erior
iliac spines iliac spines
Posterior inferior ~"'-'h-----j~-----.1L-- Med ian

iliac spine sacral crest
Ante rio r sacral - ----r;__-~dl~~,..~ '~~--'!!I~- Sacral hiatus
Pecten pubis
for am ina
Posterio r -----'l~---"IIi!
Pubic tu bercle Acetab ulum sacral fora mi na
Ischial spine Pub ic sym physis Ischial spine
Obt urato r fo rame n

Ischial tuberosity
A Anterior view.
B Post erior view.
126
Fig. 10.7 Female pelvis: Superior view Female Male
Interspinous
diameter
Right
ob lique
diam et er
Left
oblique
diame ter
Transverse
Linea
diam et er of
termin alis
pelvic inlet plan e
A Mal e an d fema le p elv is.

Pelvic inl et plane
A Pelvic m ea surem ents.
Sacral
Sacroiliac Iliac
canal
joi nt tub erosit y
Prom ont or y
Pub ic
Ala of sacrum
sym physis
l
j lliac crest
Inn erlip ~
Intermediate -..1
Iliac --=~ __ Subpubic
t ubercl e angle
lin e /i
Oute r lip _~'-- Iliac fossa B Fem al e. C Ma le.
Ant erior
Arcuat e
superior
lin e
and inf erior
iliac spines Gender-specific features of the pelvis
Ischial
spine
Structure
Pecten pubi s
Pubic False pelvis Wide and shallow Narro w and deep
t ubercle Heart- shaped
B Fema le p elvi s. Pelvic inlet Transversely oval
Pelvic outlet Roomy and roun d Narro w and oblong
Ischial tuberositi es Evert ed Invert ed

Fig. 10.8 Male pelvis : Superior view Pelvic cavit y Room y and shallow Narrow and deep
Sacrum Short , wide. and flat Lon g. narrow, and convex
Subpub ic angle 90-100 degrees 70 deg rees

Trans
t ubercular
dista nce
Int erspinous
distance
~ Clinical
A Pelvi c m easurements. Pelvic inlet plane Childbi rth

A non- optimal relati on between t he matern al pelvis and t he fetal head
may lead t o com pli cations during childbirth. pot enti ally necessit ating a
Iliac
crest
1
Inner lip
Intermediat e
line
Outer lip '"
l Median
sacral crest
Ala of
caesarean sectio n. Maternal causes include earlier pelvic t rauma and inna te
malfo rmation s. Feta l causes include hydrocephalus (disturbed circu lation
of cerebrospinal fluid , leading to brain dilat ion and cranial expansion).
sacrum
V ----'r--- lllac fossa

~-,:t:~~~~t-----t- Base of
sacrum
Arcuat e - ---trl. ,- - Ante rio r
line superior
and inferior
iliac spines
Ischial
spine
lliop ubic
em inence
B Ma le p elvi s.
127
Pelvic Ligaments
Fig. 10.9 ligaments ofthe pelvis

Ma le p elvi s.
Sacral Ante rior longit udi nal

promont ory ligam ent Iliolum bar ligament
Ante rior
sacroiliac - ---f- - - - - - - - -----;:::-
ligam ents
Ante rior _
superior iliac
spine
Inguinal ligament - -- '\:\. .
Sacrot uberous
ligam ent
Anter ior inferior - -----',
iliac spine ' --3II~~---~"L'---- Sacrospino us ligament
Coccyx - - ---' Ischial spine
Pubic symp hysis --~;'-

Pubic
t ubercle
Obt urator
A Anterosu perio r view. membra ne
L4 spino us process
Iliac crest Iliol um bar ligam ent
Iliac t ubercle
Ilium , glute al
surface
Posterior superior
iliac spine
Interosseous - - -"'<:, -- - - - -f>-"<:

sacroiliac ligament s Posterior inferior
iliac spine
Posterior
Greater sciat ic - - ----'i:- - -
sacroiliac ligam ent s
foramen
Sacrospinous - - ----\:,.--- - _,
ligament Ischial spine
Obt urator
Lesser sciatic
m embrane
fora men
Coccyx
Sacrotubero us
ligament
'---- - - Ischial
B Po st er ior vi ew. tuberos ity
128
Fig. 10.10 Ligam ents of the sacroiliac joint Fig. 10.11 Pelvic measurements
Male pelvis. Righ t half of female pelvis. medial view.
See Table 10.1.
Diagonal
Int ervert ebral
conju gate
disk LS spinous
process True
conju gate
Pelvic ----~. Linea
inlet termi nalis
Promon tory ~-':...,.,"'l;f---r--- Sacrum

Pelvic out let
Ant erio r superior , ;;.:,.- - - Sacral canal

iliac spine
ca. 60' ca.1S'
"'C ~~_i:~~l!~~..-'5-+.:--- Ant erior
:i sacroi liac
ligam ent s
Greater sciatic --------'.::---------~l__-
foramen
Arcuate line -L:.....,..!.. Sacrospinou s

ligame nt
Pecten pub is - - - - . . -- ---!!' Sacral hiatus
Lesser sciatic - - - --:;...'----:~".._--:-------'!!.__

forame n
Sacrot uberous
ligament
Symphyseal Obtura tor Ischial

surfa ce m em brane t uberosit y
A Right half of pelvis. medial view.

Sacral
Sacrum canal
Posterior superior
iliac spine Iliac tuberosit y
Post erior
sacroiliac ------::-,.:;.~'2_'l \
ligam ent s Inte rosseous
sacroiliac ligam ent s
~-.-\-~'&----- Sacral
tu berosity
Sacroil iac joi nt
~""+"'-- lI i u m
Great er sciatic forame n

Ischial spi ne
Ischial Coccyx
spine
Sacro
tub erous
ligam ent
Pubic
sym physis
B Oblique sect io n.
superior view.
'-~ " I
129
Muscles of the Abdominal Wall
~ The oblique musclesof the abdominalwall consist of the external rioror deep abdominalwall muscles(notablythe psoas major)are func
~ and inte rnal obliquesand the transversus abdominis. The poste- tionally hip muscles(see p. 138).
Fig. 11.1 Muscles of the abdominal wall

Rightside, anterior view.
Pectoralis major, --~~~~
ste rnocosta l
part
- -- - Ste rnum
Serrat us
anterior
Pectoralis major. --1~~
abdo minal part
External oblique -
Ext ernal oblique _ _

aponeurosis
- -
---.-J
>- l.inea alba

Internal ----!c--+------"~-h-,;
int ercostals . ---~~- Costal
.,,_~"7.:i' ;.
-
cart ilage
--=:::0 - Ste rnu m
External
int ercostals ' ..L::""-'e J- Xiphoid
Ant erior rect us - - -----j rl-- - - Umbili cus
process
sheat h
Rectu s -~~-~I+;~tf"t"-,
abdom inis
Inguin al --r-----;~
Exte rnal
ligament
oblique
Internal _ _--IlL
Superfic ial ----1-------~.=:O;'''''''
inguinal ring
oblique
'-.+- - - Umb ilicus
Internal obl iqu e
aponeurosis
Ante rior superior -

Sperm atic cord, Fundifor m ligament
iliac spine
cremaster mu scle of th e penis
A Superficial abdominal wall muscles. Inguinal ligament --!--.....=:,,~
Ant erior rectu s -7-----~"06=--

sheat h
,-/./ ~"----- Spermat ic

cord,
cremaste r
muscle
B Removed: Externaloblique. pectoralis major. and serratus anterior.
130
_ --'!::::...__ Sternum
Tendi nou s
inte rsect ion s
Rectu s
abdo m inis
Ext ernal
Linea alba
oblique
Internal --~ lII! l~~,,*"-- Umb il icus

ob liq ue
Transversus
abdom inis
Ingu inal - - ;,-
ligam ent
Ste rnum
Transversus ------J:'----~~~~--
abdo minis
apon eurosis
(ante rior Pyramidalis
rectus sheat h)
Posterior rect us sheath

(t ransversus abdo mi nis
apon eurosis)
Spermatic cord.
crem aster mu scle
Ext ernal obliqu e Linea alba
C Removed: Intern al oblique.

Internal oblique - -
Transversus - - - -I I b t t- - - Um bilicu s

abd om inis
Sem ilunar - ----It

line
Rectu s - - .-,--
abdominis
Inguinal ligam ent _ - --t-- - .

Transversus abdomin is
apon eurosis
(passes ant erior to th e ~---~---- Deep
rect us abdomi nis inguina l ring
below t he arcuat e line)
M'f~-- Spermat ic
cor d
D Removed: Rectus abdomini s.
131
Inguinal Region & Canal
~ The ingui nal region is th e ju nctio n of t he anterior abdo mina l wall th e passage of st ruct ures into and out of t he abdom inal cavity
~ and th e anterior th igh. The inguinal canal is an impo rta nt site for (e.g., compon ents of th e spermatic cord).
Fig. 11.2 Inguinal region

Righ t side, anter io r view .
Exte rnal Int ernal Transversus Rectu s

obliq ue ob liq ue abdo mi nis abdo m inis
- - -- Linea alba
- - --+1------ - Ant erior rectu s

sheat h
Inguinal ligam ent - - - - -- - -- - Superficial

abdom inal fascia
External ob liqu e
apo neuro sis
..r-~=...c-'------'---l----- Ilioin gu inal n.

Femoral a. and v. - - - - --'- - ---"l
~-____._~-____:_--- Genit ofemoral n.,
genital branch
~~;-.c-r----- Reflect ed
ingui nal ligament
~r--- Spermatic cord
'-----~=--'---------'---- Lacunar ligame nt
Pub ic tubercle
Lat eral crus
Su erf icial .
. P I ' Intercrural fibers
Inguin a ring {
Plane of
Medial crus sect ion in
Table 11.1
132
Structures of the inguinal canal
Structures
Ant erio r wall Q)
@
Formed by
External obli que apon eurosis
Internal oblique mu scles

0-.----i~
Superf icial ----"=---~

abdom inal
I."!:'''''~--
--
::to
0
Roof fascia ~
Q) Transversus abdom inis 3
S'
Wall Posterior w all
@
G)
Transversalis fascia
Parietal perit oneum Subserosa -

Q
Ing uinal ligament (den sely interwove n Pecti neal

fibers of t he lowe r exte rnal obliq ue ligame nt
Floor ® aponeurosis and adjacent fascia lat a Spermatic cord ----"...---~~ Lacunar
ofthigh) ligament
Opening in external oblique ~"*-- Superior

pubic ram us
Superficial apon eurosis: bounded by medial and
ingui nal rin g latera l crus, inte rcrural fibers, and
Openings reflect ed inguinal ligam ent
Pect ineus
Outpouc hing of the t ransversalis
Fascia lat a
Deep inguina l ring fascia lateral to the lateral umbilical
fo ld (inferior epigastric vessels)
Sagittal sect ion through plane in Fig. 11.2.
Fig. 11.3 Dissection of the inguinal region Fig. 11.4 Opening of the inguinal canal
Right side, anterior view. Right side, ant erio r view.
Ext ernal
ob liqu e - -....-.....-----<- - -- -- - -- - External
apo neurosis oblique
Internal -~~~!liii~
Inguinal ~...
aponeuro sis
obliq ue
ligam ent
""""~::--'''''=:------ Ilio hypogastric n.,

Lateral crus -------"~=:- anterior
Genito - -----'tr'~~""
cutaneous
Intercrural ------------'~-,...
femoral n..
branch
fibers genital branch
Spermatic cord Ilioin gu inal n. .:£1~~-..;-u.!-+-- Superf icial

ingu inal rin g
(cut ope n)
A Superfi cial layer.
Spermatic cor d wit h cremaster

mu scle and cremaste ric fascia
Interna l ---~=-"- ",-.
obliq ue
A Divided: Ext ernal ob lique aponeu rosis.
~.:~--- Spermatic cord ~----;'~----- Int ernal

with cremaster Transversus _~~~.iItl~·,l obliq ue
m uscle abdominis
Inferior epigastric
B Removed: External obliqu e apon eurosis. Deep - ---' a. and v.,
inguinal ri ng inte rfoveo lar
ligame nt
Ilio inguinal n. '~" -'K ----"-'i--;-- Hesselbach's
Transversus ----'~~~:..,;::..
triangle
abdomin is
Transversalis Reflecte d
Inguinal Rect us fascia inguinal
ligam ent abdo m inis
ligament
Transversalis .L...-~'=-.-'''!
fascia Femoral Spermatic cord, inte rnal

~. ""........- - Spermat ic cord a. and v. sper matic fascia
wit h internal
spermatic fascia B Divided: Int ernal obliqu e and cremast er.
C Removed: Int ernal obliq ue.
133
Abdom inal Wall & Inguinal Hernias
~ The rectu s sheath is creat ed by fu sion

~ of th e aponeuro ses of th e tran sversus Cent ral --,..--------~ Pariet al pleura,
tendo n
diaphrag mat ic part
abdominis and abdomina l oblique
mu scles. The inferior edg e of th e
Diaph ragm
posterior rectus sheat h is called th e

Cost al part
- - -
arcuate lin e. of diaph ragm
Linea alba
Fig. 11.5 Abdominal wall and Transversalis
rectus sheath fascia
Plane of
section in B
Posterior - - -----iN
rect us sheat h
Transversus - -----""
abdom inis
Arcuate line - - - --;
Plane of _ _ ---';;~
sect ion in C
N-'i."L - - - - - Iliacus
Rect us -----~~~
abd om ini s
A Posterior (in terna l) view of t he

ante rio r abdom inal wall.
Membranou s layer.
Rect us
superficial fascia
sheat h (ant erior layer) Linea alba
Ext ernal ob lique
apon eurosis
Extern al
obliq ue
Internal Parieta l
Rect us sheat h
ob lique perit oneum
(post erior layer)
Transversus Internal
abdo m inis obliqu e
B Superior to Transversus
aponeurosis apon eurosis
arcuate line. abdo m inis
Int ernal
oblique apon eurosis
Rect us sheat h Superf icial
(ant erior layer) Linea alba abdom inal fascia
Pariet al
perito neum
C Inferio r to
arcuate line.
134
Fig. 11.6 Abdominal wall:
Internal surface anatomy Arcuate
-
):
0
Co ro nal sect io n, po st eri or v iew. Th e three Umbilical
line
folds
§
fo ssae of th e ante rio r abd o m inal wa ll (circled) ~ A~ ~
3
are sit es o f potenti al herni ati on. Transversus :i'
Transversalis
abdominis Medial Lateral
-
Q
fascia
Parietal
peritoneum
h;:¢,cT~-- Femoral n.
• = Lateral ing ui nal fossa Psoas major }
(deep ingu inal ring) Interfoveolar _ " /lU V •• ~L-. Iliacus Iliopsoas
ligament ----":~~~~~:a
• = Medial inguinal fossa
(Hesselbach's triang le) Femoral a. and v.
• = Femoral ri ng
Ductus
• = Supravesical fossa
Obturato r
deferens
a., v., and n.
~ Clinical
Inguin al and femoral hern ias

Indirect inguinal herniasoccur in younger malesand may be congenital or
acquired and more common in females.
acquired; direct inguinal hernias are alwaysacquired. Femoral herniasare
Deep
inguinal
ring
- -- - External oblique
Inferior --"y~---- aponeurosis
Inguinal I.
Superficial
epigastric
a. and v. Location of
Inguinal
inguinal ring Hesselbach's
canal
Peritoneum t riangle
of hernial sac _____ Transversalis
Femoral fascia
a. and vv. Transversalis -r-.- - Peritoneum
fascia ( ~ internal Cremasteric -+--_~----<
fascia of hernial sac

spermatic fascia)
Sartoriusand ~ _ - - -- Cremaster muscle
~t""lF--- Cremaster andspermatic cord
pectineusunder
muscle and fascialata
spermatic cord
A Indirect inguinal hernia. B Direct inguinal hernia.
Inguinal I.
Deepinguinal lymph nodes ~ Superficial inguinalring
Femoral a. and v. - - - ----'-<U ·,. ,~~,.---- Uterine round I.
:----'---- - LacunarI.
Peritoneumof hernial sac --~---.----'--!f-+ p~-- Saphenoushiatus
Transversalisfascia ---=-----l '-~~~'t:.
Fascia lata - - - - I r'-'i_~+---- Long saphenousv.
C Femoral hernia.
135
Perineal Region
Fig. 11.7 Perineum and pelvicfloor: Female

Lithotomy positi on. caudal (inferior) view . Seep. 192
for the ext ernal genita lia.
Labium Prepu ce Mon s

major of clit ori s pubi s
Glans clito ris
Inferior Ext ernal urethral

pub ic ramu s orif ice
Ischial ram us Labium min or
Anterior inferior ~ ~
iliac spine ~ Vagina
(vaginal orifice)
---
Anterio rsu perio r - - - --
~
iliac spine Poste rio r labial
com m issure
(~~=:=:;;=:~=====::'l='
Urog enita l }
trian gle Perineal
region
Anal t riangle
Perineal
raphe
Ischial
spine
Anus
Coccyx
A Perineal region . Sacrum
Bulbospo ngios us
Superficia l Ischiocavernosus
perineal
(Colles' ) fascia
Perineal mem brane
Perin eal bod y --------:?iC=----;_~ ~~

Superficial t ransverse
Ischial
---------""-:;~ perineal
t uberosit y
Obt urat or int ernu s

Obturator
_---~-----7.~~1
fascia
Glute us maximu s
Inferior pelvic
diaphrag mat ic fascia

Levat or ani
Anococcygeal
ligam ent
Ext ernal anal
B Muscles of the pelvic floor. Coccyx Anal clef t sphincte r
136
~ The bilateral boundaries of t he perin eum in bot h sexes are th e tu berou s ligam ent , and th e coccyx. The gr een arrows indicate th e ante
~ pubic sym physis, ischiopubic ram us, ischial t uberosity, sacro- rior recess of t he ischioanal fossa, superior t o th e urog enit al mu scles.
Fig. 11.8 Perineum and pelvic floor: Male

Lithot omy positi on, caudal (inferior) view . See p. 196
......:t:
for t he genitalia.
O'"
go
Superior Scrot um Penis
pubi c ramus
3
S'
Glans penis
-
Q
Inferior
pubi c ram us
Ischial ram us
Ante rior inferior ---........

r.:=5!5:~~e"-------------- Perineal raphe
iliac spine _____________
Anter ior superior - - - --

iliac spine ~
~-----.:---.:::,------------- Anus
Acetabulum
Ischial
.- =-- - - - ---,-,,,.-,---- - - - ---,,-,;-- - - - Coccyx
t uberosit y
Ischial
spi ne
A Perin eal regi on . Sacrum
Bulb ospongi osus
Ischiocavernosus
Superficial
perineal
(Colles') fascia
Perineal mem brane
Ischial ------.,..,-"'!!!!!~i;;;;,--.!:i!!:
t ubero sit y !!..,...,----:-;-""'~t-;:-------- Superficial tr ansverse
perineal
Obt urator ---~lliii:=

F.::- - - ----;;::-- - - - Obturator int ernus
fascia
Glut eus maximu s
Inferior pelvic
diaphragm at ic fascia
Levat or ani
Anococcygeal Ext ernal anal

B Muscles of th e pelvic floor. ligam ent sphincter
137
Abdominal Wall Muscle Facts
Fig. 11.9 Anterior muscles Fig. 11.10 Anterolateral muscles Fig. 11.11 Posterior muscles
Anterior view. Anterio r view . Ante rio r view. The psoas major and ilia
cus are togeth er known as th e iliopsoas.
A Externa l B Interna l C Transversus

ob lique . obliqu e. abdomini s.
Abdominal wall muscles

Mu scl e Or igi n Inser tion Innervation Action
Anterior abdominal wall muscl es

Pubis (between pubic tubercle and Cartilages of 5th to 7th ribs, Interco stal nn. Flexest runk , compresses abdomen, stabi lizes
<D Rectu s abdom ini s xiphoid process of sternum (T5 T12) pelvis
Pubis (anterior to rectus Linea alba (run s w ithin the rectus Subcostal n. (12th
a> Pyramidalis abdominis) sheat h) int ercost al n.)
Tenses linea alba
Anterolateral abdominal wall muscles
Linea alba, pubic tubercl e, Intercost al nn.

Q) External obliq ue 5th to 12th ribs (outer surface) Unilateral: Bends t runk to same side, rota tes
anterior iliac crest (n -T12)
tru nk to opposite side
Thoracolumba r fascia (deep
10t h to 12th ribs (lower border s),
layer), iliac crest (intermed iate
o Internal oblique line), anter ior superior iliac spine,
linea alba (anterior and posterior Bilateral: Flexes trunk, compressesabdomen ,
layers) stabilizes pelvis
iliopsoas fascia Inter costal
nn. (T?- T12),
7th to 12th costal cart ilages (inner ilio hypogastric n.,
surfaces), thoracolumba r fascia ilioinguinal n. Un ilateral: Rotates trunk to same side
® Transversus
(deep layer), iliac crest , anterior Linea alba, pubic crest
abdomi nis
superior iliac spine (inner lip), Bilateral: Compre ssesabdomen
iliopsoas fascia
Posterior abdominal wall muscles
T12- L4 vertebral bodies and Hip joi nt: Flexion and external rotation
Superficial Direct branches
® Psoas associated int ervertebral disks Lumb ar spine (wit h femu r fixed):
layer from lumbar
majo r (lateral surfaces) Femur (lesser trochanter) , joint Unilateral: Cont ract ion bends t runk laterally
insert ion as iliopsoa s muscle plexus (L2-L4)
Deep layer L1- L5 (costal processes)
Bilateral: Contraction raises trunk from supine
(j) Iliacus Iliac fossa Femoral n. (L2-L4) positio n
Unilateral: Bends t runk to same side
® Quadrat us Iliac crest and ilio lumbar ligament 12th rib, L1-L4 vertebrae T12, L1-L4
lum borum (not show n) (tran sverse processes) spinal nn. Bilateral: Bearing down and expi rat io n,
stabil izes 12th rib
l38
.J ~~-=~~~- 5t h rib
....
....
Xiphoid ~"='--..I~ )::.
process 0
Q.
External o
obliq ue 3
5'
Linea alba External
oblique
aponeurosis

Q
Umbil ical --=--"~

Fig. 11.12 Anterior and posterior ring
abdominal wall muscles Outer li p of
A nt erior vi ew. iliac crest
Anterio r superior
iliac spine
..... I~r~!!\---- I n g u i n a l
Superficial ,T. ~ lig ament
5t h rib inguinal
ring
B External o b li q ue.
l;;;;;;l1oiI~r.r-- Xip hoid
proce ss
Linea
Xiphoid -.L...---olIlH
alba
process
10t h rib
Quadratus --~
lurnborurn Linea - - ---+-.:.. - i= H-- Internal oblique
alba aponeurosis
Psoas major --~~!-'-"'J~~

Interna l ob lique
Iliac crest - - -----:;,.. Iliac fossa
Iliac crest ,
intermediate line
Iliacus --+~~ Rect us
abdo mini s Anterior superior
iliac spine
Inguinal ligament
7-- - Inguinal
ligam ent
Pubic --p!;j~J::?'lJt'-';
sym physis
Iliopsoas -------f~~
C Int ern al ob liqu e.
Pubic ----,r--=--+--~
tu bercle
Ste rnum - - --d.

Lesser --+------iil~
tr ochanter
Pyrami dalis
Pubic Xiphoid - --=_ H '
symphysis process
A A nte rior and pos terio r mu scle s.
Linea alba --4~
Transversus
Posterior --~~
abdomi nis
rect us
--;B_- - Aponeurosis of
sheat h
t ransversus abdom inis
Arcuate lin e ---,J-l.~ Inner lip of iliac crest
Anterior superior
Ante rior -----.lI~!-_ _________ iliac spine
rect us sheat h Inguinal ligament
Pubic -+-~(.J .~
symphysis
D Tra n sver su s abd omini s.

Pelvic Floor Muscle Facts
Fig. 11.13 Muscles of

the pelvic floor
Superior view . lIio coccygeus
Obt urato r --~"""'-~

int ernu s
Anococ cygeal
---+~ Coccygeus
ligame nt
~---,---------'iMf- Piriform is
A Levator ani. B Outer layer

o f th e p elv ic floo r.
Muscles of the pelvic floor

M uscle Origin Insertio n Innervation Action
Muscles of the pelvicdiaphragm

Superior pubic ramu s (both
CD Puborectalis sides of pub ic
Anococcygeal ligam ent
Direct branches of
Pubi s (lateral to origin of
Levator ani @ Pubococcygeus sacral plexus (54). Pelvic diap hrag m: Support s pelvic viscera
puborecta lis) Anococcygeal ligam ent . inferior anal n.
Internal obturator fascia of coccyx
@ lIioco ccygeus
levator ani (te ndi nous arch)
Direct branches from

Coccygeus Sacrum (inferio r end) Ischial spine Supports pelvic viscera. flexes coccyx
sacral plexus (54-55)
Musclesof the pelvicwall (parietal muscles)

Femur (apex of gr eater Direct branches from Hip j oint: External rotation. stabilization.
Piriform is' Sacrum (pelvic surface)
trochant er) sacral plexus (51-52) and abduction of flexed hip
Obturator membrane and bony Femur (greater trochanter. Direct branches from Hip joint: Externa l rotation and abduction
Obturato r intern us'
bounda ries (inner surfa ce) medial surface) sacral plexus (L5-51) of flexed hip
Sphincter anderector muscles
Encircles anus (runs posteriorly from perineal body to
@ External anal sphincter Closes anus
anococc ygealligament)
® Exte rnal ureth ral sphincter Encircles ureth ra (divi sion of deep tra nsverse perineal muscle) Closes uret hra
Pudendal n. (52-54) Females: Compresses great er vest ibular

Runs ant eriorly from perineal body to cli tori s (fema les) or penile
® Bulbospongiosus raphe (mal es)
gland
Males: Assists in erection
Maintains erect ion by squeezing blood
Q) Ischiocavernosus Ischial ramu s Crus of clitoris or peni s
into corpu s caverno sum of clitoris or penis
' The piriformis and obt urator internus are considered muscle s of the hip (see p. 374 ).
The femal e and ma le ext ernal genita lia are shown on pp. 194. 203.
Fig. 11.14 Sphincter and erector

muscles of the pelvicfloor
Inferio r vi ew . See pp. 194. 20 3 .
Fig. 11.15 Pelvic floor Levator hiatu s Prerect al fib ers
Female pelvis. Obt urat or canal Pubo recta lis
Pub ococcygeus
1 Le~a to r
Obt urator fascia
(ob t urato r internu s m uscle) lIiococcygeus
am
....
....
::t:.
e-
Ischial spine g..
3
Tendinous arch _ _J-/lr;:-~-- :i'
of levator ani
_~-co~~---
'--- - - ---\---4.------ Coccyge us
:..-=--- - - --=-------\..------ Piriform is ~
Q
-
Anococcygea l
raphe
A Superior view.
Pubic -----.~----.!L
sym physis Prerecta l fibers
Pubic arcuat e -------=:..--~_.liiiil:l:::.-,. Obtu rat or
ligam ent internu s
Levato r Pubo
hiat us rectal is
Acet abulum Pubo Levato r
coccyg eus ani
Ischial
llio
t ube rosity
coccygeus
Piriform is
B Inferior view.
Ant erior sacroiliac II.
Arcuate line Piri for m is

cr~c~h~ Coccyge us
Obt urator
int ern us fascia Ischial spine
Posterior --- Tendi no us arch ----->"'!--,jlll;-, ~--

superior of levato r ani
iliac spine
Pubic sym physis Anococcygeall.
lIioco ccygeus }
Pubo coccygeus Levator
I
Pirifo rm is --If----c-. .C Deep t ransverse Puborect alis ani
Coccygeus perineal
Sacrospinous I. C Medial view of right hemipelvis.

Pubic tub ercle
Sacrotub ero us I.
Coccyx "''!!:~''----- Obt urator

foramen
Ischial spine
Levat or ani
D Right lateral view.
1'4~
Divisions of the Abdominopelvic Cavity
Fig. 12.1 Organ layers and quadrants

A nte rior view . Th e orga ns of th e abdo men and pe lvis can be cla ssi
fi ed by layer. by qu adrant (u sing th e umbi lic us at L4 ) , by level ( up pe r
and low er ab domen, and pelv is), or with respect to th e prese nce of a
m esenter y (Tab le 12 .1) .
Liver Suprarenal
glands
-'.;~r--- Stomach
!!-I~fT,.'~c---7-- Kidneys
~~~""i"';i~t=L-- Transverse
colo n 10+- - - - Abdomi nal
aorta
'--""--- - Ureters
Small int estin e

(j ejunum and ileum )
Gallbladder \
Urinary bladder Fig. 12.2 Peritoneum and mesentery
C Po ster io r lay er.

A Anterior layer.
Duodenum
l -i- - - Descending
colon
Ascending colon w it h cecum
and vermiform appendix
Int raperitoneal
B Midd le lay er. organ
Organs of the abdomen and pelvis

l ocation Organs
: Int raperitoneal organs: These organs have a mesentery and are completely covered by t he periton eum.
• Sto mach • Gallbladder

• Small intestin e (jej unum, ileum. some of • Cecum w it h verm iform appendix (porti ons of variable
: Abdom inal peritoneal cavity t he superio r part of the duodenum ) size may be retrop erit oneal)
• Spleen • Large int estin e (tran sverse and sigmoi d colons)
• Liver
...... .. .
. Pelvic peritoneal cavity • Uter us (fundus and body) • Ovaries • Uterine tu bes
: Extraperitoneal organs: These organs either have no mesentery or lost it during developm ent .
: Primarily • Kidneys • Suprarenal glands • Uterine cervix

.......................................... ........ ................................... ....... ........................................... ...............................................
: Ret roperitoneal • Duodenum (descending, horizonta l, and ascending) • Ascending and descending colon
: Secondarily
• Pa ncreas • Rectum (upper 2/3)
l l .
• Urinary bladder • Sem inal vesicle • Vagina
: Infraperitoneal/subperitoneal • Dist al ureters • Uterine cervix • Rectum (lower 1/3)
• Prostate
142
Fig. 12.3 Peritoneal relationships
Midsagittal section t hrou g h male pelvis.
viewed from the left side.
~'I----,I"-7:---i- Lesse r
Parietal ome nt um
peritoneum (o me nta l
bursa)
r': 1~-+-----o-- Parietal

Greater -~"tl l!l
peritoneum
omentum
Visceral
Esophagus
perito neum
Liver. bare area
Omenta l foramen
Hepatogastric
ligam ent
Celiac trunk
Omenta l bu rsa
A Peritoneal cavity. The peritoneum is :':::;"-::-I\,t;~ti~--- Splenic a. and v.
show n in red. Pancreas
Lef t renaI a.
Stomach ---';--'-"-'+lL-- - - Super ior

mesenteric a.
Midd le colic a. - - --'--!.L
Left renaI v.
Transverse - - ---!'--'!l!1L
m esocolon Pancreas.
uncinate process
Abdomina l aorta
Transverse - - --T-;HfI Duodenum .

colon horizontal part
Greater omentu m - - ---f;:t,, Mesentery
Jejun um --~HH
and ileum L5 vertebra
Rectus abdom inis - - ---+ Left common iliac

a. and v.
Rectovesical
Urinary bladder ---+---'-';~~.-"
pouc h
Vas defe rens. ----T----'-"k-->~...,..~ Rectum

ampu lla
Prostate
' - - - - - Deep transverse

Bulbospongiosus -------, perineal
Scrotum,
septu m
B Organs of th e abdomen and pelvis.
~ Clinical
Acute abdominal pain

Acute abdo minal pain ("acute abdomen") may be so severe that t he as appendicitis, perforation du e to a gast ric ulcer (see p. 159) , or organ
abdo mina l wall becomes extremely sensitive to to uch ("g uardi ng") and blockage by a stone , t umor, etc. In women, gyneco logica l processes or ectopic
the intest ines stop functio ning . Causes include organ inf lammation such preg nancies may produce severeabdomi nal pain .
143
Peritoneal Cavity & Greater Sac
~ The larg est part of th e peri t on eal cavity is th e great er sac. Th e anteri or su rface of t he t ran sver se co lo n . Th e t ransver se co lo n di vid es th e
~ g reat er o me nt u m is an ap ron -li ke fold of per it on eum suspend ed periton eal cav ity into a su p raco lic co m part ment (liv er. ga llbladd er, and
fr om th e g rea te r curva t u re of th e st o m ac h and cove ring th e st o mac h) and an infracolic co mpart ment (intestin es).
Fig. 12.4 Dissection of the peritoneal

Falciform
cavity
ligament of liver Anter ior v iew .
~--------+-- Liver, left lobe
Ligamentum
teres of liver
jii¥'-~7-- Stomach
Liver, right lobe ---.:~~--..-,;.-='C::
.------+- Left colic flexure
Gallbladder - -!'or- ....,.;.
r--;,-;;- - Transverse
colon
Ascending - - _ I .'iHlI-- - Great er oment um

colon
Taeniae coli ----T.\~ 7--\- - Transversus abdomin is,

int ernal and external
oblique muscles
Ileum ---l------~~
j--+--~~.----t-- Lateral umbil ical fold

Rect us -+ - - - - - - +__ (wit h inferior epigast ric
abdomi nis a. and v.)
muscle hH--'T-L- - - - ' - --t- Medial umb ilical fold
(with obliterated
umb ilical a.)
Arcuate Median umbilical fold Greater oment um Epiplo ic Taeniae Transverse

line (with obliterated urachus)
("F1,,"d ~'YJ
appendi ces coli colon
A Greater sac. Retracted: Abd omin al w all. I
Ligamentum - .,.__.,..
teres of liver
Transverse ---+-~I-'rlil
c,_ ;~+- Pa rietal
mesocolon
peritoneum
with middle
colic a. and v.
Jejunum
(covered by
visceral perit oneum)
Ascending - - -+-;:'=-.
colon
Taeniae coli ----~~ .ii>--+ - - Transversusabdo mi nis,

internal and external
oblique muscles
Ileum --+---~
,'!-4- ---"-'lk-- -\-- La teral umb ilical fold

Rectus - -+- - - - - - - -j! (wit h inferior epigastr ic
abdominis a. and v.)
muscle 11111:. f--l-j-T."""'-----'-----,l--'lll---- MediaI um bilicaI foId
(wit h obli t erated
umbilical a.)
B Inf raco lic co m pa rt me nt. Reflected: Great er Arcuate Median umb ilical fold
144 o ment u m and tran svers e co lo n . line (with oblit erated urachus)
Greate r oment um
(reflect ed superiorly)
~=o;;;=":~~~-"~f~~~--___;r-- Transverse
colon
Ligam entum --+-~
teres of liver
Epiploic >--1-- - Parietal
appendic es perit oneum
Transverse ------\:-----1~.--'J - -- _ 1'-- - - Left colic
mesocolon fl exure
.-----~~---- Jejunum
- - - - - Descending
Right - - -- :----::'ii colon
colic flexure
:'+-:;--- - - - Transversus abdornini s,

Mesentery (cut) - - - --;-- 4: int ernal and exte rnal
oblique muscles
Taeniae coli - - -- - - -';;.;.
--4i--~--- Sigmo id
Ascending colon -------~.r m esocolon
Ileum ----=------~"=
Cecum - - f- - - - - ----' f-1 ...- - - - --T- - - Sigmoid

colon
Rectum ------;'--------~17----~
.r .....-~.r---'l._--- _+- Lateral um bilical fold

(w it h inferior epigast ric
Rect us --+------------~ a. and v.)
abdo minis m uscle
Median - +- - - - - - - - - - - - -'---- - % -:----'d.; - j +--++- - - !'-- " ' - - ----':-- - !- - Medial umbilical fold
umb ilical fo ld (with oblit erated
(with obl it erated umb ilical a.)
urachus)
C Mesenteries. Reflected: Greater ome ntum and tra nsverse

colon . Removed: Int raperit oneal small inte stines.
145
lesser Sac
Fig. 12.5 Lesser sac (Omental bursa)

Ant erior view. The lesser sac (omenta l bur sa) is the portio n of the perito
neal cavit y locat ed behind th e lesser omentum and stomac h.
Gallbladder Liver, caudate lobe
Hepato du odenal Cardiac Vest ibule of Splenic recess of

ligament Liver, left lob e orifice Diaphr agm omen t al bur sa omenta l bursa
Liver, right lobe
\ Diaphragm, \ Inferior
hepatic surface vena cava
Pancreas Gastr oco lic ligament Duode num

(cut)
Greater Transverse Inferior recess of Hepatodu od enal

ome nt um mesocolon ome nt al bur sa ligam ent
A Boundaries of the lesser sac (omenta l bursa). B Posterior wall of t he lesser sac (omenta l bur sa).
Fig. 12.6 Location ofthe lesser sac

Liver
H-~f-- Lesser ome nt um
Lesser sac
Stomach - -1+-
Gastroco lic ligam ent
Transverse colon
Greater om ent um ~-l--- Mesentery

A Sagitta l secti on .
Liver Pancr eas Lesser sac Boundaries ofthe lessersac (omental bursa)
Direction Boundary Recess
Anterior Lesser om entum , gastrocolic ligament -
Inferior Transverse mesocolon Inferior recess
Superior Liver (with caudat e lobe) Superior recess
Pancreas, aort a (abdominal part), celiac
t runk , splenic a. and v., gast rosplenic
Posterior -
fo ld, left suprar enal gland, left kidn ey
(superior po le)
B Transverse
Right Liver, duodenal bu lb -
sect ion, inferior Inferior
view. Left Spleen, gastrospl enic ligament Splenic recess
vena cava
146
Fig. 72.7 Omental bursa in situ
Ant erior view. Divided: Gastrocolic ligam ent. Retracted: Liver.
Reflected: Stoma ch.
Sto mach.
greater curvat ure
Stomach.
posterior surface
Gastrosplenic lig ament
Lef t gastri c a.
Lef t sup rarenal

gland
Vestibule of
om ent al bur sa Lef t kidn ey.
supe rior pole
Ome nta l for am en
Com m on
hepati c a.
Duod enum ,
Pancreas
descend ing part
Transverse
Righ t kidn ey mesocolon
Middl e colic a.
Right colic fl exure and v.
Gast rocolic ligament
Ascending colon - - -H :!-' Transverse colon
Greater - - - - - :-f:-t,ch+ Descending colon

oment um
Boundaries of the ome ntal foramen

The commun ication betwe en the gr eater and lesser sacs is th e ome nta l
(epiploic) foram en (see arrow in Fig. 12.7).
. Direction Boundary
. Hepatoduodenalligament w it h th e portal v., proper hepatic a"
. Ant erior
, and bile duct
.. ... ... ... ......... ....... ............. .... ............ ............ .....
, Inferior , Duod enum (superior part)

.................................................................................................................................
~ Posterior : Inferior vena cava, diaphragm (right crus)
........ ....... ........ ....... ... ... ... ..... .. .... ..... ..... ..... .... ... .... ... ...
~ Superior ~ Liver (caudate lobe)
147
Mesenteries & Posterior Wall
Fig. 12.8 Me senteries and organ s of

the peritoneal cavity
Anterior view. Removed: St omach, jejunum,
and ileum . Reflected: Liver.
Ligame nt um Lesser om entum,
Liver, teres of liver hepatoqastrk Liver.
right lobe ligament left lobe
Cardiac
orifice
Superior }
Gallbladder bord er
Spleen
Gast ric
surface
Lesser oment um,
hepatoduod enal
ligament Yfrfi - - - Gastrosplenic ligamenl
Om enta l foramen
Hfi':r- - - - Pancreas
Duode num , fH1-7- - - - Transverse
superior part m esocolon , root
Sto mach, pyloric part Left colic flexure
Greater omentum Transverse colon
Right colic flexure Duod enojejunal

flexure
Transverse colon
Duodenum,
hor izont al part
Mesent ery - - - ---,7-' :-rr~---- Descending colon

(cut )
Taeniae coli - - - - - - ---;'i7

1+7 -'+ - - Transversus abdornini s,
int ernal and external
Ascending colon - - - - - - - -x'-:-\ oblique m uscles
Ileum ---+---------'~
;.w;=..- - - -.;::;r-- Sigmo id m esocolon
(cut)
Cecum ---f-------~k.i
Rectum - ----j- - - - - --'i01T-- ----'='
Lateral umb ilical fold

(with inferior epigastr ic
Rectu s abdo mi nis --T--------=-------l~ a. and v.)
Median --i-------------~~_;_;;~;__'i___'i\_';H~ HI ~ f____,H~c:f;_~,.L-------!..----_'f!__- Medial umbi lical fold

umbi lical fold (w it h oblite rated
(w it h ob lite rated Ydl um bili cal a.)
urachus)
148
Fig. 72.9 Posterior wall of the
peritoneal cavity
Parietal Diaphra gm , Hepatic Inferior Cardiac Anterio r vie w . Removed: All intrap eritonea l
perit oneum hepat ic surf ace vv. vena cava orifice o rgans. Revealed: St ru ct u res of th e retro p erito
neum (se e Tab le ' 2 .4 and p. , 80 ).
Right suprarenal
gland
Hepato duodenal
ligament (wi th portal
v.. proper hepat ic
a., and common !llI_ - - Splenic a. and v.
bile duct)
~---ii'!!t¥.~'----- Pancreas
Right kidney (body and t ail)
s u p ~~~ ~ ~~--- Left kidney
Duodenum
{ Descending - --'----"' II
Left colic a. and v.
part
Descending colon
Pancreas (head) - - - ---4-l...' (site of attac hme nt)
Horizontal Superior mesenteric

part a. and v.
Duodenum
Ascending Inferior mesenteric a.
part
Abdo mi nal aort a ----~

::>+H-- - - Transversus abdom inis,
internal and exte rnal
oblique muscles
Mesent eric roo t - -- ---i'--------H±
I~-#.--'L...!,-_ _ Paracolic gutter
Right com mo n iliac Parieta l

a. and v. peritoneum
Ascendi ng colon
~-"------'-'-.;..,.!>'_____,~~'i'_"'-------+--- Sigmo id
(sit e of attachm ent )
mesocolon
Mesoappendix ---+---------->1l~
"?-- - - - -..,;!-- - Left ureter
Right ureter ---!-----------'~....::!!loi:~1!!i!
~-------""!--- Ext ernal iliac a.
Rect um --~'-----------''!1f!!.'-------__.J,\'-----::.-~
. ~~,..--------'~----+-- Lateral umb ilical
fold (w ith inferior
epigast ric a.
Rectu s abdo mi nis _ _ +- ~_=_~_:_.,--.....J~
and v.)
Median --i---------,---.,.".--~~~.,J,i~::_':*'*'·f +-H~!----4-'--------.,--~=-------,:!--- Medial umbi lical

umbili cal fold fo ld (wit h
(with obliterated obliterated
urachu s) umbilical a.)
Structures of the retroperitoneum

See pp. 216. 228, 239 for neurovascular struct ures of the retroperitoneum .
Classificat ion Organs Vessels Nerves
Primari ly • Aort a (abdominal part) • Lum bar plexus branches

• Kidneys
retroperitoneal • Inferior vena cava and o Iliohyp ogastric n.
• Suprarenal glands
(Retroperitoneal when tributaries o Ilioinguinal n.
• Uret ers
formed) • Ascending lumbar vv. o Genitofe m oral n.
• Pancreas • Portal v. and tr ibutaries o Lateral fem oral cut aneous n.

Secondarily • Lumbar. sacral, and iliac n Femoral n.
• Duodenu m (descending and hori zonta l parts: some of ascending part)
I ell o per tt on eal
• Ascending and descending colon lym ph nodes o Obturator n.
(Mesentery lost during • Lumbar t run ks and • Sympat het ic trunk
• Cecum (portions; variable)
development) cisterna chyli • Auto nomic ganglia and plexuses
• Rectum (upp er 2/3)
149
Contents of the Pelvis
Fig. 12.10 Male pelvis Rig ht com m on Sigmo id

iliac a. and v. m esocolon
Taeniae coli
L5 verteb ra Sigmo id colon
Right vas
deferens
Rectovesical
po uch
Perito neal
covering
of rectum
Rect um ~lF-H-----''------ Visceral
pelvic fascia
Parietal on bladder
pelvic fascia
on rectum Superio r
pubic ramu s
Right
uret er Urinary bladd er
Levator ani Inferior pub ic

ram us
Right sem inal Prost ate

vesicle
A Parasagitta l section, viewed Externa l anal Perin eal Recto

fro m t he right side. sphincter body prost at ic fascia
Rect ovesical Urinar y Parietal

Rect um pouch bladder peritoneum
Rectove sical
sept um Pubic sym physis
Ret ropub ic space

Ampu lla of Suspensory
ductu s def erens ligam ent of penis
Prost ate Penil e fascia
Corpus caverno sum

Bulbo uret hral of penis
gland
Sphincte r uret hrae
Bulbo spo ng iosus
mu scle Corpus spo ngiosum
of penis
Scrotal sept um
B Midsagitta l sect ion, viewed

from t he right side.
150
Right common iliac Sigmo id Fig. 12.11 Female pelvis
a. and v. mesoco lon
Taeniae coli
L5 ver te bra Sigmo id colon
Proper ovarian
ligament
Uteru s
Rectouterine
po uch
Perit on eal
coveri ng
of rectum
Rectum Visceral
pelvic fascia
Visceral
on bladde r
pelvic fascia
on rect um Superior
pub ic ramu s
Right uret er
Urinary bladd er
Levator Inferio r
ani mu scle pubi c ramus
External Perineal Vagina

anal sphincte r bod y
A Parasagitta l sect ion. viewed

from the right side.
Lef t com mo n iliac Ovarian suspensory ligame nt

a. and v. (wit h ovarian a. and v.)
L5 verteb ra Right fall opi an

tube
Right uret er Right exte rnal

iliac a. and v.
Right ovary
Rect us abdo mi nis
Ovarian ligam ent
Uter ine fund us
Ute rine corpus
Round ligam ent
Rectoute rine of ut erus
pouch
Pari etal peritoneum
Rectum Vesicouterine
pouch
Uterine cerv ix
Urinary bladd er
Post erior
vaginal fo rnix Pubic
sym physis
Ante rior
vaginal forn ix Vagi na
Levator ani mu scle Crus of clitori s
Exte rnal anal Deep t ransverse

sphincte r perineal
Yoll
B Midsagitt al sect ion. viewed

from the right side.
151
Peritoneal Relationships
Fig. 72.72 Peritoneal relationships Broad ligament Rectouterine Utero sacral Ovarian suspensory
in the pelvis: Female of ute rus Rectum pouch fold ligament
Uterine
t ube
Left ovary
Sigmo id
Cecum - - ---:::= 00--
colon
Uter ine fundus -~~-----' -='--- Ovarian
ligament
Vesicouterine
po uch .--P'S''''-- - - - - Lateral umbilical
fold (with inferior
Transverse
epigastric a. and v.)
vesical fold
Urinary Rectus
bladder abdomin is
A Lesser pe lvis, anterosuperior view.
Median umbi lical Medial umbilicus fold
Retracted: Sma ll intestin e lo o ps and fold (with obliterated Supravesical (wit h obliterated
colon (port ions) . urachus) fossa umbilical a.)
Uterine fundus Rect um Ext ernal iliac a. and v.
Transverse
cervical
ligament
Levator ani
Superior and ----im:-~~' . ::
inferio r fascia
Ischioanal
of pelvic
fossa
diaph ragm
Perineal
membrane Sigm oid
Sphincter colon
Superficial Vesicouterine
urethr ae Vagina
perineal fascia pouch Uterus
B Muscles of t he pe lvic floo r. Coro na l Urinary bladder Rectouterine

pouch
sect io n, anterior view. Recto vaginal
sept um Ret roperiton eal
space
Rectu m
C V iscera l fasciae. M idsagitta l sec t io n,

vi ew ed from t he lef t side .
152
Fig. 12.13 Peritoneal relationships Rect ovesical Transverse
in the pelvis: Male Ileum Rectum pouch vesical fold
Cecum - -- --,
Pariet al
---~~
perito neum
Vas
def erens
Vermi form
append ix ~ Sigmoid
", ~ colon
Lateral ing uina l
fossa --e;;;;,.o'I~J..,;.'/,,'~!
: ~ Lat eral um bilical fold
(w ith inferior epigastric
Urinary bladder a. and v.)
A Lesser pelvis, anteros uperior view. Median umb ilical fold Medial umb ilicus fold
(with underlying Rectus (w it h unde rlying ob lit erated
Retracted: Small int est ine loops and
ob literated urachus) abdom inis um bilical a.)
colon (po rtions).
Urin ary bladd er Perito neum ,
parieta l layer
7':.,..*- - Vas
defere ns
Obt urato r Superior
internu s and inf erior
fascia
Levator ani
of pelvic
diaphragm
' '"'"'...,..-----;''~~~--- Sigmo id

mesocolon
Perineal Sigmo id
mem brane Bulb of pen is Crus of penis Urin ary colon
bladder
'-:;~~---=-----t--- Rectovesical
B Muscles of th e pelvic floo r, Coronal Rectove sical po uch
sect ion, anterior view. sept um
Retr operit o
Ret rop ubic
neal space
space
Perineal Rectum
body
C Visceral fasciae, Midsagittal sect ion,
viewed from th e left side,
153
Pelvis & Perineum
Fig. 12.14 Pelvis and urogenital triangle

Divisions of the pelvis and perineum
Coronal sect io n, anterior vi ew.
The levels of the pelvis are determined by bony landmarks (iliac crest and pelvis
inlet. see p. 126). The contents of the perineum are separat ed by the pelvic
diaphragm and two fascial layers.
Perit oneu m Uterus Vagina

• Iliac crest
• Ileum (coil s)
.... .. . . .. .... • . . . •• •... ••.. •. .. ..... . • •. •• ••. •..... .
• Cecum and appendix

.. ... . ... . . . . . . . . .. . .. .. .•. ... .. . .•
! False pelvis • Sigmoid colon "~~1f2-c..g~;- Pelvic

Obt urato r diaphragm
• Common and externa l iliac aa. and vv, internus
• lumbar plexus (branc hes)
Deep dl}f---#- - - - - Int ernal
Pelvic inlet transverse '/f§~~~7 pudendal
• Dista l uret ers perin eal a. and v..
(with fascia) pud endal n.
• Pelvi s • Urinary bladde r
Inferior Perineal
....•.................................................................................
Rectum - . pubic mem brane
•.. ~.: . ~~g i na : u.t~~us :. ute~ i ~.~ . tubes . a n? OVar ies ramu s
, Pelv is proper Ischi ocaver- Bulbo- Vulva Superfi cial Skin
i 0 : Ductu s deferens. sem inal vesicle. and
nosus spong iosus perin eal
pro state (Colles' ) fascia
.............. . .... . ..............
• Internal iliac a. and v. and branches
A Femal e.
•. .~ . S.a~~a. 1 pl~~.U. S. H H H 'H'HHH HH H'HH H HHH'

• Inferior hypogastric plexus
• Pelvic d iap h ra g m ( Lev ator an i with superficial and inferior pelvic

, diap hragmatic f ascia )
Urinary
• Sphincter ureth rae and deep tr ansverse
Perit oneum bladder Prost at e
perin eal mm.
..................................... . .
• Urethra (membranous)
• Vagina
i Deep pouch • Rectum
. ... .. ..... ... ..... .............. ...... .... ............ ....... ... ...... . Superficial
• Bulbou rethra l gland pelvic

diaphr ag
• Ischioanal fossa mat ic
Obt urato r - - - \'r
• Interna l pudendal a. and v., pude ndal n. and int ernu s
fascia
branche s
l evat or ani
• Perineum • Per ineal m embra n e
• Ischiocavernosus, bulbocavernosus, and Perin eal -----FF.it:~;;;;=::=:~~ k~~==::;:~5 Inferior
superficial transve rse perineal mm. me m brane
pelvic
Superficial --'>~ diaph rag
• Uret hra (penile)
• Superficial perineal mati c
• pouch H ~ ~ l itoris and penis ' HHHH H ' (Colles') fascia
fascia
• Interna l pude ndal a. and v., pudenda l n. and
bran ches
Ischiocaver- Urethra. Bulb of Bulbo
• Superficial perineal (Colles') fascia no sus memb rano us peni s spongiosus
, Subcutaneou s part
• Fat
i perineal space
B Mal e.
Sk in
o Peritoneal cavity
Sub peritonea l space
o lschioanal fossa
Visceral pelvic fascia
Parieta l pelvic fascia
154
Fig. 12.15 Pelvis: Coronal
section Suspensory ligamen t Uteri ne External iliac
ofthe ovary Rectum fund us a. and v.
Ant erior view.
Iliacus
Ovary
Ute rine tube Uterin e round
ligam ent
Uter ine cervix

Transverse cerv ical
ligam ent Paravaginal
Obt urato r tissue (fascia)
int ernu s Vagina
Ischioanal Pudendal
fossa (Alcock's) canal
Inferior pubic
Levat or ani ramus
Deep Crus of clito ris (with

t ransverse ischiocaverno sus)
perineal
Superfi cial Vestibul e Vestibu lar bulb (with

A Female. perin eal fascia of vagina bu lbospon giosus)
Uri nary Internal urethra l Urete ral Paravesical

bladd er orifice ost ium fossa
Glut eus
m inim us
,:V~'i'-2H++,.mF--- Head of femu r
Venou s
Obt urat or
plexus
internus
Sem inal
Prost at e
colliculus
Ureth ra,
membranou s Obt urator
part exte rnus
Deep
Quadratus
tr ansverse
femoris
perineal
Inferior
pub ic ramus
Adducto r --*\:.r~ Crus of penis

mu scles (wi th ischio
cavernosus)
Superficial Bulb of penis, Subcut aneo us

perin eal corpus spon giosum perineal space
B M al e. (Colles' ) fascia (wit h bu lbospongiosus)
155
Transverse Sections
Fig. 12.16 Abdomen: Transverse section

Inferior view.
Int ernal
thoracic Transverse Greater
Common a. and v. Duod enu m colon omentum
bile du ct
Superior Pyloric part

m esent eric
a. and v.
Ante rior
Gallb ladder Sto mach
wall
Liver.
right lobe
Posterio r
Inferior wa ll
vena cava
Intercostal
a.• v.. and n. Ome nt al
bursa
Interm ediate
lum bar Splenic v.
lymph nod es
Rig ht suprarenal Pancreas

gland
Spleen
Kidney
(wi t h right
renal a.)
Transverse }
colon Left
col ic
flexure
Descend ing colon
Abdom inal
aorta Spinal cord Perirenal Left kidney
(in vert ebral canal) fat capsule
Vertebral
veno us plexus
156
Urinary Fig. 12.17 Pelvis:
Fem oral a., v.. and n. Pubis bladd er Pect ineus Transverse section
In ferio r v iew.
I~" ';;"--- Iliop soas
Obturator canal
(in let)
Head of femur
Ligam ent um te res

of fem oral head
Right uret er
=;-.,.--';~--..''"-77;i;--''--~~- Obtu rator
(cut obli qu ely)
intern us
Uterine cerv ix Uterovagin al

veno us plexus
Sciat ic n.
Ischial spine
Rectum
Glute us
maximu s
A Femal e.
Sacrospinal Coccyx Rectouterin e Uterosacral

ligam ent pou ch ligament
Urinar y
Rect us abdo m inis bladder
Ductu s
deferens
Fem or al a., v., and n.
Iliop soas
Head of fem ur
Obturator a., v., and n. ~~~~~' Inferior vesical a.
Vesicopro static
Sem inal vesicle venous plexus
Recto vesical Inferior

sept um hyp ogast ric plexus
Rectum Obtu rato r

intern us
Sciati c n. Ischial spine
Glut eus maximus Sacrospinou s

ligame nt
Coccyx
B Ma le .
157
Stomach
Fig. 13.1 Stomach: Location Fig. 13.2 Surfaces of the stomach
RUQ LUQ Esophagus - -

Lesser omentum Sto mach
(hepatogastric
ligament)
Hepat ic Phrenic
Pancreas ---/.lIll---------=rt;;,=~~"l'--4"+-_ Omenta l bur sa surface surface
Liver Spleen
Trans
pyloric
- - Epigastric
plane
surface
Inferior Abdo minal Left

A Ant erior view.
vena cava aorta kidney
A Anterior view. B Transverse sect ion, inferior view.

Splenic surface Phrenic
surface
Fig. 13.3 Stomach Renal surface -~-- Suprarenal
Anterior view. surface
Pancreat ic -~;--
surface
Colom esocolic ----''- Hepat ic

surface surface
B Posterior view.
Greater
curvature
Duodenum
Esophagus, -
advent it ia
Muscular coat
of esophagus,
longitudinal layer
A Ant erio r wall.
Esophagu s
Duod enum ,
superior part
Oute r longi- )
tudi nal layer
Middl . I Muscularis
I e circu ar t
ex rema
Iayer
Inner oblique fibers
Body with
longit udinal
rugal folds
B Muscular layers, Removed: Serosa and sub

serosa. Windowed: Muscular coat.
158 C Interior. Removed: Ant erior wal l.

~ Th e sto mach is fo u nd in t he right and left u p p er q uad ra nts. It Fig, 13.4 Stomach in situ
-.iiiII is intraper iton eal, its m esenteri es b ein g t he lesser and greater An t er io r vi ew of t he o pe ne d upper abdo men .
o menta . A rr ow ind icates th e o ment al foram en .
....
Ligam entum
Fa lciform ligam ent
of liver
Liver.
left lobe Esophagus
-
w
::l
teres of liver
~
o-
Liver. Q
rig ht lobe
~
Q
~--cf."-rii-- Fundus ~
Gallb ladder
~~-- Cardia
Hepato
esophageal
ligam ent
St omach
(body)
Lesser Spleen
omentu m
Lesser
Hepato curvat ure
gastric
ligam ent
Right kid ney Great er
curvat ure
Right coli c - ------\B"<&

fl exure
~:-wKt---- Descending
colon
Ascending - - -----1W Hh ' l lcw,M-- - - Transversus

colon abdo minis,
internal and
exte rnal
ob lique
muscles
Duodenum Pyloric canal Pyloric ant rum Greater omentum
~ Clinical
Gastritis and gast ric ulcers

Gastr it is and gastri c ulcers. t he t wo most common diseases of t he sto mach. dark brow n material in vomit. Gastritis is limited to t he inner surface of th e
are associated with increased acid production and are caused by alcohol. stomach. while gast ric ulcers exte nd int o th e st omach wall. The gastric ulcer in
drugs such as aspirin. and the bacte rium Helicobacterpylori. Symptoms include C is covered with fibr in and shows hemati n spots.
lessened appeti te. pain. and even bleeding. whic h manifests as black stool or
Gastric
ulcer
Gastric
Rugal antrum
folds
A Rociy o f normal <to rn ar h . R No rm a l pvlorir ant r u m . C Gastr ic ulcer.
159
Duodenum
~ The small int est ine consists of th e du odenum, jejunum, and

~ ileum (see p. 162). The du od enum is prim arily ret roperit oneal
and divid ed into four part s: superio r, descending , hor izontal , and
ascending .
Fig. 13.5 Duodenum: Location Fig. 13.6 Parts of the duodenum

Ant erior view. Ant erior view.
Inferior
RUQ LUQ
Duode nal vena cava
bulb Celiac trunk
i
Superio r part Suspensory ligam ent
~
of duodenum
Superior ~~~;;::::- Superior mesent eric a.

Duodeno duodenal flexure
Duodenum ----~~ ~1 X jej unal
fl exure Descendi ng part ~
Jejunum
and ileum
Inferior ~Jeju nu m
duo denal flexure
Ascending part
Hori zontal part

Fig. 13.7 Duodenum
Ant erior view with the ant erior wa ll ope ned.
Py lori c
Comm on - - - - - f orifice
bile duct
Duodenum
(superior part)
Circular fold s
(valves of Kerckri ng)
Accessor y
pancreatic duct ------------- - Pancreas
Minor
duodenal papill a
Duodenum -----+~
(descendi ng part ) - -- -- ----1,----- - - Duodenojejunal
flexure
Main pancreati c
duct
Major Superio r
duod enal papill a mesenteric a. and v.
Longitudinal
layer
Muscularis {
exte rna Circular Jejunum
layer
Submucosa Duod enum
(hori zont al part )
160
Fig. 13.8 Duodenum in situ
An t eri or v iew. Removed: Sto mach , liver, sma ll intest ine, an d larg e por
tive ti ssu e.
Thinned: Retroper iton eal f at and co n nec
t ion s of t he t ran sver se co lo n .
-
w
5"
Pariet al Inferior Common Phrenicosplenic ~
perito neum vena cava Hepat ic vv. hepati c a. Esophagu s ligam ent :3Q
Diaph ragm Spleen
-
Hepat ic surface
Left gastr ic a.
of diaph ragm
Hepat odu od enal

ligam ent
(w it h porta l v.)
Right suprarenal
gland
Pancreas Splenic a.
Right kidney
Left colic flexure

Duodenum
(superior part )
Left kidney
Superior duode nal

recess
Right colic flexure
Jej unu m
Transverse colon
Superior me senteric
a. and v.
Ascending colon
Descending colon
Inferior duodenal
recess
Duod enum Righ t Root of Duodenum Duod enum Left colic

(descending part ) col ic a. me sente ry (horizo nta l part) (ascend ing part) a. and v.
~ Clinical
Endoscopy of the papillary region

Two im po rta nt duct s end in the papill ary region of t he duode num: the (ERCP), in which dye is injecte d endoscopically int o t he duodenal papill a.
com mo n bile du ct and t he pancreati c duct (see Fig. 13.7). These duct s may be Duodenal divert icul a (generally harm less out po uchings) may com plicate t he
exami ned by X-ray t hrou gh endoscopic ret rograde cholangiopa ncreato gra phy procedur e.
Stomach
Circular
folds
Papillary
region Duodenal
diverti cula
A Endoscopic
appearance. B Radiog raph.
161
Jejunum & Ileum
Fig. 13.9 Jejunum and ileum: Location Fig. 13.10 Wall structure of the small intestine
Ant erior view. The int raperitoneal jejunum and ileum are enclosed Macroscopic view s of th e longit udinally opened small inte stine.
by t he mesentery proper.
RUQ LUQ
~~~~~r----
r Duod eno
jejunal flexure
Ascending
0~~~~~~- Jejunum
and ileum
colon
RLQ LLQ
Rectum
A Jej unum . B Ileum .
Fig. 13.11 Jejunum and ileum in situ Greater ome ntu m Epiploic Taeniae Transverse
Ant erior view. Reflected: Transverse colon. (reflect ed superior ly) appendi ces coli colon
A
Ligamentum
t eres of liver
Transverse
m esocol on (with
middle colic
a. and v.)
~:!!'"4-- Jej unum
Ascending
colon
Taeniae coli .,......., "">---':- - Transversus abdomi nis,

.. inte rnal and external
Cecum --~---~~ oblique m uscles
Ileum - - -y - - - - -"!IiiIf=........
!.- - - - ----,-'\:-- - 4,--- Lat eral umbi lical

fo ld (with inferior
Rectu s --+---------~ epiga stri c a. and v.)
abdom inis
f-+:-.f--~-------__t- Medial umbilical fold
(w it h obliterat ed
umbi lical a.)
Arcuat e Median umbi lical fo ld

162 line (with oblit erat ed urachus)
~ Clinical
Crohn's disease
Crohn's disease, a chron ic inf lammat ion of the digestive t ract, occurs most
often in the termina l ileum (30%of cases). Patie nts are generally youngand
suffer from abdominal pain, nausea,elevated body temperature, and diarrhea .
Init ially, t hese symptoms can be confused w ith append icit is. Comp licatio ns of
Crohn's diseaseofte n include anal fist ulae (B).
-
IN
5"
~
3
-
Q
A MRIshowing B Doub le-contrast
t hickened wa ll of
radiograp h. Arrow
te rmi nal ileum .

indicates fistu la.
Fig. 13.12 Mesentery of

the small intestine
Ligament um
Anterior view, Removed: Stomach , Liver, Hepatogastric Liver,
teres of liver
jejunum, and ileum . Reflected: Liver, rig ht lobe ligam ent left lobe
Esophagus
Gallb ladder ----!~~~04'--
Lesseromentum , 111 1 • • .C - - - - - Spleen

hepatoduodenal ~
ligam ent 'f.!-- - - Gastrosplenic ligament
Omenta l fo ramen
~--- Pancreas
Duodenum , ---~ a:-- - - Transverse mesoco lon
superior part (root)
Stomach, pyloric part - - - "Ji\T Left colic flexure
Right colic f lexure Duode nojeju nal

f lexure
Transverse colon
Duodenum ,
horizont al part
Mesentery -------''------c *"~--- Descending colon

(cut edge)
Taeniaecoli ------~~
Ascending colon - - - - -- -!tc'"
Term inal ileum ---1-----~ 7m~--__;4_-- Sigmo id mesocolon

(cut edge)
Cecum --+-----~
Rectum - -+---- - - - - --.1iir -- -----'''''';
163
Cecum, Appendix & Colon
~ The large intestine consists of the cecum . appendix. colo n. and verse colon. and sigmoid colon are int raperi tonea l (suspended by
a.iiiiII rect um (see p. 166). The colon is divid ed into four parts: ascend the m esoappendix. transve rse mesoco lon. and sigmoid mesoco
ing. transverse. descending. and sigmoid . The appen dix. t rans- lon . respect ively).
Fig. 13.13 large intestine:

Fig. 13.14 Ileocecal orifice
location RUQ
lUQ Ante rio r view of longitudi nal corona l sectio n.
Ante rior view.
Left colic
i
Ascending - - l -- Circular layer } Muscular
fl exur e
colon coat
Transverse Longitudina l layer
colon Ileal Superior lip
papilla.
ileocolic
labrum Inferior lip ---+----¥lr~iii;;;,
Cecum
RLQ LlQ
Rectum
Fig. 13.15 large intestine

Ant erior view.
Left colic
fl exure
Greater oment um Transverse
(cut) Haustra m esocolon
Right --:>0'-------.
colic flexure
Descending
colon
Ascending
colon
Ileal papilla.
fr enulum
lliocecal labrum.
superior and
inferior lips
Cecum
Mesoappe ndix
(with
appendicu lar a.) Sigmoid
colon
Rectum (with
peritonea l reflect ion)
164
Fig. 13.16 large intestine in situ
-
!2J- - - Greater
oment um
w
Transverse :r
~
colon
Transverse --+~, ;,J

Left colic
(splenic)
-o
Q
~
mesocolon flexure Q
:::J
,P',j,lr'l- - - Jejunum VI
H-I:t- - - Descending
Right - -+--.:i colon
colic (hepatic)
flexure
Mesentery - --i-
(cut) Sig mo id
m esocolon
Left
Ascendi ng - - - ----.loll
colo n Sigmoi d colic
colon fl exure
Ileum --7------'~ Right colic
fl exure
Cecum --t-------'~
Rect um ----,t----~'i!:f--....".,
Transverse
colon
- Coloni c
Rectu s --+-----;:----,,.-~.._ haustra
abdomini s
Sacrum
Cecum - Ilium
A A nterio r view. Reflected: Tra n sv er se co lon
and greater o m entum. Removed: Intrap eri
t on eal sm all in t estin e. - Sigmoid
colon
B No rmal radiograp hi c app earance. Doub le

co nt rast radiograph. an te rior v iew .
~ Clinical
Colitis Colon carcinoma

Ulcerative colitis is a chro nic infl amm at ion of t he large int estine, oft en start ing Malignant t um or s of t he colon and rect um are am ong th e most fr equent
in th e rect um . Typical symptom s include diarrhea (someti mes with blood), solid tumors. Mo re tha n 90%occur in patient s over t he age of 50. In early
pain. weight loss, and inflamm at ion of ot her organs. Pati ent s are also at higher stages. t he tu mor may be asymptomatic; later symptoms include loss
risk for colorectal carcinom as. of appetite. changes in bowel movements. and weight loss. Blood in the
stoo ls is particu larly incri minating, necessitating a t horough examination .
Hemorrhoid s are not a sufficient explanatio n fo r blood in stoo ls unless all other
tests (including a colonoscopy) are negati ve.
B Early-phase colit is. Residual C Colonoscopy of colon carci

A Colonoscopy of ulcerative
norm al mucosa appears as noma. The t umor partia lly blocks
colit is.
pseudo polyps. t he lum en of t he colon.
165
Rectum & Anal Canal
Fig. 13.17 Rectum: Location Fig. 13.18 Closure ofthe rectum

Left lateral view. The puborect alis acts as a
muscular sling that kink s the anorectal junc
t ion . It functi ons in the mainten ance of fecal
continence.
Sigmoid
colon
-":~~"=&-'------ Rectum
RLQ Coccyx
A Ant erior view.

Pubococcygeus
Ilium - -+- - Pubis
Pubo recta lis Perineal

flexure
Pub is - ---1:1- "1
Ischi um
!~~~'?-=----- Perin eal
fl exure
B Left ant erolat eral view.
Fig. 13.19 Rectum in situ

Coronal section, ant erior view of the fem ale pelv is. The upper thi rd of
th e rectum is covered w it h visceral peritoneum on its ant erior and lateral
sides. The middle third is covered only ante riorly and th e lower third is
inferior to th e pariet al periton eum .
External Taeniae Sigmo id
ili ac a. and v. Rectum coli mesocolon
f1L2- - Sigmo id
col on
Urete r - - - "-"-'+ -''ii
Parietal ------'-'<~--+-'~"- - - ~T-.!+:r_~,--- Ute rosacral

perit on eum fold
Super ior and inf erior

pelvic diaphr agm atic fascia
External anal --------2-..-:-"H-----.----~rl:;;,~&

sphincter
YoU.
Int ernal anal Anal Transverse

sphincte r canal rect al fold
166
Fig. 13.20 Rectum and anal canal
Coronal sect ion. anterio r view w it h t he
anter ior wall remo ved.
-..
w
5"
~
Visceral perito neum

~'!----- Superio r tr ansverse
rect al fold
Middle tra nsverse

rectal fold Circular layer }
Muscularis
exte rna
":-- -- Lon gitu dinal
layer
Parietal --------'=.. ~
perito neum
Recta l amp ulla
Superior fascia
Inferior t ransverse
Pelvic recta l fo ld
diap hragm
{ Levator ani
Inferior fascia ---~l(t~~ :~ '
Hem orrh oidal
plexus
Inte rnal anal

Deep part ----"----~=- sphinct er
~ ........... , \ ....-
;f---"-- - - - - Anal colum ns
External anal Superficial - - - - --"=- "-c- Anal sinuses
sphincter part
Anal valves
Subcuta neou s ---...!!!!~---''''''''~
part Corrugato r
cuti s ani
Anal pecten Subcut aneous

(w hite zone) Anocutaneo us Anus Perianal skin veno us plexus
line
Regionsof the rectum and anal canal

." " " " " " " " " " " " .... " " " " " " " " " " " " " " " " " " " " " " " " " . " " " " "
Region Epithelium
Colon -like w it h crypts; sim ple

CD Rectum colum nar w it h gob let cells
o Colum nar zone St ratified. nonkeratini zed

---l~~-- CD
o Anal pect en squamo us
Anal canal
Stra tified. keratinized
Anorecta l
----L,-----,--,---_-r.-~
j unct io n
Dentate line
-------,.----"'-------"'J~
~~;:o,-- Q)
0) Anal
canal
o Cut aneou s zone squamo us wit h sebaceous
glands
St ratifie d. keratinized
Anocuta - --=--c==:--'S - l - '1---,-,-------.,"""'--==----- @) o Perianal skin (pigmente d) squam ous wit h sebaceous
neousli ne ~---~~~L ®
gland s. hairs. and
"" " " " . " , ., , , " " " " .

" " " " " "" " " " " . " " " , .." . .. " " ;, " " " " ..
sweat glands
167
liver: Overview
Fig. 13.21 Liver: location

S
~
~
RUQ LUQ
~ RUQ
E
0
't:l Left kidney Liver
.Q Liver
~ and supra
Right kidney and
Duodenu m renal gland
Transverse
suprarenal gland
Ascending
colon Pancreas
colon
Descending Ascending
Small colon colon
intesti ne
A Ante rior view. B Post erio r view.

Lesser
Stomach
omentu m
Pancreas
Omental bursa.
vestibu le
Liver
Inferior Abdom inal

vena cava aorta
Fig. 13.22 liver in situ C Tran sv erse sec tio n, inferior view,
Anterior v iew w it h liver retracted . Removed:
Sto mach, jejun u m, and ile u m . The liv er is
intrape ritonea l except for it s "bare area"
(see Fig. 13.26); its mesenteries include
th e fa lciform, coronary, and trian gula r
Ligamentum
lig am ents (see Fig. 13.27). Right lobe teres of liver Hepatogastric Left lobe
of liver ligament of liver
Esophagus,
cardiac orifice
Gallbladder
Spleen
Lesser omentum,
hepat oduodenal
ligament
~=---- Gastrosplenic ligament
Omental foramen
!!-!+.~--- Pancreas (body)
Duodenum , !rt1f-'-- - - Transversemesocolon

superior part (root)
Stomach, pyloric part Left colic flexure
Right colic flexure Duodenojejuna l

flexure
Transverse colon
Mesentery (cut)
Duodenum,
horizontal part
168
Fig. 73.23 Abdominal MRI
Inferior view . Right lobe Hepati c Left lobe Stomach (with Rectus
of liver porta l v. of liver left gastric a.) abdo minis
-..
w
5"
~
External
oblique
Left colic
f lexure
Caudate lobe
of liver
Inferior
Spleen
vena cava
A Transverse section Right lung Azygos v. Spinal cord (in Abdom inal Diaphragm Left lung
t hro ugh T12 verte bra. verte bral canal) aorta
Duodenum . Pancreas. Superior Transverse

Gallbladder decending part head mesenteric a. and v. colon
Left renal v.
Right lobe
of liver
Jejunum
Decendi ng colon
Inferior vena cava
Diaphragm.
External oblique
rig ht crus
Renal sinus
Left
Right Renal pyramids
kidney
kidn ey RenaI cortex
Lati ssimus
dorsi
B Transverse secti on Iliocost alis Quadrat us Longissimus Spinal cord (in Abdominal Psoasmajo r
th rough L2 verte bra. lum borum t horacis verte bral canal) aorta
169
liver: Segments & lobes
................................ ...... "' .
Fig. 13.24 Segmentation of the liver IV

A nterior v iew. The co mpon ents porta l t riad (he patic artery, po rta l
• VIII
172 , 219) divi de s the liver in t o he
vein , an d hepat ic duct, see p p.
patic segm ents (see Table 13.2).
• VII III
VI ~ Ligament um
teres of liver
V
Fibrous
appendix
A Diaphragma tic
surfac e, ante-
-. Inferior
riorview. vena cava
Branchesof hepati c veins
VI
Branches of porta l vein
Branches of proper hepatic artery III
Branches of hepat ic duct
V
B Vi scera l su r Ligamentum /
face, inferior ter es of liver
Fig. 13.25 liver: Areas of organ contact IV Gallbladder
view.
Visceral surface, inferior view.
Hepatic segments
Part Division Segment
Posterior part I Caudate lobe
II Left
- - -+ - Suprarenal Left part Left lateral division
III Left antero lateral
impression
Left medial division IV Left medial
- - i.-- - Renal
imp ression V Right anterome dial
Right medial division
VI Right antero lateral
Right part
VII Rig ht posterolatera l
Right lateral division
VIII Right posteromedial
Gastric Duodenal Colic
impr ession impr ession impr ession
Fig. 13.26 Attachment of liver to diaphragm

Parietal Inferior Abdo mina l
peritoneum vena cava aorta
Left t riangular I.
Bare area
I-~ Hepatic surface

of diaphragm - ---''b--..-.-- St omach
(no pariet al
perit oneum )
Right -----'-_'+.~
suprarenal gland
Right kidney ----::,-~7--
Right
t riangular I. Duodenum - - - +-- - - - -
A Diaphragmatic su r face of t he liv er, B Hepat ic su rf ace of t he

posterior view. dia phragm, anterio r v iew.
170
Fig. 13.27 Surfacesofthe liver
Coron ary I.
Th e liv er is divid ed by it s li gam ent s into four
lobes: right , lef t, caudate , and qu adrat e.
IN
5"
~
- - Left lobe,
diaphragm ati c
surface
-
Right lobe,
diaph ragm at ic '------- Falciform I.
surface
~ Ligamentum t eres
(contain s ob lit erated
umbil ical v.)
Inferior border
L. of Bare
Inferior vena cava area Caudate
A Anterior vie w . Fibrous process
appendix of liver
Coronary I.
Right lobe,
visceral surf ace
Left lobe,
visceral surface
Portal v.
Left hepati c duct
Proper hepat ic a.,
right branch
Proper hepatic a.,
left branch Right hepati c
duct
Proper hepati c a.
Cystic a.
Ligamentum
te res of liver
Quadr ate Bile duct Cyst ic duct Gallbladder
lob e
B In ferio r vi ew.
Left and interm ediate Groove for

Left t riangular I. hepat ic vv, inferior vena cava Right hepat ic v.
Fibr ous
app endix of liver
Bare area
Left lobe,
visceral surface
Caudat e pro cess
Right hepat ic duct

Proper hepati c a.,
left branch ~ Right t riangul ar I.
Ligamentum
teres of liver
Branch of cyst ic a.
Quadrate lobe
Gallb ladde r
C Posterior view.
Right lobe, visceral surface
171
Gallbladder & Bile Ducts
Fig. 13.28 Gallbladder: Fig. 13.29 Hepatic bile ducts: location

Project ion ont o surface of the liver, ant erior view.
l ocation
RUQ Rig ht du ct of Lef t duct of
I "
caudate lobe caudate lobe
Left hepat ic
duct
Commo n
hepaticR~~:~ ~.
Common ~_ -" t,:
l I . ,-
J~:-"'"
hepati c du ct
.
hepati c d uct I_ L ". . .:" .IN. .{:.<",
1 ~~ ,~~,~ - ..~~~~,
!!i_ _ ,{ ". ,,"
- -.=-- Liver,
Bile duct Cyst ic du ct • ,';f :-B''-' '<t ' ~' left lobe
Liver. "'./~\ ) \ \ \.i! t-

right lobe /
,r.
~.I
:
' \' Lef t hepati c
du ct
A Ant erior view . Bile du ct
- - - - Bare area Gallb ladde r
=-- - - - - - - Ligament
of vena cava
Caudate lo be - - - - - ....!,,------,-,~-- Inferior vena cava
Left lob e - - - Porta l v.
Right hepatic
Left hepati c du ct - - --=-- -!!!!l;,.'J

du ct
Ii!~~---- Com mo n
Bile d uct ----~f--__<ll hepati c duc t
Quadrate lo be - - - --=''E---- Cystic duct
Ligam entum teres of liver - - - -} - - - -- Gallbladder

B Inferior view .
Fig. 13.30 Biliarysphincter system Fig. 13.31 Extrahepatic bile ducts

Ante rio r view. Opened: Gallb ladder and duod enum .
Sphincter
Rig ht - - ---......... 4-- - Left
Duod enum - -+---+1 of bi le duc t
(w all) hepat ic du ct hepat ic du ct
Sphincte r Cystic duct

Hepato -+--+-.A of pan creati c
pancr eati c
duct
Neck - - -- - --!f.
am pulla
Sphincter of
hepat op ancreati c Infundibu lum - ------;_/:
amp ulla
A Sphinct ers of th e pancreatic and bile duct s. - - - - - - - Duo den um,

Gall superio r part
bladder
Bo dy --_~
Duod enum ,
m usculari s exte rna
~---~~-- Bile duct
Fundus ~------- Accessory

pancreatic duct
-i-- - Bile du ct
Mino r duod enal

.#--- - - Longitud inal papill a
slips of d uodenal
m uscle on bil e Major duodena l
Sphincte r -----'="=-~~=i duct papill a
of hepat o
pancreati c Du od enum , - - -- Duodenum ,
am pulla descend ing part ho rizo nt a l p art
172 B Sphinct er system in th e du odenal wall.

Fig. 13.32 Biliary tract in situ
Anterio r view. Removed: Stomach, small
int est ine, tran sverse colon, and large portion s
of th e liver. The gallbladd er is int raperit oneal,
covered by visceral peritoneu m where it is not
Inferior
vena cava
Hepat ic
vv. Esophagus
Abdom inal
aorta

w
3'
~
attached to the liver.

Spleen
Liver,
right lobe
Left
Left hepati c suprarenal
du ct gland
Right hepat ic Celiac t run k

duct
Common Splen ic a.
hepat ic duc t
Common
Cystic du ct - ----H--m , hepati c a.
Proper - - ....p,-;ffiO
hepati c a.
Gallbladder - - ----H-W IlJ Left colic

flexure
Bile duct - - - - 'iH';m;
Pancreas
Right colic
flexure Left kid ney
Hepato
Jejunum
pancreat ic
duct (opening
on majo r
duodenal
papilla)
Duod enum , Pancreatic Duodenum , Supe rior mesenteric

descending part du ct ascending part a. and v.
~ Clinical
Obstruction of the bile duct

. Asbile is sto red and concentrated in th e gallbladder, cert ain subst ances,
such as cho lestero l. may crysta llize, result ing in the form ation of gallstones.
Migrati on of gallston es into the bil e duct causes severe pain (colic).
Gallston es may also block the pancr eatic duct in th e papil lary regions,
causing hi ghly acute or even life-threatening pancreat it is.
Gallston es
Ultr asound appearance of t wo gallstones. Black arrow s mark th e echo -f ree

area behind th e sto nes.
173
Pancreas & Spleen
Fig. 13.33 Pancreas and spleen: Location

Sto mach
Lesser Gastrosp lenic

omentu m ---r--!J'f-- - - _ -i!( ligament
(hepatoga stric
ligament)
Oment al bursa,
RUQ
splenic recess
10th rib Pancreas
Spleno renal
Liver ligament
Pancreas
Spleen
Inferi or Abdom inal Lef t

vena cava aorta kidn ey
A Ant erior view. B Left lateral view. C Transverse section, inferior view.
Duodenum, Fig. 13.34 Pancreas

Accessory superior part
pancreati c du ct Ant erior view wit h dissection of th e
Pancreatic Pancreas pancreatic duct .
(from t he do rsal
du ct (body)
pancreat ic bud )
Duodenum , - Pancreas
descendi ng (t ail)
part
"=-- - - --j!fc-- - Superior
me senteric
a. and v.
Pancreat ic du ct
(fro m th e vent ral
pancreatic bud) D d
uo enum , Pancreas Duod enum,

Pancreas
hor izont al part ascending part
(head) (uncinate process) Posterior ----:MI'~ Superior
ext rem ity bord er
Gastri c
surface
Fig. 13.35 Spleen
~---'~- Hilum
Splenic a.
Splenic v.
Renal
surface
Inferior
bord er
Coli c
surface
Inferior
border
A Costal surface. B Visceral surface.
Diaphragm atic
surface
174
Fig. 13.36 Pancreas and spleen in situ
A nter io r vi ew . Removed: Liver, st o m ach. sm all Parietal Inferior Hepatic Com mon Left Celiac
perit oneum vena cava vv. hepat ic a. gast ric a. tr unk
inte st ine . and la rge in t est in e. Th e pancreas
is ret roper ito neal. w h ile th e sp lee n is Superior
border
} ....
IN
in t rap er it o neal. Gastric Spleen
surface
S"
~
Hepat ic surf ace
of diaphragm ~
-o
Q
Q
~
Hepatodu odenal I ,' ~U-'--- Splenic

ligament
Right kidney - - l!...\.,!ClJ
Pancreas - - \L\-\ill.
(body)
Duodenum, --~I'L
superio r part
Pancreas ---J+~
(head)
Duodenum , -----!~u
descending part
Descending
colon
Left colic
a. and v.
Duodenum , Mesentery Uncinate Duodenum . Superior mesent eric

hor izont al part (root) process ascending part a. and v.
Fig. 13.37 Pancreas and spleen:
Transverse section
Inferio r view. Sect io n through Bile duct Transverse colon
L1 ve rte bra .
~t Superior Pyloric part

mesenteric
a. and v.
Gallbladder Sto mach
Liver, righ t lobe
Inferior
vena cava
Splenic v.
Right suprarenal
gland Pancreas
(tail)
Spleen
Right renal a.
Right kidney
TranSVerse }
colon Left
colic
Abdo mi nal Descending flexure
aorta colon
L 1 vertebra Spinal cord (in Left kid ney and
vertebral canal) perir enal fat capsule 175
Kidneys & Suprarenal Glands: Overview
Fig. 13.38 Kidneys and suprarenal glands: Fig. 13.39 Kidneys: Areas of organ contact
location Anterior view.
Right suprarenal Left suprarenal

gland
gr d
Stomach
RUQ
(area of contac t)
Right
Spleen
suprarenal
Liver (area of cont act )

gland
LUQ (area of co ntac t ) Pancreas

Right kidn ey - ------=oi
Right renal (area of contac t)
f---==-----!----- Left uret er
hil um Descendin g colon
(area of cont act)
Right colic flexure
Urinar y (area of contact)
bladder
A Anterior view.
Duod enum Right Left Left renal
(area of cont act) urete r ureter hilum
Fig. 13.40 Right kidney in the renal bed

Sagittal sect ion th rough the right renal bed.
12th ri b
Subcostal n. Right lung
Right kidn ey
Pleural cavity Attachm ent
Iliohypo gastric n. bet w een liver
Diaphragm and diaphrag m
Ilioinguina l n.
Perir enal fat capsule
Liver
Right suprarenal
gland Hepatorenal
Ret rop eriton eum - ..,.....-' recess
Renal fascia,
ante rior layer
Right kidn ey - ---=--
Parietal
Renal hilum - - ---' .......--- perit oneum
~~;.-- Duodenum ,
B Posterior view with th e trunk wall opened. Renal - -- -1
descendi ng part
fi brous capsule
Renal fascia, - ----:----':

retrorenal layer
Transverse
Iliac crest - -- - "
colon
Fig. 13.41 Suprarenal gland

Anter ior view.
Right
suprarenal v.
~ Medial
border
Cortex
Branch Fibrous capsule

of midd le
__+ - - Centra l v.
suprarenal a.
Left -,-i~-- Medull a
suprarenal v.
A Left gland. B Opened right gland.
176
Fig. 13.42 Kidneys and suprarenal glands
in the retroperitoneum
Anteri or vi ew. Both th e kidn ey s and su p rare nal
g land s are retroperiton eal.
Diaphragm. Inferior Proper Splenic
hepatic surface Port al v. vena cava Esophagus hepatic a. fossa
________ Costod ia

~ phragmat ic recess
Hepatoduod enal
ligam ent Left gastric a.
Right suprarenal __~ L L " .

gland Left suprarenal
gland
Hepati c duct
Splenic a.
Right kidney ~~Hi:-Jf--- Pancreas
Duodenum , -~~
superior part Transverse
mesocolon
Parietal - ----1lcTW (root )
peritoneum
Left renal
a. and v.
Left kidney
Ht- - Attac hment

of descending
Superior mesent eric
colon
a. and v,
Attac hmen t
of ascending
colon
Duodenum . Mesentery Abdomi nal Duodenum . Left colic

horizontal part (root) aorta ascending part a. and v.
A Removed: Intraper iton eal org ans . alon g w ith

portion s of th e ascend ing and d escencl ing
co lon.
Inferior
vena cava Esophagus
Left superior
suprarenal a.
Left suprarenal
gland
Celiac t runk
Left midd le
and inferior
suprarenal aa.
Left suprarenal v.
Left renal a. and v.
Left ovarian/ test icular

a. and v.
Perirenal fat capsule Left ureter
Right ureter
Iliohypogastric n.
Right ovarian/
test icular a. and v. Ilioinguinal n.
Inferior mesenteric a.
B Removed: Periton eum . sp leen. and ga stroin
t estinal o rg ans. al ong w it h fat cap sul e (l eft
side ). Ret ract ed: Esophagu s.
177
Kidneys & Suprarenal Glands: Features
Fig. 13.43 Right kidney and suprarenal gland

Ant erior view. Removed: Perirenal fat capsule.
Retracted: Inferior vena cava.
Diaph ragm - -+--:1ch-' ~--- Inferio r vena cava
Inferior phren ic - -+-CiiH;

a. and v.
Superio r - ----lHiiF-: l-:

suprarenal aa.
Rig ht - - TH'iirtl
suprarenai gl and
- - - Superio r m esent eric a.

Subcost al n. _ _ ---+!:~+-
(12t h int ercostal n.) Left renal v.
Righ t kid ney --~M-JP Right renal a. and v.
Right ur et er - - tH:rl+
Ilio hypogast ric n. : - - - Rig ht t estic ular!

ovaria n a. and v.
Ilioin guin al n. - - - .!.!----'-'-'
Fig. 13.45 Kidney: Structure

Right kidn ey wit h suprarenal gland .
Rig ht suprarenal
Right sup rarenal gland
g land
Superio r pol e ..",;-- - Superior sup rarenal aa. - - ""
Midd le supr arenal a.
_ - - Right suprarena l v.
Renal
Inferior sup rarenal a.
cort ex
Ant erior '--- - - Medi al border Fibro us
surface capsule
Lat eral
bord er
-1 ...._~-- Right renal a. and v.
Renal
hilum
Renal "r-- - - Renal pelvis
hilum
Poster ior
..\ - - - Right ur et er
surface
'--- --m-- - - Inferior po le
A Anterior view. B Posteri or view.
178
Fig. 13.44 left kidney and suprarenal gland
Ant erior view. Removed: Perirenal fat capsule.
Retracted: Pancreas.
Superior Left suprarenal Inferio r ....w
Esophagus suprarenal aa. g land phrenic v.
5"
Inferior vena cava ~
Inferior phre nic a. -
Q
Abdom inal aorta
Port al v.
Left gastr ic a.
Midd le suprarenal a.
Pro per hepati c a.
Left suprarenal v.
Commo n hepat ic a. - ----',
Subcost al n.
Bile du ct
Pancreas (ta il)
Sple nic a. and v.
Inf erior suprarenal a.
Pancreas (neck) Left renal a. and v.
Lef t kid ney
li:f-H~--- Transversus abdomi nis.

int ernal and exte rnal
Left testicularl o blique
ovarian a. and v.
Genitofem or al n. Left Ilioi ng uin al n. Iliohypogast ric n.
uret er
C Posterior view w it h upper half part ially remov ed. D Midl ong itu dinal sect ion. posterior view.
179
Ureter
Fig. 13.46 Ureters: Location ~ The ureters cross th e com mo n iliac artery at its bifurcation into
Ant erior view. ~ th e exte rnal and int ernal iliac arteries.
Left suprarenal
gland and kidn ey
Fig. 13.47 Ureters in situ

Ant erior view. male abdomen. Removed: Non
urinary organs and rect al st um p. The ureters
Rig ht - - - - ---1 Uri nary are retr op erit on eal.
ure-er bladder
Left mi ddl e Left inferio r phrenic
suprarenal a. a. and v. Left superio r
Abdom inal suprarenal a.
aorta
Celiac t runk Left suprarena l
gland and v.
Inferior vena cava
Rig ht suprarenal
Left inferior
gla nd and v.
suprarenal a.
Perirenal - - 4 '=+-l
fat capsule
Ureter
Inferio r - ----iltff (abdo minal part )
mesent eric a.
Rig ht ovar ianj - - ----f.=+Jet

te sticular a. and v.
Psoas major
Righ t co m mo n ---J.'~4
iliac a. Iliacus
Med ian sacral _---LH!.--1~~ Left int ernal

a. and v. iliac a. and v.
Sacral plexus
Left ext ernal iliac

a. and v.
Rig ht duct us Inferio r epigastric

deferens a. and v.
Rect um Uret er
(pe lvic par t )
Urinary Median umb ilical
bladder Pubic ligam ent
sym physis
180
Fig. 13.48 Ureter in the male pelvis
Superior view.
-
IN
S'
-~
Rectum with periton eal
Right ureter covering on anterio r wa ll Left uret er Q
Median um bilical --'

ligament Urinary bladder.
apex
Ilium
---If!-~-----:;;.------- Pelvic diaphragm.

Urinary bladder. superior fascia
body
Deep dor sal
Transverse perineal
penile v.
ligam ent
Pubic symphysis - - - - - ---;- - - ---=- Pubis
Fig. 13.49 Ureter in the female pelvis

Superio r view.
Sacral promontory
(wi t h m edian
Right Rect um sacral a. and v.) Rect out erine
ureter pouch
I / Left ovarian a. and v,

/ (in ovarian suspensory ligament)
Right ovary
Uterosacral fo ld (wit h
uterosacral ligament )
Right uter ine
t ube Passage of left
ureter t hro ugh broad
Broad -,-.,..: ligament of uterus
ligament of ut erus
-l~~-- Ut erus. posterior
surface
Round ligament
of ut erus
Ut erine fundus
Right external iliac
a. and v.
Parietal Urinary bladder.

periton eum body
Vesicouteri ne .rc:-~-~---- Median umb ilical fold

pouch (oblit erat ed um bilical a.)
Transverse
vesical fold
Pubic
Median umbilical
sym physis
ligament
181
Urinary Bladder
Fig. 13.50 Male urinary bladder Rectovesical Transverse

Ileum Rect um pouch vesical fold
Cecum - - -J
Parieta l ----'~k-
perito neum
Ductu s
deferens ~
Vermifo rm
Sigmo id
appendix
colon
Latera l ingui nal
fossa Lateral umbilical fold
(with inferior epigastric
Urinary bladder a. and v.)
Median umbilica l fold Medial umb ilicus fo ld
(w it h underlying Rect us (with underlying
A Anterosuperior view. oblite rated urachus) abdomi nis obliterated umbi lical a.)
Right comm on Sigm oid

iliac a. and v, m esocolon
Taeniae coli
L5 verte bra Sigm oid colon
Right ductus
defe rens
Rectov esical
pou ch
Visceral
perit oneum
Rect um =~H-i- Visceral

pelvic fascia
Parieta l
pelvic fascia
Right
ureter
Levator ani
Right seminal Prostate

vesicle
B Para sagi tta l secti o n, vi ewed from t h e ri g ht.

External anal Perineal Recto
182 sphincter body pro stat ic fascia
~ The urinary bladder is retr opubic and
~ retrop erit oneal in location.
Fig. 13.51 Female urinary

bladder Broad ligament
of ut erus Rectum
Rectouter ine
pouch
Uterosacra l
fold
Ovarian suspensory
ligam ent
-
w
S"
~
~
-
o
Q
a
Uteri ne
t ube
...t_ - - Left ovary
Sigmo id
Cecum
colo n
Uteru s ---=P ..: Ovarian
ligament
Parietal -----"~_
peritoneum
Deep ingui nal ring
;:;-<"--- - - - - - Lateral umbi lical fold

Transverse (w it h inferior epigastr ic
vesical fold a. and v.)
Urinary bladder Rectu s abdom inis
Med ian umbilical Medial umb ilicus fold

A Ant erosuperior view. fo ld (with obliterated Supravesical (With oblite rated
urachus) fossa um bi lical a.)
Sigmo id colon
and mesocolon
Proper ovarian Uterin e t ube

ligament
Round ligament
Uterus of uterus
Rectouterin e Vesicouterine
pouch
pouc h
Visceral
Visceral
peritoneum
peritone um
Rectum
Visceral
pelvic fascia
Visceral
pelvic fascia
Right ureter
Urinary
bladder
Levator ani
<u:
External Perineal Vagina

anal sphincte r body
B Parasagittal section, viewed from t he right.
183
Urinary Bladder & Urethra
Visceral Fig. 13.52 Female urinary bladder and urethra

perit on eum
Mid sagittal sect ion, viewed fr om t he left side.
Pariet al -
periton eum
"TI-H .------ Rectouterin e
Vesicout erine --~~~ pou ch
pou ch
Ovarian suspensory ligame nt ~ .--r--~~;w_-_J\¥-,-;---- Left com m on iliac
(wit h ovarian a. and v.) ~ a. and v.
Right ut erine ;.,>\--- - - L5 verte bra

t ube
A Perito neal covering.
Right exte rnal h~~~~h'+-'l\;f.-'i---- Right uret er
iliac a. and v.
~P-d-~~~~~='----- Right ovary and
Rectu s abdomin is
ovarian ligam ent
Uteri ne fund us
Uteri ne bod y
Round ligam ent
of ut erus
Rectu m
Uterin e cervix
Urinary bladd er ----+---\---"l~
Posterior
Pubic - - --\- - + ..,
vaginal fo rnix
sym physis
Ante rior
Vagi na ----'<---+--~~'="*-h~' r.~]' vaginal for r
Crus of clitori s ----~7"'-'--_t.\' Levator ani
~~~"'-------,i~-- Ext ernal anal

Uret hra - - - - -- - -"'!::lii sphincter
Deep t ransverse
perin eal
B Right female hemip elvis.
Pariet al - - _~ ....-.--.r- Visceral Fig. 13.53 Male urinary bladder and urethra
perito neum perit on eum
Mid sagittal sect ion, viewed fr om th e left side.
Site of bladder / Rectoves ical
pun cture pouch
Urina ry Rect ovesical
bladder pouch Rectum
A Perito neal covering.
Pubi c sym physis
Ret ropu bic space

Rectovesical
septum
Am pulla of
vas deferens
Prostate
Bulbo uret hral

gland
- -- Bulbospongiosus
B Right male hemipelvis.
184
Fig. 13.54 Wall structure
Anterio r vi ew of co ro na l secti on . Inte rurete ral Urinary bladder
fold (bo dy)
Right ureter, -------.,

I I
j, - ." .
intr amural part ess..
. \ ~ ,
Inte rnal uret hral

Mucosa w it h )
orifice with longitud inal folds
bladder uvul a ~--- Submucosa Ureth ra
Orifices of --~+
ureth ral glands , - - - Muscularis
Fig. 13.55 Urinary bladder and urethra
Anteri or view.
Pelvic bone Urinary bladder

Pelvic retroperito neal ~ (body)
space with veno us
plexus of bladder
'Lx.::.-,c;....;,;-;- - - Ureteral orific e
~~-- Bladder fundu s

Exte rnal uret hral
and trigon e
sphincter """~'------- Bladder neck (with
uvula of bladder)
Ischiopubic ramus - - -- """'--...."
Crus of clitori s - - ----==--::---'-'+'t
(wi t h ischiocavernosus)
Perin eal me mbra ne
Vesti bular bulb (wit h

bulbospo ngiosus)
Labium mi nus Ext ernal Labium majus
uret hral ori fice
A Fema le pe lvis in coro na l sec t io n ,
Urinary
bladder
~~~~::.-- Ureth ra (pre

Urinar y prost atic part )
bladder
Ductu s
(body) Prostate
deferens
Urethra (mem
Pariet al branous part)
pelvic fascia \ \ti~~I-- Urethral
ampull a
Crus of penis
Urethra
Levator ani
Orifices of (spongy part)
uret hral glands
Exte rnal urethra l
sphincte r
Bulbou rethra l
gland Navicular
Crus of penis (with Ureth ra,

fossa
ischiocavernosus) Superficial Bulb of peni s spongy part
perineal fascia (w ith bulb ospongi osus)
B Ma le p elvi s in coronal sec t io n. C M ale uret hra in longitudina l section .
185
Overview of the Genital Organs
~ The genital organs can be classified top ographica lly (externa l

IIIiiiiII versus int ernal), functiona lly (Tables 14.1 and 14.2), or ontog e
netica lly (see p. 204) .
Female genital organs
Organ Function
•. .()var~ ~ ~~lTlce l l .andh o.rITl O'~ ~?roduction .

: Internal • Uterin e (fallopian) tube
... ....... ...... .....
S.it ~ . o.~conce?tion .a~d .t ran sp o. ~tor~~n for zygote
genitalia , Uteru s • Organ of incu bation and parturi t ion
.. .... .... .... ..... ... ..... .... ... ............ .................... .... .... ...... ... ........ ......... ... ........ ....•
• Vagina (upp er portion)

............................. ... ... . ... ..................! Organ of copulatio n and parturiti on
:. ya 9. i ~ ~ (~ e~ ~ i ? ~ I ~ )... . . ..... ... . .
: Labia majora and minora
..: Copulatory organ
. Ext ernal : Clit oris
, Vulva
• genitalia
• Production of secret ions
Right uret er
Fig. 14.1 Female genital organs
Ovarian suspensory - - - -+1

ligam ent
Right ute rine tub e - - ----,;4__ ,
Right ovary - -1+--
Round ligam ent

of ut erus - - '<--- Ut erus
---:f--- Vagina Median umbili cal - -----',,'\. --T:i"'-- Uteri ne

ligam ent cervix
Lot-'''<:--1-,----- Glans and crus
Labia mi nor a of clitori s '-1-- - Vagina
Urinary - - - - --''v--'
bladder ----;;o:'-=!;L--- - Ureteral
Vestibu lar bulb
Vestibu le - - -'c--+:--' orific e
;e-- - Greate rves t ibular Clit ori s ----\-"~
(Bartholin's) gland
A Int ernal and externa l genitalia . Uret hra r=r- - - - Greate r

vestibular gland
Labium maju s Labium mi nus
B Urogenita l syst em. Note: The fema le urinary and genita l tracts are
functi ona lly separate, though topog raphically close.
186
Male genital organs
Organ Function
Test is Germ cell and ho rmo ne prod uction
Epididymis Reservoir for sperm
Internal Ductus deferen s Transpo rt fo r sperm

genitalia Prostate
Accessory
Seminal vesicles Production of secretions (semen)
sex glands : ,
Bul bouret hral gland
Penis Cop ulatory and urinary organ
External Urethra Urinary and t ransport o rgan fo r sperm

genitalia Scrotum
: : Protec tion oftesti s
of t he testis
Right kidn ey
Fig. 14.2 Male genital organs
Inguinal Uret er Urinary Ductu s

canal bladder defe rens
Sem inal vesicle
Ejaculat or y ------>,;..-~'--~ Right uret er

duct
Prostat e
Bulbour et hra l --*--+~ \
gland -+----"~~-+ Median Ductus
umbilical ligam ent defere ns
8-- +-+'1-- - Uret hra
Penis - - - - + H-
---'~-- Epididymi s Urinar y - - -+- ---\T+--' Uret eral o rifice

bladd er
//-'1 -1'--- Sem inal vesicle
Testis _ _ ¥ --.-!L
r A===-- - Ejaculatory duct
Peni s (co rpus Prostat e

cavern osum )
A Seminiferous st ruct ures . Bulbou rethral
gland
Bulb of penis
(corpu s
spongiosum )
Scrot um Test is Epididym is
B Urogenital system. Note: The male urethra serves asa common uri
nary and genital passage.
187
Uterus & Ovaries
Fig. 14.3 Female internal genitalia

The ut eru s and ovaries are suspe nded by th e
Perit oneal ----{ .r:i£'!~- Uterine
me sovarium and m eso m et riu m (portions of
covering tub e
t he b ro ad ligam ent ).
Mesosa lpinx
--;,....,~~==*=- Aort ic bifur cation

Internal iliac a. :, I""•..----Fo- Common iliac a. Mesometr ium - --eo I::
------'!,,---'P- External iliac a.
A Locat ion. Ante rior view.
B Mesen t eries. Sagittal sect ion . The broa d

ligam ent o f t he ut eru s is a com b inat ion of
Fig. 14.4 Ovary t he m eso salpinx, m esovariu m , am d m eso
Poste rior view of th e rig ht ova ry. me tri u m .
Mesovarial Uterine t ube
Meso margin
varium
Uterus, --~
posterior surface
Proper ovarian ligament -----=--=.::::i:~ . .to.': ,~ -

Ut erine pole --~=~~~-- iF~-----,~<---7-"'----- Vascular pole
Follicular st igma (bulge

-----;>l;l~---~
from graafian follicle) "/~----"--_ Ovarian a. and v.
(in ovarian suspensory ligament )
Mesometr ium
--~o=~----
Medial surface
Free margin
Longit udinal
Fig. 14.5 Curvature ofthe uterus ut erine axis
Midsagittal sect io n, lef t lat eral view. The po si Endomet rium (in uterine cavity)
tio n of th e uterus can be d escribed in term s o f Longitu dinal cervical axis
Myometri um (in cervical canal )
fl exion (CD) and ver sion (0),
Perimetri um
(serosa) --l-
Uterine fundus ~
Uterine body
CD Flexion : Ang le bet w een th e

uter in e body and isth mu s.
o Version : An gl e between th e
Ut erine ist hm us
Supravaginal part
I Vesicouterine
pouch
Ut erine cervi x
~
Vaginal part Anterior vaginal Longitudinal Longitu di nal

cervica l canal and th e va gina.
fornix axis (in vagina) body axis
188
Fig. 14.6 Uterus and uterine tube
Mesosalpinx (w ith
Left uterine tub e Proper

Uterine t ubal branches of
ovarian
fund us ut erine a. and v.)
Ist hmu s ligam ent
I
Infund ibulum
Left ovary Fimbriae at

abdomina l ostium
Ovarian a. and v. (in ovarian ~
suspensory ligam ent )

Vesicular }
appendices Emb ryon ic
.. h remn ant s
Epoop oron
Uterine body
Mesometri um
Ut erine cervix Right ureter

Uterosacral ligament
Vagina ------l~
(in uterosacral fold)
A Posterosuperior view.
Left ute rine tu be
Uteri ne fundus
Ute rine Uterine
Mesovarial margin
ostium
Ampulla
Infundi bulum
Fimb riae at
abdomi nal ost ium
Right ovary
Supravaginal
Uterine part
Cervical canal
cervix {
Vaginal part
Vaginal fornix. lat eral part
Ext ernal os
B CoronaI sect ion, poster io r view wit h
Vagina. ant erior wall
ut erus straight ened. Removed: Mesome
triu m .
~ Clinical
Ectopic pregnancy .'

After fertil izat ion. t he ovum usually implants in the wall of t he ute rine cavit y. life-t hreatening bleeding into t he peritoneal cavit y. Tubal pregnancies are
However, it may become implant ed at ot her sites (e.g., the uterine tube promoted by adhesion of t he tu bal mu cosa, mostly due to inflamma t ion .
or even the perito neal cavity) . Tubal pregnancies, t he most common t ype
of ectopic pregnancy, pose the risk of tubal wall rupt ure and potentially
189
Vagina
Fig. 14.7 Location Fig. 14.8 Structure

Midsagitta l section. left lateral view . Posteriorly angled coro nal sect ion.
poste rio r view.
Vesicouter ine Serosa
pouch (perimetr ium)
Recto uteri ne Uteri ne cervix.

pouch Posterior lip
supravaginal part
of ute rine os
Uterine body - - -
Ut erine os
Ant erior lip
of uterine os
Uterin e cervix. --------....,.
vaginal part
Urinary bladder --~=: ~~~ .. Anteri or

vaginal
Vaginal rugae
colum n
Vagina. --~~~d!'-ifL~~L
anterior wall Vagina,
ant erior
Urethra
wa ll
Vesicovagin al sept um --~~~rwfj~~~~~~ Rect ovaginal sept um
~l-n-- Ureth ral carina
(clinical t erm )
Vaginal orifice ----'-7~
Vaginal vest ibule t ransverse Ext ernal ;R- - - Vaginal vestibu le

wi t h labium minu s perineal uret hral orifice w it h labium minus
Fig. 14.9 Uterine cervix: Transverse section

Inferior view.
Urinary
Femor al a., v., and n. Pubis bladder Pecti neus
Obtu rato r canal
(inlet )
Rig ht urete r --""",--'-~~"----~f--'-c
(cut obliquely)
;~~,...-';~r:-'~F?----'-:;..,--- Obt urato r
internus
Ut erine cervix --~~~::-"S;....,.c---'-;~'iiM'",,----T---T"T'~~<
~T---f'H~T-~~:;':-:~~~io--- Uterovaginal
venous plexus
Sciatic n. --~~!!
'--;:'-=---=---=,r.!-- --'- - - Ischial spine
Rect um ---=~~---==~~----~
Gluteus
maxim us
Sacrospinal Coccyx Rectout erine Uterosacral

ligam ent pouch ligam ent
190
Fig. 14.10 Female genital organs: Coronal section
Ant eriorvi ew. The vagi na is bot h pelvic and perinea l in locat ion. It is also
retroperit on eal.
Uterine Rect um Sigmo id

Right fundu s colon Pariet al
ureter perito neum
Ilium -------.
Right exte rnal ---~..Ji~

, ~~:'---- Iliacus
iliac a. and v.
'-7'":-.-~<=----- Left ovary
Left uteri ne
t ub e
Round ligam ent

of ut erus
Pelvic retr o
Cervix w ith ----~~~'" periton eal space
ut erine os
Vagin al arte rial

Obt urato r internu s - -- - - .L..J1-+.' branches and
(with obt urator fascia) veno us plexus
Vagina, posterior
Levat or ani w all wi t h vaginal
~-:'2-'"".~ rugae
(w it h sup erior and inferior
pelvic diaphragm atic fascia)

Deep tra nsverse Ischiopubic ramu s
perineal
Superficial Crus of clitoris wit h

perin eal (Coll es') fascia ischiocavernosus
Perineal a. Rou nd ligam ent Labium m inus A. of

of ut erus vest ibu lar bu lb
Labium majus Vest ibu le of vagina Vest ibular bu lb w it h

wit h vaginal orifice bu lb ospon giosus
Fig. 14.11 Vagina: Location in the pelvic floor

Inferior view.
Transverse Pubic Deep dorsal
perin eal ligam ent sym physis clitoral v.
Dorsal clit or al
a. and n.
Fem ale
uret hra
Inferior
pubic ramu s
Perineal me m brane Vagina Ischiocavernosus
191
Female External Genitalia
Fig. 14.12 Female external genitalia

Lithotomy position with labia m ino ra separated .
Mon s pubi s -----.,~ Anterior labial

com m issure
Prepu ce -~-.Pc'"
of clit ori s Clito ris
Labia min ora ----;:'-~~....,.- Ext ernal

uret hral
or ifice
Labia m ajo ra -~~-':'---<,..---¥i
~-- Vest ibule

Openi ng of greater
vesti bu lar (Bart holin's)
" " - - - - Posteri or
gland s
labial
com m issure
Perineal - - - - - - -<
raphe
~----- Anus
Fig. 14.13 Vestibule and vestibular glands

Lithotomy position with labia separat ed.
Ext ernal
urethral orifice
Labia m inora
Bulbospong iosus
Vaginal orifice
Vest ibule
Vest ibular bulb
Greater vestibu lar

(Bart ho lin's) gland
Orifi ce of greater
vestibu lar gland
192
Fig. 14.14 Erectile muscles and tissue: Female
Lithotomy posit ion. Removed: Labia, skin, and perin eal mem brane;
erecti le mu scles (left side) .
Deep t ransverse Clit oral Clit oris Glans of

peri neal pre puce (b ody) clit oris
Isch iocavernosus
Super ficial
tran sverse
perineal
Levat or ani Bulbo Vestibu lar Clit ori s Ischio

spo ng iosus bu lb (crus) cavernosus
~ Clinical
Episiotomy
Episiotomy is a common obstetric pro ced ure used to enlarge t he birth th ere is imminent danger of perineal lacerat ion, and an episiotomy is often
canal during t he expul sive st age of labor. The procedure is generally used to perf or med . More lat eral incisions gain more room , but th ey are more difficult
expedite the deliver y of a baby at risk for hypoxia d uri ng th e expulsive st age. to repair.
Alte rnately, if the perin eal skin turn s wh ite (indicating dim inished blood flow) ,
Bulbospon
giosus
Lateral Midline
episiotomy episiot omy
Perineum
~~~~- A n u s Ischio
cavernosus
Deep
transverse
Mediolateral perineal
episioto my
1'- - - - - Superf icial
A Typ es of episiot omy.
transverse
perineal
Obturator
internus
Posterior ------;~~~---:ill
Levator ani
commi ssure
External anal Glut eus

sphincter maximus
B Mediolateral episiotomy at height of co nt ract io n. C Pelvic floo r w it h crow ning of feta l head.
193
Neurovasculature of the Female Genitalia
Fig. 14.15 Nerves ofthe female

perineum and genitalia
Sacral
plexus
Pudendal n.
Inferior
rectal nn.
External anal
sphincte r
A Ne rve sup p ly to the femal e ex te rna l Dor sal Posterior Perin eal nn.
g enitalia. Lesser pelvi s, left lat eral vi ew. clit or al n. labial branches
• Ilioinguinal n. and
genitofemora l n.,
genital branch
0 Pudendal n.
Posterior femoral
0 cutaneous n.
Midd le cluneal nn.
Superior cluneal nn. External Glans of Bulbo Dorsal clitoral n.

urethral orifice clitoris spongi osus (pudendal n.)
0 Inferior cluneal nn.
• Anococcy geal nn. Posterior labial nn.

(pude ndal n.)
labium mi nus
Deep t ransverse
Superficial perineal
tr ansverse
perineal
Perineum
; -- - - - - - Post erior fem oral
cuta neous n.,
Perineal nn. perineal branches
(pudendal n.)
Poste rior fem oral
cut aneous n.
Ischial
tuberosity
Pudendal n.
Anus
Externa l anal Inferior recta l nn. levator Gluteus Inferior
sphincte r (pudendal n.) ani maxim us cluneal nn.
B Senso ry innervation of the fem al e

perin eum. Lithotomy po sition .
194
Fig. 14.16 Blood vessels of the female external genitalia
Inf er io r view.
....
~
~
Deep dorsal
Dorsal
~
Deep
clitora l a. Crus of clito ris clitoral v.
a
Q"
clitoral a. Vestibu lar bulb Deep clitoral vv. Venous plexus of t::
vestibu lar bulb ,.,.
n
-.
A. of
vestibular bulb
Superficial
tran sverse perineal Posterior ~
Posterior
vestibu lar bulb labial w . 0
labial branches
Perineal vv.
~
Q
Perineal a.
Inferior Inferior
Int ernal
pudendal v. =
VI
Int ernal rect al a. recta lw.

pudendal a.
A A rte rial supp ly. B Ven ou s drai nage.
Fig. 14.17 Neurovasculature ofthe female perineum

Lith otomy p o siti on .
Bulbo Vestib ular bulb

spo ngiosus
Ischio Dorsal clitoral a. and n.

cavernosus
Ante rior labial branches

(pudenda l n.)
Superficial
transverse perin eal
A. of vestibular bulb
Posterior labial
branches (pudendal n.)
Ischial tub erosit y
Inferior rectal
a. and v.
Pudendal n.
Internal
pud endal
a. and v.
Deep Perineal nn. Inferior Levat or ani

t ransverse perineal rect al nn.
195
Penis, Scrotum & Spermatic Cord
Fig. 14.18 Penis, scrotum, and spermatic cord

Anterior view. Removed: Skin over the scrotum and spermatic cord.
Superficial Cremaste ric fascia

inguin al ring and cremaster mu scle
Ext ernal Int ern al

spermat ic fascia spermat ic fascia
Femo ral a. and v. Test icular plexus
Test icu lar a.

Ductu s deferens
Pam pi nif orm

plexus External
(test icular vv.) spermatic fascia
Processus
Epid idym is - - - - - -----::::; ; ? ' = - - - ---i vaginalis
Pariet al layer Tuni ca dartos

Tunica
vag inalis
{
Viscera/l ayer
Scro t um
Fig. 14.19 Spermatic cord: Contents

Cross section.
A. and v. of ------~ Ob lit erat ed
duct us deferens processus vaginalis
Ilioin gu inal n.
Ductu s deferens ~~~:--G~~~~-~~~~---- Aut onom ic nn.

(test icular plexus)
Genit ofem oral n.,
genit al branch
--"'ffi- '-¥.:'r-- - Test icular vv.

(= pampin iform plexu s)
Test icular a.
Ext ernal
Fibrous stro ma spermat ic fascia
Crema st eric fascia

Cremast er
Int ernal
Cremasteric a. and v.
spermat ic fascia
196
Fig. 14.20 Penis
Urin ary
bladder
Uret hra
(preprostatic
part )
Super ficial dorsal
Prostate pen ile v. Penile skin
Superficial
Urethra
penile fascia
(me mbra no us Dor sal
part ) penil e
Deep
a. and n. penile fascia
Bulbou rethra l
gland Urethral Deep
Tunica albug in ea
am pulla dorsal
of corpus
penile v.
cavernosum
Crus of penis
Cor pus
sponqiosurn ,
bulb of penis Uret hra
Deep
(spongy part )
penil e a.
Corpus
Orifices of
cavernosum
Penile sept um
urethral glands
Corpus
31~----:i'=--- Uret hra
cavernosum Tunica albug i
(spong y part)
nea of corp us
Branches of
deep penil e a. spo ngio sum
Corpus
Uret hral a. spongiosum
Glans penis Navicular
fossa
B Cross sect ion through the shaft of the penis.
External
urethra l orif ice.
urethral crest
A Longitudinal sectio n.
Corona
Pub ic sym physis
of glans
Dorsal
penile
a. and n.
I Deep
do rsal
Glans
penis
penil e v.
Corpus - - -+-)
~--'----";;.------- Deep caverno sum
Corpus penil e a.
caverno sum
Corpus
spongiosum
Body
of pen is
Bulb of penis. Superior
corpus spong io sum spo ng iosus pub ic ram us Crus of penis
C Cross sect ion through th e root of th e penis.
Obt urato r foram en
Bulbospo ngio sus
Ischiocavernosus
Ischiopub ic ramu s
Root
Bulb of penis
of penis
Deep transverse
perineal
Perineal mem brane
D Inferior view.
197
Testis & Epididymis
.~ Fig. 14.21 Testis and epididymis

~ Left lateralview.
ca
~ Skin - - - - - - - - -
E
.g Int ernal spermat ic
..Q fascia
c:x::
Tunica vaginalis, ----!---~

parietal layer
,;- -- Epididymi s, body
Epididymi s.
head ~.J---- Testi s wi t h tuni ca vaginalis,
vi sceral layer
Glans peni s - ---'[!';
Scrotu m
A Testis and epididymis in situ.
Testicular a.
Pampiniform
plexus (test icular vv.)
Epididymi s
~-4---- Epidid ymi s
(head)
(body)
Septu m -_~~..L.c.=. ..,
Epididymi s
(body) Rete test is _ _ ~~~2J~~ Ductu s
Mediast inum in testicular def erens
testi s m ediastinum
Ductu s deferens
Epididymi s Epididymis
(ta il) (t ail)
Lobul e
B Surface anatomy of the

testis and epididymis. C Sagittal section.
198
• II> .... • • • • .. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • <II •••••••••••••••
Abdominal· .
. Covering of the testis
wall derivative
CD Scrotal skin Abdominal skin
Dartos fascia and

11) Tunica dartos
muscle
External spermatic
Scrotal septum ------:::....::!~~lIlj/ll ® External oblique
fascia
Cremaster muscle
Testicular mediastinum ® Internal oblique
and fascia *
with rete testis
Internal spermatic Transversalis
®
fascia fascia
Tunica
Tunica vaginalis,
Testicular a. albuginea @
parietal layer
Peritoneum
Tunica vaginalis,
Ductus deferens Pampiniform plexus @
visceral layer
* The transversus abdominishas no contribution

. .. .
•
.Transverse section through right testis, superior view.
to the spermatic cord of the testis.
Fig. 14.22 Blood vessels of the testis

Left lateral view.
Testicular
vv. (pampini Testicular a.
form plexus)
A. of
Epididymal duct Epididymal duct
ductus deferens
(head of epididymis) (body of epididymis)
'I~
II Vv. of ductus
deferens
- - - - Cremasteric a. and v.
Efferent
ductules
Straight
seminiferous Ductus
tubules
deferens
Rete testis
Lobule with convoluted Epididymal duct
seminiferous tubules (tail of epididymis)
o Seminiferous tubules.
199
Male Accessory Sex Glands
Fig. 14.23 Accessory sex glands CD Urinary bladder ® Seminal vesicle

~ Ureter (spongy part) ® Prostate
Q) Ductus deferens (j) Bulbourethral gland
@) Urethra
Central zone
Ejaculatory
duct* Peripheral zone
®
Prostatic
capsule
Pubis
Urethral
sphincter
Corpus Corpus Ischio

cavernosum spongiosum cavernosus
A Posterior view. *The ducts of the seminal vesicle and ductus

deferens combine to form the ejaculatory duct.
B MRI. Coronal section, anterior view.

Fig. 14.24 Prostate
The prostate may be divided anatomically (top
row) or clinically (bottom row).
Neck of
bladder Base
Urethra
I Prostatic
isthmus
Prostate
Membranous
pa rt Ureth ra
Ejaculatory
duct orifices
Apex
~+'--~--+-- Seminal
colliculus
A Coronal section, anterior view. B Sagittal section, C Transverse section,

left lateral view. superior view.
D Peripheral zone D Centra I zone D Periurethral

(outer zone) (inner zone) zone
200
Fig. 14.25 Prostate in situ
Sagittal section through the male pelvis, left lateral view.
Visceral Urinary Urinary

Bladder (apex) peritoneum bladder (body) bladder (neck)
Superficial abdominal Rectovesical

fascia (deep layer) pouch
Pubic symphysis Urinary bladder (fundus)
Retropubic space
Seminal vesicle
Superficial dorsal
penile v.
Rectum
Ejaculatory duct
Prostate
Rectoprostatic fascia
Deep transverse
Corpus spongiosum of penis perineal
Bulbourethral gland
Glans penis Bulbospongiosus
Prepuce
Urethra,
navicular fossa Scrotal septum Scrotum
Prostaticcarclnoma:and hypertrophy ,
Prostatic carcinoma is on~ of the ,most common malignant tumors inolder of the gland, prostatic carcinoma does not cause urinary outflow obstruction
men, Qftengro\JVing ala subcapsular, location in the peripheral zone ofthe ' i~ 'its early stages. Being in the peripheral zone,the tumor i~ palpable a~'a firm
: prostate. Unlike benign prostatic hyperplasia, which begins inthe central, part mass'through the anterior wall of the rectum during rectal examination.
::!--+~~~- Rectouterine
Urinary ----=r--~~~ pouch
bladder
::::-:;-~~~~-- Rectum
Prostatic
carcinoma,
subcapsular
B Prostatic carcinoma
(arrow) with bladder
A Common site of prostatic carcinoma. infiltration.
" ,"In' certainprostate diseases, e~pedally ca~cer,increased arn~Lints of a' protein,

, prostate-specific antigen or PSA, 'appear in the blood~ This protein can be,
me~sured byasirnple blood test. . .
201
Neurovasculature of the Male Genitalia
Fig. 14.26 Neurovasculature of the male genitalia Fig. 14.27 Neurovasculature of the penis and scrotum
Left lateral view.
Femoral External pudendal Superficial

Dorsal Deep transverse
a. and v. a. a n / inguinal ring
penile n. perineal
Ilioinguinal n.
~~~- Sacral External

plexus spermatic fascia
Pudendal n.
Inferior
rectal nn.
Perineal nn.
Posterior scrotal nn.

Superficial dorsal
penile vv.
A Nerve supply.
Deep dorsal
penile v.
Dorsal penile
Dorsal Deep Internal a. and n.
penile a. penile a. iliac a.
Superficial
Middle rectal a.
penile fascia
Internal
pudendal a.
Inferior rectal a.
A Anterior view. Partially removed: Skin and fascia.
External
pudendal a. and v.
Deep dorsal
B Arterial supply. penilev.
Dorsal penile
a. and n.
Prostatic
venous plexus
Tunica
Vesical venous albuginea
plexus
~,.......rr-- Internal
iliacv. Superficial dorsal
penile vv.
Deep Internal
penile vv. pudendal v.
Inferior
==r---- Deep penile
rectal vv.
fascia
Bulbar penile vv.
Posterior
scrotal vv. Corona of
glans
C Venous drainage.
Glans penis
B Dorsal vasculature of the penis.
202
Fig. 14.28 Nerves of the male Ilioinguinal n. and
Bulbo genitofemoral n.,
perineum and genitalia genital branch
Scrotum spongiosus Posterior scrotal nn.
Lithotomy position.
(pudendal n.) Pudendal n.
CJ
Posterior femoral
CJ cutaneous n.
CJ Anococcygeal nn.
Dorsal n. of penis
(pudendal n.) Middle cluneal nn.
Superficial Gracilis
CJ Superior cluneal nn.
transverse
perineal Ischio
CJ Inferior cluneal nn.
cavernosus
Perineum
Adductor
magnus
i..F - ' : I p t - - - . , ! ! B 7 ' - - - - - - - - Posterior femoral

cutaneous n.
Pudendal n.
Ischial
tuberosity
Perineal nn.
(pudendal n.)
Anus
External anal Inferior rectal nn. Levator Gluteus
sphincter (pudendal n.) ani maximus
Fig. 14.29 Neurovasculature of the

male perineum
Corpora Deep dorsal
Lithotomy position.
cavernosa penile v.
Arcuate pubic
Corpus ligament
spongiosum
Transverse
perineal ligament
Spermatic -~~~~
cord Dorsal penile a.
Bulbo
spongiosus Dorsal
penile n.
Posterior
scrotal nn. Muscular branches
Bulbourethral
Perineal nn. gland
Anus Ischial
tuberosity
Inferior
rectal nn. Internal
pudendal a. and v.
External anal
sphincter Pudendal n.
Gluteus Inferior rectal

maximus a. and v.
203
Development of the Genitalia
~ The male and female genitalia are

IIIIiiiII derived from a common gonadal
primordium.
Fig. 14.30 Development of Genital tubercle

the external genitalia ----,,-'(fit,·. \ Urogenital fold
Urogenital sinus ~~r- Labioscrotal swelling
Anal folds G:::J
cf
Glans penis
Penile Prepuce of clitoris
t ~ ;~:~~~sa
raphe Glans of
clitoris
of penis
Vestibule
Scrotum of vagina
Perineal Perineal
raphe Anus raphe

Anus
Fig. 14.31 Descent of the testis

Left lateral view.
Processus Pubic Peritoneal
Testis Epididymis vaginalis symphysis cavity
Peritoneal
cavity
Obliterated _ _--+~----l.
processus ~------- Ductus
vaginalis deferens
Ductus Inguinal
deferens canal
Gubernaculum Labioscrotal Gubernaculum

Pubic symphysis swelling
A 2nd month of B 3rd month. C Birth. o After obliteration of the processus
development. vaginalis of the peritoneum.
204
Fig. 14.32 Development of
the internal genitalia
Anterior view.
Mesonephric -~ ~~-- Gonad primordium
(wolffian) duct
Paramesonephric -~ \+'";;;ii............- - Caudal gonadal

(mOllerian) duct ligament (gubernaculum)
Primordium of prostate --~ Primordium of

bulbourethral glands or
Urogenital sinus - - - + greater vestibular glands
Uterus
Seminal vesicle Uterine tube
i.~~4..1~~,.--~-----"..,."..,2.-- Epoophoron
Ductus deferens
Ovarian suspensory
Prostatic
ligament
utricle
Ovary
Prostate
--~------....,....-'"
Proper ovarian ligament

Bulbourethral
gland
Gartner's duct
(embryonic remnant
Spermatic cord
of wolffian duct)
Epididymis Round ligament

of uterus
Vagina
Greater vestibular Pa ra ureth ra I

Appendix of testis Testis gland gland
A Genetically male embryo (testicular primordium). B Genetically female embryo (ovarian primordium).
Nonfunctioning remnants in italics. Structures common to both sexes in bold.
Rudiment Male 'structure Female structure

Und ifferentiated. gonad Testis Ovary
Cortex Seminiferous tubules Follicle
Rete testis Ovarian stroma

Mesonephric Efferent ductules paradidymis Epo- and paroophoron
Ureter, renal pelvis and calices, collecting ducts
Mesonephric (wolffian) duct
r.
duct, ductus deferens, eJdLUldLUI YUULL, seminal vesicle -
Uterine tube, uterus; vagina (superior Mo~gagni's

Paramesonephric (mullerian) duct Appendix of testis .
hydatids
..
Bladder,'urethra
Urogenital sinus
Prostate, bulbourethral gland, prostatic utricle Vagina (inferior po greater and lesser vestibular glands
Phallus (genital tubercle) Corpus cavernosum of penis Clitoris, glans of clitoris
Genital Glans'of penis, penile raphe Labia minora, vestibular bulb
Labioscrotal Scrotum Labia majora
Gubernaculum (;1 n- of testis Proper ovarian ligament, round IIYdlllellL uf ULel U~

Genital tuberde(ofMOller) Seminal colliculus Hymen
205
Arteries of the Abdomen
Fig. 15.1 Abdominal aorta and major branches

Anterior view. The abdominal aorta enters the abdomen at the T12 level
through the aortic aperture of the diaphragm (see p. 54). Before bifur
cating at L4 into its terminal branches, the common iliac arteries, the
abdominal aorta gives off the renal arteries (see p. 209) and three major
trunks that supply the organs of the alimentary canal:
Celiac trunk: Supplies the structures of the foregut, the anterior portion
of the alimentary canal. The foregut consists of the esophagus (distal
half), stomach, duodenum (proximal half), liver, gallbladder, and pan
I-~~~~+---- Celiac trunk
creas (superior portion). (L1)
Superior mesenteric a.
(L1)
Superior mesenteric artery: Supplies the structures of the midgut: '"'t--I1?"'----7-"--- Renal aa.
the duodenum (distal half), jejunum and ileum, cecum and appendix, Inferior mesenteric a. -------::::'::=---~~. (L1/L2)
ascending and transverse colons, and right colic (hepatic) flexure. (L3)
~~-f----t----- Left common
Aortic bifurcation iliac a.
Inferior mesenteric artery: Supplies the structures of the hindgut: the
(L4)
transverse colon (distal third), left colic (splenic) flexure, descending and
sigmoid colons, rectum, and anal canal (upper part).
. .. . .
@ The abdominal aorta gives rise to three major unpaired trunks (bold) and the
Right superior
Left superior unpaired median sacral artery, as well as six paired branches.
suprarenal a.
suprarenal a. ,..
Branch from abdominal aorta Branches
Common hepatic a.
@ ® Inferior phrenic aa. (paired) Superior suprarenal aa.
Right gastric a. ---;::~~
Left gastric a.
Proper hepatic a. Spl-enic a.
Gastroduodenal a. ~-- Left inferior @ Celiac trunk Proper hep~tic a.
- .
~ suprarenal a. Common
Right gastric a.
hepatica.
® r: a.
® ® Middle suprarenal aa. (paired)

F,---- ® @) Superior mesenteric a.
@ ® Renal aa. (paired) Inferior suprarenal aa.
@ ® Lumbar aa. (1 st through 4th, paired)
@---~~ ~---® @ ® Testicular/ovarian aa. (paired)
® Inferior mesenteric a.
External iliac a.
@ ® Common iliac aa. (paired)
Internal iliac a.
.... . .. . .. ... .. .. . . .. .. . . .... . . ....... .,
. @) Median sacral a.
206
Fig. 15.2 Celiac trunk Common Abdominal
hepatic a. aorta
Celiac
trunk
Left
gastric a.
Common --~~~~~~-.;p.,:#+---- Splenic a.

hepatic a.
)~7------'~-:------- Abd ami naI
aorta
Gastroduodenal a. ------!i\.
l!:!--~- Left gastro

Right gastric a. -----':iii omental a.
Anterior/posterior superior ---~!!L---"'II!!JIIII...

pancreaticoduodenal a.
Right gastro
A Location, anterior view. Duodenal branches
omental a.
Inferior pancreatico
duodenal a.
~-- Superior mesenteric a.

B Celiac trunk distribution.
Fig. 15.3 Superior mesenteric artery

Anterior view.
Fig. 15.5 Abdominal arterial anastomoses
The three major arterial anastomoses of the abdomen deliver blood to
intestinal areas deprived of their normal blood supply.
Esophagus
Stomach
CD Celiac trunk Liver
Inferior (supplies the foregut): Gallbladder
pancreatico Pancreas
-...tJ~~~~--- Superior Duodenum
duodenal a.
mesenteric a.
Jejunum and ileum
Middle
~~~~'="'-.:--';----- Right colic a.

o Superior mesenteric a. Cecum and appendix
colic a. (supplies the midgut): Ascending colon
Hepatic (right colic) flexure
Ileocolic a. Transverse colon
Splenic (left colic) flexure
@ Inferior mesenteric a. Descending and sigmoid colons
(supplies the hindgut): Rectum
Anal canal (upper part)
Fig. 15.4 Inferior mesenteric artery
Anterior view.
Pancreatico- -------;;D
duodenal aa. 'e;----- Middle

colic a.
I!----- Left
colic a.
Inferior --~-----"~~'.\I\
Common
mesenteric a.
1!!----- Superior
rectal a.
~-- Middle/
Superior
inferior
rectal a.
rectal aa.
Sigmoid aa. Left colic a.
207
Abdominal Aorta & Renal Arteries
Fig. 15.6 Abdominal aorta

Anterior view of the female abdomen. Removed: Abdominal organs
and peritoneum. The abdominal aorta is the distal continuation of the
thoracic aorta (see p. 68). It enters the abdomen at the T12 level and
bifurcates into the common iliac arteries at L4.
Esophagus
Inferior
Left superior
vena cava
suprarenal aa.
Left inferior
phrenic a.
Aortic aperture
of diaphragm Left middle
suprarenal a.
Celiac trunk
Left inferior
suprarenal a.
Superior
mesenteric a. Left renal a.
Left 1 st
lumbar a.
Abdominal aorta
Inferior
mesenteric a. Left ova ria n a.
(testicular a.
Right common in males)
iliac a.
Left ureter
Median
sacral a.
Left iliolumbar a.
Right internal Left superior
iliac a. gluteal a.
Right external Left lateral
iliac a. sacral a.
Right Sacral
umbilical a. plexus
Right
Left deep
obturator a.
circumflex
iliac a.
Right inferior
vesical a.
Left inferior
epigastric a.
Femoral a. and v. Uterine a. Right middle Right inferior

rectal a. gluteal a.
Obturator branch of right Right internal

inferior epigastric a. pudendal a.
208
Fig. 15.7 Renal arteries
Left kidney, anterior view. The renal arteries arise at approximately the
level of L2. Each renal artery divides into an anterior and a posterior
branch. The anterior branch further divides into four segmental arteries
(circled).
Medullary pyramid
Interlobar a. Arcuate a.
(between the (at base of medullary
medullary pyramids) pyramids)
Major calix
Superior segmental a.
Anterior superior
segmental a.
Capsular branches
Interlobular a.
Inferior suprarenal a.
Fibrous capsule
Left renal a. ---------l

Branch of posterior
(main trunk)
segmental a.
Left renal a. Renal pelvis
(anterior branch)
Anterior inferior
Left renal a. segmental a.
(posterior branch)
Inferior segmental a.
Ureteral branches
Left ureter
(origin from
renal pelvis)
Renal hypertension'
The kidney i~ an importantbloodpressure sensor
and regulator. Stenosis of the renal artery reduces
blood flow through ~he kidn~y and stimulates
_increasedproduction'of renin,'a hormone that

c1e~ves angiotensinogento form angiotensin L
· Su~?equentcleavage yields angiotensin II, which
· induces vasoconstriction andan increase in blood
· pressure. Renal hypertension must be excluded (or
.. >~on~irmed)wh~ndiagnosing high. blood pressure.
Stenosis of the right renal artery (arrow),

visible via arteriography.
209
Celiac Trunk
'S 3 The distribution of the celiac trunk is shown on p. 207.
~
~
~ Fig. 15.8 Celiac trunk: Stomach, liver, and gallbladder
E Anterior view. Opened: Lesser omentum. Incised: Greater omentum. The
.g celiac trunk arises from the abdominal aorta at about the level of L1.
..Q
c::e
Proper hepatic a., Abdominal
left branch aorta Left gastric a.
Proper hepatic a., Inferior Lesser
right branch vena cava omentum
Liver
Stomach
Gallbladder Spleen
Cystic a.
Proper
hepatic a.
Portal v.
Celiac trunk -~~~
Common -~~~
hepatic a.
Bile duct
Right
gastric a.
Posterior
superior
pancreatico
duodenal a.
Gastro
duodenal a.
Splenic a.
Anterior superior Pancreas Greater

pancreaticoduodenal a. omentum
210
Fig. 15.9 Celiac trunk: Pancreas, duodenum, and spleen
Anterior view. Removed: Stomach (body) and lesser omentum.
Inferior Common Celiac

vena cava hepatic a. Left gastric a. trunk
Splenic a.
Posterior
gastric a.
Short
gastric aa.
Cystic a. --------i
Proper -------'
hepatic a.
Portal v. - - -
Right gastric a. ------;;~
Gastro- _-------w
duodenal a.
Left gastro
omental a.
Supra A. of pa ncre
duodenal a. atic tail
(variant)
Pancreatic
Posterior superior branches
pancreatico Great
duodenal a. pancreatic a.
Anterior superior Inferior

pancreatico pancreatic a.
duodenal a.
Duodenal branch
Posterior branch Superior Dorsal Transverse

Inferior mesenteric a. pancreatic a. mesocolon (root)
pancreatico and v.
duodenal a. {
Anterior branch Inferior pancreatico Anastomosis between
duodenal a. superior mesenteric a.
and inferior pancreatic a.
211
Superior & Inferior Mesenteric Arteries
Fig. 15.10 Superior mesenteric artery

Anterior view. Partially removed: Stomach and peritoneum.
Note: The middle colic artery has been truncated (see Fig. 15.11). The
superior and inferior mesenteric arteries arise from the aorta opposite
L2 and L3, respectively.
Portal v.
Inferior vena cava
Proper hepatic a. Left

gastric a.
Right gastric a.
Common
Gastroduodenal a. hepatic a.
Splenic a.
Left renal v.
Left
renal a.
Right gastro
omental a.
Superior
mesenteric
Anterior superior
a.
pancreatico
duodenal a. Middle
colic a.
Inferior pancreatico
duodenal a., anterior
and posterior branches
Jejunal aa.
Right colic a.
Marginal a.
Ileocolic a. Ileal aa.
Colic branch
Ileal branch
Posterior
cecal a. Vasa recta
Anterior
cecal a.
212
Fig. 15.11 Inferior mesenteric artery
Anterior view. Removed: Jejunum and ileum. Reflected: Transverse colon.
Greater
omentum
Transverse --~====:-,=-~~-i::=-=~~~--=='==::::::tl;s.'
colon
Left colic (splenic)

flexure
Middle Superior
colic a. mesenteric a.
Duodenum
Abdominal aorta
Right colic a.
Descending colon
Inferior vena cava
Inferior
Ascending colon mesenteric a.
Left colic a.
Right common Aortic bifurcation

iliac a.
Sigmoid aa.
Ileocolic a.
Colic branch
Superior
rectal a.
Ileal branch
Posterior Sigmoid colon

cecal a.
Anterior
cecal a.
213
Veins of the Abdomen
Fig. 15.12 Inferior vena cava: Location

. . ... .. . " .
Anterior view.
Hemiazygos v.
Azygos v. ----~
@ -----:~~.. ~ ..p-P------!:!------- ®
(1)
®
Inferior vena cava
L4 vertebra ------,,-'==...,~
G------ Abdominal aorta
~--=,-"':'--- Common iliac v.
\.O.!------':*":!----@
Fig. 15.13 Tributaries of the renal veins

Anterior view.
Right inferior Left inferior

phrenic v. phrenic v.
Anastomosis
Inferior ---'---------+.::=oo
vena cava
0 Hepatic vv. (3)
@ ® Suprarenal w. (the right vein is a direct tributary)
@ ® Renal vv. (paired)

renal v.
® ® Testicular/ovarian w. (the right vein is
@ ® Ascending lumbar w. (paired)
@ ® Common iliac w. (paired)
® Median sacral v.
Right testicular! Left testicular!
ovarian v. ovarian v.
214
Fig. 15.14 Portal vein Left gastric v. (with Right Short
To hepatic vv. esophageal vv.) gastric v. gastric vv.
The portal vein (see p. 218) drains venous
blood from the abdominopelvic organs sup
plied by the celiac trunk and superior and
inferior mesenteric arteries.
,.,'o---t''h''---r---- Splenic v.
Cysti c v. -------':-----,=-:=--=----",----7"'--4'J
"<I!o------>...-~---- Pancreatic vv.

Portal v. --+--'-----,~L--~~~-____7'ii.~~"".
Splenic v. ~----- Left gastro

Portal v.
Inferior omental v.
Posterior superior
mesen
Superior --------'-----;!I!" pancreatico
teric v.
mesen duodenal v. .....,;;:~~~~---------Right gastro
'".J.1I-±::::::-:-===-",-..,..:,.---- L4
teric v. Inferior omental v.
pancreatico
duodenal v. (~)--~--'---o----,-----~....,..-\-- Inferior
mesenteric v.
Superior
mesenteric v.
A Location, anterior view.
Midd Ie col ic v. ------I------:---'------~----'<~
Left colic v.
Right colic v. ----\-~--+~~~.,,_J:u" __ .._?T
Ileocolie v. -----I'------:--.----+~-~ ~-------'::~~~r__ Sigmoid vv.
Appendicular v. ---+---+--71/
Subclavian v. ~~==~,.---- Azygos!

Right Left Esophageal hemi
gastric v. gastric v. vv. azygos v. Ileal Jejunal Superior
vv. vv. rectal v.
Superior
vena cava
B Portal vein distribution.
f+--f-.-+----~- Internal
thoracic v.
Porta I v. ------\-,.".,.........---.-,L-+--4:
~...,.;r------H--- Inferior
vena cava
Superior
Paraumbilical vv. --~-~-----f-I epigastric v.
* Clinical -'----,-..--~-~_.~-
/_A-~------jn-- Common
Superior -----i--:!---f.. iliacv. Cancer metastases' ".' " " ,,' ,.' ,
mesenteric v. Tumors in the region drained by the superior ;' '
Periumbilical vv. ---+-+--------'t-':---l.... rectal vein mayspread thro'ugh the portal,
Inferior
to
venous system the capillary bed of the
Inferior epigastric v. Iiver(hepatic metastasis).Turnors drained
mesenteric v. by the middle or inferior rectal veins may
Ascending metastasize to the capiilary bed ofthe lung
lumbarv. .(pulmonary metas~asis) via the inferior vena
Colic vv. cava and right heart..
Superior Middle/inferior
rectal v. rectal v.
C Collateral pathways (portosystemic collaterals). When the portal

system is compromised, nutrient-laden blood may be transported
to the heart via the venae cavae without passing through the liver.
Red arrows indicate flow reversal. 215
Inferior Vena Cava & Renal Veins
Fig. 15.15 Inferior vena cava

Anterior view of the female abdomen. Removed: All organs (except the
left kidney and suprarenal gland).
Hepatic vv. Left inferior

phrenic v.
Esophagus
Inferior vena cava ------=~~
Celiac trunk
Right suprarenal v.
Left suprarenal v.
Superior
mesenteric a.
Right renal v. ---~~ Left ovarian

a. and v.
Ureter
Right ovarian ---~~

a. and v.
Left ascending
Abdominal aorta --------i~~
lumbarv.
Left 3rd
Inferior --------i~~
lumbarv.
mesenteric a.
Left common
Right common
iliac a. and v.
iliacv.
Deep circumflex
iliac a. and v.
Right internal
Left latera I
iliacv.
sacral v.
~~~~~~~-- Left superior

Rig ht externa I
gluteal v.
iliacv.
Right --------i~------=-'-:'-------"!'';;____''ii~~
obturator v.
~~~~~~~~~-- Median sacral
Right middle
a. and v.
rectal v.
Right inferior
'----7'-:;7---::iii~~~~~~~~~~g_-- Rectum
epigastric a.
(and rectal
and v.
venous plexus)
Right internal
pudendal v.
~~~~~~1- Uterine venous
plexus
Right inferior
gluteal v.
Vesical venous
plexus
Right uterine v.
Right inferior
vesical v.
Femoral a. and v. Vagina Urethra
216
Fig. 15.16 Renal veins
Anterior view. See p. 209 for the renal arteries in isolation.
Left inferior
phrenic v.
(anastomosis with
Right inferior
left suprarenal v.)
phrenic a. and v.
Left superior
Inferior vena cava suprarenal aa.
Left inferior
phrenic a.
Right superior
suprarenal a.
Celiac trunk
Right suprarenal v. Left middle

(typically opens suprarenal a.
directly into inferior
vena cava) Left suprarenal v.
(typically opens
Right middle ---=!!'!'!!'!: into left renal v.)
suprarenal a.
Left inferior
suprarenal a.
Right inferior Left renal

suprarenal a. a. and v.
Right renal
a. and v.
Superior
mesenteric a.
Right testicular!
ovarian a. and v.
Left testicular!
ovarian a. and v.
Right ureter
Abdominal aorta
Ureteral branches
(from testicular!
ovarian a. or
Inferior
common iliac a.)
mesenteric a.
217
Portal Vein
~ The portal vein is typically formed by the union of the superior

~ mesenteric and the splenic veins posterior to the neck of the pan
creas. The distribution of the portal vein is shown on p. 215.
Fig. 15.17 Portal vein: Stomach and duodenum

Anterior view. Removed: Liver, lesser omentum, and peritoneum.
Opened: Greater omentum.
Common Inferior Hepatic Celiac Esophageal

hepatic a. vena cava vv. trunk vv.
Proper hepatic a., Left gastric
left and right branches a. and v.
Portal v. Short
gastric vv.
Spleen
Right kidney
and supra
renal gland Splenic
a. and v.
Gastro
duodenal a.
Posterior
superior Left gastro
pancreatico omental
duodenal a. a. and v.
Anterior
superior
pancreatico Splenic a.
duodenal a.
Pancreatico
duodenal v.
Greater
omentum
Inferior pancreatico Middle Superior Rig ht gastro Right gastric

duodenal a. colicv. mesenteric a. and v. omental a. and v. a. and v.
218
Fig. 15.18 Portal vein: Pancreas and spleen
Anterior view. Partially removed: Stomach, pancreas, and peritoneum.
Hepatic vv. Celiac trunk Left gastric a. and v.

Inferior vena
cava
Short
gastric vv.
Proper hepatic
a., left and
right branches
Portal v.
Splenic
a. and v.
Right
gastric a.
Gastro- -~~
duodenal a.
Left gastro
Right
omental a. and v.
gastric v.
Left supra
renal v.
Anterior and
posterior
superior
pancreatico Left renal
duodenal aa. a. and v.
Left ureter
Pa ncreatico
duodenal v.
Ri9ht~'··
~
gastro- \
Left ovarianj
testicular
Inferior pancreatico Superior omental Left Inferior a. and v.
duodenal a., anterior mesenteric a. and v. ascending mesenteric v.
and posterior branches a. and v. lumbarv.
219
Superior & Inferior Mesenteric Veins
Fig. 1S. 19 Superior mesenteric vein

Anterior view. Partially removed: Stomach, pancreas, peritoneum, mesen
tery, and transverse colon. Displaced: Small intestine.
Left gastric
a. and v.
Proper
hepatic a. Inferior vena cava
Portal v. ------::-::-'!~
~==-:-- Splenic a. and v.
Right gastric -------':-:-~J!,±,

a. and v.
Gastro ~~- Left renal a.
duodenal a. ~=---+-i'-- Inferior mesenteric v.
Right gastro --------7::-===:::::::;

~~- Middle colic
omental a. and v.
a. and v.
Pancreatico
duodenal ~~~- Superior mesenteric
a. and vv. a. and v.
Right colic ----~;;==:-

a. and v.
Inferior ---------==-*-=~
vena cava
Jejunal aa.
Ileocolic ----===~~ and vv.
a. and v.
Ileocolic a., --------'---~~

colic branch Ileal aa.
and vv.
Cecal vv. --~--=-------::---=-==~~
Posterior cecal a.,

appendicular v.
Anterior Ileocolic a.,
cecal a. ileal branch
220
Fig. 15.20 Inferior mesenteric vein
Anterior view. Removed: Stomach, pancreas, small intestine, and
peritoneum.
Portal v. Inferior vena cava
Left gastric
a. and v.
Proper hepatic a.
Splenic a. and v.
Right gastric
a. and v. Left renal a.
Gastro Inferior
duodenal a. mesenteric v.
Right gastro
omental a. and v. Middle colic
a. and v.
Superior
mesenteric
a. and v.
Right colic Left colic

a. and v. a. and v.
Ileocolic
a. and v.
Jejunal/ileal
aa. and vv.
Inferior mesenteric
a. and v.
Left common
iliac a. and v.
Sigmoid
aa. and vv.
Cecal vv.
Posterior cecal a. Anterior cecal a. Superior rectal a. and v.
221
Arteries & Veins of the Pelvis
.. " " " ,. " " .. ••••••••••••••••••• " •• " •••••••••••••••••• (It
Right common iliac v. ~-Inferior vena cava

Right common iliac a.
Right internal iliac v.
Right internal Median
iliac a. sacral a.
LS vertebra
Right
external
iliac a.
Right external
Superior iliacv.
®
Piriformis •
vesical a.
Inferior
epigastric a.
Prostatic ---~-~
• Umbilical a., venous plexus
occluded
Deep dorsal
part
A. of ductus penile v.
Obturator branch deferens

• of inferior epigastric a.
Inferior rectal a. • Deep penile vv.
• A Male pelvis. • A Male pelvis.
Right common Inferior vena cava

iliac a. Abdominal
aorta
Right
Right
internal
internal
@ iliacv.
iliac a.
Uterine a.
Uterine vv.
®
Right---+---->
Vaginal a.
external
iliac a.
Right
external
®
Superior
iliacv.
vesical a.
Uterine
venous plexus
Vaginal branch and vaginal
of uterine a. venous plexus
• B Female pelvis. • B Female pelvis.
The i,ilternal iliac artery gives off five parietal (pelvic wall) and four visceral
,(pelvicorgans) branches. * Parietal branches are shown in italics. '
CD Superior gluteal v.
Branches @ Lateral sacral v.
CD Jiolumbara. @ Obturator vv.
@,,, Superior gluteal a.
0 Vesical vv.
@
® Vesical venous plexus
A. of ductus deferens
Middle rectal w. (rectal venous plexus) (also superior and inferior
.0 Umbilicala . ®
Superior vesical a. rectal W., not shown)
<~ Obturator a. (j) Internal pudendal v.
® Inferior vesical a. ® Inferior gluteal vv.
(J) Middle rectal a. The male pelvis also contains a prostatic venous plexus and veins draining the
penis and scrotum. The female pelvis contains'the uterine and vaginal venous
® pudendal a. Inferior rectal a.,
plexus.
s .....
r
'It:' 'VI Y'Ult:'U
,~In the female pelvis. the uterine and vaginal arteries may arise directly from
the'internal iliac artery.
222
Fig. 15.21 Blood vessels of the pelvis
Abdominal aorta ------+:!!!H Idealized right hemipelvis, left lateral view.
Left common
iliac a. and v. Median sacral a.
Right internal iliac a. and v.

Umbilical a.
Right iliolumbar a.
Right ureter
Right lateral sacral v.
Right external
iliac a. and v.
Right superior gluteal a. and v.
Right obturator
Superior rectal a.
a. and v.
and v. (from/to inferior
mesenteric a. and v.)
Right superior
vesical a. and v.
~~~7--- Right inferior vesical
Right ductus a. and v.
deferens and a.
~+--,-,-------,5a--- Right middle rectal
Left ureter ----7---=-~~1iliIiI

a. and v.
Left superior and Seminal vesicle
inferior vesical
a. and v. Left middle rectal

a. and v.
Dorsal penile a" -------=f-------..,...~- __
deep dorsal penile v.
Prostate
Spermatic cord --~,-------"""~~ Left inferior recta I
a. and v.
Left internal pudendal
a. and v.
Posterior scrotal branches,
posterior scrotal v.
A Male pelvis.
Right internal
Right common iliac a.
iliac a. Median sacral a.
Right ovarian a. and v. ~ Right iliolumbar a.
(in ovarian suspensory ligament) ~

Right umbilical a.
Right uterine a. and v.
Right ureter
Right inferior
Right superior vesical a" vesical v.
vesical a.
Superior rectal
Right ovary and ------:-+i~~$"
a. and v.
uterine tube
Right vaginal a.
Right obturator Right middle rectal
a. and v. a. and v.
Right external iliac ~'-'¥-~~-- Uterine venous
a. and v. plexus
Right round Left uterine
ligament of uterus a. and v.
Left superior Vaginal venous
vesical a., vesical v. plexus
Left middle rectal
Left ureter a. and v.
Left inferior vesical
a., vesical v.
Left inferior rectal

a. and v.
Left internal pudendal
a. and v.
B Female pelvis. 223
Arteries & Veins of the Rectum & Genitalia
Fig. 15.22 Blood vessels of the rectum

Posterior view. The main blood supply to the rectum is from the superior
rectal arteries; the middle rectal arteries serve as an anastomosis be
tween the superior and inferior rectal arteries.
Abdominal Inferior
To portal v. aorta vena cava
Inferior
mesenteric t /:: /
a. and v. Median sacral
a. and v.
Sigmoid
aa. and vv.
Superior rectal
a. and v.
Left externaI
iliac a. and v.
Left obturator a.
Left inferior Right inferior

gluteal a. gluteal v.
Left middle Right middle

rectal a. rectal v.
Left internal Right internal

Levator ani pudendal v.
pudendal a.
Left inferior Right inferior
rectal a. rectal v.
224
Fig. 15.23 Blood vessels of the genitalia
Anterior view. Left ureter
Left ovarian a. and v.
Abdominal Inferior mesenteric a.

aorta
Inferior vena cava ------;o>;~

Left common
iliac a. and v.
Median sacral Left interna I

a. and v.
iliac a. and v.
Left external
Rectum
iliac a. and v.
Uterine a.,
Uterine tube
tubal branch
Uterine fundus ~~~~$;---"s.:=---- Ovary

~~::...........,,~~~~--- Umbilical a.,
Middle rectal a. -----;:,~==~~----" patent part
Obturator a., v.,
Round ligaillent - -
and n.
of uterus
Uterine
Inferior
a. and v.
vesical a.
Vaginal a.
Mesometrium
Superior vesical
(of broad ligament)
a., vesical v.
Urinary bladder Umbilical a.,

occluded part
YoIL
A Female pelvis. Removed: Peritoneum (left

side). Displaced: Uterus.
Iliacus Psoas major Right ureter
Testicular a. and v. Internal iliac

a. and v.
External iliac
a. and v.
Sacra I plexus
Umbilical a.
Inguinal ligament
Inferior epigastric Rectum

a. and v.
Saphenous hiatus Urinary

bladder
External pudendal
a. and v.
Femoral a. and v. Penile suspensory

ligament
Pampiniform plexus
(testicular vv.) Left ductus
deferens
Right ductus Dorsum of penis
deferens
Dorsal penile a.,
Internal deep dorsal penile v.
spermatic fascia
Testis
Epididymis Glans penis
B Male pelvis. Opened: Inguinal canal and

coverings of the spermatic cord. 225
Lymph Nodes of the Abdomen & Pelvis
Fig. 16.1 Lymphatic drainage of the internal organs

See Table 16.1 for numbering. Lymph drainage from the abdomen, retroaortic nodes. Efferent lymph vessels from the lumbar and preaortic
pelvis, and lower limb ultimately passes through the lumbar lymph nodes form the lumbar and intestinal trunks, respectively. The lumbar
nodes (clinically: aortic nodes). The lumbar lymph nodes consist of the and intestinal trunks terminate into the cisterna chyli.
right (caval) and left lateral aortic nodes, the preaortic nodes, and the
Thoracic duct --v Cisterna chyli
0---- Left lumbar

trunk
Left common
iliac Ln .
..............
/_._'\
. ..........
CD \~:~ aA
I " ;/'
j/~~-0
--l ~r-- CD Inferior phrenic Ln.
j ~l @ o Celiac Ln.
Cisterna _ _ bJ (_._-_._
chyli i Lumbar G) Superior mesenteric
i! Ln. Preaortic
Ln.
:~:!~
Ln.
Lumbar @) Inferior mesenteric

Ln. Ln.
~ 6 ® Left lateral aortic Ln.
j~~
® Right lateral aortic (caval) Ln.

(j) Retroaortic Ln.
® Common iliac Ln .
• • • • • • • • • • • • • • • • • • • ••'V , : : .
226
Fig. 16.2 lymphatic drainage of the rectum Fig. 16.3 lymphatic drainage of the bladder and urethra
Anterior view. Anterior view.
Abdominal aorta
and I.n.
L- Superior rectal a.
\\"'\
Common
iliac I.n.
1~
(/
/).-/
Internal ------'-,--'----~
Internal iliac a.
iliac I.n. :-----+,,/-,1_ _ Externa I

and I.n.
iliac Ln.
Superficial
Superficial and
inguinall.n.
deep inguinall.n.
Fig. 16.4 lymphatic drainage of the male genitalia Fig. 16.5 lymphatic drainage of the female genitalia
Anterior view. Anterior view.
Inferior vena cava -----+;-- ---+f---- Abdominal aorta
,//. \
Right Common
}!. . common iliac I.n.
r( \\
I II iliac a.
\ .\., ..
) /'
\"1 ;
Internal
Internal iliac Ln. --,--".~--",. ~-~ ~
'c.:.-'
iliac I.n.
\
'"f------if-fu'>-+/--- Sacra I I. n.
External
External iliac I.n. Sacrall.n.
iliac I.n.
Superficial Deep
inguinall.n. inguinall.n.
(horizontal
group)
Superficial inguinall.n.
(vertical group)
lymph nodes of the pelvis

Numbers continued from Table 16.1.
® Superior mesenteric Ln.

Preaortic I.n.
@) Inferior mesenteric I.n.
® Left lateral aortic Ln.

® Right lateral aortic (caval) Ln.
® Common iliac Ln.
® Internal iliac Ln.
@) External iliac I.n.
Horizontal group
® Superficial inguinall.n.
Vertical group
@ Deep inguinal Ln.
® Sacral Ln.
• • • • .. • • • • • • • • • • • • • • . • • • • •• • • • • • • • • • • • • e' ~' , ". ; ,: ;
227
lymph Nodes of the Posterior Abdominal Wall
~ Lymph nodes in the abdomen and pelvis may be classified as ei
~ ther parietal or visceral. The majority of the parietal lymph nodes
are located on the posterior abdominal wall.
Fig. 16.6 Parietal lymph nodes in the abdomen and pelvis

Anterior view. Removed: All visceral structures (except vessels).
Inferior vena cava Esophagus
Celiac I.n.
Diaphragm
Inferior Abdominal aorta

phrenic I.n.
Intestinal trunk
Superior
mesenteric I.n.
Left lumbar trunk

Cisterna chyli
Right lumbar
trunk Retroaortic I.n.
Retrocava II. n. Left lateral aortic I.n.
Intermediate
lumbar I.n. Inferior mesenteric I.n.
Right lateral
cavall.n. Common
iliac I.n.
Common
iliac a.
Internal
iliac I.n.
Sacrall.n. --------:-''-=~-----'''~
External
iliac I.n.
Inguinal ----7----'---..:~_¥~.
ligament
Intermediate ----=-----:"-----.,-~-~~
lacunar I.n.
~gL ...~[J;~~~~\F~#f~=~~- Superficial inguinal

I.n. (horizontal
Deep
--~==.;.=--=~~~ and vertical groups)
inguinall.n.
228
Fig. 16.7 Lymphatic nodes of the urinary organs
Anterior view.
Inferior phrenic Ln.
Retrocava II. n.
Left lateral aortic Ln.
Right lateral caval Ln. --------¥.......
~~~~r--- Preaortic Ln.
Intermediate lumbar Ln. ------5:::i:=;
~-- Common iliac I.n.

Promontory Ln. -----*~=
Fig. 16.8 Drainage of the kidneys (with pelvic organs)
Thoracic duct
Right lumbar trunk Cisterna chyli Left lumbar trllllk
t
Lateral aortic Ln.,
lJ;jtermediate h:lmbar I.n. :Preaortrc Ln.,
Retroaortic Ln. '
t
Obtwratbr L'n. Subaorticl;p. Sacral Ln. ,
t lateral, medial, and

intermediate externa:l '
Promontory Ln.
Lateral, medial, and
Superior and inferior
gluteal-Ln. '
'iliac I.n. , intermediate common
Interiliac Ln. iliac Ln.
t
t
Lower limb, uterus,

and vagina
229
Lymph Nodes of the Anterior Abdominal Organs
Fig. 16.9 lymph nodes of the stomach and liver

Anterior view. Removed: Lesser omentum. Opened: Greater omentum.
Arrows show direction of lymphatic drainage.
Inferior vena cava Celiac I.n. Cardiac

lymphatic ring
Left gastric
I.n.
~~-- Splenic I.n.

Hepatic I.n. -------:-;,~
Portal v. ----".;.-~
~~-- Left gastro
omentall.n.
Pancreatic I.n. --~~
Suprapyloric I.n. -------+~~
Subpyloric I.n. --~~
Right gastro
omentall.n.
230
Fig. 16.10 lymph nodes of the spleen, pancreas,
and duodenum
Anterior view. Removed: Stomach and colon.
Left gastric Ln.
Cystic Ln. --~:-.:-,
Splenic Ln.
Hepatic Ln. --~~~
Celiac Ln.
Suprapyloric Ln.
~---- Pancreatic I.n.
Retropyloric Ln. --~~~ (superior)
Subpyloric Ln. -----;------7
Pancreatic Ln. --------'~~
~~~..,------ Superior
(inferior)
mesenteric I.n.
Pancreaticoduodenal
Ln.
Fig. 16.11 lymphatic drainage of the stomach, liver,

spleen, pancreas, and duodenum
"Thoracic duct
Cisterna chyli
Hepatic I.n. Intestinal tru"nks Splenic I.n.
Cystic Ln.
Foraminal Ln.
1
Celiac I.n.
Superior mesenteric Ln.

Gastric Ln. (right and left)
Pancreatic Ln.
(superior and inferior) Supra-, sub-, "and
retropyloric Ln.
Pancreaticoduodenal Ln. Gastro-omentall.n.

(superior and inferior) (right and left)
231
Lymph Nodes of the Intestines
.S Fig. 16.12 Lymph nodes of the jejunum and ileum

-- Anterior view. Removed: Stomach, liver, pancreas, and colon.
~
~
~
e
.g
..Q
c:(
- - - - Abdominal aorta
~---=..:..o.:~~~~~ Celiac I.n.
Thoracic duct with
cisterna chyli
~~~~f----- Superior
Transverse colon ---~~ mesenteric Ln.
Duodenum
Ascending colon ---~~
~~-- Intermediate
mesenteric Ln.
Ileocolic Ln. ---~~~
JuxtaintestinalLn.
~-~--Ileum
Fig. 16.13 lymphatic drainage of the intestines
Thoracic duct
t
Left lumbar trunk Cisterna chyli' . Intestinal trunks
. Lateral aortic I.n.

Preaortic I.n.
Juxtaintestina·ll.n.
Prececall.n.
Retroceca II. n..
Left colic I.n.
Ileocolic Ln.·
Middle colic Ln. Appendicular Ln.
Right colic Ln. . ...
232
Fig. 16.14 Lymph nodes of the large intestine
Anterior view. Reflected: Transverse colon and greater omentum.
Epicolic I.n.
Superior
Middle colic I.n. mesenteric I.n.
Left colic I.n.

Right colic I.n.
Paracolic I.n.
Inferior -------=....:....,+-=:=
mesenteric I.n.
Ileocolic I.n. Intermediate

colic I.n.
Sigmoid I.n.
Superior
Prececall.n. rectall.n.
233
lymph Nodes of the Genitalia
Fig. 16.15 lymph nodes of the male genitalia

Anterior view. Removed: Gastrointestinal tract (except rectal stump)
and peritoneum.
=---=-=-==-:'-:--:---- Left Ium ba r I. n.

Right lumbar Ln. ----:---~
~~~--- Inferior mesenteric Ln.

Intermediate
lumbar I.n.
~~~--- Common iliac Ln.
Abdominal --~;...+
aorta
~~~~~-- Sacral Ln.

Promontory Ln. --f~~~~
~~'55"-~~-- External iliac Ln.
External ----:---~~~~~
iliac a.
~~;--~i1'7--~-- Rectum
. . .~ ~·-.&Ullrl&iiii~~~~___=_+---Superficial inguinal
Urinary bladder -----====--=-=-:-=----:;,,.,,..::---~---=.-~ I.n. (horizontal group)
Deep inguinal Ln. ---=--~----7:=-----+------,-:~----Ji.
~~~'-------e:-:::-:~~~;-....--Superficial inguinal
I.n. (vertical group)
Epididymis ------;;--------~~~~~
Testis -~;----------~-~~~ ~-------~----.,,-=..,,;..---Penis
~-------~---.--+--- Scrotum
234
Fig. 16. 16 lymph nodes of the female genitalia
Anterior view. Removed: Gastrointestinal tract (except rectal stump) and
peritoneum. Retracted: Uterus.
Intermediate ----~ Inferior mesenteric Ln.

lumbar Ln.
Common iliac Ln.
Promontory Ln. ~~
Rectum ~~:=S::::~~~--- Sacrall.n.
Uterine tube Internal iliac Ln.
Ovary ---~----'-::~~
External iliac Ln.
Mesometrium --------i"'''---------''"~:.............,~~~
.....
~~~~~~~~--- Obturator Ln.
Intermediate ~~!!!L.:::::;lL..-~~~~~~~-- Superficial inguinal

lacunar Ln. Ln. (horizontal group)
~~~~~~~--f-;-'=':"'=~~-- Superficial inguinal

Deep inguinal Ln. Ln. (vertical group)
Fig. 16.17 lymphatic drainage of the pelvic organs
Thoracic duct
t
, Right lumbar trunk Cisterna chyli' ~'- left lu'inbar trunk
Left lumbar Ln.
Lateral c~lVal Ln. t LateraI aortic'I. n.
Precaval Ln; ~ntermediate lumbar I.n. Preaortic I.n.
, Retrocava II. n. Retroaortic Ln.
t
Lacunar I.n. (lateral. ---. Common iliac I.n. ~ Internal iliac I.n.
medial. and intermediate)
Obturator I.n. Subaorbc I.n. Sacral Ln.
t . Lateral. medial. and

intermediate external
Promontory Ln.
Lateral. medial. and
Superior and inferior
gluteall.n.
, iliac Ion; intermediate common' '
t
. Interiliac Ln. iliac Ln.
t
Visceral pelvic I.n.
Superficial inguinal Ln.
Pararectall.n.
Jt
Parauterine Ln.
ParavaginaIL~.
Latera'i vesical Ln. ......t - - - - \ . , l
Pre- and retrovesicall.n.
235
Autonomic Plexuses
.............. " IJ •••
Ganglia Subplexus Distribution
Sympathetic
trunk with
lumbar ganglia
A Celiac ganglia
Gastric plexus
Splenic plexus
plexus • Liver, gallbladder
• Stomach
• Spleen
Pancreatic plexus • Pancreas
Superior mesenteric plexus
• Pancreas (hea'd) • Cecum
• Duodenum • Colon (to left
• Jejunum colic flexure)
• Ileum
-:-~.UlJlraf·enal and renal plexus
• Suprarenal grand '

Aorticorenal
Inter- ---:+--+",,~~ Ureteral plexus • Kidney
ganglion
mesenteric • Proximalureter
plexus
Ovarian/testicular plexus
Inferior mesenteric plexus
Left colic plexus • Left colic flexure
• Descending and sigmoid colon

• Upper rectum '
• Pelvic viscera
• Middle and lower rectum
Sacral -------,,4r...-.....;~- .-'---..;:_- ...,~ • Prostate

• Ejaculatory duct
ganglia .• Seminal vesicle
Prostatic plexus • Penis
• Bu1bourethral
• Urethra
gland
Pelvic ganglia
• Ductus deferens
Deferential plexus
• Uterus • Vagina
Uterovaginal plexus
• Uterine tube • Ovary
Ganglion
Vesical plexus • Urinarybladder

impar
Ureteral plexus • Ureter (ascending from pelvis)

.. .. .. • .. .. • .. • • • .. .. • .. • • • • • • .. • • • • • • .. .. • • .. • • • • • . . . : . " , , , . . . " " . " , •••• , . " " ...... " " ...... " " ' " ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' " .. " " " " .. " . " , , .. ; , , , , , , , . " ...... " . " . " . " " " " " . " , , , . , , . , , " " " " " ' " " " " " " . " " . , , , , , ..,., d •• "
236
Fig. 17.1 Autonomic plexuses in the abdomen and pelvis
Anterior view of the male abdomen. Removed: Peritoneum and majority
of the stomach.
Posterior vagal trunk, Posterior Anterior

celiac branch vagal trunk vagal trunk
Right greater
splanchnic n.
Left greater
Right lesser
splanchnic n.
splanchnic n.
Left lesser
Celiac ganglion splanchnic n.
Suprarenal
Superior
plexus
mesenteric ganglion
Renal plexus --~~ ~~-- Aorticorenal

ganglia
Lumbar
Intermesenteric ------r-:;...= ganglia
plexus
Sympa
thetic
Ureteral plexus -----;~ Inter trunk
ganglionic
Inferior trunk
mesenteric
ganglion ~'<---- Testicularj
ovarian plexus
~~~~~-- Hypogastric nn.
Superior hypo ---~~~

gastric plexus
~~~~~~-- Sympathetic trunk,
sacral ganglia
Gray rami
~~~~~=---- 1st sacral n.,
communicantes
anterior ramus
Pelvic Left hypogastric n.

splanchnic nn.
Sacral plexus
Ga nglion impa r -----7--"-------;-'----'------:.."..-----".,..,------'--------"
237
Innervation of the Abdominal Organs
Fig. 17.2 Innervation of the anterior abdominal organs

Anterior view. Removed: Lesser omentum, ascending colon, and parts of
the transverse colon. Opened: Lesser sac. The anterior and posterior vagal
trunks each produce a celiac, hepatic, and pyloric branch, and a gastric
plexus. See p. 245 for schematic.
Posterior vagal trunk,

celiac branch
Anterior vagal trunk
Anterior
gastric plexus
Anterior Gastric plexus

vagal trunk, (on left
hepatic branch gastric a.)
~~-- Splenic plexus
Anterior ~*--- Left greater

vagal trunk, splanchnic n.
pyloric branch
Left lesser
Margin of splanchnic n.
hepatoduodenal
ligament
Celiac ganglia
Hepatic plexus (on

common hepatic a.) Branches of
gastric plexus
Pancreatic (on gastro
plexus omental aa.)
(on pancreatico
duodenal aa.)
Superior ---~~
mesenteric
plexus
(on superior
mesenteric a.)
238
Fig. 17.3 Innervation of the urinary organs
Anterior view of the male abdomen and pelvis. Removed: Abdominal
organs and peritoneum. See p. 246 for schematic.
Right greater Posterior

splanchnic n. vagal trunk
Right lesser Anterior

splanchnic n. vagal trunk
~i---- Celiac ganglion
~~-- Aorticorenal
Suprarenal plexus ganglia
~--- Superior mesen

Renal plexus
teric ganglion
Intermesen- ------=;-
teric plexus
Sympathetic trunk, Inferior mesen

lumbar ganglia teric ganglion
Ureteral plexus ---~ ~--- Testicular plexus
Inferior mesen
teric plexus
Iliac plexus ---+;; ~~~~~-- Superior hypo

gastric plexus
Left hypo
Sympathetic trunk, gastric n.
sacral ganglia
1st sacral n.,
Right hypo --------'---'!O~ anterior ramus
gastric n.
Inferior hypo
gastric plexus
Pelvic splanchnic nn. --------,...="'---=-~~~
Middle rectal
plexus
Vesical plexus -------~--~
Prostati c plexus ------;;;;~~-----'-=---=---~~---=
239
Innervation of the Intestines
Fig. 17.4 Innervation of the small intestine

Anterior view. Partially removed: Stomach, pancreas,
and transverse colon (distal part). See p. 245 for schematic.
Anterior vagal trunk, Posterior Anterior

hepatic branch vagal trunk vagal trunk
Right greater
splanchnic n. Posterior vagal
trunk, celiac
branch
Left greater
splanchnic n.
Celiac ganglia
Splenic plexus
Left lesser
splanchnic n.
Aorticorenal
ganglion
Rena I plexus
Superior mesen
teric ganglion
Superior
mesenteric
Testicular
plexus
(ovarian) plexus
~:::;::~-~~----:;:~~~~~---
Jejunal and ileal aa.
(with autonomic
plexuses)
Right colic a. --~~~
(with autonomic
plexus)
Ileocolic a. -------;....-~~
(with autonomic
plexus)
240
Fig. 17.5 Innervation of the large intestine
Anterior view. Removed: Jejunum and ileum. Reflected: Transverse and
sigmoid colons. See p. 245 for schematic.
Transverse
colon
Left colic a.
Middle and right (with autonomic
colic aa. (with plexus)
autonomic
plexuses) Descending
colon
Intermesenteric
plexus
Inferior mesen
teric ganglion
Ileocolic a. (with
autonomic plexus) Inferior mesen
teric plexus
Ascending colon
Superior hypo- Sigmoid aa.

gastric plexus (with autonomic
plexus)
Right hypo
gastric n.
Inferior hypo
gastric plexus,
branches to
descending
colon and
Superior
sigmoid colon
recta I a. (with
autonomic plexus)
241
Innervation of the Pelvis
Fig. 17.6 Innervation of the female pelvis

Right pelvis, left lateral view. Reflected: Uterus and rectum.
See p. 247 for schematic.
Intermesen- ----r--f!-;'-O
teric plexus
Inferior mesen
teric plexus
Lumbar --~~ "~~~i'---=-~----- Sympathetic trunk,

splanchnic n. lumbar ganglia
Gray ramus ----;~~~---=-~~~

Lumbar nn.,
communicans anterior rami
Ureteral plexus -----~- ------'~~~~____7_-- LS vertebra
Superior hypo- - - - - - - - - " , ;

gastric plexus Left hypo
gastric n.
Right hypo- -----~
gastric n.
1st sacral n.,
anterior ramus
Ovarian plexus -----~ Lumbosacral

trunk
Obturator n. --~~~~
~'----'iii~~~-- Sacral plexus
Right inferior ----':7-~~5

hypogastric ~~~~=..,.-.,---- Pelvic splanchnic nn.
plexus
Vesical plexus -------'-------':-----=; ~~"'------,~~-- Pudendal n.
Right utero- ---....:,.;...:.-:.;.,..:......;~~-------'=~;;; ~.-=-;~~~~-- Right middle

vaginal plexus rectal plexus
242
Fig. 17.7 Innervation of the male pelvis
Right pelvis, left lateral view. See p. 247 for schematic.
Intermesen -~-...,...,
teric plexus
Inferior mesen -~~."l

teric plexus
Lumbar --~~~~, Sympathetic trunk,

splanchnic nn. lumbar ganglia
Grayramus ---~~~.....---~~~
Lumbar nn.,
communicans
anterior rami
Ureteral plexus -----~~ LS vertebra
Superior hypo -----~~~=~

gastric plexus Lumbosacral
trunk
Right hypo
gastric n.
Left hypogastric n.
Iliac plexus ---~~~
Pelvic splanchnic nn.

Obturator n. ------'~~
Middle
rectal plexus
Deferentia I
plexus
Pudendal n.
Seminal vesicle -------':~b~~L6~
Inferior rectal
plexus
Vesical plexus ----~~,...=-~~-------:::
Prostatic plexus -----7AiJ~~~~§~~~ Inferior rectal nn.
Cavernous ----...,~
nn. of penis
Posterior
Dorsal n. scrotal nn.
of the penis
243
Autonomic Innervation: Overview
Fig. 17.8 Sympathetic and parasympathetic

nervous systems in the abdomen and pelvis
Sympathetic Parasympathetic
Head and neck . -
Dorsal
vagal
nucleus
- - Sympathetic
trunk
[>- Sympathetic
1------4Eii (paravertebral)
ganglia
Thoracic ----':---'----+-----~-------I
splanchnic
nn.
Lumba r ~--';---------;---l
splanchnic nn.
Sacral S2
splanchnic nn.
54
Superior and inferior Pelvic
mesenteric ganglia (with splanchnic nn.
intermesenteric plexus)
A Sympathetic nervous system. B Parasympathetic nervous system.
Effects of the autonomic nervous system in the abdomen and pelvis

, Organ (organ system) Sympathetic effect Parasympathetic effect
Longitudinal and circular muscle fibers 1 i motility
Gastrointestinal
Sphi ncter muscles Contraction Relaxation
tract
! secretions i secretions
"
Glands '
capsule Contraction
Liver i glycogenolysis/gluconeogenesis No effect

r
It-" pancreas ! insulin secretion
Pancreas"
Exocri ne pancreas .' ! secretion i secretion
......
UCLI U::>UI vc::> ILde Relaxation Contraction
Urinary bladder
Functional bladder sphincter Contraction Inhibits contraction
Seminal and ductus deferens Contraction (ejacu lation)
Contraction or relaxation. depending on No effect

Uterus
hormonal status
Vasodilation of the arteries of the penis

Arteries Vasoconstriction
clitoris (erection)
Suprarenal glands (medulla) Release No effect
ley Vasoconstriction ( urine Vasodilation

244 '1111dlyUdLL r
Fig. 17.9 Autonomic innervation of
the intraperitoneal organs
I_®
Right greater Left greater

splanchnic n. splanchnic n.
Splenic
Hepatic plexus plexus
~-~~-=;;
~~
Anterior
gastric plexus
,'' I
~<' ~ ~ Pancreatic
plexus
-\--0
Posterior Branches of Branches of
Pyloric branches gastric plexus celiac plexus superior mesenteric plexus
A Innervation of the foregut. As the left and right vagus nerves

~ Sympathetic trunk
descend along the esophagus, they become the anterior and
Posterior vagal trunk
posterior vagal trunks, respectively. Each trunk produces a celiac, ® (from right vagus n.)
pyloric, and hepatic branch, and a gastric plexus. Anterior vagal trunk
@
(from left vagus n.)
CD Celiac ganglia
(?) Superior mesenteric ganglion
@ Inferior mesenteric ganglion
@) Greater splanchnic n. (T5-T9)
® Lesser splanchnic n. (T1 0-T11 )
® Least splanchnic n. (T12)
(j) Lumbar splanchnic nn. (L1-L2)
Lumbar splanchnic nn.
®
(from 3rd to 5th lumbar ganglia)
Sacral splanchnic nn.
®
(from 1st to 3rd sacral ganglia)
@ Pelvic splanchnic nn. (52-54)
Thoracic
splanchnic nn.
\\..~~===:::::t;~~---------=~-ti~,-----{---
Superior
mesenteric
plexus
~---ij:::::::::=-----+----+~~-!----- Inferior
Lumbar mesenteric
splanchnic nn. plexus
Inferior hypo- Inferior rectal plexus > -' -.Sympathetic fibers'

gastric plexus ..- :Par~~ympathetic fi,ber.s,
."'-
B Innervation of the mid- and hindgut. and pelvic ganglia
*Synapse in the lumbar sympathetic ganglia.
245
Autonomic Innervation: Urinary & Genital Organs
Fig. 17.10 Autonomic innervation

of the urinary organs
,-''-': 'Sympathetic fibers, .. '
-',-, ~~~asympatheticfibers
Numbering continued from p. 245.

Renal plexus
(3) 5ymJ?athetic trunk
® Posterior vagal trunk (from right vagus n.)
Q) Inferior mesenteric ganglion
(I) Lesser splanchnic n. (T1 0- T11 )
Sacral splanchnic nn. (from 1st to 3rd
® sacral ganglia)
T10 Ureteral plexus
@) Pelvic splanchnic nn. (52-54)
(on upper ureter)
® Renal ganglia
T12
@ Superior hypogastric plexus
L1
® Inferior hypogastric plexus
-,- - Urinary bladder
--..." ---=,...::--=-.....::::...,---- Semina I

vesicle
Vesical plexus
Prostate
~ Clinical-~-'---------_.'-~~~--
Referred pain from the intern'al organs . , .. . " ' :. .. ~ ' .~ . . ' ~. ,
The"converge'nce of somatic andvisceral afferent fibers to a common level of sites of pain, a phenomenon 'know l1 as referredpair;L Pain in)pulses.from a,
t~e sp.i~al cord confusesthe relationship bet~een the perceived and actual parti~ular organ are consistently projected to th~ same 0ell-defined skin ar.ea.
Pancreas
Gallbladder -
~~~ Stomach Small

~intestine
-~~-Large
intestine
Left
kidney
A c D
246
Fig. 17. 11 Autonomic innervation of the genitalia
-"-. Sympatheticfibers·. Numbering continued from p. 245.

-.- .Parasympathetic fibers ~ 5 m athetic trunk
® Posterior vagal trunk (from ri ht vagus n.)
@ Superior mesenteric ganglion
Q) Inferior mesenteric ganglion
® Lesser splanchnic n. (T1 0-T11 )
~-'
@ Pelvic splanchnic nn. (52-54)
® Renal ganglia
@ 5uperior hypogastric plexus
@ Inferior hypogastric plexus
Intermesenteric
plexus @ Intermesenteric
@
plexus
@
__--I·----<10J-----oo+--I
@
@
Hypogastric n.
Ovarian
plexus
Vesical
plexus
Prostatic
plexus Deferentia I
plexus Uterovaginal
plexus
Testicular
plexus
A Male genitalia. B Female genitalia.
247
Surface Anatomy
.S Fig. 18.1 Palpable structures in the abdomen and pelvis

~ Anterior view. See pp. 40-41 for structures of the back.
~
c:
~
E
.g
..Q
-=:r:
Transumbilical
plane
(L3-4 disk)
Anterior superior - -
iliac spine (ASIS)
Inguinal ligament ---::-:--:---
Pubic symphysis --+'-'-----------:::-:;-'~~ ~c::===_=~~____:__-~-____:__- Pubic tu bercle
A Bony prominences.
Rectus --~~~=--_
abdominis
Tendinous ------F=~=~=~
insertion
----'-.....:=:..-:=::::=:===:;=:J!.....---- Li nea al ba
External --~"'-----
oblique
>
~~=;;.,--- Semilunar
line
Anterior superior ---:-_

iliac spine (ASIS)
~~~~~~S';---- Superficial
inguinal ring
Sartorius _:=--~
Quadriceps -----'0'===--
femoris
B Musculature.
248
Fig. 18.2 Surface anatomy of the abdomen and pelvis
Anterior view. See pp. 40-41 for structures of the back.
Ql: How would this patient's abdomen be

subdivided for descriptive purposes into
four quadrants? Name five organs in each
quadrant.
A Female abdomen and pelvis.
Q2: A patient's inguinal region shows a slight

swelling just superior to the middle of the
inguinal region. What factors (age, ana
tomical) might assist you in determining if
this is a direct or indirect inguinal hernia?
See answers beginning on p. 626. B Male abdomen and pelvis.
249
Upper Limb
19 Shoulder & Arm Ligaments of the Wrist & Hand 302
Ligaments of the Fingers 304
Bones of the Upper Limb

252
Muscles of the Hand: Superficial & Middle Layers 306
Clavicle & Scapula

254
Muscles ofthe Hand: Middle & Deep Layers 308
Hume rus
256
Dorsum of t he Hand 310
joints of t he Shoulder
258
Muscle Facts (I) 312
joints of the Shoulder: Glenohumeral joint

260
Subacromial Space & Bursae

262
Anterior Muscles of the Shoulder & Arm (I)

264
22 Neurovasculature
Anterior Muscles of the Shoulder & Arm (II)
266
Posterior Muscles of the Shoulder & Arm (I)

268 Arteries ofthe Upper Limb 316
Posterior Muscles of the Shoulder & Arm (II)

270 Veins & Lymphatics of the Upper Limb 318
Muscle Fact s (I)

272 Nerves of the Brachial Plexus 320
Muscle Fact s (II)

274 Supraclavicu lar Branches & Posterior Cord 322
Muscle Fact s (III)

276 Posterior Cord: Axillary & Radial Nerves 324
Muscle Fact s (IV)

278 Medial & Lateral Cords 326
Median & Ulnar Nerves 328
20 Elbow & Forearm Superficial Veins & Nerves of the Upper Lim b 330
Posterior Shoulder & Axilla 332
Radius & Ulna

280
Anterior Shoulder 334
Elbow joint
282
Topography of the Axilla 336
Ligaments of the Elbow joint

284
Topography of the Brachial & Cubital Regions 338
Radioulnar joints
286
Topography of the Forearm 340
Muscles of the Forearm (I)

288
Topography of the Carpal Region 342
Muscles of the Forearm (II)

290
Topography ofthe Palm ofthe Hand 344
Muscle Facts (I)

292
Topography of the Dorsum of t he Hand 346
Muscle Facts (II)

294
Transverse Sections 348
Muscle Fact s (III)

296
23 Surface Anatomy
21 Wrist & Hand
Surface Anatomy (I) 350
Bones of the Wrist & Hand

298
Surface Anatomy (II) 352
joints of the Wrist & Hand

300
Bones of the Upper limb
..Q Fig. 19.1 Skeleton ofthe upper limb

.§
-.l
Right lim b. The upper lim b is subdivided int o th ree regio ns: arm , fo re
~ arm, and hand. The shoulder gird le (clavicle and scapula) jo ins th e upper
Q. lim b t o th e th orax at t he ste rnoclavicular joint.
:§-
Acrom io
__I!.""'li~""-:""'",,_.J~t-- clavicular jo int
~C:oiiii'JfbilJ-- Shoulder joi nt

Shoulder
gi rdle
Arm
Scapula Scapular
spine
Hum erus <-j)-- - Hum erus
Elbow
j oint Olecranon ----o:~-M~
)
" Wilr-- Head of radius
Forearm
~>-+---- Radius
Radiu s
Ulna Uln a -_~
1st
met acarp al
Carpa l bo nes - - -&-4>-(},{
Hand
4t h proxim al phalanx
Phalanges
4t h mi dd le phalanx - - -H
4th di stal phalan x - - --f;
A Ant erior view. B Post erior view.
252
Fig. 19.2 Palpable bony prominences
Except for th e lunat e and trapezoid bon es, all of th e bon es in th e upp er
limb are palpable to some degree t hroug h t he skin and soft tissues.
Clavicle Superior ang le

Acromion Clavicle
/ Clavicle,
Acrom ion L - ----------- acro m ial end
'-- - Coracoid Coracoid process -----===< -}-- - - - Acro m ion

process Greater tubercle ~ !--- - Great er
tubercle
Lesser tub ercle
Scapular
spine
Inferior
angle
Medial Inferior
bord er angl e
Hum erus
Lateral - - Medial
epicondyle epico ndy le Head of
radiu s
Olecrano n
Shaf t of ulna, - 1
po sterior surface
Ulna - -- -I
Radius - -- --\-
Styloid pro cess

of ulna l Styloid
_____ Pisiform bon e V process
of radiu s
=:-- - - - Hamulu s of
ham ate bon e
1st
".----- - Met acarpo
Met acarpals --~7--L7-+----
m et acarpal
phal angeal joi nts
2nd
metacarpal 1st proximal
phalanx
Phalanges - '-f...--'--r.--q-i----!-,
1st distal
phalan x
C Lateral view. A Ant erior view. B Posterior view .
253
Clavicle & Scapula
~ The shoulder gird le (clavicl e and scapula) connects th e bone s of (pair ed hip bon es) is firm ly int egrated into th e axial skeleto n (see p.
~ th e upper lim b to t he th oraci c cage. Wh ereas th e pelvic gird le 358) , the shoulder girdle is extr eme ly mobile.
Fig. 19.3 Clavicle

Right clavicle. The S-shaped clavicle is visib le and palpab le along its
ent ire length (g enerally 12 to 15 cm ). Its med ial end art iculate s with th e
st ernum at the ste rno clavicular joint (see p. 258). It s lat eral end articu
lat es with t he scapula at the acromioclavicu lar joint (see p. 259 ).
Conoid
tubercle
Acrom ial -----i

end \
-~~ .....
Ste rnal
art icular surface
Shaft of
Sternal
clavicle
end
A Superior view .
Im pressio n for
costo clavic ular ligament
Groove for
subclavius mu scle
Conoi d
tub ercle
B Inferio r view.
Clinical
Scapular foramen
Scapular foramen
The superior tra nsverse ligarnent of th e
scapula (see p. 259) m ay becom e ossified.
tra nsfor ming t he scapular rio tch int o
an ano ma lous bony canal, th e scapular
fo rame n. This can lead to compression of
t he sup rascapular nerve as it passes th roug h
th e canal (see p. 33 3).
254
Acrom ion Coracoid Scapular Superior Superior Fig. 19.4 Scapula
pro cess not ch border angle Right scapula. In its normalanatomical posi
tion, the scapula extends from the 2nd to the
Subscapular 7th rib .
fossa
Supraglenoid
tu bercle
Acromion
Infraglenoid
Superior angle
tu bercle
Coracoid
Medial
process
Lateral bo rder
bo rder Supragleno id
Glenoid
t ubercle
cavity
Infr aglenoid
t ub ercle
A Anteriorview.
Inferior angle
Posterior Costal
surface surface
Superior Superior Scapular Scapular Coracoid
angle bord er not ch spi ne process
Acromio n
Supra
spinous Inferior ang le
fossa
Acromial B Right lateralview.
ang le
- - - - Glenoid
cavity
Medial
bord er
Infr aspinous
fossa
Lat eral
bo rde r
C Po st erior v iew. Inferior angle
255
Humerus
Fig. 19.5 Humerus

Right hume rus. The head of t he hu merus art iculates with t he scapula at humerus articu late with t he radiu s and ulna, respect ively, at th e elbow
t he glenoh umera l joint (see p. 25 8). The capite llum and tro chlea of t he (cubital) joint (see p. 282).
Greater Intert ubercular Lesser Anatomi cal Head of Greater
groo ~e ~
t U be
" ro""si~t_y_
y neck hum erus t uberosity
tUberOS\ i t _
Intert ubercular
". Head of gro ove
Anat om
hum erus
ical neck
Lesser
~JlP-- Anatorn
t uberosity
ical neck
Surgical
-r-- - - Surgical neck
neck
Crest of
greater
Radial
tub erosit y
groove
(for radial n.)
~
Delt oid
/
tub erosity
Ant ero-
lat eral
surface
-<
Shaft of hum erus,
anterol ateral
surface
Medial -
bord er
Lateral
supracondy lar
ridg e
Med ial
\
Medial
supracondylar supracondylar
ridg e ridg e
~
Radial
_________ Coro noid
fossa
~ fossa
Lateral - --.-- .,"'" Radial fossa
(
Medial Medial
supra
epicondyle epicondyle
condy lar
ridg e Capit ellum
Lateral Capitellum Trochlea

Ulnar groove Later al
epicondyle
(for ulnar n.) epicondyle
'---v-' Lateral epicondy le
Olecranon Trochlea
Condyle of hum erus
fossa
A Anterior view . B Lateral view. C Posterior view .
256
~ Clinical
Fractures of the humerus

Anter ior view. Fractures of th e proximal
hume rus are very common and occur
predomin antl y in older pati ent s who sustai n
a fall onto th e outst retc hed arm or direct ly
onto t he sho ulder. Three main t ypes are
Anatomical Head of
dist inguished.
neck humerus
Lesser
tuberosit y
-~ Greater
tub erosity
Inter
t ubercular
_ Lesser
tu berosity
groove
Crest of - -- " "
lesser
tu berosit y --~-- Head of
Anatomical hum erus
neck
Greater ~ A Extra -art icularfract ure.

tuberosity
Intertu bercular Lesser

Head of
groove tuberosity
hume rus
E Proxima l (s u pe rio r) view.
Shaftof - (
hum erus.
anterom edial
surface
B Int ra-arti cular fract ure.
Capit ulotro chlear Ulnar
c,p ;" ,~ qroov e 7"'0< groove
Med ial
Olecrano n fossa
border
C Comminute d fractu re.
Medial F Di st al (inferior) view.

supracondylar Extra-art icularfractu res and int ra-articular
ridg e fract uresare ofte n accompanied by injuri es of
+-- Olecranon the blood vessels that supply the humeral head
Trochlea ~ fossa (anterior and posterior circumflex humeral

art eries), wit h an associated risk of post
of hum erus
traumatic avascular necrosis.
Medial epicondyle Fractu res of th e hum eral shaft and distal

hu me rus are fre quent ly associated wit h
damage to th e radial nerve.
D M edial view.
257
Joints of the Shoulder
Fig. 19.6 Joints of the shoulder: Overview

Righ t shoulder. ante rio r view .
Acrom ioclavic ular
joint
Subacromial
space
':-;. . . .~~ ",":~--"----- Sternocla

vicu lar joint
Fig. 19.7 Joints ofthe shoulder girdle

Right side, superior view.
Acromioclavicular
joi nt (with acro mio-
clavicular I.)
N ~ _.....
.....
Coraco
acromial I.
Glenoh umera l
joint
Fig. 19.8 Scapulothoracic joint
Right side, superior vi ew. In all m ovements
of th e shoulder gird le, th e scapula glid es on a
curved surface of loose connective ti ssue be
tween th e serrat us ante rior and the subscapu
laris mu scles. This surface can be considered a
scapulot horacic joi nt.
Scapulotho racic
joint
Scapulot horacic Posterior Sternoclavicular joint
joint sternoclavicular I. (w ith anterior
sternoclavicular I.)
Acro mion - - +
Head of - !---'-----
hum erus
258
Fig. 19.9 Sternoclavicular joint Artic Costo
Anter ior
ular clavic
Anteri or view with sternum coronally sterno Inter
Clavicle di sk ular I. - - l st rib
sectio ned (left) . Note: A fibr ocartilaginous clavicular I. clavicular I.
artic ular disk com pensates for the mismatch
of surf aces between th e two saddle-shaped
art icular facet s of the clavicle and manub rium
st erni.
Costal
cartila ge Manubrium Ste rnoco sta l
stern i joint
Fig. 19.10 Acromioclavicular jo int
Ant erior view. The acromi oclavicular joint is a
plane joint. Because t he articulating surface s
are flat . th ey mu st be held in place by st rong
ligam ents. greatly lim it ing th e mobility of th e
joint.
Clavicle, Coracoclavicular I.
acromia l
Acrornio- end Conoid I.
clavicular I.
Acrom ion -,
Coraco
acromial
Coracoacrom iall. ~~~~~.~
arch
1 Coracoid process
--''----------~-- Superior t ransverse
scapular I.
:..,,--- - - - - - - - - - "rt-- Scapular notch
Lesser tub erosit y --~~---'-
Inte rt uber- _ _"---'1_

cular groov e >--- - -t- - Scapula.
cost al surface
- Medial
border
Hume rus
~ Clinical
Inj uries of the acrornloclavlcularjolnt

A fall onto the out stre tc hed arm or shoulder fr equent ly causes dislocatio n of the acro mioclavicular joint and dam age to t he coracoclavicular ligam ent s.
A St retching of ligaments. B Rupture of acrom ioclavicular ligament. C Com plete dislocati on of acrom ioclavicular jo int .
259
Joints of the Shoulder: Glenohumeral Joint
Fig. 19. 11 Glenohumeral joint: Bony elements

Right shoulder.
Suprag lenoid Scapular Scapular Scapu lar

Coracoid tubercle Clavicle notch
notc h spine Clavicle
process
Acro m ion
Head of hum erus ~ Acrom ion
Head of
hum erus
Greater
tu berosity
Gleno id
cavity
Inter
tu bercu lar
groove
Anatomical
neck
Infraspinous
fossa Hum erus
A Ant erio r view. B Posterior view.
Fig. 19.12 Radiograph ofthe shoulder

Ant erop osterior view.
Head of humerus
Glenoid cavity
,..-'-"~------ Greater tub erosit y
260
Fig. 19.13 Glenohumeral joint: Capsule and ligaments
Rig h t sho ulde r.
Acro mio Coraco Scapular Superior transverse
clavicu lar I. clavicular I. not ch scapular I.
Coraco Acromio
Clavicle clavicular I. clavicular I.
Acro mion
Inter ~-----.J!-
tu bercular
synovial
sheat h
Int er
t ubercular
groove
Joint capsule. Lateral Scapula. Infraspinous Scapular Joint

glenohu meral II. bord er costa l surface fossa spine capsule
A A nt er ior v iew. B Po ste rior v iew .
Fig. 19.14 Glenohumeral joint cavity Fig. 19.15 MRI of the shoulder
An t erior v iew . Superio r Co ro n al section, ant erio r v iew .
Acromio Coraco t ransverse
clavicular I. clavicular I. scapular I.
Corace Clavicle Acrom io

acro mia l I. clavicular I.
Subcoracoid
bursa
Head of
humerus
Transverse
I. of
hum erus
Subscapul aris Lati ssimus do rsi
Intert uber Subte ndinous

biceps brachii, Intertubercular cular synovial bursa of
long head groove sheat h subscapularis
261
Subacromial Space & Bursae
Fig. 19.16 Subacromial space Fig. 19.17 Subacromial bursa and glenoid cavity
Right shoulder. Right shoulder. lateral view of sagittal sect ion with humerus remo ved .
Coracoacrom ial arch Coracoacrom ial arch
Acro m io n Coracoacr om ial Acro m io n Coracoacr omia l Coracoid

ligam ent proce ss
Supra I
spinat us
Subacro m ial
bur sa ' -!"""';'!- - Subt endinous bursa Subacromi al
of subscapularis bu rsa Subte ndino us
Subdeltoid --~-~-
Infraspinat us ~~ II' U
bur sa of
bu rsa Greate r t uberosit y
subscapularis
--!!!'--J:-ll--- - Transverse ligam ent Glenoid cavity - - -td!'.. 'H:+- - Tendon of
of hu merus biceps brachii,
Glenoi d labrum --~-¥~~ lo ng head
'1'----/ -+-- - Int ertu bercu lar
t endon sheat h Joint capsule --~--'-----"'" ""'::::::::'~4~~ ~<------->...- Subscapularis
Infraspi nat us -----1~_. ,
Teres mi nor
Teres min o r - - -l!-"'-::!- Axillary recess
Infraspinat us - - ---+ Subscapularis

Biceps brachi i,
sho rt head
Biceps brachii,
long head Scapula. lat eral bo rde r
A Latera l view.
'-""="--K -_ Scapula
Acrom ial arti cu lar

surface
Subacrom ial
bursa
Subdelt oid
bursa
Great ertubero sity ------"~
Int ert ubercular

groo ve Joint capsule
B Superior view. Not e th e position of th e sub
Lesser t uberosit y Hum erus
acromial bur sa between the supraspinat us
mu scle and th e coracoacromial arch.
262
Fig. 19.18 Subacromial and subdeltoid bursae
Right shoulder. anterior view.
Subcut a-
Coracoacro m ial
neou s acrom ial
arch
Coracoacro mi al bu rsa
Trapezius
ligam ent I
~
Coracoclavicular
co racoi: crom ion ligam ent
process - - Clavicle
Subacromia l - - -- - -...,rc-
bursa Superior tra ns
~~o--- verse scapular
Subdeltoid - - - ---.--. ' ligament
bur sa - - - l st rib
Glenoh um eraI
----;f-----!'!---~~!____(
<
j oint capsule
~ Subt endinous
bur sa of
Deltoi d subscapularis
Tendon sheat h - - -- - - -- Subscapu laris

in int er
t ubercular
groove
Hum erus
Biceps brachll, Biceps brachii, Corace- Teres

long head sho rt head brachialis major
A Locati on of bur sae.
~ ~~~==---- Skin
--'-----=- - Subcuta neous tissue
Trapezius
Subacrom ial
bursa
Supraspinat us
tend on
Head of hum erus --+--H:,-'.jd-L,HH-~c+"'Sc'p!.

-----"'~~~~c::;;i;;~~~r- Scapula.
glenoid cavity
Subdelto id ----:'-------,F-J'=I~
bursa ,~~2~i~,i;- Subscapularis
~=~~~~~~~~~= Glenoid labru m

Axillar y recess
Deltoid -r-r-r-r- -r--c,
,ll'i _n.l~....d:.~~~,..L-!-_ _ Teres maj or
..._,..--+--Jr------1J~- Latissimu s dorsi

B Corona l sect ion. The arrow s are
po int ing at t he supraspinat us
t endon , w hich is f requent ly
injured in a " rot at or cuff t ear"
(fo r rotato r cuff. see p. 3). n
263
Anterior Muscles of the Shoulder & Arm (I)
..Q Fig. 19.19 Anterior muscles

.§
..... Right side, anterior view. Muscle origin s (0 ) are show n in red,
~ insertions (I) in blu e.
Q"
s
Clavicle
Trapezius
Verteb ra promin ens
(0 )
Sternocleido
mast oid
Deltoid --~--T.'-+-- I'

-----"'''=.,.--- Manubrium ste rni
Clavicul ar
part
Coracob rachialis
=--::~~::::~---~~t-- Sternocos ta l Pect or alis
part major
Teres m ajor --~~'.HJ
Abdom inal
Latissimu s dor si --P.:1~ii--';lfilH-H-i
part
Biceps
brachii
1~~:~
Short - - -YfJ'-8'-f+ ---T-~~!- Sternum
head
Serrat us --~-+-I:-~+.B~~
ant erior
/
Lat issimu s - --fr---;;:--'-"j-l--f.--:S H-:f

dor si
- - - - - - - - -- Rectussheath
Biceps brachii --~:E-l:-:f.~
"--..-.,..-'-,..- - - - - - - - _ - - - - Exte rnal ob lique

Brachialis -----:l-~~r7tf:~
Med ial ----j;r-:".--;~M:~'f#~~

epicondyle
A Super ficia l dissecti on .
264
D
7 (D)
Pect oralis Supra-
minor spinat us Subclavius
Clavicular p'"
Clavicle
Acrom ial part (0)
Coraco id process ----::;-------'=~'-

"':::::::::~-~L:-~~~~=---- Sternocleido
mastoid (0)
'----!!!!~----,=--~~-s--- Pectora Iis major.

clavicular part (0)
Subscapularis ----+-J-t-~~~
- ---.L..----!"- - - Manubrium ste rni
Pecto ralis maj or (I) - - -+-9
>-----:;--- - - - Costa l
cart ilage
- - - -- - Sternum
\:7J!i!lCL--~~\-,-t-+-f----"!----J--+-------'------- Serratu s
~~: ~
ante rior
Biceps
brachii
{ Short - ---lifihf!f!-+ k - .
head
Pectorali s major.
ste rnocosta l part (0)
Latissim us - - lH'-H.f !-fl+:tr'-rr!-c

do rsi ,------ - - Xiphoid pro cess
~'---- T12 verteb ral

body
Lateral -
epicondyle Costa l arch
Medial
Brachialis epico ndyle
B Deep dissecti on. Removed: Sternocleidom astoid. tr apezius, pect oralis

major, delt oid. and exte rnal oblique mu scles.
265
Anterior Muscles of the Shoulder & Arm (II)
Fig. 19.20 Anterior dissection

Right arm, anterior view . Muscle origins (0) are show n in red, inser
tion s (I) in blue.
Delt oid (0) Subclavius (0)

Trapezius (I) Supra Supra Serratu s
spinat us spinat us ant erior (I)
Pect orali s
min or (l)
Coraco Coraco
brachialis brachialis
Pect oralis Pect oralis
major( l) maj or (I)
Latissim us ~-+-C-----t";~ l " r Latissimu s -~...,---'~ !
dor si dor si (I)
Biceps -~'!--'.!~'-H-l Biceps -~e--:1*H

brachii, brachii ,
sho rt head short head
Biceps - --H++.-, Biceps - -w."fm

brachii , brachii,
lon g long
head head
Pro nator teres (0)
Com mo n head
of flexor s (0)
Brachialis Brachialis
- 7 . 7 - - -- Bicipit al - - - - - - Bicipita l
apon eurosis aponeurosis
A Removed: Thoracic skeleto n. Partially removed: Lat issim us dorsi and B Removed: Latissimus dorsi and serratu s anterior.
serrat us ante rior.
266
Deltoid
Biceps brachii,
Biceps brachii, Subclavius Serratus
short head (0)
shor t head. anterior
and coracobrachialis
Supra
Supra
spinatus (I)
spinat us
Sub- - ..... ~l-' Sub ------;"'O;----"i~...

scapularis (I) scapularis
Intertub er
cular groove
Lati ssimus - -+-iH l-S
dorsi (I)
Latissimus - -e--
dorsi
Biceps
brachii,
Teres major -----I~
long head
Pectoral is
Pector alis
major
major (I)
Deltoid (I) Deltoid
Coraco Subscapularis (0)

brachialis
. r;t;ii+'f.~---- Brachialis
Brachioradialis - - - -7
Extensor carpi
radialis longus ~
Extensor carpi Pronator teres

radialis brevis
Common head Common head

of extensors of flexors
'------ - Brachialis
+ 4 - - - Biceps brachil, Biceps brachii
radial tuberosity (I) Supinator
-5--- - - Flexor digitorum

profundus
C Removed: Subscapularis and supraspinatus muscles. Partially removed: D Removed: Biceps brachil, coracobrachialis. and teres major.
Biceps brachii.
267
Posterior Muscles of the Shoulder & Arm (I)
Fig. 19.21 Posterior muscles

Right side. posterior view.
Sem ispinalis
capit is
' ~- St ernocleido mastoid
Splenius
capiti s
Descend ing - - ---''---------',+ 'co '
part
Trapezius Transverse
part
---- --- - -==:-
- - - Scapular spine
Ascendi ng _ _ --".,---~L-_
part
Teres majo r
Triceps
brach ii
Lat issimu s --~2---"'---+~ !!"'--_-,--L-,-"~-. Lateral

dor si head
Ext ensor carpi

radialis brevis
Ext ensor carpi

radi alis longu s
Olecranon
External ~~~--- Anconeus

o bliq ue
Thoraco lumbar .
fascia ______ L....!!........l~~- Flexor
carpi ulnaris
/
Ext enso r
carpi uln aris
Ext ensor
dig itorum
Iliac Int ernal

A Superficial dissect ion. crest obl ique
268
Superior - -----=--'---'-7:;;;;;;:>" ....~
nuchal line
--'~!-- Sterno cleid o
masto id
~H'¥.~-- Semisp inalis

capit is
Splenius capiti s
Sem ispinalis cervicis
Rho mb oid min or
Levato r scapulae
Rhomboid major
Acrom ion
Trapezius Supraspinatus
(cut)
Scapular spine
Scapula, m edial bo rder
Teres mi nor
Teres major
Erect or spinae, - -- 4 -l'il! -=-fil - - - - - Lati ssimu s

tho racol umba r fascia
dor si (cut)
Serrat us
posteri or inf erior
Lati ssimu s do rsi Exte rnal obliq ue

(cut )
,
I
/ ,
B Deep di ssecti on. Partially removed: Trape Thoracolu mb ar Int ernal
zius and lati ssimu s do rsi. fascia oblique
269
Posterior Muscles of the Shoulder & Arm (II)
Fig. 19.22 Posterior dissection

Right arm, posterior view . Muscle origins (0 ) are show n in red , inser
ti ons (I) in blue.
Levator Supra Supra

Rhomboid scapulae (I) spinatus Trapezius (I) spi natus
minor( l)
Delt o id,
Deltoid clavicular par t (0)
__- - Delt oid ,

acro m ial
part (0)
t;~~~;;~~~~~~l Deltoi d,
spinal part (0)
Teres m ino r
Infra
spinat us
Teres
m inor
Teres major
Rhom boid Latissim us do rsi,

major(l) scapular part (0)
Triceps
Triceps brach ii, brachii, Triceps brachii.
lo ng head lat eral head long head
Brachio radialis --~~---n

Ext enso r carpi --~,~
Ext ensor - --¥.i!..L
radi alis brevis (0)
carpi radialis longus
Common head ---~¥--..'
Ext ensor ----!~1
of exte nsors (0)
carpi rad ialis brevis
Com mon head ------<, .~
Olecranon - - ':-+.'-'-" t-
of flexo rs (0)
Anco neus - - -+--i---'"':-.....",,-'
Anconeus (0 and I) - ----""- h'ltik-
Flexor - --+-+
carpi ulnar is Flexor - - - ---"i:: -\ Supi
carpi ul naris (0) nato r
Ext ensor ---t-:;---~~'- (O and I)
Flexordigitorum - - - - - --t:
carpi ulnaris
profundus (0)
Ext ensor ---t;+~--'--rl
dig it oru m
A Removed: Rhomb oid s maj or and m in or, B Removed: Deltoid and forearm mu scles.
serrat us ante rior, and levat or scapulae.
270
Supra Levator Supra
spinatus (0) Rhombo id scapulae spinat us Trapezius
m inor Delto id,
clavicular part
Supra Supra
spinatus (I) spinat us
Infra Infra
spinat us (I) spinatus
Teres
Teres
m inor (l )
m inor
Delt oid,
spinal part
Triceps Triceps
brachii, brachi i,
latera l head lat eral head
--:--+--'-:-~- Teres m inor (0)
-+'-1-~l-- Infra ~~---r- Radial

spinat us (0) groove
Teres major
Teres m ajor Deltoid (I) Delt oid
Rhom boid Latissimu s dorsi ,

Brachialis (0) Brachi alis
m ajor scapular part
.'-i~I---- Triceps -~-- Triceps

Triceps brachii, brachii, brachii,
long head medial head m edial head
,,-"1!:--"! - - Triceps
brachi i,
lat eral head
(cut edge)
Exte nsor carpi \'1--- - Brachio

radialis longu s radialis
Ext ensor carpi

radialis brevis
Common head - - -
of exte nsors
Com mo n head - - '

of flexors
Triceps brachii
Anconeus ----'------'~--':-
C Removed: Su pra sp inatus, infra spi natus, an d t er e s min or. Partially D Removed: Tri cep s b rach ii and teres m ajor.
removed: Triceps b rac h ii.
271
Muscle Facts (I)
~ The actions of the three parts of the deltoid muscle depend on but at greater than 60 degrees, they act as abductors. As a result, the
a.iiIII their relationship to the position of the humerus and its axis of parts of the deltoid can act antagonistically as wellas synergistically.
motion. At less than 60 degrees, the muscles act as adducto rs,
Acromion
Fig. 19.23 Deltoid
Rig ht shoulder.
Clavicle
r"""""JC:::'.....,------ Delto id
(clavicular
part)
Scapula
A Parts of t he deltoid, right lateral view. B Right lateral view. Shaft of Deltoid
hum erus t uberosit y
Acromion Deltoi d Coracoid Delto id

(clavicular part) Clavicle process (clavicular part)
Deltoid
(acrom ial part )
!!lr - Delt oid

_::::!!!!!~.L;,-- Clavicle (acromi al
Scapular -';'!!I''''=''5iI!l part )
spine
Delto id
(spinal
-w-r-r-i-r-r- Scapula. part)
costal Scapula, -~~~. .~i\~
posterior
surface
surface
Deltoid
tu berosity
E - - Delt oid
Shaft of - t uberosity
hum erus --'+ - Shaft of
humerus
C Ante rior view. o Posterior view.
Parts of the deltoid

~ Q) Clavicular part : Lateral one t hird of clavicle : Flexion, internal rotati on, adduct ion
: Deltoid : @ Acrom ial part : Acromion : Humerus (delto id t uberosit y) ' Axillary n. (C5. C6)
272
Fig. 19.24 Rotator cuff
Right sho ulder. The rot ator cuff consist s of fou r mu scles: supraspinatus.
infraspinatu s. teres m inor. and subscapularis.
Acrom ion
Supra-
lI'" / spinat us
~ -. - Coracoid
process
Great er
t uberosity
Infra Subscap
spinat us ularis
A Posterior view. B Ant erior view.
Teres ------1~+-
Scapular Supra- Superior
Acrom ion not ch spinat us bord er m inor
Superior ang le ------iB-- - Shaft of

hu merus
Greater
Lateral --'Ii-'\-~
tu berosity
~ bor der
Lesser _--'----~~
tu berosit y
Intertuber
Inferior
cular groove
angle
Medial bor der

Crest of greater
- D Lat eral view.
--~~;,,-+-- Subscapularis
tub erosit y
Crest of lesser
- - --'-
tubero sity
Supra Scapular Coracoid

spinatus spin e process Acro m ion
Shaf t of hum erus - - -
Inferior angle ------'.....' "

C Ant erio r view .
Teres Shaft of
min or hum erus
E Posterior view.
Musclesof t he rotator cuff

: <D Supraspinat us : Supraspinous fossa : Abdu cti on

... . . . .. •. •.. ••. . •. .. . .• . ••• . •. .• . . •
. . , Suprascapular n. (C4- C6)
.o Infraspinatu s . .. ... : Scapula : Infraspinous fossa
.............. , Humerus
: Greater t uberosity
.............................................
, Exte rnal rotation
. G) Teres m inor Lateral border : Axill ary n. (C5. C6) External rota tio n. w eak adduct ion
..... ... ...... ....... ..... .......... ..... ..
: @) Subscapularis Subscapular fossa . Lesser tu berosit y : Subscapular n. (C5. C6) : Internal rotation
... .. ,,,', - . ...... .:
: .
273
Muscle Facts (II)
..Q Fig. 19.25 Pectoralis major and

E
:.:; coracobrachialis
'- Anteri or view.
Q.I
Q.
:§
Acromion
Coracoid
process - - - ---'
ii~~~~~~~~:=.,----;~=: Pectorali
major s
(sternocostal
part)
Coraco- ---,,....~+-I ; ----' =--~ Sternum

brachialis
A Sche ma tic.
Pectoralismajor ---~--7---t-Ik----¥''''''~
(abdominal part)
Clavicular --:-7li~"-""
part
Sternocostal
part
Abdominal
--~-11'
part
C Pectora lis major and coracobrach ialis.
B Pecto ralis maj or in neutra l position (left)

and e levation (right).
Pectoralis major and coracobrachialis
M uscle Origin Insert ion Innervat ion Act ion
, ~) Clavicu larpart ....•. ~ lav icl~ (lTl e~ ia l ha l~ . • Entire muscle: adduction, internal
• Medialand lateral : rotation
: Pectoralis major •.C?J St erno cost~ 1 pa rt H~t e.r~~rTl a.~~ H~o. s.t a.I ~ a.~~i la.~e s l ~6 H ~Uub::~~xr e st of greater • pectoral nn. • Clavicularand sternocostal parts:
• (C5-Tl) • flexion; assist in respiration when
• (}) Abdomi nal part : Rectussheath (anterior layer)
: shoulder is fixed
............................................... ............................................................. ........................... . .
Humerus(inlinewith crest : Musculocutaneous ~ Flexion, adduction, internal

: @) Coracobrachialis : Scapula(coracoid process)
of lesser tuberosity) : n. (C6. C7)
.... ... .. ..... ... .... .............. .... .... ..... ............... .... . ,
• .
rotation
Fig. 19.26 Subclavius and Clavicle 1st rib
pectoralis minor
Right side, anterior view.
Acromion
Coracoid
process
Subclaviu s
A Schematic.
Pectorali s -----'--~---~-:?i'-''''''~~~~~~~~
minor
3rd ~--~r--+-~~~~~---f
through
Fig. 19.27 Serratus anterior 5th ribs
Right lateral view .
Coracoid
pro cess
Acrom ion
-==-----\-7- 1st rib
Glenoid
B Subclavius and pecto
cavit y
ralis minor.
Serratus -+---!:J~=--f=-?"--=::. "'~

anterio r
Inferior -
angie
9t h rib
A Serratus anterior. B Schematic.
Subclavius,pectoralis minor, and serratus anterior

Mu scle Origin Insertio n Inner vati on Action
CD Subclavius 1st rib Clavicle (inferior surface) N. to subclavius (C5, C6) Steadies the clavicle in the sternoclavicular joint
Draws scapula downward, causing inferior

Medial and lateral pectoral
o Pectoralis minor 3rd to 5th ribs Coracoid process
nn. (C6-T1)
angle to move posteromedially; rotates glenoid
inferiorly; assistsin respiration
I}) Superior part Superior part; lowers the raised arm
Entire muscle: draws scapula laterally forward ;

Serratus anterior @ Int ermediate part 1st to 9th ribs Scapula (medial border) Long thoracic n. (C5-0)
elevates ribs when shoulder is fixed
® ,,,,,,,v, va' Inferior part: rotates scapula laterally

Muscle Facts (III)
Fig. 19.28 Trapezius

Posterior view. Superior - --'-- - --r-
Externa l occipital
nuchal line
protuberance
Nuchal ligament
'-'liI- - - Trapezius
(descending part)
C7 spinous pro cess
Trapezius
(t ransverse part)
Scapular spine B Sc he matic.
+-L...~;Nr---l;-\ll-- Trapezius
(ascending
part)
C1 (atlas)_~~~JI'
C2 (axis) JA~...~;n:'f>- C1-C4
tr ansverse processes
Levator scapulae
A Trap ezius.
Rhomboid m inor
T12 spinous
proce ss
Fig. 19.29 Levator scapulae with C7 spinous _~--+
process
rhomboids major and minor
Acro mion
Rig ht side , poste rior view.
T1 -T4 1~;;; ,,~I , <c~~ - =.,,-~- Scapular
spinous spine
pro cesses
~ \----¥-T--'~;_i"- Medial
Rhomboid ~ bord er
major
~~-I---+-"- Scapula,
posterior
surface
'---'.l.~---__- Inferior
angle
B Levat o r scap u lae w ith rho m boids

A Schematic. m aj o r and m in o r.
Trapezius, levator scapulae, and rhom boids major and minor

Q) Descending Occipital bone; spinous Draws scapula obliquely upward; rotates glenoi d cavity
Clavicle (lateral one third)
part process of C1-0 superiorly; til ts head to same side and rot ates it to opposite
Accessory n.
Trapezius
o Transverse Apone uro sis at T1- T4
Acromion (CN X); cervical Draws scapula medially
part spino us processes
plexus (C3-C4)
Q) Ascending Spinou s process of Draw s scapula media lly downward
Scapular spine
part T5- T12 Entire m uscle: steadies scapula on thora x
Transverse process of Draws scapula media lly upwa rd w hile moving inferior ang le
o Levator scapulae C1-C4
Scapula (supe rio r angle)
medially; inclines neck to same side
Dorsal scapular
® Rho mboid m inor Spino us process of C6. C7 Med ial bo rder of scapula n. ((4 -(5)
Spinous process ofT 1- T4 above (mi nor) and below Steadies scapula; draws scapula media lly upwa rd
® Rhom boid major (majo r) scapular spine
~ vertebrae
CN = cranial nerve.
Fig. 19.30 latissimus dorsi and teres major
Post erior view .
Scapula
Teres majo r
'---------!---U_ _ Lati ssim us dor si
(scapular part)
- - - - - T7 spi nous
processes
L- Lati ssimu s dor si
(verte bral part )
'---- - - Latissimu s dorsi

(iliac part)
Thoracolumbar ---~~=----'
fascia /j)It.:' ---C -- Iliac crest
-~I---- Ilium
j",jl ,-JL..,I -----'!L-- - - - Sacrum
B Latissimu s dorsi and

A Latissimu s dorsi. t eres major.
Coracoid
Acrom io n process Clavicle
'G~~~~-L- Scapula,
costa l surface
Teres major ------!''f-L.l!!--~-----'

D Common inserti on
of th e latissimu s !!!!!!'''''''''---+- - - Inferior
Lati ssimu s ----~-!---!~
dorsi and teres ang le
dorsi
C Teres major. major, ante rior view.
latissimus dorsi and teres major

Spinou s proc essofT7-T12 vertebrae;
CD Vert ebral part
thoracolumbar fascia
Latissimu s Crest of lesser Internal rotation, adduction, ext ension,
(6) Scapular part Scapula (inf erior angle) Thoracodorsal n. (C6-C8)
dorsi tuberosity of the respiration ("cough mu scle")
0) Costal part 9th to 12th ribs humerus (anteri or
:,/1 , crest (posterior one t hird) angl e)
@) /liac part ""
Scapula (inferior angle) Lower subscapular n. (C5-Cl) Int ernal rot at io n. adduct ion. exte nsio n
® Teres maj or 277
Muscle Facts (IV)
~ The ant erior and poste rior mu scles of t he arm may be classified part of the anteri or compartm ent , it is f unctiona lly grouped with the
~ respect ively as flexors and exten sors relative to th e move ment of m uscles of the shoulder (see p. 274) .
the elbow jo int. Altho ugh t he coracobrac hialis is topographically
Fig. 19.31 Biceps brachii

Supraglenoid Scapula,
tu bercle ant erior surface
and brachialis
Right arm. anterior view .
Lesser --~~l
t uberosity
Intert uber- - ----L-l.-+
cular gro ove
Shaf t of
Biceps brachii - ------1r..I.1 humerus
(long head)
A Schemat ic.
ll:;-m 'Hlll -- - Brachialis
Biceps
brachii
Med ial
epicond yle
Lat eral -
epicon dyle
V Bicipital apon euro sis

Ra d ia l --~ Ulnar
tuberosit y tub erosit y
Radial tuberosity. - 0.,...--;--'----- Ulnar t ube rosity ,
biceps brachii brachialis t endon
tendon of of in serti on
inserti on
B Biceps brachi i and brachialis. C Brachialis.
Anterior group:Biceps brachii and brachia lis

M uscle Origin Inserti on Innervat ion Actio n
. ill Long : Elbow joint : flexio n; supinat ion'

: Supraglenoid tub ercle of scapula
. head
: Biceps : Shoulder joint: flexion ; st abilizat ion of humeral
.....: Radial tuberosity : Musculocuta neous n. (C5-C6)
• brachii : head during deltoid contraction; abduction and
: 0 Shor t
head
i Coracoid process of scapula , inte rnal rotation of th e hum erus
.. . •• •. .• ••. • ••. • •. .••. ..• •..••. . . . .. . . ... . . . . ... . .. .
: Hum erus (dista l half of ante rior . : Musculocutaneous n. (C5-C6)
: Q) Brachialis : Ulnar tuberosity • Flexio n at the elbo w jo int
: surface) .L : a.~ ? r~d ia l ~ : p •.l1li~.?r).... . . .... ..... .... ..... .. ..... . ....... . .. . ...... . .
• Note: When the elbow is flexed. the biceps brach ii acts as a powe rful supinator because th e lever arm is almost perpend icular to t he axis of pronation /supination.
278
Fig. 19.32 Triceps brachii and anconeus
Rig ht ar m, p os t erio r v iew.
Scapula. Scapular Lateral head,

posterior surface spine Acromio n
te ndo n of origin
Long
head Radial groove
I Greater
tub erosit y
;. ~"""",.-. " r-.I.i:I - - Inf raglenoid Medial head
tub ercle
- .,m - - Shaft of
hum erus D Sche matic.
Anconeus
Triceps brachii
(m edial head)
B Partially removed:
Triceps brachii Triceps brachii Lat er al head o f
(long head) (lateral head)
triceps brachii .
- Shaft of
hum erus
Lat eral
head
Medial head
Medial - Lateral
epicondy le epicondyle
Olecranon Anconeus
Tendo n of
insert ion
Anconeus
Radius
A Tr ice ps b rac hi i and anco neus. C Partiallyremoved:
Long h ead of
tric eps b rac hii.
Posterior group:Triceps brachii and anconeus

Mu scle Origin Inserti on Innervation Action
.C? L? n. ~ ~ e ~ d . Scapula (infraglenoid tu bercle)

; Elbow joint: exten sion
: Triceps : 0 Medial head ; Posterior hume rus, dista l to radial groove; med ial inte rmuscular sept um .
• brachii ·: · ·· · · ······· ········,"" """' ,·· I I .: Olecranon of ulna : Radial n. : Shoulder joint , long head:
: Q) Lateral head I :~;~~~r humerus. proximal to radia groove ; ateral interm uscular. , : ,.•: (C6-C8 )
: exte nsion and adducti on
..... ... ... ... ... ........ ...............
: Olecranon of ulna : Exte nds t he elbow and

:o Anconeus . Lateral epicondyle of humerus (variance: poste rior jo int capsule)
(radial surface) : t ight ens it s jo int
. . .. ............ . .. .... .. ... ... ...... ....................... ..... •............. ..... ... .......
Radius & Ulna
Fig.20.1 Radius and ulna

Right forearm.
Trochlear notch Olecrano n
Head of radiu s. Head of radi us.

Articular arti cular art icular
fovea circumference circum ference
Coron oid
process Radial
Neck of Neck of
radius notch radius
Radial
notch
Radial Coro noid Radial

tuberosit y process t ubero sity
Ulnar
t uberosit y
Shaf t of ulna,
ant erior
----K Posterior
bo rder
Ante rior
surface
Med ia l ~\'
border surface
Int erosseou s
border
Shaft of radi us. Post erior

anterior surface borde r
Posterior
surface
--< Lateral
surface
Dorsal
Articu lar Head of tu bercle
circum Head of ulna
ference ulna
Styloid process Carpal art icular St yloid process Sty loid proc ess Styloid process
of radius surface of ulna of ulna of radiu s
A Ant erior view. B Post erior view.
280
Olecranon
Proxim al -~~-- Olecranon
radiou lnar joint
t Dor sal
Trochlear
not ch
Trochlear
notch
Proximal Cart ilage-fr ee

radioulnar joint st rip
Art icular Coro noid
fovea process
Coronoid
Head of
artic ular notc h process
radius
circumf erence
D Pro xima l v iew .

Ulnar
t uberosity
Radial
tub erosit y
t Dorsal
Posterior Radial Ulnar
t
Poste rio r
surface interosseous interosseous surface
border border
Ant erior
bord er
Shaft of ulna,
anterior surface
\
\ I,
.- .$., ..".......
Radius \-?
Int erosseous I Ulna
Lateral Ante rior Ant erior membran e Anterior Medial
surface border surface surface surface
Shaft of radius, - - E Tran sverse sect io n, proxi ma l v iew .

ante rior surface
Int erosseous
Interosseous
border Art icular St yloid process
m embrane
circumference of ulna
t Dor sal
Head of ulna
Sty loid process Dista l radioulnar Sty loid pro cess Carpal art icular Dist al radioulnar
of radius joint of radi us surface joint
C An t ero su p erio r vi ew . F Di sta l view.
281
ElbowJoint
..Q Fig.20.2 Elbow (cubital) joint
,§
....,j
Right limb. The elbow consists of three articulations between the humerus,
li; ulna , and radius: the humeroulna r, hurneroradial, and proximal radiou lnar
Q. joints.
:§
~=---- Hum erus Hum erus
Lateral border
Medial
Lateral _________
supracon dylar
supracondylar ~ ridge Medial
ridge supracondylar
Coronoid "-- - - Lateral
Radial fossa ridg e
fossa supracondylar
Lateral _________ Olecranon fossa - - - --<-- ..,;l ridge
Medial
epico ndyle -------- epicond yle Medial - ., •. --- - Lateral
Capite llum --~- epicondyle

epicondyle
Trochlea
Ulnar
!",:';~k-+---- Coronoid Head of radius,
Head of radius --~.....,- groove
process articular
circum ference
Neck of radiu s - - --+- - ' Capitulotro chlear Olecranon
groove
Radial - - - +
tub erosity Radius
Ulna Ulna - - - -'-
A Anter ior vie w . B Posterior v iew.
Humerus - -- Humerus
Radial Head of Medial

Lateral - - Hum eroradial
Radius t uberosity radiu s
supracondylar supracondylar join t Radius
ridge ridg e
Capitellum
Medial
epicondyle Capitellum
Olecran on
Humerou lnar
joint
Ulna Coronoid Trochlea

Olecranon Proxima l Head of Ulna
process
radioulnar joint radius
C M edial vi ew . D Latera l vi ew .
282
Fig. 20.3 M RI of the elbow joint ~ Clinical
Sagittalscc tion.
Assessing elbow injuries
The fat pads between the fibrous capsule and synovial mem brane are
part of the norm al anato my of t he elbow jo int . The anterior pad is most
readily seen on a sagit t al MRI while the poste rior pad is of ten hidde n within
the bony fossa (Fig. 20.3) . With an effusion of the joi nt space, thei nferior
edge of th e anterior pad app ears concave as it get s pushed superiorly by
th e intra- artic ular fl uid. This causest he pad to resemb le t he shape of a
ship's sail, t hus creating a characteristic "sail sign ." The a lig nm ent of t he
prom inences in t he elbow also aids inthe ident ification of fr act ures and
dislocations. · ..
A Posterior view of exte nded elbow : The epicondyles and olecrano n lie in a
st raight line.
Fig.20A Humeroulnar joint

Sagitt alscct ion th rough the humeroulnarjoint, medial view.
Brachialis Triceps brachii

B Lat eral view of flexed elbow: The epico ndy les and olecranon lie in a
st raight line.
Fat pad
.~f---ff:"t:1~-----;:--- Corono id
fossa
(-""","""~,"",,,:-"'---~-- Olecranon
fossa
C Posterior view of flexed elbow : The t w o epicondyles and th e t ip of t he
Olecranon olecranon form an equilateral tr iang le. Fract ures and dislocat ion s alter
bursa t he shape of t he t riang le.
Trochlea
Olecranon
Trochlear
notch
Coron oid process Ulna
283
Ligaments of the ElbowJoint
Fig.20.5 ligaments of the elbow joint

Right elbow in flexion .
- -'3- - Hum erus
Lateral
sup raco ndy lar
ridge
Olecranon - - ---------77
fossa
Medial - Lateral
epicon dy le epicon dy le
Radial
Hum erus
collate ral I.
Ulnar collate ral I.
Olecranon
Radial Ann ular I.

Radius tu bero sit y of radiu s
A Posterior view.
Ulnar collateral I.
(anter ior part)
Medial
epicon dyle
Ulnar collateral I.
(posterior part)
\i I
Ulnar collateral I.
(t ransverse
Lesser tu berosit y. part)
supracondy lar Ulna Coro noid Olecranon
ridge process
B Medial view.
Lateral
epicondy le
Saccifor m
recess Radius
Joints and ligaments of the elbow

Joint Articulating surfaces Ligament
Humeroulnar : Ulna (t rochlear

: Trochl ea : Ulnar collate ral I.
: j oi nt : not ch)
..... ....... ....... ...... ...... ..... ... ., .
! Hum eroradial : Capitellu m : Radius (art icular : Radial collateral I.

Olecranon Radial collat eral Annu lar I. Neck of Ulna l j~int . ... .. . . .... ... . ... . . .... ... . . ... ........ . ' ~o.v~~ ).
" ' n
I. of radius radius
'. Proximal •.• Radiu s (art icular .: Ulna (radial
: Annu lar I.
C Lateral view. : radioulnar jo int ! CIrc umference) ; notch ) . nnn n nn . nn n . .. .
284
Fig. 20.6 Joint capsule of the elbow
Right elbow in ext ension, anterior view.
Me dial
epicon dyle
Joint ----~
capsule
Lat eral
epicondy le
Radial
collateral I. Ulnar
collatera l I.
Ann ular I. ------,~-- ;;;;:;,....
of radi us
Radial ----!-'-~ c
ft ·~J-- Ulnar
tub erosit y
tub ero sit y
Radius - - - - Ulna
A Int act joi nt capsule.
Radial fossa
Capit ulot roc h Coronoid

lear g roove fossa
Lat eral Med ial

epicondy le epicon
dy le
Capite ll um - - -!--
Trochlea
Radial co llate ral I.
Ulnar collateral I.
Coronoid
process
Ulna
B Windowed joint capsule.
285
Radioulnar Joints
~ The proxim al and dista l radiou lnar joint s fu nct ion toge t her to en for pronat ion and supinat ion run s obliquely from th e cente r of th e hu
~ able pron ati on and supinatio n movem ent s of t he hand. The joint s meral capite llum th rough th e cente r of th e radial articular fovea down t o
are fun cti onally linked by t he interosseous membrane. The axis th e sty loid pro cess oft he ulna.
Fig. 20.7 Supination Fig. 20.8 Pronation

Right forearm. anter ior view. Right fo rearm, anterior view.
Axis of Olecranon
pronatlonr
supinati on
Radial ~ Trochlear
collateral !. ~ not ch
Corono id
Art icular - ----''= pro cess
fovea
Ulnar Proxima l radio
collateral l. ulnar joi nt
~--- U l n a r +1' - - Ulnar

Radial - - - ---! Radial - -
t uberosity t ubero sity
tuberosit y tuberos ity
~>-1--- Oblique cord
-<1
Ant erior - - - - f ----t- - - Shaft of ulna
border
Inte rosseous
bord er
of ulna "
Interosseous
bord er
of ulna
Interosseous
bor der
of radius
K - -+- - Interosseous Interosseous

membrane membran e
Radius
Head of ulna
-...#-J-- Dorsal
Palmar
Head of ulna ---;;~.~;;:.,... tub ercle
radioulnar I.
Styloid process - - - -----".'1
Sty loid process of ulna
Sty loid process of ulna
of radius
286
Fig.20.10 Distal radioulnar joint rotation
~ Clinical
Right forearm, dista l vi ew of articu lar su rfaces of radius and ulna. The dorsal
and pa lma r radi ouln ar ligam ent s st abilize th e di stal rad io ulnar joint.
. Subluxation of the radial head ("nursemaid's elbow") ..
When small children are abrupt ly pulled up by thei r arm. t he im matur e
head of t he radius can dislocate from the annular ligament. resulti ng in
Radius, carpal
painfu l pronation.
art icular surface
Fig.20.9 Proximal radioulnar joint

Right elbow , proxima l (superior) vi ew .
Head of ulna
- ---J- - Olecranon
Head of radius. Art icular
lunula fovea Dorsal radiouln ar
Sty loid I.
Trochlear process
notch Extensor
of radius Dorsal carpi ulnaris Styloid process
t ubercle tendon of ulna
A Supinati on .
Sty loid process

Annular Proximal radioulna r Coronoid of radius
I. joint process
A Proxima l articu lar su rf aces of radius

and u lna .
---r-~-----i=----- Ulnar
- ---,1- - Olecranon
not ch
--..L- + - - -----=''--Art icular
Trochlear circumference
notch
Styloid process
of ulna
Annular Radial not ch Coronoid
B Sem ipronation.
I. of ulna process
B Radiu s rem oved .

Dorsal radioulnar
I.
~ Clinical
Radius fracture
Fallsonto the outstretched arm often result in fract uresof th e dist al radius.
In a "Colies'.fractu re." t he dista l fragment is t ilt ed dorsally. Head of ulna
Dorsal -
-
Styloid process Palmar

of ulna radiouln ar I.
C Pronati on .
Styloid processof
A B radius
287
Muscles of the Forearm (I)
.Q Fig. 20.11 Anterior muscles

.§
-.I
Right fore arm , ant erior view. Muscle origins (0) are show n in red,
~ insert ions (I) in blu e.
Q.
:§
Biceps brachii --~-H',-- Triceps brac hii - - - Brachialis
Brachialis
Medial epicon dyle

(com m on head
of flexor s)
Biceps brachii, - --fl...,.,f'f--l+-'

tendo n of ---'-+~f.1...;;;--- Bicipi tal
insert ion apo neuro sis ---,;:'li~-+--- Pronato r
teres
Brachioradialis - -F-t,.-;--" Biceps brachii (I) ---j~7."-i
Exte nsor carpi ---7-~--t-- Pron at or

Sup inator ------!~ ~~
radialis longus teres
Extensor carpi ----'!~~"--:!'!II---- Flexor

radialis brevis carpi radialis
~~I-- Palmaris
longus
Flexor
carpi ulnaris
+i!'---;1f-~~~- Flexor digi to rum Flexor digitorum

superfi ciaIis superficialis
Flexor - - lHl-'J
Flexo r - --;'r.
pollici s longus
po llicis longus
Abductor
pollici s longus
Brachioradialis (I) - -Ci1U
. il-----='T - Flexor
carpi ulnari s (I)
Abductor
-\l"*~-+--- Palm aris pol licis
longus longus (I)
IrB-r.Hib1~----\1:fu-"-- Flexor digi torum ~C+Hnr--'a--&-,'--'\\-\lll--'--- Flexor digit orum

superficialis, superficialis
tendon s of inserti on te ndo ns
Flexor po llicis Flexor po llicis

longus, tendon longus te ndo n ,
of in serti on I
+--- -----!rB- --\--2"--- - --' Flexor digi tor um +-----1H!----'~----' Flexor digitorum
profu ndus, tendon s profu ndus
of insert ion tendon s
A Superfi cial f lexor s and radialis group . B Removed: Radialis group (brachioradialis, ext ensor carpi radialis longus,
and ext ensor carpi radialis brevis), flexor carpi radialis, flexor carpi
ulnaris, abdu ct or pollici s longu s, palm aris longu s, and biceps brachii.
288
Brachialis I!!lii! - - - - Brachiali s
Pronator teres.
hum eral head
Pron ator te res.
Extensor carpi ---~ Medial epicondyle.
hum eral head (0)
radialis brevis common
Com mon head of
flexor s (0)
Lateral epicondy le. ~ head of flexor s
com m on head of
exte nsors. supinator Flexor digitorum
superficialis.
Flexor digito rum ulnar head
superfic ialis.
Pronato r teres.
Biceps brachii (I) --t---~ ulnar head (0 ) Biceps brachii - - ----,D-
ulnar head
Sup inator --"-It'--'-~;-:;;!l~. Supinator - --"-IIiiir--#+ Brachialis
Flexordigitorum ---i~~ Flexor digitorum - -- ihll"
superfic ialis. superficialis.
radial head (0) radial head
Flexor digito rum +- - - - Flexor digitorum

profundu s pro fundus
Pronator Pronator
teres (I) teres
Flexor - -+CoL' Flexor - - +-
po llicis longus po llicis longus
Pronator
quadratu s
Brachioradialis --iJ.~::=::;"''''
• •"i-----::r-- - Flexo r
carpi ulnaris
Abductor
po llicis longu s
Flexor
carpi radialis
Flexor diq ito rurn

Flexor poll icis Flexor superficialis
longus t endon pollicis longus
( 'Jr--------irl-'ir--+-2~--.J Flexor digito rum Flexor diq it orurn

profu ndus profundus
tendon s
C Removed: Pronator tere s and flexor digitorum superficialis. D Removed: Brachialis, supinator. pronator quadratus. and deep flexors.
289
I Muscles of the Forearm (II)
.Q Fig. 20 .12 Posterior muscles

.§
.... Right forearm, posterior view. Muscle origins (0) are shown in red, inser
ll:i tions (I) in blue.
Q..
s
Brachioradiali s Brachioradialis
Triceps brachii Triceps brachii
Medial ------'
Olecrano n
Exte nsor carpi epicondyle. Extensor carpi
radialis brevis com mo n radialis longus
head of flexor s (0)
Anconeu s Extensor carpi Anconeus (0 and I) Extensor carpi
radialis long us radialis brevis
Extensor Flexor Supinator

digi toru m digitorum
profu ndu s
Flexor Extensor Flexor
carpi ulnaris carpi ulnaris carpi ulnari s (0 )
!(;:~\\1rl.ilt--H-- Abd ucto r

Extensor carp i po llicis longu s
radialis brevis -l.!--'-7--'Hff-- - Ext ensor
Ext ensor Iln r -4H-!--- - Abd uct or
polli cis longus
digiti m inimi pol licis longu s
Exte nsor
Extensor polli cis brevis
polli cis brevis Ext ensor
indicis
I H-Hc'J,-- - Dorsal
tubercle
Ext ensor carpi ---jf-~/' lI" 1 , 4'~""""-- Ext ensor carpi

radi alis brevis radialis long us
Exte nsor t endo n tend on
poll icis
Inter- ---+H-~!-+----L I longus
t endinous tendon
con nect ions
Ext ensor --4f#~--l--H-~;!-:-fL.---'-l-:~ II

digitorum Ext ensor
tendo ns. digit i
I -'~~- Extensor
do rsal digit al m inimi (l )
digito rum (I)
expansion
A Superficial extensors and radia lis group. B Removed: Triceps brachii, anconeus, flexor carpi ulnaris,extensor carpi
ulnaris, and extensordigitorum .
290
Brachioradia lis (0) Brachioradialis
Extensor carpi
radialis longus
' \-- - - Extensor carpi

radialis brevis
' I!.- - - Supinato r,

Medial -------' hume ral head
epicondy le,
common head Lat eral epico ndyle,
of flexor s com mon head
of ext ensors
Anco neus ----L-----''w-''
Flexor - - - ----!':" Iil ~f---- Supinato r Flexor - - - ----1:
digitorum digitoru m
profu ndus pro fundus
Flexor - - -- - f--o":
carpi ulnaris
Pronat or t eres
---.~-- Abduct or
pollicis longus
:--+-- - Ext ensor --c~_I--__ Extensor

polli cis long us (0) pollicis longus
~Hf--- Extensor ~~i----- Exte nsor

pollicis brevis pollicis brevis
I-i\ ~,----~:!--- Extensor -11~~~--- Exte nsor

indicis indici s
--~--- Interosseous
membrane
Brachioradialis (I) Brachioradialis
:';-- - - Dorsal
tu bercle
Abductor Abducto r
poll icis longus (I) pollicis longus
Extensor carpi -----.f--;~rl-----l e-~ ......- - Ext ensor carpi Exte nsor carpi -----.~"..__t---llr.... R'--~--"o:-- Extensor carpi
radialis brevis (I) radialis longus (I) radialis brevis radialis longus
Ext ensor
polli cis brevis
Extenso r Ext ensor

pollicis longus (I) pollicis longus
Extensor
digiti
m inimi
C Removed: Ab d uc tor po ll icis lo n g us, ex t ens o r p ol lici s lon g u s, and rad ia o Removed: Flexor digito r u m profu ndus, su p inato r, ex t enso r p o llicis
lis group. brev is, and ex t enso r indici s.
291
Muscle Facts (I)
Fig. 20.13 Anterior

compartment
Right forearm. anterior view.
0---- Flexo r dig ito rum

Int erosseous
m embrane superfi cialis
(humeral head)
Flexor _ _
digitorum
superficialis
(ulnar head)
;
,
A Superficial. C Deep.
B Intermediate.
Anterior compartment of the forearm

M uscle Origin Insertion Innervation Acti on
· Superficial group
: Humeral head: medial epicondy le

: Lateral radius (distal to : Elbow: weak flexor
: Q) Pronator teres : of humerus
: supinator insert ion) : Forearm: pronation
: Ulnar head: coronoid process
.... ..... ................, . ........... : Median n. (C6. C7)
i -.~
: Baseof 2nd metacarpal
: Wrist: flexion and abduc t ion (radial :
: 0 Flexor carpi radialis . (variance: base of 3rd
: deviation) of hand .
: metacarpal)
...........................: Media l epicondyle of humerus ............................................ , .
: Elbow: weak flexion
: Q) Palmaris longus : Palmar aponeu rosis : Median n. (0. C8) : Wrist: flexion tig hte ns palmar
: apo neurosis
....................................................... ................................................ ....................... .... . .
: Humeral head: medial epicondyle : Pisiform; hook of hamate; base : Wr ist: flexion and adduction (ulnar
: 0 Flexor carpi ulnaris
: Ulnar head: olecranon : of 5th metaca rpal : Ulnar n. (0-Tl) : deviation) of hand
· Intermediat e group
: Elbow: weak flexor ..
: Hum eral head: media l epicondyle Sides of m iddle phalanges of
: ® Flexor digitorum superficia lis : Ulnar head: coro noid process : Median n, (C8. T1) : Wr ist. MCP. and PIPjoi nts of 2nd to
2nd to 5th digits
! 5th digits: flexion
· Deep group
® Flexor digitorum profundis

! Ulna (two thi rds of flexor surface) : Distal phalanges of 2nd to 5th • Med ian n. (C8. Tl) ! Wrist. MCP. PIP. and DIPof 2nd to
: and inte rosseous membrane digits (palma r surface) ~ Ulnar n. (C8. Tl) ~ 5t h dig its: flexion
.......................... ............ . .
: Wrist: flexion and abduction (radial
: Radius (midanterior surface) and : Dista l phalanx of t humb : deviation) of hand
~ 0 Flexor po llicis longus
: adjacent interosseous membrane : (pal mar surface) : Carpometacarpa l of th umb: flexio n
: Media n n. (0. C8) : MCP and IP of thu mb : flexio n
............................................. . .. . ..
: Dist al quarter of ulna (anterior : Dista l qua rter of radi us : Hand: pronat ion
: ® Pronator quad ratus : surface) : (anterior surface) : Distal radioulna r joint: stabilization
: DIP = dista l inte rpha langeal; IP = interphalangeal; MCP = metacarpopha langeal; PIP = proxima l inte rpha langeal.
... ................................. .............................
Fig.20.14 Superficial and intermediate groups Fig.20.15 Deep group
Right forearm , anter ior view. Right forearm, anter ior view.
Iv
<:>
!:!!
0
- - - Medial 0
epicondy le s
(common ~
head of Cor ono id (;1
flexo rs) process tilQ
§
Radial Radial
Ulnar
t ube rosit y t uberosity
tuberosity
Pronator
teres Int erosseous
Palmaris
m emb rane
long us
Flexor
carpi
Flexor
radialis
carpi
ulnaris
Flexor
digit orum
pro fundus
Flexor pollicis
longu s
Flexor
digitorum
superf icialis
Pro nator
quadratus
Base of 2nd Pisiform bon e
metacarpal Tubercle of
Hook of t rapezium
hamat e Pisiform
bone
Base of 5t h
m eta carpal
Palmar
apo neurosis
If ~it---TlHl-1.t-~1F:t-----:>---'I--'''''----- 2nd
t hrough 1st distal
5t h m idd le phalanx, base
phalanges
293
Muscle Facts (II)
Fig.20.16 Radialis group

Right fo rearm, po ste rior view.
)
/
Posterior compartment of the forearm: Radialis muscles

: Distal humerus(distal surface), lateral : Sty loid processof the radius ! Radial n. (C5.C6) : Elbow: flexion
: CD Brachioradialis
: intermuscular septum : Forearm: semipronation
: Lateral supracondylar ridge of distal
: 0 Extensor carpi radialis longus . h ! 2nd metacarpal (base) ! Radial n. (C6. 0) .!. Elbow'.weakflexion
! umerus,lateral intermuscular septum
.... . ,.................................................................... . ! Wrist: extensio n andabduction
! ill Extensor carpi radialis brevis : Lateral epicondyle of humerus : 3rd metacarpal (base) ! Rad ial n. (C7, C8)
Fig. 20.17 Radialis muscles ofthe forearm
Right forearm.
Humerus - - -
,rjL ~a--- Hum erus
Brachioradia lis
Lat eral supra

condylar crest ~
Lat eral -'-"-\-~~--- Lateral

epico ndyle epi condyle
Olecranon
Extensor carpi
radiali s long us
Ext ensor carpi Ulna - - ---',-

radialis lo ngus
Ext ensor carpi

radial is brevis
-t--i--,r7.lt---'~r---- Extensor carpi
radiali s brevi s
-1-++- - - Radius
Int erosseou s - - - ---'!! I

Radi us - - - --t- I mem brane
1- - - - Brachioradialis,
te ndo n of
insert ion
'-'-- - - Styloid process

I ~k---- Styloid pro cess of rad ius
of radius
Baseof 3rd - - -. /
metacarpal I ~Hl.Rc------",c---- Baseof 2nd
metacarpa l Baseof 3rd -------j~__4'~+._:...,. Baseof 2nd
metaca rpa l metaca rp al
-I----T-~-'-:--- 2nd
me tacarpa l
3rd
met acarp al
-!-- - ......- f - - Shaft of

2nd
met acarp al
A Lateral (radial) view .
B Posterior view.
295
Muscle Facts (III)
Fig. 20.18 Superficial group Fig.20.19 Deep group

Right forearm, posterior view . Right forearm, posterior view .
e-+--- @
•~--,;--- CD
Posterior compartment of the forearm

• Superfi cial group
: Wrist : exte nsion

: Dorsal digital expansion of 2nd to
, (j) Extensor digitorum : MCP, PIP, and DIPof 2nd to 5th digits:
: 5th digi ts
...: Common head (lateral epicondyle : ~.x. ~~ n. .s i ? n. / ~ b. ~ ~ ~ ~ i ? n o f f i n. 9. e. r ~ .
! of hum erus) : Wrist: extension, ulnar abd uct ion of hand
! • Radial n.
, Q) Extensor digiti mi nim i , Dorsal digital expansion of 5t h digit : : MCP, PIP, and DIP of 5th digit: extension and
(C7,C8)
• abduction of 5t h digit
................................. . , . . .
: :
: Common head (lateral epicondyle
: Wrist : extension, adduction (ulnar deviation) :
: Q) Extensor carpi ulnaris : of humerus) : Baseof 5t h metacarpal
. ~ ~~ .
: Ulnar head (do rsal surface)
, Deep group
Olecranon, lat eral epicondyle of .

: Radius (between radial tuberosity : Radial n.
, 0 Supinator hum erus, radial collatera l ligament, • Radiou lnar joints: supinat ion
• and insert ion of pronator teres) : (C6,G)
......................... . : . a n. n. u l ar l i 9. a JTl e n..t. ?~ ~a. ? i ~ ~ . ........ ......... .... ..............
: ® Abduct or pollicis longus : Radius and ulna (dorsa l surfaces, • Baseof 1st metacarpal : Radiocarpal joint: abduction of the hand
. . . ! i n. ter o s s ~ ? u ~ rT1.~ m b ra n e ) . ~ a r P ? ITl e. t a. c a r p a l joi nt of th um b: abduction
, . : Radiocarpal joint: abduction (radial
• Radius (posterior surface) and : deviation) of hand
, ® Extensor po llicis brev is : Baseof prox imal phalan x of t humb
, interosseous membrane • Carpometacarpa l and MCPof t hu mb:
. . : Radial n. ! extension
. -. ••. • •.. . . . .. ... . ... . . . ... •. ••• . •• .
: (C7,C8) , Wrist: extension and abd uct ion (radial
• Ulna (posterior surface) and deviation) of hand
: (2) Extensor po llkis lon gus : Baseof dista l phalanx of t hum b
• interosseous membrane Carpometaca rpal of t humb: adduction
MCPand IP of thumb: extens ion
............... ' .
, Ulna (poste rior surface) and • Posterior digital extension of i Wrist: extens ion
: ® Extensor indicis
! interosseo us membrane • 2nd digit : MCP,PIP, and DIPof 2nd dig it: extens ion
, DIP = distal interphalangeal; IP = interphalangeal: MCP ~ metacarpophalangea l: PIP = prox ima l interpha langeal.
296
Fig.20.20 Muscles of the posterior forearm
Right forea rm , posterior view.
Lateral ~;---- Lateral

epicondyle epicondyle
Olecrano n _----'-=~-- I
;~T.:--- Comm on head of Ulnar Olecrano n

exte nsor digitorum , groove
exte nsor digit i
m ini mi , and exte nsor
carpi ulnari s
~=---- Sup inato r

Ulna - --'-
Ext ensor carpi - - -----:: =:=:-I/i Post erior - - - --,

ulnaris bord er
of ulna
---'-1- - - Radiu s
~Hl-- Abdu ct or
pollicis longus
Extensor dig it i ---!i~T , ' 1 Ext ensor ----+:~"

m ini m i po llicis longus
Radius Exte nsor

pol licis brevis
Extensor ---~,....
ind icis
Base of 1st
Base of 5th m et acarpal
m et acarpal
5t h proxim al
phalanx, 2nd -----:-----7--f-i--f-+~,....
base meta
carpal
r-"---.l!-+-:::->----[-;;-;--r----F,;1--l!---~,.,..___+-- Dor sal
digit al
expansio n,
int ert endi
nous con
nect ions 1st dista l
phalanx,
base
A Superfici aI exte nsors. B Deep exte nsors w it h supinat or. 297

Bones of the Wrist & Hand
Fig.21.1 Dors al view

Righthand.
Phalanges '
2nd distal phalanx -
2nd middle phalanx
Meta
carpals
2nd proximal phalanx -
I Carpal
bones
Bones of the wrist
and hand
: 1st to 5th proximal phalanges

..................................................
Phalanges L~ ~.? t? ~t.~.r1l.i?? I~.?.ha la ng es '

: 1st t??~ ~..~i.S.t~ l .p~a. I~~.9.~s. .
Metacarpal
, 1st to 5th metacarpals

bones
i. !.r~ p..e.~ i u. r.n. J~~~.p.h. ?i ~ .
: Carpal bones i yap.e~? i ?...... Lunat~ . . . . . . ..
, Capitate . : .!.ri~ .u. ~tru.r.n. . .

, Hamate
: 'T here are onlyfour middle phalanges (the
.. t~.u. r1l b. ~as ~ ~ ly a proximaland a distal p ha. l~ n x.):H ' Trapezoid
Triquetru m
Lunate
Styloid process
of radius Styloidprocess
of ulna
Radius - -+-- -i!!----- Ulna
298
Fig. 27.3 Radiograph of the wrist
Antero pos te rior v iew of lef t lim b.
Fig. 27.2 Palmar view

Rig h t han d . -
tv
I
Tuberosit yof - - Hook of
distal phalanx
hamate
Capita te Pisiform
Scaphoid
Triqu etrum
Head
Mid dle
Shaft phalanx
Lunate
Base
~ Clinical
Scaphoid Fractures
Scaphoid fr act ures are the most com mon
carpal bo ne fractures. gener ally occurring at
the narrow ed w aist between t he pro ximal
and dist al poles (A. right scapho id) . Because
blood supply to th e scaphoid is t ransm itted
via th e distal segment, fractures at the waist
can comp rom ise t he sup ply to th e proxima l
segme nt, of t en result ing in nonunion and
~-!!------ Sesam oid avascular necrosis.
bon es
Meta Distal
Shaft
carpal
t
Trapezoid
Pisiform - -- -".1 >-.- r:S~--- Tubercle of
trap ezium
Triq uet rum - - --¥ A Proxima l

Capitate
Lunate
Tubercle of
scaphoid
St yloid
process Sty loid process
Ulna
of radiu s
{ Head
- -f-- - Radius
299
Joints of the Wrist & Hand
.Q Fig . 21.4 Joints of

e
:.:i
the wrist and hand
I..
cu
Q.
:§
Distal int er

phalangeal
joint
~'""'-- Proxima l
int erphalangeal
joint
Inter- .-r .-..
phalangeal
joint of
thumb -r~l/f--- Met acarpo
phalangeal Tuberosit y of -
joint distal phalanx T - - - Distal
phalanx
Met acarpo
phalangeal
joint of
t humb
Middl e
phalanx
Carpom etacarpal
joints
Mid carpal
Carpom etacarpal joint
Proximal
joint of thumb
phalanx
1Il!!~~~...[iI:~'1'l Ra diocarpal
Ii join t
Dist al
radtou lna' 1st - - -\
joint Head
proxima l
phalanx
Meta
Shaft
A Jo int s of th e wri st and han d . Right hand, carpal
1 s t ---~
pos t erior (dorsa l) view. m etacarpal
Base
Trapezoid
Trapezium --8-_
Capitat e
,r'!f--- - - Lunat e
Sty loid process - - - - ;-' -7L- - - Scaphoid

of radius , ,,.--- - St yloid process
of ulna
Radius Ulna
B Carpom etaca rpa l join t of the th umb. Radia l vi ew. Th e 1st metac arpal
b one ha s bee n m oved slig h t ly d ista lly to exp o se t he articu lar sur face
o f the t rap eziu m. Two car d inal axes o f moti on are sho wn here:
C Rad iograph of wri st. Radia l v iew. (a) f lexion / exten sio n and (b) abduction/adduction .
300
Fig. 21.5 Wrist and hand: Coronal section
Right hand.
I n''''''~------if-',----;i-t-- Dist al interphalangeal
joint
Dist al
phalanx
Middle
'r \-c\----I--+--+++-- - n-=''T- - Proximal
phalanx
int erphalangeal
jo int
n rmr rt.'T-;nfitir-- Metaca rpop halangeal

join t
Collateral ligament s --'i~~~[---j-'-;r";;'l;

Int erphalangeal joi nt
, st dorsal 4t h dorsal interosseous

int erosseous
5t h metacarpal
Metaca rpophalangeal ~
joi nt Abducto r digit i mi nimi
, st metac arpal -~, ' ,' I II ,

Carpometaca rpal joint
Opp onens pollicis
Hamate
Trapezoid -¥~S-+"-f1=' Capitate
Carpo metaca rpal \ '-'Jif-'I--- - Pisifor m
joint of th e thumb "":'1:;-Wcrf-- - Triquet rum
Trapezium """"'<'+-- - Ulnar collatera l ligam ent
Radial collate ral ligament
~=:'~~~7-4~=- Ulnocarpal disk
Scaphoid Lunate
Midcarpal joi nt ~ >~T\"i-_ _ Distal radiou lnar
Radiocarpal joint jo int
-'iliic''1<Tm--';>--- Interosseous
m embr ane
A Joint s of th e w rist and hand.
Midd le phalanx -
Collate ral
lig aments
Proxim al ~
phalanx
- - - Metacar pophalangeal
jo int
Carpometaca rpal
Interosseous
m et acarpal ligament joi nt
Trapezoid Hamate
Triquetru m
Capitate
Extensor carpi Lunate

radialis longus
tendon
Sca phoid Radius Interosseous Ulna
B Coron al MRI. memb rane
301
ligaments of the Wrist & Hand
.0 Fig. 21.6 Ligaments ofthe hand

.5
....., Right hand.
~
~
Distal interphalangeal
joint (collateral II.)
I ~-r--+t- Proxim al
interphalangeal
joint (collateral 11.)
1!+-- r-r+l-- Metaca rpophalangea l
joi nt (collate ral II.)
L-,'I"l--#--i\llr -- DorsaI
Dorsal carpo metacarpal II.
metacarpal II.
Dorsal ------'.;~r~----~_...:
Ulnar carpal
intercarpal II.
collatera l I. -t-'-- +- Palmar II.
Radial carpal
Proximal -~::-i-~"'"
collate ral I.
Dor sal inte r
radiocarpal I. pha lan
geal joi nt
capsule
Dor sal
radiou lnar I.
Deep - - - -'!'r- r- JI
tr ansverse
metaca rpal II.
Metacarpo
A Post erior (dorsal) view.
phalangeal
joi nt capsule
Palma r ----:~'\--+_\",.t.
metacarpal II.
~'='c'-7-.~- Palmar
Palmar --r-"'--l'~- carporneta
interca rpal II. carpaili.
Flexorca rpi ---r.

...... ..." -r-- - Radiocarpal
ulnaris te ndon
collateral I.
Palmar ---7:TT-:.............~i.:!!~..,
ulnocarpal I.
Palmar
radioca rpal I.
Palma r
radioulnar I.
B Anterior (palmar) view.
302
Fig. 21.7 ligaments ofthe carpal tunnel
Right hand , anterio r view.
l\J
-..
Hookof --+.--T..£~
hamat e
Pisiform - ---¥.'l.---
bon e
Carpal Tubercle of
t unnel trap ezium
ent rance
- --1f-- - Radius
Ulna ------;!---
A Carpal tunn el and flexor reti naculu m . Ulnar { Hook of .. ;:""'"'7--"",,-- Carpometacarpal jo int
carpal hamate of t he t humb
em inence Pisiform - ----.ll - ~;7--- Flexor ret inaculum
(tran sverse carpal l.)
Triq uet rum
Radial
Tubercle of t rapezium carpal
Lunate }
Tubercle of scaphoid em inence
B Bony boun daries of th e carpal t unnel.
Fig. 21.8 Carpal tunnel

Transverse sect ion . The conte nts of th e carpal tunn el are di scussed
on p. 342. See p. 343 for t he ulnar tun nel and palm ar carpal ligament .
Palmar Flexor retina c Hook of Flexor

Ulnar tu nnel carpal I. ulum (tran s hamate ret inaculum
verse carpal l.)
Pisiforrn .;1::, \
~.r, i.~. ; ".
.. ~ . ·~:~. .·\2
. .. ,
/
.--------
Carpal t un nel
_ /
/
Passage fo r
flexor carpi
radialis t endon
(considered
part of t he
..1.
.. i '. L
Carpal t un nel
carpal t unnel)
Trapezoid
A Proximal part of t he carpal t unnel. B Distal part of th e carpal tunn el.
303
ligaments of the Fingers
Fig. 21.9 Ligaments of the fingers : Lateral view

Right middle fi nger. The outer fibrous layer of the tendon sheaths (stra which also bind the sheat hs to the palmar surface of the phalanxand
tum fibrosum) is strengthened by the annular and cruciform ligaments. prevent palmar deviation of the sheaths during fl exion.
Proximal Flexor Flexor

Distal int er int erphalangeal di git orum digitorum
phalangeal jo int Metacarpo superf icialis profund us
joi nt phalangeal joint t endon te ndon
AS C3 A4 C2 A3 Cl
A Extension. Not e: Whereas the 1st through 5th annularligaments Al

(A1-A5) have fixed positions. t he cruciform liga ments (C1-C3) are
highly variable in theircourse.
Phalangogl eno id I. Collateral I.
- - - Meta
carpal
bon e
Accessory
Al collatera l I.
D Flexion of the metacarpo

C Extension ofthe metacarpophalangeal phalangealjoint. Note: The
B Flexion. joint. No te: The collateral ligament is lax. collateral ligament is ta ut.
Crucifo rm I. Phalangoglenoid I. Cruciform I. Phalangoglenoid I.
Collate ral II. Collateral II.
Flexor
D eep t ran sverse Fle xor digitorum di gitorum
m etacarpal I. profund us superficialis
tendo n tendon
E Joint capsules. ligaments. and digital tendon sheaths.

304
Fig. 21.10 Anterior view Fig.21.11 Third metacarpal: Transverse section
Right middle fing er. palmar view. Proximal view.
Dist al int er

phalangeal
Flexor - - joint s (collatera l II.)
digito rum
pro fundu s
tendo n
Extensor
digito rum tendo n
t Dorsal
t
3rd met acarpal --++i----+.~

bone
Deep
tra nsverse
metaca rpal I.
Palm ar I.
Flexor Flexor
dig itoru m digitorum
profundus te ndon Annular I. superfi cialis
(Al) te ndon
Metacarpal
bone ~
Flexor - - ----i+ -+_
digitorum
superf icialis
tendon
Flexor digitorum
profundu s tendo n
A Superficial ligam ent s. B Deep ligam ent s with digital

t endon sheat h rem oved.
Fig.21.12 Fingertip: longitudinal section

The palm ar articu lar surfaces of th e phalanges are enlarged pro xima lly
at th e j oint s by th e palmar ligam ent. This fib rocarti laginou s plate. also
known as th e volar plate. form s the floor of th e digita l t endon sheat hs.
Dist al Dist al inter phalangeal

Nail phalanx joint
:==t:~~:~~~t5~~~~~~'~-~ - - - Extensor digitoru m

te ndon (dorsal
Tuberosit y --Jl~--'c:'-";il". digit al expansio n)
of distal
Middle phalanx
phalanx
~5~~t::::;:~~~- Palm ar I.
~~;':::;=--e:§~;';;;;;::::;;-- Flexor digitorum
profundus tendon
305
Muscles of the Hand: Superficial & Middle layers
Fig. 21.13 Intrinsic muscles of the hand: ~ Clinical

Superficial and middle layers
Right han d , palm ar su rface.
Dupuytren's contracture
Gradual at rophy of th e palmar aponeurosis
leads to progr essive shor te ning of the palm ar
fascia, chief ly affecting t he 4th and 5th digits.
Over a period of years. t he contr actu re m ay
become so severe that th e fingers assume a
flexed position (with fing ertips to uching th e
Cruciform II. --,~---+-+-+-----:
palm s); severely com prom ising th e grasping
- - Annu lar II. (Al - A5) ability of t he hand . The causesof Dupuyt ren's
contrac t ure are poo rly understoo d. but it is a
relatively common condition, mo st prevalent
in men over 40 and associated wi t h chronic
Deep
Superf icial t ransverse liver disease (i.e., cirrhosis). Treatm ent
tr ansverse m etacarpal I. generally consists of completes urgical
m etacarpal I. rem oval of t he palmar aponeurosis.
Transverse fascicles -tl---~c7.";-----'-<"'-----~ Adducto r pollici s

Longitudina l - l;-\'l.....""''h--'-,~..-..,,---T-
fascicles
Abducto r dig iti
mini m i
~.>r-----'---=--r--'"---.:=i'f-'''--- Flexor digit orum

profund us
Oppone ns te ndons
pollicis
Flexor
retina culum '
Flexor Antebra chial

carpi ulnaris fascia
Palmaris Flexor
longu s polllcis
te ndo n longus
tendon
A Palmar aponeuro sis.

Flexor dig itorum
• Also known as t ransverse carpal ligament.
superficialis tendons
Commo n fl exor -~'----'--iH--H

tendo n sheath Flexor ret inaculum
r:"'F'l--ifl-f-JH '7hP-- - Pronator quadratu s

B Carpal and d igital tendon
Flexor dig itorum --~-f!~~-:J I
sheat h s. Removed: Pal m ar
superfi cialis -t-f ft -- - - Flexor polli cis longus
apo neurosis, palma ris
lo n gu s, antebra ch ia l fas cia,
and pa lmari s brev is.
306
~ Clinical
-
Tendon sheath commu nication
I\J
The digital tendon sheath of t he th umb is •
conti nuous wit h the carpal t endon sheath
of thepollicis longus. The remaining fingers
show variable commu nicat ion wit h t he carpal
tendon sheaths (A is t he most comm on
variat ion). Infecti ons wit hin t he.tendon
sheaths from punct ure wounds of t he f ingers
can tr ack proximally to comm unicating spaces
of th e hand.
Deep
tra nsverse 1st dor sal
metacarpal I. int erosseus
Adductor pollicis
(t ransverse head)
Lumbricals
Adductor pollicis
(obliqu e head)
Flexor po llicis
A B c
brevis (super
Opp onens ficial head)
digit i minimi
Flexor Abductor
digit i minim i pollicis brevis
Abductor Opponens pollicis r- -='-'' 'r- - - -+J-- r - - - Flexor digitorum

digit i mi nim i Flexor profu ndus tendons
ret inaculum
Abductor
pollicis
longus
Flexor pollicis
longus tendon
Flexor digitorum
superficialis
C Superficia l muscles of th e han d . tendon s
Removed: Ten do n sheaths.
Flexor digito rum
prof undus t endons -~tl..~~~~~I~.\~i-"1J.\J-
Abducto r Flexor pollicis

digit i brevis (super
minimi ficial head)
Lumbri caIs -~--'~\-i-'lrt-4WH.L!!i-"'.,-,
Opponens pollicis
"""';n;or-- - Flexor pollicis br evis
Flexor digiti minimi (superf icial head)
ltT~I>J!i-"-A'l--- Flexor retinaculum

Flexor carpi
ulnaris t endon
Abduct or poll icis

longus tendon
Flexor digit orum ----I;;~<hH-
D M idd le lay er of m uscle s. Extensor pollicis brevis
profundu s
Removed: Flexo r d igi torum Flexor carpi radialis
su perf icialis, fl exo rs ca rpi t endon
rad ialis an d ulnari s, and
p ro nat o r q uadratus . Flexor poll icis longu s
307
Muscles of the Hand: Middle & Deep Layers
..Q Fig.21.14 Intrinsic muscles:

.5
..... Middle and deep layers
~ Right hand. palmar surface.
Q.
:§
I
I'
Flexor polli cis
longus tend on
Flexor
Adducto r po llici s
dig itoru m
(tran sverse head)
superficialis
tendon s Adductor poll icis
Lumbricals - I~~~,~\ ~~~~f1~ldl£j

J----\ (ob lique head)
~
Flexor pollicis
Abduc to r - brevis
digiti mini m i
. -~/J Abd ~ctor pollieis
Flexor ' / brevis
digit i m inimi
2nd and 3rd
palmar int erossei

X
Oppo nens digit i mi nimi
Flexor digi t i m inimi ~
Abduc tor digiti m inim i ,- _t:.~~'----:::::lIfI
A Midd le layer of mu scles of th e hand. Cut:

Flexor digitorum profundu s. Iurnb rka ls, Adducto r pollicis
1st throu gh ---+~~~H~, -H'l--tt-11Hli'-----";!'-!!Jl
flexor polli cis longu s. and flexor digiti 4th dorsal
int erossei Flexor pollieis brevis
minimi.
Flexor po llicis brevis

Oppo nens di giti minimi (deep head)
l st th rough 3rd -~~"""N
palma r interossei
--~-- Oppo nens po llici s
Flexor carpi Abducto r po llic is

ulnaris te ndo n longu s te ndo n
Extensor pollici s brevis
Flexor carpi
radialis tendon
B Deep m uscles of the hand. Cut: Oppon ens
digiti rninim i, opponens poll icis. flexor po lli
cis brevis. and adductor po llicis (tran sverse
an d ob liqu e he ads).
308
Fig. 21.15 Origins and insertions
Righ t hand. Muscle origins show n in red,
insert ions in blu e.
Extensor - - - - -----,.:IL Ext ensor
-
l\J
indi cis digiti minimi
Extensor
dig ito rum
Palmar and
do rsal
inte rossei
Extensor
polli cis longus
Extensor
pollicis brevis
Adducto r
Dorsal intero ssei
pollicis
Abducto r Extensor
pollicis longus carpi ulnaris
Ext ensor carpi Extensor carpi

radialis longus radialis brevis
~~'+------'Il--1IlL----II,-a-L--- Flexor dig itorum
pro fundus
~--F-~..-----"Ip;l'-"1------i~"'I----- Flexor digito rum

superf icialis A Dorsal (posterior) view.
.----+-r-'\---ri''r-----e, -- - - H - - Int erossei
Q !!!i\.------ Flexor pollicis long us
Adducto r poll icis
Abducto r
digit i mi nimi
Flexor pollicis brevis

and abd uctor
polli cis brevis
Flexor
digit i mi nimi Jl--- - --h--..,.-- - 1st dor sal int erosseus
r------,f!f-U'------- Flexor carpi radialis

Opponens digiti minimi
J>- - - Opponens pollicis
Ext ensor carpi ulnaris -----'~. )I.~:_--\-.",..--;
Abduc to r pol licis longus
Flexor carpi ulnaris

_J-- - - - Abdu ct or pollicis brevis
Flexor pollicis brevis CD l st palmar interosseus
CD 2nd dor sal interosseus
CD 3rd dorsal interosseus
Ulna 8) 2nd palma r int erosseus
Radius
® 4th dor sal interosseus
CD 3rd palmar int erovseus
B Palmar (ant erior) view.
309
Dorsum of the Hand
Fig. 21.16 Extensor retinaculum and dorsal carpal Fig.21.17 Muscles and tendons ofthe dorsum
tendon sheaths Right hand.
Right hand , posterior (d o rsal) view.
-"'-H~W+tHj"'t=+-- lnte rte n

dinous
connections
Dorsal carpal
t endon
sheaths
0 - - -+-... ·
~~,.
Extensor
retinac ulum
Extensor
Dorsal digitorum
t ubercle Extensor
carpi ulnaris
Exten sor
digiti minim i
Ext ensor
A Po st erio r (dorsal) view. pollicis brevis
Dorsal compartments
for extensor tendons Exte nsor Extensor
polli cis Ext ensor dig iti
Abductor poll icis longu s longus indicis m inimi
Dor sal t uber cle
~
Extensor pollicis brevis
Ext ensor carpi radiali s brevis \
Extensor carpi radialis "-J lf:-- .JJN
Extensor carpi radialis brevis Extenso r carpi radia lis lon gu s - --.,<')) ....
Q) Extensor pollicis longus
Extensor digi torum

Abdu ct or pollic is lo ngus Ulna
Extensor indicis
Extensor digiti minimi Radius Exte nsor digitorum
® Extensor carpi ulnaris
B Dorsal co mpa rtments . proxima l view of section in Fig . 2 1.16 .
310
Fig.21.18 Dorsal digital expansion
Right hand, midd le fin g er. Th e d or sal d ig ita l ex pansio n perm it s th e lon g
di gita l flexors and th e short m uscles of t he hand t o act o n all three finge r
-
I\J
j o int s.
Distal
phalanx
Lateral --f'-+."'-'
bands
Extensor
Cent ral slip - -----!---'--i digitorum t endon
Lumbrical slip
t Dorsal t
I 3rd metacarpal
~
~
\ .i-> 3rd dorsal interosseus
Collateral II.
»>: (fibersattac hed to
extensor tendon)
I 3rd dorsalinterosseus
J (fibersattached
2nd
to bone)
lumbrical
Deep transverse - "':r =t-- Deep transverse
~
rnetacarpal l. metacarpal I.
, ,p
~ Annular I. (A1)
2nd lumbrical
Flexor Flexor
digitorum digitorum
Ext ensor superficialis profundu s
3rd digit orum tendo n tendon
metacarpal tendon
A Posterio r view. B Cro ss sect io n t h ro ug h 3rd m etacarpa l head , pro xima l v iew.
2nd dorsal 3rd

Dorsal digit al int erosseus met acarpal Dist al Proximal
interphalangeal interphalangeal Vinculum Deep t ransverse
PT ~
Distal Extensor jo int joint longum metacarpal I.
digit orum
tendon
~.. . ........ I
Vincula Flexor
brevia digito rum

Metacarpo Flexor
Lumbrical 2nd phalangeal digito rum
profundus
slip Flexor Flexor lumbrical joint superficialis
digitorum digito rum
C Radial view . superficialis profundus
D Radial view w it h co m mo n t end on sheat h of f lexo r dig ito rum super
tendon tendon
fi cialis and p rofundu s o pe ned .
311
Muscle Facts (I)
~ The in trinsic muscles of the hand are divided into three groups: The thenar muscles are resp onsible fo r movement of the thumb. wh ile
a.iiiiII the thenar. hypothenar. and metacarpal mu scles (see p. 3 14). the hypothenar muscle s m ov e the 5t h d ig it.
Thenar muscles
: Transverse head: 3rd metacarpal
: <D Adductor pollicis U~~ lm~ r. . s. ~.r f~.~e ) . : Via the ulnar
Ulnar n.
CMCjoint of thum b: adduction
: Oblique head: capitate bone. : sesamoid MCPjoint of thumb: flexion
! 2nd and 3rd metacarpals (bases)
................................................. . : Thumb (base .............. ....................................... ....... ..... ..... .......
. :.' Scaphoid bone and tr apezium , .
; G)Abducto r pollicis brevis : of proximal : Median n. : CMCjoint of thu mb: abduction
: flexor reti naculum
...... .. .. ....... ..... .: phalanx) .................. ..... . .... .. ............ C8. Tl
: Superficial head: flexor : Via the radial : Superficial head:

! reti naculum : sesamoi d : median n.
: Q) Flexor pollicis brevis : CMCjoint of t hum b: flexion
: Deep head: capitate bone,
: Deep head: ulnar n.
........ . .. .. .. ~rapez iu~ .. .. ... .. ... .... .... ... .. .... .... .... ... .... ... ..... ... ..... ..... .... ... ..
...~ OP.~.o. nens.P.o. IU.~i S. . : Trapezium First metacarpal (radial border) ! Median n. : CMCjoin t ofthumb: opposition
!..~M~ ~ .~~ r.Porn~t~~a rpal ; rv1~~.~. rnetacarpophalange~ I ~ .
Fig. 21.19 Thenar and hypothenar

muscles
Right hand . palmar (anter io r) vi ew .
Hypothenar muscles
M uscle Origin Insert ion Innervatio n Action
® Opponens digiti : Draws metacarpal in palmar

: 5t h metacarpal (ulnar border )
minim i : direction (opposition)
Hook of hamate, flexor reti naculum .
[@Flexor digiti minim i 5th proximal phalanx (base) : MCPjo int of little finger: flexion
; Ulnar n. ; MCPjoint of lit tl e finger: flexion

: CD Abductor digiti : 5t h proxim al phalanx (ulnar base) and dorsal : (C8, Tl) : and abduct ion of little finger
: Pisiform bone
mini mi : digit al expansion of 5th digit l PIPand DIPjo ints of little finger:
extension
..................... ............... ....., : :........ . .
. ..: :.' Tightens t he palmar aponeurosis
: Palmaris brevis : Palmar aponeurosis (ulnar border) :. Skin of hypoth enar eminence
; : (protect ive fun ct ion)
.................... ................ : ; : .
~ I P ~?i s tali n t~rp ~~ l a n g ea l ; tvlCP = m et a ~ ~r p op ha la ngea l; PIP = proximal int erphalangeal.
312
Fig. 21.20 Thenar and hypothenar muscles
Righ t hand . palmar (ant erior ) view.
5th proximal
phalanx
1st proximal
phalanx
5th meta- --ti ~"'~-t\ TranSVerse )
carpal head Adductor
':I-F- + - Oblique pollicis
Abductor - ---111<'\ ,~\

head
digit i minimi
Abducto r
Opponens --~~~ pollicis brevis
digiti minimi
Hook of
hamate
-~~~---..::l~-- Capitate
Pisiform - - --. .
Trapezium
Scaphoid
A Removed: Flexor pollici s brevis. oppo nens

po lllcls, and flexor digit i min imi.
5th
proximal
phalanx 1 st
proximal
phalanx
R"-~~-- Flexor
pollicis
brevis
Hook of _+~,-""I,-"!,-",,,,=~"" ~ o p po n en s
hamate pollicls
.-.r--_ Capitate
Trapezium
B Removed: Addu ct or po llicis. abducto r

pollici s brevis. abductor digiti rnin irn i,
and op pon ens di giti minimi.
313
Muscle Facts (II)
~ The metacarpa l mu scle s of the hand con sist of the lu m br ical s and
~ int ero ssei. They are resp o nsib le for th e movement of the digits
(with the hypoth enars, which act on the 5th digit) .
Fig.21.21 Lumbricals Fig. 21.22 Dorsal interossei Fig.21.23 Palmar interossei

Right hand, pa lmar vi ew . Right hand, pa lma r view . Rig ht hand , palmar vi ew .
M eta carpal muscles

Muscle
group Muscle Origin Inserti on Innervation Act ion
CD 1st 2nd digit (dde) Median n.
Tendons of flexor digitorum profu ndus (radial sides) 2nd t o 5th dig it s:
0 2nd 3rd digit (dde) (C8, Tl)
• MCPjoi nts: flexion
Lumb ricals
0 3rd 4th digit (dde) • Proximal and distallP join ts:
Tendons of flexor digitorum profu ndus (bipe nnate
exte nsion
@) 4t h from media l and lateral sides) 5th digit (dde)
2nd digit (dde)

® l st 1st and 2nd met acarpals (adjacent sides,two heads)
2nd proximal phalanx (radial side)
3rd digit (dde) 2nd to 4th digits:
® 2nd 2nd and 3rd met acarpals (adjacent sides, two heads) • MCPjoi nt s: flexion
Dorsal 3rd proximal phalanx (radial side)
• Proximal and distallP jo ints:
interossei 3rd digit (dde)
0 3rd 3rd and 4t h metacarpals (adjacent sides, two heads) exte nsion and abductio n
3rd proxima l phalanx (ul nar side) Ulnar n.
from 3rd digit
(C8, T1)
4t h digit (dde)
® 4t h 4th and 5th metacarpa ls (adjacent sides, two heads)
4th proximal phalanx (ulnar side)
2nd digit (dde)
® l st 2nd metaca rpal (ulnar side)
2nd proxima l phalanx (base) 2nd, 4th, and 5t h dig its:
• MCPjoints: flexion
Palmar 4th digit (dde)
®! 2nd 4th metacarpal (radial side) • Proximal and distal lPjo ints:
interossei 4t h proximal phalanx (base)
extension and adduct ion
5t h digit (dde) toward 3rd dig it
® 3rd 5th metacarpal (radial side)
5t h proximal phalanx (base)
dde dorsal digital IP Mep metacarpopha langeal.
1314
Fig. 21.24 Metacarpal muscles
Right ha nd . palmar (a nte rior) view.
2nd distal phalanx. base -

l\J
2nd proximal phalanx
.I !lH-- - - +--!-- 2nd metacarpal
1st lumbrical
2nd lumbrical
3rd lumbrical 2nd --,,---,-----~-__..,..;:---+--+<-___'_1f.__________1c;_

(often arises by through
two heads) 5th
4t h lumbrical proximal
H0 0 k 0 f -----''-'''1''' (often arises phalanges
hamate by two heads)
P·IS 'flo rm ------r:• Trapezoid

3rd dorsal ----';rlHrr~. .+ :· 2nd dorsal
interosseus interosseus
Radius 4th dorsal 1st dorsal

interosseus interosseus
2nd through 1st

5th metacarpals metacarpa l
Flexor digitorum
profundus tendons
A Lumbri cal mu scles.
B Do rsa l inter osseu s mu scles.
1st palmar --'c-+-PJr--'=--ff!H+--+'H~ \tn

interosseus
2nd palmar
interosseus
3rd palmar
interosseus
2nd thro ug h
5th metacarpals
C Palmar interosse us m uscles.
315
Arteries of the Upper limb
Fig.22.1 Arteries of the upper limb

Right limb, anteri or v iew .
1J,;~.iIto'------- Vert ebral a.

Subclavian a.
Thyrocervical
Brachiocephalic --,---'ozz;~~7.IT-:"::=,,",::' ~
t runk t runk
Subclavian a.
Axillary a. -~-5-~
Common carot id a.
Brachioce phalic tru nk
~-----''\,..--~'----::1L--- Superio r t horacic a.

Axillary a.
. - - - Thoraci c aorta
Ante rio r and r,:--~f---- Int ernal t horacic a.

post erior circumf lex
hum eral aa,
CirCU m fleX }
Ulnar a. Profun da brachii a. scapular a. Sub-
Thoraco - scapular a.
dor sal a.
Brachial a. ---~ lf) · .
'l.--- - - - - .".-<:.:.,- - .,f-!!- - - Lat eral
_II
t horacic a.
Radial
collater al'; :
Middle
collate ral a.
~
Radial
A M ai n art eria l seg me nt s.
recurren t a.
.~..L;H - - Ulnar recurrent a.

~++,;,~-- Common int erosseous a.
Posterior -~~~'l
interosseous a.
Ulnar a.
Superficia l -~~~~~r;
palmar branch
(radial a.) Deep palmar arch
Superficial palm ar arch
Commo n palma r
digit al aa.
Palm ar digita l aa.
B Co u rse o f t h e arteries.
316
Fig. 22.2 Branches of the subclavian artery Fig. 22.3 Scapular arcade
Right side, ant erior view. Right side, poste rior view .
Ascendi ng Vertebra l a.
cerv ical a.
Subclavian a.
Supe rficia l cerv ical a. Thyro
Sup rascapular a.
(sup erficial branch) cerv ical
t runk
Dorsal scapular a.
(d eep branch) Transverse _ _ -§--Y
Acrom ial
cervic al a. br anches
Transverse
cervica l a. Axillarya .
Inferior Ant erio r
th yroid a. Circum flex --.JI--7------,::>""'.L:-=::::::~ circumflex
scapular a. hu me ral a.
Com mo n
,, ".-.a!'i~-- Posterior
carot id a. circum flex
Dorsa l
scapular a. humeral a.
Supra Thyroce rv icaI
scapular a. t runk Subscapular a.
Profunda
Axil larya. Cost ocervical
br achii a.
t runk
Subclavian a. Brach ial a.
Clavicle
1st rib
Sup reme inter Int ern al
cost al a. t horacic a.
Fig. 22.4 Arteries of the forearm and hand

Right lim b. The ulnar and radial art eries are interconnect ed by th e super
ficia l and deep palmar arches, t he perforating branches, and the dorsa l
carpal network.
Int erosseou s recurr ent a. - -1r o\':.lN r---I-- - _ Common

Posterior int ero sseous a. - --fi----'o' , int ero sseous a.
Ant erior intero sseo us a. - " '--71 Posterior -+----'1:--~-'-I- Ant erior
int ero sseou s a. intero sseous a.
Ulnar a.
Dorsal Palmar
Posterior Radial a. Radial a.
inte rosseous a. Int erosseous
membrane
Dor sal carpa l ~

netwo rk h f t- - - Palmar carpal
Deep palm ar bran ches (t o
Dor sal
arch palm ar carpal
carpal a.
net w ork)
Perfo rating ---+~...
Superf icial palm ar
bran ch
arch ~~ll~~"-(\ Dor sal carpal a.
Perforating fli'!r.-:f.:4-A.,~r- Dor saI

bran ches met acarpal aa,
"' n,.-'-;fri'"-+- Com mo n palma r

Proper digital aa.
palmar
digital aa.
Do rsal
dig it al aa.
A Righ lilliddle finger , lateral view . B Ante rior (palmar) view . C Posterior (dorsal) view .
317
Veins & Lymphatics of the Upper Limb
Fig. 22.5 Veins of the upper limb Fig. 22.6 Veins ofthe dorsum
Rig ht lim b, an te rio r view. Rig ht hand , p o st eri or view.
Deltope ctoral Subclavian v. -----~;IC--~
gro ove
Axillar y v. - --i- - h r
I'-.Jf-- - Cephalic v.
Thoraco - - -7---'-----,H - --!
Cephalic v. - - ---.--1 epigast ric v.
Thoraco - - - - If H--'lt-----;,q.-'= - BasiIic v.

Basilic hiat us - - -1- -'0 do rsal v.
Y+-+----f"'-.""- - Dor sal venous

Basilic v. - - - f - -- -£ Brachial vv. -----K net work
/--{ !e..p;~ --.h.-+---\'-; ,.---- Int ercapit ular w.
Median
- -- +-!----=-:' . A'c------'c-+- - Dorsal digita l vv.
cub ita l v.
Median ante - - -f--f-- l

brachial v.
Median
Cephalic v. basilie v. Anterior int er
Ulnarvv.
osseous w .
Perforatorw.
Superficial Deep palmar

palma r venous venous arch ~ Clinical
arch
,-...".. - Palmar Venipuncture

/,vH c-+-f-- - Intercapit ular w .
m etacarpal vv. The veins of t he cubit al fossa are frequentl y
used when dr awing blood . In preparati on,
a tou rniqu et is applied. This allows arter ial
rn;>---H - Palma r dig ita l w. blood to flow , but blocks th e ret urn of
venous blood . The resulti ng swell ing makes
t he veins m ore visible and palpable.
A Superficia l vei ns. B Deep ve ins.
Fig. 22.7 Cubital fossa

Rig h t lim b, ante rio r view . The su bc uta n eou s ve ins o f t h e cu bita l fossa
hav e a high ly v ari ab le co u rse.
Basilic v.
Median
Cephalic v. cephalic v. Cephalic v.
jf-~- Median
" ....'9--\-f- Median
cubita l v. cubital v.
I/;-- -\-- Deep Accessory
Median -f---~ m edian cephalic v.
H H - Median
ant e- cubital v. Median
basilic v.
brachial v. cephalic v.
Cephalic v. Basilic v.
Basilic v. II---F--+-- Median
antebrachial v.
A M- shaped . B Acc essory cep ha lic ve in . C Absent m edi an cub ita l vein.
318
~ Lymph from the upper lim b and br east drains to t he axil lar y lymph subcutaneous ti ssue, w hi le t he deep lym phat ics accompa ny t he art eries
~ nodes. The superficial lymp hati cs of the upper lim b lie in th e and deep veins . Numerous anast o m oses exist bet ween t he two system s.
Fig. 22.8 lymph vessels of the upper limb

Rig ht lim b.
Dorsolateral ,,.."'ff- - - Axillary
lymph
arm territory
nodes
Dorsomedial
arm territor y
Middle _ --!<V/I'/
arm territory
<-'<-t- - Cubital lymph

nodes
Radial bundle
territory
Radial bundle Ulnar bundle
territory territory
f)f-fc+f - MiddIe
forearm
territ ory
Radial group
of lymphati cs
Ulnar group
of lymphat ics
I"'--t--T-;i--- Dorsa I
descending
A Anterior vi ew . lymphati cs B Posterior view.
Fig. 22.9 l ymphat ic drainage of the hand Fig. 22.10 Axillary lymph nodes
Right hand , radia l view. Most of the hand drai ns to the axillary nod es Right side, anterior view. The axi llary lymp h nodes are divided into t hr ee
via cubita l nodes. However, t he t humb, inde x fi ng er, and dorsum of t he
hand drain directly.
Lymph vesselsascending from A

levels w it h respect to t he pectora lis minor. They have major clini cal
im portance in br east can cer (see p. 65) .
l.evel l t evel l
\~
J
the palmar to dorsal side
Right
lymphati c
duct
Radial
bundle
territory - -----'--- Level III
Radial group of
lymphatics
Pectoralis
minor
319
Nerves of the Brachial Plexus
~ A lmost all m uscles in t he upper lim b are inn ervated by t he t hree trunks, six div ision s (three anter ior and t h ree po steri or) , and t hree
~ br ach ial plexu s, w hic h arises fro m spi na l co rd segm ent s ( 5 t o T 1. co rds. The inf raclavicu lar pa rt of t he b rach ial p lexus co nsist s o f shor t
The ante rio r ram i of t he sp inal nerv es give of f direct b ranches br an ch es t hat arise dir ectly fr o m th e cord s and lon g (term ina l) bran ch es
(sup raclavi cul ar part of th e br ach ial p lexu s) and m erg e to form th at traver se the limb.
Dorsal scapular n.
Nervesof the brachial plexus
Suprasca pular n. C5
Posterior Supraclavicularpart
cord
Lateral cord · Direct branches from the anterior rami or plexus trunks
. ...... ..... ...... .................... ...................... ..... .•.••.•••• .• ..•.... ... . .. . .. . . . . . ..• . .
Medial cord : Dorsal scapular n. . : C4" C5

............................................ ... ........ .. .. . ........... ............................... , "
Phrenic n.
•
: Infraclavicular part
: Suprascapular n.
.............................................. .......................... ........... .....:
: N. to th e subclavius
...................................... ..........................................., : -
: Long t horacic n.
' C5-C6 '
: C5-C7
:
; C4- C6
:
N. to th e
Axillary n. _-"--\c---:t9~'ll,r I subclavius
Long
thor acic n.
Musculo
cutaneous n.
: C6-C7
Medial brachial : : ~
cutaneous n. : Medial
, .root
Medial and : - : .
Median n. ---~-+I lateral . ~ ~?i ~ IP.~c to.ra l n. • C8-T 1

pecto ral nn. : Medial ; Median antebrachial
Rad ial n/
/
Radial n. - - - "'S
Deep
branch
Tho raco
dorsal n.
•
; cord ; cutaneous n.
.... .... .............................
• Medial brachial
; cutaneous n.
.......................
• Ulnar n.
. ...... ..........,
......................................................... .... ..... ........-

,-
Tl
.. -
•cz-r:
.
Superficial
: yp p~r s~ b<;c~ p ~ larn . • C5-C6. H
_
branch
: Thoracodorsal n. : C6- C8
·
_
• •
...., ..,
: Posterior
; cord
:
:
:
H · H H
: Lower subscapular n. . . "! C5-C6

Axillary n.
Radial n.
-
H . H H • •• • H . H.
• C5- T1
.
.. ,•,.
.....
if!'-f.~~r---- Anterior antebrachial

int erosseous n.
320
Fig. 22.11 Brachial plexus
Right side, ant erior view.
Ant erior
(vent ral)
rami
Upper trunk ((5-(6)
Middle t runk (Cl)
Lower trunk (( 8- T1)
Anterior divisions ---Ar;,'h~~'~-=-

of (5 -Cl Posterior
divisions
Lateral cord - --,- I I

of C5- Tl
Ante rior divisio n

Poste rior cord -~~.
ofC8-T1
Axillary n. - - - -I
Musculo- -~~r.JIVi
_rs~~--- (5 spinal n.
cut aneous n.
Radial n. - Median n.
r.l--I!- Midd le scalene -------i~.• Phrenic n.
Anter io r scalene
A Structure oft he brachial plexus. Upper tru nk
Midd le t runk
'---'~-- Tl spinal n.
Int erscalene space
Commo n carot id a.
Subclavian a.
Lateral
cord
Subscapular n. -----,-.;----'~~---..llMo--'
Medial
cord
r~ . .......::!~ _ _~~_ _=~,,---- Long t horacic n.
Axillary a. - ----I- i-----lb--H
Axillary n. ---~~!--~
"------ -----"''=. - - - -- 'k - - Int ercostobra chial n.
Posterior - - -..----1:f!---- ,
circumflex
hum eral a. ~----~~---..:;:-!------ Medial brachial
Musculo ---i-'::'~"----L cut aneous n.
cuta neous n.
------"'~;;;:-::-::~--~I----- Medial pect oral n.
Radial n. ----+~'-S'1_
Median n. ------'- ---[
C Course of th e Median antebrachial Ulnar n. Thoracodorsal n. Lateral

brachial plexus. cut aneous n. pectoral n.
321
Supraclavicular Branches & Posterior Cord
Fig. 22 .12 Supraclavicular branches ~ The supraclavic u lar b ran ch es of the br achi al plexus arise d irect ly
Rig ht sho u lde r. ~ fr om th e p lexu s ro ots (anteri o r rami of t he spina l n erves) o r f rom
t he p lexu s t ru nks in t h e lat eral cerv ical t rian g le.
~ ..-r-,,- - - Transverse pro cess

of at las (Cl)
Dor sal scap

ular n. Levato r
scapulae
Verteb ra
promin ens
~ Scapula.
(C7)
superior ang le
Rhomboid
minor
Rhombo id >--7~~~--'Il--+.!l!-- Scapula,

major medial
borde r
C4 spinal n. -~"=-....I, .
Superior transverse
scapular ligam ent
Suprascapu lar n. in
the scapular not ch
Acromi on
A Dorsal sca p ula r n erve. Po st erio r v iew.
Supra ----4.!!!""'~"...
.,/ Greater
spinat us tuberosit y
Scapular
spine
At las (Cl) --------+~1lo. Infra ------'-!!!!'I!~,.lli;"M~__......L__:'~.I..<.../
spinat us
C5 spinal n. ---=-~~)
N. to t he subclavius
B Supra sca pu lar n erve. Posterio r view.
1st rib
Long
Serrat us
thora cic n.
ante rior
Supraclavicular branches
Nerve Level Innervated mu scle
Levator scapulae
Dorsal scapular n. C4-C5
Rhomb oids major and min or
Supraspinatus
Sup rascapular n. C4- C6
9t h rib ---s~:--~""'!!!!'-= Infraspinat us
Subclavius
Nerve to the subclavius C5-C6
Int ercostobr achial nn.
C Long th o raci c n er ve and nerv e to t he su b
Long th oracic n. (5-0 Serratus anterio r
clavius . Rig ht lat eral v iew .
322
Fig.22.13 Posterior cord: Short branches ~ The poste rio r cord gives off th ree shor t branch es
Right sho ulder. ~ (ari sing at th e level of th e plexus cord s) and two
long branch es (te rmi nal nerves, see pp. 324-325).
( 5 spinal n.
Subsca pularis
2nd rib (cut)
Upper subscapular n.
Lower subscapular n.
(6 spinal n.
A Subscapu lar nerves. Ant eri or view. T7 spinous

process
T1 2 spinous - -
process
Branches of the posterior cord
Nerve Level Innervated muscle
Short branches
Upper subscapular n. Subscapularis Thoraco Iliac crest
(5 -(6 lumbar fascia

Subscapularis
Teresmajor
Thoracodorsal n. (6-(8 Latissimusdorsi
Long (terminal) branches
Sacrum - -
Axillaryn . • (5 - (6 • See p. 324
Radial n. • C5-Tl • See p. 3 25
. ..............
B Tho racodorsa l nerve. Posterior view.
323
Posterior Cord: Axillary & Radial Nerves
Fig. 22.14 Axillary nerve: Sensory distribution ~ Clinical

Right lim b.
The axillar y nerve may be damaged in a fracture of t he proximal humerus.

Supra- --~ This result s in limi ted abilit y to abduct the arm, and may cause a loss of
clavicular nn. -.. ...... \ profile of t he shou lder.
Superio r
lateral
~
brachial
Fig. 22.15 Axillary nerve
cutaneous n. Right side, ant erior v iew .
(axillary n.)
\ At las (Cl) -------::;;=--
\ C5 spinal n. ---l-i~~=''''~~ ..
Middle scalene -----"~c l
Phrenic n. - -- -+-f-.\'
Ante rior ----T~~ IIJ

scalene
A Anteri or vie w . B Poste rior view.

Axillary a.
Delt oid - -='- +-- -
Superior lat eral

brachial cut aneous n.
(termina l sensory
branch of axillary n.)
Axillary nerve
((5-(6)
M otor branches Innervated mu scles
Deltoid
: Muscular branches
Teres min or
Sensory branch
: Superior lateral cutaneous n.
324
Fig.22.16 Radial nerve: Sensory distribution Fig. 22.17 Radial nerve
Righ t limb, ante rior vie w with fo rearm pr onat ed .
(
\ Post erior
brachial
Posterior cord
cuta neous n.
Axillarya . - - - --to",
Radial n. ----~~-,!. ·"JII
( Inferior
latera l
! brachial
cutaneous n.
Posterior
antebrac hial
Posterior brachial - -
cutaneo us n.
Radial n. (in radial groove) 'i
/
cuta neo us n.
Inferior lateral -------'>;
brachial cutaneous n.
Triceps --+.'J~-7
brachii
.- -"-----'" .- - Radial tun nel
1~i1"---- Brachialis
A An t eri or v iew . B Post erio r vi ew. f :Mr'b''-- - - - Radial n.• deep branch
(in supinat or canal)
Supinator --if+-~
Poste rior - - Brachioradialis

interosseous n.
Radialis -----J~~~tt1 Radial n..

Radial nerve ((5-T1) muscle group superf icial branch
Motor b ranches In nervated muscles Abd uctor _--'J~"""
pollicis
, Brachialis (part ial) Extensor
.................................. . ... .. ............................... ........ longus
: Triceps brachii pollicis brevis
......................... ............ ...............
Muscular branches : Anconeus Extensor ----t'-H+: I Extensor
digi torum pollicis
: Brachio radialis longus
: Ext ensor s carpi radialis longus and brevis
. . ..... ........... ....... ........... ... .............. .... ................
• S u pin.~ to r
: Ext ensor digitorum Dorsal digi t al nn.
Deep branch (t erm inal E~t~.n~?r ?i~ it i n.n.inillli .

branch: posterior Ex~e n. s?rcarp iHulnari s .
int erosseous n.)
: Ext ensors pollicis brevis and longu s
............ .......... . .............. ....... .
: Ext ensor indicis

...........................................................
. Abdu ctor pollicis longus
Sen so ry b ranch es
Articu lar branches fr om radial n.: Capsule of th e shoulder joi nt

.......................................................................
Articular branches fr om post erior interosseous n.: Joint capsule of t he
wri st and fou r radial m etacarp ophalan geal joints ~ Clinical
..... .... .. ..... .. .. .. ... .... ..... .. . -..-... .... .....•.
Posterior brachial cutaneo us n. . .

.. ...... ........... ... .. .... .............. .................... .
Chronic radial nerve comp ression in the axilla (e.q., due to exte ndedj
Inferior lateral brachi al cutan eous n.
improper crutch use) may cause loss of sensatio n or motor func t ion in
Posterior antebrac hial cuta neous n, the hand , forearm. and posterior arm . More distal inju ries (e.g., during
. . •. • .... . .. . . .... •.. ••. •. . •. •••. . . . . . •••. . • ••. . ... ..
anesthesia) affect fewer muscles. pot ent ially result ing in w rist drop with
: Dor sal digital nn.
Superficial branches ............................................................................. ..................
intact t riceps brachii functi on.
: Ulnar comm unicati ng branch
325
Medial & Lateral Cords
~ The medial and lat eral cords give off fo ur short branches. The of t he brachial plexus, alt hough t hey are act ually t he cuta neous
~ int ercostobrachial nerves are included wi t h th e short branches branc hes of t he 2nd and 3rd intercos t al nerves,
Branches of the medialand lateral cords Fig.22.18 Medial and lateral cords: Short branches
Right side, ante rior view.
Nerv e level Cord Innervated muscl e
Short branches
Lateral pect oral n. C5-0 Lateral cord Pect oralis major
Medial pectoral n. C8- Tl Pect oralis major and min or ..-'9ow.~~- Brachial plexus
Lateral cord
Medial brachial (C5-Tl )
Tl Late ral
cuta neous n.
Medial cord pect or al n.
Medial antebrachial - (sensory branches)
C8-Tl
cutaneous n.
Intercostobr achial nn. T2- B

Long (terminal) branches ~~~~~,-=:;!,,==-- Medial
Coracobrachialis pecto ral n.
Musculocuta neous n. C5-0 Lateral cord Biceps brachii h,-- -=---===-- - Pectora lis
Brachialis mi nor
Median n. C6-Tl See p. 328 ~·'f1~~5.>-T~-=:-::--- Pectora lis
Medial cord major
Ulnar n. O - Tl See p. 329
Fig. 22.19 Short branches: Sensory distribution
A Medial and lateral pectoral nerves,

Medial brachial
cuta neou s n.,
intercostobrachial n.
Posterior 2nd and 3rd
ramus inte rcosta l nn.
Medial ante
brachial cut aneous n.
., ~~_P":n"';;;--;;J-- B
-«
Int ercosto vertebra l
brachial nn. ~ ..... body
/7~
~ A n te r i o r
cutaneous
Anastomosis
with med ial branch of 2nd
brachial int ercost al n.
,""OW", n. ~ Lateral
cutaneous
branch of 4th
int ercost al n.
B Int ercost obrachial nerves.

A Anter io r view. B Posterior view.
326
Fig.22.20 Musculocutaneous nerve
Musculocutaneous
Right limb. ante rior view.
nerve ((5-C7)
Ante rior M ot or bran ches Innervat ed m uscles

Coracoid Lateral scalene
: Co racobrachialis
..... ........ ... ......... .... ..... ..
proc ess co rd
Mu scular br anches : Biceps brachii .
Int ertu bercu lar
groove , Brachi alis
: Sensory branches
, Later al ant ebrach ial cuta neous n,

Axillarya.
: Arti cular branches:Joint capsule of th e elbow
: (anterior part)
Mu scul o
cuta neou s n. : Note: Mu scu locuta neous nerve in nervation of t he
: arm is pur ely m otor; in nervat ion of t he for earm is
Biceps brachil, : purely sensory.
sho rt head
Biceps brachli . ----rr; . ~
lo ng head
Coraco brachialis
Brachialis
Biceps brachi i - --,h ="
Fig.22.21 Musculocutaneous nerve: Sensory distribution
Brachialis --~'H-i--BI
Lat eral --++~

ant ebrachial
cut aneous n.
Lateral
ante brachial
cut aneous n.
Radius
A Anterior view. B Posterior view.
327
Median & Ulnar Nerves
~ The median nerve is a term inal branch arising from both t he Fig.22.23 Median nerve:
~ medial and lat eral cords. The ulnar nerve arises exclusively from Sensory distribution
th e media l cord.
Fig. 22.22 Median nerve

Right lim b, anterio r view . (
Medial cord - - --;r .....~
Axillary a. --~----:-:1
Lat eral root
Median n.
{
Medial root
Median n. --~~
l J::lc;T.---- -{-- Com mo n and

pro per palmar
Proper
digi ta l nn.
palmar
dig it al nn.
Articular branch - - - l;;;;;;j A Anterior view . B Posterior view .
Median nerve (C6-Tl)

Pronator t eres, - - -r- w r
ulnar head M otor branches Innervated muscles
; Pronator ter es
; Flexor carpi radialis
~~-- Flexor : Direct muscular ........ .... ......... ................. ..... ....... .... ..... .
dig it oru m , branches : Palmaris longu s

............................................
Anterior - - T.':'i'!" superf icialis
: Flexor digitorum
ante brachial
int erosseous n. .....•. ~ u. p.~r~i~ i.a. l i~ .
Flexor pollici s : Muscular branches~r.o. .n. a.t o. r.9u.a~r.a~u.s

longu s : from ante rior : ~le~ o.rp.0 l l i~i~ lo.n~ u~
; antebrachial ; Flexor digitorum
: inteross~~u.~ .~: ...............•..p.ro.fu.~~u.~ya.d.ia l~a lf) .

; Abductor pollici s brevis
............, .
: Thenar muscular : Flexor po llicis brevis
; branch : (superficial head)
......... ...................................
: Oppon ens po.llicis
/f-;'M4'''ff+H-~i-- Common : Muscular branches

palmar digital : from common : 1st and 2nd lumbricals
nn. : palmar dig ital nn.
1st and 2nd ~ Clinical
lum br icals
; Sensory branches
1llJEl---'i.-¥.1'---i"....,.----;;.,.--- - Proper palmar Median nerve injury caused by fract ure! Art icular branches: Capsulesof the elbow and
digital nn. wrist joints
dislocation of the elbow joint may result in ...... ...... .... ..... ... .... ........ ............................. ..... .... ... .. .....•.
compromised grasping abilit y and sensory loss l. r..a. lm ar branch of m~d. i a..~ ~ .(~~~.~ a. r. ~r.n. inence! .
in t he fing e rt ips (se e Fig. 22 .23 for t errit ori e s).
Commu nicating branch to ulnar n.
Seealso carpal tunnel syndrome (p. 343). . .
• Common palmar d i~ it~.l n n .
328
Fig.22.24 Ulnar nerve:
Sensory distribution
Fig.22.25 Ulnar nerve
Right lim b, ante rio r v iew.
Medial cord
Axil lary a.
I \
\
J
Ulnar n. ---~!!--1i
Ulnar n., - - -t1

dorsal
branch
Com mo n
and pro per
palmar Dor sal ---L..---H'+!.
digita l nn. digital nn.
-~ " _ Medial
epicondyle
A A nte rio r view. B Post er ior v iew . Ulnar groove
Ulnar nerve (0-T1)

Motor branches Innervated muscles
·..Fle~o r~ a. ~p'i~ I ~a. ri~ . Flexor ---.,!,+-,,~

: Direct muscular digito rum Flexor
, branches : Flexor digitorum
carpi ulnaris
profu ndus
; profundus (ulnar half)
...... .... ... ..... ...•....... ... .. ....

-,
; Muscular branch from

. : Palma ris brevis
: superior ulna.r.n.
'..~b?~.c~?~?igiti .~ in.i mi
: Flexor digiti minimi
. ?~~ ?~~~.S d. i~ it i 0 i~ i~ i·· .
: 3rd and 4t h lumb ricals
: Muscular branches
: from deep ulnar n. ' P~'I ~~'; ~ ~'d'd~~;~ I "" "" "-J >i 1,-.1-- - Superficial branch
, interosseous muscles
.... ... -. .•... ... -.., .
Deep branch
: Adductor polli cis 4t h com mo n
.............................
: Flexor pollicis brevis

palmar digita l n.
: (deep head)
Int erossei Clinical

: Sensory branches
Proper palmar Ulnarnerve palsy is the most com mon
Arti cular branches: Capsules of t he elbow, carpal,
digit al nn.
and metacarpophalangeal joi nts
periphe ral nerve damage. The ulnar nerve
............................................... .... is mo st vulnerable to trau ma or chron ic
: Dorsalbranch (terTTli n~ I b.r.~ n.~h.~~:??r~~ I ? i.9. i~a. I .n.~ .) compres sion in th e elbow joint and ulnar
Palmar branch tunn el (see p. 343 ). Nerve damage causes
"clawin g" of t he hand and atrophy of t he
...r..r?p.~r..p..a.I.f1la.r..? i~ it al .n. ~ . (f.r?f1ls~~erfic i a l.br~ nc~ ) .. interossei. Sensory losses are ofte n lim ite d
: Com mon palmar digit al n. (from superficial branch: to the 5th digit.
. terf1l inalb~a n.~he s:proper ~almar di9.ita l . n.n :) ...
329
Superficial Veins & Nerves of the Upper limb
Fig. 22.26 Cutaneous innervation of the upper limb: Fig. 22.27 Superficial cutaneous veins and nerves
Anterior view of the upper limb
/"( Supra
1 - clavicular nn.
~-::=- ~~::~~~ u s} Int ercos-

Axillary n.
branches
-s:
" /
Supra
clavicular nn.
~
Late ral ta l nn. Superior - - --fH
7~
II K. cut aneous Intercost al nn.,
\\. '" branches

Medial brachial
lateral
brachial
cut aneous n.
anterio r
cutaneo us
1 cut aneous n.,

int ercosto
brachial n.
(axillary n.) branches
~T------- I n te r-
cost o
brachial n.
Medial
antebrachial
cut aneous n. Cephalic v. - ----If-fl H'iP~--- Medial
brachial
Inferior - ---H--'i'
t ---.'f--f;1--- Musculocut aneous n. cuta neous n.
lateral
brachial Basilic
cut aneous n. hiat us
r LJ_ _ Palmar branch (radial n.)
Palm ar - - +f-I-
branch
- - - - Basilic v.
Ulnar n.
Median n. Comm on ..L----I:--II+.-iJU \\+------'~ Comm on and .y..H't-r-- - - Meclial
and prop er palm ar Lateral ante brachial
prop er digit al nn. antebrachial cuta neous n.
palmar cutan eous n. .1Jj,.J,,*~,+---- Meclian
digital nn. (mu sculo cubital v.
cuta neous n.)
A Perip heral sensory cut aneous inn ervation. Cephalic v. - - --i---E/

H~1!!---,-l----- Median
ante brachial v.
C4 - --f-
- - - 12
- - 13 I~~--r---- Medial
antebrachial
C5 - -13 cuta neous n.
--------- 13
fH- - - Ulnar n.,

palmar branch
11
l;-J~~':r---- Median n..
C6 palm ar branch
%--'-'--t1f------ PaImar
aponeurosis
C7
C8
A Ant erior view. Seep. 344 for nerves of th e palm .

B Segmental, radicular cut aneous innervation
(dermat omes).
330
Fig. 22.28 Cutaneous innervation of the upper limb:
Posterior view
Supra- ---~~ " """~,,,------ Supraclavic ula r nn.

clav icular nn.
Superi or
Int ercost o lat eral br achi al
brachial n. cuta neo us n. \ \'-tft--+ - Radia l n.
(axil lary n.)
Medial Media l
brachial _ - Y}- - - Posterior brachial ante brac hial
cuta neo us n. cuta neo us n. cuta neo us n .
(radia l n. )
Mu sculo cu t aneou s n.
.\ J .J"il-- - - Inferior
lat eral brachi al
cu ta neo us n.
~~~~~
(radial n.)
Ulnar n. {
Dorsal -~q{f--D:-J: I Prope r palm ar

Posterior digital nn . digital nn.
antebra chi al ( me dian n.)
cut aneo us n.
(radial n.)
A Perip h era l se ns o ry c u t a neo us inn ervati on.
Lat eral
ante brac hial
cuta neo us n.
(m usculo
cuta neo us n.)
T2 --"<:--C4
H R .------ Acc essor y T3
cep halic v. C5
T4 -
If--rr- - Cephalic v.
T5 - -
C6
Radial n.,
superf icial
br anch T1
Ulnar n., - - --,f
dorsal branc h
Dor sal venous - --If!-7HI\\lin
net w or k
Int ercapit ul ar vv . ----;U--I\-tJ-~n(i1
Do rsal dig ita l vv . - ---1tf-<, -f C8
B Po ste rior view. See p. 3 46 for n erves of t h e d o r sum .

B Segm enta l. radi c ular c u ta n e o us innervation
. . ...................................... . . .................... . ...... . ..........
(d erm atomes) .
331
Posterior Shoulder & Axilla
.Q Fig.22.29 Posterior shoulder

,5
-.I
Right shoulder, posterior view . Raised: Trapezius (transverse part) .
lii Windowed: Supraspinatu s. Revealed: Suprascapular region .
e,
s
Trapezius, ---~----4,--
descending part
Suprascap ular a.
(with superior t ransverse
Posterior rami - - - ( scapular ligament )
of spinal nn.,
medi al branches c- -=
..,,;;,:::.,......;;;..:... Sup rascapular n.
(in scapu lar not ch)
Trapezius, ---------~'___""==,;:
t ransverse part
Coracoclavicular
Sup raspinat us
ligam ent
Accessory n. and
bran ches of Scapu lar spine
cerv ical plexus
Post erior ram i

of spinal nn.,
lateral bran ches
Supe rior lat eral

brachial cuta neo us n.
(axillary n.)
Trapezius,
ascending par t
Inferio r lat eral

brachial cuta neo us n.
(radial n.)
Latissim us Infraspino us Teres Posterior br achial

dor si fossa m ajor cutaneous n.
(radial n.)
332
Neurovascular tractsof the scapula
Transmitted
Passageway Boundaries structures
[ Supe rio r tr ansverse

, Scapular
CD , not ch
: scapular lig am ent , [ Suprascap ular a. and n.
: scapula
"-"'! ~---+- Inferio r tra nsverse
............. ..... ...... .. .... ....... ... ...... .... ... .. .... ,. . .
scapular ligament
0 : Medial bord er [ Scapula : Dor sal scapular a. and n.
•. . •.•• •. . . . . .. . . . . . . . . . . . . . . •. • •• . .
Q)
j Triang ular
: Teres maj or and mino r ' j Circumflex scapular a.
[ space
...................................
. : Triceps brac hi i, hum erus, , Profunda brachi i a.

@ :. Triceps hiatu s
: t eres majo r : and radial n.
.... . , .. ............................... .
: Post erior circu m fle x
: Quadrangu lar : Teres m ajo r and m in or,
® ; space : t riceps brachii, hum erus
: hume ral a. and
• axillar yn : . ... .... ... . . . ....• •
Fig. 22.30 Axilla: Triangularand quadrangular spaces

Right shoulder, posterior view.
Clavicle
Supraspinatu s - - - ---"'= ==-- - ~-- Acromion
Scap ular spine ----=:;=;;~~~~-~::::.

Suprascapular a. and n.
Shoulder j o int
capsule
Infraspinat us ----~~'--o-'3"'"''''
~-=---- Teres m inor
Deltoid
Axillary n. and poste rior

circum fl ex hum eral a.
- - -- Triceps brachi i,
Circumflex ---T~""--------,----'.i~ lat eral head
scapular a.
Radial n.,
Teres majo r ----=.---...L....--6'=-c--~-,...-----o'- ~ m uscu lar branches
Profunda brach ii a.
and rad ial n.
(in rad ial groove)
Long
head
Triceps {
br achi i
Lat eral
head
333
Anterior Shoulder
..Q Fig.22.31 Anterior shoulder: Superficial dissection

.5
-.I
Right shoulder.
~
Q.
s
Superficia l
t horacic fascia Subclavian v.
Pectoralis - -f"::-+
Clavipectora l
minor
fascia
Pectoralis
major
A Sagitta l section t hro ug h anteriorwa ll.
External
jugular v.
"'ffi~~~----- Transverse n. of neck
,~~~H~-~'--- Sternoc leidomastoid
Subclavian v.
Pectora lis major,

Cephalic v. ---!!-...L...:'----'f-H-+-~'--:o~~~~ clavicu lar part
(in deltopectoral
groove)
Clavipectora l fascia
Tho racoacromia l a.
Med ial and lateral

pectora l nn.
-===-=~'------ Pectora lis major,

sternocosta l part
Biceps brach ii
Brachial fascia ~
Lat issimu s dors i
B Anterior view . Removed: Plat ysma. mu scle fasciae, superficia l

layer of cervica l fascia, and pectora lis major (clavicu lar part) .
Revealed: Clavipectora l tria ng le.
334
Fig. 22.32 Shoulder: Transverse section
Right sho u ld er, inferior view.
Head of Deltoid
humer us
Subdeltoid
z.:~~~::.-- Pectoralis
1 bur sa
major
~t:::1!:.~~-- Pecto ralis

mino r
..".lIil'-.,;;lilII'''--- - Coracobrachialis
t Anter ior
Axillary a. and v.,
cords of brachial plexus
Subscapularis
Delto id
) - -- -- Ribs
~"'------ Serrat us
anterior
+Posterior
Glenoid
labrum
Rhomboid
major
Fig.22.33 Anterior shoulder: Deep dissection

Right limb, anterior vi ew . Removed: Stern ocl eidoma stoid,
omohyoid, and pectora li s major. Thi s di ssection reveals th e
ne urova scular contents of th e lat eral cervica l triangle (see Suprascapular a.
Internal jug ular v.,
pp . 580 -5 8 1) and axilla (see pp. 336-337) .
common carot id a.
Axillarya .
Thoracoacromial a.
Deltoid
Ext ernal ju gular v.
Cephalic v. Thyrocervical trunk
Subclavian a. and v.
Clavicle
Pector alis major - - -,",
Subclavius
Superior t horacic a.
Median n.
Long t horacic n.
Ulnar n.
Axillarya . Pectoralis majo r

and v.
Pect oralis m inor
Subscapular a. Lat eral Medial and lateral

thoracic a. pect oral nn. 335
Topography of the Axilla
Fig- 22.34 Dissection of the axilla

Right sho ulde r, anterior view .
Median n. roots
Musculo cut aneou s n.

Axillary
a. and v.
Subclaviu s
Long
Deltoid thoracic n.,
superior
thoracic a.
Cepha Iic v. - ----,P --s-c7-''--<
Pectoral is ------..~~~,.,.::....--,=:..
major
'~E~~~~!~=----
!~ Medial
lateral and
pectoral nn.
~~~~~~::~~=:e;~~:;~=--- Lat eral

Biceps thoracic a.
brachii
Median n.
Ulnar n.
~~~..-----=---- Pectoralis
m ajor
Thoracodorsal Long thoracic n.

a. and n.
A Removed: Pecto rali s major and c1avip ectoral fascia.
Pectoralis major Pector alis Pectoralis

Ant erior w all Pectoralis minor minor major
Clavipectoral fascia Medial and
lat eral cord s
Intertubercular groove
Lateral wall
of hum erus
Subscapularis
Posterior wa ll Teres major
Latissimu s dorsi Biceps brachii,
Lateral thoracic wall '----- - - - - - - - Serratu s
Medial wall ante rior
Serratus ant erior
___- - - - - - Subscapularis
~--c-::;:-c-:;~--- R i b
~ I------='='
Posterior cord
Scapul a
... 1O . .. .. " .. .. . "
336
Subscapu lar a.
Media l and lat eral Lat eral co rd
co rd br anches
Axillarya .
Radial n. Medial co rd
Axillary v.
Brachial a.
Long t ho racic n..

super io r t hora cic a.
Upp er subscapular n.
Lat eral t horacic a.

Median n.
Ulnar n.
Thoracodo rsal
Brachial v.
a. and n.
B Removed: Ant eri or w all (pectora lis ma

jor and min or, and d avip ectoral fascia).
Retracted: Medial and lat eral cords of th e
brachial plexus.
Posteri or Deltoid
cord
Coraco id
pro cess
Pect or alis
min or
Delt oi d
Lateral and m edi al co rds

Coracobrac hialis
Sup rascapular n.
Radial n. (in scapular not ch)
Upp er subscapular n.
Low er subscapular n.
Biceps - - --\- Subscapu laris

br achii
Biceps _ Thoracodo rsal n.

fascia
Radial n.,
mo tor branches
C Removed: Media l and Serratus
lateral cor ds, and axillary Lon g head ante rio r
vessels. Revealed: Poste Triceps brachii
rior cord . Teres majo r
337
Topography of the Brachial & Cubital Regions
.Q Fig.22.35 Brachial region

.5
-.I
Right arm , anterior view. Removed: Delt oid ,
lii pectorali s majo r and mi nor. Revealed: Medial
Q. bicipita l groove.
s
Musculoc uta neous n.
(piercin g th e Coracoid Lateral
coracobrachiali s) process cord
Pect oralis
Pectoralis major min or
Axil lary
a. and v.
Medial brach
ial cutan eou s n.
Medial cord
~.----- Medial ante
brachial cuta
neo us n.
Bicipi t al
apon eurosis scapularis
Cubital
fossa
Ulnar n.
Teres
major
Long head
M e~
Triceps brachii
Ulnar n. (in Inferior ulnar Latissimu s Serrat us
ulnar gr oove) collat eral a. dor si anter io r
338
Fig. 22.36 Cubital region
Righ t elb ow, anteri o r v iew .
Skin - -----t- - .......-iIiIiIiiil Subcu t aneo us
ti ssue
,-,r- - - Basilic v.
Biceps - - ----cit
brachii ~_-- Medial
Cephalic v. - - --§- ant ebrachial
cut aneo us n.
Medial
epicondyle
-+---+--'~e--tt--- Median cubita l v.
Lateral - ---f,--ft-rK ~...,!-- Deep median

antebrachial cubit al v.
cut aneous n. (perfor ator v.)
Median
basilie v.
Cephalic v. ----.-,--\;;H~
Biceps brachii
Median ante- --+-~""~fP-- 1 __ -fl.t-- - Basilic v.
Brachial a.,
brachial v. ...,..- .....
Brachialis median n.
Triceps brachii
Musculocut aneous n.
Brachioradialis -----j~ Superior ulnar
A Cutaneo us neu ro vascu la r st ruc t u res in t he
collate ral a.,
~~~~~I: ~
cubital fo ssa. ulnar n.
. Deep - ---.E----C'
Rad raI n.
j
branch
Superficial -
branch
--i--iil1
+t.-"-': -cH-- - Median n.
Biceps --r-1W'
Medial ant ebrachial brachi i te ndon 1.---" HUmeral )
head Pro -
Superficial fascia cuta neo us n. Radial nator
recurr ent a. Ulnar teres
Ulnar a. head
Radial a. - --7-a- Flexor

Cephalic v.
carp i radialis
Supinator - ---;:-71r-
Biceps brachii Palmaris
(and fascia) lon gus
Brachial a. and v.
Pronato r --~v-f-' Flexor
Median n. Inferior ulnar
t eres carpi ulnaris
collateral a.
Brachialis Superio r ulnar
collate ral a.,
Lateral ant ebra

ulnar n.
chial cuta neous n.
(m usculo
cut aneous n.)

C Deep cu bital fo ssa. Removed: Bice ps b rac h ii
-fftt'---.f--fltT- Pronato r t eres (di stal mu scl e belly). Retracted: Brachi o
Biceps brachii t endon
radiali s.
Perf orator v.
RadiaI a. - -+-1l-H'--++
.r ",,=hI-- Bicipital
Exte nsor carpi

aponeurosis
radialis longu s
Brachiorad ialis - H'"",,1ir
Cephalic v. -~'-"<i~"
Medial ante- ~~.Jo;;;o::U,h.tl
brachial v,
B Su pe r fi cia l cu b ita l fossa . Removed: Fasci ae

an d ep ifascial n eu ro v ascul ar st r uct u res.
339
Topography of the Forearm
Fig. 22.37 Anterior forearm

Right forearm , ant erior view.
Media n n. Median n.
Triceps
brachii
Biceps - -- - h-\;--- Inferior ulnar Biceps

brachii Superior ulnar
brachii collatera l a.
coll ateral a.,
;9- - - Superio r ulnar ulnar n.
collat eral a., Brachialis
Brachialis -------.ilrhi-'W~..-+* Inferior ulnar
ulnar n.
collateral a.
Medial Brachio
radialis Medial
epicond yle
epicondyle
Brachial a. Radial n.,
Biceps --+Jf~rr--i-~+\ superficial
brachii ~'-d--ib*-- Pronator branch Pronato r teres,
tendo n teres hum eral head
Biceps
.........'--' ~-- Flexor brachii
Radial a. - l'ffiJ;;---'H--;-'--!
carpi radialis tendon Flexor
carpi radialis
- --'-'----:'-';J!-- Bicipita l Com mo n inter
Brachio- ----j+t:-.-'
Palmaris
aponeurosis osseous a.
radialis lon gus
~~!-- Palmaris Posterior inter -
longus osseous a. Pronat or teres,
ulnar head
Ant erior inte r
Exten sor - osseous a.
carpi radialis Flexor
brevis Pronat or dig it orum
Flexor teres superficialis
carpi ulnaris
Ext ensor
carpi radialis
longus Flexor
carpi ulnaris
Flexor carpi - +t- l;¥-1it;-;-- -;;
radial is Radial a.
Abd ucto r Flexor ---H-~~, :l

pollicis long us ~Hi-it~-+"--- Flexor pollicis longus
digitoru m
Abdu ct or
Radial a. superficialis
polli cis longus
IH H '--llH - - Palm aris longu s
Median n.
te ndo n
Pron ator - - +f-j
1*+- - Ulnar a.
quadratu s Flexor digit orum
Flexor poll icis
longus
super ficialis
I+ t -"--"'=-- - + - Med ian n. Flexor carpi tendons
radialis tendon
"" 77 - - - Ulnar n. Ulnar a. and n.
(in ulnar t unn el) -~iI-+--- Flexor
retinacul um
~~-- Hypoth enar
'''l:''''~ . . .' muscles '!X,-'~- Hypoth enar
m uscles
Thenar Palm ar Thenar Palm ar branch

mu scles aponeurosis m uscles of median n.
A Superficia l layer. Removed: Fasciae and superficia l B Middle layer. Part ially removed: Superficial fl exor s (pronato r
neurovasculature. t eres, f lexor di gitorum superficialis, palmari s longus, and
f le xor car p i radiali s).
340
Fig.22.38 Posterior forearm
Right forea rm, ant erior view du ring pronation. Reflected: Anconeus and
tr iceps brachii. Resected: Exte nsor carpi ulnari s and ext ensor digit orum .
Median n.
Biceps brachii - --=! - \
Triceps brachii, - - --f-

Musculo - --+'--1iiii~~ Brachial a. latera l head Brachio
cutaneo us n. radialis
Muscular
branches - -+.2r- - Brachialis
Extensor carpi
Radial n. Super ficial Olecranon - - radialis lon gus
branch
;'---+':-- Biceps Arterial
Deep Anco neus - - -i1f--1 net w ork of
branch brachii t endon
elbow and
lat eral
Extensor - - -,--,.-'Ji!-, epico ndyle
carpi ulnaris
Int erosseous ---f-~~

Radial a. -l.':'-~
recurre nt a.
Passa ge --~~'
through Exte nsor
Brachio
int erosseou s digit orum
radialis
memb rane
tlf.i=- - - Posterior
int erosseou s n.
Pronator --+f-'!---t4!~
Posterior - - h :-lof'l
teres int erosseous a.
Flexor - -i+- Extensor carpi

digitorum radialis brevis
superficialis, and long us
radial head
Ext ensor
carpi ulnaris Extensor
pollicis lon gus
Ante rior interosseous a.
(piercing the m em brane) - 8 - - - Abd uctor
pollicis lon gu s
1+-'' 7- - Median n.
Ext ensor ---~i!'J Ext ensor
Flexor ----,!'\-H~ indici s pollicis brevis
pollicis longus
Int erosseous
memb rane
Abd ucto r
po llicis lon gus
HY,~rf-f---- Flexor
Extensor carpi
digitorum
radialis longus
prof undus
tendon s ~- Radial a.
Pronato r J-r - - Ulnar

quadratu s a. and n. Exte nsor
Radial a., po llicis
+'--7-i~-f--f---- Flexor dorsal carpal branch long us
Radial a. digitorum t endon
Ext ensor carpi
supe rficialis
radialis brevis
tendon s
tendon
C Deep layer. Removed: Deep flexors.
341
Topography of the Carpal Region
Fig. 22.39 Anterior carpal region Superficial Median n.,

Right hand, anter ior (palmar) view . palmar arch thena r branch
Flexor digiti -----'J:~~~ ••" I'{II ~~~~~~- Flexor po llicis

minimi brevis, super
ficia l head
Abductor
digiti minimi q ,A i£J'--- - Abd uctor
po llicis brev is
Palmaris brevis ------:~~~~~~
~--- Opponens
po llicis
Flexor retinacu lum (trans

verse carpal ligament)
Radial a., superficial

palmar branch
,...-lr - - Median n.
Pronator
quadratus
-----!'----- - Flexor carpi

radialis
"i--e==-t- - Flexor po llicis

longus
Palmaris lon gus
tendon Radial a.
Flexor digitorum
A Ulnar t unnel and deep palm . superficia lis
Superficia l Media n n.,

palmar arch thenar branch
Flexor po llicis brevis,

superficia l head
Flexor digiti
m inimi
Abductor po llicis brev is
Abductor digiti ----~" ~.\
mini mi
Opponens po llicis
Superficia l
branch
UI'OC' { Deep branch
Flexor retinacu lum
(transve rse carpal ligament )
Radial a., superficia l

palma r branc h
Ulnar a.,
deep branch
Media n n.
Ulnar a. -----o;c7-'~_HI
Flexor carpi radialis
and n.
Flexor po llicis long us
Flexor digitorum - ----:; -H:iib -:-d--H

Radial a.
superficialis
Extensor carp i radia lis

Flexor carpi long us and brevis
ulnaris
B Carpal t unnel with flexor retinaculum
wi ndowed .
342
Fig.22.40 Ulnar tunnel Palmar
Right hand, ante rio r .-------- aponeurosis
(palm ar) view.
Hook of -~~::;;;;;......-=~~ Ulnar a. and n.,
hamat e superficial
branches
Hypoth enar -...,....:~
muscles
I
I
Super fic ial Deep
palmar arch palma r Ulnar t unnel
arch (d istal hiat us)
::::~;:;~--- Palmar carpal
Hook of Pisiform ligament
hamate
l" Pisiform
Flexor carpi - -
ulnaris
--!-J'-- I Palmaris
longus
A Bony landmar ks.

I- Radiala .
Ulnar a.
and n.
--..L!-..l....!-~,f--• .• --I!-!-----r-!--..,,-!L-¥.- Flexor digito rum
superficialis tendons
B Apert ures and wa lls of the ulnar t unnel.
Fig.22.41 Carpal tunnel:

Cross section
Right hand, proxima l view. The
t ight fit of sensit ive neurovascular
st ruct ures w it h closely apposed. Flexor ret inaculu m
frequentl y moving t endons in t he (t ransverse carpal
ligament)
carpal tu nnel of t en causes prob
lem s (carpal t unnel synd rome ) Abducto r pollicis
Ulnar a.
w hen any of th e str uct ures swell longus tendon
and n.
or degenerate. Pisiform Exte nsor pollicis
brevis te ndo n
Exten sor po llicis

longus te ndon
::....--- - Radial n.,

superficial branch
Exte nsor carpi

Extensor carpi radialis longus te ndo n
ulnaris te ndo n
Exten sor carpi
Exte nsor digiti radialis brevis te ndo n
minim i te ndon Hamate Exte nsor digito rum Capit at e
A Cross sect io n t hroug h t he rig ht wri st. and exten sor indicis ten do ns
Flexor ret inaculum

(t ransverse carpal ligam ent )
Flexor digitorum Superfic ial palmar

superficialis tendons a. and v.
--~~,.:.;=;=~~~~~~~~~~;~~~~~~
Flexor carpi
Palma r carpal radialis te ndon
ligam ent
Ulnar a. and n. ----:'-!---..J-~;,;;
Median n.
Flexor pollicis
longus tend on
Synovial cavity -~Hi 'j
Scaphoid
B St ruct ures in t he ulnar tu nnel (g reen) Capitate

and carpal t unnel (blue). Flexor digitorum profu ndu s t endons
343
Topography of the Palm of the Hand
Q Fig. 22.42 Superficial neurovascular

E: structures of the palm
:::A
... Right hand , ant erior view.
QJ
~
--+--f---+-~ Palmar digital nn.
(exclusive area of
median n.)
Palmar
digit al n. '=+------!!-+-~~--- Med ian n.,
(exclusive palmar
I Lr~f!h- Palm ar digital aa.
area of branch
ulnar n.)
Palmar ----l:¥--'~-~~r-"'-'ff,i_-'t.i
digital nn.
Ulnar n., - - ,-----
palmar
Radial n.,
branch
dor sal
digital n.
Com mo n ----t1rt.-~-=fri-'---__'_H''cll
palmar digita l aa.
I~--ffi~- Palmar
A Sensory territori es. Extensiv e overlap exists digital nn.
between adjacent areas. Exclusive nerve of thum b
territori es indi cat ed w it h darker shading.
I""::;:;i!!:!:~~~~'--- Add ucto r
pollicis
Abd ucto r ----I~:...~ ~~
digiti mini mi Flexor pollicis
brevis, super
Palmar ------;~----""'R~-r'=\--
ficial head
aponeuro sis
- - - - Abdu ct or
Palmaris ---------.::~~:-..~;:: polli cis brevis
brevis
Flexor retin aculum --~;::;;!~~~~T7' Radial a.. superf icial

(transverse carpal palmar branch
ligam ent )
IH~--- Radial a.
Ulnar a. and n.
----,l -- - - Ulnar t unnel
Palmaris longu s - - - -'----""=""- ---<
tendon
B Superf icial art eries - - ------!E---- Ante brachial

and nerv es. fascia
Fig.22.43 Neurovasculature
of the finger
Right midd le fing er, lat eral view.
Palmar digital n., Palmar digital a. Digitopalm ar

do rsal branch branches
Palmar dig it al n.
Vincula Vincula
Prop er palm ar Commo n palm ar brevia longa
digita l a. and n. digit al a.
A Nerve s and art eries. B Blood supply to th e flexor
tendon s in th e t endon sheath .
344
Fig.22.44 Deep neuro Fig.22.45 Innervation
vascular structures patterns in the palm
Median
of the palm Right ha nd , comm unicat ing
Right ha nd, anterior view. branch
anterior v iew.
Ulnar
comm unicating
PaIm ar ----..:-H--R'Ir----L---¥.---::'.tIl
branch
digital aa.
and nn.
Palmar
digital nn.
Lumbri cals 1st dor sal B Median and u lnar

interosseou s commu nicating
branch es (20 %).
Addu ct or
pollicis
Superficial
palmar arch Flexor pollicis
brevis, super
Flexor digiti
ficial head
minimi
Abdu ct or Radial a., super A U ln ar co m mu
dig it i minim i fici al palmar branch nicat in g bra nc h
Ulnar n., --'\it'~~ Abductor (45 % of cases) .
superf icial branch pollicis brevis
Ulnar a. and --7-4\~ I ~ Oppo nens po llici s

n., deep branches
Palm aris longus ~ Flexor reti naculum
Palm ar carpal ligam ent Radial a., superficial

Ulnar a. and n. ----t--4l-H palmar branch
Flexor digitorum
superf icialis
I Median n.
Pronato r
C No co m m u nicating
bra nc hes (20 %) .
Flexor -
quadratus
carpi ulnaris Radial a.
Flexor poll icis longus Palmar ----~=-i__T'i\--c"M---:=i""':\\

Flexor carpi radialis Extenso r carpi digita l aa.
radiali s longus and nn.
and brevis
Common -----I,I+-,~'l'£--~l+_l__"'l_:
A Su pe rf ici al palma r arc h. palmar
digital aa. - - -f{I'---S:Il - Lumbricals
Abducto r -r-c-a
:-r-~~-i!I---'---- Adduct or po llicis,
digit i m inimi
t ransverse head
Flexor digi t i - """' .n"
minimi Abducto r
Palmar met a pollicis brevis
carpal aa. Flexor
Opp onens poll icis
dig iti m inim i brevis
Superf icial Deep palmar arch
palmar arch
Adductor polli cis,
Deep
j
obli que head
Ulnar n. branch
Superficial Opponens
branch pollicis
Ulnar a., Radial a.,
deep branch superficial
palma r
Ulnara. branch
and n.
Radial a.
Pronator
quadratu s
B Deep pa lmar ar ch.
Flexor carp i Ant erior
ulnari s interos
seous a. 345
Topography of the Dorsum of the Hand
Fig. 22.46 Sensory innervation of the dorsum

Right hand , posterior view.
f-+-- /--;-?--s-----.-----.- - - - Palma r dig ita l nn.,

dor sal branches +--..,:'---!-~-k---- Media n n.,
(me dian n.) dorsal branches
Exclusive area - -"1- + -+ of palm ar
Dorsal of me dian n. digit al nn .
digita l nn .
(radial n.) Dorsal digita l n.
Hc+.--~H-r-- Do rsal di g it al nn. (exclusive area
(ulnar n.) of ulnar n.)
_~L-_ _ Ulnar n.,

do rsal branc h
Radia ln.•
super ficial branch
~
and dor sal
digi t al nn.
Radial n.,
superficial branch
A Nerves of th e dor sum . B Sensory territ or ies. Ext ensive overlap exists between adjacent areas.
Exclusive nerve t erritories indi cated with darker shadi ng.
Fig. 22.47 Anatomic snuffbox

Righ t hand, radial view. The th ree-sided "anat om ic snuffbox" is
bo unded by th e tend on s of insert ion of th e abd uct or pollicis longus and
exte nsors pollicis brevis and long us.
Extensor carp i
radi alis longus
Ext enso r dig itorum Trape Exte nsor carp i Ext ensor
and ext ensor ind icis zium radialis brevi s poi lic is lo ngus
Radial n.,
,ii~~~:JC:~~:~~~==L- superficial bra nch

1st dorsal Ii! Styloid proce ss
int erosseous of radi us
Radia l a.,
do rsal carpa l
~~~~~i~~~;!~~~~~~:!~F!~'""""""
~~- Scaphoid
branc h
Exte nsor Radial a.

Radial a.
po llicis brevis
1st Abd uctor
metaca rpa l po llicis longus
346
Fig.22.48 Neurovascular structures of the dorsum
I 'HJf -'----fft--e'1 '--- DorsaI

digit al aa.
Dorsal -----'~ff'&------,H1Ift_l1\_t_---""I'-H'lc" ~~ , .,1
int erossei
+ H 'T-- Dor sal

meta carpal aa.
Ext ensor
digit orum
pollicis brevis
~Hr+-'l--IJ--MHW-- Radial a., dor sal
Extensor carpi --'""",~'-'01"""' \ carpal branch
radialis brevis
and longu s Exte nsor digit i m inim i
Radial a. Ulnar a., dors al

carpal branch
Exte nsor
Dor sal carpal retin aculum
net work Exte nsor
carpi ulnaris
Dor sal
A Superficial st ruct ures.
digit al aa.
Extensor
po llicis longu s Dor sal
metacarpal aa.
Ext ensor carpi

radialis brevis
Radial a. - ---";:-.:-':':! ;
Ext ensor carpi

radialis longus
Dor sal carpal --+--+-'~'!1

net w ork
B Deep st ruct ures.
347
Transverse Sections
Fig. 22.49 Windowed dissection

Right limb, anterior view.
Triceps
brachii
Biceps ----*i~
Deltoid ---~'-f'-,L
br achi i
Brachialis
Medial
epicondyle,
com mon head
of fl exors
Biceps brachii - - --'-+H!------.f--'-.

Pecto ralis ----P.--:-±--'-!!-+--!-----,h"-~~~""7"':;_. te ndo n Bicip ita l
m ajor ap oneuro sis
Brachio- -----+~L,+
radiali s
Ext ensor ------'0

Pro nat or
Corace- --~'+-'~c+Jf.e-.!!!~
teres
car pi radia lis
br achialis
lon gu s Flexo r
carpi radia lis
Teres m ajor Ext ensor
carpi radia lis Palmaris
Biceps brachii, _ _-.l~--": brevis lo ngus
lo ng head
Radius --+~~ Ulna
Biceps brachii, - -- --''Hi'--;-----,-+-+ +- /

short head
Brachio - - - --H
~--- Flexor
radia lis
carpi ulnaris
Humerus -----JL4~~~- Flexor digi torum

supe rfici alis
Flexo r ---+-~'Il
po llicis lon gu s I,!
Abducto r
po llicis lon gus
--1
Flexo r carp i - -"'--H!-i--
radi alis
Biceps ------'-+L!~L_flf+_+
brachii
+--7-+---- - - - Palmaris
lo ng us
- :...!...+ -- -- -- Flexor reti naculum

(transverse
Brachialis carpal ligament)
Brachio- --~
radialis
- "'-- - - Palmaris
Medial brevis
epico ndy le
---,,...----~-"<-_T_-- Palmar
apo neurosis
A Dissectio n of th e arm. B Dissecti on of th e forearm.
348
Fig. 22.50 Transverse sections
Right lim b, proxim al (superior) view.
Posterior
(dor sal)
t Triceps brachii,
lateraI head
Triceps brachi i,
long head
Triceps brachll,
Radial n.
media l head
Lateral inte r Medial int er

muscular sept um m uscular sept um
Hum erus - - H -fJ Ulnar n.
Brachialis --~-c+I'
Brachial a. and v.
Median n.
Biceps brachii, Musculo

long head cutaneous n.
Biceps brachii,
Ante rior short head
(vent ral)
A Arm (plane of sect ion in Fig. 22.49A).
Posterior
(do rsal) Abdu ct or
t Posterior inte rosseou s
Interosseous
a.. v.• and n.
po llicis long us
Extensor
m embrane carpi ulnaris
Extensor Extenso r
poll icis brevis po llicis longus
Extensor
digitorum
Radiu s Flexor digitorum

profundus
Exte nsor carpi ---r-"-!ld--~Uli ,
radialis longus Ulnar n.
Ant erior int erosseou s

a.• v.. and n. Ulnar a.
Extensor carpi Flexor

radia lis brevis carpi ulnaris
Brachio radialis
Flexor digito rum
superficialis
Radial n.
(superf icial branch)
Palm aris
Pronator Flexor long us
te res carpi radialis
Ante rior
(ventra l) Radial a. Median n.
B Forearm (plane of sect ion in Fig. 22.49B) .
349
Surface Anatomy (I)
Fig. 23.1 Upper limb :

----=~-=-- Clavicle
Anter ior view
Deltoid
- ----+- Cephalic v.
(in deltopect oral
Pectoralis - - gro ove)
major
Biceps - - Triceps brachii,
brachii lateral head
Cephalicv.
Median -----ti~"""~
- - Exte nsor carpi
cubital v.
radialis longus
- - Brachioradialis
Flexor carpi
ulnar is
1.-'-',--":-- Palmaris longus
tendon
Fig. 23.2 Palpable
Hypoth enar
bony prominences
Palm eminence
~"'!l'''l.-- Palmer venous Rig ht limb .
1st digit
net wor k
(t humb )
Clavicle
_ _ 5t h digit
(little finger) Acrom ion
Coracoid process -------''''- I.......
A Surface anato my, right limb . B Musculature, left limb. Greater and lesser
tubercles
Latera l - - Medial
epicondy le epicondy le
Tubercle of
scaphoid
Tubercle of
trape zium , -' - --'-" ' - Metacarpo
phalangeal joi nt s
A Anterio r vie w.
Int er- '-----<c---~_+."f
phalangeal
joints
350
Ql: Wh ich cut aneous nerves are m ost vulner Fig.23.3 Upper limb:
able durin g int ravenous pun ctures (e.g., Acrom ion ---=...,-'~ Scapular _ _~_ Posterio r view
dr awin g blood, inject ions)? spine
Infraspinatu s - -
Teres majo r - -- -
Lon g head } Triceps
Lati ssimu s ~.
Lat eral head brachi i
dor si
Olecranon ----'~- - - - Exte nsor carpi

radialis longus
Ext ensor carpi --+-~

ulnaris
Flexor carpi - - -];.:. \ Ext ensor
ulnari s di gito rum
St ylo id pr ocess
of radius
Extensor di git oru m --~~~

t endons, dor sal
venou s netwo rk
-+- - - Acrom ion A Surface anatom y, left limb. B Musculature, right limb.
Great er
t ube rcle
Scapular
spine
Q2: Palpation of w hich skelet al landm arks

wou ld allow you to locat e and exami ne
th e collate ral ligam ent s of th e elbow?
O l ecra non ~ ~-- Head of

radius
Stylo id pr ocess
of ulna
Triq uet rum bone ~
Capitate bo ne
Met acarpaIs - -'i-ii-'r-"T-7---"
Phalanges -L~"#LH-H B Posterior view. See answers beginning on p. 626.
351
Surface Anatomy (II)
Fig.23.4 Palpable bony structures Fig. 23.5 Surface anatomy of the wrist
Left hand. Lef t wri st, ob lique ant ero latera l view .
/ Distal inte rphalangeal

/ (DIP)jo int
- -- Hypoth enar em inence
Pisifor m
-«--- Proximal int erpha lang eal Flexor carpi
(PIP) join t ulnaris t endon
Thenar - - - --
em inence
Metac arpop halangeal
(MCP) j oint
- - - Palmari s
longus
tend on
Flexor
~"""--- Hook of hamate
carpi radialis
Tubercle of ---=>;.-... tend on
t rapezium
Tubercle of
scaphoid Q3: How can t he palpab le tendo ns in the w rist
Ulna
be used to dete rm ine the location of key
Sty loid pro cess
of radius
arte ries and nerves?
A Ante rior (palma r) view .
Fig. 23.6 Anatomic snuffbox

Left hand, obliq ue postero latera l view .
Exte nsor digitoru m ---t'-~-

Phalanges tendon s, dorsal
veno us net work
-~- Head of 1st

Extensor - - - - -
meta carpal
pollici s
longu s
~ooo=T--'-~~ Capitate
Triquet rum Sty loid ------- Extensor
process of pollic is longu s
Sty loid process Sty loid pro cess radius Anat om ic
of ulna of radius
snuffbox
Q4: Tenderness in t he base of the anatomic

snuffbox can suggest a fracture of whic h
of t he carpal bo nes?
B Posterior (dorsal) view. See answers beginning on p. 626.
352
Fig. 23.7 Palm
DIPjoint
crease
PIPjoint
crease
Mep j oint
crease
/ Dist al tr ansverse
/ 1 crease
~ Proxima l tr ans Palmar veno us
verse crease network
-----~- Midd le crease
- - - Hypot henar -=-~~'----- Flexor pollicis brevis
em inence
Adu ct or pollicis brev is
Pisiform - - -,;;;~I"'----- Tubercle of

Thenar - - - Distal w rist crease
em inence - -- Proximal w rist

tr apezium
Thenar
crease
Palm aris
crease
("life line") longus
tend on
A Su rface anatom y, left pa lm . B Mu scu lat u re, rig ht pa lm .
Fig. 23.8 Dorsum
>-~-~- Dorsal digit al

expansion
-~~~~+----,~- Metac arpal heads
Ext ensor digiti min im i

~ -~~~+'7-~'-+~'- Ext ensor dig it or um,
do rsal veno us network
Extensor indi cis

Extensor pollicis
longu s
Anatomi c snuffbox
Sty loid process

of ulna
::f>------ Distal ~ nd prox imal
exte nsion creases
Ext ensor ret inaculum
A Su rface anatomy, lef t h an d . B M usc u lat u re, rig ht hand.
353
~ ----"""
Lower Limb
joints of the Foot (II) 404
24 Hip & Thigh

jo ints of the Foot (III) 406
Bones of th e Lower Limb 356

Ligam ents of the Ankle & Foot 408
Pelvic Girdl e & Hip Bone 358

Plantar Vault & Arches of th e Foot 410
Femur 360
Muscl es of th e Sole of th e Foot 412
Hip joint: Overvi ew 362

Mu scles & Tendon Sheath s ofthe Foot 414
Hip joint: Ligaments & Capsule 364

Anterior Muscles of th e Thigh . Hip & Gluteal Region (I) 366

Anterior Muscles of the Thigh , Hip & Gluteal Region (II) 36 8
Posterior Muscles of th e Thigh , Hip & Gluteal Region (I) 370
27 Neurovasculature
Posterior Muscles of the Thigh , Hip & Gluteal Region (II) 372
Mu scle Fact s (I) 374

Arteries ofthe Lower Limb 420
Muscle Fact s (II) 376

Veins & Lymphatics of the Lower Limb 422
Muscle Fact s (III) 37 8

Lumb osacral Plexus 424
Nerv es of the Lumbar Plexus 426
25 Knee & Leg Nerves of the Lumbar Plexus: Obturator & Femoral Nerves . . 428
Nerves of the Sacral Plexus 430
Tibi a & Fibula 380
Nerve s of the Sacral Plexus: Sciatic Nerve 432
Knee j oint: Overvi ew 382
Superfi cial Nerves & Vessels of the Lower Limb 434
Knee j oint: Capsule, Ligaments & Bursae 384
Topog raphy ofthe Inguinal Region 436
Knee j oint: Ligam ents & Menisci 386
Topography of the Gluteal Region 438
Cruciat e Ligaments 38 8
Topography of the Anterior & Posterio r Thigh 440
Knee Joint Cavity 390
Topography of the Posterior & Med ial Leg 442
Muscles of the Leg: Anteri or & Lateral Views 392
Topog raphy of th e Lateral & Anterior Leg 444
Muscles ofthe Leg: Post erior View 394
Topography of th e Sole of the Foot 446
Transverse Sect ions 448
28 Surface Anatomy
26 Ankle & Foot
Surface Anatomy 450
Bones of th e Foot 400
Joint s ofthe Foot (I) 402
Bones of the lower limb
Fig. 24.1 Bonesof the lower limb

Right lim b. The skeleto n of t he lower lim b consists of a limb gird le and leg (t ibia and fibu la), and foot. It is connecte d t o th e pelvic girdle by th e
an at t ached free lim b. The free limb is divided into t he thig h (fem ur), hip joint.
Posterior superior Iliac
iliac spine crest
"'----- - Iliac crest
Hip bone - -J-- - Ant erior superior

iliac spine
_""'""'~-- Hip joint

Ischial
Pubic tubercle
spine
-'--1""'--- - Greater trochanter
Ischial - - - ---'' '=,

tuberosity
Lesser
tro chanter
--\- - Femur
Thigh
Lateral
condy le
Med ial
Pate lla epicondyle Knee joint
Tibial Lateral t ibial

plateau condy le
Medial
ti bial Head of fibu la
condyle
Tibia
Fibula
Low er leg Fibula
Ankle Media l
mortise malleolus
Talocrura l
-..!,.,-- - (ank le) joint
Lateral
Tarsals { mal leolus
Calcaneus
Metatarsals{ Calcaneus , ~ Tuberosit y of
5t h m et at arsal
Phalanges {
A Ante rio r view. B Right late ral view. C Posterio r view.
356
Fig. 24.2 Line of gravity Fig.24.3 Palpable bony prominences in the lower limb
Righ t lateral view. The line of gravityruns verti Mostskeletal elements of the lower limb have bony prominences.
cally from the whole-body center of gravity margins. or surfaces (e.g.. medialor tibial surfaces) that can be palpated
to the ground with characteristic points of through the skin and soft tissues.
intersection.
Iliac crest -----'--------:;..-
,G- '-,--'+- - - External audit or y canal Posterior ~

superio r
.'e""'------i-::'r- - Dens of axis (C2) Anter io r - -
iliac spine
superior
iliac spine Sacrum -
Pubic
/ tub ercle
Infl ecti on po int s Greater ----' Greate r
of vert ebral troc hante r - - Pubic sy mphysis t roch anter
colum n
Ischial
tu berosity
$--"-----;~- Cente r of gravit y
Hip joint
17--cH- - - Knee joint

Patella
Lateral ______ Lateral
epico ndyle --------.t Medial

epicondyle
epicondyle
Lateral t ibial - - -' ~-- Lateral
condy le Medial tibi al tibi al cond yle
Head of fibul a ~ condyle

Head of fibula
G-'-'c - - - Ankle joint Tibial
t uberosity
:--- - - Tibia,
medial
surface
';- - - Medial m alleo lus - - - • .
Navicular t uberosit y ~ Calcaneal tub erosity
-:-- - - Tuberosity of
- - - Metata rso
5t h m etatarsal
phalangeal joint s
Interphalangeal join ts of t he foo t
A Anterior view . B Posterior view .
357
Pelvic Girdle & Hip Bone
Fig. 24.4 Pelvic girdle ~ Each pelvic gird le consists of a hip bone cart ilag ino us pubic sy m physis and t o t he
An terior view. Pelvic ring in red. IIIiiIII (coxal bo ne, innominate bone), which sacr um via th e sacro iliac joints . These at
articu lates with the head of a femur. t achm ent s create the bony pelv ic ring (red) ,
Hip bone Sacrum Sacroiliacjoint Un like t he shoulder girdle, the pe lvic permitting very little motion . This stability is
girdle is firm ly integrated into th e an important prerequisite for the transfer of
axia l skeleton: t he paired hip bon es trunk loads to the low er lim b (necessary for
are connected to each other at th e norma l gait).
Iliac crest --~ ---,-- -;a- - Iliac tub erosit y
Iliac fossa --~:....----- Post erior superior

iliac spine
Pubic Arcuate
symphysis line Anterior superior
iliac spine - - ----.ctr - Auricular surface
of ilium
Anterior inferior --!.

iliac spine
:....--~---- Ilium (body)
Arcuate line - - - - -----.,;!-
Ischial spine
Pectineal line - ------'J~-- Ischium (body)
Fig.24.5 Righthip bone
Symphyseal surface Ischial tub erosity
Inferior Obturator
pubic ramus foramen
Iliac fossa -----i-~---- E" ' .--!!-."...- Iliac B Media l view.

tuberosity
Anterior superior - - """~-- Auricular

iliac spine surfaceof
ilium
+-- - - - - Arcuat e
line
Anterior inferior - --+
iliac spine
"1-- -Ischial
spine
./' Pectineal
./' line
Symphysea l
surface
Obturator
foramen
Ischial
A Anterior view. tuberosity
358
Fig. 24.6 Components of the hip bone
Rig ht hip bone. The three bony elements of the hip bone (il ium, ischium,
and pubis) come toget her at the aceta bulum. Defi nitive fusion of the
V-shaped growth plate (triradiate cartilage) occurs between the 14th
and 16th years of life.
Iliac crest - - -----,:"
Iliac w ing
(ala)
Ilium --~------
(body) Aceta bulum
-- Triradiate
cartilage
Superior
Acetab
pubic ramus
ulum
Pubis
Inferior
Ischium pubic ramus
(body )
Ischial Ischial Obt urato r

tub erosity ramu s fora men
A Triradiate cartilageof the hip bone. Lateral view. B Radiograph of right acetab ulum of a child.
Iliac crest
Ante rior
gluteal line
Glutea l surface Inferior

gluteal line
Anter ior superior

Poste rior iliac spine
superior
iliac spine
}- - - - - Anterior infe rior

iliac spine
Posterior -~_ _- - ~
inferior
~----- Acetabula r rim
iliac spine
Greater
,~_---- Lunat e surface
Acetab ulum
sciat ic notch F--+- - - - Acetabu lar fossa
i"k--"'.....= ,--- Acetabul ar notch
Pubic
t ubercle
- + -0;''------ Obturator
foramen
Ischial - - -'"=
t uberosity
C Lat eral view.
359
Femur
..Q Fig. 24.7 Right femur

.5
....
Head - - - - - - -- - --#'--
~ Trochant eric
....o fossa
Greater Neck -------------T..-'~ Greater

tr ochant er tro chant er
.:.---~~~-- Intertrochan
teric crest
Intert rochan Lesser
te ric line t rochant er
Pectin eal - - -"f-

lin e
~~- Gluteal
t uberosit y
Shaft Lateral
lip
} Lin ea
aspera
Medial
lip
Medial ----ir--- - Lateral
supracondylar supracondylar
line line
Adduc to r
t ubercle Popliteal surface
Medial
epicondy le Intercondylar
line
Lateral - - -E,f Lat eral

epicondyle epicon dyle
Lateral -----'~ Latera l

condyle condy le
Med ial
condyle
Patellar Intercond ylar
surface not ch
A Anteri or view. B Posterior view.
360
Fig.24.8 Head of femur in the hip joint
Right hip joint, superior view.
Acetab ular
Ilio pect ineal
labrum Pat ella bursa
II Patellar
_ ~ surface
~ of femu r
Aceta bulum
_ ---3.. ....:.,-__ Head of Head of
femur fem ur
Fovea of .:
femoral -t Fibro us
~ ..., Ligam ent - - - - ---J\'! H>\y '+.r
- 'o--------;-t- Neck of membrane
:;~;~~' "
head of head
femu r
of fem ur Neck of
femu r
Greate r
> Acet abulum
Greater
t ro chant er
t rochant er
Medial
condyle
Lat eral
co ndy le Ischium
~~~~~~~i~~~~
~ ~;fII1I!l~~,+- Trochant eric
bur sa
C Proximal view. The acetabu lum has been

sect ioned in t he horizont al plane.
~ Clinical A Transverse sect ion.
, Fractures of the femur

Femo ral fractures caused by falls in pati ent s
w it h osteo poro sis are mo st frequentl y locat ed
in t heneck of th e fem ur. Femoral shaf t
fractures are less frequent and are usually ,
caused by st rong t rauma (e.g.• aca r accident) .
Pat ellar surface of

fem ur (fem oral trochlea)
- - - ---"'n c-- Pat ellar

surf ace
offem ur
B Tl -weig ht ed MRI.
Late ral - -'.-

con dyle Me dial
co ndy le
Int ercond ylar

not ch
D Dist al view. See pp. 382-383 for th e knee

joint.
361
Hip Joint: Overview
..Q Fig.24.9 Right hip joint

.5
-.I
The head of th e femur artic ulates wit h th e acetabu lum of t he pelvis at
th e hip joint. a special typ e of spheroidal (ball-and -socket ) joint. The
~o roughly spherical femoral head (with an average radius of curvat ure of
approximate ly 2.5 cm) is largely cont ained within th e acet abulum.
-.I
Anterior - - -..:,,
superior
iliac spine
Iliac crest
Bony aceta bular

rim
Head of femu r
Posterior superior
iliac spine
Greater
trochanter ~ Pubic
t ubercle
Posterio r ~
inferior
Intertrochan Neck iliac spine
t eric line
of fem ur
Lesser Head of fem ur

t rochant er
Greater
t rochanter
-'---- "'--- - ---7- - Neck of

fem ur
Int ertrochan
teric crest
A Anteri or view. Ischial Lesser ...--f--- - Glut eal

spine tr ochanter tuberosit y
Ischial ----::~~+--- Pect ineal

tu berosit y line
...,-- ---4-- - Linea

aspera
B Posterior view.
362
Fig.24.10 Hip joint: Coronal section
Right hip joint, anterior view.
Epiphyseal
line
Neck of Ilium
fem ur
Acetabu lum
Head of
femur
liga me nt
of head of
fem ur
Acet abu lar
fossa
Acet abular
labrum
Shaft of
Trochanteric femur B Tl -weight ed MRI.
bursa
A Coronal sect ion.
~ Clinical
Diagnos ing hip dysplasia and dislocat ion

Ultra sonogra phy, th e mo st import ant im aging m et hod for screening t he abduc tion of t he hip j oint, and leg sho rtening with asymm etry of t he gl ute al
infanthi p, is used to ident ify m orphological changes such as hip dysplasia and fo lds.
dislocation . Clinically, hip dislocation present s it self with inst abilit y and lim ited
' ~i '.4J~J';
_", J 'Ii.', ;~ " '''''b
,• :"
I:; ,,:'",1 " .t'

"';;; ~
", Acetabular
,--n
~ ~
Bony
acetab ular rim
Acetabular - - -- -'
~ t.·
labrum
f labrum
I IJ, ' : ' .
, • Ossification
.t. ~ ~;
center
I '
Femur -+-f-. /
~r~'
Femur ----t--t-t
.
tt,, \~·"¥J, u
Inferior Inferior
margin margin
of ilium of ilium
JJ• '.....
~
' • f,' •
A Normal hip j oint in a 5-mo nth -old. B Hip dislocation and dysplasia in a 3-mo nth -ol d.
Hip Joint: ligaments & Capsule
.Q ~ The hip jo int has t hree major ligaments: ili ofemoral. pub ofemo
,5
-.I
IIIiiiiiII ral, and ischiofemoral. The zona orbicularis (annu lar ligament )
is not visib le ext ernally and encircles th e femora l neck like a
~
o
buttonho le.
-.I
Fig.24.11 Hip joint: lateral view
~~---- LS verte bra
Post erior superior --~

iliac spi ne ~-- Iliac crest
Ante rio r superio r

Posterior -~'&-I,
iliac spine
sacroi liac II.
Ingu inal I.
Sacrum
Pubofemo ral I.
Sacrospi no us I.
Pubic t ub ercle
Iliofemo ral I.
Greater trochant er
Ischiofemoral I.
Femu r
A Ligam ent s of th e hip joint.

[ol nt ----:'ii----T'--if -- --,--;;'------ ...,.-'
capsule
l-l'.'.=--+-- - Acet abular

labrum
~;d~~;-ll'-- Fovea o n
femo ral
,,~~-:-;-,~'---- Acet abular Acet abular fossa head
labr um
ti:'i<i'i-- - Aceta bular Obt urat o r Great er
roof me m brane trochante r
"''''k-- - Joint
capsule
L. of
head offem ur
- - -=.-:--'t-:a-- Acet ab

ular +-- - Lesser
fossa trochant er
B Joint capsule. The capsule has been divided

and th e femora l head di slocated to expose
th e cut ligam ent of th e head of th e femur.
C Acet abu lum of right hip joint . Note: The

lig ament of th e fem oral head (cut ) trans
m it s bran ches from th e obt urat or art ery
t hat nourish the fem oral head (see p. 421 ).
364
Fig.24.12 Hip joint: Anterior view
___ L4 verteb ra
Iliofemoral I. ~ Anterior longit udinal I.
J I
Iliac crest - - - L5 verteb ra
- - Sacral promontory
A Liga m ents and Pubofemoral I. Anterior superior

w eak spo t (red). iliac spine Anterior sacroiliac II.
Inguinal I. - - -- ",
!lIt---;-'--- - Sacrotuberous I.
::"''';;;;:;:fi-;cf-- Sacrospinous I.
Iliofemoral I. - ----'-'----:
Ischial spine
Neck of femur
Greater
Pubic symphysis
troc hanter
Greater
trochanter
Intert rochan- - + -
t eric line
Intertrochan- -L..3;~- Pubofemoral I.
teric line
B Ligame nts of the hip joint.
C Jo int capsule. Removed: Fib ro us m embran e

(at level o f fem oral nec k ). Exposed: Syn ov ial
m emb ran e.
Fig.24.13 Hip Joint: Posterior view
Iliolum bar I.
L4 verteb ra
Iliac crest
LS vertebra
A Ligam ents and Ischiofemoral I. --,J.'-:iT----~-- Posterior superior

weak spo t (red) . iliac spine
Posterior sacroiliac II.
;--~-- Iliofem oral I.

Ischial spine
Fibrou s
Greater t rochanter
memb rane
Sacrospinous I. - -t-.....,------ .
/~--+- Intertrochanteric
crest
Sacrotuberous I. ------'l:--~k-
Lesser trochant er
B Ligam en t s of the hip j o int.
C Jo in t capsu le.
365
Anterior Muscles of the Thigh, Hip & Gluteal Region (I)
..Q Fig.24.14 Muscles of the hip and thigh: Anterior view (I)
.§ Right limb. Muscle origin s (0) are shown in red . insertions (I) in blue.
...
-.l
~
.....o Iliac crest - - - - --:-;,.-9"
- - Ant erior
long it udinal
ligam ent
Iliacus - - -I--b* [---; Sacral
prom ont o ry
Anterior - - + Psoas major
super ior
ili ac spine
Pirif ormi s p,.,,..,...---- - Sartorius
Tensor - ---j!-
fasciae lat ae
Ing uinal ~;r;;-_--t:--';J--- Rectus

Iliop soas ----ii-:~~+---'it'-'
ligam ent femoris
Pubic
sym physis
Pect ineus
A Removed: Fa scia lata of thigh (to the lateral iliotibia l tract) . B Removed: Sartoriu s and rectus femoris.
366
."",!i.b- - - - Psoas
Psoas major (O)
major
Iliacus - - ---,!'-..,, Iliacus (0)
Sartorius (0) ~
Sarto rius (0 )
Tensor
fasciae latae
Gluteu s
Piriformi s Glut eus ~~~--'-=';-- Piriformi s
medi us
m edius
Rectu s ~!'!!~--=- Rectus
Glut eus - - +-.It'-+ '1 Glute us
femoris (0) femoris
mi nimu s minimus
Piri formi s ------,~4"'--.. Pirif ormi s Pecti neus (0)
IIiofemora I - - ---+----';o-t' 4----,-.1f'
ligam ent Obt urato r Obt urato r
ext ernus ext ernus
Iliopsoas
Vastus
Pecti neus Iliopsoas (I) .?:l'l+-I-- - - Adducto r
lateralis
brevis
Adductor
minimu s
Vast us - - - +.'- -'*:. v
m edialis Adducto r Vastus
brevis medialis (0)
Addu ctor
longu s
;a--- - Gracilis
Gracilis
Vast us
Vastus ---'iil-iifi--1i-- -r-- Add ucto r
int erm edius
int ermedius (0) magnus
ff6-+~--- Adduc t or
magnu s
Art icularis - - -- +-

- f-+-+-I'§_ - Add ucto r genus (0)
hiatu s '--+-7-rr.=f-- - Adducto r
hiatu s
,.-----¥.~J--- Art icularis
Vastus ---~
genus
lateralis
rff- - - Vastus
med ialis
Ilioti bial Semim em branosus (I)

tr act (I)
Patellar ligam ent
;eon~:o~f
Biceps ....... ...' ---- Gracilis (I)
femoris (I)
IE':+7 - - Pes anserinus IF+-- - - Sarto rius (I) )
Quadriceps insert ion
femori s (I) IH - - - Sem i (pes anserinus)
tendinosus (I)
C Removed: Rectu s fem ori s (compl etely) , va stu s later ali s, vastu s media D Removed: Qu adriceps fem ori s (r ectus fem oris, vastu s lateral is, va stus
li s, iliop so as, and t en sor fasci ae lata c . mediali s, vastu s interm ediu s), ilio psoas, t en sor fascia e lat ae, p ectineus ,
and mid p orti on of adductor longus.
367
Anterior Muscles of the Thigh, Hip & Gluteal Region (II)
Fig. 24.15 Muscles ofthe hip and thigh: Anterior view (II)
Right lim b. Muscle origin s (0) ar e shown in red , in sertio ns ( I) in blue.
~1j".;::::::-- Psoas major
Iliacus
Sarto rius
Rectus Piriformis (0) ~-""~~- Pirifor mis

femori s Rectu s
femori s
Pecti neus (0)
Piriform is (I) Pirif ormi s Pectineus
Obt urator
Glute us exte rnus (0) Glut eus Gracilis
minimus (I) minimus
Addu ctor
Vast us Gracilis (0 ) Vastus longu s
lateralis lateralis
Adduct or Adductor
Iliop soas long us (0) Iliopsoas brevis
Adducto r Adducto r Adducto r

minimus brevis (0) m agnus
Vastus
Quadratus Obt urato r
medialis
femori s externus
Vast us -------1~
int ermedius
Art icularis
Adducto r genus
hiatu s
Tendin ous
insert ion of
adducto r magnus
Adduct or Adduct or
t ubercle magnu s
Semi- Iliotibial Semi

m em branosus (I) t ract m embranosus
Gracilis (I) Biceps Gracilis
femo ris
Sarto rius
Quadriceps
femori s Semi
te ndinosus
A Removed: Gluteu s m ed ius and minimus. piriform is. obturator ex te rn us, B Removed: A ll mu scles.
ad d uc to r br evis and lo ng us. and graci lis.
368
Fig. 24.16 Muscles of the hip, thigh,
and gluteal region : Medial view
Midsagitta lsection.
LSvertebra l body
Iliac crest ~--
Sacral prom on tory

Iliacus - - - - - .,L,e-t."
Anter ior superior - - - - -H

iliac spine
Sacrum
Psoas m inor ----~~""SZ- ;,
Psoas major -------j~Hf*..
Obtu rato r - - ---iH!L--£I.

int ern us Pirif orm is
Pubic ------,E-ll-'-:-
sym physis
Glute us
maximu s
Sarto rius ---tIJ'i\ \\" l d ~ '\

Adducto r
Adductor ----Ht.~+i
mag nus
lon gu s
Rectu s ---:-I1, I1~\\ Semi

fem or is t endi nosus
Gracilis
Sem i
memb ranosus
Vast us ------'Ltt--f"--H
m edialis
Patella - ----'l-
Patellar ligam ent - - - -----':'-.
Pes anserinus ~~-"'-7.'
(co m mo n tendon
of insert ion)
Tibialis - - -+--; 1Il

ant erior
Tibia
369
Posterior Muscles of the Thigh, Hip & Gluteal Region (I)
Fig. 24.17 Muscles ofthe hip, thigh , and gluteal region : Posterior view (I)
Right lim b. Mu scle origin s (0 ) are show n in red, inserti ons (I) in blue.
L5 spino us
pro cess
Iliac crest Iliac crest
Ante rior Ant erior

superior superior
iliac spine iliac spine
Glute us --"-'1~H--- Glute us

medius mini mu s
Glute us - -----i"'----- -- -
maximu s Tensor
Tensor
fasciae lat ae fasciae latae
Gem ellu s
Glute us .------~H--+--- Piriform is

super ior
maxim us
lL"'. -=-'------Ci'-T- - Glute us
Gemellu s
medius
inferior
Obturator ----!'---'.\~
int ernu s -~"---+-- Quadratu s
Great er femoris
trochant er
Sarro - - ------0
:1'----,- - Gluteus
maximu s
tuberous
ligam ent
;f,'-- -i-- - Adductor
Ischial
magn us
t ubero sity
Addu ct or - -+-..
magnu s
Iliot ibial
Y
t ract
Semi " "i+.ir--:-t---- - Biceps fem ori s, Semi -4-+.1il---.--i - - Biceps

t endin osus long head te ndi nosus femor is,
lon g head
Gracilis Gracilis
Sem i Semi
m em branosus m em branosus
T~~:---tr---- Plant aris ~--rr--- Plantaris
Pesanserinus - -.;-"=\\
Gastr ocn emiu s. med ial Gastrocnem ius, medial

and latera l heads and lat eral heads
A Removed: Fascia lata (to iliotibial tract) . B Partially remo ved: Gluteu s m axim us an d m edius.
370
Tensor Tensor
fasciae fasciae
latae (0) lat ae (0)
Glute us ,------ Glute us Gluteus -~c----.-+ '---- - - Glut eus

maxim us (0) mi nimu s maximu s (O) minim us (0)
Gemellus
Geme llus , - - - - Rectu s
superior
superio r fem oris (0)
~'>!!.--- Piriformis
Geme llus Piriformi s
Gemellu s
inferior
inferior
Gluteus
Glute us Obturator
Obt urator
medius and
medius (I) int ernus
intern us
min imu s (I)
~""'::=+-.F-- Quadrat us
~=-+---;~- Quadrat us
femori s Sem imem- --+~-+-=
femoris
Sacro
branosus (0)
tu berous
.....,_ . ---- - Vastus
ligament
lateralis (0) Biceps femoris
(lo ng head) and '''''''' ,IfM-- - Glut eus
Adducto r ..... ~m'----- Gluteus
semite ndinosus (0) maximus (I)
magnu s maximu s (I)
Add ucto r --'i-;----s-;~!!---c~- Adducto r

mag nus magnu s
Vastus 'Eir-- - Vast us

inte rm edius int er
Semi mediu s (0)
mem branosus
~--- Biceps
Sem i femori s, ---i- - - - Vastus
t endin osus (cut) short head lat eralis (0)
-h~--- Biceps
femor is,
Gracilis Biceps short
femori s, Adductor ---:--f-+ head (0 )
lon g head hiatus
lr - - - - Plantaris (0)
1"~-7--- Plantaris
Gastro cnem ius, -----,;=--~'"
medial and
lateral heads (0)
Semi- - - -'Iii!. Biceps

m embranosus (I) femori s (I)
Popli teus (I) - - - -'
• ,{~-!--2-f--"---- Soleus (0)

Gastrocne mius, - --f-.<,....Th 7 - -fJ
med ial and ~-:-:--- Tibi alis
lateral heads posterior (0)
Flexor digit orum - - -!,...,.
long us (0)
C Removed: Sem ite nd inos us an d bi ce ps femo ri s (partia lly) ; g luteu s m axi D Removed: Ham strings (sem it end inos us. sem imem b ra nos us, and b icep s
mu s and m ed iu s (compl et ely) . femori s), gl uteus minim us, gastrocnem iu s, and muscles o f th e leg . 371
Posterior Muscles of the Thigh, Hip & Gluteal Region (II)
.Q Fig.24.18 Muscles of the hip, thigh, and gluteal region: Posterior view (II)
,5
-.I
Right limb. Muscle origins(0) are shown in red, insertions(I) in blue.
~
....o
Tensor
fasciae latae
Glut eus
mi nim us
GIut eus - --<:!=- "--.,.--# Rect us femoris

maximu s
Obt urator int ernus
Gemellus Gemellus and ext ernus.
superio r Obtu rator superior geme llus supe rior
externus and inf erior
Geme llus Gemellu s
inferior Gluteu s inferior Glute us
m edius and me dius and
Obt urator Obt urat or
min imus , mi nim us,
inte rnus (0) internu s
pirifo rm is (I) piriformis
=------,!;.__-#-- "-;J'-- Quadrat us

Semi ~~~.I;---.,r-J;-- Quadratu s
fem oris (0) femoris
mem branosus
Iliopsoas (I) ~-- Glut eus
Biceps fem or is maxim us
(long head) and
sem ite ndinosus Pect ineus
Adductor H- - - Vastu s

m agnus (0) later alis
Adductor
brevis
Adducto r
brevis Vastus - - - Vastus
medialis int ermedi us
Addu cto r
lon gus
} - - - Add ucto r l.' }--- - Add uctor
mag nus (I) magnus
Adductor --~
longu s
. r.~---- Biceps
femo ris,
short head
Vastus - - - - _+"
m ediali s (0)
Adductor I it- - - - Plant aris

Adductor
magnu s (I) magnus
Gastrocnem ius, - ----f;'!;"' - - ---"-'- ; .

m edial and
lateral heads
Sem i- ----liii!. Biceps

m em branosus fem oris
Popliteus - - - - - - - '
1lH7f---7tC't----"- Soleus
,~. -'!'I+.I - - Tibialis

posterior
Flexor - - ---f.;1I
digi tor um longu s
A Removed: Pi riformis, obturator internus, quadratus femoris. and B Removed: All muscles.
372 adductor magnus.
Fig.24.19 Muscles of the hip, thigh, and gluteal region: lateral view
Note: The iliotibial tract (the thickened band of fascia lata) functions as a tension band
to reduce the bending loads on the proximal femur.
L4 spi no us ----~i~n
pr ocess r-_ _ J
- -r-- - - Iliac crest

Posterior supe rio r ---e~
iliac spi ne
-:--- - - Anterior superio r

Glut eus ---1iii'-'--"-'\-------'--~
iliac spine
mediu s
fltl 'il·f.-Hi'!-- - - Tensor

fasciae lat ae
Gluteu s --~"---~
maximu s
r--- - Sartorius
Rectu s
femori s
Iliot ibial tr act ---~
Lo ng head
Biceps
femoris
Shor t head
Vastus
lat eralis
~-- Patella
1''1'.-·'1 -- - - Patellar
Head of fibul a -------,F--'!-" ligam ent
+-- - Tib ial

t uberosity
Fibu laris lo ng us ------,f,-- 'PfJYHi:
;+lIr--- - Tibiali s
Gastrocnem ius - - -#-- ante rio r
373
Muscle Facts (I)
Psoas and iliacus muscles
M uscles Origin Inserti on Innervation Action
, Psoas minor
: T12- L1 verteb rae and interve rteb ral

: Iliopecti neal arch I ! Assists in upward rotation of th e pelvis
................................... ...•..~ i s k(l ~ter.al..s~ rfaces )
.. ... . . .. ... . . . . . . . . . . .. • -.. .... .•.. ... .... .
· .
: Superficial: T12-L4 and associated • Direct branches fr om the • Hip jo int: flexion and ext ernal rotation
: interverte bral disks (lat eral surfaces) : lum bar plexus (psoas) (L2- L4) • Lumbar spine: unilateralcont ract ion
: ® lIiopsoas : CD Psoas major
:. Deep: L1- L5 verte brae (t ransverse (wi t h t he femu r fixed) bends t he tr unk
, Lesser t rochant er
: processes) later ally to t he same side; bilateral
...................... . .. . . . . . . . . . ••• . . - - .
cont ractio n raises th e t runk fro m t he
:o Iliacus , lliacfossa · Femoral n. (L2- L4) supine positi on
Fig.24.20 Muscles ofthe hip

Right side.
~;{-- ~
U --1O--- @
(j)
- - Iliot ibial
t ract
B Verti cally oriente d

A Iliop soas mu scle.
anterior view. \ gluteal m uscles.
posterior view.
C Hori zontally ori ent ed glute al
muscles. posterior view .
Gluteal muscles
Muscle Origin Insert ion Innervation Action

: Sacrum (dorsal surface. lateral part). : • Enti re mu scle: ext ends and externa lly
: ilium (gluteal surface. poste rio r part )• . • Upper fib ers: iliotibial tr act : Inferior glut eal rot ates th e hip in sagitta l and coro nal planes
@) Glut eus maximus
; t horacolum bar fascia. sacrot uberous . • Lower fib ers: gluteal tub erosit y : n. (L5-52) • Upper fib ers: abducti on
....... L I.i 9. a ~~ ~.t.. . ... ..... .... ........... . ............... . . . . . . .
• Lower fibers: addu ct ion
~ Ilium (gluteal surface below th e • Enti re mu scle: abdu ct s th e hip. stabilizes t he
: Greater trochanter of th e femur
0) Glut eus mediu s • iliac crest bet ween th e ante rior and : (lateral surface) pelvis in t he coronal plane
. .... ? ? ~te. r. i ? r g l ~ t~ ~ l l i n e. ) . • Anterio r part : fl exion and int ernal rot at io n
: Ilium (gluteal surface below th e ~ Greater trochanter of th e femur : Superior glut eal • Poste rior part: extension and exte rnal
, ® Glut eus minimu s rotation
• origin of gluteus mediu s) : (antero lat eral surface) ; n. (L4-5 1)
............................ . . .. . . . .
• Tenses th e fascia lata
(J) Tensor fasciae latae : Ante rior superio r iliac spine : Ilioti bial tra ct • Hip joi nt : abduct ion. flexio n. and inte rnal
rotation
.. ... ..... ... ............. .......... .... ... ...... . .
: Direct branches • External rot atio n. abdu cti on. and exte nsio n
: Apex of th e greater t rochanter of
~ ® Piriformi s : Pelvic surface of the sacrum : from th e sacral of th e hip joint
• th e femur
• plexus (51-52) • Stabilizes th e hip joint
. : Inner surface of th e obt urato r : Medial surface of th e greater
, ® Obturator internus : membran e and it s bony boundari es : t rochanter
... ... . ... .......: :
• Ext ernal rotati on . adducti on, and extension
.... ...~ Direct branches
· Jointl y with obturator internus : of th e hip joint (also act ive in abduct ion.
• Gemellu s superior: ischial spine • ~ fr om th e sacral • depending on the joint' s posit ion)
@ Gemelli · tendon (m edial surface. greater
• Gem ellus inf erior: ischial t uberosit y • • plexus (L5. 51)
, , tr ochanter)
. ® Quadratu s femori s ·' · L~~~ ;~ l b~~d~~ ~f ~h~ i ~~h i~ I ~~b~ ~~~ i~;·· Intertrochanteric crest of th e fem ur • : Exte rnal rot atio n and adduct ion of the hip joi nt
Fig.24.21 Psoas and iliacus muscles Fig. 24.22 Superficial muscles of the gluteal region
Right side, anterior view . Right side, post erior view .
Iliac crest
~"1-- Gluteus
Thoraco
.
medius
lum bar
fascia
n~X
Tensor
Gluteus fasciae
rnaxirnus lat ae
L5 vert ebra
Sacral promontory
- Iliot ibial
- - --jl-- Iliacus
t ract
Anterior
superio r
iliac spine
- - - Inguinal
ligament
Sacrospinous ligament
Greater
t rochanter
Tibia
~~#-- Inter
trochanteric
line
Lesser
t rochante r
Fig.24.23 Deep muscles of the gluteal region
Iliac crest Iliac crest
- .,\-- - Ilium , glutea l

Ant erio r superio r surface
iliac spine
Posterior glutea l line - Cf---et---'--- -fl --".fll----- - Glute us mi nim us
-,-4 :1----- Gluteus medius
Piriformis Piriform is
Gemellus superior Obturator internus Gemellus superior
Obturator int ernus ~ and infe rior and inferior
Quadratus femo ris Ischial spine -AkLO~i~?;;~~ Quadratus femoris
Greater troc hanter \ ; - Greatertrochanter
Sacrotuberous
ligam ent
~ Intertrochanteric
crest
Ischial
Glutea l tube rosity
tuberos ity
A Deep layer with gluteus maxim us removed . B Deep layer with glute us med ius removed.
Muscle Facts (II)
.Q ~ Funct ionally. t he medial th igh mu scles are considered Prom ont or y

,5
.... a.iiiiII th e adducto rs of t he hip.
~
....o
Fig.24.24 Medial group: Superficial layer
Righ t side. ante rior view .
cJ
"=,,-£'---"....-;""7 - - Superior
Greate r pubic ram us
t rochanter
Lesser ---+--~
t rochante r
Pect ineus
~~w--- CD
~-!--- 0 - - i!-- Adductor

brevis
Adductor - l-
longus
------:! - - Femur
It:-o-!!- - - + - -4 - Gracilis
~-,k~-- Patella
A Schematic.
Gracilis t endo n :.,

of insertion
Fibula
Tibi a - +
B Superficial adducto r gro up.
Medialthigh muscles: Superficial laye r

Muscle Orig in Insertion Innervation Action
: Femora l n., • Hip joint: adducti on, exte rnal rotation, and slight
: Femu r (pectinea l line and t he
j ill Pectineus j Pect en pubis : obtu rato r n. flexion
: proximal linea aspers)
: (L2, L3) • St abilizes t he pelvis in t he coronal and sagittal planes
. ..... .. ... .... .. .. . - ' ' .
, Superior pubic ram us and ' Obtu rator n. • Hip join t: adduct ion and flexion (up to 70 degrees);
, Q) Adductor longus , . id f h hvsi Femur (linea aspera, medial lip in • (L2-L4)
. .. j ante n?r Sl e o t e sy' ~ p ysis ., t he middle t hird of t he femu r) . . .

extension (past 80 degrees of flexion)
, Q) Adduct or brevis , Inferior pubic ramus • Stabilizes t he pelvis in t he corona l and sagittal planes
T T i b j ~ ( ~ ~d j ~ i b~ ;d ~ ; ~f th ~
...• Obtu rator n.
.• Inferior pubic ramus below ' (L2 L3) • Hip joi nt: add uct ion and flexion
; @ Gracilis : t uberosity, along w it h t he tendons : •
: th e sym physis • Knee joi nt: flexion and internal rot ation
: of sartorius and semite ndinosus)
... .... .... ..... -...... ........ ..•....
Fig.24.25 Medial group: Deep layer
Right side . ante rio r vi ew .
~=---"--~,"""f""=-~-- Superio r
Greater pubic ram us
t rochanter
Lesser ---+--~
tro chanter
;-- '1-- - - Adductor

minimus
~!----- Fem ur
\ ,
\ \ t-- +- - Adducto r
magn us
J\
+',, - ---1'--- - Adductor hiatu s
e+-----,1--~!----- Adduct or
magnus,
tendin ous
part
('-.
\
-,-c*+-- - Patella
\
A Sche ma tic.
- £ H _ - Tibial
t uberosit y
Fibula
B Deep ad d uc to r group.
Medial thigh muscles: Deep layer

Out er surface of th e obt urato r • Hip joint: adduction and ext ernal rotation
CD Obt urato r exte rnus Trochanteric fossa of th e femur Obtu rato r n. (L3. L4)
membran e and it s bony bou ndaries • St abilizes the pelvis in th e sagittal plane
Hip joint: adduction exten sion. and slig ht
@ Adduct or minimus Inferior pubic ramu s Medial lip ofthe linea aspera Obtu rato r n. (L2-L4)
flexion of the hip joint
• Deep part ("fl eshy insert ion" ): • Deep part: obt urato r • Hip joint: adduction. extention, and slig ht
med ial lip of the lin ea spine n. (L2-L4 ) flexion (the tendinous insert ion is also
Inferior pubic ramus. ischial ramus.
Q) Adductor m agnus • Superfi cial part ("tendinous active in internal rotation)
and ischial tub erosity • Superfi cial part:
insert io n"): adductor tub ercle • Sta bilizes the pelvis in th e coro nai and
tibial n. (L4) sagittal plane
of the femur
Muscle Facts (III)
~ The anterior and posterior m uscl es of the t high can be classified as

~ exte nsors an d f lexors . respect ively. with reg ard to th e knee joint.
Fig. 24.26 Anterior thigh muscles

Right side. anterior view.
Anterior superio r
iliac spine -
Ant erior inferior
iliac spine
Acet abular roof
Greater
Greater
troch anter
trochanter
Intert rochante ric -~~
line
Rectu s
Lesser
femori s
trochant er
'D- - - Sartorius Vastus
interm edius Quadriceps
~~=r---- Rectu s ~~~...- - Vast us femori s
femoris lateralis
~-- ® Vastus
m edialis
~-- ®
Vastu s Vast us
lat eralis media lis .f--~!I---- Rectu s
femo ris
Tendon of - - --.s,..-f
insert ion
of quadriceps - --r-llt-- Patella Sartorius
femoris Medial patellar
retin aculum
-c.J'---- - Tibial
A Sch ematic. tuberosit y
B Superficia l group. C Deep g roup. Removed: Sartoriu s and rectu s

femori s.
Ante rior th igh muscles

Muscle Origin Insert ion Innervation Action
• Hip joint: flexion. abduction. and

Med ial to t he tibia l tub erosity
Femora l n. externa l rota tion
CD Sartorius Anter ior superior iliac spine (together with gracilis and
(L2. L3) • Knee joint : flexion and internal
semitendinosus)
rotation
Anteri or inferior iliac spine. Tibial t uberosity (via patellar
o Rectus femo ris acetabu lar roof of hip joint ligament )
• Hip joint: flexion
• Knee joi nt: extension
Linea aspera (media l lip). Both sides of t uberosit y on the
Q) Vastus medialis
intert rochant eric line (distal part) media l and lateral condyles (via the
Linea aspera (latera l lip). greater media l and longit udinal patellar
Quadriceps @ Vast us lat eralis ret inacula) Femoral n. Knee joi nt: extension
t rochanter (lateral surface)
femo ris" (L2-L4)
Tibial tube rosity (via pate llar
® Vastus interm edius Femo ral shaft (anterior side)
Artic ularis genus

Anter ior side of femoral shaft at Suprapatellar recessof knee joint Knee joint: exte nsion ; prevents
(distal fibers of vastus
level of the suprapatellar recess capsule entrap ment of capsule
"The ent ire muscle insert s on the tibial t ubero sity via the patellar ligament.
Fig. 24.27 Posterior thigh muscles
Right sid e, posterior view.
Ante rior superior

iliac spine
~---r--- Poste rio r superior
iliac spine
'-...-~<------- Posterior inferior

iliac spine
Ischial spine
Sacro
tu berou s
ligam ent
Ischial
Gluteal tu berosit y Com m on
tub erosit y
head
Linea aspera
Semi Semi Biceps fem oris,

t endinosus -T't-- Biceps femor is, tend inosus sho rt head
long head
Biceps fem ori s,
long head
Semi
m embranosus
Pop lit eus -----";>,., __
Medial tibi al
A Sche matic. Semi memb ranosus ~ condy le
t endon (part) Head of fi bula
Popliteus ------''+.-~.J..\
Pop lit eus
Interosseous
Pes anserinu s - --h t:
membran e
B Superficial g ro u p. C Deep group. Removed: Biceps fem oris (long

h ead ) and sem it end inos us.
Posterior thigh muscles

• Hip joint (long head): ext ends

Long head: ischial tuberosity , th e hip, st abilizes t he pelvis in
sacrot uberous ligam ent (common Tibial n. (L5-S2) t he sagittal plane
<D Biceps femoris head w it h sem ite ndinosus) Head of fi bu la • Knee joi nt: flexio n and exte rnal
rotatio n
Short head: lateral lip of t he linea Com mon fibula r n. Knee jo int : flexion and externa l
aspera in t he midd le th ird of t he fem ur (L5- S2) rotation
Med ial t ibial condyle, obliq ue
o Semimembra nosus Ischial tu berosit y
po plitea l ligam ent , poplit eus fascia
• Hip joi nt : exte nds t he hip,
stabi lizes th e pelvis in t he
Ischial tu berosity and sacrot uberous Medial t o th e t ibial t uberosi t y in Tibial n. (L5- S2) sagitta l plane
o Semiten din osus ligament (common head w it h long the pes anserinus (alo ng with th e • Knee jo int : flexion and internal
head of biceps femo ris) t endon s of gracilis and sartori us) rot at ion
See p. 399 for po pliteus.

Tibia & Fibula
.Q ~ The tib ia and fib ula artic ulate at two joint s, allowing limi t ed mu scles in t he leg. It also acts wit h th e ti biofibu lar syndesmo sis t o sta bi
,§ ~ m ot ion (ro tatio n). The crural intero sseous m emb rane is a sheet lize th e ankle joi nt.
........ of tough connective t issue th at serves as an orig in for several
~
....o
Fig. 25.1 Tibia and fibula
Right leg.
Lateral condyle ~-- Tibial plateau Tibial plateau
Tibiof ibu lar Tibiofi bular

joint joi nt
---.~- Medial
condyle Head of fibu la
Neckoffibula - -----'........ r ll ;--§-- - Neckof fib ula
---j~~-- Tibial Head of tib ia

tu berosity
Solealline - -----",------ ,
Interosseous - -+--F,;- - ---!f -- Int erosseous

m em brane memb rane
Tibiofibular - --!---: Malleo lar groov e

syndesmosis (fo r tibialis
Medial posterior te ndon) Lateral
malleolus malleolar fossa
Lat eral -----!-~ --....'---- - - Ankle Medial Lateral
malleolus mo rt ise malleolus malleolus
A Ant erior view. B Posterior view.
380
~ Clinical
Fibular fracture
Int ercond ylar Posterior inter When d iagnosing a fib ular fract ure. it
em inence cond ylar area is im port ant to determ ine whether t he
syndesmosis (see p. 380) is disrupt ed. Fibular
fracturesmay occur distal t o. level w ith. or -
proxim al to t he syndesmosi s: t he latter t w o
frequently involve tearing of the syndesm osis.
Fibula
Tibia
Syndesmosis
Medial
malleolus Lat eral
malleolus
Talus
Calcaneus
Lateral Medial
condy le con dyle
Ant erio r
Tibia l int erco ndylar
t uberosity area
C Proximal view.
Posterior Poste rio r

surface In th is fr actu re. locat ed proximal t o th e
surface
syndesmo sis, t he syndesm osis is torn , as
Int erosseous indicat ed by the w idened me dial j oint space
membrane of t he upper ank le jo int (see p. 40 5).
Tib ia
Lat eral - - - {
surface
I Medi al
~ surface
Fibula Media l
surface
- - - Ant erior
border
D Transverse sect ion. superio r view .
Art icu lar surface Inferior Art icular surfa ce of

of lat eral malleo lus art icular surface medial ma lleo lus
t
Lat eral Medial
malleolus malleo lus
Lateral
malleo lar fossa Tibia
E Distal view.
381
Knee Joint: Overview
..Q
~ In th e knee jo int . th e femu r art iculate s with th e t ibia and pat ella. in th e knee jo int (cont rast to th e hum erus in th e elbow ; see p. 282).
.S
..... ~ Both joints are cont ained w ithin a com mon capsule and have Instead. it form s a separate rigid articu latio n with th e tibia.
communicating arti cular cavities. Note: The fibu la is not includ ed
~
c Fig. 25.2 Right knee joint
.....
- - - +---- - - Pop lit eal surface
Intercondylar not ch
Patella -----T--f-~-
Medial Lateral epicondy le
Lateral epicondyle - - + - epicondyle
Lateral femoral condyle
Lateral femoral condy le - ---\-'--;C- Medial femor al
condyle ~---oJI--- Int ercondylar
Lateral ti bial condy le -------,;~~~~iI eminence
Tib ial plateau _---=~~-----,--...:Y ~1""---1- Tibiofibu lar joint
Head of fibula
-1 - Neck of fibula

- -!---I7- - - Tibial
tuberos ity
Soleal line - - \ (
Fibula - Fibula
Tibia Tibia - --,-
A Ant erior view.

B Posterior view.
Lateral - -->,,--
femoral condyle
-'--~~~- Lateral
t ibial
condyle
Tib ial
t uberosity
- + - - Tibia
C Lateral view.
382
Fig. 25.4 Patella
Ba se
~-------:-- Articular
surface
A Anterior Apex B Posterior Apex

view. view.
Fig.25.3 Knee joint: Radiograph s
Patellar I. Prepatellar
(quadriceps tendon) bursa
Medial facet
Patella - - -+ -----l''-;--;,L,t-.e.c..,.
" 1-'' ':-- - - - Ra diographic
LateraI facet - ---+-----.H'l-H ---4-==,...,. view in D
....._"""'''---'''~'-cP.-'c-~--- Joint space
Patellar surface ----E-;---cC!!---f-,/;~hrh_~~.:.v Vt---"i--c,------"' : - - - Synovial

of femur membrane
Fibrous - --+-+----' Medial
membrane
collateral I.
Lateral collateral I. - - -;---<-i±-7-f
":'--2,---';':";-~-Tfft;;Y---l-- Cruciate II.
Lateral femoral _.....J~-¥-~-;; r-r-r-i-i-ir-r-r-ri-r--r-: Medial

condyle femoral
condyle
A Ant eropo steri or projection .
Popliteal a.and v. --,~~~~~~~
Gastrocnemius -----"&--'~~~r-T~;.-
C Transverse sect io n through femoropatellar

joint. Dista l view w it h right knee in slight
flexion.
D Radiograph ic view of pate lla and femora l

B Lat eral projection . t rochlea. Tangentia l radiographic view
with right knee in 60 degrees of fl exion
(" sunri se" view) . Not e th e width of th e
joint space due to th e thi ck articular
carti lage.
383
Knee Joint: Capsule, Ligaments & Bursae
.Q Fig. 25.5 ligaments of the knee joint

ligaments of the
.5
..... knee joint Anterior vi ew of right kne e.
~
o
Ext rinsic ligaments
..... : Patellar I.
. .
, Medial lon git udi nal patellar Femur
, retinac ulum
................................
: Lateral longit udinal patellar
: Anter ior side : reti naculum
, Medial tran sverse patellar
ret inaculum
Vastus
Lat eral transverse patellar
int erm ediu s.
retinacu lum tendon of
........ ..............................................................................................
: Medial and lateral ' Medial (t ibial) collater al I. inserti on
Vast us --~~~
: sides Late ral (fib ular) collateral I. lateralis Vast us
.... . .... ... ..... .... .... ...... ..
medialis
Oblique pop litea l I.
, Posterior side ...... ........................................
: Arcuate poplit eal I.
. Int rinsic ligaments
: Anterior cruciate I. Rectu s femori s.

: Post erior cruciate I. te ndon of
................................................. insertion
: Transverse I. of knee
.............................. ...................................
: Post erior meniscofem oral l.
Lateral tran sverse ......,----- Medial collat eral I.

pat ellar retinacu lum
Lateral longit udinal ~Y.-'-.t.M!-NH---- Medial

pate llar reti naculum t ransverse
patellar
ret inaculum
!1II1/:,-¥liiJ- - - - Medial
longit udinal
Head offibula - - - - If,--- patellar
retinaculum
~~-- Patellar I.
.-f.h,..L--!!IL--_ TibiaI
tuberosity
- .Jf- - Tibia
!- - - - .J- - Interosseous

m embran e
384
Fig. 25.6 Capsule, ligaments, and periarticular bursae ~ Clinical
Posterior view of right knee. The joint cavity communicates with peri
articular bursae at the subpop liteal recess, semimembranosus bursa,
Gast rocnemlo-semlmemb ranosus bursa (Baker's cyst)
and medialsubtendinous bursa of the gastrocne mius. Painful swelling behind t he knee may be caused by a cyst ic outpouching
of t he joi nt capsule (synovial pop liteal cyst ). This frequent ly result s fro m a
rise in int ra-art icular pressure (e.q., in rheumat oid arth ritis) .
Semi ----';--1l+'ti~,
membranosus
Poplit eal
fossa
Femu r - - - ; --
---.d----+:ii+s ::'a-r i - - Gastrocnemius,

medial head
Medial
subte ndinous Lateral
bur sa of subtendi nou s
gastrocn em ius bur sa of
gastrocn em ius A Baker's cyst in th e right pop liteal fossa. Baker's cyst s of ten occu r in
t he m edial part of t he pop lit eal fossa between t he sem ime m branosus
tendon and th e medial head of t he gastrocn em ius at t he level of t he
posterom edial femoral condyle .
Obliq ue
poplit eal I.
- - Lateral
collatera ll.
Medial
collatera l !. Arcuate
pop liteal I.
Sem i
membranosus
bursa Poplit eus
Subpo plitea l
recess
----t - Fibula B Axial mag net ic resonance imagin g (MRI) of a Baker' s cyst in t he popliteal
Tibia - - .;L-
fossa, inferior view.
385
Knee Joint: Ligaments & Menisci
Fig. 25.7 Collateral and patellar ligamen ts ofthe knee joint

Right knee joint. Each knee joint has medial and lateral collatera l liga direct cont act w ith eit her the capsule or the lateral m eniscus. Both col
m ent s. The media l collateral ligam ent is atta ched to both th e capsule lateral ligaments are taut w hen the knee is in exte nsio n and st abilize th e
and the medial meniscus. w hereas th e lat eral collat eral ligament has no joint in th e coronal plane.
Femu r - - - -
::--c...r - - - - - - - Quadriceps - --;:;- - - - - -----".....

femori s t endon
Femoropate llar
joint
Patella
---i~-- Medial epicondy le
- -=-----.i':--f'-H '::-'------: - Medial femoraI

condy le
Lateral
..,.,Jr- - Medial m eniscus Lateral collateral I. -----'-~..--l ~~....-~
Patellar I.
--;-=-+i+--flil=- - Medial Posterior I. of --~~/'i
collater al I. fibular head
~ V;-tI-'------;=----'---+-,"~-- Anterior I.
of fibular
head
Fibula ---:- -----" Tibial

tu bero sity
Tibia. - - ,....-
m edial
surf ace
A Media l view. B Lat eral view.
386
Fig.25.8 Menisci in the knee joint
Right t ibial plat eau, pr oxima l vi ew.
'b) Clinical
! Anterior cruciate I. ':;iiiiiiiili~~b-- Patellar I.
Injury of the menisci
The less mobile medial meniscus is more
Medial Transverse I. suscept ible to injury th an t he lateral
meniscus of knee meniscus. Trauma generally result s from
sudden extension or rot ation of th e flexed
knee while t he leg is fixed.
Tibio
fibular
joint
Medial Lateral
collateral I. collateral I.
Post erior Posterior menisco Lateral Head of A Bucket-handle tear.

cruciate I. femoral /. meniscus fibula
A Right t ibial p latea u w it h cr uciate, pat ell ar,

and co llateral lig am ent s di vid ed .
Medial meniscus Anterior cruciate /.
B Radial tear of posterior horn .
B Atta chm ent sit es of m eni sci and cr uc iate

lig am ent s. Red lin e ind icates t he tib ial Head of
at ta chm ent o f th e synovial m em br ane fibula
that covers th e cr ucia te ligam en t s. The
cr uc iate ligam ent s lie in th e su bsy no vial
co n nec t ive ti ssue. Posterior cruciate /. Lateral meniscus
Fig. 25.9 Movements of the menisci

Rig ht kn ee joint .
Pa tella
Ext ension
Patellar
ligament
Lateral
collateral
ligament
Flexion
A Ext ensio n . B Flexio n. C Tib ial plateau . proxima l v iew.
387
Cruciate Ligaments
..Q Fig. 25.10 Cruciate and collateral ligaments

E Right knee joint. The cruciate lig aments keep the articu lar surfaces of the femu r and t ibia in
:.:J
contact, w hile sta bilizing the knee joint primarily in the sagit t al plane. Portion s of the cruciate liga
ments are taut in every joi nt position .
.....
Int ercondylar
notc h
Patellar
surface Lateral fem oral
of fem ur condyle
Med ial
Ant erior Anter ior
femora l
cruciate I. cruci at e I.
cond yle
Transverse I. Posterior
Posterior
of knee m enisco
cruciate I.
fem oral I.
Lateral Medial Lateral
m eniscus meniscus meniscus
Lateral Lateral
Medial
collater al I. collat eral I.
collate ral I.
Ant erior I. of Posterior I. of

fibular head fibul ar head
(refl ect ed
inferiorl y)
Head of fi bul a
- -l-- - Pat ella
Fibula - - ---;;- o-o-f'f'---;I -- Inte rosseous

m emb rane
Tibia - - -+"...=--
A Anterio r view. B Posterior view .
388
~ Clinical
Rupt ure of cruciate ligam ents

Cruciate ligam ent rupt ure destabilizes
the knee joint, allowing t he tib ia to move
forward (anterior "drawer sign" )o r
backward (po sterior "dr awer sign" ) relative
Fig.25.11 Right knee joint in flexion to th e femur. Anterior crui::iate ligament
Anterior view with joint capsule and patella removed . rupt ures are approxim at ely 10 times mor e
commo n tha n post erior ligam ent ruptu res. '
The mo st comm on m echanism of injury is an
inte rnal rot ation tr auma w ith th e leg fixed. A
lateral blowto th e full y exte nded knee with
th e foot plant ed tends t o cause concomita nt
rupt ure of th e ant erior cruciate and media l
Patellar surface ----:J--~~---- collate ral ligam ent s, as well as t earing of th e
of fem ur atta ched medial meniscus.
Posterior
cruciate I.
Lateral fem oral Medial femor al

condyle condyle
Lateral Ante rior

collater al .. cruciate I.
Lateral Medial
m eniscus meniscus
Head offibula ----;0--'
Medial collatera l I. A Rupture of anterior cruciat e ligam ent.

Anter ior view.
~---C;!~'c+--- Tibial
Fibula - ---+ tub erosity
Tibia
Fig. 25.12 Cruciate and collateral ligaments in flexion and extension

B " Anterior drawe r sign." Medial view.
Right knee, ante rior view. Taut ligame nt fibers in red.
Right knee joir t in flexion.
A Extension . B Flexion . C Flexion and inte rnal rotation .
389
Knee Joint Cavity
Fig. 25.13 Joint cavity Fig.25.14 Opened joint capsule

Right knee. lateral view. The joint cavity was dem on strated by inject ing Right knee. ante rior view with patella reflect ed dow nward.
liquid plastic into th e knee j oint and later rem oving th e capsule.
~ Quad ricep s te ndo n
Supra pate llar

pou ch
..>«: Femur - -----;;- -
Suprapate llar - - t----:iilIIIiF.1l..::!o....

Patella po uch
Lateral
Lateral collate ral I. meni scus
rc-- - --;;;i!"""=- .2:----- Femur.
-!-- - Pat ellar l. pate llar
Subpop litea l surface
Lateral
recess Inf rapatellar fem oral
bursa co ndy le
Ante rior Medi al

cruciate I. femo ral
condyle
Fibula - - --'-- - - ----..;il-- - Tibia Lateral -
7:. ";~'-f,-- Medi aI
col late ral l.
meniscus
/ /'C- - - - - m 1f-- Alar fo lds

Lat eral
me niscu s
--~--#--- Infra
Fig. 25.15 Attachments of the joint capsule pate llar
Right knee j oint, ante rior view. fat pad
- - ----1f---EilK--- Pat ella.

art icular
surface
"-------='-- Joint capsule

(cut edge)
\,""---7-'7:lir-c~-;r;-;~-- Supra pate llar

pou ch
Fibula - - - ; - -~-- Ti bi a
390
Fig. 25.16 Suprapatellar pouch during flexion
Right knee jo int. medial view.
Suprapate llar Quadriceps

pouch femoris
.._---!.-- - Sites of
attac hment
of the joint Patella
capsule
Patellar -----r I ro-"--~_ _

liga
ment
A Neutral
(O-degree)
position. \ B 80 degrees
of flexion .
C 130 deg rees
of flexion.
Fig. 25.17 Right knee joint: Midsagittal section
Femur Fig.25.18 MRI of knee joint

Sagitta l T2-weighted MRI.
Supra
patellar
pouch
Quadriceps
tendon
Anterior
cruciate I.
Tibia
391
Muscles of the Leg: Anterior & Lateral Views
.Q Fig. 25.19 Muscles of the leg: Anterior view

E
:::i
Right leg. Mu scle origins (0) shown in red. insertion s (I) in blue.
~
o
-.I
Rectu s ---\--'"",",~-tt l '
femo ris
Femur
Gracili s
Vastus ---'+~'''''
~i
lateralis
.£-- - Sartorius
Iliot ibial -----'~ "
tr act
~--- Vastus
medialis
- ---'YL---''Hi-- - - Patella
Fibularis --~ " I
.....~-- Tibial
longus (0)
tub erosit y
Patellar ligament - ----;;'1-:i'-:-'--:'l1--"-
Pes anserinus
Tibial --~-:,-!--f-';+-- (comm on t endon
tub erosit y of insert ion of
sart orius. gracilis.
and sem ite ndinosus) _ _'---4 Tibialis
ant erior (0)
Gast rocnemi us.
medial head
Ext ensor --~
Fibularis digitorum longu s
longus Soleus
Tibia
-~---- Extensor
hallucis longus
Extensor - - --;--f--'\'
digitorum longus
t+~~--- Ext ensor

hallucis longu s
Fibul aris
brevis
\:>,...- - Medial
malleolu s
Ext ensor ---~m~ ,l\ ~C'-!!~- Ext ensor
digitorum brevis hallucis brevis
Fibularis tertiu s --~ I \. ~~-- Ext ensor

(variable) hallucis brevis Fibul aris - - ---HIli • •
Tibialis
tertius (I)
ant erior (I)
Int erossei
~f.L1'1H'!.HMl-~~~- Extensor
digitorum long us
, -tir -- Ext ensor H-~~':--*---F--M- Ext ensor
hallucis long us digitorum longus (I)
A All muscle s shown .

B Removed: Tibial is anterior and fibu laris longus; exten sor digitorum lon
gus t endons (distal portions). Note: The fibu laris t ertius is a division of
the ext ensor digitorum longus.
392
Fig. 25.20 Muscles of the leg: lateral view
Right leg.
Biceps -----!:'~~
femoris.
long head
.*'~--- Vast us
lat eralis
Biceps femo ris, - - - + ;:-'-;:rl;t"l
~--"-;-----:lf-- Pat ella short head
Biceps femori s. - - - - -b.-

common ten don
Pat ellar ligament
Fibu lari s - ---'!!!!\
lo ng us
Head of fibu la ---+-~_ e- Lateral

tib ial condyle
",=~--f---- Int ero sseou s
m embra ne
Gastroc
nemiu s,
lat eral head
.~c--+---- Tibialis Fibularis

ante rior longus
Tibi alis
Ext ensor anter ior
digi torum lon gus
Soleus - ----!;;-J-+
~~~--- Ext ensor
digit orum longu s
Triceps - -'----'l-"---fu:1I'
Ext ensor
surae
hall ucis lo ngus
Fibularis - --
brevis
Fibula ris - - - - --H-. I
t ert ius
Fibularis - ----!--'!u.! t'., Ext ensor

brevis
V hallucis longus
Exte nsor
digitorum brevis
Fibularis tertius
(variable)
Exte nsor halluci s
brevis and
ext ensor
dig it o rum br evi s
Fib ulari s - - -----,' .\ 1 1-- - Tibialis

br evis ante rio r
Fibularis Fibularis Ext ensor
longus brevis digito rum longus
Fibu lari s
Ext ensor
t ertius
hall ucis br evi s
Extenso r
d ig itorum brevis
Ext ensor
di g it o rum
Exte nsor
lo ngus
hallu cis lo ngu s
C Removed: All muscles.
393
Muscles of the leg: Posterior View
.Q Fig.25.21 Muscles of the leg: Poste rior view

,5
-.I
Right leg . M uscle o rig ins (0) shown in red, in sertion s ( I) in blue .
~
o
.....
Gracilis
Sem i- ------'~c+.lc_ Iliotibi al

t endin osus t ract Gast roc nem ius,
m edial head (0)
Gast ro cnemius,
lat eral head (0 )
Semi- - --''-IH 6fff.
memb rano sus Plantari s
Biceps Plant aris

fem o ris
Bicep s femo ris (I)
Gastroc- ---~'l------ 'H' l . Poplit eus

nerniu s, Gastroc Fib ularis
m edial head nernius, lon gu s
late ral head
Sol eus
Planta ris - -£!-la.

te ndo n
Fibul aris brevi s

Fibu lari s
brevis
Achillestendon
Soleu s
Flexor
Flexor
digitoru m longus dig itorum long us
Flexor Flexo r
hallucis lo ng us hallucis lo ngus
Fibular is Fibu laris lo ngu s

long us
Lateral
ma lleo lus
Calcane us Tibialis Calcane us

po ste rio r
Fibul ari s
Fib ularis
brevis
Flexor brevis
Flexor
digito rum long us
Fibularis d igit orum lo ng us
longu s
Fibularis
Flexo r lon gu s
hall ucis lo ngus Flexor
hallucis lo ng us
A Note: Th e b u lg e o f t h e calf is p rodu ced main ly by th e tri cep s su rae B Removed: Gas trocn e m ius (b oth head s) .
394 (so le us and th e t w o h ead s of th e ga st ro cn emiu s).
1'1- - - - Planta ris (0 ) ; - - - - Planta ris
Gastrocn em ius. - - --r.i!T Gast rocne m ius. - - -----;'!:!lI"
med ial head (0) med ial head
·v !..----- - Gastrocne m ius. ~. '!l.------- Gastrocnem ius.
lat eral head (0) lateral head
Poplit eus (0 and I) Poplit eus
Biceps femoris (I) Biceps fem oris
Fibu laris Fibularis
lon gus (0) longus
Soleus (0) -----tli~r~r+ 1 Soleus -----l!~~
7 - - - Tibialis .: ~~I--- Tibialis
poste rior po ster ior
Flexor ---~"- ' ;II Flexor - - --If

dig it or um long us digitor um long us
f - - - Flexor -f- - - Flexor

hallucis long us halluci s longu s
-+i+- - - Int erosseous

membrane
\\'. '11- - - - Fibu laris
brev is
Crural - - -- --i
chiasm
J-~iiIi.:4I'~~-- Triceps Planta ris ---I~"II~~r--- Triceps
surae (I) surae
Plant aris (I)
Tibialis Fibularis Tibialis Fibulari s

posterior brevis (I) posterior brevis
Tibialis Tibia lis Fibularis

ant erior (I) ant erior longu s
Flexor Flexor
hallucis lon gu s digit or um longus
Flexor
hall ucis longu s
Go!.---'l!'''---'' - ---'- Flexor
digitorum longu s
C Removed: Triceps surae, planta ris. poplit eus, and fibul aris D Removed: All m uscles.
longus muscles. 395
Muscle Facts (I)
~ Th e muscl es of t he lower leg contro l th e f lexion / extension and

~ su pinat io n/ pro nati o n of th e foot as we ll as provid e support for
the knee, thigh, hip, and glutea l muscl es.
- -+-- - Femur
Fig.25.22 Lateral compartment
Righ t leg and foot.
-:-;:--;:-'-j~- Lateral
tibi al
condyle
Lateral t ibial
1st metatarsal
surface
1-:-- + - - Interosseous
memb rane ...,:a.- - Medial
cuneiform
CD Cuboid
Fibularis
longus
tendon
Fibularis -----li~-S
t ertiu s
C Course o f t he fib u laris longu s t end on ,

,, \ .~~-~-- Fibularis
plantar vi ew.
longus
A Fibu lari s gro up , anter ior vi ew. ' ,-'lH~~;---- Fibularis

brevis
Lateral
malleolus
Fibularis Fibularis Tuberosit y

longus brevis of 5th
B Lateral co m pa rt ment, righ t latera l vi ew . tendon tendon met atarsal
Lateral compartment
: Fibula (head and proximal t wo third s of th e • Talocrural joi nt: plant arfl exion
. CD Fibularis : Medial cuneifor m (plantar side).
. lat eral surface. arising partl y from th e • Subta lar joint: eversion (pronation)
longus ; 1st metatar sal (base) : Superficial
intermuscular sept a) • Supports t he tran sverse arch of the foot
................................................................................................... .....: fibu lar n. . .
: 5th metat arsal (tub erosity at th e • (L5, S1)

: 0 Fibularis : Fibula (distal half of t he lateral surface). • Talocrural joi nt: plantar flexion
: base, with an occasional division to
brevis : int ermuscular septa • Subt alar jo int: eversion (pronatio n)
: the dorsal aponeurosis of t he 5th t oe)
... .....: .
Fem ur
Fig. 25.23 Anterior compartment
Right leg, anterior view.
Lateral
t ibial
condyle
Head of A
fi bula
Tibial
tuberosit y
Shaft of t ibia
.,-'-~rl--- Tibialis
ante rior
.I~~l--';;;~-f--- Exte nsor

A Schemat ic. B Anterior compartm ent.
digit or um
longus
__ Anterior compartment

, -\--+.~-- Extensor
Tibia (upper t w o hallucis
Medial cuneiform
t hirds of th e lateral longu s
(medial and • Talocrur al joint: dor siflexion
CD Tibialis surface), interosseous Deep fibular Fibularis --:i'-t-~,
plantar surf ace), • 5ubta lar j oint: inver sion
anterior mem brane, and n. (L4, L5) te rti us
first met at arsal (supinat ion) Medial
superficial crural fascia
(medial base) malleolus
(high est part )
• Talocrural j oint : dorsiflexion

• 5ubt alar join t: act ive in
Fibula (middle 1sttoe (atthe bot h eversion and inver sion Fibu laris Ext ensor
o Extensor th ird of th e m edial dorsal aponeu rosis Deep fib ular (pro natio n/supinati on), tertius digitorum
hallucis te ndon longu s
surface) int erosseou s and the base of its n. (L5) dep ending on the initial
longu s tendon
membrane dist al phalanx) positi on of the foot
• Extends the MTP and IP
j oints of the big to e Exte nsor
Fibula (head and 2nd to 5t h toes • Talocru ral joint: dor siflexion hallu cis
longu s
Q) Ext ensor ant erior border) , t ibia (at the dorsal • 5ubt alar joi nt : eversion
Deep fibular te ndo n
digitorum (lateral cond yle) , aponeuroses and (pron ati on)
n. (L5, 51)
longu s and interosseous basesof the di stal • Extends the MTP and IP
membrane phalange s) j oints of the 2nd to 5th t oes
1st t hroug h 5t h
Fibularis • Talocrural j oint: dorsifl exion distal phalanges
Distal fibula 5th met atar sal Deep fibular
tertius (see • 5ubtalar joint: eversion
(anterior bo rder) (base) n. (L5, 51)
Fig. 25.22A) (pronation)
IP MTP
Muscle Facts (II)
~ The m uscl es of th e po steri o r co mpartment are d ivid ed i nto t w o

~ grou ps: th e su perfic ial and d eep f lexors. Th ese g roup s are sepa
rat ed by th e tran sv erse in t erm uscul ar sept u m .
Fig. 25.24 Superficial flexors

Rig ht leg . po steri o r vi ew .
~--- Fe m u r
Gastrocnemius.
medial head
(cut)
- - Lateral femoral Plantaris
Medial femoral epicondyle
epicondyle Gastrocnemius.
Plantari s
lateral head (cut)
Medial t ibial - Head of fi bula

condyle
Tendinous
arch of
soleus
Plantaris
Gastrocn emi us. -~--,
t endon Soleus
lateral head
Gastrocnemius.
A Sch emati c. Fo ot Triceps Gast rocnemius. - ---ii;lc---- Triceps
medial head
surae medial head surae
in p lantar fl exio n .
Gast rocnemius.
lat eral head
Plant aris ---~

tendon
Medial !--!- - - Achilles' Talocrur al ---lJ'I - - Achilles'

malleolus t endon join t tendon
Talus _ _ ~~ .....
..::11-- - Lateral Talus
malleolus
Navicular Subt alar ....~--Yil----- Calcaneus
joint
1st met atarsaI
'~J--- Calcaneal
tu berosit y
B Superfic ia l f lexo rs. C Superf icial fl exo rs w it h gastrocn em iu s

removed (p orti on s of m ed ial and lat er al
heads) .
Superficial flexors of the posterior compartment

: CD Gast rocnemius : Femur (medial and lat eral epicondyles)

.. . - . • Talocr ural joi nt: plantar flexion
: Triceps surae : @ Soleus : Fibula (head and neck, posterior surface). • Knee joint : flexion (gastrocne mius)
, t ibia (solealli ne via a tendinous arch)
Fig. 25.25 Deep flexors
Right leg wit h foot in plant ar flexion , post erior view.
- +-- - Femur
) -0
Pop liteus
Medial tib ial -

Head condy le Head
of fibu la of fibu la
Soleal line - -- :!,-(
Tibiali s --ilIH --- Tibialis

posterior posterior
Crural
chiasm
Flexor - --fr ill'
Planta r digitorum
chiasm longus
Flexor Posterior
hallucis surface
longus offibu la
A Schemati c.
Tibialis - - --.f i. .~- Int erosseous

post erio r m emb rane Medial -
Fibula Calcaneal m alleol us
t uberosit y
Calcaneal - i..L.f'e,.., Lateral Calcaneus - - - t-
Late ral
tu berosit y malleolus malleolus
Tibialis - I
Tibialis -----,--~, ~... Tuberosit y
Tuberosit y
post erior posterior ~r.t--- of 5t h
Talus t endo n
of cuboid tendons met at arsal
Tibialis post erior -~~,'1lI[
tend on Tuberosit y
Flexor H.,.~1¥t-~-- 1st th ro ugh
of 5t h hallucis
Medial 5t h m et a
me tata rsal longus
cuneifo rm \+->t7W"---- Flexor tarsal s
tendon digit orum
longus
tendons
B Deep flexors. C Tibialis posterior.
D Insertion of th e tibiali s posterior.
Deep flexors of the posterior compartment

Navicular t uberosity ; cuneiform s . • Talocrural joint: plantarflexion
: Q) Tibiali s : Interosseous membrane, adjacent
(m edial, interm ediate, and lateral); • Tibial n. • Subta lar joint: inversion (supinati on )
posterior : bor ders of t ibia and fi bula
2nd to 4th metatarsals (bases) : (L4. L5) • Support s th e longitudinal and tran sverse arches
........................... .......................... . . . .
:o Flexor
: Tibia (mi ddl e third of posterior
• Talocrural join t: planta r flexion
digitorum 2nd to 5th distal phalanges (bases) , • Subta lar joint: inversion (supinati on )
: surface)
longus • MTPand IPjoints of the 2nd to 5t h toes: plantar flexion
Tibial n.
(L5- S2) : • Talocrura l joint: plantarflexion
Q) Flexor • Fibula (dist al t wo thirds of posterior
: • Subt alar joint: inversion (supinatio n)
hallucis : surface), adjacent interosseous 1st distal phalanx (base)
~ • MTPand IPjoints of th e 2nd to 5th toes: plantar flexio n
longu s ~ m embran e
............................ ......................................., .
.. . . . . . . . .. . ... . . . . .. .: ~ Su.p po rts th e medial long itudinal arch
: Lateral fem oral condyle, posterior : Posteri or tibi al surface (above th e ' Tibial n. : Knee joint: flexion and internal rotati on (stabilizes th e
: @) Popliteus : horn of th e lateral m eniscus • origin at th e soleus) (L4-S 1) . knee) . . .
: , ; ..
• IP = inter phalangeal: MTP ~ met at arsophalangea.'.: .
Bones of the Foot
.Q Fig. 26.1 Subdivisions of the Fig. 26.2 Bones of the righ t foot
,§ pedal skeleton
.... Right foot, dor sal view. Descript ive anatomy
~ divides th e skeleta l element s of th e foot into
, st distal phalanx - - - -
....o th e t arsus, metata rsus, and forefoot (ante
ta rsus). Funct ional and clin ical crit eria divide
the pedal skelet on into hindfoot, midfoot ,
5th distal phalanx

and forefoot.
- - 5th middle phalanx
Forefoot
(phalanges)
j } Foref oot
Head ----7---'''' 5th proximal phalanx
!
, st met a- Shaft _ _ ~,.----.
Metatarsus tarsal
(metatarsal bones)
~-- 5th metat arsal
Calcaneus
Talus
Neck Calcaneal tuberosity -----'~iIII.i:.I...:c~.

Body Head Intermediate
cuneiform A Dorsal (superio r) view.
Posterior process Navicular Medial
cuneiform
Calcaneus , st metatarsal
Cal
caneal -l.-+-"
tuber
osity
La teral
cuneiform
Lateral process of Medial process of Tuberosity of 5t h 5t h proximal 5t h middle 5th distal
calcaneal tub erosity calcanealt uberosity 5t h met atarsal metatarsal phalanx phalanx phalanx
B Lateral view.
400
..........------- 1st dista l phalanx
---J!- - 1st proxim al phalanx
5t h proximal phalanx - - - ~ ''j:;:3!~i----- Sesamoids
---.ll- - l st
met atarsal
Med ial
cuneifo rm
Intermediate
Tuberosity of cuneiform
5t h m etatarsal ~
- - - Lateral
Groove for ------'=.-~~ cuneiform
fi bularis
longus ten don ~ -'l"- - Navicular
Tuberosit y
of cubo id - -c"-- Head
Cubo id - - - - Neck
. ~--- Body
Talus
Calcaneus - -+---:-
.;- - - - Posterior
process
Suste ntaculum Talus
ta li
C Plantar (in ferior) vi ew. Neck
Head Body
1 st
Medial
~
et a ta rs a l
t ubercle Posterior
Proxim al phalanx Base process
Late ral ) of t alus
of big toe Shaft ~ t ubercle
~ Head
~, c. Base
Shaft
Head
Calcaneal
tub erosity
1st distal phalanx Med ial process of

calcaneal tu berosit y
D Medial v iew.
401
Joints of the Foot (I)
Fig. 26.3 Joints of the foot

Right foot with talocrural joint in plantar
flexion.
Talocrural (ankle)
joint
Subtalar ----+~..I"'....._~~~-- Talonavicular joi nt } Tranvlerse

tarsa
(ta localcaneal) joi nt Calcaneocuboid joint joint
Intercun eiform joints ----+-~~~::"'il

Cuneocuboid joi nt -------j~- Cuneonavicular joint
Tarsom et atarsal _ _J-,..""....

Plane
joints
of seW
r--iil"-- Interm etatarsa l joi nts
~
Metatarsophalangeal
joints
Proxima l
inte rphalangeal Fibula
joints , t,l7~f,l-T---- Tibia
Lateral
malleolus
i:J.,!,~~"!-;;',...;-",,=---- Talocru ral (ank le)
Interosseous joint
Distal
talocalca nean
int erpha langeal
. ' ~7'T--- Medial
ligament
joints
malleolus
Calcaneus
Talonavicular
A Anterior view. Transverse jo int
ta rsal jo int Calcaneo
cubo id joi nt jo int
Cubo id - - -+---+-p.,;. ;.:l:'!~..;;.---- Interm ediate
Intercuneiform ---r--;'!T.rt,,*~~ffi'¥.'4'+-J cuneifo rm
joint s
Tarsom etatarsal joints ------"lr'P~l-b"-_rl::~i-;'Y"'*:;.,,;-"'"""r:'<

(Lisfranc's joi nt lin e)
Abd uctor - - -+f1fJ 'l

& ,---- - Abductor
digiti min imi
hallucis
Int erossei --+!!~P.!!!!!
:;+~!------ 1st met at arsal
Proximal inter
phalangeal joi nts
Ir , ,\Y--=::--<:7'1F.- - 1st metatarso
phalangeal joint
D\':-H - - 1st proximal

phalanx
:"",,~,------ 1st distal

B Superior view of coronal section. phalanx
402
Fig.26.4 Proximal articula r surfaces Fig.26.5 Distal articular surfaces
Right foot. proximal view. Right foot . distal view.
Base of 1st
proxim al
Superior tro chlear
sur face of ta lus
~ A
to..J
O'l
I
~
phalanx :t:.
B
-
:::l
;:I;
l'tl
Q
1(0
Head of ta lus (w it h
articu lar surface
C cr
...,.
0
fo r navicular)
i
A Metata rsophalangeal joi nts.
D
- Calcaneus
t
~--r---,---,----,- 1st throu gh
Calcaneus (w ith art icular
5t h met at arsals surface fo r cubo id)
A Talonavicular and
calcaneocuboid joints.
Base of 1st - ----".;:-- -~-- Base of 5t h

met at arsal met at arsal
Tuberosit y of
5t h metatarsal
B Tarsometat arsal join ts.
B Cuneonavicular and Calcaneus (wi t h

calcaneocuboid joi nts. arti cular surface for cub oid)
Int ermediate la teral
cuneifor m cuneifo rm
Talus
Intermediate
cuneifo rm
Medial
cuneiform
----'l~-- Cubo id
Medial - ----''t-
cuneiform
......lII;::;:iill.-l-- Tuberosity of
5t h me tata rsal
C Cuneonavicular and calcaneocuboid j oint s.
Calcaneus
C Tarsometa tarsal j oints.
~
l st
Base met ata rsal
Shaft
Navicular - -'t---IL- - ---1~-- Cuboid Head
D Talonavicular and calcaneocuboid joint s.
1st t hro ug h 5t h Sesamo ids

met at arsals
D Metatarsopha langeal joints.
403
Joints of the Foot (II)
Fig. 26.6 Talocrural and subtalar joints

Right foot. The tal ocrura l (ankle) joint is form ed by th e di stal ends of
th e tibia and fibul a (ankle morti se) arti culating wit h the tro chlea of the
talus . The subt alar joint consists of an anterior and a posterior compart
ment (th e ta localcanean and taloc alcaneonavicular joints, respectively)
Tibia -~--
divided by th e int erosseous tal ocalcanean ligam ent (see p. 409) .
Fibula
o---'ll---- - Ankle mortise

M ed i al ---~
malleolu s Lateral malleolu s
Talocrural jo int
Talus
Navicular ~---'-T---- Subt aler (ta localcaneal) joint

i"'"-'~----cc-,-,..,-~k----- Suste ntac ulum t ali
1st
met atarsal Tuberosit y of 5t h metat arsal
Calcaneal tuberosity
A Posterior view with fo ot in neutral

(O-degr ee) position .
. A
. ;/
~JT sect ion
Plane of
Ankle m or ti se
Ext ensor
Tibialis halluci s
anterior
Ext ensor
digito rum
Lateral malleolar Tibiofi bular

art icular surface syndesm osis
Tibia
{ Medial
malleolus
' -¥ V;-;"';';";-","'<-- - Talocrur al joi nt
Talus, superior
trochlear surface 1 4,,*,;&,;~t.:---':--- Medial malleolar
art icular surface
Tibialis ---+-'-~
posterior
Flexor _ - -'i:-"-- "NI,] f

digi torum longus
Flexor
hallucis longus
Fibularis longu s
Posterior - --7"----'
tib ial aa, and vv.
Abduc to r ---n-~~ Calcaneus

hallucis
B Coron al section, proximal view. The Quadrat us ---T-'-~~C- I,'

Flexor
ta locrural joint is plant ar flexed. and th e
plant ae
digito rum brevis
subta lar j oint has been sect ioned through
it s posterior compartm ent.
404
Fig. 26.7 Talocrural and subtaler joint s: Sagittal section
Interosseous Tibia
Right foot , medial view.
ta localcanean ligament
Talocr ural joint
Talocalcaneonavicular joint
(anterior compartment
of subta lar j oint )
Navicular
f+7+-- Achi lles'
Cuneiforms tendon
2nd metatarsa l
Calcaneus
Short peda l Plantar Plantar calcaneo

m uscles aponeurosis navicular ligament
Fig. 26.8 Talocrural joint

Right foot.
Tibia --~--,il-- Tibia
Fibula Fibula
- +- Ank le
Media l mortise
Lat eral ma lleolus
malleo lus
Lateral
Talus
malleo lus
Navicular ----f,~-- Calcaneus
Superior t roch lear surfac e of ta lus Sustentac Superio r troch lear surface of
(anterior diam eter ) ulum ta li ta lus (posterior diameter)
A Anterior view. B Post erior view.
Inferior
Anter ior articular surface
diameter
Media l
ma lleo lar
surface
Media l
Superio r ma lleo lus
troch lear
surface
Posterio r ...J
diameter
Lateral ma lleo lar Media l malleolar
Lateral tubercle art icu lar surface articu lar surface
C Proximal (superior) view of ta lus. D Distal (infe rior) view of ankle mort ise.
405
Navicular Lateral ma lleolar Fig. 26.10 Talus and calcaneus
artic ular surface surface The t wo tar sal bon es have been separate d at
Anterior t alar art icular th e subta lar joint t o demon strat e th eir art icu
surface lar surfaces.
Supe rior t rochlear ~..l Cubo id art icular surface

surface
Medial malleolar - -
surface .~l!!!--- Sinus t arsi
Medial - '~.iiii~'-";.-- Sulcus calcanei
Posterio r
process
ofta lus
t ubercle
Groove fo r
flexor hallucis
lon gus tend on
~ /I - --!!! -- Posterior t alar
artic ular
surface
Lat eral Sustent ac-
tubercle ulum t ali
Middle t alar art icular Calcaneal body

surface
Superior troc hlear
A Dor sal (superior ) view.
surface
Lateral malleolar
su rface ~
Posterior calcaneal Navicular artic ular
art icular surface surface
Posterior t alar
artic ular surface Midd le ta lar
artic ular surface
~ Cubo id art icular

surface
Ante rior calcaneal Navicular art icular

artic ular surface surface
Sinus t arsi
B Lateral view.
Cubo id art icular Middl e calcaneal
surf ace art icular surface
Sulcus ta li
Groove for Posterior calcanei
flexor hallucis
articu lar surface
longu s tendo n
Medial t ubercle
Medial
Calcaneal process Groove for

flexor hallucis
t uberosity I Lateral Superior troch lear
{ Lateral ~ 1 I long us tend on
t ube rcle surface
proce ss
Med ial malleo lar

surface
C Plant ar view.
Navicular artic ular
surface
Anterior ta lar - -
art icular surf ace ~---=~~- Sustentac
~
ulum t ali
Cuboid articular
surface --.",-'!~-- Calcaneus
Midd le ta lar art icular

surface
D Medial view.
407
~--+--- Inte rosseous
membrane
+- - Fibula
Medial - ----7- ""~:--i~-- Poster ior tibi o

malleolu s fibu lar I.
Deltoid I. Lateral
malleolus
Talus ---?+c:~:... Poster ior t alo

fibular I.
lWJi!-- - - Calcaneofibular
I.
Calcaneus
C Poste rior view in plantigra de foot position.
~r--- Tibia
Fibula - - -
Posterior t ibiofibu lar I.

Tibi ofibul ar syndesm osis
Ant erior ti biofibular I. } (syndesm ot ic 11. )
Lateral
m alleol us
Dorsal tar sal II.
Anterior ta lo
fibular ligament
Calcaneo- ----;-! : - - - - - -;

fib ular I.
Calcaneus ----:-'- - -
Long plantar I.
Bifurcate I.
Interosseous Dorsal calcaneocuboid II. 5t h metata rsal

D Lat er al vi ew. ta localcanean I.
409
Plantar Vault & Arches of the Foot
Fig.26.12 Plantar vault

Right fo ot . Th e for ces of t h e f o ot are di st ributed amon g t w o lat eral (fibu alongitudinal and atransversearch inthe sole ofthe foot, helping the
I ",~) "'m.\ \\\~ ~~ m~Gi",1 \\i'Di",l) ~"''j <;. \\\~ "'~~dl\~~m~l\t <)~ t\\~<;~ ~ d'j <; CS~dt~<; {GGt ab">G~ b \/extic.all aads.
Medial - --',,---'S---..'-1f+l
rays Lateral rays
Cuneiforms --f';'~~h--;; l
Cuboid
Talus ---,- B Pes rect us: C Pes p lanus: Loss O Pes cav us: E Pes t ransve rse
Norma l p lant ar of lo ngitud in al Increa sed heig ht p lanu s: Loss of
arches. arch (flat fo ot) . o f lo ngit udi nal tran sver se arch
arch. (splay foot).
A Plantar vau lt , su perio r vi ew . Lat eral rays in

g reen, m ed ial ray s in red .
Fig. 26.13 Stabilizers of the transverse arch

Right fo o t. The tran sver se pe da l arc h is sup po rted by b oth active and Note: Th e arch of t he forefo ot has only passive sta bi lizers, w he reas th e
p assive st ab ilizing st ruc t u res (m uscles and ligam ents, respect ive ly) . arches of t he m eta t ar sus and t arsus have o n ly active stabi lizer s.
Plantar
ligament
B A nt er ior arch
(fo refoot) , Base of 1st Deep transverse
Deep --Pw"---::3--'h~ 1st proximal phalanx
p roxim al v iew . proximal phalanx met atarsal ligament
tr ansverse
met at arsal 1st met at arsophalangeal
ligament joint Adductor
hallucis,
~"4'H;--+- Adducto r hallucis, transverse
t ransverse head head
Plant ar ----;-;Jf-f-- -<f-- Adducto r hallucis,

oblique head Base of
ligament s
5t h
1st metata rsal meta
t arsal
C Me t at arsal arch, Base of 1st
proxi ma l vi ew . met at arsal
-..!-- - Medial cuneiform
Cuboid - - I!!7"'- Intermediate Lateral
cuneiform cuneiform
Tibialis posterior
Fibularis
-
longus
Medial malleolus
Sustentaculum
tali
Calcaneus -~~- Talus
o Tarsal reg io n, Medial Tibialis Fibularis Tuberosity of 5t h

A Planta r view . pr oxi ma l v iew. cuneiform posterior longus metata rsal
410
Fig. 26.14 Stabilizer s of the longitudinal arch
Right foot , medial view.
Flexor hallucis
longu s
Flexor digitorum
Navicular Talus lon gus
_ _-.!~-!+ Medial
Medial
cuneifo rm m alleo lus
Medial
t ubercle
Plantar Lon g plantar Plantar calcaneo navicular Sustent ac

aponeurosis ligament ligam ent ulum t ali
A Passive st abilizers of th e longitudinal arch.
Dor sal interossei
Quadratus
planta e
Plantar aponeurosis
B Active sta bilizers of t he longit udinal arch. Sagittal sect ion at th e

level of th e second ray. The majo r act ive st abilizers of th e foot are
th e abdu ct or hallucis , f lexor hallucis brevi s, flexor digi torum brevis,
quadrat us planta e. and abductor digiti minimi.
411
Muscles of the Sole of the Foot
.Q Fig. 26.15 Plantar aponeurosis

.5
.... Right foo t, plantar vi ew. The p lantar apon euro sis is a tough ap oneurotic
'- shee t , t hickest at th e center, that b lends w it h th e d orsal fascia (n ot
~ sho w n) at th e bord er s of t he fo ot.
....c
-'3--h--,:f..:>.....:r~'7.f:>.-- Annular II.
'~I+----'>..-'!=----.:-4.-- Cruciform II.
- --4Jtti'<"--i.t1--H-..f1'--:-"--"*",H-- Superf ciaI

tr ansverse
metacarpal I.
Transverse
Fig.26.16 Intrinsic muscles
fascicles Right fo ot, p lantar view.
Flexordigiti - --l;-r,.
min imi brevis ,7 77- - Flexor
hallucis brevis
3rd plantar ---l-h~' 'lI ' k
int erosseus
. :~--- Medial
plant ar septum
-~ii~~~~M~:10~~':I~1
Abduct or
hallucis Flexor
digitorum
Plantar ------'\'--'c-----'~\"(.
brevis ,,!--fh tl/l-- Flexor
aponeurosis
tendons hallucis
longus
tendon
Fibularis - - - - f l Tibialis posterior '-'\-\,,;;-~~"il~i P-iklk7lH--- LumbricaIs

longus 3rd plantar
Flexor interosseus - i,-IT--'tia.

digitorum longus -'J-H~&--- Flexor
4th do rsal
- - - - Flexor interosseus --If-+4-'!'l~' hallucis brevis
hallucis longus
Flexor digit i - ----+-+<l, ff-IHilf-'iiI -- - Flexor
minimi brevis dig itorum
- - -- Calcaneal tub erosity brevis
Abductor
digit i minimi
Abductor
hallucis
Fibularis _ _ -+1
longus Tibialis posterior
'!I---_ _ Flexor
Plantar - ----liI'I-"''---!....}'--'
digitorum longus
aponeurosis
.~;,----- Flexor
hallucis longus
A Sup erficia l (first) layer. Removed: Plantar apon eurosis, including th e

su perf icial transverse m et acarpa l ligament.
412
FIexor ---, +-if",---;lfiIjtT:jffi;ift;IJ
digitorum brevis ......h drH-- - Flexor hallucis
tendons longus t endon
Flexor --*\.'..I.~~--\\\-WHi-V-
digito rum longus ,1d~4-",r:,:n 4.f-fl!ilIf--- Adducto r halluc's,
tendons tran sverse head
~t-\-W;;rl!H\~~f!~"; Iw.iIll--- Lumbricals
3rd planta r
int erosseus - - -l-l--,--<ll-'I"
~~-- Flexor
4t h dorsal - - I-+----l--a;.. ... hallucis brevis
interosseus
Flexor digiti - - H k
-~-IJ- "';'T- - - Flexor
min imi brevis di gitorum longus
Abductor
'.H,-7.----t+~-"-1t_-- Fibularis longus
digiti minim i
tendon
Abduct or
hallucis
Quadrat us ---,----~~
plantae
Fibularis longus - -----1'\ Tibialis posterio r
Flexor digitorum
Flexor
longus
digit orum -+._- - Flexor hallucis
" ••.1- Flexor hallucis
brevis longus
longus
Flexor ~,....--4+H'-<--!A+iHA--lAH+ Lumbricals
digitorum
brevis
tendons
B Second layer. Removed: Flexor digitorum brevis,

Transverse head } Adduct or
'HiIJ-- - Oblique head hallucis
Plant ar and --fli~-f,-il!-ifqil~~ . I 'M Ilk :-'ci\rilt -- =- Flexor hallucis brevis,

dorsal interossei
medial and lateral heads
Oppo nens
digit i minim i Abducto r
Flexor digiti -----!L-c\~ hallucis
min im i brevis
Tuberosit y of -----,, _. •",,' \ \ l ~.4-+--+--J~fL---?¥:.....c;'r1l-HJ..i!k--- Fibularis longus

5t h met atarsal t endon
'Y.L-f""-'/-7- - - Tibialis posterior
Fibularis brevis
t endon
Long plantar I, -----FlfH+,-;c'c' 1
Quadrat us plantae -----7+-'!II----'r-4,~*
Fibu laris longu s ---~~~s.~~~

i
Abductor digiti - ------J!+---A !-H-- - - Abductor hallucis
minimi
Flexor
11-- - - digit orum longus
Flexor
hallucis longus
C Third layer. Removed: Abdu ct or digiti minimi, abducto r
hallucis, quadrat us plantae, lum bricals, and t endon s of
in sertio n o f th e fl exors dig itorum and hallu cis lo ng us.
413
Muscles & Tendon Sheaths of the Foot
Fig. 26.17 Deep intrinsic muscles

Right foot , plantar view.
Planta r ligam ent s
1st through 4th lumbrica ls
Transverse head } Adductor
Flexor digit i minim i

Oblique head hallucis
brevis
. . . .r'--""lIIf>--- - Flexor hallucis brevis
1st dorsal int erosseus

3rd plantar int erosseus ---li~F T
" " '---c'--.lli'-- -
4th dorsal interosseus

"-1--,-- # - - 2nd dor sal int erosseus
~-- Abducto r hallucis
"w'6iow...r--r..= rr-- - Adductor hallucis, oblique head
1st plantar int erosseus
Oppo nens dig iti m inimi -I-l~q4"--- Flexor halluci s brevis
Flexor digiti m inimi brevis --ft~ \ "'-- - Tibialis ant erior tendo n
\. \t+--'+'-'--7',,;---;.rr\tl~t---- Fib ularis longus tendon

" r'-~-+--- Plantar calcaneonavicular I.
Long plant ar I. --1mtft-o'Lffi-,

Fibularis brevis -----l-I '" Tibialis posterior t endon
Quadrat us plantae - --+cfl--f----ir'-1'i-i-' Flexor
Fibularis longu s --j;~~~:liil hallucis longus
Abductor digiti minim i - --t+-.l'
-"'-c-.._ _
'~:M--- Abduct or
Flexor digito rum

hallucis Flexor digito rum
brevis Flexor ---"'~7~:N brevis
dig itor um
Planta r aponeuro sis 1st t hrough 4t h
long us
dor sal int erossei
{,Jffi~.- Flexor hallucis brevis

Flexor digit i
A Fourt h layer. Removed: Adductor hallucis, minim i brevis Abd ucto r hallucis
flexor digiti minimi brevis, and flexor hal Abduc to r digit i mini mi Adducto r hallucis
lucis brevis.
1st thro ugh 3rd Add ucto r hallucis.
planta r interossei --r-~~4~W'-:~I--l--A--- t ransverse head
Opponens digit i mi nim i
3rd plant ar interosseus
-------'l I -f--- -f-- - 1st dorsal int erosseus
2nd dorsal interosseus
4t h do rsal int erosseus - - -+--t,1H i .l .
"'*;----.- - - 1st plantar interosseus
2nd plant ar int erosseus Tibialis anterior
3rd dorsal inte rosseus - - -+--', ,-.1
Add ucto r hallucis. oblique head - --f---a-. .'-'\lIi
:l';-- - - Fibularis longus
Flexor digiti mi nim i brevis
[ -- r- Tibialis posterior
Abductor digiti
minimi and
fibul aris brevis
Flexor hallu cis

brevis
Abd uctor digit i m inimi - - -H I

flf!Jt -- - Quadrat us
plantae
Flexor digitorum _ ---1rllr:t r '----- - - Abductor
brevis hallucis
B Muscle origin s (red) and insertions

(b lu e) o n t h e fo ot.
414
Fig. 26.18 Tendon sheaths and retinacula of the ankle
Right foot. The superior and inf erior exte nsor retinacu la ret ain the long
"~I---- Triceps surae exten sor tendon s. the fibul aris retinacula ho ld the fibular muscle ten
Fibularis - --+.
don s in place. and the flexor retina culum ret ains the long fl exor t endon s.
longus
- Tibiali s
ant erior
--n- - - Tibi a
Ext ensor - - ---f-jP 'T:
digitorum longu s -t-~4lt--- Exte nsor
hallucis longus
Fibulari s -
brevis
Superior - - - --H";,-- -
extensor
Medial
retinaculum
mall eolus
Lateral - ---t ---"--7,,"~-- Inferior ext ensor

mall eolu s ret inaculum
Fibularis
brevis .--1.r"'\-¥-~+-- Tendo n sheat h
Tibialis -
Fibularis terti us - - --:cc-JI ~e:r,~:-+--- Ext ensor hallucis brevis ant erior ',~I;-i-7---- Triceps
(variable)
nTfliHilll\-lk--i\lH'~--- Extensor surae
Tuberosity of Tibia - -tt--
digitorum brevis
5th met atar sal -+-,ITH--i- - - Flexor
Extensor digitorum digitorum longu s
Superior ______
Abduct or longus tendons
digit i min imi extensor ----- Tibialis posterior
!J+.-f-IbI---RcMa,.U --;I.+-,, - - Int erossei retinaculum
-1"'-'. - Exte nsor Medial malleolus
hallucis longus
~!..-l--- Flexor
tendon
hallucis longu s
c. '-'!t+-- - Tendon sheat h
Achilles' tendon
----'~--'-+-- Flexor
retinaculu m
A Anterior view with t alocrura l Flexor

joint in planta r flexion. halluci s longus
Tuberosit y of Tibiali s
5th met atar sal posterior
Flexor hallucis Tibialis Flexor Calcaneal
longus anterior digitorum longus tuberosit y
Tibialis anterior B Medial view .
Exte nsor hallucis longu s
Exte nsor digitorum longus
Superior 11• ..,4 -+-,'-1--- Fibula

exte nsor ret inaculum
Fibularis
Inferior te rt ius
extensor reti naculum
Ext ensor
Lateral malleo lus digito rum brevis
Exten sor digitorum
longus tendons
Superio r ----t------::;;~-
Extensor
fibu lar retina culum
hallucis longus tendon
/ Exte nsor
Fibularis longus digitorum
Inferior brevis t endon s
fi bular retin aculum
Abducto r
dig iti minimi
C Lateral view.
Dor sal aponeurosis
415
Muscle Facts (I)
~ The dorsal surface (dorsum) of th e foot contains only two brevi s. The sale of t he foot , how ever, is com posed of fou r comp lex layers
~ muscl es, t he exte nsor digitorum brevis and the exten sor halluci s that mai nt ain t he arches of t he foot.
Fig.26.19 Intrinsic muscles of the dorsum

Right foo t, do rsal view .
.--?r- - Extensordigitorum
brevistendons
5t h distal phalanx
1st ----.-
proximal
phalanx 5th middle phalanx
5th proximal phalanx
Extensor hallucis 5t h metatarsal

brevistendon
Extensor hallucis brevis

Medial cuneiform - - ii--
A Schematic. Intermediate cuneiform - -\ -- ---Ir - Extensordigitorum brevis
Navicular - -F--.,.-,
Tuberosity of 5t h metatarsal
Talus Superior trochlear surface
!f----- - - Calcaneus
B Dor sal m uscles of the foot.
Intrinsic muscles of the dorsum

. 2nd to 4t h toes(at dorsa l aponeuroses and bases of t he : Extension of the MTP and PIPjointsof
CD Extensor digitorum brevis .' caIcaneus : middle phalanges) . Deep fibular n. : the 2nd to 4th toes
... .. : (dorsalsurface) ............. (L5,Sl) ' :
o Extensor hallucisbrevis 1st toe (at dorsal aponeurosisand proximal phalanx) : Extension of t he MTPjointsof t he 1st toe ;
. ~!.~. ~. r11~.t~ tar.s?p. ,hala n ge a l ; PIP= proximal interphalangeal.

Fig. 26.20 Superficial intrinsic muscles of the sole
Right foot, plantar v iew.
~~~I---- Cruciform
ligament s
Sesa moids
:"=~~:-:tl---- Flexor
digitorum brevis
A Fir st lay er (sch ematic).

J
Tuberosit y of - -.
5th m etat arsal l
Tuberosit y of ----"-----'2.;~\Ov!
cuboid - - Abductor
hallucis
Abdu ctor ----'oT~
digi ti minimi
1- - Plantar
aponeurosis
B Intrinsic mu scles of the sa le, fir st lay er.
Superficial intrinsic muscles of the sole

Calcaneal tube rosit y 1st t oe (base of proximal phalanx via • 1st MTPjoint: flexion and abduction of the 1st toe
Q) Abdu ctor hallucis
(m edial process) the medial sesamo id) Medial plantar • Supports the longitudinal arch
2nd to 5th to es (sides of middl e n. (S1, S2) • Flexes the MTPand PIP joints ofthe 2nd to 5th toe s
o Flexor digitorum brevis Calcaneal tuberos it y phalanges) • Supports the longitudinal arch
(medial tubercle), • Flexesthe MTPjoint of the 5th toe
plantar aponeurosis 5th toe (base of proximal phalanx), Lateral plantar
G) Abdu ct or digiti minimi • Abdu cts the 5th t oe
5th metatarsal (at tuberosity) n. (S1-S3)
• Supports the longitudinal arch
MTP = metatarsophalangeal; PIP= proximal int erphalang eal.

Muscle Facts (II)
..Q Fig.26.21 Deep intrinsic muscles of the sole

.§
..... Right foot. plant ar view.
'
~
o
.....
.ll'-\lli'-ili~~i--- ®
(j) ------;~'J1\\\ft
G)- -"--"
Flexor digitorum
longus tendon
A Second layer. B Third layer. C Fourth layer.
Deep intrinsicmuscles of the sole

M uscle Origin Insert ion Innervat ion Action
CD Quadratus Calcaneal tuberosity (medialand Flexor digitorum longus tendon Redirects and augments the pullof flexor
Lateral plantar n. (51- 53)
plantae plantar borders on plantar side) (lateral border) digitorum longus
1st lumbrical: medial plantar • Fl exes the MTP joints of 2nd to 5th toes
o Lumbricals Flexor digitorum longus tendons 2nd to 5th toes (at dorsal n. (52, 53) • Extension of IP joints of 2nd to 5th toes
(four muscles) (medial borders) aponeuroses) 2nd and 4th lumbrical: lateral • Adducts 2nd to 5th toes toward the
plantar n. (52, 53) bigtoe
Medialhead: medial plantar
1st toe (at base of proximal n. (51, 52)
Q) Flexor hallucis Cuboid, lateral cuneiforms, and • Flexes the first MTP joint
phalanx via medial and lateral
brevis plantar calcaneocuboid ligament Lateral head: lateral plantar n, • Supports the longitudinalarch
sesamoids)
(51,5 2)
Oblique head: 2nd to 4th • Fl exes the first MTPjoint

metatarsals (at bases) • Adducts bigtoe
1st proximalphalanx (at base.
Lateral plantar n., deep branch • Transverse head: supports transverse
@) Adductor hallucis bya common tendon viathe
Transverse head: MTPs of 3rd (52,53) arch
lateral sesamoid)
to 5th toes, deep transverse • Oblique head: supports longitudinal
metatarsal ligament arch
® Fl exor digiti 5th metatarsal (base), long 5th toe (base of proximal
Flexes the MTPjoint of the little toe
minimi brevis plantar ligament phalanx) Lateral plantar n., superficial
® Opponens digiti Long plantar ligament; fibularis branch (52, 53) Pulls 5th metat arsal in plantar and medial
5th metatar sal
mlnlrnl " longus (at planta r tendon sheath) direction
• Flexes the MTP joints of 3rd to 5th toes
(j) Plantar interossei 3rd to 5th metatarsals (medial 3rd to 5th toes (medialbase of
• Extension of IPjoints of 3rd to 5th toes
(three muscles) border) proximal phalanx)
• Adducts 3rd to 5th toes toward 2nd toe
1st interosseus: 2nd proximal

phalanx (medial base)
Lateral plantar n. (52,53)
• Fl exes the MTP joints of 2nd to 4th toes
® Dorsal interossei 1st to 5th metatar sals (bytwo 2nd to 4th interossei: • Extension of IP joints of 2nd to 4th toes
(four muscles) heads on opposing sides) 2nd to 4th proximal phalanges • Abducts 3rd and 4th toes from 2nd toe
(lateral base),
2nd to 4th toes (at dorsal
aponeuroses)
IP - MTP "May be absent.
Fig. 26.22 Deep intrinsic muscles of the sole
Right foot , plant ar view.
Flexor
digitorum
longu s
tendon s
1st dor sal

int erosseus
1stthroug h
4th
lumbri cals
3rd planta r
--~"
interosseus
Medial
cuneiform Lateral sesamo id
Met atarso "---~,,,"=~+--!--c~~~~--"-;'!S--f!
)( phalangeal Medial sesamo id
Tuberosit y joint
of 5t h capsules
met atarsal Quadratu s TranSVerse}
plant ae head Addu cto r
Long Opponens Obli que halluci s
plantar Flexor digiti

head
ligament minimi
digi t orum
longu s Flexor -~L;, I. Medial }
Fibul aris - head Flexor
longus digiti
Lateral hallucis
t endon minimi
head
Flexor brevis
digitorum
brevis
Suste ntac ulum

ta li
Calcaneus - ----'.----
Fibularis
- ~..,.. ~~-,-!..!-~~ Tibialis
longu s
posterior
t endon
t endon
A Intrinsic mu scles of th e sale, second and

fourth layers. Long plant ar
- --=c-I'+.c-,--; Plant ar
ligament
calcaneonavicular
ligament
Lateral process
- --\--
B Intrinsic mu scles of the sale, third layer.
419
Arteries of the Lower Limb
Fig.27.1 Arteries of the lower limb

Righ t lim b , anterior (A) and p o st eri or (B) v iews.
Abd ominal
~ ~- Abdomi nal
aorta
Comm on -----.-i'~ aor ta
iliac a. Comm on
Int ernal iliac a.
iliac a.
Ext ernal
------'.,...-~ Deep circum Internal iliac a.
iliac a.
flex iliac a. Superior and inferior
- ---¥- - Inguinal glut eal aa.
Superficial
ligam ent
epigast ric a. Ext ernal iliac a.
Superf icial circum - - - --I-"........r. ~~;L_ Inferior
Profunda
femo ris a.
- i U>-- flex iliac a. epigastric a.
Piriform is ~~h--9-- Ext ernal
pud endal aa.
Addu cto r
- - -L.... iJ Lateral circum -~c-~;x~I p..~~
flex femoral a.
canal
Profunda
- - + --PI-..!!I Medial circum flex
fem oris a.
femo ral a.
1st t hro ugh 3rd
----+'-'H---iW I
perforating aa.
B-- - - Femora l a.
--,-4 - - - Add ucto r canal

Fibular a. (with adducto r magnus)
.' +-7-t- - - Adduct or

hiatus
Poplit eal a. - - - - ! --
Dorsal - ---;q .l Lateral superior
pedal a. and inferior
genicular aa.
Medial superior and
inferior genicular aa.
A B Anterior tib ial
------'~rl
recurrent a.
Fig. 27.2 Arteries of the sole of the foot

Right fo ot, p lantar v iew . I ,""f -+- - Int erosseous
m embran e
Anterior - - -+-H :
\"P-----!I------,~ Proper plant ar ti bial a.
digita l aa.
F;~"('-!1-~M=',.+ft---4fL-- Comm on plantar

Plantar meta ---\-!..!::cl+..:H-;~MHJ digital aa.
tar sal aa.
Superf icial branch } Medial

Deep - --i1lii1Mib\l planta r a.
plant ar arch ' ~='!::J-I-- Deep branch Anterior lat eral
Ante rior m edial
""lIIlrr.~ .... ~\. malleolar a.
malleolar a.
Lateral
tarsal a. --:~~Wl~-- Dor sal
II £'~-- Abdu cto r pedal a.
Arcuate a.
- - 4 ,f;
hallucis
Lateral
---~--'IlII.1 Dorsal metatarsa l
plantar a.
aa.
Medial
plantar a.
Posterior
t ibial a. C Course o f t h e arteries , ante rio r view.
420
~ Clinical Fig. 27.3 Arteries of the femoral head
Rig ht hip joint. anterior view.
Femoral head necrosis

Dislocation or fr act ure of t he femor al head (e.g., in patient s w ith
oste oporosis) may disrupt th e anast om oses betwe en t he foveal arte ry and
th e femoral neck vessels, result ing in femoral head necrosis.
Acetabular roof
Head of fem ur Aceta bular

labrum
Acetabu
Femoral lar fossa
neck vessels
Ligam ent
of head
Synovial Foveal a. of fem ur
m emb rane
Medial circum
Fibrous -~~--~C¥~.
flex femo ral a.
mem brane
Zona
Iliopsoas orbicularis
tendon
Profu nda
femoris a.
Lateral circumfl ex
femoral a.
Lesser t rochant er
A Right fe mur.
Fig. 27.4 Arteries ofthe thigh and leg B Corona l sectio n .

Right leg .
Popliteal a.
Lateral superior
genicular a.
Medial superior
genicular a.
Sural aa.
Middle genicular a. Lateral inferior

genicular a.
Medial inferior
genicular a. Posterior t ibi al
-a-H1I!!--- Addu ctor recurrent a.
Ante rior
brevis t ibi al a.
Anterior ti bial
Fem oral a. Posterior recurrent a.
tibia l a. h .------ - Fibular a.
Popliteal a.
B Lon g it u d inal sect io n.
Communicat ing - -;l:;;-1Jl+-- - Perforati ng

branch branch
Medial malleolar
branches
-Z1 :a-- - - Lateral malleo lar

branches
Medial
~ )-7.b---- Calcaneal
plantar a. branches
A Perforating arteri es, poster ior view. C Arterie s o f th e p o sterior leg . 421
Veins & lymphatics of the lower limb
.Q Fig. 27.5 Veins of the lower limb Fig. 27.7 Veins ofthe leg
.§ Righ t limb, anterio r view. Right leg, posterior view.
-.l
~o
Superficial
circum fle x
Superfi cial
epigastric v.
-.l iliacv. Fem ora - - -+--\
Inguinal ~dc--- Ext ern al popli t eal v.
External ligament "r--+--- Popli t eal
Femo ral v. i1 iacv.
(in sapheno us pud endal vv. v.
Pir iformis Long
hiatu s) sapheno us
Ante rior
v.
fem oral Lat eral Medial
Accessory circ umflex
cut aneo us v. circum flex
saphenous v. femora l fem or al
vv. vv.
Deep l----ft-,------:::- Long
femora l v. saphen ous Post erior - - --,-, Short
v. arch v. saphenous
Fem oral Accessory v.
v. sapheno us
v.
Lon g
sapheno us v. Ad ductor
canal
Poplitea l
v,
Add ucto r
hiatu s I+ -+-- Add uctor A Superfi cial (epifascial) veins.
magnu s
~"..-.~"'fj-- Genicular vv.

Poplit eal v.
rr . ~-'--- Dor sal venous
Dor sal venous

arch Long
network
saphenous v. Shor t
sapheno us v.
Ante rio r
A Superficial (epifascial) veins.
tibial v.
Anterior ----\~-;
Fibularvv.
ti bial vv.
Fig. 27.6 Veins of the sole of the foot
Right foot, plant ar view.
Posterior Sho rt
t ibia l vv. sapheno us v.
Short --~ II ' J'l1
sapheno us
v.
W'-'tf-~---f'=n>-q.-- Piant ar
di gital
Plant ar - - +-H''--\--,,,*---jl w .
meta t arsal
Dor sal _-"---=CLU ,
IJ-r---H:--+! -- Do rsal
vv.
veno us
veno us Lateral
arch network malleo lus
Pianta r ---t--\-'-'---\7--'11
ofthe foo t
veno us
arch
f"'---"=--- Medi al
Lateral - - \ - " ". plant ar B Deep veins.
plant ar v.
B Deep veins.
v.
Sho rt
saph enou s
v.
Post erior
tibial vv.
422
Fig. 27.8 Clinically important Fig. 27.9 Superficial lymphatics
""'\ ~
-
perforating veins Rig ht limb. Arrows indi cate t h e ma in direc tion s o f lymphati c dra in age.
Right leg , med ial vi ew. /
-,//
Anus - -;,VI-' '' i
External
iliacv.
\ Superficial ---;-,,-,
inguinal
Ln.
Scrot um -t ~:-c:-_
~\, "
Long \~-----''---!---+- Femor al

saphenous v. Superfic ial
v. Antero popliteal
Long Ln.
medial
saphenous
bundl e
Dod d's vv. v.
Shor t
saphenous
Postero
v.
lateral
bundle
I V<- - f - Femo ral
v.
Long
saphenous A An t eri or v iew. B Post erior v iew.
v.
Boyd's vv.
Fig.27.10 Lymph nodes and drainage
Right limb, anter ior view.
Common iliac lymph nodes
Posterior lumbar lymph nodes

t ibial vv.
Inferior vena cava
Com mo n iliac v.
Posterior - - -+-1 111'- Internal iliac lymph nodes

arch v. Cockett' s
• Receive drainage fr om
vv.
- Pelvic organs
- Pelvic wall
\, - Glutea l muscles
Supero late ral

I.n.
J Intern al
iliac v.
- Erectile tissues
- Deep peri neal region
Supero medial
(
Ln.
Inferior
Ln. Deep iliac lymph nodes
Superficial ing uinal lymph nodes Inguinal ligam ent • Receive drainage from
• Receive drainage from - Deep portions of
th e lower limb
- Skin ofthe limb Long
(except the calf and the lateral

saphenous
border of the foot)

v.
- Abdomina l wall below the umb ilicus
- Lower back
- Gluteal region , bowe l, anal region
- External genitalia
Femora l v.
(in women, also the ut erine fundus
along th e round ligam ent)
Superficial popliteal
Deep popliteal lymph nodes lymph nodes
• Receivedr ainage fro m • Receivedrainage from

- Leg - Lateral bord er of foot
- Foot - Calf
423
lumbosacral Plexus
~ The lum bosacral plexus supplies sensory and mot or inn ervati on t he lum bar and sacral spinal nerves, w it h cont ribut ions from t he subcos
~ t o th e lower lim b. It is fo rmed by t he ant erior (ventral) ram i of t al nerve (T12) and coccygea l nerve (Col).
ilioinguinal n.
Genitof emoral n.
Pudendaln. --~--~~
Inferior ------'r~
cluneal nn.
Nerves of the lumbosacral plexus

Lumbar plexus
• Iliohypogast ric n.
...... ' L1
femoral
cut aneous n.
• Ilioing uinal n. . __ - ~ 427
• ~~~i.t?t.~~or~ l.~ . . . . . . . . . . . . . . . . . . L L.1 -:: ~ 2. ..

: Lateral femo ral cut aneous n. • L2-L 3
. .... .... .... ..... ..... .. ..... . . .
Sciatic n. , Obt urato r n.
............................ . ...........• L2-L4 . ~: ~2 ~ .
• Femoral n. • p. 429
: Sacralplexus
, Superior g l ute aln . .L.~-::~~ p.431

· Inferior glut eal n. ' LS- S2
Tibial n. -------I-....; .. ...... .. ..... ... .... . ........ .... .... ........ .... ............ ....................... .... .
· Posterio r fe ~? ra l c~ta n e0u.~ .~. : · . ~ ~ -:: S. 3 . . . : .~: ~3 ~

Commo n ------+-;,....;, , Sciatic n. · ~? ~ ~o ~ fibular n : . .L~::: ~2. . .. .. . . P: ~ ~2.. . . . .
fibu lar n.
. T.ibial n. • L4- S3. .. . : ~ : ~3 ~ .
· Pudendal n. • S2-S 4 • pp. 194,202
Deep
fibu lar n.
Tibial n. ----t-+-----;,
Superficial
fi bular n.
Lateral sural cutan eous

n. (wit h
Sural n. ------+-1.111 comm unicating branch)
Medial and
lateral
plantar nn.
424
0- T12 Fig. 27.11 lumbosacral plexus
Subcostal n. ~ Right side, anterior view.
k j- Ll
lIiohyp o- - - - -,;
gastri c
n.
Ilioinguinal
n.
lumbar
plexus
~ ...--- l S
, -' - - Tl 2
12t h rib
~--.;~ 4Iiiiil~l_
.... . . :-· vert ebra
Subcost al n.
Superior
glut eal n.
Iliohyp ogast ric n. _______
Inferior
gluteal n.
Sciatic n. - - ---'I"
- Co l
-----:;-----"~~~~~
Sacral
plexus Genit o-
femor al n.
Coccygeal l umb osacral

plexus trunk
Obt urator n. --.-!~~>i':"!--------Z------<:.J\ Sl

Pudendal n. ----~ verte bra
A St ruct ure of th e lum bosacral plexus.

Superior
and inferior
gluteal nn.
Coccygeal plexus.
anococcygea l nn. ~~~~~- Coccygealn .
Muscular
branches
Ant erior Pudendal n.
fem oral - --!----..- - - -r--<0f:7tt,
cuta neous Inguinal
branches ligament
Femo ral n.
Muscular - - H r -;-
branches
Saphenous n. _ _ l--++--;-~~
I '---=~++---- Muscular branches
Sciatic n.
(common fib ular n.
and t ibial n.)
B Course of th e lum bosacral plexus. 425

Nerves of the lumbar Plexus
.Q
Nerves of the lumbar plexus
.§
-.I
Nerve Level Innerva ted m uscle Cut aneous branches
~o Iliohypoga stric n. T12- Ll Anter ior and lateral cut aneous branches
-.I Transversus abdomin is and internal obli que (inferior por ti ons) d : Ant erior scrot al nn.
Ilioingu inal n. L1
9: Ant erior labial nn.
Genita l branch
Genitofem oral n. Ll-L2 ci : Cremast er (genit al branch)
Femoral branch
Lateral fem oral cutaneous n. L2-L3 - Lateral femo ral cutaneo us n.
Obt urato r n. L2-L4 See p. 428
Femoral n. L2- L4 See p.429
Psoas major
Quadratu s lumborum
Short, direct muscular branches T12- L4 -
Iliacus
Intertransversarii lumborum
Fig. 27.12 Sensory innervation of the inguinal region

Right male inguinal region . anterior view.
Ilioingu inal n. -------;~- - -- - - -- - Genitofemoral n.
Lateral
cutan eous
Iliohyp o branch
gast ric
n. Ante rio r - - -+!-I-'--+- - - - ---,
cut aneous
branch Ext ernal inguin al ring
Ilioinguinal n.
Lateral fem oral Genit al branch } Genit o

cuta neous n. fem oral
-i--- -- Femoral branch n.
---j;!--""'-- -- Ante rior scrota l branches
\--+-- h...--f- -="":- - Femora l n.,

anterior cuta neous
branches
426
Fig.27.13 Nerves of the lumbar plexus
Righ t side. anterior view wit h the anteri or abdom ina l wa ll rem oved .
Transversus t#I,-- - - Quadratu s

abdom inis 'ril- - - - Quadratu s lumbor um
lumborum
Internal
oblique
Iliohypogast ric n. '"==- - Ilioinguinal n.
~;-- Psoas major

Iliac crest ~f-- Psoas major
Iliacus - ---..-..,
Lateral Iliacus
cut aneous
branch
Inguin al --,1-!- - Ingui nal _-----,:'----_ L-_

ligament ligament
. r '...-:7~-- Exte rnal

Ilioinguinal -----:-------------;;0:-j~- Ext ernal
ingui nal ring
inguin al ring n.
Spermat ic
cord
A Ilio hypoga stric nerve. B Ili oi ng uin al ner ve.
n f - - - - Quadratu s
lumborum
I! i!'.!:!!'!'--- - - Psoas major

~---- Quadratu s
lum borum
Iliacus
:.=~-- Genit ofemor al n.
Late ral femor al
Inguinal
=-- - Psoas majo r cut aneous n.
ligam ent
Iliacus - - -L....-''!!
Inguinal - ------'- _
ligament
Spermat ic
Fascia lat a _--.L.--+_ -+\ _ cord
Femoral
- - -+---<.. Genit al branch
branch
'\L--':-'-;-- -- Spermat ic cord
C Genitofemora l ne rve .
D Lateral femoral cut aneo us ner ve.
427
Nerves of the Lumbar Plexus: Obturator & Femoral Nerves
.Q Fig. 27.15 Obturator nerve

.5
.... Righ t side . anterior view.
~
....e
Fig. 27.14 Obturator nerve: Sensory distribution

Rig ht leg, media l view.
\-- ---1 '--- Cutaneous

branch
Obturator _ _ --L --:~~-----\!. Linea

n. terminalis
Pectin eus
Obtu ratar - ---+--!-=------;, ---,! i=-~~,.--- Ant erior

ext ernus branch
Posterior
branch
Add ucto r _---1_----I~ __
brevis
Muscular - -+- - +-----,,:'

branches
Obturator nerve (l2-l4)

/
; Direct branch ; Obtu rator extern us
........................ ............................................... ........, .
-1_ - Cutan eous
branch
· ~9 d u ~ ~? r l ? n. ~ ~s
~
.
• Adductor brevi s
: Anterior branch ......................
• Gracilis
...........................
; Pectineus
: Poste rior branch : Adductor mag nus
; Sensorybranches
: Cutaneous branch
428
Fig. 27.16 Femoral nerve
Rig ht side . ante rior view.
Psoas major - - - - + - - - - -- -1--;;
L4 Fig. 27.17 Femoral nerve: Sensory

vert ebra distribution
Right li m b, ante rio r view.
Mu scular branch ---+--t-ffi-~T~
Iliacus ---';---'-;---7'Ii--'-<-,
Inguinal ligam ent --+----7l~ ~"", . " '\,,,

Iliop soas
Sartori us --f------crr- I ~h-=:br- Anterior
cuta neo us
branches
r = ,,----- - 'Ei-- - Fem ora l n.

Muscular branches
lIio::liFiOr---- - Ant erior

Rect us femoris
cut aneous
branc hes
Infr a-llar
pate
Pecti neus
branch Saphenou s
Medial n.
; -- - - - - -i-- - Saphenou s
cut aneous
n.
branches
Muscular
branches
Vastu s
int ermediu s
Vastus
lateralis
Quadric eps -;-- - + - -- Vastoadduct or

fem oris Rectu s
--~lrr-----':=-l-1.1 membrane
femoris
Vastus
media lis
..,L-__ Sartorius Fernoralnerve{ 12-L4)
Pecti neus
i Muscular branch es
i Sartorius
.............................................
: Quadriceps fem ori s
, Sensory branches
: Ant erior cut aneou s branch
. Saphenou s n.
,L---£,f+- - - Infr apatellar branch
Ti-:- - - Sapheno us n.
429
Nerves of the Sacral Plexus
Nerves of the sacral plexus

Nerve Level Innervated mu scle Cut aneous branches
Gluteus medius
Superior gluteal n. L4-s1 Gluteus minimus -
Tensor fasciae latae
Inferio r glut eal n. L5-s2 Gluteus maxim us -
: Inferior clun eal nn.
Posteri or femora l cut aneous n. 51- 53 - Posterior fem ora l cutan eous n.
: Perineal branches
N. of pir iformis 51-52 Piriformis -
Obturator internus
Direct branches N. of obturator internus -
L5-s1 Gemelli
N. of quadratus femoris Quadratus fem ori s -
Common fibular n. L4- s2 See p. 432
Sciat ic n.
Tibial n. L4-s3 See p. 433
Fig. 27.18 Sensory innervation of the gluteal region Fig.27.19 Posterior femoral cutaneous nerve:
Right limb, posterior view. Sensory distribution
Right limb , post erior view.
Superior clun eal nn. - ......... "
Lateral branch Inferior clun eal

(ili ohypog astric n.) nn.
Perineal branches
Inferior clun eal nn. -\--~'-+.(/

(posterior fem oral
cutaneous n.) Posterior femora l
cuta neous n.
Fig. 27.20 Emerging sacral nerve

Horizont al sect ion, superior view.
Ventra l Ante rior Vent ral ramu s

(ante rior) sacral (to sacral plexus)
root forame n
Dorsal
ramu s
Posterior Lat eral branch

Cauda sacral (to t he cluneal
equina for amen nn.)
430
~ Clinical
Smallgluteal muscle weakness

The small glut eal muscles on th e st ance side st abilize t he pelvis in th e
coro nal plane. Weaknessor paralysis of t he small gluteal muscles from
dam age to th e superior gluteal nerve (e.q., due to a fau lty int ramuscular
inject ion) is manifested by weak abduction of th e aff ect ed hip joi nt .
In a posit ive Trendelenburg 's test , t he pelvis sags to ward th e norm al.
Fig. 27.21 Nerves of the sacral plexus
unsupported side: Tilti ng t he upper body toward th e affect ed side shifts
Rig ht li m b.
t he cente r of gravit y onto th e sta nce side, th ereby elevati ng th e pelvis
on t he swing side (Duchenne's lim p). Wit h bilateral loss of the small
gluteals. t he p atient exhibit s a t ypical waddling gait.
Glut eus Superior
minimus glut eal n.
Gluteus medius Insuffi cient
and minimus small gluteals
Shifte d
center
of gravity
Pelvis
--'ii l i- - - GIute us sags
m edius
~--- Tensor
fasciae Stance leg
latae
Swing leg
- - - - Iliot ibial
t ract
A Nor mal gait. B Small gluteal C Duchenne's limp.

A Su pe rior g lut ea l n erve. Lat er al vi ew . muscle weakness.
Piriform is
(w it h n.)
~---i.<;-JJr-T--- Glut eus Gem ellus
Inferior ------,,r-- -.,.-'---'-.J maximus Obt urato r superior
glute al n. internu s (wi t h n.)
::::::~"""'----''<--- Gemellus
Muscular Sacrotuberous inferio r
branches iigament
Quadratus
fem oris
(w it h 11 .)
Sciatic 11 . - -----<. Sciat ic n. - -- - - - - ----:-1
B Inferi o r g luteal n erve. Poste rio r vi ew . C D ir ect bra nch es. Poste rior vi ew.
431
Nerves of the Sacral Plexus: Sciatic Nerve
~ The sciat ic nerve gives off several direct mu scular branc hes
~ before dividing into t he t ibial and com mo n fibu lar nerves
proximal to t he pop lit eal fo ssa.
Fig.27.23 Common fibular nerve
Fig. 27.22 Common fibular nerve: Sensory distribution Right lim b, lateral view.
."'j"-- Anterior
superior
iliac spine
Lateral sural
cutan eous n. Sciat ic n. - - _.. ...
Fibul ar
communicati ng
branch
Medial dor sal )

cut aneous
n. Superfic ial
, ! ~---;,+--- Medial dor sal fibular
Int erm ediat e ----r4. \
cuta neous n. Intermediate n.
dorsal 'Hl- - - do rsal cuta -
cutan eous n. neous n.
Lateral cut aneous )
n. of big toe Deep - -i- - Biceps fem oris,
Com mon ---~ shor t head
Medial cut aneous fibu lar fibular
n. of 2nd toe n. n.
A Right leg, anterior view. B Right leg, lat eral view. H ,:tt4I----!- - Biceps femoris.
long head
Neck of fib ula Head of fibul a
Common fibular nerve (L4-S2) Deep

fi bular n.
Nerve Innervated muscles Sensory branches Superficial
Direct branches from Biceps femoris (short fibular n.
sciat ic n. head)
-
Medial dor sal cutan eous n.
Fibularis brevis and
Superfi cial fi bular n. Interm ediate dorsal Fibu laris
longus
cuta neous n. longus
Tibialis anterio r Ext ensor

Lateral cuta neous n. of
Extensors dig itorum digitor um long us
big toe
brevis and longus
Deep fibular n.
Extensors hallucis brevis
Medial cuta neous n. of Fibularis 1-- - Superfi cial
and longus
2nd toe brevis fibul ar n.
Fibularis tert ius
Extensor - - - lia Medial dor sal
halluci s longus cut aneous n.
Interm ediat e
Lateral ------::r-:'J:t~~= dorsal cuta
m alleol us neous n.
432
Fig. 27.24 Tibial nerve Fig. 27.25 Tibial nerve: Sensory
Rig h t li mb. distribution
Rig ht low er lim b. po st er ior v iew .
Proper
plant ar
-~~H1+1kNi\--H
digit al
nn.
Lum bricals --m~~~~~~~H~~L Adduc tor

hallucis
Com mo n plant ar
dig ital nn. Flexor hallucis
Latera l plant ar lo ngu s t endon Medial
-+--+'~.
n., super- --I--J-..-J~ sural
~\ .'lh- Muscular
ficial branch cut aneous
branches n.
Abducto r
dig iti mi nimi ;.-<-+-- - Fibu lar
--\H1r1--4-- Flexor communicati ng
digitorum branch
longus
tendon Sural --1-4---1
Lateral _ _..L.._
n.
plant ar n. - Abductor
hall ucis
Quadrat us
i N .!-l-- - - Lateral dor sal
plant ae
Medial cutan eou s n.
Medial
plantar Flexor calcaneal ~' ~.!.f----- Lateral calcaneal
Sciat ic n. --~~*~',
digit or um branches branches
n.
brevis and ~-.--!-+---,_-- Prop er plant ar
plantar digit al nn.
Sacro --~o'!l~~( apo neu rosis
tu berous
ligam ent Tibial n.
B Rig ht fo ot, p lantar v iew .

Muscular - - ' - . ""
branches Adduc tor
magnus,
Biceps femoris, --~~!>"! medial part
lon g head
Tibial nerve (l4-S3)

Semi - -.--JH -"
tendin osus Nerve Innervated muscles Sensory branches
;5-- - Biceps femoris ,
shor t head Sem ite ndi nosus
Direct branches Sem ime m branosus
-
from sciati c n. Biceps fem oris (lo ng head)
Semi- -~"--"+-l- Add uctor mag nus (m edial part)
m embranosus H'......- +--- Tibial n.
Poplitea l fossa Triceps surae
Plantari s Medial sural cutaneo us n.
Pop lit eus Medial and lateral
Tibial n.
Tibialis posterior calcaneal branches
Flexor digitorum lon gu s Lateral do rsal cuta neou s n,
Flexor hallucis lon gu s
"'1!Jff~l-- Tendino us arch
Adduc tor hallucis
of soleus
Flexor digitor um brevis
Medial
Flexor hallucis brevis (m edial Proper planta r digit al nn.
Gast roc nem ius plant ar n,
head)
Soleus
1st and 2nd lum bricals
Flexor halluci s brevis (lateral
Deep flexors head)
Quadrat us plant ae
Abductor digit i m inimi
Lateral Flexor digit i minimi brevis
Prop er plantar digit al nn.
planta r n. Oppon ens digiti min imi
3rd and 4t h lumbricals
1st to 3rd plantar interossei
1st to 4t h dorsal inte rossei
Lateral Adducto r hallucis
malleo lus
Tibial n. (i n _ _+.o
mall eolar canal)
A Po st eri or v iew.
433
Superficial Nerves & Vessels of the lower limb
.Q Fig. 27.26 Cutaneous innervation: Anterior view Fig. 27.27 Superficial cutaneous vein s and nerves
,5
.... Right limb . Right limb.
~
....o lIiohypo - - - -IF- Genit ofem ora l n.
gast ric n.
Lat eral - 7'-"------ Ilioi nguinal n.

femora l Extern al
cuta neou s n. inguinal ring
Exte rnal
pud endal vv.
Obt urator n. Accessory
Femora l n. Femoral n., ------::'----i-i~
saphenous v.
ant erior femora l
cutaneou s
branches
Lon g
saphenous v.
Fascia lat a -----'o--f-+---'---f--
Cf~~~~~.
Obt urat or n.
Sciat ic n.
{
Tibial n.
Saphenous n.,
infrapatellar
branch
A Periphe ral sensory cuta neous inn ervation .
Saphenous n.
(fem oral n.)
Lateral sural
cuta neo us n.
---/'i
~
Lon g
saphenous v.
52 --I'---~+
(common
L2 - -!-- - fib ular n.)
L3 - -\'r-....,..,,
Superf icial
fibular n.
r \;.'':--¥+- - Int erm ediat e do rsal

cutan eous n.
Med ial dor sal

cut aneous n.
Sural n.
(tib ial n.)
Deep fi bular
n.
L5 ---+-+
51 - --+ A Anter ior view.
B Segmental, radicu lar cuta neous
inn ervat ion (dermato mes).
.. . . . ..... . .. ~ . ..... . . . .
434
Fig. 27.28 Cutaneous innervation: Posterior view
Right limb.
Superior cluneal nn. - - - , . - - t'---

"/ Iliohypo gastric n.,
\ ") '~ '-"'\ lateral cut aneous
branch Cluneal nn. <f" - -+
~
Midd le cluneal nn.
Post erior Lateral

femoral femora l
cuta neous n. cutaneo us n.
Inferior
- - -'k:;:----<
cluneal nn.
(posterior femoral Obtu rato r n.
cuta neous n.)
Lateral femoral
Com mo n
cuta neous n.
fib ular n.
Posterior femo ral - - - ,!--,---..l,-f--'..

Femoral n. - ----\::-i..
cuta neous n.
Tibial n.
Obtu rator n.,
cuta neous branch
A Periphera l senso ry cutaneou s innervation.
Medial sural
cut aneous n.
(ti bial n.)
Saphenous n.
(femoral n.) Lateral sural
cut aneous n.
L3
(common fibular n.)
55
L4
54
L5
-t
53
Short ---~~~
saphenous v. h--i~--- Sural n.
52
(tib ial n.)
51
Calcaneal
branches
...IJIi'~-- Lateral dorsal
cut aneous n.
(tib ial n.)
Medial and lateral
plantar cuta neous
branches
L4
--~..'
B Post er ior vi ew.
B Segmenta l. radi cu lar cutaneou s L5
inn ervation (d erm atomes).
• • • • • • .. ~ .. • • • • • • .. • . o. o....o.o.o..o.o.. . t • • • • • • • • • • • • •
435
Topography of the Inguinal Region
.Q Fig. 27.29 Superficial veins and lymph nodes

,5
..... Right male ingui nal region, anterior view . Removed: Cribrifo rm fascia
about t he saphenous hiat us.
~
o Superficia l and superolateral Ingu inal Ext ernal
..... inguinall .n. ligament iliac v.
/ Ext ernal iliac

Ln.
Superfic ial circum - ---f-----~ Rosenrnul ler's
flex iliac v. I.n.
Superficial - - +-- - - - --';,.--- .,..".::-"';.;1' Ext ernal

epigast ric v. pud endal v.
Saphe nous - --;! - - - - - - - - -----< ,,_=~:--;=-~-- Superficial and

hiatus superom edial
inguinal Ln.
Femora l a. ---!-~~-.L-~~r__-__!_~__!~, Wr~~
and v. Deep inguinal
Ln.
Ant erior femo ral - - i ---e"---- - - -+--+--+t, Superf icial and

cuta neous v. inferior in guin al
Ln.
Long
saphe nous
v.
Fig. 27.30 lnquinal region

Right male ingu inal region, anterior view.
Ext ernal oblique - - - - - - -H

Linea alba
Int ernal oblique +- - - - Rectu s
abdo m inis
Transversus
abdomin is - - - - -+l - - - - - Ant erior rectu s
Lateral femora l sheat h
cuta neous n.
Superfi cial circumflex
iliac a. and v.
Ingui nal liga ment

- - - - - - ---; _ - - - - - -- - Superf icial
abdo mi nal fascia
Genito femo ral n., Ext ernal ob lique
femora l branch apon euro sis
Superf icial
inguinal Ilioinguin al n.
ring
~<""::,,,-----~r..:---.----- Genitofemora l
n., genital branch
Reflex ligam ent
Fem or al a. and v. - -----'- ------'\-----'- - ------Jf--'--;,-,--'

(in saphe nous hiatu s)
H~~~+--- Spermat ic cord (cut)
,':--T7-'iiiO'------'-+ - - Lacunar ligament
Ext ernal
pud endal a. and v.
Ant erior
fem ora l
cuta neo us v. Long sap he no us v. Pe ct in eu s
436
Ilioin guinal ligament
Structures in t he inguinal region
Anterio r
~ Region Boundari es Conten ts
superior
j Ant erior superio r iliac : Femoral n.
iliac spine
: CD Lacu na : spine : Lat eral fem oral cut aneous n.
mu scul orum : Ingui nal ligament : Iliacus
.· l l i?p.~~t i~~~ I ~ rch : Psoas majo r .
: Ingui nal liga me nt : Femo ral a. and v.
: 11) Lacu na
: Ilio pectin eal arch : Genit of emora l n. (femora l branch)
vasoru m
Iliopect ineal
~a~u.~~~ l ig~ rnent~?s~~rn u lle~·~ Iy.rn Ph node
arch Reflex ing ui nal • Med ial cru s j Ilioing uinal n.
ligam ent :0 Ext ern al
: Lat eral crus : Genitofemo ral n. (genita l branch)
lIio pu bic in gu inal ring
Pubic tubercle : Reflex inguinal ligam ent : Sperm at ic cord
em inence
Lacu nar ligament
Fig.27.31 Lacunae musculorum and vasorum

Righ t inguinal region , ant erior view.
Ext ern al
--.,------2~~~
obl iq ue
Lat eral fe mo ral ----~~ ;~ Ext ern al obliq ue

cuta neo us n. apo neuros is
Inguin al ligame nt ~..L
Fem or al n. --------~--'Il
Lacuna {
m usculo rum Iliacus --~~~
Iliopsoas { Int ercr ural fi bers
Psoasmajo r
Medial crus Exte rnal
Ilio pectin eal bursa Lateral crus } ingu inal ring
Iliop ect ineal arch Ref lex ing uinal ligament
Aceta bular fossa Fem or al rin g
Lacunar ligament
Femo ral branch of
genit ofemo ral n. Pubic sym physis
Lacuna Femora l a.
vasorum and v,
{
Rosenrnuller's I.n.
Ischial spine
Ischial tu berosit y
437
Topography of the Gluteal Region
..Q Fig. 27.32 Gluteal region

! Right g lu t eal reg io n, po st erio r view.
~
o
-.l
Glut eal fascia

(g lut eus m edius)
---"";t-~?'v-+!-- Glut eal fascia
(glute us maximu s)
-"i~I;--iI!l----- Glut eus m ediu s

Glute us - - - - - - - ,;¥,-'-
maximu s
Superior glut eal
a., V. , and n.
Inferior gluteal
a., V., and n.
~ ~"~ri~~"--;I-- Piriformi s
Geme llus superio r
Gluteal sulcus Fascia lata 1!~~i~ and inferior
Posterior femoral --""~::§i
cut aneous n.
I ~'--'-Il-- Obtu rator
A Fascia e and cut aneous n eurova scu lature. int ernus
Pudendal n., - --:oM:=:::
perineal branches Sciat ic n.
Obt urat or int ernus (w it h a.)
Sacrot uberous Quadr atu s

ligam ent fem ori s
Ischial tu berosit y Gluteus maximu s
Posterior fem oral

cutaneo us n., Addu ctor mag nus
perin eal branches
Addu ct or m agnus
Superior
cluneal nn. Gracilis - - - - -h'l- .

~-""---lrn-- Posterior femoral
cutan eous n.
.-'-"'!I--- - Iliohypogast ric n.,
lateral branch
Gluteal fascia C Deep g lutea l reg ion . Partially removed: Gluteu s ma ximu s.
(gluteus m edius)
Midd le
cluneal nn.
Glut eus
maximu s
Inferior
cluneal nn.
Addu ctor
magnu s
Posterior fem oral
cuta neous n.
(with biceps femoris,
lon g head)
Semi
Sem it endi nosus
m embranosus
B Glutea l reg ion. Removed: Fascia lat a.
438
Sciatic foramina
Posterior Transm itted
Foram en Boundaries
superio r st ruct ures
iliac spine
Q) Suprapirifor m Superior gluteal a.,
portion and n.
V. ,
Inferior glutea l a.,

... ~---------; ~ G) Great er V., and n. Greater sciatic not ch
Piriformis --'E-.'-5----rt~ Int ernal pudendal a.
sciat ic Sacrospinous ligam ent
foram en o Infrapiriform and v. Sacru m
Sacro portion Pudendal n.
spinous Sciatic n.
ligam ent Posterior femora l
cuta neous n.
Sacro
t ub erou s Greater sciat ic Internal pudendal a. Lesser sciat ic notch
ligam ent notch and v. Sacrospino us ligam ent
G) Lesser sciati c for am en
Pudendal n. Sacrotub erous
Lesser sciat ic Obturator internus liga me nt
not ch
Fig.27.33 Gluteal region and

ischianal fossa
Right glutea l region, p o st eri or vi ew .
Removed: Gluteu s maximu s an d mediu s. ! -- - - - Ant erior superior
iliac spine
Glute us
Posterior superior ----t-":r----~ mi nim us
iliac spine
Tensor fasciae
latae
Superior gluteal
a. and n. Piriformi s
Geme llus
Inferior glutea l n. ~....::o..._~_,---'- superior
Inferior glutea l Obt urator

aa, and vv. int ernu s
Pudend al n. Geme llus

inferior
Int ernal pud endal
a. and v. Branch of m edial
circumflex
Obt urator fem oral a.
inte rnus
Trochante ric
Pudendal canal bur sa
(Alcock 's canal)
Quadrat us
Sacrot uberous ligament
femoris
Adductor ----~~I;--
Sciatic n.
m agnus
Add uctor
Gracilis - - -- --'l
magnu s
Sem ite ndino sus ------I;,-\l-~-1l-- 1st perfor ating a.
Sem i Biceps femori s. Posterior femor al

membra nosus long head cut aneous n.
439
Topography of the Anterior & Posterior Thigh
Anterior superior Inguinal Superficial Fig. 27.34 Anterior thigh

iliac spine ligament epigast ric a.
Right thi gh, anterior view.
- -- -- - External obliq ue
Superficial aponeurosis
circumflex iliac
a.
Tensor
fasciae latae
Iliopsoas --f-'-~.--j,.,-
Femo ral n. - -1>--"-!,llI';;;"r --'-+.c-c External pudendal a.
Femoral a. and v. - -f-- 4-'--!'-',-------.,,.......W- f

~--,----- Spermat ic
cord
Pect ineus
Profu nda _---.!Ll-!!.-~~I~
femo risa.
Sarto rius -4JlHilf -- Adducto r

longus Externa l iliac
a. and v.
Gracilis Superior and inferior
Rectu s femoris Ing ui nal ligam ent - - - -!H;-!h-=' \ '. " g lut eal aa.
Lateral femoral - - -1'+"'-'1 :t:l 1'o - Femor al n.

cuta neous n.
Sacral plexus
Sarto rius ---!!++J~+
I':J' ~::..:-~----;---- Fem oral a.

and v.
Add uctor Rect us fem or is ---1H-!H.~
magnus ~--='""i"lf-- Me dial circum flex
Lateral circum flex femor al a.
femo ral a.,
./"' - - Pect in eus
Quad riceps - ----i"'""\,;"--'---'-+"'--+"7-¥.-F ascend ing branch
femor is Obtu rat or n.
Profunda ---+~
femo ris a. ~lill---- Add ucto r br evis
Perfo rat ing a. ---+ljif'-'il~1PJ
Lateral circum flex - -ffi---H='"+-t f -- - Add uct or lon gus

femo ral a..
descend ing branch
- - -- Addu ctor mag nus

Pat ellar vascular --J-~7'---f'
network ~-!'----- Descending Femoral a. and v.•
genicular a. Vastu s -4-h-;-\--~f--- saphen o us n. (in
inte rme d ius vastoa dd uct o r
mem brane)
Rect us ----;~;t---'.-¥'--i"':, ....'!u.
A Femoral t riangle. Removed: Skin, subcut aneous t issue, fem ori s Obt urato r n.,
and fascia lata. Windowed: Sarto rius. cuta neous branch
Vastu s - - Til',...-'H l'::-++\r-=-+
m edialis
Vastus -----+-+"'< .~~~" --- Sart o rius

lateralis
~#C----- Sapheno us n.
B Neurovasculatur e of th e anterior thigh . Removed: Ant erior abdomina l

w all. Partially removed: Sart or ius, rectu s femori s, adductor longus, and
440 pect ineus.
Fig. 27.35 Posterior thigh
Righ t t hi gh , p ost erior v iew,
---¥'P'--';- - - Superio r
cluneal nn.
Iliohypo
gastr ic n.,
lateraI branch
Gluteal fascia
(g lute us
mediu s)
~~-- M i d d l e
cluneal
nn.
-'.'-!~i----
Glute us
ma Ximu s ~
Glute us ~~=-,,"=-- Glut eus
maximu s medius
Superior
:'-.----:--<+;+- - Inferio r glut eal a., V.,
cluneal and n.
4$;1\-. - - - Glut eus
nn. mini mu s
Inferior
*-'------c::'-!!-_ Adducto r glut eal n. Piriform is
mag nus
Pudendal n.
Medial circu m flex
~---"",=~!-- Post erior femoral a.
femoral Inferior
cuta neo us glut eal a. Trochante ric
n. Sacrot uberous
bursa
ligament Glute us
Posterior --~*"' maximu s
Fa scia lata, femo ral Quadratu s
iliot ibial t ract cutaneous n. femoris
Obt urator Sciatic n.

internus (with a.)
Biceps femori s,
long head Add ucto r ----1!~~ llo1:;;=-::---~=- 1st perfo rat ing a.
magnus
Biceps femoris,
long head
~-t!'l:'------l-+- Add ucto r
mag nus
l +i~""--....!H--- Tibial n. P.-lc+.-~+.-~--*- 2nd perfo rat ing a.

Popliteal - ---4!-f
a. and v. ',\If.(.?\r-\l:- - - Commo n
fibu lar n.
Gracil is ------1~
l~,,'c--"*--- Lateral sural Sem i ---~_\t4b-

cutaneou s n. tendi nosus
3rd perforat ing a.
Addu ct or ----~+-~c__~
IP.:b::!\-- f'+- - Sural n. hiatu s -ilt r - - Biceps fem oris,
short head
Poplitea l a. and v. - - - ';dh-t--:: + - - - Iliot ibial tract
Commo n
A Glutea l reg io n and t hig h . Removed: Fascia lat a.
Semi ---L.....tct-cH~ fibu lar n.
membranosus = i\f- - - Biceps femo ris,
long head
Tibial n. --~-t'--..l
Plant aris
Medial sural - - - .H-F----';
cuta neous n.
,f tr+- - - Lateral sural
cuta neous n.
Gastrocn em ius
B Neu ro vascul ature o f th e post eri or t high. Partially removed: Gluteus ma xi
rn u s, g lut eus m edius, and bicep s fem or is. Retracted: Sem im embra nosus. 441
Topography of the Posterior & Medial leg
.Q Fig. 27.36 Posterior compartment

,5
-.l
Right leg. posterior view.
~
o
-.l
Sem i- --H~.
Sem i- - . ------''?<-- H ten di nosus
tendi nosus ,""";'-4--'*- - - Biceps Gracilis
fem or is
Sem i- ---';~.,-----'-fl;-'
Sem i
me m bra nosus
m embranosus
Ti bial n. Tibi al n. '1.,"+'-- - Co m mo n

~,------,---1+----- Plantari s fibul ar n.
Gastroc- ----'ri-Ho-~·l'j
nemiu s \"~~oLl"
"-l\-~--- Com mo n
fibular n. Poplit eus
Po plit eal a.
'\+'lv.r.-rt'-'lIT+-- - Med ial suraI and v.
cut aneou s n.
Tend ino us arch ---~-T
Long -1-% ;-- - Lateral sural of so leus Soleus
saphenous v. cut aneous n.
:I III " -~:!I--+-+-- Gastrocnemiu s.

lateral head
~f-;--1.!.j~....- t- - Gastrocnem ius.
Deep fascia - - - :-iI-- ' medial head
of th e leg
Posterior t ib ial a. ---;;--F.iif-'-~t l

r-:'il -- Communicatin g
Short ------'!oHk' bran ch Tibial n. -~-9!IL+'-I--* 1
sapheno us v.
,+ -tD_- - - Fibul ar a.
Flexo r d ig it orum - --1ilI-...J'-c
lon gu s
+-1-- - - Tibi alis
post erior
Sapheno us n. IH-i-hfJ--- Sural n.
Fibul aris
Flexor halluci s ----.----ii-7-fH-- ---,lj:-'
brevis
lon g us
Perforating }
br anch Fibular a.
Com m uni
cat ing br anch
Fibula ris lon gus
Latera l malleolu s
" ""--':- - - Do rsal cuta neo us n. ~~--',---- Achilles' t endo n

Tibi al n.. ---~" of t he foot
m edial calcaneal
branch A..J~4:::~-.~- Calcaneal ret e
A Superf icial neurovascular st ruct ures. B Deep neurova scular st ruct ures.
442
Poplitea l Biceps femoris . Fig.27.37 Popliteal region
a. and v. Sciatic n. lon g head Right leg, posterior view.
Gracili s Biceps Biceps

fem oris. femo ris
Sem i- _ _ ...L.~_--lA"L...
short head
me mb ranosus
~<--~--4---- Deep pop lit eal

Semi Poplite al a. -------1~-L..J~
Com m on lym ph nodes
tendi nosus and v.
fibu lar n.
Gastrocn emius.
Planta ris
Gastroc ----h--.~-~
med ial head
Medial superio r nem ius
Subtendinous genicular a.
Short
bur sa of the
,..,,-----"'--- -'7- - - Lateral superior saphenous v.
media l gastroc
nemiu s head genicular a.
Planta ris
Midd le genicula r a.
I'",=~~~r--
~
Gastroc
nemiu s,
Sem imem branosus
lateral head
bur sa
Obliqu e pop liteal - -----;-+----'::: ~!?i~~~+-- Lateral inferior
ligam ent genicular a. B Deep lymph nodes of th e poplit eal region.
Sem im em br anosus Posterior t ibial

tendon recu rrent a.
Medial inferior Plantaris

Fig. 27.38 Posterior compartment:
genicular a. tendon
Medial view
Tibial n. Right foot.
Fibularis Fibula Deep flexor s

grou p
Superfi cial
Poplite us Tricep s Ext ensor - ---=-"'"--.-= flexor s
Gastrocn emius } surae group
A Deep neurovascular str uct ures. Tibia - - .;+- h,..1"-'~-~- Tibial n.,
posterio r t ibial a.
Superior extensor
reti naculum
Medial
Medial malleolus ma lleo lar
(w ith subcutaneous bur sa) branches
Tibialis
po sterior
Inferior exte nsor
reti naculum Flexor digi
torum longus
Tibiali s ant erior
i-IJ--D --'_ - - Flexor hallucis
longu s
Medial
tarsa l aa. Achilles'
tend on
Ext ensor hallucis ~
longus te ndon ~ ~~+-;l-- Media l
Med ial plantar a..

.",...,_ .... . calcaneal
branch
superfici al branch
Tarsal tu nnel
Flexor
retina culum
Media l plantar 1st meta Abductor Media l plant ar Lateral plant ar

a. and n. t arsal hallucis a. and n. a. and n.
443
Topography of the lateral & Anterior leg
Fig.27.39 Neurovasculature of the leg: Lateral view

Right lim b. Removed: Origin s of t he fibu laris longus and exte nsor
digi torum longus.
Head of - - - - -
fibula
Short
head Iliotibial
Biceps {
~
Ti bia
fem oris Lon g tr act
Anterior
head """'- - "" Deep fibular n..
intermuscular
.• anter ior t ibi al
sept um • a. and v.
Patella
Super ficial
j~~~~~~~~d~[~~~-
fi bular n.
lo ng
Saphenous n.•
saphenous v.
Common
fibular n. Lateral t ibial Fibu la Interosseou s
cond yl e me mbrane
Posterio r
Head of fib ula --,j~-+t-'-'-'" Tibi al n.,
Ant erior crural intermuscular
sept um posterior tib ial
intermu scular
a. and v.
septum Fibular a.
and v.
Later al sural ----,fl!-,~---!-li ll ~!!--- Deep fibular
cutaneo us n.
n. Transverse Deep fascia
Superf icial inte rm uscular Sural n., short of t he leg
Gastr oc septum saphenous v.
nem ius fibu lar n.
Fibularis
Medial sural _II lon gus
cuta neo us Compartments of the leg
n. (t ibial n.)
Tibialis Neurovascula r
anter io r Compartment M uscular contents
Cornrnu - * -\"-:: conte nt s
nicating
branch ' - - Extensor Tibialis anterior
Soleus digi toru m Extensor digitorum

longu s longus Deep fibula r n.
<D Anterior compa rt me nt Ant erior tibia l a.
Sural n. - - -!-1 Extensor hallucis and v.
longus
Fibularis tertius
Fibul aris longus

l-!'!i~~-- Supe rficial
<Ii Lateral compa rtment Superficia l fibu lar n.
fibular n. Fibulari s brevi s
Triceps surae (qast roo

Deep fascia o Superficia l nemi us and soleus) -
of th e leg part
Plant aris
Posterior
Tibialis posterior
Medial do rsal Intermediat e compa rt me nt Tibial n.
cut aneous dor sal Flexor dig itoru m Posterior tibial a.
@) Deep part
n. cut aneou s n. longus andv.
Fibular a, and v.
Flexor hallucis long us
Lateral -~--'-'ff-:---+-
malleol us
Lateral
calcaneal
b ranches
444
~ Clinical
Fig.27.40 Neurovasculature of the leg and foot:
Anterior view
Rig ht lim b wi t h fo ot in p lan t ar f lexi o n .
Compart ment syndrome
Muscle edema or hematom a can lead to a rise in t issue pressure in th e
compart ments of t he leg. Subsequent comp ression of neurov ascular
. st ruct ures m ay cause ischemia and irreversible muscle and nerve damage.
Patien ts wit h anteriorcompa rt ment syndrome, th e m ost comm on for m.
suffer excruciat ing pain and cannot dorsifl ex t he toes . Eme rgency incision
Pate lla - - --\--;:::-
of t he fascia of th e leg may be performed to relieve compression .
Pes anserinus
Pate llar ligament - - -----i\-+----:,-- (insert ion of
sartorius,
gracilis. and
semit end inosus)
Gast rocne mi us
Fibularis longus
Tibialis
anter ior
Fibula
_ - - - - - Tibia
Fibular a., - - - - -l-!' t_+! ---''\----+~----- Extensor

Muscular
perforat ing hallucis longu s
branches
branch
~'l:i$;#--- Deep fibu lar
--\-----,~--- Tibialis anterior n.
Ext ensor --+*-~
t endon
hallucis longus
::---:.'D--- - - Ante rior tibial
Anter io r ------J~~a~~; a. and v.
lateral Extensor ----'i-~
malleolar a. digitorum longus
Deep -----!fA-~~~.....¥---'f-\,L,
'------- Soleus
fi bular n. Superficial - - -* \\1
f9.--~~~ \i~~iifi~ii--- Ante rior

fi bular n.
tibia l a.
Extensor
hallucis brevis
Fibular is brevi s - -- ---; Superior exte nsor
Ext ensor reti naculum
digit orum
brevis Dorsal Inferior ext ensor
pedal a. reti naculum
Lat eral '\-- - Medial malleolus
tar sal a.
Late ral do rsal Dorsal pedal a.

cut aneous n.
cH++-----li~f---- Arcuate a. Exte nsor
Interm ediate
hallucis brevis
dor sal
Dorsal ---~f-~
Deep cuta neous n. Exte nsor
int erossei plantar a.

Medial dor sal - - ----i!+fIlh nH--lliir hallucis longus
cuta neous n. t endon
Dorsal --"""H/;~~~~¥f~iPd~+-~~' Extensors
m et a halluci s longus Dorsal

Deep fi bular
ta rsal aa, and brevis meta tarsal n.
tendons aa,
Exte nsors ----.rif.H 'T:
digit orum I'\"f!-'--t-N-~c--- Deep fibu lar
longus and n., cutaneou s
brevis branch
tendon s B Ne u ro v asc u lat ure o ft he leg . Removed:
Dorsal ----rn~:i---HiJ+_'f_---+l_R_+l---H Skin, su bc u ta ne o us ti ssu e, an d fasciae.
digit al nn.
Retracted: Ti b ialis anter io r an d exte nso r
ha ll uc is lon gu s.
Dorsal -----~fdI'-------{~~-----tl-\l
digita l aa.
A Neu ro v ascul atu re o f th e d o rsu m .
445
Topography of the Sole of the Foot
.Q Fig.27.41 Neurovasculature of the foot: Sole

.§ Right foot, plant ar view.
-.l Prop er piantar -------.;:---,-;~""*f_+._a___ih\ ,. ~,
~
digital aa.
o
-.l Proper plant ar ------ff~:w.----'l1'H\:'--.L.Jiffi-_+._\\
dig it al nn.
Com mo n -"-4.----''---c-'*¥.'.-~~H...,..,.I
plant ar Medial plant ar
digit al nn. n.
Medial planta r
Lat eral -+~\ )
a., super
plantar a.
ficial bra nch
- --JL.,L,-e:--'--!-- :!- Piantar

apo neurosis
Lateral --"-"-;"-'~"'--...I'Ih , Medial plantar

plan tar n., a., deep
super ficial branch
branches
~~~~-----.ir--- Medial plant ar
n., super
ficia l branch Prop er plantar ----!!'-i!---~----'l-~K!!!'--+.
~
Lateral ------l--"I-----7.~rI-i1~. digital aa.
planta r sulcus Medial plant ar and nn.
sulcus
Flexor digi ------.~-----;:~U/~~~i"fh'I~'W,.;,nil1 11U~ '
toru m brevis,
Abdu ct or te ndo ns
halluci s
Plant ar - -'-----,.-7\4 ~~~i4-'H--~ m~ ! I -l:HlJ~+- Flexor hallucis

met at arsal aa. longus
t endon
~,~~~HHil>,H;,~--.!!ii~H!---- Commo n
plantar
A Superficial layer. Removed: Skin, subcut ane Lateral plantar -----..:-'~-'m digital nn.
n., super
ous ti ssue, and fascia.
ficial branch Medial plant ar
a., super
Lat eral ---;-~~\-1 ficial branch
plant ar n.,
deep branch Medial plant ar
a., deep
branch
Quadrat us ---7+~'<-'
plantae Flexor digi
t orum longus
te ndo n
Medial
planta r n.
Abducto r
hall ucis
..L--;ll~-'----- Plant ar
apon eurosis
B Midd le layer. Removed: Plant ar apon eurosis

446 and fl exor digit orum brevis.
Proper plantar -----"HL.fIl'*---'f¥.H\'-Li~~,\
digita l aa. and nn. Flexor digi torum
longus tend on s
Flexor digitoru m ----!----s;i.4---~.¢~»JJh7:"I:

brevis tendo ns Lumbrica ls
Plant ar
int erossei
Transverse
head
Obliqu e
1f Addu ctor
hallu cis
Plant ar met at arsal head
aa.
Flexor hallucis brevi s
Deep ----.,...-.b*'"*~~
plant ar arch
Medial plant ar
a., deep branch
Lateral -------,,;-~~~::t_J
plantar n., Flexor hallucis
deep branch longus t endon
Quadratus - - ...-:.+ ...,...

planta e Medial
plantar a.
Media l
plantar n.
Lateral plantar Abdu ctor

a., v.. and n. halluci s
Flexor - - - - -'--H - '.7-----'-"o= ,........

digitorum Plant ar Fig. 27.42 Neurovasculature of
brevis apo neurosis the foot: Crosssection
Coronal sect ion, distal view.
Int ermediate
dor sal cuta
Interossei neous n.
Exte nsor
C Deep layer. Removed: Flexor digitorum digitorum longus Deep fibular n..
longus . Windowed: Add uctor hallucis dorsal pedal a.
3rd m etat arsal
(ob lique head). Extensor
halluci s brevis
Ext ensor
digitorum longu s
Lat eral dorsal

cut aneo us n.
Dor sal m et a
2nd m etatar sal

tarsal a.
Medial cuneifo rm
Abdu ct or
digiti min imi
'I rl_ _ + Tibialis ante rior

Opponens
digiti min im i
Deep layer of
plantar fascia
Flexor digiti
---;----;;---~
m inim i brevi s
Lateral plant ar
a. and v.
Lateral
plant ar sept um
Lateral plantar
n., deep bran ch
Lateral plant ar n.,
supe rf icial branch Flexor hall ucis
brevis
Quadr atu s Apon euro sis
plant ae of fl exor Flexor halluci s longu s
digi toru m longus
Fibularis
longu s Flexor Deep Medial plantar
digitorum brevis plantar arch septum 447
Transverse Sections of the Thigh & leg
Fig. 27.43 Windowed dissection

Right limb, pos terio r v iew. Iliac crest
S~~~,---- Gluteus
me dius
Glut eus
maximu s
Glut eus
Piriformi s
minimu s
Gem ellus
superior and
inferio r
Obtu rato r
inte rnus
Glut eus
maximu s
'!;,-- +-- Quadratu s

femo ris
'b--- --+-- - Add uct or

Gracilis - -----7- . magn us
Adductor _ _---'1-'-_
magnus
~ Iliot ibial
tract
Sem ite ndinosus
- '----- +-- Femur
Biceps femoris ,
Rectu s
long head
fem ori s
Vastus m edialis ------;,------"'""~~ Vastus
Sartorius int erm ediu s
Gracilis Vastus
lateralis
Addu ctors brev is
and longus Biceps
femo ris.
Sciat ic n. short head
....L- - - Iliot ibial
Adductormagnu s --~~ t . I, 1
tra ct
Sem itendinosus ---~t-;!!--
Biceps
femoris,
Sem ime m branosus -----'fl'H~!.
long head
Plantari s
Gastrocnemius
Fibula
Tibia - - -!- - -
Interosseous
membra ne
Soleus
Triceps
surae Gastroc --7'L.-~
{
nerruus
Achilles'tendon - - - -4!-
448
Fig. 27.44 Transverse sections Quadri ceps femoris
--,
Right lim b, proxima l (superior) view. ~ .A~
Vastus Vast us Rect us Vastus

mediali s int erm ediu s femori s lat eralis
Ant erior
Medial
int ermu scular
sept um
Femu r
Sartori us
Femoral
a. and v.
Profunda femo ris a., -1-~-!i!
deep femora l v.
Adduct or Sciat ic n.
brevis
Addu ct or
longus Lateral
inter
mu scular
Gracilis sept um
Adductor Short head }

magnu s
Biceps femori s
Semi Semi Long head

m embranosus tendinosu s
A Th ig h (plane of section in Fig . 27.43).
Deep fibular n.,

ant erior t ibial Tibialis Ext ensor
Anterior a. and v. ant erior hallucis longu s
Tibia Ext ensor

digit orum longus
Anterior
interm uscular
Int erosseous septu m
m embrane
Fibularis
brevis
Tibialis
posteri or Fibularis
longus
Flexor
digitorum Posterior in
longus t ermu scular
sept um
Tibial n., posteri or
t ibial a. and v.
Fibula
Plantaris
te ndo n
Soleus
Transverse Flexor
Fibular
int ermuscular hallucis longu s
a. and v.
sept um
Gastro cnemiu s, Gastrocn emius,
medi al head lat eral head
B Leg (pla n e o f sect io n in Fig . 27.43).
449
Surface Anatomy
Fig. 28.1 lower limb: Anterior view Fig.28.2 Palpable bony prominences
Right lim b.
Iliac crest - --
Anter ior -
Anterior superior - superior
iliac spine - - Tensor fascia iliac spine
lata Pubic
/ t ubercle
Greater -
troc hanter - - Pubic
- --Rectus symphysis
femoris
Ischial
Adductor
tub erosity
long us
Vastus
medialis
Lateral tibial -
condyle 1 - - - Medial tibial
Tibial
condyle
tu berosit y
Tibial
tuberosity
- - Fibularis
longus
Gastroc
nemius - - -Tibialis
i -- - Medial
anter ior
surf ace
of ti bia
Medial
Lateral mall eolus
malleolus Navicular
I ~' tube rosity
F -'r-.-f::-- Extensor Tuberosity ----() /
of 5th .....r-:-.~-t--- Metatarso
Extensor digitorum
metatarsal phalangeal
hallucis tendons joi nts
longus
Interphalangeal joi nts of the foot
A Surface anatomy, right limb . B Musculature, left limb. A Ant erior view .
Ql: The hip joint is not dir ect ly palpabl e. How

would you correctly locate the head of the
femur based on surface anatomy?
450
Fig.28.3 lower limb: Posterior view
Iliac crest ---!.------;~~

Iliac crest - -- -
Po steri o r ~
superior
Glut eus
iliac spine
m edius
Sacrum »->
Glut eus - - -
maxim us
Glut eal
fo ld Ilioti bial
t ract
Semi memb ranosus, -!5-!"----

semitrendinosus
-~~- B icep s
femoris
_ _ Lateral 1- - --+- Popliteal
Medial - epicondyle
fossa
epicondyle
Head of fibula
Achilles'
t endon
Flexor -
--''--- - Calcaneal
Navicular tube rosity
digitorum I
longus
tuberos ity ~;L--- Sole of
- - - Tuberosity of tendon
foot Iiir:!~.--- Fibularis
5t h metatar sal longus
tendo n
B Posterior view . A Surface anato my, left lim b. B Musculature, right lim b.
Q2: Whi ch palpable landm arks wou ld yo u use

t o locat e th e sciat ic nerve (in t he gluteal
region). t he com mo n fi bular nerve (at th e
knee). and th e ti bial nerve (at t he ankle)?
See answers begi nning on p. 626 .
451
Head & Neck
29 Bones of the Head 34 Nasal Cavity & Nose
Anterior & Latera l Skull 454

Bones of t he Nasal Cavity
520
Posterior Skull & Calvaria 456

Paranasal Air Sinuses 522
Base of th e Skul l 458

Neurovasculature of the Nasal Cavity 524
Ethmoid & Sphenoid Bones 460
35 Tempora l Bone & Ear

30 Muscles of the Skull & Face
Temporal Bone 526
Muscles of Facial Expression & of Mast ication 462

Externa l Ea r & Auditory Canal 528
M uscle Origins & Insert ions on the Skull 464

Midd le Ear: Ty m panic Cavity 530

Middle Ear: Ossicu lar Chain & Tympanic Membrane 532

Arteries of t he Middle Ear 534
Inner Ear 536
31 Cranial Ne rves
36 Oral Cavity & Phar ynx
Cranial Nerves: Overview 470
CN I & II: Olfacto ry & Optic Nerve s 472

Bones of the Oral Cavity 538
CN III, IV s VI:
Tem poroma ndibular Joint 540
Oculomotor, Troch lear & Abd uce nt Nerves 474

Teeth 542
CN V: Trigem inal Nerve 476

Oral Cavity Muscle Facts 544
CN VII: Facial Nerve 478

Innervat io n of the Oral Cavity 546
CN VIII: Vest ibu locochlear Nerve 480

Tongue 548
CN IX: Glossopharyng eal Nerve 482

Topography of the Oral Cavit y & Salivary Glands 550
CN X: Vagus Nerve 484

Tonsils & Pharynx 552
CN XI & XII: Accessory & Hypoglossal Ner ves 486

Pharyngeal Muscles 554
Neurovasculature ofthe Pharynx 556
32 Neurovasculature of t he Skull & Face

37 Neck
Innerv at io n of the Face 488
Arteries of the Head & Neck 490

Bones & Ligaments of the Neck 558
Externa l Carotid Artery:

Musc le Facts (I) 560
Anterior, Media l & Posterior Branc hes 492

External Carotid Artery: Terminal Branches 494

Muscle Facts (III) 564
Vein s of the Head & Neck 496

Arteries & Veins ofthe Neck 566
Topography ofthe Superficia l Face 498

Innervat ion of the Neck 568
Topography of the Parotid Region & Tem poral Fossa 500

Larynx: Cartilage & Structure
570
Topogr aphy of the Inf rat em poral Fossa 502
Larynx : Muscles & Levels
572
Topograph y of t he Pterygopa lati ne Fossa 504

Neurovascu lature of the Laryn x, Thyroid & Parathyroids 574
Topography of the Neck: Regions & Fascia

576
33 Orbit & Eye Topography ofthe Anterior Cervica l Region
578
Topography of the Ant erior & Lateral Cervica l Regions 580
Bones of the Orbit 506
Topography of the Lateral Cerv ical Region

582
M uscles of th e Orbit 508
Topography of the Poster ior Cervical Region

584
Neurovasculature of the Orbit 510
Lymphatics of the Neck

586
Topography of the Orbit 512
Orb it & Eyelid 514
38 Surfac e Anatomy
Eyeball 516
Cornea, Iris & Lens 518

Surface Anatomy
588
Fig. 29.2 Anterior skull
Ant erior view.
Nasion
/
Front al Parieta l bon e
in cisure
Suprao rbita l
Supraorbit al ~ . foramen
marg In I ._______________ ~:#~;r--- Sphe noi d bone,
Nasal bon e • greate r w ing
Sphenoid bo ne, Parietal bo ne

lesser w ing
Orb it
Ethmoid bone,
perp end icular
plate
Infr ao rbi t al ----+--~ Zygo mati c bo ne

margin
Midd le nasal ---,-------::::;;----"'~-------: Pirifo rm (ante rio r

concha nasaI) apert ure
Maxi lla
Vome r -
Inferio r nasal Infrao rbita l

concha foram en
Ante rior nasal
spine
Mandibl e ---~--
~~~--;iif---- Ment al
for amen
~ Clinical
Fracturesof the face

The framelike construction of th e facial skeleton leads to character ist ic patte rns for fr acture lines
(classified as Le Fort I, II, and III fractu res).
455
Fig. 29.4 Calvaria Fig. 29.5 Structure of the calvaria
Cross secti on .
Diploic vv. Emissary v.
Dural
sinus
Dura
mater
---"----~""'"~-- Fronta l
bone
Coronal
suture
Parietal
bone
Sagitta l
sut ure
Fronta l
Fronta l Fronta l
crest
bone sinus
Parieta l Lamb do id
fo ramen sut ure
Occipita l bo ne
A Externa l calvaria, superio r vi ew.
Arter ial
grooves
Groove
for
Parietal superior
bo ne sagittal
sinus
Granular
foveolae
(for arachnoid
granulatio ns)
B Intern al calvaria, inferior view. The int erior

of t he calvaria is marked by grooves for th e
mening eal arteries, dural veno us sinuses, and
arachn oid granu lati on s (see pp. 606-6 10). Parietal foramen
457
Fig. 29.7 Cranial fossae
The interior of th e skull base consists of three successive fossae th at
become progressively deeper in th e frontal-t o-occipit al directi on .
- ,,---';k - - - Ante rior
Ante rior
cranial fossa
cranial fossa
Middle Jugum
cranial fossa spheno idale ~~-- Lesser wing of
Poster ior sphenoid bone
cranial fossa
Dorsum _---;';~~~-"-c-___,
sellae
Forame n -~~~
magnu m
Poste rior -~~~

cranial fossa
Foram en
mag num
A Midsagittal sect ion, left lat eral view. Fronta l B Superio r view of opened skull.
crest Front al
Fig.29.8 Base of the skull: Interior

Superio r view.
Et hmo id bon e,
Optic canal cri sta galli
Ant erior clino id Fronta l bon e

proc ess
Foramen ovale Lesse r wi ng
Foramen
spinosurn Greate r wi ng
Sphenoid
Ar te rial bon e
groove Hypoph yseal
fossa (sella
Foramen lacerum
t urcica)
Dor sum sellae _~!,;;--:!=~""=~:o--:,.--------;---f.c------------:
Clivus
Hypoglossal --p;~~~~
canal
Internal
acoustic meatus
Jugula rforamen
For am en magnu m
Groove for
transver se
sinus Poster ior cranial
(cerebellar) fossa
Confluence of th e sinuses
(interna l occi pital
prot uberance)
"
-----;O-~~---- Cerebral fossa
459
Lesser Sphenoid Fig. 29.10 Sphenoid bone
wing crest The sphenoid bon e is th e most st ruct urally
comp lex bon e in th e human body.
--~'.!-+- Orbita l surface
Superior ------''r--'~O'.------'"x+ • .:::~-- Tem poral

orbital surface
fissure
"'--- - - Foramen
rot undum
Pterygoid --------=-<'------~.------"lP~1!I
canal
Pterygo id
process
)
A Ant erior
view.
Jugum Superior orb it al

sphenoidale fi ssure
...r«'-~~'-!-!..--- Greater
wing
~-----,.;--- Foram en
rotundu m
Anteri or clino id
process
Tuberculum Hypophyseal Posterior clinoid

B Superior view. sellae fossa pro cess
Opt ic
canal
Superior orbi t al
fissure
Anter ior
clinoid .,,-- -;;;='--- - Greaterwing.
process cerebral surface
Foram en
rot undum
Cancellous tr abeculae
Medial Plate } Pterygoid

1.o..;:L:,-- - - Lateral plate pro cess
C Posterior
vi ew. Pterygoid fossa
Lesser Sphenoid Apert ure of

w ing crest sphenoid sinus
Foram en
rotundum
-( Medial Plate} Pterygoid
l
~~-i---'-----'--- Lat eral plate proc ess
I Temporal
. ' ~d~+--- For amen ovale
su rrace
Foramen spinosum
D Inferior view. Note: The vomer sit s

Pterygo id Superior orbita l Body Pterygoid
below the sphenoid crest (see p.
hamulus fissure fossa
538).
461
Galea
apo neurot ica
Auricularis
superior
Occipit of rontali s. ----~i--

front al belly
Temporo
pariet alis
Orbicularis
oculi
Anter ior auricular

mu scle
Nasalis
Levator labii
superioris
alaeque nasi
Levator labii
superioris
Zygomat icus
minor
Orbicularis Auricularis
ori s posterior
Zygomat icus
major
Menta lis
Depressor
anguli oris
B Left lat eral view . Platy sma
Fig. 30.2 Muscles of mastication

Left lat eral view.
f,:7'7"'-- Temporalis
~~~~~=:-- Lat eral

Capsule of tempo ro pterygoid
mandibul ar joint
Sty loid process Lateral

ligament
~
B Deep layer. Removed:
Mandib le (coro noid
PP",' p ro cess) and low er
Dec }
A Sup erficial layer. Masseter t empo ra li s.
Superficial part
463
Fig.30.5 Skull base: Origins and insertions
Inferior view of extern al skull.
Mm. of mastication:
Trigeminal n.• mandib
ulardivision (CNV3)
Massete r
Medial
pte rygo id
Lateral
pterygoid
Pharyngeal mm.:
Tem porali s
Glossopharyngeal
n. (CN IX) and
vagus n. (CNX)
Lingual rnrn.: Hypo
glossal n. (CNXII) Tensor veli palat ini
Hyoglossus Levator veli palatini

(see Fig. 31.25)
Stylo pharyngeus
Genioglossus
(see Fig. 31.2 5) Middl e pharyngeal
constric to r
(not shown )
Digast ric.
Prevertebralmm.:
ante rior belly
Ventral cervical n.
rami and cervical
plexus
Nuchaland intrinsic
baCkmm.: ~. Rectu s capit is
lateralis
Dorsalrami of
cervical nn.
Longus capitis
Splenius capit is
Rect us capit is
Longissim us capitis ante rio r
Obliquus
capit is superior
Sternocleidomastoid
Rectus capitis and trapezius: Acces
posterior m ajor sory n. (CNXI)
Rectus capitis Ste rno cleido masto id

posterior minor
Semispinalis capit is Trapezius
Fig. 30.6 Hyoid bone: Origins and insertions

Genio hyoid
Mylohyoid Geniohyoid
St ylohyoid
Mylohyoid
--...._-~IC---- Stylohyoid
Sternothyroid Sternohyoid
~~---~
Omohyoid Sternohyoid Omo hyoid Sternothyroid
A Ant erior view. B Obliqu e left lateral view.
465
Fig. 30.10 Muscles ofthe mouth
Left later al view.
A Zygo m at ic u s m aj or an d B Levato r labii su pe rio ris and C Lev at o r an d d epressor an g u li D Bucci na to r.

m in or . de p resso r lab ii infer io ris. o ris.
E Orb icu lari s o ris. anteri o r view. F M en t ali s. anteri o r v iew.
Muscles of facia l expression: Mouth and neck
Muscle Origin Insertion " Main action(s) " "
Mouth
CD Zygo matic us majo r Zygomatic bo ne (lateral surface, Skin at corner of th e m outh Pulls corner of m outh superio rly and laterally
m inor posterior part ) Upper lip just medial to corn er of th e mouth Pulls upp er lip superio rly
Levato r labii superio ris

Maxilla (fro nta l process) Alar cart ilage of nose and upp er lip Elevat es upp er lip, opens nost ril
alaequ e nasi (see Fig. 30 .8C)
Maxilla (front al proc ess) and Elevates uppe r lip, dilates nostril. raises ang le of
Q) Levato r labii supe rioris Skin of upp er lip. alar cartilages of nose
infra or bital region th e mouth
Mandi ble (ant erior porti on of Lower lip at midline: blends with m uscle
@ Depressor labii inf eriori s Pull s low er lip inferiorly and laterally
oblique line) from op posite side
® Levator anguli oris Maxilla (below inf raorbi tal fo ramen) Skin at corner of th e mouth Raises angl e of m outh , help s for m nasolabi al furrow
Mand ible (oblique line below canine. Skin at corner of t he m outh: blend sw it h
® Depressor anguli oris Pull s angle of m outh inferiorly and latera lly
prem olar. and first mola r teeth) orbicu laris or is
Presses cheek against m olar t eeth . wo rking with

Mandibl e. alveolar pro cesses of tongue t o keep food bet w een occl usal surfaces and
ill Buccinator maxilla and man dible, pt erygo- Angle of mouth, orbic ularis oris out of oral vestibule: expels air from oral cavity!
mand ibular raphe resists diste nsion w hen blow inq
Unilateral: Draw s mouth to one side
Act s as or al sphincte r
Deep surf ace of skin
• Compresses and protrudes lip s (e.g., when
® Orbi cularis oris Superiorly: maxill a (m edian plane) Mucous m embrane of lips
w hist ling . sucking. and kissing)
Inferiorly: ma ndi ble
• Resists distension (wh en blowin g)
Risorius (see p. 46 2) Fascia over masset er Skin of corner of th e mouth Retracts corner of mouth as in grima cing
® Ment alis Mandi ble (incisive fossa) Skin of chin Elevates and protrudes lower lip
Neck
Depressesand wrink lesskin of lower face and
Skin over lowe r neck and upper Mandi ble (inferior bord er), skin over lower
Platysma (see p. 463 ) mouth; t enses skin of neck; aids in forced depression
lateral th orax face, angle of m outh
of th e mandibl e
* T he re are no bo ny in se rt ion s fo r t he muscles of Facia l e xpress io n .
"" All mu scles of facial are innervated v: ,,'c '''~' ''' '''I "" CC, 'fJU' ''' buccal, mandibular, or cervical branches arising from it s parotid plexus.
467
Muscles of mastication: Pterygoid muscles
. .
: 0 Superior head
Greater w ing of sphenoid bone : Tem porom andibular joint : Bilateral: Protr udes mandible l
(infratemp oral crest ) .. U a.r t icular disk) Mandibular n. (CN V3
) via : (pulls artic ular disk forward ) :
.. .......... ...............
: Lateral pt erygoid
: Lateral pt erygoid plate (lateral lateral pt erygoid n. ~ Unilateral: Lat eral movements '
, @) Inferior head , Mandib le (condylar process) : of mandible (chewing)
: surface)
............................................ . .
, @ Superficial head : Maxilla (tub erosity) ~ Pterygoid t uberosit y on
~. Medial pterygoid · ···',:· · M~d i~ I ~~ rf~~~ ~i i~~~r; i pH;ery·g~ id: medial surface of th e l.' Mandibular n. (CN V 3) via .' Elevates (adduct s) mandib le
.®D h d . medial pterygoid n.
~ eep ea : plate and pterygoid fossa : mand ibu lar angle
........ ....... .
Fig. 30.13 lateral pterygoid muscle superiOr }

Left lat eral view . head Lateral
Inferior pt erygoid
head
Zygomat ic ----" """'~=cc=-- Arti cular

arch (cut) disk
Condylar
head
Sty loid
process
A Schemat ic.
B Left lat eral pt erygoid mu scle. Coronoid
process (cut )
Removed: Coro noid pr ocess
of m andib le.
Fig.30.14 Medial pterygoid muscle

Left lat eral view .
Pterygoid
process.
lateral plate
Medial
pterygoid
(superf icial Medial
head) pterygoid
A Schema t ic. \ (deep head)
B Lef t m edial pteryg oi d \
mu scle. Removed: Coro
noid process of mandi ble. Mandib ular
angle
Fig.30.15 Masticatory muscle sling

Ob liq ue po st erior view .
Temporali s
Superior
head Lat eral
"J,I-D':rl-- Inferior pterygoid
head
Deep part »->:
Masseter J
Superficial
l part
Medial
pterygoid
A Schemat ic.
B Revealed: M uscu lar sling form ed by

th e masseter and med ial pte rygo id
m uscles t hat emb ed th e mandi ble.
469
~ The cranial nerves contain both afferent (sen sor y) and efferent tion to t he gen era l fiber types, the crania l nerves may contain specia l
~ (moto r) axon s that be long to eit her th e somatic or th e autonom ic fiber types associated with particu lar st ruc t ures (e.g ., auditory apparatus
(vi scera l) ne rvous system (see pp. 622-623). The somati c fibers and tas te buds). The cran ial nerve fibers originate or term inate at spec ific
allow interact ion w ith t he envi ron ment, whereas the v isceral
f ib er s regulate the au tonomic activity of interna l organ s. In add i
nuclei, whi ch are sim ilarly classified as eith er ge nera l or special, somatic or
vi scera l, and afferent or effe rent. ~
w
-
:::J
Q'
Classification of cranial nerve fibers and nuclei
This color coding is used in subsequent chapters to indicat e fiber and nuclei classificat ions.
Fi ber t y pe Fibe r type Exam pl e

General somat ic efferent General somatic afferent Conduct impu lses from skin, skelet al m uscle
Innervate skeletal muscles
(somato motor funct ion) (somatic sensatio n) : spindles
......... . . - .
General visceral efferent Innervate smooth mu scle of t he viscera, : Conduct impulses fro m ret ina, audito ry and
Special somat ic afferent
(visceromotor func t ion) int raocular muscles, heart, salivary glands, etc. : vestibular apparat uses
•...
Innervat e skeletal and cardiac m uscle derived General visceral aff erent
Special visceral efferent : Conduct impuls es from viscera, blood vessels
from branchial arches (visceral sensatio n)
....... .. . - .
: Condu ct impulses fro m taste buds, olfact or y

Special visceral afferent
: mu cosa
Fig.31.2 Cranial nerve nuclei II' Cranial nerves

The senso ry and m oto r fibers of crania l nerve s III to XII orig inate and
terminat e in t he brain stem at specific nuclei . Fu nction al
Cran ial ner v e Or igin fi ber t ypes
•
Efferent (motor) nuclei Afferent (sensory) nucle i
CN I: Olfactory n. Telencephalon'
Oculomotor n. Trigeminal n.
nuclei (CNIII) ~ nuclei (CN V) CN II: Opt ic n. Diencephalon'
• ....
Nucleus of - -- - -----+- - -'1 CN III: Oculomotor n.

Mesencephalon • •
tr ochlear n. (CN IV)
CN IV: Trochlear n.
•
Nucleus of CN V: Trigeminal n.
• •
abducent n. (CN VI)
CN VI: Abducent n.
Pons
•
CNVII: Facial n.
••• •
CNVIII: Vest ibulocochlear n.
•
Salivatory nuclei - - - - ---1"""'=_ CN IX: Glossopharyngeal n.
•• •••
Nucleus ambi guu s CN X: Vagus n.
Medulla oblongata
•• •••
Dorsal vagal nucleus
CN XI: Accessory n.
• •
Nucleus of
hypog lossal n. (CN XII)
,
»>: Spinal nucleus
of t rigeminal n. (CN V)
Nucleus of solit ary trac t

CN XII: Hypog lossal n.
:
• The olfactory and optic nerves are extensions of th e brain rather th an tru e
•
nerves; they are t herefore not associate d wit h nuclei in t he brainstem.
Spinal nucleus of
accessory n. (CN XI)
A Posterior vi ew with the cere b ellu m Visceral L

oculom ot or
removed .
CN III nucleus
Nucleus of ~ ~ Nucleus of
tr ochlear n. (CN IV)
oculomotor n. I / ' ./
Mesencephalic
nucleus
CN V Mot or nucleus
Principal (partia l)
sensory nucleus
Inferior - - - _!Ik-=:=c--''--- .7'>'. 'vJ

salivatory
nucleus (CN IX)
('''""- - - - - Nucleus of solit ary tra ct
B Midsag itta l sect io n , lef t lat era l view.
471
Lateral Opt ic Lat eral genicu Fig. 31.4 Optic nerve (eN II)
ventricle tra ct late body The optic nerve passes fro m t he eyeball through the optic canal into the
a'
midd le cranial fossa. The t wo optic nerves jo in below th e base of the di
encephalon to form th e optic chiasm, before dividing int o the two optic w
tracts. Each of th ese tracts divid es int o a lat eral and m edial root. Many
Opti c retina l cell gangli on axons cross th e midlin e to the contralateral side of
radia ::l
-
the brain in the opt ic chiasm. See p. 619 for the mechani sms of sig ht.
tion
Q'
St riate
f
area
Opt ic Meyer's
chiasm loop
A Optic nerve in th e geniculate visual path

way. left lateral view . Opti c n. ---:---~,.~?o
Late ral
geniculate
Opt ic bod y Thalam us
t ract
Optic ----f--i.4--~...-~
chiasm
Opt ic
t ract
Opticn. 7 Lateral
geniculate
body
Opt ic
chiasm
Medial
geniculate
bod y
Mesencephalon
Opt ic ----'o-~l----'i4..
B Terminati on of th e opt ic tract, left postero radiat ion
lateral view of th e brainstem. The optic

nerve contain s the axon s of retina l ganglion
cells. wh ich terminate mainly in th e later al Occipita l
genicu late body of th e diencepha lon and in pole
the mesencephalon (superior collicu lus).

C Course of th e opt ic nerve , inferior (b asal)
view .
Opht halmic n.
(eN V,l
Opti c n.
Opt ic
tr act
Opt ic
canal D Optic nerve in th e left orbit, lat eral view.
Super ior orb ital
The optic nerve exits the orbit via th e optic

fi ssure
canal. Note: The ot her cranial nerves ente r
ing the orbit do so via the superi or orbital
fissure.
473
~ Note: The oculomotor nerve supplie s parasympathetic innerva superioris) . It s parasympathetic fib ers synapse in th e ciliary ganglion .
IIIIiiiII ti on to the int raocular muscles and somat ic motor innervat ion Note: Oculomotor nerve palsy may affect exclusively the parasympa
to most of the extraocular muscl es (also th e levator palpebrae th etic or somat ic fibers. or both concurr ent ly.
Fig. 31.6 Course ofthe nerves inner

...
w
vating the extraocular muscles Superior a'

-
Right orb it. :::I
rectu s
Q'
CN III.
superio r
division
Superior
Oculomoto r n. ob lique
(CN III)
~~---~~~:e------,---.lf--- Lateral
rect us
(cut)
CN 111. Medial Inferior Inferior

inferio r rect us rect us oblique
divi sion
A Lateral view .
Supraorbita l n.
Levator palp e
Superior Levator palpe Superior brae superioris
opht halm ic v, brae superior is rectu s
Superior Superior
Lacrim al n. ob lique rectu s
Frontal n. Medial Lacrim al

rectu s gland
Trochlear n.
(CN IV)
Inferior Lat eral
Superior
rect us
rect us
ob lique
Optic n. Trochlear n. #""'----- - - - - - - Abducent n.
(CN II) (CN IV) (CNV I)
Med ial Oculomotor n.

rect us (CN III)
Oculomo to r n.
(CN III) Optic n.
(CN II)
Inferio r
rect us
Lateral Abducent n. Inferior

rectu s (CN VI) ob lique
B Ante rio r view. CN II exits th e orb it via th e C Super ior view of th e ope ned orbit. Note t he
optic canal. w hich lies medial to t he supe relati on ship between t he optic canal and
rior orbi ta l fissure (site of eme rgence of CN t he superior orbita l fissure.
III. IV. and VI).
475
Fig. 31.9 Course of the trigeminal nerve divisions
Right lateral view. Ante rior
Posterior et hmoidal n.
eth moidal n.
Frontal n.
Superior
orbit al fi ssure
....".- - - - - - Lacrim al n. (w ith gland)
Nasociliary n.
~--""--~-- Infrat rochlear n.
Recurrent m eningeal ---...::~~~i~~~q
branch f+;~->,---I--- Long cili ary nn.
Opht halmic SJ
division (CN V,) , - """""'-\--1'- Shor t ciliary nn.
Nasociliary
Ciliary ganglion
root
Commu nicati ng
branch to
zygo mati c n.
A Opht halmic divi sion (CN VJ Part ially
ope ned righ t orbit.
Foramen rotund um - - , Zygomat ic n. (with

communicating
Maxillary division ----l:=O~~~~~~~rI~ branch)
(CN V, )
'--''d--rf---.'7-- - - Infrao rbit al n.
Meningeal branch
: i-.'iIii'tI.:=--a~-=---- Midd le superio r
Ganglio nic branches to alveolar n.
pterygopa lat ine gangl ion ;:---rr---"lo","-=~-- Ante rior superior
alveo lar
Pterygopa lat ine branches
ganglion
Posterio r superior
alveolar nn.
B Maxill ary divi sion (CN VJ Part ially opened

right m axillary sinus with th e zygo matic
arch rem oved.
Trigeminal Mandibu lar Foramen

ganglion division (CN V3 ) ovale
Infraor bit al
for amen
:-~---------}--- Buccal n.
l!"----------~-- Medial and

lat eral
pterygoid nn.
Auriculotemp oral n.
Masseteric n.
~~~~~~~~2~~~t- Inferior
~ branches dental
C Mandi bul ar division (CN VJ Partia lly Lingual n. lr'~t"="~l--- Mental n.
opened mandible w it h th e zygo mat ic arch (in mental
foramen)
remove d. No te: The mylohy oid nerve (not
shown) branches from t he inferior alveo lar Inferior alveolar n.
nerve ju st befor e t he mandibular foram en. (in mandibular canal) 477
Facial nerve (CN VII)
Course Fibers Nuclei Function
: Innervate:
Effects of
nerve injury
w
Q
Q
~
; Emerges in t he cerebellopont ine Special visceral

. Facial nucleus
• Musclesof facial expression
• Stylohyoid Q'
~
: angle bet ween the pons and efferent : Peripheral facial
• Digastric (post erior belly)
~ olive; passes through the ~ nerve injur y:
• Stapedius
; internal acoustic meatu s into ..[ paralysis of
; the temp oral bone (petrous ~ Synapse wit h neurons in t he pterygopa latin e or submandibular ganglion. ~ muscles of facial
: part) , where it divid es int o: : Innervat e: • expression on
• Greater petrosa l nerve Visceral • Lacrimal gland ~ affected side
: Superior salivatory
• Stapedial nerve • effe rent (para- • Sm all glands of nasal mucosa, hard and soft palate
; nucleus
• Chorda t ympani • sym pathetic)" • Submand ibu lar gland : Associated
• Sublingual gland : disturbances
• Certain visceral efferent fiber s ....................................................~ Small salivary glands of tong ue (dorsum) ...: of tast e,
~ pass t hrough th e st ylomastoid : Special visceral ~ Nucleus of the : Peripheral processesof fibers from geniculate ganglion form t he chorda : lacrimation,
~ foram en to t he skull base, ' . ~ f~~ r.~ n t ~..... .. ; solitary t ract : tympani (gustatory fibers from tongue) : salivat ion, etc.
~ forming th e int raparotid plexus
•. Sensory fibers from th e auricle, skin of the auditory canal, and oute r surface of t he t ympan ic
~ Somatic afferent
.... : membrane trave l via CN VII to the princip~ lse~~ a.ry..~ucleus?~th.~~ri~~~i~a ln ~r~~ ,..... .. .
~ • Group ed to form nervus intermedius, w hich aggregat es wit h th e visceral effe rent fiber s from the facial nerve nucleu s.
. .. . .
Fig. 31.12 Course of the facial nerve

Rightlateralview. Vi sceral efferent (parasympathetic) and specialvisceral
afferent (taste) fibers shown in black.
Lacrim al gland
Trige minal n. (CN V) Communicat ing
branch to
zygomat ic n.
Deep
Int ernal carot id a. pet rosal n.
(wit h int ernal (sym pat het ic) CNV,
carot id plexus) Nasal glands
Geniculate gangl ion
Superior saliva
tory nucleus'
Fa cial n. (CN VII)
\
Chorda t ymp ani
~~;;";~~~:). ':rJ'----T--- Sublingual

gland
Glandular branches
Subm andibular
gland
• Parasympatheti c
479
Fig. 31.15 Vestibular and cochlear
(spiral) ganglia
Note: The vestibu lar and cochlear roo ts are
st ill separate st ruct ures in th e pet rous
part of t he t em pora l bone .
CNV III
Sem icircular
duct s
Superio r
-TL--.tI~-- part Vestibular
:"~;--- Inferior
gang lion
part
~~~~--c-- Spiral
ganglia
Utr icle
Fig. 31.16 Vestibulocochlear nerve in

the temporal bone
Geniculate Cochlea
ganglion
Posterior sem i
circular canal
Oval w indow -~~~~~~~f~~ Semicanalof

te nsor tympani
_ "'~ . . - Internal carot id a.

Sigmoid sinus
• _I!.-- Pharyngotym panic
.~ (auditory) t ube
L • • ·. -_ - - - ------ Int ernal
caroti d plexus
Anterior wall of
tympa nic cavit y
Chorda tympani
Facia l n.
Round Tym panic Internal Tym panic n. Greate r
(in facial canal)
w indow plexus jugularv.
Transverse crest
A Medial wall of th e t ympanic cavity ,
Facial n. (CN VII)
oblique sagit ta l sect io n.
Nervus
int erm ediu::s__, ,, ~,,,,,
B Cranial nerves in th e
inte rnal acoustic meatu s.
Posterior oblique view of
t he rig ht meat us.
Cochlear n.
CNV III {
Vestib ular n. Sacculo Poster ior
am pullary n. Utricu lo am pullary n.
ampullary n.
48
A B E F
Glossopharyngeal nerve(CN IX)

Effects of
Cours e Fibers Nu clei Functio n nerve injury
Parasympathetic presynaptic fib ers are sent to th e ot ic gangli on ;

postsynapt ic fib ers are distributed to
Visceral effe rent Inferior salivato ry
• Parotid gland (A)
(parasympathet ic) nucl eus
• Buccal gland Isolate d lesions
• Labial gland of CN IX are
Innervate: rare. Lesion s
Special visceral effe rent • Const ricto r m uscles of the phar ynx (phar yngeal branchesj oin with the are generally
Nucleu s am biguus
Emerges fr om (branchiogenic ) vagu s nerv e to form th e phar yngeal plexus) accom panied
the medulla • Sty lopharyngeus by lesions of
oblongat a; CN Xand CN XI
Receive sensor y information fr om
leaves cranial Nucleus of th e solita ry (cranial part ).
VisceraI aff erent • Chem orecept ors in t he carot id body (B)
cavity throu gh tra ct (inferior part) as all three
• Pressure recept or s in the carot id sinus
th e j ugu lar eme rge jo int ly
for am en Nucleus of th e solita ry Receives sensory inf ormation from the posterior t hird of th e ton gue (via the from th e jugular
Special visceral afferent
tr act (superi or part) inf erior ". ." (C) foramen and are
Peripheral proce sses of the int racranial superio r gang lion or the ext racranial suscept ib le to
inferio r ganglion arise from injury in basal
Spinal nucleus of • Tongu e. soft palate, phar ynge al muc osa, and tonsils (D,E) skull fra ctures.
Somat ic affer ent
trigem inal nerve • Mucosa of th e t ympanic cavity . internal surface of th e tympanic
membrane. pharyng otympanic tube (t ympanic plexus) (F)
• Skin of th e exte rnal ear and audito ry canal (blends wit h th e vagu s nerve)
Fig. 31.19 Glossopharyngeal nerve in the tympanic cavity Fig. 31.20 Visceral efferent (parasympathetic)
Left antero lateral view. The tympanic nerve contai ns visceral effe rent fibers of CN IX
(presynapt ic parasympath eti c) fib ers for th e ot ic ganglio n. as well as
somatic afferent fibers for th e t ymp anic cavity and pharyng ot ympani c
tube. It join s w it h sym pat het ic fib ers from th e internal caroti d plexus Tymp anic n.
(via t he carot icoty m panic nerve) to form th e t ymp anic plexus.
Glossopharyngeal n.
(CN IX)
Mandibular
~
Tubarian Carot ico divi sion
branch tym panic n. (CNV J )
Tymp anic
plexus
~.-/\--'------------ Lesser
pet rosal n.
Otic
gang lion
Postganglio nic parasym

pat hetic fibers (run a shor t
Internal caroti d distance wi t h t he
plexus auric ulotemporal n.)
Tym panic
Prom ont or y of
labyrint hine w all
Inferior Tym panic

ganglion plexus
483
Fig. 31.22 Course of the vagus nerve
The vagus nerve gives off four major branches in the neck. The inferior
laryngeal nerves are the termin al branches of the recurrent laryngeal
nerves. Note: The left recurrent laryngeal nerve winds around the aortic
arch, while t he right nerve win ds around the subclavian artery.
Vagus nerve branches

in the neck
<D Pharyngeal branches
@ Superiorlaryngeal n.
® Right recurrent laryngeal n.
Vagusn, ® Left recurrentlaryngeal n.
(CNX)
Cervical cardiacbranches
- -7--- CD
'----1-- Internal branch

(internal laryngeal n.)
f------j f-- - External branch
(external laryngeal n.)
Cricothyroid
muscle
Right inferior -----'-'----\:~;--.) .... olf;.- - t--- - Leftinferior

laryngeal n. laryngeal n.
......---'-,- CD
'~'---.,.----- Internal branch (sensory)
Cricothyroid ---~:.-r::-_~~ k-- ; - External branch (motor)

muscle
A Branches of t he vagus nerve in t he neck. Anterior view. B Innervation of the pharyngeal and laryngeal muscles. Left lat eral view.
485
Fig. 31.25 Hypoglossal nerve Precentra l
gyr us
Post erior view of t he brainstern w it h t he cerebellum rem oved.
Note: C1, w hich inn ervates t he t hyro hyoid and geniohyoid. runs
briefly wit h t he hypoglossal nerve. ;t" ~/ w
.....
~
Q
Q
:::I
-
Q'
'r-- - - Corti co

bulbar
fib ers Sty loglossus
Fig. 31.26 Hypoglossal nerve nuclei

Note: The nucleus of t he hypog lossal nerve
is innervat ed by corti cal neurons fro m th e
contra latera l side.
Nucleus of
the hypo
~ Genioglossus
X
I
glossal n.
Hyoglossus
~;.-~ ::::;;" ~T-----;'i:'- - Nucleus of

Thyr ohyoid
th e hypo
glossal n.
Foram en
magnum
Hypoglossal
canal C1 spinal n.
A Ante rior view. Fig. 31.27 Hypoglossal nerve lesions

Superior view.
Hypoglossal t rig on e Paralyzed

(in rho mboid fossa) geniog lossus
~
Nucleus of th e
hypoglossal n.
A Normal genioglossus
Olive Tongu e
mu scles.
B Cross sect ion throug h t he medu lla B Unilateral nuclear or
oblongata . periph eral lesion.
Hypoglossal nerve (eN XII)

Course Fibers Nuclei Function Effects of nerve injury
: Emerges from t he medulla ob longata. • Innervates: . Cent ral hypoglossal paralysis (sup ranuclear): ton gue deviat es .
, leaves t he cranial cavit y through t he • Nucleus of • Int rin sic and ext rinsic ' away from th e side of th e lesion •
: Somatic
. hypoglossal canal. and descends lat erally : t he hypo - mu scles of th e tongu e ' Nuclear or peripheral paralysis: tong ue deviate s toward t he :
: eff erent
: t o t he vagus nerv e. CN XII enters th e roo t • glossal n. (except t he palatoglossus• • affect ed side (due to prepond erance of m uscle on health y side) •
• of t he tongu e above t he hyoid bon e. supplied by CN X) . . .. F. I ~ ~.c. i d paralysis: both nuclei inj ured; tongu e cannot be pro t ruded •
487
~
Fig. 32.2 Sensory innervation of the face Ophthalm ic
divisio n
_ _-----';-_ _ Greaterocci
pita l n. (C2)
Trigemina l n. Maxill ary
(CNV) divi sion
Spinal nn.,
J
A
Mandi bu lar dor sal rami
Supr aorb it al n. divi sio n ~
(fro m CN V,)
Transverse
cervical n. ~-f-- - ",,----- Supraclavic
C3, {
vent ral Great auri cular n. / ular nn.
ram i Lesser occipita l n.
Infrao rbit al n.
(from CN V,)
B Sensory innervation of the head and neck, left lateral view. The oc
cipu t and nuchal regions are supp lied by t he dor sal rami (b lue) of t he
spinal nerves (the greate r occip ita l nerve is the dorsal ram us of (2) .
Ment al n.
(fro m CNV )
A Sensory branches of th e trigem inal nerve, anterior view. The sensory

branc hes of t he t hree d ivision s emerge from the supraorbit al, inf raor
bital, and me nta l foramina , respect ively.
Maxillary division Ophtha lmi c d ivisio n

(CN V,) (CN V,)
Supraorbit al n.
Supr atrochlear n.
Trigeminal
ganglion
Pterygopa lati ne
gangli on
Mand ibu lar d ivision
(CN V 3 )
Infrao rbit al n. €i~~~~iiiiilfi!!!~~~~-- Auri cu lotempora l n.
Masseteric n.
Buccal n.
Lingual n.
Infer ior
alveolar n.
Menta l n.
Myloh yoi d n.
C Divisions of t he t rigem inal nerve , left lateral view .
489
~ Clinical
Carot id arte ry at herosclerosis

The carot id art ery is oft en affected by ath erosclerosis,a hardening of arter ial art ery does not preclude coronary heart disease or at herosclerot ic changes in
walls due t o plaque formati on : The examiner can det ermi ne t he status of t he ot her locati ons.
arteries using ult rasound. Note: The absence of at herosclerosis in t he carotid
A Common carot id arter y wi t h "normal" flow. B Calcified plaque in t he carot id bulb.
Fig. 32.4 External carotid artery: Overview

Left lat eral view.
Termi nal
branc hes
I
Medial
~--#--",-"'!""';-;,==~=.;;<..::;~-- Superficial
branch
t empo ral a.
Posterior
;o..;;~'------ auricular a.
Occipita l a.
A Sche matic o f th e ex terna l carot id artery. j -- -- Maxillarya .
kiii~e.iF.'",=------ Ascending
pharyngea l a.
~_;'--T-1---- External carot id a.

--'~~_.---- Int ernal carot id a.
---'nij; ; . - -- -- Carotid bif urcation

Branches of the
external carotid artery

Superior
t hyroid a.
Group Artery
Superior t hyro id a.
~"~=-~.¢--- Vertebra l a.
Common
• Ante rior (p. 492) Lingual a.
...................... . .. ... ................................ carot id a.
: Facial a.
.................................................................. U'!~d-~~~::::::~--- Thyrocerv ical

: Medial (p. 492) • Ascending pharyngeal a. t runk
.... .......................... . .
: Occipital a. , ,;;r-- --'!"''''-- - - - Subclavian a.

• Posterior (p. 493) n • •• ••••••••••••• • • •• • •
• Posterior auricular a.
; ~ax i l la ry a.
• Terminal (p. 494)
L ~ uperfic ia l tempor al a.
B Co urse of t he external carot id ar te ry.
491
Fig. 32.6 Posterior branches
Left lat er al vi ew. Th e po st eri or br an ch es of th e
exte rna l ca rotid artery su p p ly th e ear (p . 534 ),
po st erior sku ll (p. 499), and po st eri o r neck
muscles (p . 58 5).
Superficial -----l'--- -...-"'--ci

t emporal a.
~--7-:...L..-- Posterior
auricular a.
_11'1-- - - - Occipita l a.
F.-- - - Ext ernal carot id a.
I
rr-- - - Vertebral a.
I
I
r
Posterior
branch
A Arteri es o f th e post eri or bran ch .
Superficial
t emporal a.
Maxillarya .
Ascending
pharyngeal a. Occipit aI a.
Facia l a. - - --'t:'I
Lingual a. ---~I I
Internal carot id a.
Ext ernal caroti d a.
. .- - Com mon carot id a.
B Course of th e po st er io r br an ch es.
Anterior, medial, and posterior branches of the external carotid artery

Branch Art ery Divisions and distrib utio n
: Superior t hyroid a.
........ . 'H ~ la n.d ~ l~r ?ra nch (to thy roid gland); superior laryngeal ~ : ; st: rn.?cl ~i 9. ?':l ~ st o.i~br~n. ~.~
, Dorsal lingual branches (to baseof tongue, epiglottis); sublingual a. (to sublingual gland, tongue, oral floo r,
: Lingual a.
~ Anterior branch ....... . ....... : oral C~~ ity)
: Ascending palatine a. (to pharyngeal wall, soft palate, pharyngot ympani c t ube); to nsillar branch (to palatine
Facial a.
~ ton sils); submental a. (to oral floor, submandibular gland); labial aa.; angular a. (to nasal root)
...... .. ... ..... ... ..... .................. ....... ........ .......... ... ... .. ...... .... ..... ..... ... .... ... ...... ...... ... . ... ...... ... ..... .... .... ... ......... ....... .............. ..... .. ....................
, Medial branch H H HH .. ~s.C.~n.~.in.~ ph~ r.Y.n.~.~~I~ :

..H'H H . : Pharyng:al branches; int erior t ymp anic a. (to mucosa of inner ea r.);P?st.~r.i? rH~en i n.~:.a. la : .. . H ..
~ ? c.~ ipi.ta. I ~ :H ?c~ ipita. I. b. r.a nc hes ; descending branch (to posterior neck muscles)
, Posterior branches . . Stylomastoid a. (to facial nerve in facial canal); post erior tympanic a.; auricular branch; occipit al branch;
, Posterior auricular a. : parotid branch
: For t erminal branches, see Table 32.3.
493
Fig. 32.8 Maxillary artery ~ Clinical
Left lateral view. The maxillary arte ry consists of three part s: mandibul ar
(blue) , pt erygoid (g reen), and pt erygop alatin e (yellow ).
Middle men ingeal artery
The mid dle m eningeal ar te ry supplies t he men inges and overly ing calvaria.
Rupt ure of th e arte ry (gene rally du e t o head traum a) results in an epidu ral
he matoma .
Midd le m eni ngea l a. Frontal branch Parietal branch

Posterior
superior
alveo lar a. Dee p auricular a.
Buccal a.
Inferior alveolar a.
A Division s of th e maxillary arte ry.
Middle meningeal a. Petrous branch
A Right mid dle m eningeal arte ry, med ial view of open ed skull.
Infra Calvaria
orb ital a. Spheno
Rupt ured middle
palat ine a.
meninge al a.
Deep tem Fract ure .------ -- Arachnoid
por al aa.
- -- - Dura mater
Epidural
B Epidural hematoma
Pter ygoi d hem at om a.
br anch Schema t ized
coro nal sect ion.
Sphenopa latine artery
The sphenopalat ine arte ry supplies t he wa ll of t he nasal cavity. Excessive..

Maxillarya . nasoph aryng eal bleeding fro m t he branches of t he sphe no palati ne ar tery
Masseter ic a. may necessit at e ligati on of th e m axilla ry artery in t he pt erygopalatine fossa.
Buccal a.
Lateral posterior Posterior sept al
nasal aa. branches
An te rio r and
Spheno
Menta l palat ine a.
posterior
branch
superio r
alveo lar aa.
B Cou rse of th e maxillary art ery.
Descending
palatin e a.
Lesser palat ine a.

Greater palatine a.
C Lateral w all of nasal cavit y, left lat eral view .
495
Fig. 32.10 Deep veins of the head
Lef t lat eral vi ew. Removed: Upper ram us,
Deep Cavernous Superficial co ndy lar and co ro no id pro cesses o f mandibl e.
t emporal w. sinus t emporal v. Th e pteryg o id ple xu s is a venou s network sit u
at ed betw een th e mandibular ramu s and th e
muscl es of ma stica ti on . The cavern o us sinus
Superior
I con ne cts br an che s of th e facial ve in to th e

ophthal sig moid sin uses .
mic v.
Superior
and
inferior
Angularv. petro sal
sinuses
----5j!!!!i-----¥-- Sig moid

sinus
Deep
facial v.
I ..lf-"-~f- Retromandibular v.
"""-- - - Int ernal

j ugularv.
Facial v.
Fig. 32.11 Veins of the occiput Parieta l --~-;

emissary v.
Poster ior vi ew . Th e superfic ia l veins of th e
oc ciput co m m u nic ate w it h th e dural ve nous --:------.----~fl-- Superior
sin uses via em issary ve ins that drain t o dipl oic sagitta l sinus
vein s (calva ria. p. 4 57) . Note: Th e ex te rna l Occipita l - -- -- L-- --f--- Confluence
vertebral ven ou s pl exus traver ses th e ent ire emi ssary v. of th e sinuses
length of th e spine (p. 611).
Sigmoid ~-'H--- Transverse
sinus sinus
Venous plexus
around for amen ~-- Mast oid
magnum em issaryv.
i""9H/ii~--- Condylar
emissaryv .
n -----'lr --- - - - Internal
ju gular v.
External verte bral
'\-- - - - Occipita l v.
venous plexus
Venous anastomoses
The extensive venous anast om oses in th is region provide rout es for t he spread of infections.
· Extracranial vein Connecting vein Venoussinus

· Angular v.
... ..... .......................... : ? ~.P.~ri?r.~.~~. i ~~~r.i?~ ? p. h.~ha l m ic vv.
Cavernous sinus'
• Vv. of palati ne t onsil ! ~~~ry~? i~.~ I~~u ~: i~f~r i?r opht halmic v.
•..~.u. Per fici a l temp oral v. ........ d. d . .............. ..d. ~ Pa r i~t~ I ~~ issa ry v~: . d .d . ... . .... ... . .. . . . . ~~p~ri?rsa g itta l ~ in u.s d .
· Occipital v. : Occipital emi ssary v. . Transverse sinus, conflu ence of th e sinuses

~ Posterior auricular v. · Masto id emissary v. ..d..d...d...... . ddd . . . d. ddd... dddd! Sigmoid sinus
.... .. ....dd d..ddd dd..dddd.dd.dddd....ddd dddd.
: External vert ebral venous plexus ~ Condylar emissary v.
~ • Deep spread of bacterial infect ion from th e facial region may result in cavernous s i nu s t.h.~?rn bos is .
497
Fig. 32.13 Superficial neurovasculature of the head
Left lat era Iview.
Superficia l tempora l a.• Superfi cial temporal Superficial tem poral a.,
fronta l branch a. and v. parietal branch
Supraorbital n.
(branch of CN V,)
Supratrochlear n.
(branch of CN V,)
Zygo mat ico

orb it al a.
Auriculotempora l n.
Angula r v.
Transverse
facial a.
Infraorbit al n.
(branch of
CN V2 )
Paroti d duct ----,----.!l~'-----'-~~

Greater
occipital n.
Buccinator
Lesser
occipita l n.
Ste rnocleido
Ment al n. mastoid
(branch of
CN V)
Occipita l v.
Parotid gland
Great auricu lar n.
Masseter Parot id plexus Ext ernal

of facial n. (CN VII) j ugular v.
499
Fig. 32.15 Temporal fossa
Left lateral view. Removed: Sternocleidomas
toid and masseter. Revealed: Temporal fossa
and temporomand ibula r joint (p. 540).
Tem porom andibular
joint capsule
Coronoid
process
Facial n.
Paroti d
duct
Hypoglossal n.
Superio r
cervical ganglion
Subma ndibular ----!~~~~~~

gland
Int ernal
carot id a.
Ext ernal
carot id a.
Facial a.
and v.
Superior Commo n Int ernal Accessory n.

t hyro id a. and v. facial v. jugular v.
501
Fig. 32.17 Deep layer
Left lateral view. Removed: Lateral pt erygoid mu scle (both heads). Revealed:
Deep infratemp ora l fossa and mandibular nerve as it ente rs th e mandibu
lar canal via th e foramen ovale in t he roof of th e fossa.
Superficial tempo ral

Temp oralis a. and v.
Deep Late ral pterygoid

tem poral nn.
Infraor bital a. Auriculote mpo ral n.
Sphenopalatine a.
~~ ~~f---j,-- Mandibular n.
(CNV,)
Posterior superior
alveolar a. ~---~~~--"':'------- Midd le
meningeal a.
Buccal a. and n.
Maxillarya.
Buccinato r
Medial pterygoid
Lingual n.
Facial a. and v. Facial n.
Masseter Inferior alveolar

a. and n.
Mandibular
foramen
Fig.32.18 Mandibular nerve (eN V3 )

in the infratemporal fossa
Mandibu lar
division (CN V,)
Mandibular div ision
Mening eal (CNV ,)
branch
N. of tensor t ympan i
Deep (w it h mu scle)
te mporal nn.
--:=-- _.....-... ..~_- N. of tensor
Lateral veli palatini
pterygoid n. Sty lomasto id (w ith mu scle)
for amen
Medial Lesser petr osal n.
pt erygoid n. ~ Auriculo
Inferio r
fL ~ te m poral n.
alveolar n. i A Auriculo- Commu nicat ing
Buccal n. =="I"fi.~l!!r~"f\ I I t emp or al n. branch to auric Otic ganglion
ulote mporal n.
Lingual n. )
Parotid
branches Chorda t ympani
Medial Lingual n.
pterygo id n.
(w it h mu scle)
Inferior . .~- Mylohyoid n.
alveolar n.
A Left lat eral view. B Medial view .
503
~ The maxillary division of the trigeminal nerve (eN v 2 • see p. of the pterygopalatine ganglionsynapse with ganglion cells t hat inner
IIIiii3I 477) passes from the middle cranialfossa through the foramen vate the lacrimal. small palatal. and small nasal glands. Thesympathetic
rotundum into the pterygopalatine fossa. The parasympathetic fibers of the deep petrosal nerve (sympathetic root) and sensory fibers
pterygopalatine ganglion receives presynaptic fi bers from the of the maxillary nerve (sensory root) pass through the pterygopalatine
greate r pet rosal nerve (the parasympathetic root of the nervus ganglion without synapsing.
intermedius branch of the facial nerve). The preganglionic fi bers
Fig. 32.20 Nerves in the pterygopalatine fossa

Left lateral view.
Gang lionic branches
Inferior orbital
fi ssure
Superior alveolar nn.,

Pterygopa latin e
posterior superior
gang lion
alveolar branches
Greate r pet rosal n.
Deep petrosal n.
Pharyng eal n.
~-- Internal
carot id plexus
Interna l carot id a.
Passageof neurovascular structures into pterygopalatine fossa

Origin of st ruct ures Passageway Transmitted nerves Transmitted vessels
: 0) Infraorbit al n. : Infr aorbital a. (and accompan ying vv.)
. Orb it : Inferior or bita l fissure
.....................................................................
: Pterygoid canal : A. of pterygoid canal (with accom panyi ng vv.)
: Palate
: Lesser palatine canals , CD Lesser palatine nn.
.... ... .. ..... ... .. ... .. .. .. .. .. .... ... . ... ... ....... .... ... .... ..... ... .... .... .... ... ... ... ...... ... .
. Nasal cavity : Spheno palat ine for amen

: ® Medial and lateral posterior superior and posterior
: Spheno palati ne a. (wit h accom panying vv.)
.. .. inferior nasal branches (from n a.s o pala ~ in e n..: . ~ N V2)
505
Frontal bone.
orbita l surface
Fro nt al Superior
sinus or bita l fissure
Structures surrounding the orbit

Direction Bordering struct ure
Zygomat ic bon e.
Sphenoid bone,
orbita l surface Frontal sinus
lesser wing
Superior
Zygomat ico
i Anterior cranial fossa
. .
orbital fo ram en ~ Sphenoid bone.
greater w ing
Medial . Ethmoid sinus
Maxilla.
Inferior
orbita l surface
Certai n deeper st ruct ures also have a clinically impo rtant relati onship
Infraorbit al
to the orbit:
.............. .......................................
canal
Sphenoid sinus : Hypophysis (pituitary)
................ ....... ....... ......... ........ .... ... ..... ............ ......
Inferior Maxillary
Midd le cranial fossa ; Cavernous sinus
.. .... .... .... ........... ............. . .
orbit al fissure sinus

Opt ic chiasm ... ! Pt erygopalat ine fossa.
Palatine bone.
pyramidal
pro cess
C Medial view of right orbit.
Front al Crista Ethmoid
•..\ . sinus galli bo ne

Fron tal bone.
orbita l surface
Sphenoid bone.
lesser w ing
Perpendicular
plate
Opt ic canal
Ethmoid bone.
Superior
orbital plate
orbital fissure
(lam ina papyracea)
Superior
Sphenoid bone.
nasal concha
greate r w ing
Zygoma t ic bone.
orbita l surface
Infraorbital
canal
Midd le
nasal concha
Maxillary
sinus
Inferior
nasal concha
Vome r
Palat ine
process of th e
maxilla
o Coronal section , ant erior view.
507
Fig.33.4 Innervation of the extraocular muscles
Righ t eye, lat eral view with t he tem poral wall of t he orbit rem oved.
Medial
rect us Superior
Levator palpebrae
superioris obl iqu e (with tr ochlea)
Com m on
tendin ous ring
-----"''''=~----.----- Superior
rectus
Oculomotorn. ~
(CN III)
Lat eral
Trochlear n. C rectus
(CN IV)
Inferior
oblique
Inferior
rect us
Inferior orbital
fissure
Maxillar y
Clivus sinus
~ Clinical
Oculomotor palsies
Oculom ot or palsies may result from a lesion involving an eye m uscle or its Im pairm ent of t he coord inated actio ns of t he extraocular m uscles may cause
associated cranial nerve (at th e nucleu s or along t he cour se of the nerve). If the visual axis of one eye to deviate fro m it s no rma l position. The patient will
one ext raocular muscle is weak or paralyzed, deviation of t he eye wi ll be not ed. the refo re perceive a doub le image (diplopia).
A Abdu cent nerve palsy. Disabled: B Trochlear nerve palsy. Disabled: ~-+- Superior
Lateral rect us. Supe rior obliq ue. rectus
.~+---- Lateral
rectus
Visual (opt ical) axis
C Compl ete ocul om otor palsy. Disabled: Superior, inferior. and me dial rect i
and inf erior ob liqu e.
D Norm al visual and orbital axes.
509
Fig. 33.7 Innervation ofthe orbit
Lateral view of the right orbit. Removed: Fronta l n.
Lacrima l n.
Temporal bony wall. Oculom ot or n., (wit h gland)
superior bra nch
Ocul om ot or Suprao rbital n.
n. (CN III) Inte rnal caroti d
a. w it h internal
carot id plexus Infra
t roc hlear n.
Trochlear n.
(CN IV)
Opht halmic
division
(CNV,)
Trigemi nal Ciliary

n. (CNV) gang lio n
Trigemina l
Parasym
gangli on
Mandi bular pathetic
divi sion roo t
(CN Vl )
Abd ucent n. Maxillary division

(CNVI) (CNV,)
Opti c n. (CN II)

Oculomotor n" Sympa t het ic Nasociliary
inferio r branch root root
Fig. 33.8 Cranial nerves in the orbit

Superior view of the ant erior and m iddle cra
nial fossae. Removed: Cavernous sinus (lateral Periorbita
(periosteum of t he orbit)
and superior wa lls), orbita l roof, and periorbita
(portion s). The trig em inal ganglion has been Supratrochlear n.
retract ed lat erally. Supraor bital n.
..
'
Caverno us sinus
Abdu cent n. Trigemin al Mot or root Sensory root Middle

(CNVI) gang lio n cranial fossa
Trigemin al nerve (CN V)
511
Fig.33.11 Neurovascular contents of the orbit
Sup er io r v iew. Removed: Bo ny ro o f o f o rb it , p er itorbit a, and
retro-o rbita l fat. Superior
opht hami c n.
Supraorbit al
aa. and nn.
Infratroc hlear n. - - """'---.!.J

Cribrifo rm plate
-~~y~~---- Levator palpebrae

superioris
Suprat rochlear - -.::..----7-Gl=..-- -
a. and n.
Poste rior ethm oidal
a. and n. '---- - Lacrima l a. and n. (w ith gland)
- -- - Superior rectu s
Supraorbita l a. '------ -- - - - Abd ucent n. (CN VI)
Nasociliary n. "-- - - - -- - - -- Inferior

opht halmi c v.
Trochlear n.
(CN IV)
Front al n.
A U p p er level.
Levato r palpebrae
Medial superioris
rectu s
Superio r rect us
Superior
oblique
Superior
opht halmic v.
Nasociliary n. ~--- Lacrimal a. and n.

(w it h gland)
Long ciliary nn. --~¥~~---=-,=.
Later al rectu s
Trochlear n. (eN IV) ---'iiiii~~'----=---:r
Short posterior ciliary aa., Inferior

short ciliary nn. opht halmic v.
Abducent n. (CN VI)

Opt ic n. (CN II) ----;:-~=~~::=~~
Nasociliary n. ---~~::~)~~~~~~ -=:;•••;;:::-__ Ciliary ganglion

Oculomo tor n. (CN III)
B Middle lev el. Reflected: Levato r pa lpeb rae

su pe rioris and su p erior rect us. Revealed:
O ptic n erve.
513
Fig.33.14 Lacrimal apparatus
Righ t eye, ante rior view. Removed: Orbit al sept um (parti al). Divided:
Levat or palpebrae superioris (t endon of insert ion) .
Levato r palpebrae
Orbit al - - - - - "' - - + - - --.,...-- - --"'::".--
superioris
sept um
Lacrimal
caruncle
Lacrim al gland, - - - - - - - - - - - ;1-- - --.£11
orbita l part
Superior and
inferior lacrim al
canaliculi
Upper eyelid
Lower eyelid r--..- Superior and

inferior puncta
Nasolacrimal
duct
Infraorb it al Inferior
foram en nasal concha
~ Clinical
lacr imal drainage

Perimenopa usal women are frequent ly subjec t t o chro nically dry eyes
(keratoconjunctivitis sicca), due to insuffic ient tear produ ct ion by th e
lacrima l gland. Acut e infl amm at ion of t he lacrimal gland (due to bact eria)
is less com mo n and charact erized by inte nse inflamm ation and ext rem e
t enderness to palpati on. The upp er eyelid shows a characteristic S-curve.
515
Fig. 33.16 Blood vessels of the eyeball
Tra nsv erse section at the leve l o f the optic /
-- Lesser art erial circle of iris
nerve, superior vi ew. The arteri es of t he eye /

Scleral venous sinus
aris e from t he ophthalm ic artery. a termin al
bran ch of t he in t ern al caro t id artery. Blo od
is drain ed by four t o eight vorti cose vein s

that o pen into the su perio r and inferior
"'~~-- Anterior
Greater conjunct ival a.
ophthalmic vein s.
art erial circle

of iris
Anterior
ciliaryaa .
Long
Art erial circle of Zinn posterior
Vorti cose v.
(and von Haller) cillaryaa .
ciliary aa. capillary layer)

Pial vascular Cent ral retinal a. and v.
plexus j . I Opti c n. (CN II)
~ Clinical
Opticfundus Optic disk Macula lutea
The opti c fundus is th eonly place in the body wher e capillaries can be examined direct ly. Exami nation of
I
the optic fundu s permits observat ion of vascular changesthat may be caused by high blood pressure or
diabetes. Examinat ion of t he opt ic di sk is important in determ ining intr acranial pressure and diagno sing
multiple sclerosis.
Nasal Temp oral

•
Physiological cup
B Normal opt ic fundus in the opht halmo scopic
examinat ion.
Opt ic disk
(blind spot)
Central reti nal

a. and v.
(sites of
ent ry and
emergence)
A Schemat ic. C High int racranial pressure; t he edges of t he

opt ic disk appear less sharp.
517
Fig.33.19 Pupil
Pupil size is regulated by t wo int raocular
muscles of t he iris: t he pup illary sphincte r.
w hich narrow s t he pupil (parasym pat het ic
innervat ion), and th e pupill ary dilator, w hich
enlarges it (sym pat heti c innervat ion).
A Norm al pup il size. B Maximum con stricti on C Maximum dilatio n

(m iosis). (my driasis).
Fig.33.20 lens and ciliary body

Posterior view. The curvature of th e lens
is regulat ed by th e muscl e fib ers of
t he annular ciliary body.
Lens
Iris
Ciliary bod y.
t pars plicata
Ciliary bod y.
pars plana
Chor o id
Zo nular Retin a.
fibe rs o pt ical part
Ciliary proc esses Ciliary m uscle Ora serrat a
Fig.33.21 light refraction by the lens

Transverse sect ion, superior view. In th e norm al (emme t ro pic) eye, light distant sou rce (far vision) . Cont ract ion of th e ciliary m uscle. with zonular
rays are ref racted by t he lens (and cornea) t o a foca l point on th e reti nal fiber relaxat ion, causes th e lens to assume a m ore rounded shape (near
surface (fovea cent ralis). Tensing of th e zonular fibers, w it h ciliary mu scle visio n).
relaxat ion, flattens th e lens in response t o parallel rays arriving from a
Nearsighte d ness No rma l
(myo pia) vi sion
Ret ina
Farsighted ness
Lens (hypero pia)
Fovea cent ralis

Incident
light rays
Lens
A Norm al dynam ics of th e lens. B Abnor mal lens dynamics .
519
Super ior
meatus
Sphenoid bon e.
lesser w ing
Hypop hyseal fossa

Lacrimal bone
Maxilla. fr ont al
pro cess
Superior concha
(et hm oid bone)
Anterior nasal ------..~-_(./

aperture
Medial Plate } Pt eryqoiid
process
Lateral plate
Choana
Midd le meatu s
Inferior Palat ine bone.

concha hori zontal plate
Middl e concha
Maxilla. palat ine process Inferior (eth moid bon e)
meatu s
B Lateral wall of th e right nasal cavity. Sagitt al sect ion. medial view.
Removed: Nasal sept um. Note: The superior and middle conchaeare
partsof th e et hmoid bone. whereasth e inferior nasalconchaeis a
separate bone.
Cribriform Orifices of posterior

plat e et hmo id sinus
Superior nasal
concha (cut )
Sphenoid sinus
Spheno palat ine

Ethm oid bu lla foram en
Lacrimal bone ---~~~------;-
Uncinate --------:~~-~:------:-~
process
!"
Inferior
concha (cut )
Maxilla. palat ine
process
Maxillary Palatin e bo ne.

hiatu s per pend icular plate Inferi or meat us
( Lateral wall of the right nasal cavitywit h th e conchae removed. Sagittal

section, medialview. Revealed: Pa ranasal sinuses (p. 522).
521
Fig. 34.5 Bony structure of the paranasal sinuses
Co ro nal sec t io n. anter ior v iew.
Fronta l Et hmo id Anter ior

sinus bone cranial fossa
Fro nt al bone
Sphenoid bone.
lesser wing
Maxillary
sinus
nasal concha Vome r
A Bon es o f th e para nasa l sin uses.

Cribriform Crist a Frontal
plate galli Perpendic ular
plate
Orbita l plate Superior

meat us
Superior
concha Orbit
Midd le Middle
et hm oid sinus ----'~-----~L: meatus
Midd le _ _ ~~~~~T--"o# Osti um of

maxil lary sinus
concha
Uncinat e process
Maxillary
sinus
Inferior
meat us
Inferior Palatine
concha process
Vomer of maxilla
B Et h moid b o n e (re d ) in t h e para nasal sinuse s.
~ Clinical
Deviated septum
The norm al positi on of th e nasal septum creates two rough ly sym m et rical
nasal cavities. Ext reme lateral deviation of t he sept um may result in
obstru cti on of th e nasal passages. This may be corrected by remov ing
porti ons of t he cart ilage (septoplasty).
Sinusitis
When t he mucosa in th e et hmoi d sinuses becomes swollen due to
C MR I thro ugh t h e p ar ana sal sinuses.

inf lamm ation (sinusitis). it blocks t he flow of secretions from t he fron tal
and maxillary sinuses in th e osteom eatal unit (see Fig. 34.4) . This
m ay cause microo rganism s to becom e trapp ed. causing secondary
inflam mat ions. In pati ent s wi t h chron ic sinusiti s. the narrow sites can be
surgically widened to establish m ore effect ive drainage ro utes.
523
Cribrifor m plate Sphenoi d sinus Fig.34.8 lateral nasal wall
Sphenoet hmo id
recess
\
Superior
----~"---,""'
meatu s
Mid dle -
meatus
- 4 -7 ~?~~~iii;~~l~'-T,;~;:----- Pharyngea l
t on sil
Inferior
f-'B=-;----;7:c-\T-- - SaIping 0
nasal concha
pharyngeal
fo ld
Limen nasi
Nasal vesti bu le Inferio r

meatus
Uvula
A Mucosa of th e lateral nasal w all. Sagittal

sectio n, viewed fro m t he left side.
Olfacto ry fib ers,
posterio r
eth mo idal a.
Ante rior
- - - - -.F-----i'--,
et hm oidal a.
Pte rygo palat ine
ganglion
Inferior poste rior
nasal branches.
lateral po sterior
Descending
nasal aa. palat ine a..
greate r
and lesser
palatine nn.
~ Clinical
Nosebleeds
Vascular supply to t he nasal cavity arises
from bot h th e int ernal and exte rnal carot id
arte ries. The anterior part of t he nasal

Greate r palatine a. and n.
sept um contai ns a very vascularized region
referred to as Kiesselbach's area. This area
B Nerves and arteries of th e lat eral nasal wall,

is t he m ost com mo n site of signific ant
nosebleeds. left lateral view.
Fig.34 .9 Nerves of the nasal cavity Ante rio r et hmoidal n.

Left lateral view. (CNV,) Olfacto ry
fibers (CN I)
Ante rio r
Lateral
ethmoid al n. superior
(CNV,) poster ior
External
CN V, nasal
nasal
branches
branch
Med ial
nasal
~~;:.:::::~~t,:-.~~~~~-- Pterygo
branches palati ne
.=~r--- Trigeminal ganglion
ganglion
Inferior
po sterior
nasal branches
Medial superior Pterygopalat ine
gang lion (in Lesser
posterior nasal
pterygop alat ine palati ne nn.
branches (CN V,)
fossa) Greater
Nasop alat ine n. (CN V,) Spheno palat ine
foram en Internal nasal branches palatine n.
A Nerves oft he nasal sept um. B Nerves of t he lat eral nasal wall.
525
Fig.35.2 Part s of the temporal bone
- - - - - --r'---- Squamo us
part
Stylo id Squam ous

process part
Tym panic - ------1¥-----;;;_ Pet ro us

Tymp anic
part part
part
Petro us
part
A Left lateral view. B Inferior view.
~ Clinical
Structures in the temporal bone Intern al Temporal bone.

The ma st oid proce sscont ains mast oid air cells t hat com m unicate w ith th e acoustic meatus pet rous part
mi dd le ear; t he m idd le ear in t urn com m unicat es w ith th e nasoph arynx
via the pharyn got ympanic (auditor y) t ube. Bacte ria may use t his path way
t o m ove fr om t he nasopharyn x into th e m id dle ear. In severe cases,
bacteri a may pass fro m th e mastoid air cells into t he cranial cavity, causing
meningitis.
Chorda Mastoid
t ympani Facial n. (CN VII) air cells
Facial n. (CN VII),

vest ibulocochlear n. (CN VIII)
Tympanic ---~
membrane
The pet ro us portio n of t he t emp oral bone contains th e mi ddl e and inn er
Pharyngot ympanic
ear as we ll as t he tym panic mem brane. The bo ny sem ici rcular canals are
(audit ory) tube
oriented at an approxim ate ly 4 5-deg ree ang le fro m t he coronal. t ransver se.
and sagitta l planes.
Anterior Posterior
semicircular canal semicircular canal
Mast oid process
Irrigatio n of t he aud itory canal w it h wa rm (44 ' C) or coo l (30'C) wate r

can induce a th erm al current in th e endo lym ph of t he sem icircular
canal, causing t he pati ent t o manif est vestib ular nyst agm us (jerky eye
Cochlea - --G'--- - ---l
m ovement s, vestibulo-ocular reflex). This calor ic t est ing is import ant in the
d iag nosis of unexplained verti go. The pat ient m ust be orient ed so t hat t he Cant homeatal - - _.../
sem icircular canal of intere st lies in th e vert ical plane. plane
Lat eral
semicircular
canal
Mastoi d process
527
Fig. 35.5 Structure of the auricle
The auricle of th e ear encloses a ca rti lag inous f ram ew ork t hat forms Auricular is Temp oro
a fu n n el- sha pe d recept o r fo r aco u sti c v ib ratio ns. The mu scl es o f th e superior parieta lis
(posterior part
au ricle are co nsi de re d mu scl es o f faci al expressio n , alt ho u gh t hey are W

of tempo ro - Helicis VI
ves t igia l in hu m an s. parieta lis) majo r ~
Helicis 3
"0
minor 0
-a
Auricularis
poste rior
Ext ernal
Scaphoid
audit ory OJ
0
fossa
canal :::I
/'t)
Antitragicus
Tragicus l(o
- -- -- Cymba conchae .,~

Helix ~--- Exte rnal
B Cart ilage and m uscl es of t he au ricl e, right lat eral vi ew .
audito ry canal
-------- Tragus
~ Intert ragic
, ~ mcisure Auricularis - --+. Obliquus
Antih elix I Antitragus
superior auriculae
Auricularis 7-.,..-~-- Transversus

Concha Earlobe
anterior auriculae
A Rig ht auricl e, r igh t lat era l v iew.
Ext ernal Auricularis
audito ry posterior
canal
Fig. 35.6 Arteries of the auricle C Carti lag e an d m uscl es of t he au ricle , m ed ial view of p ost eri or surface.
Superficial
te mpora l a. Perf orati ng
Perforating
branches Anterior
branc hes
Aur icularis
posterior
----<
auricular aa.
1,.£;0>1--- Maxil larya .

Poster ior
Posterior auricular a.
aur icular a.
A Rig ht later al Externa l carot id a. B Po st erior v iew o f
v iew.
th e rig ht au ricle .
Fig. 35.7 Innervation ofthe auricle
- -- Auricul ot emporal n.
(tr igemina l n., CN V)
Fa cial n. (CN VII) ~---- Vagus n. (CN X) and

glossopharyngeal n.
(CN IX)
..
Fa cial n. ----L~c-="'"
A Rig ht lat eral
view.
v
Cervical plexus, lesser occipi t al nn.
and great auricular n.

B Poste rio r v iew of
t h e righ t auricle.
529
Epitympa num St apes Fig. 35.10 Tympanic cavity
Tendon of
tensor
tympa ni
Meso
ty mpanum
""""=~02'!~- Hypo
ty m panum
Pharyngo
tympa nic
t ube
A Lev els of th e t ympanic cavi ty. Anterior v iew.

Th e t ympani c cavity is divid ed into three
level s: ep l-, rn eso- , and hyp otympanu m.
Aditus (inlet) to ---~+.2"=' -- Lesser pet rosal n.
masto id ant rum
Malleus -----,-~~
_ _ Fac ial n. (CN VII) in
facial canal
Incus ------;:'r.c~~ Prom inence of lateral
semicircular canal
Chorda tympa ni ---F:~~""-''-::-'''''F=---
~"¥:'~:T.i'-i--- Promin ence of
facial canal
Tensor tympa ni
'--,;r'---,*,~h1"'~- Stapes
Tendon of
st apedius
Tympanic ---~ . ;----,+::~-.....-<.;.:..,,>'-- Tym panic

memb rane plexus
. r'--:-:-"1:~"""--~~.-'--- Tympanic n.
B Rig ht t ympan ic cav ity. A nterio r v iew
wi t h th e anteri or wall rem ov ed .
!/
Ante rior sem i- Roof of ty mpanic Geniculate
circular canal cavity (teg men ty mpani) ganglio n Vestibular n. (CN VIII)
Posterior semi
~ Facial n. (CN VII)
~ Coch t e ar n . (CN VII I)
circular canal
-,
Lateral semi
Greater petrosa l n.
. .~ Lesser pet rosal n.
circu lar canal
·t.;.:",;,.
Oval window --~~~iji.!~~~~ '\.t· "_\.'f. ....
. Semicanat of
tensor ty m pani
Internal caroti d a.
+- - - Pharyngotympan ic
Promontory
(audito ry) t ube
Internal
carot id plexus
Anterior walt of
tympa nic cavity
Round Tympanic Internal Tympanic n.

window niche plexus ju gular v.
C An at omical rel ati on ships of th e t ym pani c

cavity. Obli q ue sag it t al sectio n showin g th e
m ed ial w all. 531
Fig. 35.16 Ossicular chain in the tympanic cavity
Latera lview of the right ear. Revealed: Ligaments of the ossicularchain
and muscles of the middle ear (stape dius and tensor tympani).
Poster ior ligament Superior lig am ent s of

of incus Incus t he incus and ma lleus
Incudo
mall eo lar joint
Annu lar
st apedial
ligam ent
Tendon of
Staped ial t ensor tympani
membrane
Tensor t ympani
Incu do
st apedial j oi nt
Int ernal carot id a.
Pet rot ympani c

fi ssure
Ant erio r ligament

Stylomast oid a. of ma lleus
Chorda tym pani

Facial n. - - ----::;,----- 1:
(CN VII) Anterior
tympan ic a.
Posteri or Chord a Tympanic Anterior pro cess
t ympanic a. t ympani mem brane of malleus
~ Clinical
Ossicular chain in hearing

Sou nd waves funne led int o t he exte rnal auditory canal set the tymp anic membrane and the oval window increases t he sound pressure 17-fold. A to t al
m embrane int o vib rat ion. The ossicular chain transm its the vib ration s t o t he amp lification fact or of 22 is achieved through the lever act ion of t he ossicular
oval w ind ow, w hich com mun icates them t o th e fl uid column of the inner ear. chain. If the ossicular chain fails to transform the sound pressure between t he
Soundwaves in fluid meet w it h highe r im pedance;they m ust th erefore be t ym panic mem brane and th e footplat e of t he st apes, t he patie nt will experience
amp lified in t he mid dle ear. The diff erence in surface area bet w een the tympa nic condu ctive hearing loss of magnitude 20 d B. See p. 519 for hearing.
Malleus Incus
A Vibr at ion of th e tympan ic memb rane causes a rocking movem ent in the
ossicular chain. The mechanical advantage of t he lever act ion of the os
sicular chain amplifies t he sound waves by a fact or of 1.3.
Pyramidal _
eminence _ _ Oval window
/ : wit h annular
Basilar
B The st apes in it s norm al posi Stapedius ------------'7- st apedial
membrane
ti on lies in th e plan e of th e oval t endon ! ligament
~----'-:'-""'o-cc.--- Tympanic
w indow .
membrane
D Propagat ion of so und waves by t he ossicular chain.

C Rocking of the ossicular chain causesth e st apes to til t. The
movement of th e sta pes base against th e membran e of th e
oval w indow (stapedial mem brane) ind uces corresponding
waves in the fluid colum n of th e inner ear.
533
Fig. 35.18 Arteries of the middle ear: Tympanic cavity
Right petr ous bone, ante rior view. Removed: Malleus, incus, portions of
chorda t ympani. and anteri or tympanic arte ry.
-.
Ante rio r semicircular
Subarcuate a. Superficial pet rosal a.,
canal
ascending branch
Int ernal
auditor ya . Facial n. (CN VII)
Superf icial
pet rosal a..
descending
branch
Anter ior
crural a.
Int ernal
carotid a.
Stylomas toi d a.,

posterior
ty mpanic
branch
Sta pedial
branch
Facial n. (CN VII) - - --=--'-'------'----=__ Tensor

ty mpa ni
Stylom astoid a. --~~-~--.r::;~ 1
Carot ico
ty mpanic aa.
Mastoid a. Posterior
t ymp anic branch Deep auricular a. Inferior t ympani c a.
535
Inner Ear
~ The inner ear co nsist s of th e vesti bular apparat us (fo r balan ce) a bo ny labyrint h fi lled wi t h peri lymph and em bedded in th e petrous part
IIriiiiiII and t he audito ry appa rat us (for hearing ). Bot h are for me d by a of th e te mpo ral bon e.
m em b ranou s labyrin th fi lled w it h endo lym ph fl oat ing withi n
Fig. 35.19 Vestibular apparatus

Rig ht lateral view .
Endolymphatic Anterior
Semicircular
canals
df~ duct ampullary n.
Superior
part
Vestibular
ganglion
u~;t
-f-- - - Inferior } (CNV III)
part
-~-=-;:l---- Utricl e
Ductus Saccule (wit h utricular n.)
reuniens
A Sche matic. Ampull ary crests and m acu lae
of utricle and saccule show n in red .

Latera l - --,------<
semicir
cular duct
Saccule
(with saccular n.)
Posterior Ductus
Endolymphatic ampullary n. reuniens
duct
B Struct ure of th e vest ibular app arat us.
Fig. 35.20 Auditory apparatus
The coc hlear labyrint h and its bon y shell form t he coc hlea, w hic h co n
t ain s t he sensory epit he lium of t he aud ito ry appa ratus (o rgan of Cort i).
Lesser
- - - Scala vesti buli )
"'•\ ~\ \-
C hi d t Cochlear
7 ~
I~
-
--
oc ear uc canal
Scalaty mpani
, Oval Round ~ Cochlearaqueduct

window
window
A Schematic.
- - Chorda
t ympani
Internal
acoustic
meatus
Spiral
ganglion -. . . . .'i~~:g~~===~~~~
Temporal bone. Semicircular canals
petrous part
C Locati on of th e cochlea. Super io r view of t he petrou s part of th e

t em poral bone w ith t he coc hlea sect io ned t ransver sely. The bon y
B Compartm ents oft he '-. -- -=' - canal of t he coc hlea (spiral canal) mak es 2. 5 turn s around it s bo ny axis
cochlear canal, cro ss sectio n. (m odio lus).
536
Fig. 35.21 Innervation of the membranous labyrinth
Right ear, ante rior view. The vesti bul ocochlear nerve (eN VIII; see p. 480) t he vest ibular and cochlear nerves. Note: The sensory organs in t he sem i
t ransmit s afferent im pulses from t he inner ear t o th e brainste m th rough circular canals respond t o ang ular accelerat ion, and th e macular orga ns
the int ernal acousti c meatus . The vestibulocochlear nerve is divided into respond to horizontal and vert ical linear acceleration.
Anterior semi Ant erior Vestibular Vestibul o

circular duct amp ullary n. gangli on , cochle ar n. (CN VIII),
superior part vestib ular part
/ Facial n. (CN VII)
/ Vestibu lar
ganglion,
Dura mater ~ inferio r part
Endolymphati c ----...... /
Cochlear commu
sac ,...,::",:---......,,~ nicati ng branch
Lat eral
~ J--f~~~i1~~~~i:- Nervus inte rmedi us
amp ullary n.
f;-~J~;i~~~~~~~~- Vestib ulococ hlear n.

(CN VIII), cochlear part
""""'--~"=-~~'--'~~~~r--- Ut ricular n.
"...-";~~~~~-- Posterior
Lateral
am pu llary n.
sem icircular
du ct
Posterior
~~~~- Spiral
sem icircular
gangl ion
duct
of cochlea
Posterior
am pulla
Round
window
Fig. 35.22 Blood vessels of the inner ear

Right anterior view. The labyrin th receives its blood supply fro m
th e inte rnal audi to ry arte ry, a branch of th e antero inferior
cerebellar arte ry (see p. 608). Vestibular n.
Vestibular (CN VIII)
Vestibular a. gangli on
I Facial n. (CN VII)
/ Internal auditory
a. and vv.
TII -=O---lfl-- - - - - - - - Nervus

int ermedi us
--J::f-- - - - - - - - Cochlear n. (CN VIII)
F~'.-;'ijj;l---------- Common
cochlear a.
.,~_\-.),~~~~~~------- Vestibulo
cochlear a.
.i'r-- - - - - Coch lear a.

prop er
V. of round
wi ndow
V. of cochlear aqueduct
537
Bones of the Oral Cavity
~ The floor of the nasalcavity (the maxilla and palatine bone) forms during development. eventually fusing at the median palatine sut ure.
~ the roof of the oralcavity.the hard palate. The two horizontal Fai lure to fuse results in a cleft palate.
processes of the maxilla (the palatine processes) grow together
Fig.36.1 Hard palate :
Inferior view
Incisive -------=f--,~__- +-::r
fossa
....- - Palati ne proc ess
of maxilla
~-- Median
palatin e sut ure
Lesser
palat ine foramen
Pte rygoid
Fig.36.2 Hard palate: Superior view

fossa Removed: Maxilla (upper part).
Posterior Pterygoid process.
nasal spine lateral plate
Foramen for Vomer Foramen

pt erygoid plexus ovale
Pt erygoid canal Incisive ------.,L..~-n·T=-'~~--- Ante rior
! canal nasal spine
Maxillary - - - F-~~--- Nasal crest

sinus
Palat ine process

of maxilla
'
,.,.
.. '.,.
Transverse ------"'~-------'
palat ine sut ure
perpendiCUlar }
plate Palatin e
Greater - -----'......~-!
palatin e canal "'(;~iiiiii~--- Pyramid al bon e
process
Fig.36.3 Hard palate :
Lateral }
Oblique posterior view Posterior plate Pterygoid
nasal spine process
Medial plate
Ante rior Sept um of
..
clinoid process sphenoid sinus Opt ic canal
",.~--------- Superior
orbita l fissure
Middle
concha
Ethmoid bone.
Inferior perpendicular plat e
orbita l fissure
~~'---- Inferior
Choana conc ha
Vome r --------'~"""'-="'ia:---+': Lateral Plate )
Median - - - - -"-;;J=-':
Pterygoid process
palatine suture Medial plate
Palatine bone
Incisive
foram en Palati ne process of maxilla
538
--~-- Head Fig. 36.4 Mandible
The mandible (jaw) is connecte d to th e viscero
Coronoid - - --+- 11
cranium at t he t empo romandibular joint
process (p.540) .
Head
Ramus
Coron oid - - -;I,

process
Alveolar -~~----\
part
Mandibular - ----,H a.
Alveoli forame n
Ment al
foramen (to oth sockets)
Body
Ment al
protu berance
A Ant erior view.
; 0 - ---::;;;;;;;1"-- Superior and

inferior genial
Mandibular
t ubercles
notch
Mylohyoid line (mental spines)
Coro noid - ~-,:;;J--- Pte rygo id

fovea
B Post erior view.
process
Mandibul ar ----;- -----,

foram en
Ramus
Alveolar
part
Ment al
~ Angle
tub ercle
Mental Oblique
C Obliqu e left lateral view. fo ramen line
Fig. 36.5 Hyoid bone

The hyoid bo ne is suspended in th e neck by m uscles between th e floor bo nes. the hyoid bon e gives attac hme nt to th e m uscles of t he oral floor.
of the mouth and the larynx. Although not listed amon g the cranial The greater horn and body of the hyoid are palpable in t he neck.
Lesser horn Greate r horn Lesser horn Greater horn

Lesser horn Greater horn
- y- Body Body
A Anterior view. B Posterior view. C Obliqu e left lateral view . 539

Temporomandibular Joint
Fig. 36.6 Temporomandibular joint Head of

ma ndib le
The head of t he mandib le artic ulates wit h t he mandib ular fossa in the
t emp oromandibular joint .
Ar ticular t ubercle Mandibular fossa

Pterygoid
fovea
Neck of
Corono id - - -'.--'1-. • ma ndibl e
proc ess
Lingu la
Mylohyo id
groove
B Head of mandible, C Head of mandib le,

anteri or view. post erior view.
A Sagittally sect ioned temp oroman

dibu lar joint , left lat eral view.
Zygo m atic proce ss

of temp ora l bo ne
Art icular
tu bercle
Mandi bu lar Petr ot ym panic

fossa fi ssure
Ext ernal Sty loid pro cess

D Mandibularfossa acoustic
meat us
of th e t emporo Mast oid process
(aud ito ry
mandibular j oint , canal)
inferior view.
Fig. 36.7 Ligaments of the temporomandibular joint
Pterygospino us
ligament
Joint
capsule
Lateral
ligament
ligam ent
Pterygoid process,
medial plate
540 A Lateral view of t he left temp oromandibular joint. B Medial view of t he right t emp oromandibu lar joi nt.
Fig.36.8 Movement of the temporomandibular joint ~ Clinical
Left lateral view. Upto 15 degrees of abduction, the head of the man
dible remains in the mandibular fossa. Past 15 degrees. the head of the
Dislocat ion of the
mandible glides forward onto the articulartubercle. tempo romandibular joint
Dislocatio n may occur if th e head of the

mandib le slides past t he articular t ubercle.
Lateral pterygoi d.
superior part The mandible t hen becomes locked in a
prot ruded posit ion, a condit ion reduced by
pressing on the mandibular row of teet h.
Lateral pte rygo id.

inferior part
A Mo uth closed.
Fig. 36.9 Innervation of the

temporomandibular joint capsule
Superior view.
Auriculot emporal n. - - Mand ibular n.

(CNV,)
..._.___1 ~ ;L,,l..--- Deep t emp oral n.
B Mouth opened to
Massete ric n.
15 degrees.
C Mouth opened past

15 degrees.
541
Teeth
- - Enamel
- - - Dentin
Fig. 36.10 Structure of a tooth 1& - -- - Pulp chamber
Each tooth consist s of hard t issue (enam el,
dentin , ceme nt um ) and soft ti ssue (d enta l
pu lp ) arrang ed into a crown, neck (cervi x),
and root.
A Principal parts of ii';.lii7~~,-- Apex of root B Histolog y of a tooth

a tooth (molar) . (mandibu lar incisor) .
Fig. 36.11 Permanent teeth

Each half of th e ma xilla and mand ib le co nt ains
a set of three ant erior t eeth (t wo inci sor s, one
canine) and fiv e posterior (post canine) t eeth
(two prem olars, thre e molars). Fig. 36.12 Tooth surfaces
The t op of th e to oth is known as th e occlusal

Incisive fossa Incisors surface.
Interalveolar
sept um
Mesial
.......1... Labial
Incisive -~~~~i>
...............
suture
Mesial .............
Molars
Lingual
Bucca l
A Maxillar y teeth . Inferior view of t he m axill a.
Buccal
Palatal
M
"?,
..
..
.,/
Distal ,/
~...../
t":-""" ~-- Premolars Mesial ":-:-::,,,'y""
Labial
Interalveolar
septum Canine
Incisors
B Mandibular t eeth . Superio r view
542 of the mand ib le.
Fig.36.13 Coding of the teeth
In t he Unit ed St ates, th e 32 permanent t eeth are num bered sequent ially coded A t o J (upper arch), and K t o T in a sim ilar clockwise fashion. The
(not assigned t o quadrant s). Note: The 20 decid uous (baby) t eet h are t hird upper rig ht molar is 1; th e second upper right premo lar is A.
(P) (0 )
Fig.36.14 Dental panoramic tomogram

The dent al panorami c t om ogr am (DPT) is a survey radiograp h t hat locat ion of wi sdom teeth , etc.) . OPTcourtesyof Or. U.}. Rother, Director of
allows prelimin ary assessme nt of t he t em porom andibu lar joints, maxil theDepartment of Diagnostic Radiology, Center for Dentistry and Oromaxiffo
lary sinuses, maxil lom and ibul ar bone, and denta l stat us (cario us lesions, facia/ Surgery, Eppendorf University Medical Center, Hamburg, Germany.
Maxillary
sinus
l " ----\ - - ----+i
32 - -+---+-'=='---
Impa cted ,,-'-- Mandi bular
t hird mo lar
ang le
(wi sdom t oot h)
31
Mandibular
30 canal
Bit e guide
* Not fu lly erupte d. 28 27 26 25 of scanner 543
Oral Cavity Muscle Facts
~ Fig. 36.15 Muscles ofthe oral floor

~ See pp. 562 -563 for t he infra hyoid muscles.
~
"'0
f!";-_-----O - - Styloid
process
~;;-~-- Mastoid
process
'-- - - Digastric
(posterior
A Suprahyoid muscles, belly)
Hyoglossus ---i'---------'''------------~
left lateral view.
Mylohyoid ------''o-------------:o~ rZ~~-- Stylohyoid
Digastric
(anterior belly)
Infrahyoid
m uscles
B Left lateral view .
Sublingual
fold
--"'1---.0-+ - - Oral mu cosa
~~"'-\o-~~-- Genioglossus
Geniohyoid
C Suprahyo id m uscles,
superior view .
Mylohyoid - - ----;;_ ::lli
D Sup erio r vi ew of th e mandibl e and hyoid bon e.
544
Suprahyoid muscles
: Mylohyoid n.
@ Anterior belly : Mandi ble (digastric fossa) : Via an intermediate
Ufr~ rn CN V3 )
: Q) Digastric
.
....
: Temporal bone (mastoid notch,
: tendon with a
fibro us loop
······1 Elevateshyoid bone (during swallow ing), !
: assists in opening mandible i
: @ Posterior belly : medial to mastoid process)
Facial n. (CN VII) :
: @ St ylohyoid : Temporal bone (styl oid process) : Via a split ten do n
: Hyoid bone : Tightens and elevates oral flo or, draws

Via median tendon .
i (body) : Mylohyo id n. j hyoid bone forward (dur ing swallowi ng),
: ill Mylohyoid : Mandib le (mylohyoid line) of insert ion
: assists in opening mandib le and m ovin g
(myo I hvoid
yOI rap he) :. (fro mCN V,)
: it side to side (mastic ation) .
: Ventra l ramus
: of C1 via Draw s hyoid bone for ward (d uring :
• 0 Geniohyoi d : Mandible (inferior menta l spine) : Body of hyoid bone

: hypoglossal n. swallowi ng), assists in opening mandibl e :
: (CN XII)
- . ... , . H H " ... ......................................
H
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • •• •• • • • • • • • • • •• • • • • • • • •• •• 0 •
: Hyoid bone (superior border of • Hypoglossal n.

'. 0) Hyoglossus , Sides ofto ngue j Depresses t he ton gue
: greater cornu) . (CN XII)
Fig. 36.16 Muscles of the soft palate

In fer io r vi ew . Th e soft p a lat e fo rms t he poste
rio r b ound ary o f th e o ra l cav ity, separating it
f rom t he orop ha ry nx .
Palatine - _
_ --,,~
aponeurosis
Pterygoid
Musculus
ham ulus
uvulae
Uvula - - ------'ll::: :t.'ll~~--~-- Tensorveli

palatini
Soft
----'-';,-----~~il!
palate
-'ro...........- - - - - Levator veli
palat ini
Orop hary nx - + ,.<--:;

(ist hmus)
Muscles of th e soft palat e

Muscle Origin Insertio n Innervat ion Action
: Medial pterygoid plate (scaphoid : Medial pterygoid

: Tight ens soft palate: opens inlet to pharyngoty mp anic tube
Tensorveli palatini : fossa): sphenoid bone (spine); : : n. (CN V3 via otic
: (duri ng swallow ing, yawnin g)
: cartila ge of pharyngotympanic tube : Palatine : ganglion)
...:--- : aponeurosis
: Carti lage of pharyngotympanic tu be; :
Levato r veli palati ni : Raisessoft palate to horizo ntal posit ion

tem poral bone (petrous part )
.......................
: Palati ne
i aponeurosis:
Accessory n. (CN
• Musculus uvulae Uvula (m ucosa)

: posterior nasal XI, cranial part) via : Short ens and raises uvula
i spine
i pharyngeal plexus
• • ••• • • • • •• •••••••••• H . . H ••••• : (vagus n., CN X)
, Palato glossus'
........ .......... .... ...
, Palatine
i.. Elev.a~~stong u~.(~?ste. ri. ?r .~~r.t. i?~):.pu.II.~s?f~.~ ~ 1~t.e .~n.to t~n~ u. .e. ..j
: Tongue (side) • Tighte ns soft palate; during swallowing pulls pharyngeal walls
: Palatopharyngeus' : aponeurosis
, ,. : superiorly, ante riorly, and m edially
' See pp. 548, 555.
545
Innervation of the Oral Cavity
Fig. 36.17 Trigeminal nerve in the oral cavity

Right lateral view.
Maxillary division Posterior }
Middl e Superior
(eN v- via foramen
Ante rio r alveolar nn.
rot undum)
Zygomatic n.
Infraorb ita l n.
(and foramen)
;-:;;.--- - - - - -=- - ---=-- - - - - - - - 7- Buccal n.
Auriculo
te mpo ral n.
Masseteric n.
Lingual n.
Inferior alveolar n.
(in mandibular canal)
Inferior dent al branches
Fig.36.18 Neurovasculature ofthe hard palate Menta l n. (and foramen)
Inferior view. The hard palate receives sensory innervation primarily
from termina l branche s of the maxillary division of th e trig emina l nerve
(eN V2 ) . The arteries of th e hard palat e arise from th e maxillary art ery.
Superior - - - - - ---=.........-4..
labial
branches
Ant erior
and midd le
superio r
Incisive foramen
Infraorbit al n.
alveolar
branches
Posterior
superior - - -- Greater Greater palatine
alveolar palatin e n. n. and a.
branches
Greate r palatine
foram en
Buccal n. Lesser palatin e

fo ramen
Lesser palat ine

n. and a.
A Sensor y inn ervation . Note: The buccal nerve is a branch of t he man Pterygoid process
546 d ibul ar d ivi sion (eN V 3 ) . B Nerves and art eries.
~ The m uscles of t he oral f loor have a com plex nerve supply wit h
~ contribut io ns from t he t rigeminal nerve (CN V 3 ) . facial nerve
(CN VII), and C1 spinal nerve via th e hypog lossal nerve (CN XII).
Trige mi nal gang lion
Fig. 36.19 Innervation of the oral

floor muscles
Mandibular division (CN V3 )
Inferior
alveolar n.
Chorda ty mpan i (CN VII)
- - - - - Lingual n.
Tymp anic
plexus
Trige mi nal
Sub mand ibu lar gang lion Facia l n.
gang lion (CNVII)
Mand ibul ar - - . ;,-;-; ,~~.........- - Mastoi d

Digastri c, cells
division (CN V)
Mylohyoid ant erior belly
Chorda
A Mylohyoid nerve (CN VJ Left lat eral view t ym pani
w it h th e left half of t he mand ible rem oved.
Stylomasto id
Lingual n.
foram en
Glossophary ngeal n. _ _ ':::::1&- - Mastoid

(CN IX) process
St ylohyo id branch Digast ric branch

(wit h m uscle) (w it h posterior belly)
Hypoglossal n.
B Facial nerve (CN V II). Sagitta l sect ion
Lingual n. (CNX II)
th rough t he right petro us bone at t he level
of th e mast oid process, medial view .
•":"h";'=7."""""iiiii:~ii~ C1 spinal n.
(ant erior ram us)
Genioh yoid
Geniohyoid branch (C1)
Superior root
(descendens
Inferior roo t
hyp oglossus)
(descendens
cervicalis)
C Ant erior rami of t he C1 spinal nerve,

left lat eral view.
547
Tongue
~ The dors um of the tongu e is covered by a high ly specialized powe rfu l mu scular body t o support it s motor properties during mastica
~ mucosa that supports it s sensory fun cti ons (ta ste and fine tactile tion, swallowing, and speaking.
discrimination; see p. 616) . The t ongu e is endowed with a very
Fig.36.20 Structure of the tongue Fili form Circum Fungiform

papillae (vallat e) papilla papilla
The V-shaped sulcus ter mina lis divide s the t ongu e into an ant erior (oral,
presulca l) and a posterior (pharyngea l, postsulca l) part.
Palatopharyngeal arch Epiglottis Lingual tonsil Lingual

} mucosa
} Lingual
aponeurosis
} Lingual mu scles
Foramen
cecum
Palati ne
ton sil
Palat o
glossal
arch
B Lingual papillae, sectiona l block diagra m.

Sulcus Dorsum The connect ive tissue between the muco
t ermin alis oftongue sal surface and muscu lature contains many
Body of
small sero mucous glands (not shown) .
tongu e
Median
furrow
' -- - - - - Apex of Lingual mucosa

A Superior view. to ngue
I
Fig.36.21 Muscles of the tongue Superior longi- ----,r-=~'--""c"+.~
The extrinsic lingual mu scles (genioglo ssus, tudina l mu scle
~~"T.-~f------ Verti cal
hyoglossus, palatoglo ssus, and st yloglossus)
Lingual sept um --r~----"-~~~~~~ o mu scle
have bony attachments and mov e the tongue
as a wh ole. The intrinsic lingual muscles .!)1!'!~~--.;-- Transverse
(superior and inferior longitu dinal mu scles, Inferior longi- --"",,~~F.'!~ muscle
t ransverse mu scle, and vertica l muscle) have tu dinal muscle
no bony attachm ents and alter the shape of Hyogl ossus - ----l;. . \Il\ ;<._
th e tongu e. Genioglossus - .......t=~~~':..f,~
Dor sum of to ngu e ..,-d~~ Sublingual

gland
~%:~-- Mylohyoid
Apex of - -
tongue
Geniohyoid
Stylog lossus B Corona l sect ion, anterior view .
f'-'f~~I-- Hyoid bone
A Left lateral view .
548
Fig. 36.22 Somatosensory and taste Taste Somatic sensation
innervation of the tongue
A nter io r v iew.
Vagu s n. --------l!!!~ -~~---- Vagus n. (CN X)
(CNX )
-'--.-....._~_---,;iR,-- Glossopharyng eal n.

(CN IX)
Fig.36.23 Neurovasculature of
the tongue
Th e lingu al mu scl es receive so ma to mot o r
Glossophary ngeal n.
inn erv at ion f ro m th e hy p o gl o ssal ner v e (CN (CN IX)
XII), w it h th e exceptio n oft h e p alat o g lo ssus - -----!- - - - Lingual n.
(ma nd ibular n., CN V,)
(su p p lied by th e vag us nerve , CN X).
Facial n. -------l;~-:<:
(CN VII, via
cho rda t ymp ani)
Apex of ton gue
- - - Ant erior
lingual glands
- - Deep lingual
a. and v.
Subling ual ~-£'-- Lingu al n.
fold Deep
Submandibu lar lingual a.
Sublingual ---~i"':~IIt;;;,;;.-----'-- :
duct
papill a Lingual n. Sty loid
(CNV l ) proc ess
,. f~~- Glosso
A Inferio r su r fa ce of t he t on gu e.
pharyngeal n.
(CN IX)
Subma ndibular
ganglion
- - - Hypogl ossal n.
(CNX II)
Lingual a. (from
exte rnal carotid a.)
Lingual v. (t o
inte rnal ju gul ar v.)
Subling ual a. Hyoid bon e
B Left lat eral v iew.
~ Clinical
Unilateral hypoglossal nerve palsy

Damage to t he hypoglossal nerve causes
paralysis of th e genioglossus mu scle on
t he affected side. The healt hy (inn ervated)
genioglossus on t he unaffect ed side will
B Act ive prot ru
sion w it h a
\ f ~ Paralyzed
~. genio-
glossuson
affected
! .~ A pex
A Active protrusion unilateral hypn
there fo re do m ina t e. u flull pro uustou .the side
w it h an intac t glossal nerve
t ongue will deviate toward th e paralyzed side.
hypoglossal nerve. ~ of to ngue lesion.
549
Topography of the Oral Cavity & Salivary Glands
~ The oral cavit y is locat ed below th e nasal cavit y and anterior

~ to th e phary nx. It is bou nded by th e hard and soft palates, th e
t ongue and mu scles of th e oral f loor, and t he uvula.
Air way Foodway

Fig. 36.24 Oral cavity
Midsagitta l sect ion, left lateral view.
I \ \\,-- - Laryngo
phary nx
A Organizatio n of
Right choana --~,--;!,-.....-'<~7
t he oral cavity. 'f;-:C'ffi--~~._IiiiiO'~:;-- Dens of axis (C2)
~ii'iT"~'-"-7-~-- At las (C1)
Sof t palate -~~!!f~~~~H~~~
Salpingopharyng eal
Uvu la fold
Palat ine tons il
Lingual t onsil
Hyoid bo ne Epiglotti s
Thyro hyoid ligam ent - ----\c-f.t"'
Vestibu lar fo ld -----1H-'t-~..." ,
Vocal fold <---",-- ' - Cricoid

Fig. 36.25 Divisions of the oral cavity cart ilage
Anter ior view.
Frenul um of
upp er lip
B Bou ndaries of the oral cavity.
Oral
vestib ule Hard
palate
Palatoglossal
Sof t
arch
palate
Palatop haryn
geal arch Uvula
Divisions of the oral cavity
Fa ucial Palatin e
isthmus ton sil Part Anterior boundary Posterior boundary
Oral cavity Dorsum : Oral vestibu le • Lips/ cheek • Dental arches

.................................................. . ................................................................
of to ng ue
proper • Oral cavity prop~r H H ~e n.t~la rch~ s ~~ I~~? 9.I ?~~~ l arc h .
: Fauces(t hroat) • Palatog lossal arch : Palato pharyngea l arch
Oral Frenulum of
vest ibule low er lip
550
~ The th ree large. paired salivary glands are the parot id. subman (watery) salivary gland . The sublingua l gland is predom inantl y m ucous;
~ dibular, and subling ual glands. The parotid gland is a purely serous the submandibular gland is a mi xed serom ucous gland .
Accessory parot id gland

Parotid gland
Parotid duct Fig. 36.26 Salivary glands
Superficial temporal
a. and v.
Parotid
gland.
superfici al
part
Parotid
plexus
Facialn. ---~7--¥.~
(( N VII)
Parotid gland. Sternocleido

dee p part mastoid
Faciala. Submandibular Sternocleido B Facial nerve in the parotid gland. left lateral
and v. gland mastoid view. The ram ification of th e facial nerve
into th e parot id plexus (see p. 478) sepa
A Parotid gland . left lateral view. Note: The
rates th e parot id gland int o a superficial
parotid duct penet rate s the bucci nator
and deep part.
mu scle to open opposite th e second
upper m olar.
Sublingual - - - r'
fold ---='l--c-+- - Oral mucosa
-="''..-~--- Genioglossus
! ~'(-=ih~-'i~~---- Sublingual
gland
Geniohyoid
f1---,-----~-- Submandib
ular duct
Mylohyoid ----"~~
Submandib
ulargland
Lingual a. Hyoglossus
Stylohyoid
C Submandibular and sublingual glands. superior view with tongu e

removed.
551
Tonsils & Pharynx
Fig. 36.27 Tonsils
Soft --~
Choana Roof of pharynx
palate
Tonsillar
fossa Nasal - - -
septum
. -~~~~----- Phary ngeal
t on sil
Torus - - - - - - :
tub ariu s
~87+-c:-:..,p----.-;.------ Pharyng eal
orifice of
pharyng o
t ympanic
tube
Soft --~......- ,- :5-''-f--!+--- - Dens of axis
palate (C2)
A Pa latine ton sils, anterior view. ~~~'-f>'i'H--- Salpingo
pharyn geal
fold
Uvu la --~~
B Pharyngeal ton sils. Sagitt al sect ion through

:'+'-'-'--'"':-':==c::'i"'-'-'-c.;-s :'-:;:;c, - - - Roof of th e roof of the pharynx.
Pharyngeal -------,;:__="~ pharynx
ton sil
Nasal --------:;~~~ n (?----~-- Tubal t on sil
conchae (ext ension of
pharyn geal
ton sil)
Soft palate
---"ll~--=-----~'---- Uvul a
L~~\----!J--- Palati ne
Lymphatic t issue
ton sil
of lateral band s
alon g salpingo
"T;- - -';l- - - Lingual
phary ngeal fold

tonsil
Structures in
¥.- ----:!!------ Epiglotti s Waldeyer's ring
Tonsil #
Pharyng eal tonsil 1
Tubal ton sils 2

Palatine tonsils 2
Lingual ton sil 1
l at eral bands 2
C Waldeyer's ring . Poste rior view

of th e opened pharynx.
552
~ Clinical
Tonsilinfections
Abnormal enlargement of t he Particularl y well developed in En larged
Enlarged palatine tonsil Choana pharyngeal tonsil
palat ine to nsils due to severe viral young child ren, th e pharyngeal
or bact erial infect ion can result

to nsil begins to regressat 6 to
in obstru ct ion of t he orop harynx,

7 years of age. Abnorma l
causing difficulty swallowing.

enlargem ent is com mon, wit h
t he ton sil bulging into th e
nasopharynx and obst ructi ng
air passages, forcing t he child to
"mout h breat he: '
Fig.36.28 Pharyngeal mucosa

Po st erior view of t he o pe ne d p haryn x. The ante rior portion of t he mu s
cu lar tub e contain s th ree o penings: choanae (to t he na sal cavity), fau cia l
isth mus (to th e o ral cav ity), and aditu s (to th e laryngea l in let).
Middle nasal Pharyngeal

concha to nsil
Choanae
Stylohyoid
___ - - Digastric muscle,

post erior belly
> -- Masseter
Faucial (orophar yngeal) ist hmus
Uvula '---------Lff- - - Medial pterygoid
Pa latopha ryngeal
arch =.. . ,-=-- - - Aryepiglottic fold
Root of tongu e
(lingual to nsil)
Epiglotti s
Piriform ------!'i~~
recess
ff!:~--- Pharynx (cut)
-f- - - Thyroid gland
553
Pharyngeal Muscles
Fig. 36.29 Pharyngeal muscles:

Leftlateralvievv
The pharyng eal mu sculature consists of th e Superior
phar yngeal constr icto rs and th e relatively pharyngeal
weak pharyngeal elevat ors. const ricto r
Sty lohyoid
Buccinator --"~hij~-:;Jtt~~=~~~
~-~~----- Sty lopharyngeus
'-,/--,~rJ------- Hyogl ossus

Myloh yoid - ..... - - - - - - --.".- =
Middle pharyngeal
constr icto r
Digastr ic m uscle
(anter ior belly)
Inferior pharyngeal
const ricto r
Thyrohyoid - - - - ' --;-
Cricot hyroid
A Pharyngeal mu scles in sit u. ~~--- Esophagus
~_-- 51
52
Superior Pharyngeal constrictors
pharyngeal
-- - -53 const ricto r Superior pharyngeal constrictor
• 51
" H H. .. , ~ ~e r y g ? ~ ~ ~ ~ y~ ~ ~ ~ I ~ ~ r t
,------ - - - - 54 : 52 : Buccopharyngeal part
: 53
.. .. . H H H L H~~I ?p~ ~. rx ~ g ~ a ly~ ~ ~ H H H H'
, 54 : Glossop haryngeal part
~~~~~~g ea l
M1 }
: Middle pharyngeal constrictor
M2 constr ict or
• M1 H HH H.H H. ~ h. ? ~.~ r ? ~ h a ry ~ ~ ~~ l pa r t
: M2 • Ceratopharyngeal part
• Inferior pharyngeal constrictor
11 } Inferior
· 11
. ...........................H ! ~X~? ~h.~ry~ g e.~ I .~ .a. r.t .
12 : Cricopharyngeal part
pharyngeal
const ricto r
12
554 B Subdivisions of t he phar yngeal constr ict or s.

Fig.36.30 Pharyngeal muscles:
Posterior view
Pharyngoba silar
fascia
_~-- Accessory
m uscle bundle
Superior -
phary ngeal r ',:!' ----r- Masset er
constri ctor
Digastri c mu scle,
posterior belly
Stylohyoid
Stylopharyngeus
Hyoid bon e, ~
great er horn Pharyngeal
ton sil
Inferior pharynge al
Pharyng eal - --t"----7-'--- --? constr ict or
raphe Pharyn got ymp anic
tub e, carti laginous
Levator veli part
palatin i
Salping o --~"L!~~~i
pharyn geus
Superior - _ -=-,;=_
pharyng eal
constrictor Pterygoi d pro cess,
Esophagu s med ial plate
Musculus uvul ae
Palato Pterygoid hamulus
pharyngeu s
A Muscles of the posterior pharynx. B Muscles of the soft palate and pharyngo
tympanic tube . The muscles of the fauces
Tensor veli palatini Levato r veli palatin i form the posterior boundary of the oral
cavity.
I
Sty loid proc ess

Stylohyoid
Superior pharyngea l
constric tor Digastr ic
, --4-- - :;--- Masseter

Salpingo ---t~. .:;.;;;
pharyng eus
Palate- ---1~~ "--7'f;#-- - - Musculus uvulae
Pharyng eal
elevato rs pharyngeus '---'t'#-- - Medial
pterygoid
Sty lopharyngeus --~~~ ' ~=i Angle of

m andib le
Middl e pharyngeal
constr ictor
Oblique arytenoid - - - -T;;:
~.;=,'!;---- Transverse
ary te noid
-; -- - - Posterior
cricoaryten oid
i-'----ift-- - - Circular muscle fib ers

of esophagus
C Mu scles in the opene d pharynx. 555

Fig.39.19 Brainstem Interpeduncular Cerebral
fossa peduncl e
The brainste m is t he site of em ergence and entry of t he 10 pairs of
tru e cranial nerves (eN III- X II). See p. 470 for an ove rview of t he cranial
nerves and t heir nuclei.
Pons
Mesen- Cerebra l
cephalon aquedu ct
Hypophysis ------,'~ Cerebellum
Pon s
Medulla
ob longa ta
-_J1 Vest ibu locochlear n.
(CNVIII)
Olive
Glossopharyngea l n. Pyramid of
A Levelsof the brainst em . (CN IX) m edull a
ob longat a
Vagus n. (CN X)
Hypoglo ssal n.
(CN XII) Anterior
med ian fi ssure
Cerebral Brachium of
peduncl e inf erior collic ulus Accessory n.
(CN XI) C1 spinal n..
~ ~ Decussat ion ventra l root

superio r } . . of pyram id s
. . . . .~~ colliculus Quadr iqernina l
Pon s Inferior plate
B Ante rior view.
Trigemina l {
nerve
M~;:~ *~ com
,",";:::: :;, Brachium of Brachium of
pedu ncle Pineal superior coll iculus inf erior colliculus
Sensory
root Midd le Superior
cerebellar
peduncle
and inferior
colliculi I
Superior
CNVIII - - - Inferior
m edullary
yz
cerebellar
velum .J.~--- CN IV
peduncle
Superior
P":~ili...""""t.-A- - Lateral cerebellar CNV
aperture peduncle
Medial
CN X Middle <, '_ em inence
Nervus int erm ediu s
cerebellar ;-..::::: Rhomboid
CN XI peduncl e
CN IX fossa
I n feri or ~
cerebellar
peduncle
Vestibular - ----';-".... Facial
area colliculus
C1 spinal n.. Postero lateral St riae Trigo ne of

vent ral root sulcus m edulla ris CNX II
Ant erolat eral
Taenia Trigone of
C Left lat eral view. sulcus
cinerea CNX
Tubercle of
nucleus cuneatu s
Tubercle of
nucl eus gracilis
D Poste rio r view.
599
Spinal Cord
Fig. 39.20 Spinal cord and segments Fig.39.21 Spinal cord in situ
The spinal cord consists of 31 segments innervat ing a specific area in t he t runk or lim bs (see Fig. Posterior view wi t h vertebral canal windowed.
39 .22) . Affe rent (sensory) poste rior rootlets and efferent (motor) anterior root let s form the poste
rior and anter ior roots, respective ly. The two roo ts fuse to form a m ixed spinal nerve, which then
div ides into various branches . Med ulla
C2 spi nal n.
o blon gat a
Posterior root (with At las (C1)
spinal gang lion)
Spi nal
ganglia Spinal n.
Vert ebra
prom inens Cer vical
Spinal
Poster io r ram us (0) enlargeme nt

cord
}
T1 spinal n.
Ante rio r ramu s
Gray ram us
com mu nica ns
Wh ite ram us
Cauda J Ante rior commun ican s
equina 1 root lets
Sympat hetic
gang lio n
A Spinal cord, posterior view. B Spinal cord segment , anterior view .
Spinal cord segment Vertebra Fig. 39.22 Segmental Lum bosacral

innervation and spinal enlargeme nt
cord lesions }
The spinal cord is divided
into four majo r regions : cer L1 spin al n. Co nus
vical, thoracic, lum bar, and med ull aris
sacral. Spinal cord segme nts
Spinal
are numbered by th e exit Cervical cord
rtfC"I'- - lesion gang lia
poi nt s of th eir associate d spi
nal nerves. (Note: This does Cauda equina
not necessarily cor relate
Spinal du ra
num erically with t he nearest L5 verte bra - -t:-="";- ma te r
skeleta l eleme nt. )
•.v,~~~-h.!- Spinal
arachno id
U\~~,....--- Thoracic cord
lesion
~~-- Sacral hiat us
Lumbar cord
lesion
ffI
Conus/cauda
equina lesion
A Spinal cord segments . B Derm atome s. Each spinal C Spina l cord lesion s.
cord segment innervates
a parti cu lar skin area
(dermatom e).
600
Fig.39.23 Spinal cord in situ: Transverse section ~ Clinical
Superior view .
Lumbarpuncture
A needle int roduced into t he dural sac (lumbar
cistern) generally slips past t he spinal nerve
root s wi t hout inj uring t he spinal cord. Cerebro
spinal flui d (CSF) samples are t herefor etaken
Epidural space
between t he L3 and L4 vertebrae (2), once
Subarachnoid r- - - Post erior int ernal t he pat ient has leaned forw ard t o separate th e
space vertebra l spino us processes of th e lum bar spine.
venou s pl exus
Arachno id
Dent iculat e Conus ---;.,-- ----:' t-
Spinal ligame nt medul laris
du ra mater
.,..A-_ Int ervert ebral Cauda -----=,---j-;~.m \ . ' : r.;;_\
foram en equina
~~ <-- - Spinal
gang lio n
'.Zioi:-':~ Spinal n.
Ver tebral a.
Vert ebral vv. Ant erior inte rnal Root 3
verteb ral venou s plexus sleeve
A Spinal cor d at level of C4 vertebra .

Anesthesia
Lumbar anest hesia may be ad minist ered in
a simil ar fashion (2). Epidu ral anest hesia is
adm in istered by placin g a cat het er in t he
epidura l space w itho ut penet rat ing t he dura l
sac (1). This m ay also be do ne by passing a
need le th rough the sacral hiat us (3).
Epidura l space
Cauda eq uina Fig. 39.24 Cauda equina

In adults, t he spinal cord ends at approximately
t he level of L1. Below t his, vent ral and dorsal
root s course throu gh th e vert ebral canal, unit
ing in t he intervertebral foram en to for m t he
spinal nerv e (see p. 36) .
Dural sac - -----'
- ----"'=---:-- Spinal Dur a mater
gang lio n
Spinal
dur a mater
Ante rior - - +----.;;7;;=',:::;O;;;--'-- ---,,-. p"
int ern al verte bral
veno us plexus
Cauda
eq uina
L4
spinal
gang lion
Sl
B Cauda equina at level of L2 vert ebr a. spinal
gang lio n
Sacral
plexu s
601
Meninges
~ The brain and spinal cord are covered by membranes called me The subarachnoid space, locat ed between the arachnoid and pia. con
~ ninges. The meninges are com posed of three layers: du ra mater tain s cerebrospinal f luid (CSF, see p. 604) . See p. 601 for th e coverings of
(dura), arachnoi d (arachnoid me m brane) , and pia mater. th e spinal cord.
Fig. 39.25 Meninges

See p. 606 fo r th e veins of th e brain .
Dura m ater
Pia mate r (on
cerebral surface)
Oute r - - - - r-:
table ., "
Cranial 0'
Bridg ingw.
bo ne Diploe - -;0
(t o superior sagitta l sinus)
Inner --;;.
1t able .r
Lat eral lacuna - --";f . - -?-_-" Superior
Superior
(closed) cerebral vv.
cerebralw.
Superior
saggit al sinus
Middle
cerebral a.
Inferior
Lateral lacuna - + - - -- - - 1M
(b ranches) cerebral w .
(open)
Arachnoid _.£.I~----'l'&1 Bridging vv.
granulatio ns
(arachnoid
villi)
Bridgin gw.
(to tranver se
sinus)
Confl uence of th e sinuses Arachno id Tent orium cc rebeln
A Superior view. Left side: Dura mater (outer B Arachn oid (mi ddle layer), lef t ante rior
layer). Right side: Pia mate r (inner layer). oblique view .
Arachn oid granulatio ns (protrusions of t he
arachnoi d) are sites fo r reabsorpti on of CSF.
Dura mater Superior sagitta l sinus

Galea
~ ll
Diploic vv.
Periosteal layer Emissary v. apo neurot ica
Memngea ayer
Epidural hematoma
Scalp w .
Neuroth elium
J~~~~~~~ii~~~111~1-
Arachnoid
Arachno id -~n!!!~. : Subdural
hemorr hage
trab eculae
Cerebra l cort ex ~
/
Pia mate r Cerebral a. Subarachnoid Cerebral v. Falx Bridgi ng v. Superio r
space cerebri cerebral vv.
C Layers of th e m eninges, coro nal sect ion. D Dura mater and calvarium , coro nal sectio n,
ant eri or view . anterior view.
602
~ Clinical
Ext racerebral hemorrhages

Bleeding bet w een the bony calvarium and the sof t t issue of th e brain rem ot e brain areas. Three types of int racranial hemorrha ge are di stingu ished
(extra cerebral hemorrhage) exerts pressur e on th e brain.Arise of int racranial based on the relat ionship t o t he du ra ma t er. See p.608 for t he arteries of t he
pr essur e may damage brain t issue bot h at t he bleed ing sit e and in m ore brain.
Superior
sagitt al
Rupture d
sinus
middle
Subarachnoid
meningeal a. "'"'il .~~- Falx cerebri
space
- - -- Dura mater -..!,'/§= - Inferior Ruptu red
sagitt al aneurysm
Calvaria sinus
A Epidura l hema t oma (above t he du ra). B Subdu ral hematom a (be low the dur a). C Subarachnoid hemo rrhage.
Fig. 39.26 Dural septa

Left anterior o b liq ue v iew. The major dural
reflection s a re th e f alx ce re b ri, tentorium
cerebelli, and fa lx cere be ll i (no t sh ow n ). Th e Fig. 39.27 Innervation of the dura
du ra l septa sep ar ate the re g io ns of th e brain mater
from each o t he r. Superior vi ew. Removed: Tentorium cer eb elli
(right sid e ) .
Tentori al not ch
Cribrifo rm plat e r---~'=---- Anterior and

posterior
\ et hmo idal nn.
(m enin geal
bra nches)
CN V,. V, .
and V 3
(me ningea l
~~~- C N V3
br anches)
(meni ngeal
bra nch)
1st and 2nd - ---F.-f!!!!!fo!!!!!!o----=''''---f ------'
cervical nn .
Fig.39.28 Arteries of the dura mater (me ningea l
br anches)
Mid sagittal sec t io n , lef t lat eral vi ew. See p . 608 ~~-- C N X
for t he arteries of th e b rain . (me ningeal
CNV, and V, branc hes)
(tentoria l
bra nches)
Midd le me ningeal a. Tent ori um

(fron t al bra nch) cerebelli
Middl e me ninge al a.
(parietal branch)
-~'+,'---- Occipita l a.
(mastoid br anch )
Vert ebra l a.
(branches) 603
Ventricles & (SF Spaces
Fig. 39.29 Circulation of cerebrospinal fluid (CSF)

The brain and spinalcord are suspended in (S F. Produced in the choroid
plexus. ( SFoccupies the subarachnoid space and ventricl es of the brain.
Arachno id Choro id plexus

granulati ons (lateral ventricle)
Choroid plexus
(3rd ventr icle)
Superior
------,L-~
sagitta l sinus
Ambie nt cistern
Int er
hem ispheric
cistern
Straig ht sinus
Int er
vent ricular
Cerebral
foramen
aqueduct
~-+--- Confluence
of t he sinuses
Cistern of lam ina r -- - - Verm ian cistern

te rmina lis
f llllhA<".----- - - - - "r:-"L----.,L- - - - Choroi d plexus

(4th ventricle)
Chiasmat ic
j
cistern
Basa l
Cerebellom edu llary ciste rn
cistern
Interpeduncular (cisterna mag na)
cistern
Median
Pontomedu llary aperture
cistern
Cent ral canal

of t he spinal cord
Spinal cord
IW \I li"'r-'~.".----- Verte bral
venous plexus
Subarachnoi d
space
Subarachnoi d space
Endone ural
Vent ricle space
Vein
Choroi d plexus
l Spinal n.
604
Fig. 39.30 Ventricular system
The vent ricular syst em is a cont inuat ion of the cent ral spinal canal int o
th e brain. Cast specimens are used to demon strate th e connect ions (
between th e four ventri cular cavit ies.
"
Ante rior - - - -----c.
ho rn
Right lateral
Inferior
vent ricle
horn
Cerebral
Left lateral aqueduct
vent ricle
Collat eral
trig one
l::l'L-~~'-- Lateral recess B Lateral vent ricles in
-
transverse section .
Posterior
_ _ ---'\,.
horn
Anterior horn
4t h vent ricle
Collate ral Lateral

A Superior view .
t rigon e vent ricle
Posterior horn
Int erventri cular -~=--j
foram en
Inferior horn
3rd
vent ricle
Cerebral
aqueduct
Lateral recess Centra l canal

C Left lateral vent ricle in
sagit t al sect ion. D Left lateral view.
Fig.39.31 Ventricular system in situ

Left lateral view . Intert halam ic Fornix Lat eral vent ricle
adhesion (cent ral part)
Inte rvent ricular
for amen
3rd vent ricle
Corpus
callo sum ~ ,
Ante rior Interventri cular
com mi ssure fo ramen
Sept um
pellucidum
Lateral <; ~
vent ricle
Forni x
Corpus (ant erior
callosum horn )
Supraoptic recess
Optic chiasm
-Infundibular
~
!
recess
Hypoph ysis
Lateral vent ricl e

..-'~;;;::.~- Quadri gemina l (inferior horn )
plate
4th vent ricle
Lateral recess.
ends in lat eral apert ure
of 4th ventr icle
Median aperture
Cent ral canal - - --!
of 4th vent ricle
A 3rd and 4th ventricles in t he midsagitta l sectio n. B Vent ricular system with neighboring st ruct ures.
605
Dural Sinuses & Veins of the Brain
Fig. 40.1 Confluence of the sinuses

Po sterio r view.
Parietal fora m en
and emissary v.
.®
Tentorium
cerebelli ~---+-------~ti"- Superior
sagittal
sinus
Principal dural sinuses
Upper gro up Low er group
~ CD : Superior sagittal : Q)
Cavernous sinus
: sinus
.. ........ .....
: 0 :.Inferior sagittal Ant erior inter Occipital

--l!'----;.--------:;;;~l External
: sinus : caverno us sinus fora men and
occipi tal
emissaryv.
protub erance
Posterior int er
: ® : Straigh t sinus ® Sigm oid
caverno us sinus
sinus
Mastoid
Con fluen ce of Sphenopar iet al

foramen and
Cond ylar canal
t he sinuses sinu s emissary v.
.....................
and emissary v.
Transverse sinus
® : Superior pet rosal Venous plexus aroun d
: sinus t he for amen magn um
(ma rginal sinus)
: @ : Inferior pet rosal
: ® ; Sigmoid sinus , sinus Venous plexus
of hypoglossal
: The occip ital sinus is also inclu ded in the upp er

canal
: W? U.~ .~~~~ F. i~: ~O .2) :.. Ext ernal verte bral
--$--lia--~l
veno us plexus
Fig. 40.2 Superficial cerebral veins

Superior
sagit t al
Bridgi ngw. sinus
Inferior
anastom oti c v. Internal
Medial and occipita l v.
lateral ~~-......~~~ Gre a t
superio r cerebral v,
cerebellar w . Straight sinus
Conflu ence of Conf luence of
t he sinuses t he sinuses
Superior and inferior Transverse sinus
petro sal sinuses Transverse sinus
Occipital sinus
Pet rosal v.
Internal jugu lar v. - - --SII
Posteromedian
medul lary v.
A Lat er al v iew of t he lef t h em isph ere. B Media l v iew of t he ri ght h em isph er e.
606
Fig. 40.3 Basal cerebral venous system Fig. 40.4 Veins of the brainstem
Basa l view. Basal view.
.tl.
0
-tl:l
0
0
e,
Basilar v.
Int erpedun ~
VI
Ante rior cularw. VI
Inter cerebr al v. ttl
Pont om esen Vi
pedun
cularv.
Deep
m iddl e Trigem inal n.
cephalic v.
-.
0
...,.
Inferior cerebral v. (CNV) Superior ::r
ttl
choroidal v. petrosal v.
tl:l
Basilarv. Superior t3-.
Internal Transverse cerebellar vv. ~
Posterior cerebra l v. po nt ine vv. l(o
venou s Great
Ant ero latera l
and ante ro
~
-.
confluence cerebra l v. ~
Transverse
median
pontin e v. -
b'
medu llary vv.
a.
Posterom edian
medu llary v.
Fig. 40.5 Dural sinuses in the skull base
Superior view of the opened cranial cavity.
Removed: Tento rium cerebel li (right side).
~=--=,,~~~,;--- Superior
opht halm ic v.
=-~~w::---- Sphenoparietal @
Ante rior sinus
®
8 intercavernous
sinus
Cavernous (J)
sinus
Venous plexus of
foramen ovale "",,-"'--~~"--- Petros qu amous
sinus
Post erior - --o-""-f.
~.,=:;;r--- Midd le
® int ercavernous m eningeal v.
sinus
~-------';"'----;-~i-:--- Superior pet rosal ®
Basilar plexus sinus
Inferior
-'-------~j__- Jug ular
@ pet rosal sinus
for am en
Marg inal sinus ,--"-~----it.,---- Sigm oid ®

sinus
:---~:--- Great
cerebral v.
Inferior Occipita l
cerebraI vv. sin us
Tentor ium ~.,..,..".~-~'-'---- Transverse G)

cerebelli Sin US
® Straight sinus
Conflu ence of t he sinu ses @)
Superior sagitta l sinus

CD 607
Arteries of the Brain
Fig. 40.6 Internal carotid artery

Left lateral view. See p. 49 0 for details of the Posterior
int erna l carot id artery. comm unicat ing a. Posterior
Internal
carot id a.
Cerebral
part
Pet rous
part
< : Poste rior
Fig. 40.7 Arteries ofthe brainstem
and cerebellum
Left lat eraI view.
Basilar a. cerebral a.
Superior
cerebellar a.
Cerv ical
part
External
caroti d a.
Com mo n _ _ ----',--'<-'-----,:;= '._~~""""'-- CN V
caroti d a.
Aor tic arch Labyrinthine a.

Antero inferior
Subclavian a. cerebellar a.
"'l~~k-~J-- Vertebral a.
Fig. 40.8 Arteries of the brain

Basal (inferior) vi ew.
Postcommunicating Anterio r
part (A2) com m unic ating a.
Ante rior
cerebra l a. Internal caroti d a.
Precom m unicat ing
part (A l) Sphenoidal }
part (Ml)
Middl e
cereb ral a.
Postcommunicatin g Insular
part (P2) part (M2)
Posterior Precom muni cati ng Posterior

cerebra l a. part (Pl) com mu nicat ing a.
Ante rior
choroidal a.
Lateral occipita l a.
(P3) Pont ine aa.
Anteroinferior Superior cerebellar a.

cerebellar a.
Posteroinferior
cerebellar a. Medial occipital a. (P4)
Vertebra l a. Anterior spinal a.
608
Fig. 40.9 Cerebral arteries
A. of central sulcus
Fig. 40.10 Cerebral arteries:

Distribution areas
The cent ral gray and w hite mat
ter have a com plex blood supply
Parieto
L'-:'C:;;;;:Jl.F-I T l r - occipit aI (yellow) that incl udes the anterior
branch choroidal artery.
Lateral Caudat e
ventri cle nucleus
~~~~f= Ante r io r .
m iddl e. and
posterior
t em por al
branches
A Midd le cerebral artery. Lateral view of the

left hemi sphere.
Aa. of precent ral. centra l. Claustr um

and post cent ral sulci Put amen
Hipp o Globus
campus pallidus
Posterior o Anter ior cerebral a.

parieta l a.. o Midd le cerebral a.
angu lar gyral o Post erior cerebral a.
branch
Midd le A Lateral view of the left hem isphere.
cerebral a.
Parieto
occipital
branch
Lateral
frontobasal a.
Ante rior. m iddle. and
post erior te mpo ral branches
B Midd le cerebral art ery. Left lateral view with

th e lateral sulcus retracted.
Pericallosal a. Cingular branch

Paracentr al
branches
comm issure Cerebral
Precun eal Optic Thalamu s aqueduct
Calloso 3rd
branches chiasm
marginal a. vent ricle
Dorsal
callosal B Media l view of t he right hemi sphere.
Polar -~"""""'~"~!:I...
fro ntal a.
__ ~.
branch
"'.?-~""''''''".-- Parietal
branch
Medial
occipit al
Posterior a. (P4)
cerebra l a. Lateral Middl e and posterior
occi pit al a. (P3) te m poral branches
C Anteri o r and p ost er io r cer ebra l arteri es.

Medial view of the right hemisphere.
609
I Arteries & Veins of the Spinal Cord
~ Like t he spinal cord it self. t he arte ries and veins of t he spinal cord
~ consist of m ultiple hori zont al system s (blood vessels of th e spinal
cord segments) th at are integr ated int o a vert ical syst em.
Fig. 40.11 Arteries of the spinal cord Basilar a. - - ----!'iF;-\

The unpaired ante rio r and paired post erior spinal art eries t ypically arise J-It\j~~-- Vertebra l a.
from t he vertebral arteries. As t hey descend w it hin th e verte bral canal.
th e spinal art eries are reinforced by ante rio r and posterior segme nta l
m edu llary art eries. Depending on t he spinal level. th ese reinforc ing
branches may arise from t he verte bral. ascending or deep cervical. pos Anterior --~'---¥'-1 1
t erior int ercostal. lum bar. or lateral sacral arte ries. spinal a.
Posterior spinal aa.

Ifl,~"'=--- Anter ior
m edullary
segme nt al a.
Posteri 0 r ho rn - - ---7'=..J:>-----ir'--;---',-'-- '----':; ~ Ascending

~ cervical a.
Poste rio r
medu llar y
segme nt al a.
1-/''---- - - Subclavian a.
Ant erior --~~--::L..:=:W

spinal a. Segmenta l a.
vasocorona
Posterior
intercost al aa.
~_ _ Posterior
segme ntal
rnedullary a.
' ~'f-"~~~~;~::::~~~=~ Anter ior

segm ental
A Spinal and segment al m edullary arte ries.
rnedullary a.
Medial
cut aneo us branch
' Great
anter ior
segm ental
rnedu llary a.
Lumb ar aa.
Posterior (do rsal)

bran ch
B Origins of t he segme nta l medullary art er

ies. In th e t hora x. th e segme nta l medullary
arte ries arise from th e spinal branch of t he C Arterial supply
post erior int ercost al art eries (see p. 34). syste m .
610
Fig. 40.12 Veins of the spinalcord ___........,r- ,~."..jJi-- Posteri or
The inte rior of th e spinal cord dr ains via venou s plexuses into an ante rior spi nal v.
and a posterior spinal vei n. The radicul ar and spinal vein s connect th e
veins of th e spinal cor d wi t h t he int ernal verteb ral venous pl exus. The
intervert ebral and basiver te bral vein s connect th e inte rnal and exte rnal
venou s plexuses, w hich drain into th e azygo s syst em.
Spinal v.
Rig ht dee p --~

ttJ '1~~+-1!---- Ant eri or
Ant erior
spinal v. spinal v. Ante rior radicular v.
cervical v. B Spinal and
radic ular
veins. Post er ior int ern al
vert ebral venous plexus
Ant erio r
Right - - -.tl --P./, interna l verte bral
verte bral v. ~)f/· U--\ venous plexus
Lef t brachio
Int er
cephalic v.
verte bral v.
Int ernal
j ugular v.
Superior - - --f l - - - Accessory

vena cava hemi azygos v.
,'1---- Subcostal v.
Ascending lum bar v.

Post erior
radicular v.
C Vert ebr al veno us
f-!l- - - Ant erior plexuses.
radi cul ar v.
Azygo sv. ---~~ . l~~· ~--- Hemi azygos v.

.& / . . - - - - Int erver teb ral v.
Posterior -~---"l;~~~ iI'

int ernal vert ebral
venous plexus (in
epid ural space) - - Ascending
IIIr rr---a-- - - Ant erior spinal v. lu rn bar v.
• "_'k-J~'!!----- Medial
and lateral
Basiver te bral v. ---=~'-'---~~ I
epidura l vv.
Inferi or - - H
vena cava
no-L1i!J~'.---- Co m mo n
iliac v.
Int ernal
iliac v.
Ext ernal
iliac v.
Anter io r
int ernal ver te bral
venou s plexus
A Venou s dr ainage D Vein s in t he sacral
syste m . and lumbar canals.
611
Circuitry
Fig. 41.1 Divisions of the nervous system

Di rec tio n of information flow divi des nerve fibers into t w o types: aff er autonomic part. The somatic nervous syste m m ediates inte raction wit h
ent (sensory) fibe rs, w hic h tran smi t im pul ses toward t he cent ral nervous t he envi ro nment, w hereas th e autono m ic (visceral) nervous system
system (eNS), and effe rent (mo tor) fibers, w hich tran smit im pulses coo rdi nates t he functio n of the interna l or gans.
away. The nervous system may also be divi ded int o a soma tic and an
Afferent Efferent
(sensory) (motor)
Joints, skin.
skeletal muscle ~ Skeletal muscle
<,
Somatosensory Somatomotor
Somatic fibers fibers
<,
i"
eNS
~
~ j
<,
-: <,
Autonomic Viscerosensory Visceromotor
(visceral) fibers fibers
)L <,
Glands, smooth
Viscera, vessels muscle,cardiac
muscle
Fig. 41.2 Organization ofthe gray matter Fig.41.3 Muscle innervation

Left obli que anterosu perior view . The gray m atte r of t he spinal cord is Indic ato r m uscles are in nerv at ed by m ot or neuron s in t he ante rio r horn
divided int o th ree co lum ns (horn s). Afferent (b lue) and effe rent (red) of one spinal co rd segme nt. Most m uscles (m ulti segm ent al mu scles) re
neuron s wit hin t hese co lu m ns are clu stered acco rdi ng t o funct io n. ceive inner vatio n fro m a m ot or co lum n, a vertical arra nge me nt of m ot or
nucl ei spanni ng several segme nts.
Posterior
Nuclear
horn (sensory) \
column Anterior
Lateral horn
root
(visceromotor) ~
Anterior horn --= J/ / / Afferent

(motor) / ~ n u cle i
Peripheral n.
~---~ Efferent
:L ~
nuclei
Columns Nuclei
Spinal cord Monosegmental

seg ment muscle innervation
612
Fig. 41.4 Reflexes Fig. 41.5 Sensory and motor systems
Mu scu lar fun ct ion at th e un co nsci ou s (ref lex) level is co nt ro lle d by th e The senso ry syste m (see p. 614) and m otor syst em (see p. 615) are so
g ray m at t er o f t he spinal co rd . fu ncti on ally interrelat ed th ey may be describ ed as o ne (sensorim oto r
syste m).
Monosynaptic refl ex Polysynaptic refl ex
Precentral gyrus (primary Central
Posterior root Posterior horn motor cortex, M1) sulcus
/ Postcent ral gyrus
Pseudounipolar
Supplementary
motor cortex
1_
Y
-> (primary sornato
sensory cort ex)
cell body (in
spinal ganglion) Premotor -r-r-r-rr-r-r-x-r-rr-r-;
cort ex
Anterior a-mo tor Anterior Int er-

root neuron horn neurons
A Po lysyn apti c ref lexes m ay be m ediat ed by recept o rs inside of or re

A Co r t ical areas of th e senso rimoto r syst em . Lat eral view of t he lef t
m ot e from th e mu scle (i.e., skin) ; th ese receptor s act via intern eu ron s
hemi sphere.
t o st im ulat e mu scle co ntrac t io n.
Posterior
Sept omarginal funiculus-
fasciculus (only in Ascending tracts
Lateral _
thoracic cord) ~ (afferent)
Interfascicular fasciculus ~ Philippe-Gombault funiculus
(only in cervical cord) ~ »> t riangle (only in
sacral cord)
Longitudinal J Anterior
fasciculus of - / funiculus Descending
post erior column t ract s
/ (efferent)
Lateral - -
fasciculus
proprius
Funiculi
Sulcomarginal ~ Tracts
fasciculus
B W hite m atter of t he spinal co rd . The w hite m atter of th e spinal co rd
co nta ins ascend ing tracts (afferent, see p. 614) and d escend ing tra cts
(ef ferent, see p. 615), w hi ch are th e CNS eq uivalent of periph eral
nerves.
B Pri ncip al intrin sic fascicl es of th e spi nal co rd. Th e intrin sic f ascicles are Interneuron
t he co nduc t io n app arat us of th e intrinsic circu it s, allowing axons t o
ascend and descend t o coo rdi nate spi nal ref lexes for multisegm ental Upper motor --7..---""~5:O>~~-- Neuron in the
neuron (in the
muscles. sensory cortex
motor cortex)
_.V.f--~+-- Terti ary afferent
Spinal ganglion (sensory) neuron
/l~
~~ I
\ \ e1r-- - - Secondary afferent
(sensory) neuron
a-moto r
- - -"---....>J
neuron
Inter
calated cell
Projection
- - --7-- +-11---,
neuron
Commissural
- - - - -+
cell
Association
cell
a-mot or
neuron
1--'-1+- Mot or interneuron
Lower motor neuron

C Intrinsic circ ui ts of t he spinal co rd .
Primary afferent
(sensory) neuron
C Overview of senso rimotor integrat io n. 613

Sensory & Motor Pathways
Fig. 41.6 Sensory pathways

(ascending tracts)
3rd neurons
Accessory
nucleus
cuneatu s
Nucleus
cuneatus
Medial ""-.
lemni scus
Unconscious
proprioception
Position sense,
consciouspropriocepti on,
vibratio n, touch
Pressure, touch
Pain, temperature
..... ...................... Spinal ganglion

(with 1st neurons)
® ®
a -motor neuron
' The fasciculi cuneatus and gracilus convey infor mat ion from th e upper and
lower limbs, respect ively. At th is spinal cord level, only the fasciculus cuneatu s
is present .
Ascending tracts of the spinal cord
Tract l ocation Funct ion Neurons
Ant erior spino - Ant erior

Q) Pathway for crude tou ch and pressure sensat ion 1st afferent neuron s located in spinal ganglia;
thalamic tr act fu niculu s
contain 2nd neurons and cro ss in th e anterior
Lateral spino Ant erior and comm issure
0 th alami c tra ct lateral fu niculi
Pathway for pain, temp eratur e, ti ckle, it ch, and sexual sensatio n
Ant erior spino -

0 cerebellar t ract Pathway for unconscious coordi natio n of mo to r acti vit ies (unconscious Projec tio n (2 nd) neuron s receive propri ocepti ve
Lateral
propri ocepti on , automati c processes, e.q, j ogg ing, ridin g a bike) to th e signals from 1st afferent fibers origi nat ing at th e
Posteri or spino fun iculu s
@) cerebellum 1st neurons of spinal ganglia
cerebe llar tra ct
Fasciculu s Pat hway for positi on sense (con sciou s Conveys inf orm ation fr om upper
® cuneatus propriocept ion) and fine cutaneous lim b (not present below T3) ("II bod ies of 1st neuro n l o . ~ t " d in spinal
Posterior
sensation (touch, vibrat ion, gang lio n; pass uncrossed t o th e do rsal colum n
Fasciculus fu niculu s Conveys inf orm ation fr om lower
® fine pressure sense, t w o-p oint nucl ei
gracilis' discrim inat ion) limb
614
Pyram idal (co rticospin al) t ra ct Extrapyramidal motor system Fig.41.7 Motor pathways
(descending tracts)
Supplement ary
motor corte xes
Corti cospinal tr act

(w it h ext ra
pyrami dal fibers)
Corticos pinal
fi bers From
cerebellum
Ventr al
lateral
CNV II --;~"--'--- nucleus
CN XII ---'H-'lr- I -f- - - Pyramid
Posterior root
/ ;t;7 - Decussation
of pyram ids r
Ante rior
root
® ®
Descending tracts of the spinal cord
Tract Function
CD Ant erio r corticospinal tract Orig inates in th e motor cortex

Most imp orta nt pat hway for Corticonuclearfibers to motor nuclei of cranial nerves
Pyramidal t ract
0 Lateral cort icospinal trac t volunta ry motor fu nct ion Corticospinal fibers to motor cells in anterior horn of t he spinal cord
Corticareticularfibers to nuclei of th e ret icular formati on
® Rubrospinal tract
Extrapyramida l @ Reticulo spinal t ract

motor system ® Vestibulospinal tract Pathway for automatic and learned motor processes (e.g.• walking. runn ing. cycling)
® Tect ospinal tract
(J) Olivospinal tract

615
Sensory Systems (I)
Fig. 41.8 Visual system: Overview

Special sensory qualities (senses)
Cran ial nerve Ref. Opt ic Lateral genicu -
Sen se
t ract late body
Vision Optic n. (CN II) Seep. 473
Balance Vestibulocochlear n. : Vestibular branch See p. 480
Hearing (CNVIII) : Cochlear branch Seep. 48 1

Facia l n. (CN VII) Seep. 478
Taste Glossopharyngeal n. (CN IX) See p. 48 2
Vagus n. (CN X) See p. 484
Smell Olfactory n. (CN I) See p. 472

area
Optic Meyer's
chiasm loop
Fig. 41.9 Visual pathways A Left lateral view.

90% of optic nerve fi bers termina te in t he lateral geniculate body on
neurons th at project t o th e stria te area (visual cor tex ). This form s t he
geniculate path way, responsib le for conscio us visual perception . The
remaining 10%t ravel alo ng th e medial root of th e opt ic tr act, form ing
th e non-geniculate pat hway. This pathway plays an im por t ant role in th e
uncon scious reg ulation of vision-relate d processes and reflexes.
u u
) Optk n,
Visual hemifield
Opt ic~~
Macular
chiasm
visual field
Fovea centra lis I
Optic /
~~ Tempora l ~
W ---m
~ crescent
B Inferior view .
t ract
~
Lateral
geniculat e
body
EB Blind 'pot Projection onto

retin a
@Y ~
®~@
Optic n.
Optic chiasm _
Optic tract G®
~ Superio r
colliculus
-~--f~----t?----~~
~
Lat eral
geniculate
body Optic radiation
Lateral geni
culate body
Visual
cortex Reticular
form at ion
A Geniculate path way. Left visual hemifield. B Non-genicul ate pathw ay.
616
~ Clinical
l esions of the visual pathway Right

Visualfield defects and lesion sites are here illustrated for the left visual Left visual field
pathway. visual field
Unilateral lesion of opt ic n.

/
Blindnessin affected eye eo
2 Lesion of optic chiasm
Bitemporal hemianopia ("bli nders") ()()
3 Unilat eral lesion of opti c tract

Contralatera l homonymous hemianopia ()()
4 Unilateral lesion of optic radiation in Meyer's loop (anterior temporal lobe)

Contralateral upper quadrant anopia ~ ~
("pie-in-the-sky" )
5 Unilateral lesion of optic radiation , medial part
Contralateral lower quadrantanopia
6 Lesion of occipital lobe
Homonymous hemianopia C)C)
7 Lesion of occipit al pole (cortical areas)

Homonymous hemianopic central scotoma 6 7
00
Fig. 41.10 Reflexes of the visual system

The refl exes of th e vi sual system are m edi at ed by t he optic (aff erent) and
oc ulo moto r (effe rent ) nerves.
~,-.;~::--- Pupillary
sphinct er
G)
Short ciliary nn.
CD ~--- Oculomoto r n.
G iliary ganglion (CN III)
/L
Optic n. (CN II) -~_/" i>:>s:ff:
Oculomotor n. (CN III,
Optic tract - -"c--:0. r
parasympathetic
. '- ---"'--- - Nucleusof oculomotor n.
port ion)
(medial rectus)
area
A--~----r4--- Perlia's nucleus Area 19 ,

Lateral ___....., ,,--- Area 17
1.!.-,~! ..:::o.--ct-=;-- Visceral oculomoto r
geniculate
(Edinger-Westphal) nuclei
body
Pretect al B Pathways for co nverge nce and acco m modat io n.
area
CD Light is received fr om an approa chin g o bje ct .
o Inform ati on is relayed via t he pr im ary ( 17) and seco ndary (19) visual
A Pupil lary light refl ex.
co rtexes t o th e nu clei of th e oc ulo m oto r nerv e.
CD Incom ing light is tran smitted via t he optic nerv e.
ill Con verg ence: Const rictio n of th e medial rectu s mu scles co nver ges
o Large amounts of light are transm itted to th e pret ectal area, bypa ss th e visual axes o f th e eyes, keeping th e app ro achin g image on t he
ing th e geni culate path w ay. fovea centralis, th e point of m aximum visu al acuit y.
ill Th e neur on s of th e vi sceral oculo moto r nucl eus synapse o n th e ciliary @) Accom m odat io n: The curvat ure of the lens is increased via co nt rac t io n
gangl ion, w hic h indu ces co nt ract io n of th e pupilla ry sphincte r. of th e ciliary m uscles. The sphincter pupill ae also co nt racts.
617
', ' , Fig. 41.14 Auditory system (hearing)
See p. 480 for th e vestibulocochlear nerve (eN VIII).
Acoustic radiation
Nucleus of medial
geniculate body
Inferior collicular
nucleus (and commissure)
Posterior
Lateral lemni scus - -----c------'l cochlear
(and nuclei) nucleus "'-.-.:~- 200 Hz
/ Cochlear duct
Medullary - - ---1++1---..
st riae
Superior
olivary nucleus
Nucleus of
trap ezoid
body Fig. 41.15 Gustatory system (taste)
When specialized epithelial cells (second ary sensory cells with no axon)
in the tongue are chemically st im ulat ed, the cell bases release gluta
mate , st im ulati ng th e periph eral proce sses of affe rent crani al nerves VII,
IX, and X. Note: Spicy foods may also st im ulat e trig eminal fib ers (not
show n).
Postcentr al
gyrus
--II
( {
Insula
Vent ral
posterom edial
nucleus of
th alamus
Geniculate
Nerve territories gangli on
Inferio r < r-Hf----,#--~.--------- Medial parabrachial nucleus
(pet rosal)
,.r "~::;;;;:~- S o li t a r y tr act nucleus (gustat or y part)
gangli on
I ' f'<'c-J~H--D or s al vagal nucleus
----!;!~---:---- S a li t o r y tr act nucleus
\ \;'-~~--ii-~'------- Spinal nucleus of trige minal n.

Glossopharyngeal -iT=,.,~~-;":;-'--:::::l"';7-~-__...-/
n. (CN IX)
Va g us n ' ---T-~
(CNX)
619
Sensory Systems (III)
Fig. 41.16 Olfactory system (smell)

The olfacto ry syste m is th e only sensory syst em not relayed in the th ala
mu s before reachin g th e corte x (t he prepiriform area is considered th e
primary olfacto ry corte x). The olfact ory syst em is linked t o ot her
brain areas and can th erefor e evoke com plex em oti ona l and
behaviora l responses (mediate d by th e hypoth alamu s,
th alamu s, and lim bic syst em): noxious smells indu ce
nausea; appeti zing smells evoke salivat ion.
Olfactor y
Olfact ory - - - ---,..!-- - -,.F"-- - - tri gone
bulb
Olfact or y - - - - - - ----->",....--7 - -
tr act
---=~--- Prepiriform
area
Lateral and
----;-------,,'~~i!c----r---.
medial stria
~~!'-----;;;---- Amygdala'
Am bient -------;~---.;r==__
gyrus
A Olfacto ry syst em, inf erior view.
' St ruct ure is deep to t he
Semilunar Diagonal Anter ior surface of t he brain.

gyrus st ria perforate substance
St ria m edull aris

of t halamus
Medial
olfactory st ria \"'--=;;;~-----"!~- Stria term inalis
~~:;:§
'#-~!,--:--~l'---- Habenular
nuclei
Anterior
perf orate substance ------i-t---c~~~::~s:i:::~iii~~~ _~\--I-~~'-TT-- Interpeduncular
nucleus
Olfactory ------::>~--'-:~~J:1 '
~""'<::,---'---'---- Dorsal t egmenta l
mucosa (wit h
olfact ory fi bers) nucleus
Amygdala
B Olfact ory syst em with nucl ei, left lateral

view of mid sagitta l sect ion.
620
~ Th e lim bic syste m, wh ich excha nges and integr at es in form ati on regulat es dr ive and affec t ive behav ior. It plays a cr ucia l role in m em or y
~ bet w een th e t elencepha lon, d ien cepha lon , and m esen ceph alon , and learning .
Corpus - - -.'
callosum
\
\
~ Hippocampus
A Midsagit ta l sectio n, left B Hippo campus, left
lat eral view. anterio r ob liq ue vi ew .
Structures of the limbic system

Outer arc Inner arc ' Subcortical nuclei
<D Parahippocampal gyrus ® Hippocampal formati on (hippocampus, entor hinal area of parahippocampal gyrus) ® Amygdala
@ Indusium griseum ® Fornix ® Dorsal t egmental nuclei
@ Habenular nuclei
ill Subcallosal (paraolfactory) area CD Septal area(septu m)
® Interpeduncular nuclei
@ Mammillary bodies
0 Cingulate (limbic) gyrus Paratermi nal gyrus
@ Anterior t halamic nuclei
• The inner arc also contains th e diagonal band of Broca (not shown).
Fig. 41.17 limbic system nuclei Fig.41 .18 limbic regulation ofthe peripheral autonomic
Th is neu ron al circ uit (Papez circuit) estab lishes a conn ect ion betwee n nervous system
inform ation sto re d at th e co nsc ious and un con scious level. The limbic syste m receives affe rent feed back sig na ls fro m its t arg et
organs. See p. 623 fo r th e auto nomic nervou s syste m .
Corpus callosum
li m bic
Thalamo
syste m
Emot ional
cingular
drive
tract
Hypothalamus
Cingulo
hippocampal
Homeostasis
fibers
Medulla
Anterior
Circulatory and oblongata
t halamic nuclei
respiratory
homeostasis
Mammillo Spin al cord
t halamic
Spinal reflexes
t ract
Mamm illary t
Targ et organs
body Hippocampus Fornix
621
Sympathetic Parasympathetic Fig. 42.5 Autonomic nervous system
Parasympathet ic
CN III
ganglia (in t he head)
g: :=: :.: : :. .+~ ~ .",.~Y- ~ ~a~~ :e~tWith

Eye
Lacrim al and
salivary glands
parasym pathetic
Cranial vessels nuclei)
Parasympath eti c
ganglia • Ste llate ganglion =
(close t o organs) inferior cervical
Heart ganglion and T1
sympat het ic ganglion
Lung
T3 Greater
splanchnic n.
T4 Stomach
Sym pat het ic Parasympat heti c
T5
~ CN S I
T6
T7
T8
Liver
Pancreas
s y mpa t~-pr--
ganglion
'"
e-~--___I
- ~--;--
synaptic
neuron s
I Parasymp at heti c
ganglion
T9 Celiac ganglion
/
Postsynapt ic ----.J
T10 1-------<.... Kidney neurons
T ll f- - - __
Target organ
T 12 f - - - -...... Intestin e
L1 I-------J. B Neuro ns of t he autonom ic nervou s

Superior and inferior syste m . Orange: Cholinergic neuron.
L2 \ - - - - . mesent eric gang lia
Green: Noradrenergic neuron.
L3
Parts ofthe
L4 colon. rect um
L5
Bladder
Sacral part
Genita lia (sacral cord w ith
} parasympath et ic
nuclei)
Inferior
hypogastri c plexus
A
Effects of the sympathetic and parasympathetic nervous systems

Organ (organ syst em ) Sympathetic NS effec t Parasympathetic NS effect
Longit udinal and circular muscle

Cast ro 1mo tili t y 1motility
fibers
intesti nal
Sphincter muscles Cont ract ion Relaxation
t ract
Glands 1secret io ns 1secret ions
Splenic capsule Contrac tio n
Liver 1glycogenolysis/gluconeogenesis No effect
Endocrine pancreas 1insulin secret ion

Pancreas
Exocrine pancreas 1secret ion 1secret ion
Bladder Det rusor vesicae Relaxati on Cont ract ion
Funct ional bladder sphincter Cont ract ion
Seminal vesicle
Cont ract ion (ejaculat io n) No effec t
Vas deferens
Uterus Cont ractio n or relaxation . depending on hormona l st at us
Art eries Vasoconstricti on Vasodilat ion of the arteries of th e penis and clito ris (erect ion)
NS = nervous system. See also p. 244. 623

Appendix
Answers to Surface Anatomy Questions 626
Index 628
Answers to Surface Anatomy Questions
Back (pp. 40-41) Abdomen & Pelvis (pp. 248-249)
Ql: The superio r bound aries of Michaelis' rhomb oid run from th e Ql: Use a verti cal and a hori zont al line through th e umbilicus (at ap
spino us process of L4 to th e posterior superior iliac spines. The proxim ately th e level of L4) to divide th e abdo me n and pelvis int o
rhomboid th en foll ow s th e curve of th e iliac crest to th e anal cleft. right and left upp er and lower quadrant s (see p. 140).
Q2: The inferior angle of th e scapula is at th e level of th e T7 spinous Liver, sto mach. tr ansverse colon, small int estin e.
process. The iliac crest is at th e level of t he L4 spinous process. LUQ spleen, pancreas, du odenum . descending colo n. left
See p. 40 fo r palpable bony landm arks. kid ney and suprarenal gl and, left urete r.
Liver. sto mach, t ransverse colo n, small intest ine.
Thorax (pp. 120-121) RUQ gallbl add er, pancreas. duod enum . ascending colon,
right kidn ey and suprare nal gland, rig ht uret er.
Ql : After carefu l inspection, undertake a syste mat ic palpation of each
Small intest ine, descending colon, left uret er. urinary
breast. Pa lpate th e tissue of each breast by qu adrant in th e foll ow ing llQ
sequence: inf erior lateral, inferior medial, superio r media l, and su bladd er. reprodu ct ive org ans.
perior lateral. Palpate th e axilla t o examine th e axillary t ail of breast Small int estin e. ascending colo n (with cecum and
t issue. The majority of lymph drainage from t he breast is t o t he RlQ vermiform appendix) , right ureter. urinary bladder,
axillary lymph nod es. The parasternal lymph nod es, w hich run along reprodu cti ve organs.
t he int ernal t ho racic vessels. drain t he me dial por t ions of t he breast.
See p. 64 for t he axillary lym ph nodes. Q2: Direct inguinal herni as are most com mon in middl e-aged or older
males and are believed t o be caused by "wear and tear." They t ypi
Q2: The aort ic and pulm onary valves are best auscultated at th e 2nd cally occupy th e medial por ti on of t he inguinal canal (having exite d
right and left intercosta l spaces. respecti vely. Locat e th e 2nd th e abdo me n th rough th e inguinal t riang le). They may also exit via
intercostal spaces by fi ndi ng th e usually palpable ste rnal angle (t he th e superficial inguinal ring . Ra rely, t hey ente r th e scrot um . Indirect
j unctio n between th e manubrium and body of th e ste rnum) . The hernias are seen in male chil dren and you ng adults and are believed
2nd ribs attach to th e sternum at th e ste rnal angle. The t ricuspid to have a congenit al basis. They generally exit via t he deep inguinal
(right at riovent ricular) and bic uspid (left at riovent ricular) valves ring and th us may occupy th e ent ire length of th e inguinal canal.
are best ausculta te d at t he left 5th int ercostal space. If t he rib s are They may also exit via th e superficial inguin al ring, and occasio nally
visible/pal pable. th e 5th rib can be fo und by count ing up from below ente r th e scrot um. See p. 133 for inguin al hernias.
(t he lowest rib at th e mi dclavicular line is t he 10th rib). See p. 87 for
auscult at ion sites; see p. 120 for reference lines in th e t ho rax.
626

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Table of Contents

, Bones, Ligaments & Joints 5 Thoracic Wall

Vert ebral Colum n: Elem ent s 4 Ste rn um & Ribs 46

Cervical Vert ebrae 6 j o int s ofthe Thor acic Cage 48

Sacrum & Coccyx 10 Diaphragm 52

Int ervert ebral Disks 12 Neuro vasculatu re of t he Diaphr agm 54

Vertebral Ligamen ts: Tho racolumba r Spi ne 20 Fema le Breast 62

Lym phat ics of the Fema le Breast 64

Int rinsic Muscles of th e Back 26 Arte ries of t he Thoracic Cavity 68

Muscle Facts (I) 28 Vein s of t he Thoracic Cavity 70

Muscle Facts (II) 30 Lym phat ics of th e Thor acic Cavit y 72

Muscle Facts (III) 32 Nerves of the Tho racic Cavity 74

Art eries & Veins of t he Back 34 Mediast inum : Overv iew 76

Nerves of th e Back 36 Mediastinum : Stru ctures 78

Neur ovascular Top ogr aphy of th e Back 38 Thym us & Pericardium 80

4 Surface Anatomy Heart : Surfaces & Cham bers 84

Condu cti on & Innervat ion of t he Heart 90

Heart: Radio log y 92

Pre- & Postn ata l Circulatio n 94

Neurovasculatu re of th e Esop hagu s 98

Lymp hat ics of th e Mediastinum 100

Surface Anato my 120 14 Reproductive Organs

Overview of the Genital Orga ns 186

Ar ter ies of t he Abd omen 206

Posterior Cord: Axillary & Radial Nerve s 324

Medi al & Lat eral Cord s 32 6

Median & Ulnar Nerv es 32 8

Superfi cial Veins & Nerves of the Upper Limb 330

Post erio r Should er & Axilla 332

Anterior Should er 334

Top ography of the Axil la 336

Topog raph y of the Brachial & Cubita l Region s 338

Upper Limb Topography of the Forearm 340

Topography of the Carpal Region 342

Top og raph y of the Palm of t he Hand 344

19 Shoulder & Arm

Bon es of t he Upper Limb

Clavicle & Scapula

joints of the Shou lder

Surface Anatomy (I) 35 0

Surface Anatomy (II) 352

Subacromia l Space & Bursae

Ant erior Mu scles of th e Sho ulder & Arm (I)

Anterior Mu scles of th e Sho ulder & Arm (II)

Post erior Muscl es of th e Sho ulder & Arm (I)

Posterior Mu scles of t he Sho ulder & Arm (II)

Mu scle Facts (II)

Muscle Facts (III)

Muscle Facts (IV)

20 Elbow & Forearm

Radiu s & Ulna

Ligam ents of th e Elbow j oint

Radiou lnar j oint s

Mu scles of th e Forearm (I)

Bones of t he Lower Limb 356

Muscles of t he Forearm (II)

Pelvic Girdle & Hip Bone 358

Mu scle Fact s (I)

Mu scle Facts (II)

Hip j oint: Overvi ew 36 2

Mu scle Fa cts (III)

Hip j oint: Ligam ent s & Capsule 364

21 Wrist & Hand

Ligame nt s of t he Wrist & Hand 302 Muscle Facts (I) 374