Dudek, Thomas M. Includes bibliographical references and index. ISBN alk. Louis, Thomas, author. QS However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration FDA clear- ance for limited use in restricted research settings.
It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at or fax orders to International customers should call The information presented in this text prepares you to handle not only the clinical vignettes found on the USMLE Step 1, but also the questions concerning basic gross anatomy concepts.
In addition, High-Yield Gross Anatomy directly addresses clinical issues and common clinical techniques e. Thomas Louis has again contributed his consider- able gross anatomy teaching experience to improve and narrow the focus of the book. Louis has taught gross anatomy for about 30 years in both cadaver-dissection and computer-assisted distance- learning gross anatomy courses. He has been a leader in developing computer-assisted distance learn- ing at the Brody School of Medicine and has received national recognition for his efforts.
I would appreciate your comments or suggestions about this book, especially after you have taken the USMLE Step 1, so that future editions can be improved and made more relevant to the test. You may contact me at dudekr ecu. Ronald W. The Vertebral Column 1 II. Joints 4 V. Vasculature of the Vertebral Column 5 VI. Clinical Considerations 5 VII. Components of the Spinal Cord 14 II. Meninges and Spaces 14 III. Components of a Spinal Nerve 16 V.
Dermatomes 18 VI. Clinical Procedures 18 VII. Central Lymphatic Drainage 33 II. General Features of the Thorax 36 II. Bones of the Thorax 36 III. Muscles of the Thorax 37 IV. Movement of the Thoracic Wall 38 V. Arteries of the Thorax 39 VI. Breast 39 IX. Anterior Chest Wall 42 X. Lateral Chest Wall 45 XI. Mediastinum 47 XIII. Pleura 53 II. Tracheobronchial Tree 55 III. Lungs 57 IV. Clinical Considerations 59 V. The Pericardium 70 II. Heart Surfaces 71 III. Heart Borders 71 IV. Fibrous Skeleton of the Heart 73 V.
Valves and Auscultation Sites 73 VI. The Conduction System 76 IX. Innervation of the Heart 77 X. Gross Anatomy of the Heart 78 XI. Clinical Considerations 80 XII. Abdominal Regions and Quadrants 89 II. Muscles 90 III. Clinical Procedure 90 IV. Inguinal Region 91 V. Peritoneal Cavity 95 II. Omentum 97 III. Intraperitoneal and Extraperitoneal Viscera 97 IV. Abdominal Aorta 98 II.
Esophagus II. Stomach III. Duodenum IV. Jejunum V. Ileum VI. Innervation of the Large Intestine IX. Appendix X. Gallbladder XI. Liver XIII. Pancreas XIV. Cross-sectional Anatomy XV. Sigmoid Colon II. Rectum III. Anal Canal IV. Defecation Reflex V. General Features II. Arterial Supply III.
Venous Drainage IV.
Clinical Considerations V. Arterial Supply V. Innervation VII. Ureter IX. Urinary Bladder X. Urethra XI. Innervation V. Adrenal Cortex VI. Ovaries II. Uterine Tubes III. Uterus IV. Cervix V. Ectocervix VI. Vagina VII. Testes II. Epididymis III. Ductus Deferens IV. Contents of the Spermatic Cord V. Ejaculatory Duct VI. Seminal Vesicles VII. Prostate Gland IX. Penis X. Bones of the Pelvis II.
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Muscles of the Pelvis VII. Venous Drainage IX. Nerves X. Support of the Pelvic Organs XI. Clinical Considerations XII. Perineum II. Anal Triangle IV. Bones II. Muscles III. Arterial Supply IV. Venous Drainage V. Brachial Plexus VII. Shoulder Region IX. Elbow Region X. Wrist and Hand Region XI.
Hip and Gluteal Region IX. Knee Region X. Ankle and Foot Region XI. Skull II.
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Scalp III. Meninges IV. Muscles of the Head V. Arterial Supply VI. Venous Drainage VII. Muscles of the Neck II. Cervical Plexus III. Cervical Triangles of the Neck IV. Larynx V. Thyroid Gland VI. Parathyroid Gland VII. Bony Orbit II. The Globe or Eyeball IV. Extraocular Musculature V.
Arterial Supply of the Orbit VI. External Ear III. Middle Ear IV. Inner Ear V. The vertebral canal contains the spinal cord, dorsal rootlets, ventral rootlets, dorsal nerve root, ventral nerve root, and meninges. The spinal nerve is located outside the vertebral canal by exiting through the intervertebral foramen. B: Abnormal curvatures of the vertebral column. Knowledge of these vertebral levels will assist in deciphering clinical vignette questions. For example, a clinical vignette question may describe a pulsatile swelling located at vertebral level T2.
Knowledge that the arch of the aorta is found at T2 will allow you deduce an aortic arch aneurysm. A widening of the atlantodental interval distance from the anterior arch of C1 to the dens suggests tearing of the transverse ligament. Posterior view Tectorial membrane cut Alar ligament Occipital bone Articular facet of dens for transverse ligament of atlas Left part of median atlantoaxial atlanto-occipital joint joint Capsule of atlanto-occipital joint Superior longitudinal Atlas C1 band Tectorial membrane Cruciate Transverse accessory part ligament ligament of cut atlas Capsule of right lateral Axis C2 atlantoaxial joint Inferior longitudinal Posterior longitudinal band ligament becoming tectorial membrane cut Figure Ligaments of the atlanto-occipital and atlantoaxial joints posterior view.
The tectorial membrane and the right side of the cruciate ligament have been removed to show the attachment of the right alar ligament to the dens of the C2. The spinal branches terminate as the segmental medullary arteries or radicular arteries, which supply the spinal cord. VI Clinical Considerations A. Denervation of Zygapophyseal Facet Joints. The zygapophyseal facet joints are synovial joints between inferior and superior articular processes.
These joints are located near the intervertebral foramen. If these joints are traumatized or diseased e. To relieve the pain, medial branches of the dorsal primary ramus are severed i. Cervical dislocations will stretch the posterior longitudinal ligament. Protrusion of the Nucleus Pulposus Figure The nucleus pulposus generally herniates in a posterior—lateral direction and compresses a nerve root.
Figure Herniated disc. B: Poste- rior view of lumbar vertebral bodies shows the relationship of a herniated disc blue and spinal nerve roots. For example, the spinal L4 nerve roots pass out laterally close to the pedicle of the L4 vertebra and therefore may not be involved in a herniated disc between the L4 and L5 vertebrae. However, spinal L5 nerve roots will most likely be involved in a herniated disc between L4 and L5 vertebrae. C: Important features of a herniated disc at various vertebral levels are shown.
From various clinical signs, you should be able to deduce which nerve root is compressed and then identify the appropriate intervertebral disc on a radiograph or MRI. Vertebral Column 7 G. It is often seen in adolescent ath- letes, most commonly at the L4 or L5 vertebra. Note that the pars interarticularis at L4 vertebra is normal large arrow. L5 Figure Oblique radiograph of a spon- dylolysis.
This occurs when the pedicles of a lumbar vertebra degenerate or fail to develop properly, or as a sequela of spondylolysis. Consequently, this may result in a degenerative spondylolisthesis, which usually occurs at L4-L5 vertebral level, or a congenital spondylolisthesis, L5 which usually occurs at L5-S1 vertebral level. The lateral radiograph shows spondylolysis at L5 small arrows with a spondylolisthesis where L5 vertebra is subluxed anteriorly with respect to S1. Figure Lateral radiograph of a spon- dylolysis with spondylolisthesis. A traumatic spondylolisthesis of C2 includes the following pathology: Fracture of the pars interarticularis bilaterally of the C2 vertebra, anterior sublux- ation of the C2 vertebra, tear of the anterior longitudinal liga- ment, and posterior fractured portion of C2 remains attached to C3 in a legal drop hanging.
The lateral radiograph shows a traumatic spondylolisthesis. Note the fracture of the pars interarticularis of C2 vertebra solid arrow and the anterior subluxation of C2 vertebra with respect to C3 vertebra open arrow. Figure Lateral radiograph of a trau- matic spondylolisthesis. The extent of degeneration may range from mild disc space narrowing and bone spur formation to severe spondylosis defor- mans which includes disc space narrowing, facet joint narrowing, and bone spur formation.
The lateral radio- graph shows narrowing of all the disc spaces below C4, resulting in a severe cervical spondylosis. The bone spurs encroach the vertebral canal, and the disc level and sclerosis of the facet joints are apparent. C4 Figure Lateral radiograph of a severe cer- vical spondylosis. The result is a complete disruption of the cervical spine, with the upper portion of the vertebra displaced posteriorly and angulated anteriorly.
C6 C7 Figure Lateral radiograph of a teardrop hyperlexion injury. Vertebral Column 9 L. A Jefferson fracture includes the following pathology: Frac- D ture of the C1 vertebra at multiple sites, lateral displace- ment or C1 vertebra beyond the margins of C2 verte- bra, and tear of the transverse ligament.
The computed tomography CT scan shows a fracture of the C1 verte- bra at multiple sites arrows. D: dens Figure CT scan of a Jefferson fracture. The usual whiplash injury is a strain of the paravertebral and neck muscles. In more severe inju- ries, tear of the anterior longitudinal ligament, tear of the anterior attachment of the intervertebral disc, and widening of the intervertebral space may occur bony fractures and dislocations are uncommon.
However, in more violent hyperextension injuries e. The lateral radiograph of a hyperextension injury shows the anterior widening of the intervertebral space at C5-C6 arrow. C6 Figure Lateral radiograph of a hyperex- tension whiplash injury. The lateral L4 radiograph of a Chance fracture shows the compressed L3 vertebral body arrowheads due to the transverse fracture arrows. Note the increased distance between the spinous processes due to tear of LF, IS, and SS liga- Figure Lateral radiograph of a Chance ments long double-headed arrow.
A lateral radiograph of the cervical region shows C1—C7 vertebrae. Note the superior projection of the dens D dotted line and the anterior arch AA dotted line of the C1 vertebra atlas. Vertebral Column 11 B. Thoracic Region Figure Clavicle T2 Air-filled trachea T3 T4 Bifurcation of Azygos vein trachea T5 Spinous process Radiologic marker of fifth thoracic T6 vertebra Head of seventh rib articulating with T7 bodies of the sixth Right atrium and seventh thoracic vertebrae T8 Pedicle of ninth thoracic vertebra Site of intervertebral Border of T9 disc left ventricle Body of 10th thoracic vertebra Right dome T10 of diaphragm Left dome of diaphragm T11 Liver Edge of descending T12 thoracic aorta Figure Normal radiology of the thoracic region.
An anteroposterior radiograph of the thoracic region shows T2—T12 vertebrae. A: Lateral radiograph of the lumbosacral region. The ears of the Scottie dog are the superior articular processes. The legs of the Scottie dog are the inferior articular processes. The nose of the Scottie dog is the transverse process. The neck of the Scottie dog is the pars interarticularis. The eye of the Scottie dog is the pedicle. Vertebral Column 13 Case Study A year-old construction worker experienced a pain in his lower back while trying to move a beam from one side of the construction site to another site.
The tibial nerve is motor to the posterior compartment muscles of the thigh except for the short head of biceps femoris , leg, and the sole of the foot. The sural nerve supplies the skin of the lateral and posterior part of the inferior one-third of the leg and the lateral side of the foot. This is because of the following. The dura continues caudally as the ilum of the dura mater or coccygeal ligament , which attaches to the dorsum of the coccyx bone.
This space con- tains fat and the internal vertebral venous plexus. A: A diagram of the spinal cord, spinal nerves, and meninges. B: A diagram indicat- ing craniocaudal extent of the spinal cord and meninges. The anterior spinal artery gives rise to sulcal arteries, which supply the ventral two-thirds of the spinal cord. The posterior spinal arteries supply the dorsal one-third of the spinal cord.
The circulation of the rest of the spinal cord depends on the segmental medullary arteries and radicu- lar arteries. Clinical symptoms include paraplegia, impotence, loss of voluntary control of the bladder and bowel incontinence , and loss of pain and temperature, but vibration and proprio- ception sensation are preserved.
Figure A: Basic organization of the spinal nerves. Note that each spinal nerve bears the same letter—numeri- cal designation as the vertebra forming the superior boundary of its exit from the vertebral column, except in the cervical region. In the cervical region, each spinal nerve bears the same letter—numerical designation as the vertebra forming the inferior boundary of its exit from the vertebral column. Note that spinal nerve C8 exits between vertebrae C7 and T1.
B: Functional components of a typical thoracic spinal nerve. V Dermatomes Figure are strips of skin extending from the posterior midline to the anterior midline which are supplied by sensory branches of dorsal and ventral rami of a single spinal nerve. The pia mater is not pierced. Although dermatomes are shown as distinct seg- ments, in reality, there is overlap between any two adjacent dermatomes. The sensory innervation of the face does not involve dermatomes but instead is carried by cranial nerve CN V; V1 ophthalmic division , V2 maxillary division , and V3 mandibular division.
Shaded areas in the table indicate dermatomes affected by a herniated disk see Chapter 1. A: A needle is shown inserted into the sub- arachnoid space above the spinous process of L4 L3-L4 interspace to withdraw cerebrospinal luid CSF as in a lumbar puncture or to administer spinal anesthesia saddle block. A second needle is shown inserted into the epidural space below the spinous process of L4 L4-L5 interspace to administer lumbar epidural anesthesia.
Note the sequence of layers superficial to deep that the needle must penetrate. Inset: Photograph shows a physician inserting a needle during a lumbar puncture procedure. B: A series of needles are shown inserted into the epidural space either through the sacral hiatus into the sacral canal or through the posterior sacral foramina at various levels. Co, coccyx. There are two types of complete SCI.
Paraplegia i. Quadriplegia i. These individuals may die quickly due to respiratory failure if the phrenic nerve is compromised. Incomplete SCI can be ameliorated somewhat by rapid surgical intervention. There are three situations that may lead to an incomplete SCI: A concussive blow, anterior spinal artery occlusion, or a penetrating blow e. Complications of any SCI include hypotension in the acute setting, ileus bowel obstruction due to lack of motility , renal stones, pyelonephritis, renal failure, and deep venous thrombosis.
Chordomas have histologic features, which include physaliphorous bubble-bearing cells with mucoid droplets in the cytoplasm. Glioblastoma multi- forme GBM is the most common primary brain tumor in adults men 40 to 70 years of age , are highly malignant, and pursue a rapidly fatal course. The MRI shows an astrocytoma which is an excellent example of an intramedullary within the spinal cord tumor.
Note that the astrocytoma arrows within the substance of the spinal cord has a cystic appear- ance. Figure MRI of an astrocytoma. Meningiomas occur more commonly in women, may increase in size during pregnancy, have an increased incidence in women taking postmenopausal hor- mones, and are associated with breast cancer, all of which suggest a potential involvement of steroid hormones. The MRI shows a meningioma that is an excellent example of an intradural within the meninges tumor.
Note the menin- gioma arrow outside of the spinal cord causing some com- pression of the spinal cord. Figure MRI of a meningioma. Spinal Cord and Spinal Nerves 23 G. The most common intra- cranial site is the cerebellopontine angle with involvement of cranial nerve VIII acoustic neuroma , where expansion of the tumor results in tinnitus and sensorineural deafness.
Figure MRI of a schwannoma. Preganglionic Sympathetic Neuron. Pregangli- onic axons have a number of fates as follows. Preganglionic sym- pathetic neurons solid line; green , postganglionic sympathetic neurons dashed line; orange. PARA, paravertebral chain ganglia; C, celiac ganglion; S, superior mesenteric ganglion; I, inferior mesenteric ganglion; SHy, superior hypogastric plexus; IHy, inferior hypogastric plexus; GSp, greater thoracic splanchnic nerve; LSp, lesser thoracic splanchnic nerve; LTSp, least thoracic splanchnic nerve; Sp, splanchnic nerve.
Postganglionic Sympathetic Neuron. The postganglionic neuronal cell bodies are located in the paravertebral chain ganglia and the prevertebral ganglia. Postganglionic axons have a number of fates as follows. This neuron sends a peripheral process to the viscera that ends as a free nerve ending or nociceptor and sends a central process into the spinal cord, which synapses with a second neuron within the spinal cord.
OT Brachial Plexus
The circled numbers indicate the three-neuron chain involved in visceral pain sensation. First neuron solid line; yellow , second neuron solid line; red , third neuron solid line; brown. Preganglionic Parasympathetic Neuron. The preganglionic neuronal cell bodies are located in the Edinger-Westphal nucleus, lacrimal nucleus, superior salivatory nucleus, inferior salivatory nucleus, dorsal motor nucleus of the vagus nerve, and gray matter of the S2 to S4 spinal cord. Preganglionic axons have a number of fates as follows. Postganglionic Parasympathetic Neuron. The postganglionic neuronal cell bodies are located in the ciliary ganglion, pterygopalatine ganglion, submandibular ganglion, and otic ganglion, and within various visceral organs.
Preganglionic parasympathetic neurons solid line; green , postganglionic parasympathetic neurons dashed line; orange. This neuron sends a peripheral process to the viscera that ends at the chemoreceptors, baroreceptors, rapidly adapting mechanoreceptors, slowly adapting mecha- noreceptors, osmoreceptors, and internal thermal receptors. These neurons also send a central process into the brainstem or spinal cord, which synapses with a second neuron either in the soli- tary nucleus, dorsal horn of the spinal cord, or gray matter of the S2 to S4 spinal cord.
The second neuron in the chain in the dorsal horn of the spinal cord projects axons to the anterolateral system ALS and the spinoreticular tract, which terminate in the reticular formation. The circled numbers indicate the three-neuron chain involved in visceral sensation. First neuron solid line; yellow , second neuron solid line; red , third neuron solid line; brown , preganglionic sympathetic motor neuron solid line; green.
General Features. All regions of the body possess lymphatic drainage except for the brain and spinal cord. A: Diagram of the lymphatic system. B: General body pattern of lymph drainage. Shaded area red , lymph drainage into the right lymphatic duct; unshaded area, lymph drainage into the thoracic duct. Arrows indicate direction of lymph low. Solid lines green , lymph vessels; blue, veins. Arrowheads and arrows indicate direction of lymph low. Shaded area red , lymph drainage into the right lymphatic duct; unshaded area, lymph drainage into the thoracic duct; solid lines green , lymph vessels; blue, veins.
The boundar- ies of the thoracic inlet are the manubrium anteriorly, rib 1 laterally, and the thoracic vertebrae posteriorly. The boundaries of the thoracic outlet are the xiphoid process anteriorly, costal cartilages 7 to 10 and rib 12 laterally, and T12 vertebra posteriorly. Ribs 8 to 10 articulate with more superior costal cartilage and form the anterior costal margin. Ribs 11 and 12 often called loating ribs articulate with vertebral bodies but do not articulate with the sternum. The osteocartilaginous thoracic cage includes the sternum, 12 pairs of ribs and costal cartilages, and 12 thoracic vertebrae with their intervertebral disks.
The clavicles and scapulae form the pectoral shoulder girdle. The dotted line indicates the position of the diaphragm separating the thoracic cavity from the abdominal cavity. This is the site where rib 2 articulates with the sternum, the aortic arch begins and ends, the trachea bifurcates, and the superior mediastinum ends.
Sensory innervation to the periphery of the diaphragm is provided by the intercostal nerves. The paralyzed dome of the diaphragm does not descend during inspiration and is conse- quently forced upward due to increased abdominal pressure. The intercostal vein, artery, and nerve travel in the costal groove on the inferior border of the ribs. Serratus Posterior Superior Muscle D. Serratus Posterior Inferior Muscle E. Levator Costarum Muscle F. Transverse Thoracic Muscle G. IV Movement of the Thoracic Wall Movement of the thoracic wall is concerned with increasing or decreasing the intrathoracic pressure.
The act of breathing involves changes in intrathoracic pressure and is called inspiration and expiration. This contraction of abdominal muscles pushes against the diaphragm. The anterior intercostal veins drain the anterior thorax and empty into the internal thoracic veins, which then empty into the brachiocephalic veins. The posterior intercostal veins drain the lateral and posterior thorax and empty into the hemiazygos veins on the left side and the azygos vein on the right side.
The hemiazygos veins empty into the azygos vein, which empties into the superior vena cava SVC. If breast carcinoma invades the retromammary space and pectoral fascia, contraction of the pectoralis major may cause the whole breast to move superiorly. A: A sagittal diagram of the breast. B: A craniocaudal CC mammogram of a normal left breast.
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The pectoralis major muscle arrows is seen. C: A CC mammogram of a benign mass arrow. D: A CC mammogram of a malignant mass. A malignant mass has the following characteristics: Shape is irregular with many lobulations, margins are irregular or spiculated, density is medium—high, breast architecture may be distorted, becomes larger over time, and calciications not shown are small, irregular, variable, and found within ducts ductal casts.
If breast carcinoma invades the suspensory ligaments, the ligaments may shorten and cause dimpling of the skin or inversion of the nipple. Innervation The nerves of the breast are derived from anterior and lateral cutaneous branches of intercostal nerves 4 to 6 i. Lymph Drainage The breast has lymphatic plexuses that communicate freely, called the circumareolar plexus, perilobu- lar plexus, and interlobular plexus, all of which drain into the deep subareolar plexus.
Clinical Considerations 1. Fibroadenoma is a benign proliferation of connective tissue such that the mammary glands are compressed into cords of epithelium. It is the most common benign neoplasm of the breast. Iniltrating duct carcinoma is a malignant proliferation of duct epithelium where the tumor cells are arranged in cell nests, cords, anastomosing masses, or a mixture of these.
Insertion of a Central Venous Catheter. In clinical practice, access to the SVC and right side of the heart is required for monitoring blood pressure, long-term feeding, or administration of drugs. The internal jugular vein and subclavian vein are generally used. The brachial plexus and subclavian artery emerge between the middle and anterior scalene muscles. The subclavian artery and subclavian vein are separated by the anterior scalene muscle. The brachial plexus, subclavian artery, and subclavian vein cross above rib 1 but below the clavicle. Note the arrangement of the subclavian vein and the internal jugular vein and their use in placing a central venous catheter the central or anterior approach and the infraclavicular approach.
Internal jugular vein central or anterior approach Figure The needle is inserted at the apex of a triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle of the right side. The diagram shows the cor- rect central approach when inserting a catheter into the inter- nal jugular vein. Figure Insertion of catheter central approach.
Chest Wall 43 2. Subclavian vein infraclavicular approach Figure The needle is inserted below the clavicle and lateral to your thumb on the right side. The diagram shows the correct infraclavicular approach when inserting a catheter into the right subclavian vein. Complications of a central venous catheter may include the following: Puncture of subclavian artery or sub- clavian vein, pneumothorax, hemotho- rax, trauma to trunks of brachial plexus, arrhythmias, venous thrombosis, erosion Figure Insertion of catheter infraclavicular of catheter through the SVC, damage to approach.
A postductal arctation of the aorta is generally located distal to the left subclavian artery and the ligamentum arteriosum. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Get access to the full version of this article. View access options below.
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