ANATOMY RECALL RECALL SERIES EDITOR AND SENIOR EDITOR LORNE H. BLACKBOURNE, M.D. General Surgeon Fayetteville, North Carolina EDITORS JARED ANTEVIL, M.D. United States Marine Corps ‘Camp Pendleton, California CHRISTOPHER MOORE, M.D. Resident in Emergency Medicine Carolinas Medical Center Charlotte, North Carolina Me LIPPINCOTT WILLIAMS & WILKINS ‘A Wolters Kluwer Company Philadelphia » Baltimore + New York + London Buenos Aires + Hong Kong + Sydney + TokyoAcquisitions E ltors Blzabeth A. Nieginski Exlitorial Director: Julie P. Martine Development Editor: Melanie Car Managing Ealvor: Amy Dinkel Marketing Manager: Aimee: Sir Copyright © 2000 by Lippincott Willams & Wilkins. All rights reserved, This book is protected by copyright. No part of t may be nsmitted, in any form or by’ any eans—electronic, mechanical, photocopy, recording, or otherwise—without produced, stored in a retrieval system, oF t the prior written permission of the publisher, exept for brief quot boxed in enitical articles, reviews, and testing and evaluation materials pro- vided by the publisher to schools that have adopted its accompanying textbook Printed in the United States of America, For information, write Lippineote Williams & Wilkins, 530 Walnut Street, Philadelphia, PA 19106, ‘Materials appearing in this book prepared by individuals as part oftheir offical dutiesas U.S. Government emplayees are not covered by the above-mentioned copyright 987654929 Care has been taken to confirm the aconracy ofthe information presented to describe generally accepted practices. However, the authors, editors, publisher are not responsible for errors or omissions or for any consequences from application ofthe information in this book and make no warranty, express ‘or implied, with respect tothe contents ofthe publication “The authors, editors, andl publisher have exerted every effort to ensure that dng selection and dosage set forth inthis text are in accordance with enrent recommendations and practice atthe time of publication. Howeser, in view of ongoing research, changes in government regulations, and the constant flow of formation relating to crag therapy and drug reactions, the reader is urged to chek the package insert for each drug for any change in dications and dosage ‘and for added warnings and precautions. This is particularly important when the recommended agent isa new or infrequently employed drug, ‘Some drugsand medial devices presented inthis publication have Food and Drug Administration (FDA) elearance for limited use in restricted! research settings, Iti the esponsibility of the health care previder to ascertain the FDA, status of each drug or device planned for use in their clinical practice,ASSOCIATE EDITORS James Boyer Fousth-Year Medical Student School Charlottoslle, Virginia “Anikar Chhabra, M.D. Resident in Orthopedic Surgery University of Virginia Charlottesslle, Virginia Hiwot Desta, M.D. in Internal Medicine Ohio State University Columbus, Ohio Kimberly Estler, M.D. in Obstetrics and Gynecology University of Rochester Rochester, New York Barry Hinton, Ph.D. Professor of Anatomy andl Cell Biology University of Virginia School ‘of Medicine Charlotteslle, Virginia Mike Iwanik, Ph.D. Professor of Anatomy and Cell Biology University of Virginia School ‘of Medicine ottesvlle, Virginia Brian Kaplan, M.D. Resident in Otolaryngology University of Virginia Charlottesville, Virginia Clinton Nichols, M.D. Resident in Radiology University of California, San Diego Ravi Rao, M.D. Resident in Nenrost Brigham and Women's Hospital Boston, Massichusetts Jeffrey Rentz, M.D. Resident in General Surgery University of Utah Salt Lake City, Utah Peter Robinson, M.D. Resident in Internal Medicine University of Colorado Boulder, Colorado John Schreiber, M.D. Resident in Radiology Stanford University Stanford, CaliforniaCONTRIBUTORS Wang Cheung, MD. Jamal Hairston, M.D. Meredith LeMasters, M.D. Steven Lin, M.D. Bruce Lo, M.D. Ana Meura, M.D. Suzanne Perks, M.D. Andrew Wang, M.D, Thomas Wang, M.D. Philip Zapata, M.D.Dedication “This book is dedicated to the medical students at the University of Virginia,Contents Preface . = x Acknowledgments mhstwasnaisensinn =) 1 Overview occ coree ve I 2 TheHead occ eececceeserseee Siesrettnssres 2 3 The Central Nervous System — co 6 4 The Cranial Nerves ‘ ae 5 The Neck tot 6 The Back .... Ep : svueene 128) 7. The Upper Extremicy a 3 The Thorax mete 195, 9 The Abdomen .. a 214 10 The Pelvis and Perineum : 253 I The Lower Extremity os 285 Index 2319Preface Anatomy Recall was written by medical students, physicians, and anatomists specifically for use during a fist-year gross anatomy course and as a review for the United States Medical Licensing Examination (USMLE) Step 1. While there are certainly a wealth of gross anatomy texts available, most are better suited for reference than for mastery of the basic anatomy required to be a suc- ‘cessful medical student and physician, Its our intention that Anatomy Recall and an atlas are all you will ned for a comprehonsive study of basic anatomy’ ‘Anatomy Recalls arranged in the extremely successful question-and-answer Format that defines the entiee Recall series—a format that emphasizes active acquisition of knowledge, rather than passive absorption of it. Where appro- priate simple figures have been included to supplement the text material. Fach Chapter concludes with a “power review” that covers the most important and Frequently tested facts in each subject area. These power roviews are ideal for 4 quick review prior to an anatomy examination, a board examination, oF a surgery clerkship, ‘Anatomy is an exciting yet demanding course. It is important to have a text that is comprehensive yet readable and emphasizes (and reemphasizes) key points. A thorough initial study of anatomy wil continue to reward you through ‘outa lifetime of clinial practice. It is our hope that Anatomy Recall will prove to be an invaluable tool for mastering the subject of anatomy. Good luck! ‘The EditorsAcknowledgments. “The editors would like to acknowledge Melanie Cann, Amy Dinkel, Julie Mar- tine, and Elizabeth Nieginski at Lippincott Williams & Wilkins for their help and vision in bringing this book to fruition, xOverview Itis important to adhere toa certain formalism when describing the location or jovement of one body part relative to another, therefore, a significant portion 1 course (like many introductory courses in medicine) is devoted -ating with other healtheare pro ofthe toteac fessionals. language necessary for comm ANATOMIC POSITION What standard position is That of a human standing facing forward, assumed when deseribing feet pointing forward " the human body? outward (the “anatoraie position”) ANATOMIC PLANES. Deseribe the three basic 1. Transverse (horizontal): \ anatomic planes. horizontal plane aeross the body anatomic position; the most commo ‘cut used in computed tomography (CT) and magnetic resonance imaging (MRI) 2. Sagittal A plane formed by a vertical midline cut that divides the body into aeutacross the body in anatomic position from side to side and top to bottom ANATOMIC DESCRIPTORS Define the following terms: Ventral “Tawar the anterior (oF front) ofthe body Dorsal “Toward the posterior (or back of the bry Medial Closer to the midline Lateral Fusther from the miWith the palms facing up, the thumbs are lateral tothe other fingers, Tateral to the forefinger? What is the position of the The great toc is medal ‘great toe (first toe) relative ta the other toes? Define the following terms: Proximal Closcr to the center ofthe body (often ‘considered the heart) Distal Further from the center ofthe body Where is the radial artery The radial arteny (inthe forearm) i distal in relation to the subelavian tothe subclavian artery (under the artery? asic Which is more distal, the The tibia femur or tibia? ANATOMIC MOVEMENTS. What are the three major Simoth, cardia, and skoletal (striated) types of musele? Describe the innervation _ Skeletal musele is gonerally innervated by and characteristics of somatic nerves (i.e,, movement is skeletal muscle. voluntary, and is located etween two stable points (ie, bones). Contraction results in movement of a structure. What four parameters are Origin: Usually the more proximal, more used to describe skeletal medial, and more stable structure that muscles? the muscle is attached to Insertion: Usually the more distal, more Tateral structure that the muscle is attached fo, and the one that is moved by contraction Tnnervation: The nerve that eases the nsele to contract Action: The result ofthe muscle ‘contracting Define the following muscle actions: Flexion Decreasing the bending the joint ng ofa joint, oFChapter | Overview 3 Extension Inereasing the angle ofthe joint, oF straightening the joint Abduction Moving one structure away from another Taterally (ie, away from anatomic position) Adduetion Moving one structure toward another medially (.c. toward the anatomie position)—think add = together Deseribe the action that ‘occurs with each of the following movements: Kicking a soccer ball Extension ofthe leg atthe knee Spreading the fingers Abduction ofthe fingers at the metacarpephalangeal joints Bringing an arm that is Adiduction ofthe arm at the shoulder ‘extended straight out and to the side laterally, toward the body What is the difference ‘Tendons attach the muscle tothe bone, between ligaments and while ligaments attach bone to bone tendons? What isa strain? partial or incomplete tear of a muscle orligament What isa sprain? A partial or incomplete tear ofa tendon2 THE SKULL The Head ‘What is the skull? What are the two regions ‘of the skull? What is the ealvaria? What is diploe? Identify the structures on the following lateral view of the skull: xo7mo 0 1 skeleton of the head, incl mandible ngthe ‘The neuroeranium (i, the portion of the skull that encloses the brain) and the facial cranium “The skull cap (i.e. the vault of the neuro cranium, oF the portion of the skull that is Teft when the facial bones are removed) “The spongy bone layer between the dense ‘outer and inner bone layers of the calvaviaChapter 2/ The Head 5 A= Inferior and superior temporal lines B= Parictal hone C= Lambdoid suture D= Sphenoid bone, greater wing E = Temporal bone F = Zygomatic arch G= Occipital bone H= External occipital protuberance T= Mastoid process J. = Ramus of the mandible K= Angle of the mandible = Mental foramen M= Frontal bone coronal suture *erion (the “p” is silent) acrimal bone sternal auditory (acoustic) meatus terior nasl spine tyloid process Iveolar process What are the superior and ‘The attachment points for the temporal, inferior temporal lines? What region lies below the The temporal fossa superior and inferior temporal lines? What is the clinical signifi- Severe mide ear infections may spread ‘cance of the proximity of the tothe mastoid process ofthe temporal external auditory meatus and bon the mastoid process? NEUROCRANIUM Bones and sutures Which eight bones make ‘The frontal bone, the two parietal boues, up the neurocraniam? the two temporal hones, the ocipital bone, the sphenotd bone, and the ethinokd bone What are the immobile Sutures junetions between the hones of the neuroeranium called?6 Anatomy Recall Which hones articulate at the: Coronal suture? Sagittal suture? Lambdoid suture? sutures called! What is the intersection of the sagittal and coronal sutures called? What is a metopie suture? What is erantorynastosis? What is Scaphocephaly? Acrocephaly? Plagiocephaly? Identify the labeled points fon the neuroeraninm on the following posterior and superior views: “The frontal and patietal bones ‘The parictal hones of ether side The parietal and oceipital bones The lamba The bagi A persistent frontal suture, present in approximately 24 of the population Premature closure of the sutures ure closure ofthe sagittal suture ure closure ofthe coronal suture ure closure ofthe coronal and lambdoid sutures on one side onlyWhat are fontanelles? What are the largest fontanelles, and where are they located? Which sutures form the borders of the posterior fontanelle? How can the anterior and posterior fontanelles be ‘identified on an infant? In adults, what is the name of the remnant of th Posterior fontanelle? What isthe location of the anterolateral (sphenoidal) fontanelle called in adults? Why is the pterion Chepeor 2/ The Head 7 agit suture Lamba hoi suture stemal occipital protuber astoid process Decipital condyle = Bregia ‘ronal sutre agital suture Lambda aambdod suture Large fibrous areas where several sutures ‘meet; often called “soft spots” on an infant's head ‘The anterior and posterior fontanelles, on the superior surface of the neuroe ‘The sagital and lambdoid sutures ‘The anterior fontanelle is diamond. shaped and palpable in children younger than approximately 18 months. The posterior fontanelle is triangular and is not palpable past I year of age. The bregm ‘The asterion ‘The ptevion (brain surgery using an anterolateral incision is ealled a “pterional spproach") ‘The thinnest part of the lateral skull, the plerion is vulnerable to fractures that ean damage the middle meningeal artery, ‘which lies on the internal ska inthis region surface8 Anatomy Recal Internal surface features Label the following view of the floor of the neure- 90 o> superior orbital sure B= Foramen rotundum ramen ovale ypoglossal canal ‘raion magn ‘ramon lacerum nternal auditory meatus = Jugular fora Anterior cranial fossa In addition to the ethmoid The frontal bone bone, which bone eo utes to the floor of the anterior fossa? What is the name of the The enbriform plate flat part of the ethmoid bone that lies anteriorly in the midline? Cranial nerve (CN) I (the olfactory nerve) through the eribriform plate?What is the name of the sharp upward projection of the ethmoid bone in the midline? What is the function of the crista gall? Which structures pass through the anterior and posterior ethmoidal Foran Middle cranial fossa Which part of the brain ‘occupies the middle ‘cranial fossa? What are the borders of the middle cranial fossa: Anteriorly? Posteriorly? Laterally? Ventrally? Which three structures pass from the middle ‘cranial fossa into the orbit, via the optic canal? Which opening between the greater and lesser ‘wings of the sphenoid one conneets the middle ‘eranial fossa with the orbit? (Chapear 21 Tae Head The crista gal It provides the anterior site for the fal cerebri Ge Fold that Hes i the longitud between the two cerebral h spheres) ‘The anterior and posterior ethmoidal nerves and vessels, respectively ‘The temporal lobes of the cerebral The lesser wings of the sphenoid bones ‘The petrous part of the temporal hone 9 ‘The squamous part of the temporal bone, the greater wings of the sphenoid bones, and the parietal bones The temporal bones and the greater wings ofthe sphenoid bones 1. EN IH (the optic nerve) 2 The ophthalmic artery (a branch of tho internal earotid artery) 3, The central vein ofthe retina ‘The superior orbital fissure10 Anatomy Reel Which six structures pass from the middle eranial fossa to the orbit through the superior orbital fissure? The foramen rotundum transmits structures between which two spaces? Which structure passes through the foramen rotundum? ‘The foramen ovale trans- mits structures hetween which two spaces? Which two structures pass through the foramen ovale? ‘The foramen spinosum connects the middle ers fossa with whieh space? Which structure passes through the foramen spinosum? ‘The foramen lacerum lies at the junction of which ‘cranial bones? Grooves on the anterior part of the petrous tem- poral bone transmit which structures? What is the name of the thin plate of bone located at the junction of the petrous and squamous parts of the temporal bon L 3 4 6 (the oculomotor nerve) IV (the trochlear nerve) CNV; (the ophthalinie division of the a c The superior ophthalmie vein The inferior opthalmie vein ‘The middle cranial fossa and the perygopalatine fossa V5 (the mavilary division of the trigeminal nerve) ‘The middle eranial fossa and the infratemporal fossa EX Y; (the mandibular division of the tal nerve) andl the accessory meningeal atery “The infratemporal fossa (ike the foramen ovale) ‘The middle meningeal artery ‘The sphencid bone and the petrous part ‘of the temporal bone "The greater and lesser petrosal nerves “The tegmen tympani‘What is the clinical signi ficance of this thin bone? What is the name of the elevation of the sphenoid bone between the two optic canals? What is the name of the depression posterior to the tuberculum sellae? What is the name of the bony ridge that defines the posterior limit of the sella turelea? What are the boundaries of the sella turciea: Anteriorly? Posteriorly? Which structure lies in the hypophyseal fossa of the sella tureica? Which space is located directly inferior to the sella tureica? Which structure forms the roof of the sella tureiea? Which processes project from the lateral aspects of the dorsum sellac? ‘What structures attach to, the posterior clinoid processes? Posterior cranial fossa Which part of the brain lies in the posterior eranial fossa? Chapter 2/ The Head 11 This bone, which soparates the tympanic cavity from the middle cranial fossa, isso thin that infections ofthe middle ear can spread to the meninges and brain, The tubercubam sellae ‘The sella tureiea (“Turkish sad") The dorsum selle ‘The tuberculum sellae The dorsum sellae ‘The pity ary el The sphenoid sinus (surgery on the pituitary gland uses a “trans-sphenoidal” approich) ‘The diaphragma sellae(1¢., one of the dural folds) “The posterior elinold processes ‘The tentorinm cerebelli (Le, the dural {old between the occipital lobes and the cerebellum) ‘The corebelliun and brain stem12 Anacomy Recall What are the borders of the posterior cranial Fossa Anteriorly? Posteriorly? Ventrally (Le, the floor)? Dorsally (i.e. the roo)? Which three structures pass through the internal audi- tory meatus (ie. the open- 1g in the posterior aspect of the petrous part of the temporal bone)? Which cranial foramen lies the junetion of the pe- trous part of the temporal bone and the occipital bone? Which six structures pass through the jugular foramen? Where is the hypoglossal © relation to the {jugular foramen? Which nerve passes through the hypoglossal canal? Which large opening lies in the posterior midline floor of the posterior fossa? “The petrons part ofthe temporal bone The occipital bone "The occipital bone and the mastoid processes ofthe temporal b The tentorium corebell LGN VI (the abducens nerve) 2 CN VIII (the vestihulocachlear nerve) 3. The labyrinthine artery Tho jugular forasnon 1. GN IX (the glossopharyngeal nerve) 2 CNX the vagus nerve) 3. CN XE (the accessory ner 4. The intemal jugular vein (superior bulb) 5. The sigmoid sinus 6. The inferior petrosal sinus ‘The hypoglossal canal lies just medial to ‘he jugular foramen, CN XII (the hypoglossal nerve) ‘The foramen magnumWhich structures pass through the foramen smmagnum? What is the name of the bony “ramp” just anterior to the foramen magnum? ‘Which small opening may be present lateral to the foramen magnum? Which structure passes through the condyloid foramen? Which structures pass through the mastoid foramen? ‘What is the name of the midline crest on the in- side of the occipital bone? Which structure attaches to this crest? ‘What is the posterior term- ination of the internal ‘occipital crest? ‘Which structures are trans- ‘mitted in the grooves that project laterally from the internal occipital protuber- ance along the occipital bone? Chapter 2/The Head 13 1. The medulla oblongata (1, the lower aspect ofthe brain stem) 2 CN XI (the spinal accessory nerve 3. The vertebral arteries 4, ‘The venous plesus ofthe vertebral canal 5. ‘The anterior aud posterior spinal esters The clivus ‘The condyloid foran “The condyloid emissary vein ‘The mastoid emissary vein and a branch ‘of the ocepital artery The internal occipital rest ‘The fals cercbeli (Ke, the dural fold that separates the cerebellar hemispheres) “The internal occipital protuberance The transverse sinuses14 Aratomy Recall FACIAL CRANIUM, Label the structures sh on the following anterior view of the skull ken Eo Supraorbita noteh Superior orbital fissure C= Inferior orbital sure D= Inferior nasal concha E = Infraorbital foramen Alveolar process G= Ghabella Optie canal Midale nasal concha ‘Zygomaticofacial foramen K = Nasal septum = Angle ofthe manchible AM= Mental foramen What is the smooth median The glabella prominence of the frontal hone called? Which bone located be- The tween the orbits contains the eribriform plate and a perpendicular plate?Which structures pass through th Infraorbital foramen? ‘Zygomaticofacial foramen? Mental foramen? Orbie Which bones form the margins of the orbit: Superiorly! Laterally? Which twa fissures form a communication between the the orbit? Which structures pass into the orbit from the infratem- poral fossa via the inferior orbital fissure? Which structures pass through the supraorbital notch? Paranasal (air) sinuses What are paranasal sinuses? Chapter 2/The Head 15 ‘The infraorbital nerve (a contimation of EN Vp) the infraorbital artery, and the infraorital vein ‘The zygomaticofacial nerve The frontal bone (orbital plate) ‘The zygomatic bone and zyyomatic process of the frontal bone The maxilla and 7ygomatic hones The ethmoid, lacrimal, sphenoid, and frontal bones "The superior orbital fissure (comnicates with the middle cranial fxs) and the inferior orbital fissure (o ‘municates with the infratemporal fossa ‘The rygomatic branch of C nally division ofthe trig and the infiaorbital artery Va the vninal nerve) ENV; (the opthaliie division ofthe trigeminal nerve, or the supraosbital nerve) and the supraorbital vessels ‘The paranssal shnises are ai spaces within the bones ofthe ski that communicate with the nasal cavity. Don't confuse the pparanasal sinuses with the venous (éural) sinuses, which convey venous blood in the16 Anatomy Recall List the four skull bones that have paranasal sinuses. What is the funet these sinuses? Which sinus, because of its location, ean often lead to the spread of infection into the orbit? Which sinus is susceptible to the spread of infeetion from a tooth? ‘Which sinuses may be present at birth? Nasal caviey Which four bones form the roof of the nasal cavity? Which bones form the floor of the nasal eavity (and the hard palate, or the anterior portion of the roof of the mouth) Which eight bones form the lateral wall of the nasal cavity? Which opening forms a communication between the nasal cavity and the nasopharynx? Which structure divides the nasal cavity into left and right parts? 1. Frontal bone 2 Masia 3 I 4. Sphenoid home wid bone Ther fetion stash alone are thought to lighten the skull and aid in resontion of the voice ‘The maxillary sinus—roots ofthe posterior maxillary teeth often project up into this sinus, ‘The masilary and sphenoid sinuses The nasal bone, the frontal bone, the cribriform plate ofthe ethinoid bone, and the body of the spend bone The palatine process ofthe masilla and the liorizontal plate of the palatine bone “The ethmoid bone ‘The medial pterygoid plate ‘The perpendicular plate ofthe palatine hone ‘The masila “The nasal bone “The frontal bone ‘The herimal bone “The inferior concha The choanae, a large opening at the back of the nasal cavity The nasal septumWhich two bones contribute to the nasal septum? What are the three bony projections from the lateral ‘nasal wall called? What are the spaces below each of the nasal conchae called? ‘The inferior meatus con- tains the opening to which space above the super ‘concha? ‘What is the rounded prom- inence on the wall of the middle meatus? ‘What is the hiatus semi- Iumaris? ‘What isthe infundibulum? Deseribe the drainage of each of the following para- nasal sinuses: ‘The anterior ethmoid "The midalle ethmoid sinus ‘The posterior ethmoid sinus ‘The frontal sinus ‘The sphenoid sinus (Chapter 21 The Head 17 The vomer ancl the perpendicular plate of the ethmoid bone “The nasal conchae—the superior and middle conchae are part ofthe ethimotd bone, while the inferior nasal concha isan independent bone Meatus (eg, the superior meatus isthe space between the superior and middle conchae: the mide bets eatus isthe space 1 the aide and inferior conchae inferior meatus is the space below the inferior conch) an th “The nasolacrimal chct “The sphenoethmoid recess The ethmoid bulla The enrved eleft below the ethmoid bulla atthe: The chs wats semilomaris terior aspect of the "The biatus seminars (ia the infiand bulum), located inthe middle nasal meatus “The ethimoid bulla, located in the middle nasal meats The superior nasal meatus ‘The middle nasal meatus (via the Front nasal duet, which opens into the infuncibuluen) The sphenocthmoidal recess1 Anatomy Recall iMlary sinus Which three arteries supply branches to the nasal cavity? What are the two primary branches of the ophthalmic artery that supply the nasal cavity? ‘What are the two branches of the masillary artery that supply the nasal cavity? Which branch of the facial artery supplies the nasal cavity? Mandible Where does the body of the ible meet each of the rami? Name the two processes on top of each of the ram What is the name of the notch located between the coronoid and eondyloid processes? What is the name of the ‘opening on the medial surface of the mandible? What structure does the ar foramen lead What structures lie in the sand ilar canal? “The hiatus semi The masilary and facial arteries (branches of the extemal carotid artery) and the ophthalnie artery (a branch ofthe intemal ‘carotid artery) ‘The anterior and posterior ethrnoidal arteries, which supply the lateral wall and rasal septum ‘The sphenopalatine artery (which meatus, and nasal supplies the conchae, septum) and the descending palatine artery (which also supplies the nasal septum) ‘The superior labial artery ‘The coronoid process (anterior) and the condyloid process (posterior) ‘The mandibular noteh The mandibular foramen The mandibular canal ‘The inferior aleolar nerves and vessels,