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Principal Authors Norman Eizenberg (MBBS) Christopher Briggs (PhD) Craig Adams (MBBS MD) Gerard Ahern (MBBS)
Contributing Authors Priscilla Barker (PhD) Ivica Grkovic (MD) Alex Pitman (FRANZCR)
Prototype Contributors Henoh Dolezal (MBBS) Zdenek Dubrava (MBBS)
Content Consultants Marius Fahrer (FRACS) Robert Marshall (FRACS) John Furness (PhD) Jenny Hayes (MBBS) Educational Consultant: Cyril Driver (Med)
Clinical Consultants Christen Barras (MBBS) Maurice Brygel (FRACS) Erica Fletcher (PhD) Robert Heng (FRANZCR) Justin Kelly (FRACS) Martin Richardson (FRACS) Andrew Rotstein (FRANZCR) Ramin Shayan (MBBS) G. Ian Taylor (FRACS)
Photography Stuart Thyer (BAppSc) Dissections Priscilla Barker (PhD) Matt Jackson (BSc) Illustration and Images Priscilla Barker (PhD) Diana Keshtiar (BSc)
Prototype Illustrations Quang Minh Phan (MBBS) Yun Fan Lu (MBBS)
Graphic Design Gavin Leys Design Consultant Chris Hanger Design Consultant Michelle Gough (BAppSc)
Acknowledgements
Department of Anatomy and Cell Biology, the University of Melbourne Courseware Development Unit, the University of Melbourne Department of Anatomy and Cell Biology, Monash University St. Vincents Hospital, Melbourne The Fiji School of Medicine, Fiji National University, College of Medicine, Nursing & Health Science The Visible Human Project (National Library of Medicine) 16 figures have been used (with permission) Ch.: 1, 13, 14 & 25)
Contents
Preface SECTION I: THE HUMAN BODY Chapter 1: Human Anatomical Terms Chapter 2: Human Form and Structure Chapter 3: Human Sexual Characteristics SECTION II: BODY SYSTEMS AND ORGAN STRUCTURE Chapter 4: Skeletal System and Bones Chapter 5: Articular System and Joints Chapter 6: Muscular System and Muscles Chapter 7: Integumental System and Skin Chapter 8: Visceral Systems and Viscera Chapter 9: Nervous System and Nerves Chapter 10: Arterial System and Arteries Chapter 11: Venous System and Veins Chapter 12: Lymphatic System and Lymph Vessels SECTION III: BODY REGIONS AND ORGAN POSITION Chapter 13: Regions of the Body Chapter 14: Arrangement of Body Regions Chapter 15: Body Compartments and Fascial Planes Chapter 16: Body Wall and Cavities Chapter 17: Neurovascular Pathways SECTION IV: HUMAN DEVELOPMENT AND VARIATION Chapter 18: Growth and Development Chapter 19: Normal Variation Chapter 20: Anatomical Variation in Structure Chapter 21: Anatomical Variation in Position Chapter 22: Pathological Changes SECTION V: PRACTICAL PERSPECTIVES Chapter 23: Surface and Functional Anatomy Chapter 24: Radiographic Anatomy and Imaging Chapter 25: Sectional Anatomy, CT and MRI Chapter 26: Ultrasound Imaging Chapter 27: Endoscopic Anatomy Chapter 28: Clinical Procedures Chapter 29: Postmortem Examination of Organs Chapter 30: Cadaver Dissection Appendices Glossary Index Annulus 200 200 200 200 200 200 200 200 157 162 166 172 177 135 140 144 147 151 19 29 41 55 68 86 105 117 126 Page 3 6 15
Preface
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Chapter 1: Human Anatomical Terms Chapter 2: Human Form and Structure Chapter 3: Human Sexual Characteristics
Animal Coelomate Chordate Vertebrate Mammal Primate Hominid Homo Homo sapiens
ANATOMICAL POSITION AND PLANES TERMS OF RELATIONSHIP TERMS OF COMPARISON SPECIAL TERMS OF COMPARISON TERMS OF LATERALITY TERMS OF MOVEMENT SPECIAL TERMS OF MOVEMENT ANATOMICAL POSITION AND PLANES
To avoid confusion in describing the location of one structure relative to another a standard reference position has been adopted. This arbitrary position is termed the anatomical position, where the body is standing upright with arms by the sides and palms facing forwards. Other terms of position include sitting, kneeling and lying.
TERMS OF RELATIONSHIP
When describing the relationship between one structure and another, the body is considered to be in the anatomical position. Terms of relationship are in opposite pairs along the three dimensions of depth, length and width. Superior is above while inferior is below. Medial (L. middle) is closer to the midline while lateral (L. side) is further from it. Anterior is in front while posterior is behind.
Fig.1.1 The anatomical position Three sets of planes associated with the anatomical position are sagittal, coronal and transverse. Sagittal and coronal planes are vertical but at 90 degrees to each other. Vertical slices parallel to the sagittal (L. arrow) suture of the skull are in sagittal planes. The midline of the body is in the mid-sagittal (or median) plane, as it is directly along the sagittal suture. Vertical slices parallel to the coronal (L. crown) suture of the skull are in coronal planes. Horizontal slices are in transverse planes. 3
TERMS OF COMPARISON
Alternative pairs of terms may be used when comparing the position of structures, or even the same structure in different species. Terms of comparison apply to any position of the body without it necessarily being in the anatomical position Proximal (L. nearest) is closer to the origin of a part while distal (L. distant) is further from the origin. Superficial is closer to the skin while deep is further from the skin. For a hollow structure, external (or outer) is further from its cavity while internal (or inner) is closer. Ventral (L. belly) is closer to the belly surface while dorsal (L. back) is closer to the back surface. The dorsal surface of the penis is in front of its ventral surface when flaccid but behind it when erect.
Fig.1.8 Terms of polarity Cranial (G. skull) is closer to the head while caudal (L. tail) is closer to the tail. Within the head, rostral (L. beak) is closer to the front while occipital (L. begin as in born first) is closer to the back of the head.
TERMS OF LATERALITY
Paired structures on both right and left sides of the body are regarded as bilateral. Unpaired structures may be midline or, if they are only on one side, unilateral. Ipsilateral refers to structures on the same side of the body while contralateral refers to those on the opposite side. Fig.1.11 Examples of special movements Other examples include movements of the foot (plantar flexion and dorsi flexion as well as inversion and eversion) and of the scapula (protraction and retraction as well as elevation and depression).
TERMS OF MOVEMENT
Movements at joints occur in pairs, each in an opposite direction. Flexion (L. bend) is to bend, decreasing the angle between two levers while extension (L. stretch) is to straighten, increasing the angle. Abduction is to move away from the midline while adduction is to move towards it. Medial or internal rotation is to turn inward around the long axis while lateral or external rotation is to turn outward. This pair of movements tends to occur in the transverse plane. 5
Germ Layers
The organism develops in three germ layers: ectoderm, mesoderm and endoderm. Ectoderm is exposed to the external environment and also forms nerve cells. Mesoderm develops into structures providing support and splits to form the coelom around the gut and the lining of the body wall. It also conveys and forms vessels. Endoderm forms membranes for absorbing nutrients and becomes continuous with ectoderm at openings to the external environment.
CHORDATE FEATURES
Chordates (G. 'cord') have the following characteristics, at least during some stage of development: - a dorsal hollow nerve cord (neural tube) - a notochord and a tail - pharyngeal pouches
Fig.2.1 Mouse embryo at 5 weeks Although humans have a particular form (external appearance) and structure (internal construction) all belong to the animal kingdom, the coelomate superphylum and the chordate phylum. We share characteristics of each of these, particularly seen during embryonic development (representing a record of preceding evolution).
ANIMAL FEATURES
An animal (L. 'breath') is a living organism capable of independent movement. Animals require an external energy source from oxygen and organic foods (in contrast to plants producing sugar via photosynthesis). Animal cells are surrounded by a cell membrane (rather than a rigid cell wall). 6
Fig.2.3 A chordate
SEGMENTATION
Segmentation and polarity are important anatomical features of all chordates, including humans. Blocks of muscle termed myomeres (G. 'muscle parts') are arranged segmentally along the body of a chordate. Although only present briefly during human development, their derivatives persist into adulthood. Segmentation is clearly manifested along the trunk but modified in the head.
Somites
Segmentation along the trunk ('metamerism') is seen in the embryo as mesoderm arranged in a paired series of similar paraxial segments, termed somites (G. body). Each somite subsequently develops into a sclerotome (G. hard + cut) and a derma-myotome (G. skin + muscle cut).
Notochord of mesoderm
The notochord (G. back + cord) is a mesodermderived flexible rod, providing support. The nerve cord lying dorsal to it is ectoderm-derived, while the gut tube ventral to it is endoderm-derived. The notochord and the tail disappear almost completely (the notochord remnant as the nucleus pulposus of each intervertebral disc, the tail remnant as the coccyx).
Fig.2.7 Section through trunk of an embryo at 4 weeks Sclerotomes form the vertebral skeleton, while dermamyotomes form segments of skin and skeletal muscle that become incorporated into the trunk and the limb buds. These mesoderm segments are located lateral to the notochord. In the adult, segmentation is still seen in the short muscles of the back and intercostal muscles, vertebrae and ribs, spinal nerves and vessels of the trunk. It is also reflected in the segmental nerve supply of skin (as dermatomes), even in the limbs. 7
Fig.2.10 Paired branchial arches of mesoderm Fig.2.8 Segments of the trunk in an adult Segmentation relies upon the differential expression of sets of genes in the long axis (about the fourth week of development). These are known as homeotic genes. They determine regional characteristics. These genes have a sudden onset of expression then fade out once their segmental job is done. This produces an acute onset of the next body segment and gradual loss of the previous segment. Genetic variation can produce loss of segments, extra segments, transposed segments or changes in segment number (e.g. with cranial or caudal shift of the vertebral column, common anatomical variations). Although structurally identical to skeletal muscles and capable of voluntary movement (e.g. in speech), branchial muscles develop from splanchnic (rather than somatic) mesoderm. These muscles, which tend to be covered by mucous membrane or located near a mucocutaneous junction, are also functionally related to smooth muscle. They are effectors for a special group of superficial reflexes (e.g. swallow and cough reflexes) arising from mucous membranes (of upper digestive and respiratory tracts) and often act in conjunction with visceral reflexes involving glandular secretion (e.g. salivation).
Branchial arches
Head segmentation ('branchiomerism') is modified from that in the trunk. Bones, cartilages and muscles of the jaw, face, pharynx and larynx are derived from the branchial arches. These commence as six paired masses of mesoderm situated between branchial clefts (ectoderm depressions overlying endoderm pouches). Branchial arches may also be termed pharyngeal arches as pouches associated with them line the developing pharynx. Branchial arch derivatives retain their nerve supply despite migration.
POLARITY
All chordates exhibit polarity with a cranial (head) end and a caudal (tail) end. The cranial part of the neural tube expands to form the brain, while the remainder develops into the much narrower spinal cord, terminating caudally.
Axial borders
Fig. 2.13 Axial borders on limb buds of embryo (5 weeks) In the embryo, a limb bud develops like a paddle (or flipper) with a pre-axial border (along the radius/thumb aspect of the upper limb and the tibia/big toe aspect of the lower limb) and a post-axial border (along the ulna/little finger aspect of the upper limb and the fibula/little toe aspect of the lower limb). During later development the limb buds lengthen considerably and the lower limb buds rotate medially. In the anatomical position the pre-axial border of the upper limb is located laterally (and post-axial border medially), with flexor compartments anteriorly and extensor compartments posteriorly. The pre-axial border of the lower limb is located medially (and the post-axial border laterally), with flexor compartments posteriorly and extensor compartments anteriorly. 9
Fig. 2.15 Axial borders and relation to dermatomes A myotome (G: 'muscle' + 'cut') is the mass of muscle supplied by a particular spinal cord segment.
Fig.2.16 Segment in the trunk The nerve supply to a muscle is retained even if the muscle migrates during development. This also applies to both peripheral nerve supply and segmental nerve supply of limb muscles. Fig.2.17 Foetus at 5 months with spinal cord exposed The bony vertebral column (derived from mesoderm of the sclerotome) replaces the notochord as the primary structural support. The notochord is incorporated as gelatinous material (the nucleus pulposus) within each intervertebral disc. In humans, the coccygeal vertebrae regress and the tail disappears.
Left-right axis
With establishment of polarity along the vertical axis, there is also the development of the left-right axis, thought to be due to the beating of certain cilia (L. eyelashes) These hair-like mobile cellular projections direct a net leftward flow of influential local fluid. The differential chemical concentration induces changes in left-right symmetry. A defect in ciliary motility may disrupt this process and even cause situs inversus, a rare anatomical variation where the thoraco-abdominal viscera are in mirror image to normal.
VERTEBRATE FEATURES
Humans are vertebrates. A vertebrate (L. 'jointed') is characterised by the presence of a backbone (the vertebral column or spine).
MAMMALIAN FEATURES
Humans are mammals. A young mammal (L. 'breast') is suckled by its mother.
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Placenta
True placental mammals also develop within a uterus (L. womb) of the mother connected by an umbilical (L. navel) cord to the foetus. The placenta (L. cake) is incorporated in the lining of the uterus. The umbilical vessels convey blood between the foetus and the placenta (until birth).
HUMAN FEATURES
Humans belong to the hominid (L. 'man form') family, the homo (L. 'man') genus and sapiens (L. 'wise man') species. The most distinctive human characteristic is the habitual adoption of upright stance and locomotion based solely on the two lower (hind) limbs.
PRIMATE FEATURES
Humans are primates. A primate (L. 'first') is able to grasp objects.
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Fig.2.21 Adult skeleton in erect posture Upright stance is associated with evolution of the largest cerebral hemispheres (and corresponding intellectual capacity) within the animal kingdom.
BIPEDAL LOCOMOTION
In contrast to standing where muscular effort is conserved, bipedal locomotion enlists the actions of many muscles. Walking on level ground involves cycles (between heelstrike of the same foot) of swing (limb not in contact with the ground) phase and stance (weight bearing) phase. Muscles not only act to accelerate the swinging lower limb (from the beginning of swing phase to mid-swing), but also to decelerate it (from mid-swing to the end of swing phase).
Fig.2.26 Phases of the walking cycle The line of gravity moves forwards in the direction of motion. At one phase of the cycle (mid-swing and midstance) it passes through both limbs. At all other phases it passes between the limbs. Fig.2.24 Line of gravity in erect posture Thanks to stable joints the precarious evolution of upright stance did not fall flat on its face.
Fig.2.27 Stabilisation of the pelvis during locomotion Fig.2.25 Weight-bearing stress at angulation of spine Due to angulation between the lumbar spine and sacrum, weight bearing creates shearing stress through the lumbosacral disc (which is obliquely oriented) and through the fifth lumbar vertebra. 13 Gluteus medius and minimus muscles prevent excessive tilting of the pelvis (supporting the trunk above it) towards the unsupported side during locomotion. The gluteal muscles literally got us up off our backsides to move.
Fig.2 28 High larynx in a chimpanzee Other mammals (and human infants) have a high larynx at the level of the soft palate and can only emit air from the mouth in short bursts. However, they can breathe and swallow simultaneously as their air and food pathways do not cross. Air is breathed into the larynx via the nasopharynx (situated behind the nose) and food from the mouth swallowed (into the oesophagus) via channels lateral to the larynx. During human postnatal development (late infancy) the pharynx lengthens as the larynx descends into the neck. This creates a new part of the pharynx, termed the oropharynx, situated between the soft palate and the larynx.
FEMALE
A genetic female is characterised by the absence of a Y chromosome. There are normally two X chromosomes.
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Section II
BODY SYSTEMS AND ORGAN STRUCTURE
Introduction: 'Structure mirrors function'
Chapter 4: Skeletal System and Bones Chapter 5: Articular System and Joints Chapter 6: Muscular System and Muscles Chapter 7: Integumental System and Skin Chapter 8: Visceral Systems and Viscera Chapter 9: Nervous System and Nerves Chapter 10: Arterial System and Arteries Chapter 11: Venous System and Veins Chapter 12: Lymphatic System and Lymph Vessels
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Somatic systems:
- skeletal system - articular system - muscular system - integumental system Somatic (L. body) systems are collectively responsible for the overall form and shape of the body. They provide support, movement and protection. Somatic systems are the musculoskeletal framework together with the covering skin. The skeletal, articular and muscular systems may be grouped into a single musculoskeletal (or locomotor) system.
3.
Visceral systems:
- respiratory system - digestive system - urinary and male genital systems - endocrine and female genital systems Viscera (L. sticky) are collectively responsible for internal regulation. They occupy cavities within the body framework and are involved with secretion, excretion and absorption. Visceral systems are made up of solid glands and/or hollow tubes (of smooth muscle, lined by mucosa). The urinary and genital (reproductive) systems may be grouped into a single urogenital system.
Supply systems:
- nervous system - arterial system - venous system - lymphatic and haemopoietic systems All organs, whether somatic or visceral, require neurovascular supply (although supply of somatic organs is by a separate set of nerves and vessels to that of viscera). Organs receive their nerve supply via the nervous system. Organs also receive a supply of arterial blood as well as drainage of venous blood and lymph. Vascular (L: vessel) refers to arteries, veins and lymph vessels. Vascular systems are classified as arterial, venous and lymphatic. The heart, together with arterial and venous systems, may be grouped into a single cardiovascular (or circulatory) system.
4.
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SKELETAL SYSTEM COMPACT AND SPONGY BONE PERIOSTEUM AND BONE MARROW BONES AND BONY FEATURES CARTILAGE OSSIFICATION AND PRIMARY CENTRES SECONDARY CENTRES & GROWTH PLATES EPIPHYSES AND EPIPHYSIAL LINES LONG BONE GROWTH AND GROWING END NEUROVASCULAR SUPPLY OF A BONE SKELETAL SYSTEM
The skeletal system is made up of bones and cartilages. In an adult there are approximately 206 bones. However, the number may vary due to the presence of accessory bones (anatomical variants created by bony parts that have separated to become discrete bones). At different stages of development cartilage (and membrane) precursors are converted to bone.
Subdivisions of skeleton
The skeleton may be subdivided according to the following modules: Head 29 bones Neck 7 bones Thorax 25 bones Back 19 bones Upper limbs 64 bones Lower limbs 62 bones Total 206 bones
Fig.4.2 Axial and appendicular skeleton of an adult The bony pelvis is made up of the paired hip bones (of the lower limb) and the sacrum and coccyx (of the back). The hyoid bone is included in the head (although it may be classified in the neck). The cervical vertebrae are included in the neck while the rest of the spine is included in the back. Bones may also be arranged into the axial skeleton (skull, spine and thoracic cage) and the appendicular skeleton (limb bones including the pectoral and pelvic girdles).
Functions of bone
Bone provides protection and support for the body as well as levers for limb movements. Bone houses a major site of blood cell production and is a vast calcium reserve. Although a skeleton (G: dried up) is the bony remnant of a dead body, in the living it has the capacity for remodelling and (up to maturity) for growth.
Fig.4.1 Disarticulated skeleton of a newborn Short bones (e.g. carpal bones in the wrist and most tarsal bones in the foot) tend to be cartilaginous at birth. One or both ends of long bones, together with parts of vertebrae, are also cartilaginous at birth. 19
Medullary cavity
Trabeculae are absent in the medullary cavity of a long bone (a cylinder is lighter and almost as strong as a solid rod). A long bone is characterised by a shaft between its proximal and distal ends. The shaft has a central medullary (L: marrow) cavity. There are no (net) forces in this part of the bone (where compressive and tensile forces cancel each other). The shaft (particularly midway along it) has a thick shell of compact bone where its perimeter is subject to considerable forces. This rigid tube resists bending forces in all directions without the need for a solid core. In dry bone all fibrous tissue and cartilage have been stripped off.
Trabeculae
Compact bone forms the hard, protective outer shell while the inner spongy (cancellous) bone possesses trabeculae (L: beams) that resemble scaffolding with spaces between them. This trabecular arrangement provides strength with lightness. Bony trabeculae in the upper end of the femur form intersecting arches. Lines of compressive stress are oriented more vertically along the femoral neck while lines of tensile stress run across it.
Fig.4.5 Compressive and tensile forces on the shaft Dry bone is also devoid of bone marrow (which during life fills the medullary cavity and the spaces within spongy bone).
Bony surfaces
The exterior of bones typically has flattened surfaces separated by sharper borders. Articular (L. joint) surfaces are the areas of bone that articulate at synovial joints. Articular surfaces are the only external surfaces of a bone not surrounded by periosteum. Articular surfaces are covered by hyaline articular cartilage. Articular surfaces are smooth and may be in the form of a small flat area (articular facet), a large rounded area (head), a knuckle-shaped area (condyle) or a pulley (trochlea).
Bony markings
An end of a long bone may include a head with a neck (between the head and the shaft). A short or flat bone may also have a head with a neck (between the head and the body). Markings may be classified into four groups: elevations, facets, depressions and holes. An elevation may be a line, a crest, a spine (L: thorn), a process, a condyle (G. knuckle), a tubercle, a tuberosity or a trochanter. A facet (Fr. little face) is a smooth, flat area. A depression may be a fossa (L. ditch), a fovea (L. pit), a groove or sulcus (L. furrow) or a notch. A hole may be a foramen (L. bore), a fissure, a meatus (L. passage), a canal or a hiatus (L. aperture). Bony elevations are produced at sites of traction Attachments of fleshy muscle fibres tend not to produce markings. Fig.4.7 Major types of bones
CARTILAGE
There are three types of cartilage (L. gristle): - hyaline cartilage - fibrocartilage - elastic cartilage 21
Hyaline cartilage
Hyaline (G. glass) cartilage covers bony articular surfaces. In addition, it is found in the chest wall (as costal cartilages) and is also associated with the respiratory tract (helping keep patent the nose, larynx, trachea and bronchi, particularly during inspiration). The model for the early foetal skeleton is primarily hyaline cartilage. Hyaline cartilage is composed of a solid matrix that can bear weight, resist compression and be almost frictionless. The glassy appearance is due to the collagen fibres in the matrix being arranged in parallel bundles. A thin fibrous membrane, the perichondrium (G. around + cartilage) surrounds non-articular cartilage. There are no blood or lymph vessels and nerve fibres in hyaline cartilage. Hyaline cartilage is avascular and aneural Vessels would otherwise be compressed and nerve endings irritated by the pressures hyaline cartilage may be subjected to. Cartilage cells (chondrocytes) receive their nutrition (from synovial fluid in joint cavities or from vessels in the perichondrium) via diffusion through the cartilage matrix.
Fibrocartilage
Fibrocartilage is a mixture of fibrous tissue and hyaline cartilage. It forms special structures in joints (disc, meniscus, labrum) that can withstand prolonged pressure, contribute to articular surfaces and act as shock absorbers. Fibrocartilage is not glassy in appearance due to the vastly increased numbers of collagen fibres arranged in irregular bundles. Except for around the periphery where pressure is minimal, fibrocartilage is avascular and aneural. Chondrocytes in fibrocartilage receive their nutrition via diffusion through the matrix. 22 Fig.4.10 Primary centres in a 12 week foetus A bones blood supply develops during the transformation of cartilage to bone. Blood vessels (from the nutrient artery and vein) invade the primary centre together with cells that subsequently form bone (osteoblasts). Unlike cartilage, bone requires a blood supply, as the calcified matrix does not allow diffusion.
Fig.4.14 Parts of mature and developing bones Fig.4.12 Endochondral ossification of epiphyses The (epiphysial) arteries are derived from separate sources to that of the primary centre (which is from the nutrient artery). Hyaline articular cartilage is retained at joint surfaces after the bone has completed ossification.
Epiphysial plate
The epiphysial (growth) plate is a plate of hyaline cartilage in the epiphysis, along its junction with the metaphysis. The epiphysial plate produces new bone at its metaphysial surface (where it is supplied by metaphysial arteries). Growth in length occurs at the metaphysial surface of an epiphysial plate.
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BODY SYSTEMS AND ORGAN STRUCTURE Mistaking epiphysial plates for fracture lines
An epiphysial plate undergoing fusion resembles a fracture line. Awareness of the likely sites for epiphyses helps avoid mistaking an epiphysial plate for a fracture line on a radiograph. An epiphysial plate may also be differentiated from a fracture by obtaining an X-ray of the corresponding bone on the other side of the body.
Fig.4.17 Epiphysial plates and lines Fig.4.16 Relationship of epiphysial plate to metaphysis The epiphysial plate disappears (along with the capacity for growth in length at this site) when the epiphysis fuses with the metaphysis. Epiphyseal fusion occurs after puberty (females generally at an earlier age than males). Although epiphyses at different sites tend to fuse at different times, the vast majority have fused by the end of adolescence.
Epiphysial line
Fusion of an epiphysis to a metaphysis is associated with disappearance of the epiphysial plate and cessation of further growth in length at this site. A thin layer of compact bone, termed the epiphysial line, is the only remnant of the plate in a mature bone. Although not visible on the external surface, an epiphysial line can be seen at times in vertical sections and in radiographs.
Nutrient arteries
The major artery supplying a long bone is termed the nutrient artery. This artery occupies a passage (termed the nutrient foramen) penetrating the shaft of the bone through to the medullary cavity. The canal of nutrient foramen (when viewed from its outside opening) is directed away from the growing end. Differential longitudinal growth results in the nutrient artery taking an oblique path (from outside to inside) through the full thickness of the bone while the bone is still growing (unequally). Equal growth would have resulted in the artery penetrating perpendicular to the shaft.
Fig.4.18 Growth of a long bone The more time an epiphysis (and associated epiphysial plate) exists the greater the opportunity for growth in length at that site. No further longitudinal growth occurs after epiphysial fusion (with disappearance of the epiphysial plate). The earlier an epiphysis appears the later it fuses. Epiphyses for larger long bones tend to appear before (and fuse after) those for smaller long bones. Within a large long bone the epiphysis for one end tends to appear before (and fuse after) that of the other end. More growth therefore occurs at one end (the growing end). The first epiphyses to appear (at about birth) are for the lower end of the femur and the upper end of the tibia (the two longest bones in the body).
Epiphysial judgement
The appearance of primary centres of ossification in the distal femur and proximal tibia is of medico-legal importance in determination of maturity and interpretation of radiographic imaging. Most lower limb growth in length occurs near the knee, as these associated epiphyses also the last to fuse. Most upper limb growth in length occurs near the ends of the long bones at the shoulder and wrist. The first epiphyses to fuse are at the elbow. 25
Epiphysial damage
In children and adolescents, injury to an epiphysis or a fracture extending through the epiphysial plate carries special significance.
Damage to an epiphysial plate will impair subsequent growth. Bone infections (spread from the blood stream) tend to occur at the metaphysis (a site of vulnerable blood supply) and may also lead to damage of the adjacent epiphysial plate. Interruption of blood supply to the adjacent epiphysis or metaphysis will similarly tend to impair normal growth.
Fig.4.23 Vessels supplying the shaft of a long bone It divides into superior and inferior medullary branches (directed towards both ends). The shaft of a long bone also receives multiple small periosteal arteries that supply the periosteum and outer compact bone.
Periosteal stripping
Although these arteries link with branches of the nutrient artery, extensive stripping of the periosteum (e.g. during surgery) may deprive directly underlying compact bone of blood supply.
Perichondrial stripping
Extensive stripping of the perichondrium (e.g. from bruising) endangers viability of the cartilage.
Vascular foramina
Fig.4.24 End arteries in a developing long bone The ends of developing long bones typically receive sets of metaphysial and epiphysial arteries. These arteries are end arteries because the cartilaginous plate is avascular and forms a barrier preventing communication between them (until epiphysial fusion). 26
Vascular circle
The arteries supplying the ends of a mature long bone arise from a vascular circle, (circulus vasculosus), derived from articular branches of arteries to the associated joint.
Fractures
A broken bone is termed a fracture (L. break). A fracture may be associated with stripping and/ or tearing of the periosteum (particularly if there is displacement of the bone ends). There is typically swelling from bleeding due to the rich blood supply (particularly of bone tissue and marrow). It is accompanied by severe pain due to the rich sensory nerve supply (particularly of periosteum). Fractures occur commonly in children. Fig.4.25 Arteries at the end of a developing bone The vascular circle is typically located around the attachment of the capsule to bone. It provides branches both to the capsule and to bone. Early in development the joint capsule attaches around the periphery of the epiphysial plate. The vascular circle around the end of a developing bone is initially located at this site and provides both epiphysial and metaphysial branches. Adults tend to have stronger bones than ligaments, while children have the reverse.
Fig.4.28 Simple and compound fractures If fractured bone is exposed to the air (by laceration of overlying skin or mucous membrane, e.g. from sharp bone fragments) it is termed a compound (open) fracture and has a significant risk of bone infection.
Fracture healing
Bone receives a rich blood supply creating much bleeding at the time of injury. Vascularity enables numerous vessels to invade the fracture site during repair. This occurs within the mass of connective tissue (termed callus) as a result of periosteal and endosteal proliferation. New bone is formed within the callus then subsequently remodelled. Uncomplicated fractures therefore tend to heal well, provided the bone ends are correctly aligned and immobilised for an appropriate length of time. 27
Fig.4.26 Anastomoses after epiphysial fusion The branches of articular arteries that correspond to epiphysial and metaphysial arteries are able to link (anastomose) with each other because the intervening (avascular) hyaline cartilage of the growth plate has disappeared with epiphysial fusion.
Fig.4.29 Alignment and immobilisation in fracture healing Healing, including of fractures is more rapid in children. Weight bearing bones heal slower than non-weight bearing bones.
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ARTICULAR SYSTEM FIBROUS AND CARTILAGINOUS JOINTS SYNOVIAL JOINTS ARTICULAR SURFACES AND CARTILAGE FIBROUS CAPSULE SYNOVIAL MEMBRANE AND CAVITY LIGAMENTS SPECIAL JOINT STRUCTURES JOINT STABILITY AND MOBILITY NEUROVASCULAR SUPPLY OF JOINTS ARTICULAR SYSTEM
The articular system is made up of joints including associated ligaments. Bones and/or cartilages meet at joints.
Types of joints
Joints are classified as fibrous, cartilaginous and synovial. The vast majority are synovial joints which are adapted for movement. Some joints, particularly primary cartilaginous joints of developing long bones (epiphysial plates) are temporary, fusing at various ages.
Fig.5.6 Secondary cartilaginous joints in midline Fig.5.4 Structure of a fibrous joint Sutures (L. seams) occur between bones of the skull creating characteristic wavy lines occupied by sutural ligaments. With age, skull bones tend to unite, forming a synostosis (G. together + bone) as the fibrous joint becomes obliterated. Sutures are not mobile but they allow for growth. A syndesmosis (G. together + band) holds the distal ends of the tibia and fibula together by a strong interosseous ligament. It permits only a small amount of movement, enough to help absorb compressive forces and avoid fracture. A gomphosis (G. bolt) is a tooth socket lined by the periodontal membrane (ligament) anchoring the tooth. It does not allow significant movement.
SYNOVIAL JOINTS
Synovial joints allow for extensive movement and are characterised by a joint cavity (in addition to the hyaline cartilage that covers the bony articular surfaces). The shape of the articular surfaces determines the particular movements permitted. Shape, depth and size of articular surfaces (as well as ligaments and muscles) contribute to the range of movement possible.
Fig.5.5 Structure of a primary cartilaginous joint An epiphysial (growth) plate is regarded as a primary cartilaginous joint, even though it is temporary. At epiphysial fusion this joint disappears, becoming a synostosis. Other primary cartilaginous joints occur in the thoracic cage associated with the costal cartilages (particularly the costochondral and interchondral joints).
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Complex joints
The vast majority of synovial joints have a single synovial cavity. In complex joints the joint cavity is subdivided into more than one compartment. This may be a complete partition by fibrocartilage disc (e.g. temporomandibular and sternoclavicular joints) or incomplete by menisci (e.g. knee joint). Complex joints enable separate movements to occur simultaneously on either side of the partition (e.g. gliding with rotation at the temporomandibular joint) whilst maintaining optimal stability.
Joint degeneration
With aging and overuse there is a tendency for joint degeneration. With this degeneration (degenerative arthritis) the articular cartilage becomes progressively thinner. This may be detected on a radiograph as a narrowing of the radiological joint space in contrast to the anatomical joint space (the synovial cavity). Thinning of the articular cartilage causes the bony articular surfaces to come into closer proximity, eventually making contact with each other. This causes severe pain due to exposure of underlying bone possessing a sensory nerve supply (in contrast to aneural hyaline articular cartilage).
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Osteophyte formation
Degenerative arthritis is also associated with formation of osteophytes (G. bone + growths) at the joint margins.
Fig.5.10 Osteophytes and encroachment on a foramen These are produced by proliferation of exposed bone with a rich blood supply (in contrast to the avascular hyaline articular cartilage). The progressive bony proliferation tends to decrease joint mobility (and may ultimately result in bony fusion). Osteophytes may also encroach on adjacent structures, especially if bordering confined spaces (e.g. spinal canal or an intervertebral foramen).
Synovial membrane
Synovial membrane is a serous membrane. It consists of a layer of flattened cells (mesothelium) on a thin bed of loose connective tissue that is highly vascular and can be thrown into folds or fringes. Synovial membrane lines the internal surface of the capsule and all non-articular structures on the interior of a synovial joint. Synovial membrane is delicate and does not extend over the articular cartilage (where it would be damaged). At sites where the capsule does not attach to the articular margin, synovial membrane is reflected onto bone (covering periosteum between the capsular margin and the articular margin).
Synovial fluid
The volume of a synovial cavity is normally very small (less than 1ml, even in a large joint). The synovial membrane secretes fluid into the joint cavity thus providing nutrition for the articular cartilage. Synovial (L. with + egg i.e. consistency of egg white) fluid acts as an adaptable lubricant for the articular cartilage. Its viscosity decreases with increased loading minimising friction (because the contained muco-polysaccharide hyaluronic acid can change its configuration accordingly). A film of synovial fluid lies between apposed articular cartilage surfaces, particularly during movement.
Synovial effusion
Synovial membrane has a rich blood supply derived from articular arteries (via branches from the vascular circle, around the capsular attachment). Irritation of the delicate synovial membrane (e.g. by mild, repetitive trauma) results in an increased blood supply to it (due to vessels dilating) and a subsequent increase in secretion of synovial fluid. An accumulation of synovial fluid is termed a synovial effusion. It produces (often visible) swelling of the joint (particularly where it is least supported). Tissue resistance limits the degree of effusion. 33
Septic Arthritis
Introduction of microbes into a synovial cavity (septic arthritis) is a potentially serious event likely to produce an accumulation of pus. Septic arthritis, as with any inflammatory arthritis, may lead to permanent joint destruction due to erosion of articular surfaces.
Collateral ligaments
Collateral (L. with + side) ligaments are typically located on the medial and lateral sides of hinge joints (e.g. elbow, ankle, knee and interphalangeal joints of the fingers and toes) perpendicular to the axis of movement. They tend to blend with the joint capsule, forming intrinsic ligaments. Collateral ligaments are important contributors to stability by preventing unwanted side-to-side movement. Some part of a collateral ligament tends to remain taut throughout the full range of flexion/extension.
Loose body
A fragment of cartilage may survive as a loose body in a joint cavity (or even grow) because it receives adequate nutrition from the synovial fluid. A loose body may produce locking of the joint if trapped between the articular surfaces. This interference with movement tends to be episodic.
LIGAMENTS
Ligaments (L. bind) are fibrous connections between bones. The vast majority of ligaments are primarily composed of collagen fibres (for tensile strength), which blend with the fibrous covering (periosteum) of the bones taking part in a joint.
Elastic ligaments
Some special ligaments, termed elastic ligaments, contain large numbers of (yellow) elastic fibres. Being able to stretch (and recoil) they are less susceptible to injury. They have a poor nerve supply (as pain fibres would otherwise be triggered by stretch). Ligamenta flava (L. yellow) of the vertebral column are elastic ligaments.
Fig.5.17 Ligaments of the elbow complex Uniaxial joints enable no other (pairs of) normal movements. Modified hinge joints (e.g. knee) permit some rotation when collateral ligaments become slack during flexion. This slackness is facilitated by the ligaments being situated eccentrically (i.e. not perpendicular to the axis of movement during the entire range of flexion).
Accessory ligaments
Accessory ligaments are extrinsic ligaments of a joint that are located at a distance from it. Although structurally separate, they function with the associated joint.
The weakest points of a ligament are at or near their attachments, rather than between them. Sometimes a fragment or flake of bone is avulsed (L. tear away) with (or even instead of) ligament rupture.
Ligament vulnerability
A ligament that is arranged in discrete parts rather than a continuous band allows more joint mobility but is weaker and therefore more vulnerable.
Fig.5.18 Grades of ligament injury In ligament injuries there is damage to the collagen fibres. Degrees range from microscopic sprain (grade I) where a few fibres rupture to partial tear (grade II) and complete tear (grade III), where all fibres rupture.
Fig.5.21 Stress test for cruciate ligaments of knee joint Ligament integrity may be tested clinically by stressing the ligament (putting it on stretch) and comparing the observable movement between the injured and uninjured sides. This can be confirmed on X-ray by performing stress views for suspected complete rupture of a ligament. With a ligament sprain, pain tends to be exacerbated by stressing the ligament.
Fig.5.24 Vascularity and healing of meniscal tears Tears to discs or menisci tend not to heal, except around the periphery (where they receive a blood supply along their capsular attachment). A meniscus trapped between bony condyles while weight bearing may split longitudinally. A dislodged fragment of meniscus may survive as a loose body in a joint cavity (since it receives adequate nutrition from the synovial fluid).
Intracapsular tendon
Fig.5.23 Special structures of knee joint
Labrum
A labrum (L. lip) deepens the socket of a ball and socket joint (e.g. hip and shoulder). A labrum is made of fibrocartilage. Being articular it is not covered by synovial membrane and is avascular (receiving its nutrition from the synovial fluid).
Tendons attaching to a bony area between the articular margin and the periphery of the capsule occur in two major joints (shoulder and knee). The associated muscles (long head of biceps and popliteus) by the location of their tendon, contribute to shoulder stability or enable rotation that unlocks the knee joint, respectively. An intracapsular tendon leaves a joint through a defect in the fibrous capsule. The tendon is covered by synovial membrane throughout its intracapsular course.
Bursae
A bursa (L. purse) is a double fold of serous membrane (containing a small amount of fluid) interposed between structures that rub together (e.g. skin, bone, ligament, tendon) reducing friction. Bursae tend to be more numerous at joints with greater mobility.
Fat pads
Fat pads are intracapsular but extra-synovial. They fill unoccupied space in a joint (e.g. below the patella at the knee joint and in the bony fossae of the humerus at the elbow joint). Fat pads help absorb compressive forces between bones. They also contribute to the spread of synovial fluid by acting as a swab and create extra folds of synovial membrane to greatly increase its surface area.
Bursitis
Irritation (e.g. by unaccustomed or repetitive movement) trauma or infection of a bursa may result in inflammation (bursitis) with associated accumulation of synovial fluid, blood or pus, respectively.
Pairs of movements
Fig.5.26 Olecranon bursitis ('student's elbow') The shape of the articular surfaces primarily determines the type of movements allowed. These movements may be gliding (at plane joints) or pairs of movements (one pair at uni-axial joints, two pairs at bi-axial and three pairs at multi-axial joints). The most common pairs of movements are flexion/ extension, abduction/ adduction, and medial rotation/ lateral rotation. Other specific pairs of movement include plantar flexion/ dorsiflexion (at the ankle joint), inversion/ eversion (of the foot) and pronation/ supination (of the forearm).
Close-packed position
The position of maximal stability is termed the closepacked position. Articular surfaces (and articular cartilages) are most apposed and the majority of ligaments are maximally taut (including the capsule, which may spiral and tighten). This is also the position of least volume in the synovial cavity (and most discomfort, if there is a synovial effusion). All other positions of a joint are loose-packed, allowing normal movement to take place (but with greater potential for unwanted movement). Articular surfaces will not be fully apposed and, in multi-axial joints, not all ligaments will be taut.
Fig.5.28 Factors stabilising the shoulder joint The contribution to joint stability from bones is dependent on the congruence of their articular surfaces.
Fig.5.29 Types of joint stabilising factors Ligaments (both intrinsic and extrinsic) act in addition to the fibrous capsule to prevent unwanted movements and movements beyond normal range. They also resist distraction of articular surfaces. Muscles (and tendons) surrounding the joint give it support. Around the most mobile joints (shoulder and hip)
Fig.5.33 Anastomosis around the hip joint The anastomosis around a joint also provides articular branches to the joint forming a vascular circle located at the capsular attachment. Arteries to the capsule (also supplying the synovial membrane) and arteries to the associated bone arise from the vascular circle. Joint structures receiving an arterial supply have a corresponding venous drainage. Many of the vascular foramina in bone, particularly those near the articular margin, are for veins.
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MUSCULAR SYSTEM MUSCLE STRUCTURE AND ATTACHMENTS TENDON, APONEUROSIS AND RAPHE DEEP FASCIA AND RETINACULA FASCIAL SEPTA, SHEETS AND SHEATHS FIBROUS & SYNOVIAL TENDON SHEATHS MOVEMENT AND SKELETAL MUSCLE FORM MUSCLE CONTRACTION AND ACTION NEUROVASCULAR SUPPLY & MYOTOMES MUSCULAR SYSTEM
The muscular system is made up of skeletal muscles together with associated structures. These are condensations of fibrous tissue (including tendons and fibrous tendon sheaths) as well as synovial tendon sheaths. The other types of muscle are smooth muscle and cardiac muscle. The former is found throughout the visceral and vascular systems in the wall of a tubular viscus or blood vessel. The latter is found only in the walls of the heart. Muscles are arranged in groups that tend to share a common fascial compartment and produce a common action. Muscles are typically paired, except for those in the midline. Fig.6.2 Major groups of skeletal muscles
Muscle belly
Skeletal muscles have a variety of shapes determined by the arrangement of their components. A muscle belly lies between the attachments of a skeletal muscle. In many cases there is also a tendon connecting a muscle belly to the site of attachment.
Fig.6.9 Regressive variations A muscle attachment (e.g. of adductor magnus) that has retreated from one bone to another (e.g. tibia to femur) during evolution may remain as a ligament between them (e.g. medial ligament of knee joint). Occasionally, some muscle fibres may also remain. This type of variation is termed an atavistic (L. forefather) variation.
Fig.6.14 Extra stretch by crossing 2 joints Contracting gastrocnemius with an extended knee and dorsiflexed ankle permits a strong contraction, but increases vulnerability of the muscle to injury from overstretching. This also occurs in contracting the hamstrings with a flexed hip and extended knee.
Tendon
A tendon (L. stretch out) is a prolongation of connective tissue linking a muscle belly to its attachment site(s). Tendons enable force to be concentrated over a smaller area and/ or transmitted over a longer distance. Tendons are found at many sites throughout the body, particularly where muscles compete for space (e.g. in the peripheral parts of the limbs). A tendon is much less bulky than a muscle belly. Some muscles (e.g. long flexors and extensors to fingers and toes) have multiple tendons.
Aponeurosis
An aponeurosis (L. from + tendon) is a broad, flat sheet of connective tissue linking a muscle belly to the site of attachment. Aponeuroses enable force to be spread over a greater area and may enclose other muscles to increase their efficiency of contraction (e.g. rectus abdominis in the rectus sheath). Aponeuroses are found at many sites throughout the body. The most extensive aponeuroses are found in the trunk (e.g. associated with anterior abdominal wall muscles). An aponeurosis is much thinner than either a muscle belly or a tendon. Some muscles (e.g. biceps brachii) insert via both a tendon and an aponeurosis.
Raphe
A raphe (L. seam) is a line of fibrous tissue where one muscle joins another. Raphes are often located in the midline of the body, uniting a muscle with its fellow from the other side. A raphe provides a relatively long attachment, utilising minimal connective tissue and occupying little space. A raphe enables its associated muscles to provide greater support, while maintaining flexibility. The floor of the mouth (formed by the mylohyoid muscles and their raphe) supports the tongue while the pelvic floor (formed by the levator ani muscles and their raphe) supports the pelvic viscera (while enabling them to expand).
Retinacula
A retinaculum (L: tether) is a thickening of deep fascia that holds down tendons. Retinacula are located near major peripheral joints where long tendons cross en route to more distal joints (to exert their primary action). Retinacula are found near the wrist and ankle joints, particularly associated with the many long flexor and extensor tendons destined for the digits. Retinacula prevent tendons from bow-stringing and can create a pulley mechanism that enhances movement of the joints distally (e.g. In the fingers and toes). Being maintained close to the axis of motion at the wrist and ankle joints, the digital tendons do not have much influence on movement at these joints. In contrast, the tendo calcaneus (Achilles tendon) crosses the ankle joint but is not covered by a retinaculum as the tendon inserts immediately distal to the joint rather than to the toes. The absence of a retinaculum allows tendo calcaneus to bowstring and to exert great leverage at the ankle joint (by being located at a distance from the axis of motion). This leverage would otherwise be reduced by a retinaculum. 45
Fig.6.16 Substitution of muscle fibres at pressure site Fleshy muscle fibres tend to be replaced by tendons at sites of pressure or friction. Fleshy muscle fibres tend to be replaced by aponeuroses at sites of increased tensile loading or where enclosed muscles benefit from a mechanical advantage.
Fig.6.19 Septum separating compartments They also may subdivide the space under a retinaculum into separate compartments for tendons. Intermuscular septa are fascial extensions forming partitions between muscles, providing them with additional area for attachment as well as routes for the passage of vessels and nerves (along the septa). Muscles with a common action are generally located in the same fascial compartment.
Fascial septa
A fascial septum (L. partition) is an extension of dense connective tissue that separates structure(s) from each other. Fascial septa typically form a perpendicular connection between deep fascia and periosteum (at these junctions the collagen fibres blend). Fascial septa also bind down skin to underlying deep fascia (e.g. in the palms, soles and scalp) or aponeurosis.
Fascial sheets
Deep fascia is generally in the form of a single sheet although occasionally it is in two parallel or concentric sheets (allowing mobility between them). It typically forms the roof of a compartment for muscles. Additional sheets of fascia may be located between muscle layers within a fascial compartment (e.g. in the posterior compartment of the calf).
Fascial sheaths
Fascial sheaths surround glands. They also surround nerves and vessels. Where nerves and vessels have a common course they tend to be enclosed within a common fascial sheath (as a neurovascular bundle). Fascial sheaths are not as tough as septa or sheets of deep fascia. They provide support, yet allow some movement or expansion.
Fig.6.22 Sheath of a neurovascular bundle Where more expansion occurs (e.g. around large veins) the fascial sheath is thinner or even absent. Fig.6.24 Fibrous and synovial tendon sheaths A synovial sheath is an elongated pouch made up of two layers of serous membrane. Each serous membrane consists of a layer of flattened cells (mesothelium) on a thin vascular bed of loose connective tissue. One layer of the serous membrane pouch lines the internal surface of a fibrous tendon sheath, while the other layer covers the tendon.
Fig.6.23 Fibro-osseous tunnels for a tendon Tendons are bound down by fibrous tendon sheaths to prevent them from bow-stringing. A pulley mechanism created may enhance movement (e.g. on the fingers and toes). The sheath is thicker (with its fibres aligned) along lines of stress. 47
Tenosynovitis
Irritation (e.g. by unaccustomed or repetitive movement) or infection of synovial tendon sheaths may result in inflammation (tenosynovitis) with accumulation of fluid or pus. Inflammation of the tendon sheath may also be associated with inflammation of the tendon (tendinitis) or of its fibrous tendon sheath (tenovaginitis).
Mesotendons
Small remnants of the connecting stalk that existed between the two layers of a synovial sheath convey blood vessels. These remnants are termed mesotendons (L. middle + tendons).
The active range of movement at a joint is dependent on muscle shortening. There is a trade-off between power and range of movement. A powerful movement requires a strong contraction acting at a distance along a lever (creating great leverage). A large range of movement requires shortening of a muscle that inserts close to the fulcrum (creating a wide arc of movement of the distal lever). The power and range of a particular movement may be deduced by considering the sites of skeletal muscle attachments (for determining leverage versus lever arc) and muscle form (for determining strength of contraction versus degree of shortening).
Muscle form
The form of a skeletal muscle is determined by the arrangement of its fibres.
Active insufficiency
Even a normal muscle will produce a weak contraction if there is insufficient overlap of its myofilaments. This is termed active insufficiency. Profound weakening of contraction occurs when it is attempted from an excessively shortened position of the prime mover.
Passive insufficiency
The prime mover action is restricted when an antagonist is unable to relax or to stretch sufficiently from lack of flexibility. This is termed passive insufficiency. Fig.6.37 Muscles crossing 2 joints can generate extra force This is due to maximal overlap of the contractile units (myofilaments). However, stretching beyond this point prior to contraction leads to a weaker contraction (tension is reduced, as the myofilaments are too far apart). Muscles crossing more than one joint can generate extra force but are also prone to overstretch.
Fig.6.40 Fixator muscles positioned close to a joint Fixator muscles tend to be the most important stabilising factor and the first line of defence (against dislocating forces). Their tone can be controlled automatically by stretch reflexes (when part of a capsule is on stretch, the overlying muscles contract more strongly).
Synergists as balancers
Excessive shortening of a prime mover may occur if the muscle crosses more than one joint because it tends to exert an unwanted action on the proximal joint. This undermines the desired effect at the distal joint. A prime mover crossing more than one joint enlists the support of synergists (G. with + work) that oppose the movement at the proximal joint(s). Synergists augment contraction by keeping the prime mover on stretch.
Motor unit
A muscular branch of a peripheral nerve contains both somatic motor and sensory nerve fibres. Each skeletal muscle fibre receives an independent supply from a branch of a motor nerve fibre.
Fig.6.41 Prime mover enlisting a synergist Opposing flexion at the wrist joint (which is crossed by the long flexor tendons to the fingers) enables the wrist extensors to act as synergists for finger flexion. Biceps and triceps are prime movers for flexion and extension at the elbow joint, respectively. In addition, the long head of biceps and of triceps cross the shoulder joint. The long head of triceps acts as a synergist for elbow flexion by opposing the flexor action of the long head of biceps (at the shoulder joint). Their roles are reversed for elbow extension. Prime movers tend to be located superficially and fixators deep. 52
Fig.6.43 A motor unit A motor unit (within a particular muscle) is the total number of muscle fibres innervated by a single motor nerve fibre (from a peripheral nerve). A motor unit is the functional neuromuscular unit. Gross movements are possible using a few large motor units (each with many muscle fibres). More precise movements require many small motor units (each with fewer muscle fibres).
Reciprocal innervation
Skeletal muscles with a common action often share a common nerve supply (as well as occupying a common compartment). Muscular branches (containing both sensory and motor nerve fibres) from particular peripheral nerves supply flexor muscles. Extensor muscles receive their branches from different peripheral nerves to those supplying the flexor muscles. Contraction of a prime mover (whether flexor or extensor) is associated with relaxation and stretch of the antagonist group. Stimulating motor nerves to a prime mover is therefore associated with a subsequent stimulation of proprioceptive fibres from the antagonist. This reciprocal innervation enables coordination between prime movers and antagonists during normal movements.
Myotomes
A myotome (G. muscle + cut) is the mass of muscle supplied by a particular spinal cord segment. The segmental pattern of nerve supply in the trunk is in a simple cranial to caudal sequence. Each intercostal nerve (the continuation of a single thoracic spinal nerve) supplies the muscles in its corresponding intercostal space. The peripheral pattern of motor distribution therefore matches the segmental pattern.
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INTEGUMENTAL SYSTEM SKIN STRUCTURE AND TENSION LINES SKIN APPENDAGES AND SPECIALISATIONS SUBCUTANEOUS TISSUE AND FAT CUTANEOUS NERVES AND OVERLAP NEUROSOMES AND REFERRED PAIN ANGIOSOMES AND SKIN BLOOD SUPPLY
Epidermis
Skin is made up of two components. A connective tissue layer, the dermis (G. skin) is covered by an epithelium (G. upon + nipple, i.e. a surface lining) termed the epidermis. Epidermis is primarily a stratified squamous (L. scale) epithelium. It contains many layers of cells that become progressively flatter towards the exterior. The outermost horny layer (stratum corneum) is dead and forms a protective layer composed mainly of the protein keratin, preventing fluid loss and acting as an additional barrier. The innermost basal layer (stratum basalis) is a single layer of cells resting on the dermis. Some of these cells, the melanocytes, produce melanin (G. black) pigment.
Dermis
Roles of skin
The major roles of skin are protection, sensation and thermoregulation. Skin provides a mechanical barrier as well as protection from microbe invasion and fluid loss. Skin may also be regarded as a sense organ, due to its contact with the external environment coupled with a rich nerve supply. 55
Fig.7.6 Relaxed skin tension lines on the back Connective tissue in living skin is oriented along the relaxed skin tension lines.
Skin pigmentation
A readily visible characteristic of skin is pigmentation. The melanocytes in the basal layer of the epidermis produce melanin pigment and transfer it to overlying cells protecting against ultraviolet damage to their nuclei. Skin pigmentation decreases the risk of sunburn and skin cancer. Intrinsic pigmentation is determined by genetic factors. An albino (L. white) has a genetic lack of melanin pigment in the skin, hair and eyes. Environmental pigmentation, produced by exposure to ultraviolet light, is reversible. Environmental pigmentation may also be due to hormones. In pregnancy there tends to be increased skin pigmentation, particularly of nipples and areolae.
Pilosebaceous units
Pilosebaceous (L: hair + grease) units are made up of hairs and hair follicles together with their associated sebaceous glands and muscles. Hair follicles (L. small bags) are located in the dermis. Hairs project from hair follicles through the epidermis to the exterior.
Fig.7.8 A pilosebaceous unit Hairs are modified in various locations. These include hairs of the scalp (capilli), eyebrows, eyelashes, nostril hairs (vibrissae), axillary and pubic hairs. Hairs are absent from thick skin (palms and soles), lips (and labia minora) and glans penis (and clitoris). Sebaceous glands are also located in the dermis. A duct from each opens into an associated hair follicle. Sebum is the oily secretion that helps make skin waterproof. Arrector pili (L. hair) muscles are small bundles of smooth muscle in the dermis attaching to hair follicles and when stimulated, make hairs stand on end. Contraction of smooth muscle associated with the nipple can make it become erect.
Fig.7.11 Section through distal phalanx of a finger Nails are primarily composed of keratin and are derived from an outer layer (the stratum lucidum) of the epidermis. A nail is made up of a nail root (deep to the proximal fold of skin), lunule and nail plate (between the lateral fold of skin on each side) projecting towards the distal margin of the digit. A nail bed lies under the nail plate and is derived from the epidermis (deep to the stratum lucidum). The thickened part of the nail bed deep to the nail root and lunule is termed the matrix.
Subungual haematoma
Even a small degree of swelling from a bruise under a nail (subungual haematoma) causes considerable pain. Drainage (e.g. using a hot paper clip) suddenly releases the pressure bringing rapid relief.
Fig.7.12 Drainage of a subungual haematoma Nail beds and associated dermis have migrated dorsally from tips of the digits. This is reflected in the neurovascular supply (from palmar/plantar digital nerves and vessels), which is retained. 57
Thick skin
Skin covering all of the body, except for the palms and soles, is termed thin (hairy) skin. Thick (hairless) skin is located on the palms and soles, where the epidermis is greatly thickened (particularly its outermost layer). Thick skin is strongly bound down to underlying dense connective tissue (improving grip).
Fig.7.15 Cutaneous openings on female perineum Other openings involving skin are for the external auditory meatus (of the ear) and the palpebral fissure (of the eyelids). Associated epidermal modifications form the epithelia of the eardrum (tympanic membrane), conjunctiva and cornea.
Fig.7.14 Sites of thick skin Sweat glands are numerous but hair follicles (with sebaceous glands and arrector pili muscles) and pigmentation are absent. Paradoxically thick skin has a thinner dermis than thin skin. Fig.7.16 Cutaneous openings for mouth and eye Specialised areas of skin occur on the breast (nipples and areolae) and on the genitals (penis and scrotum, clitoris and labia).
Friction ridges
Thick skin has prominent surface ridges termed friction (or papillary) ridges. These epidermal ridges are associated with the dermal papillae in the palms and soles. They help increase grip and also enhance sensation. The pattern of friction ridges is permanent and unique.
Skin surgery
Extra care is required with incisions and in surgical repair of wounds to areas with skin specialisations. This is to ensure accurate alignment, minimise tension and prevent disfigurement (most important on the face, particularly with lips and eyelids). Wounds tend to be under greater tension where skin is tightly bound down (e.g. to cartilage of the ears and the nose). Incisions across flexure lines and hairlines (particularly eyebrows) should be avoided. Where possible, incisions (particularly in the face and neck) should be placed along skin creases. Specialised areas of skin and mucocutaneous junctions also tend to have a particularly rich blood supply and sensory nerve supply.
Fingerprinting
Fingerprints, being unique, unchanging and accessible, can be used for identification of individuals.
Fig.7.17 Thick layer of subcutaneous tissue in thigh Fat is deposited in preferential sites depending on genetics, age and gender (typically abdomen in males, buttocks and thighs in females). Fat is not present in the subcutaneous tissue of the eyelids, ear, scrotum, penis and clitoris.
Fig.7.20 Location of cutaneous nerves and vessels Fixed skin is supplied by short (indirect) arteries running along the fibrous septa after passing through and supplying underlying muscle. In contrast, mobile skin tends to be supplied by longer (direct) arteries that pass between rather than through underlying muscles.
Fig.7.19 Compartments within subcutaneous tissue Fibrous strands in subcutaneous tissue bind the overlying skin to the underlying dense connective tissue. These occur particularly in the palms, soles and scalp where they are thickened as septa. Fibrous septa form boundaries of numerous small compartments within the subcutaneous tissue. In the breast prominent fibrous septa radiate from beneath the nipple, demarcating lobes of the mammary gland within the subcutaneous tissue. The upper septa are termed suspensory ligaments. 59
Internervous lines
An inter-nervous line is an imaginary line of nonoverlap between adjacent territories supplied by particular peripheral nerves. Inter-nervous lines on the skin are located where cutaneous nerve branches do not enter adjacent territories. The major inter-nervous line of the body is along the midline (the major line of fusion during development). Nerve branches do not cross the midline of the body.
Fig.7.22 Types of motor fibres to skin Visceral motor nerve fibres (sympathetics) are particularly important for thermoregulation, being distributed to the smooth muscle of dermal blood vessels (vasomotor fibres), sweat glands (sudomotor fibres) and even to the arrector pili muscles (pilomotor fibres). Fig.7.25 The major Internervous line of non-overlap The cutaneous branches of a particular peripheral nerve do not cross the midsagittal plane to intermingle with those from the opposite side of the body.
Fig.7.27 More than one nerve may need to be blocked The area of skin anaesthetised by injection of local anaesthetic around a peripheral nerve corresponds to the cutaneous sensory distribution of the nerve (distal to the site of infiltration) minus the area of overlap from adjacent nerves. 60
Fig.7.30 Spinal cord segment distribution Cranial spinal cord segments are distributed progressively along the skin of the pre-axial border of a limb (from proximal to distal) while caudal spinal cord segments progressively supply the post-axial border (from distal to proximal).
Fig.7.28 Segmental cutaneous neurosomes Adjacent dermatomes that are consecutive overlap extensively. Damage to a single spinal cord segment (or posterior nerve root) may produce only a small (or even no) zone of complete cutaneous sensory loss. As for peripheral nerves, overlap for pain and temperature is more extensive than that for touch across consecutive dermatomes that are adjacent to each other. Fig.7.31 Distribution of middle segment of brachial plexus
Fig 7.36 Anterior axial lines in the welcoming position The pre-axial border of each limb is then located cranially and the corresponding post-axial border, caudally (like the original limb buds).
Fig.7.37 Map based on sensory loss (Foerster) One type of map (according to Foerster) is based on the area of sensation remaining after nerve roots from segments above and below a single segment were severed. These have both anterior and posterior axial lines 62
Fig.7.38 Map based on pain radiation (Keegan & Garrett) Another type of map (according to Keegan and Garrett) is based on loss of pain sensation due to compression of a particular nerve root. These have continuous strips radiating along a limb and no posterior axial line. This map is preferred for identifying spinal segments involved in pain referral.
Fig.7.40 Sites of referred pain from heart Deep somatic pain and visceral pain are dull and illdefined (especially visceral pain which is particularly poorly localised). Deep pain is also often accompanied by referred pain. The site of referred pain tends to be in a pattern that has an anatomical basis. Thus, there can be two sets of pain. The first is the actual deep (somatic or visceral) pain from the source, experienced deeply (but often poorly localised). The second is the associated pain that is (deceptively) referred elsewhere (referred pain). Referred pain may mask pain directly from the source, making diagnosis difficult. However, awareness of the anatomical basis of referred pain can overcome this. Pain from a deep source is referred to the same neurosome. This can be territory supplied by the same spinal cord segment (segmental neurosome) or the same peripheral nerve (peripheral neurosome). An example of the former is pain referred to the umbilicus from an inflamed appendix. An example of the latter is pain referred to the ear from an impacted wisdom tooth.
Fig.7.42 Migration and referred pain to neurosomes The three locations of referred pain relative to its (deep) source are: - the neurosome overlies a deep organ supplied by the same spinal cord segment (e.g. joint capsule) - the neurosome remains but the deep organ has migrated (e.g. appendix, diaphragm) - the deep organ remains but the neurosome has migrated (e.g. limb buds). Fig.7.44 Paired organ and ipsilateral pain referral The kidneys are paired viscera located on each side of the posterior abdominal wall. Pain from the left kidney is referred to its own side of the body (the left loin) while pain from the right kidney is referred to the right loin.
Fig.7.47 Arteries pass along mobile planes Vessels cross planes at sites (of least mobility) where connective tissue is anchored. This occurs particularly at the periphery of muscles, over intermuscular septa, under flexure lines (and skin creases) and where deep fascia attaches to bone. Arteries course from fixed (concave) areas to mobile (convex) areas.
Angiosomes
Cutaneous arterial supply may be mapped into territories that represent the surface of a block of tissue (which includes bone, muscle and skin) supplied by a primary source artery. An angiosome (L. vessel + body) is the 3-dimensional block of territory supplied by a particular (named) artery and associated vein. It consists of a matching arteriosome and a venosome. Arteries and veins follow the connective tissue framework of the body, a continuous mesh between the outer dermis and inner skeleton (where it is calcified).
Fig.7.46 Angiosomes
Lymphangitis
Inflammation of lymphatics (lymphangitis) in the subcutaneous tissue (e.g. due to infection) may cause red streaks along the overlying skin.
Lymphotomes
The cutaneous lymph drainage may be mapped into territories that drain to the first group of lymph nodes encountered. The area of skin that drains to a particular lymph node group is termed a lymphotome.
Fig.7.48 Lymph capillary plexuses in the dermis These networks are arranged in superficial and deep plexuses adjacent to the epidermis and the subcutaneous tissue, respectively (accompanying the associated superficial and deep dermal plexuses of blood vessels).
Fig.7.50 Lymphotomes
Fig.7.51 A watershed Extensive overlap of lymph drainage occurs across adjacent lymphotomes due to the presence of numerous communicating networks of lymph capillaries. These zones of overlap are termed watershed areas. A watershed area of lymph drainage is of particular significance as lymph may drain in more than one direction from it.
Fig.7.54 Tumour spreads in more than one direction Watershed areas of lymph drainage are clinically important in the spread of cancer or of infection. Tumour cells or microbes may be carried in different directions to more than one group of lymph nodes. If the alternative routes are not anticipated, early detection/treatment is more likely to be incomplete and the venous system entered (with further dissemination). This is particularly important regarding the spread of cancer, including skin cancers and breast cancer. Fig.7.52 Vertical watershed The major vertical cutaneous watershed area is centred along the midline of the body where lymph drains to the corresponding lymph nodes on both sides of the body. There is also a vertical cutaneous watershed area centred on the nipple lines over the thorax. There are two major horizontal cutaneous watershed areas, one across the level of the clavicles (where lymph drains to both cervical and axillary lymph nodes) and the other across the level of the umbilicus (where lymph drains to both axillary and inguinal lymph nodes). 67
VISCERAL SYSTEMS HOLLOW VISCERA EXOCRINE GLANDS AND DUCTS ENDOCRINE GLANDS PAIRED AND UNPAIRED VISCERA SEROUS MEMBRANE AND MESENTERIES MUSCLE COATS AND SPHINCTERS MUCOUS MEMBRANE AND JUNCTION ZONE HILUM AND VASCULAR SEGMENTS NEUROVASCULAR SUPPLY OF A VISCUS VISCERAL SYSTEMS
Viscera (L. sticky) have a variety of structures and functions. Collectively they are responsible for regulating the internal environment of the body. Viscera occupy cavities within the body framework and are involved with secretion, excretion, digestion and absorption. Viscera are either hollow or solid. They are typically organised into systems comprising a tract of hollow tubes with associated solid glands.
Digestive system
The digestive system consists of hollow tubes, the digestive (alimentary) tract, together with solid viscera (the associated glands). The tract extends from the mouth to the anus. It is made up of the pharynx (oral and laryngeal parts), oesophagus, stomach, small intestine and large intestine. The associated glands are the (paired) salivary glands and the unpaired pancreas. The digestive system also includes the biliary system, made up of the liver, gall bladder and biliary tree.
Respiratory system
Fig.8.2 Digestive system
Fig.8.1 Respiratory system The respiratory system consists of the respiratory tract and the lungs. The tract is made up of the nasal cavity, pharynx (nasal and oral parts), larynx, trachea and 68
Fig.8.6 Layers of the wall of a hollow viscus A serosa typically covers all or part of the external surface of a hollow viscus (and may be continuous with a mesentery attaching to the body wall). It consists of a single layer of flat cells (mesothelium) covering vascular connective tissue. A serous membrane minimises friction from movement due to extrinsic changes in position (mobility), intrinsic propulsive contractions (motility) or expansion. The muscularis consists of at least one muscle coat. Visceral smooth muscle can produce waves of contraction (termed peristalsis) to propel its contents. The mucosa consists of epithelium covering vascular connective tissue. Mucous membranes may have numerous folds to increase their surface area for absorption (e.g. small intestine).
HOLLOW VISCERA
A hollow viscus is typically tubular, characterised by a cylindrical wall surrounding a central channel, termed the lumen (L. light, as at the end of a tunnel). Some hollow viscera are saccular, being more spherical in shape. A duct (itself a tubular viscus) conveying secretions from an exocrine gland may pass through the wall of a hollow viscus.
Fig.8.7 Normal constrictions of urinary tract The beginnings and ends of the ureters and the urethra have normal constrictions of the lumen. Normal constrictions may also occur where adjacent structures compress a tubular viscus at particular sites along its course. Such normal constrictions occur where the ureter crosses the pelvic brim and where the urethra (in the male) passes through the urogenital diaphragm.
Fig.8.9 Exocrine gland (kidney) and its duct (ureter) Although the kidney excretes rather than secretes urine, it may be regarded as an exocrine gland, with the ureter its duct.
Fig.8.10 Serosa around organs in the peritoneal cavity Fig.8.8 Types of visceral obstruction 70 Some glands are enclosed by fascia that splits to form an investing sheath.
Fig.8.13 Exocrine gland and duct A duct (L. lead) is formed from a system of internal collecting channels and emerges from the hilum of an exocrine gland. The duct transmits secretions towards its orifice opening into the lumen of a hollow viscus (e.g. bile duct into duodenum) or onto an external surface (e.g. lacrimal ducts onto conjunctiva). At the hilum of the kidney the ureter arises from the renal pelvis, formed by the union of its collecting channels (calyces).
Fig.8.11 Fascial sheath around a gland These fascial sheaths occur particularly in the head and neck (e.g. around salivary glands and the thyroid gland) where they provide both support and protection. Glands associated with a body cavity (e.g. liver, ovaries) are covered almost entirely, or at least in part, by a serosa, which reduces friction.
Orifice of a duct
A duct opening into the lumen of a hollow viscus tends to narrow as it traverses the wall. The narrowest part of a duct is its orifice (L. opening). A calculus (stone) will most likely lodge at the orifice of a duct. The narrowest part of the ureter is its orifice in the bladder (the most likely site for a ureteric calculus to lodge).
Fig.8.12 Organ shaped by its direct relations Structures directly related to an organ tend to produce grooves or impressions on it. The aorta grooves the left lung and the azygos vein grooves the right lung. Although the lungs contain air, their external form is similar to a solid viscus. Their internal structure resembles an exocrine gland with air conveyed via duct-like bronchi rather than secretions filling ducts. Fig.8.14 Narrowest part of duct at orifice
Ducts
Glands secreting into a duct are termed exocrine (L. outside + secrete).
Fig.8.16 Blood flow through an endocrine gland Endocrine glands have a very rich blood supply. Purely endocrine glands are the pituitary gland and pineal gland (in the head), the thyroid gland and parathyroid glands (in the neck) and the suprarenal glands (in the abdomen). However, endocrine glandular tissue is not only clustered into discrete organs.
Fig.8.21 Unpaired arteries supplying the gut Unpaired branches (coeliac, superior mesenteric and inferior mesenteric arteries) arising from the front of the aorta supply the stomach, small intestine and large intestine. The venous drainage is to the liver via the portal vein.
Fig.8.19 Bilateral blood supply to the uterus Midline unpaired viscera receive nerve and vascular supply lines from both sides These subsequently form a broad band of overlap across the wall of the viscus.
Mesenteries
The parietal layer of a serous membrane is continuous with the visceral layer via connecting roots to the viscera. These are termed mesenteries (G. middle intestine - an intermediary structure). A mesentery consists of two sheets of serous membrane with loose connective tissue (containing a variable amount of fat) between them. The sheets of serous membrane of the mesentery become continuous with the parietal layer of serous membrane at the parietal attachment of the mesentery (adjacent to the body wall).
Fig.8.23 The mesentery and its contents A serous membrane consists of a single continuous sheet of flat cells that secrete a small amount of fluid (into the enclosed potential space) minimising friction between structures. This mesothelium (G. middle + nipple, i.e. a surface lining) is on a thin bed of vascular connective tissue.
Roles of a mesentery
A mesentery has two major roles. A mesentery (particularly a long mesentery) provides an attachment enabling mobility. A mesentery also contains the supply lines. Vessels and nerves are transmitted in the connective tissue between the two sheets of serous membrane forming the mesentery. 74
Fig.8.28 An intraperitoneal viscus The lungs are suspended in the pleural cavities (of the thorax) and (intraperitoneal) segments of the gastrointestinal tract in the peritoneal cavity (of the abdomen and pelvis). The ovaries and the uterus also have mesenteries as they are suspended in the peritoneal cavity (of the pelvis).
Fig.8.31 Subperitoneal viscera Viscera associated with a body cavity, but without a mesentery, still tend to be partly covered by a serous membrane. This applies both to posterior peritoneal and to subperitoneal viscera.
Retroperitoneal viscera
Fig.8.32 Retroperitoneal abdomino-pelvic viscera Fig.8.29 Intraperitoneal abdomino-pelvic viscera Typically, a viscus has a single mesentery. However, some viscera have more than one (e.g. stomach and liver). 75 The gut tube (foregut, midgut and hindgut), forming the gastrointestinal tract and associated glands, commences development with a dorsal mesentery throughout its length.
Fig.8.33 Parts of gut alternately fixed and free For a very long tube such as the gut there is a trade-off between mobility and fixation. The parts of the gastrointestinal tract are alternately free (intraperitoneal) and fixed (retroperitoneal) to enable mobility while maintaining stability, respectively. In addition to altering their relative position (by mobility) those segments suspended by a mesentery have more capacity to distend (by expansion).
Torsion of a viscus
A viscus suspended on a mesentery (e.g. intestine) is in potential danger of twisting (torsion). This may subsequently cut off its blood supply.
Fig.8.36 The stomach wall Fig.8.34 Torsion and compromise of blood supply A loop of intestine may also become twisted by adhesions or by protrusion through a hernial orifice. 76
Fig.8.37 Intrinsic movement of a viscus Solids, liquids and gas are ingested at the proximal end of the gastrointestinal tract and propelled to its distal end, where the remnants are expelled. Visceral smooth muscle fibres (unlike skeletal muscle fibres) may be stretched without increasing their force of contraction. The property of stretch without increased force of contraction is termed plasticity and is particularly important in organs that may expand to store large volumes (e.g. stomach, bladder and rectum). The bladder and rectum gradually accumulate urine and faeces, respectively. At a critical point of stretch (micturition and defecation) reflexes are elicited, with expulsion of the contents. The stomach expands to accommodate a meal then gradually releases its contents.
Sites of sphincters
Sphincters are found at the distal end of viscera that act as a reservoir (e.g. bladder, stomach).
Fig.8.40 Sphincter at distal end of a reservoir Sphincters may also be located at the distal end of a duct (e.g. bile duct and pancreatic duct).
Fig.8.41 Sphincters at distal end of ducts Fig.8.38 Skeletal and smooth muscle sphincters 77 Sphincters are often located near an external orifice (particularly on the perineum).
Fig.8.42 Sphincters at external orifices on perineum Both voluntary and involuntary sphincters are present near the external orifice of the anal canal, vagina and urethra as a dual safeguard against unwanted passage (from either direction).
Fig.8.45 Direction of orifices on perineum A functional sphincter may also be created at an orifice. The direction of the orifice is at right angles to the direction of apposition of the walls of the tubular viscus (or duct) immediately proximal to it. This is particularly important for orifices opening onto the exterior of the body at the termination of the urethra, the vagina and the anal canal. The external urethral, vaginal and anal orifices are aligned in the mid-sagittal plane, while the walls of the urethra, vagina and anal canal are apposed antero-posteriorly. The anal canal is particularly well guarded. It has an involuntary sphincter (of smooth muscle) surrounded by three voluntary sphincters (of skeletal muscle) and an additional external sling of skeletal muscle (from levator ani). In addition, (although created by the anatomical sphincters) the orientation of the orifice (relative to that of the walls of the canal) may be regarded as a functional sphincter.
Fig.8.43 Functional sphincter of ureter A functional sphincter may be created by intrinsic muscle contraction by a localised increase of muscle tone in the wall of a viscus. The functional sphincter at the junction of the lower end of the oesophagus with the cardia of the stomach (cardiac sphincter) may be contrasted with the distinct muscular thickening at the distal end of the stomach (pyloric sphincter).
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Fig.8.46 The major layers of a mucous membrane The epithelial lining of viscera is avascular (as is the epithelium of skin). Mucus is secreted onto the epithelium of respiratory and digestive tracts. This may be directly from surface cells or from microscopic exocrine glands deep to the epithelium. The underlying connective tissue of the lamina propria is highly vascular (as is the dermal layer of skin). In particular, there are numerous lymph capillaries strategically located directly under a surface lining where they contribute to the first line of defence (by draining invaders to a lymph node). Although most have a blind origin they link freely to form extensive communicating networks. Fig.8.47 Horizontal and vertical junctions of supply
Developmental interfaces
Vertical junction zones typically correspond to lines of fusion. Horizontal junction zones typically correspond with tissues of differing embryological derivation (e.g. endoderm or ectoderm derived epithelium).
Fig.8.48 Major developmental interfaces of gut Endoderm forms the epithelial lining of the digestive tract (derived from the primitive gut tube) as well as the respiratory tract and part of the lower urogenital tract (which develop as an outpouching associated with the foregut and hindgut, respectively). During development, endoderm meets ectoderm at the oropharyngeal membrane and at the cloacal (L. sewer) membrane, which break down, forming openings at each end of the gut tube. Additional interfaces occur between the pharyngeal pouches and the foregut, foregut and midgut, midgut and hindgut and between the hindgut and the cloaca. The upper end of the digestive and respiratory tracts (with epithelia derived from pharyngeal pouches) and the lower end of the digestive and urogenital tracts (with epithelia derived from the cloaca) form special zones where mucous membrane covers skeletal muscle. 79
Mucocutaneous junctions
The most prominent junction zones occur at mucocutaneous junctions. These are located at the openings to the respiratory and digestive tracts (nostrils and lips) and the terminations of the urogenital and digestive tracts (near urethral, vaginal and anal orifices). There are three types of transitions that particularly occur in relation to mucocutaneous junctions: - the epithelial lining (the transition between epithelium of mucous membrane and epidermis) - the mucosal and cutaneous neurovascular territories in the underlying connective tissue (at the transition between lamina propria and dermis) - the type of underlying muscle (the transition between smooth and skeletal muscle coats and/or sphincters). These transitions in epithelium, neurovascular territories and muscle type are usually located at or near the same site.
Epithelial interfaces
Fig.8.50 Developmental interface at distal gut The reflexes coordinated by motor nerves to particular muscles are elicited by stimulation of corresponding sensory nerves that supply the overlying mucosa.
Fig.8.53 Epithelial interface in anal canal At mucocutaneous junctions, the epithelium changes from a moist, delicate lining of the mucous membrane into epidermis, characterised by an outermost dead and dry layer (stratum corneum). A line in the anal canal (the dentate line) is created by remnants of the anal membrane and demarcates the change in epithelium. It represents the site of the endoderm/ectoderm interface. 80
Fig.8.56 Anal sphincters and their innervation There is a corresponding change of underlying motor supply. Visceral nerves supply smooth muscle sphincters, while somatic nerves supply skeletal muscle sphincters. The internal anal sphincter is supplied by sympathetic nerves while the external anal sphincters are supplied by the inferior rectal nerve).
Transmucosal junctions
Junction zones also occur between different mucosal territories. Transmucosal junctions involve epithelial and/or neurovascular interfaces. They may also be associated with muscular interfaces. A change in epithelium (from stratified squamous to columnar) occurs near the gastro-oesophageal junction.
Muscular interfaces
These mucocutaneous junctions usually overlie a change of muscle tissue and particularly involve sphincters (e.g. an internal smooth muscle and an external skeletal 81
Fig.8.57 Mucosal and muscular interfaces in oesophagus Other transitions associated with the oesophagus in its lower half include arterial supply together with venous and lymphatic drainage (in the lamina propria).
Fig.8.60 Reflex territories along upper airway Fig.8.58 Vascular interface along oesophagus The type of underlying muscle (from skeletal to smooth) coats is also in transition, together with the associated type of nerve fibres. At the upper end of the digestive tract, stimulating touch and taste receptors of oral mucosa elicits chewing and salivation reflexes (via cranial nerves V3 and VII, respectively), while stimulating touch receptors of pharyngeal mucosa elicits the swallowing reflex (via cranial nerve IX). At the upper end of the respiratory tract, stimulating touch receptors of nasal mucosa elicits the sneeze reflex (via cranial nerve V2) and touch of laryngeal mucosa (e.g. by inadvertent entry of food or fluid) elicits the cough reflex (via cranial nerve X). Internervous lines for reflexes (e.g. defaecation and micturition) also occur at the lower end of the digestive and urinary tracts.
Fig.8.59 Vascular interfaces along gut Transmucosal junctions tend to be located where territories of different developmental origin meet. Transmucosal junctions correspond with neurovascular interfaces (associated with the respective foregut, midgut or hindgut artery and with the visceral afferent pain fibres that pass along them).
Fig.8.62 Segmental supply of viscera and overlying skin The pelvic pain line projects through the rectum to the pubic symphysis. Below the rectum (to the mucocutaneous junction in the anal canal) the mucosa is derived from the cloaca. Visceral afferent fibres accompanying parasympathetic nerves convey pain from it to spinal cord segments S2-4 (and refer to the perineum).
Fig.8.64 Renal vascular segments Vascular segments may be associated with subdivisions of ducts (e.g. bronchopulmonary segments of a lung); they receive a separate, exclusive arterial supply. There tends to be no arterial anastomosis across vascular segments although there may be some venous communication.
Vascular segments
Fig.8.63 Hilum and vascular segments of kidney Solid viscera (e.g. liver, kidney and lung) are often subdivided into discrete segments termed vascular segments. 83 Fig.8.65 Gut smooth muscle from splanchnic mesoderm
Neuroendocrine connections
Certain endocrine glands have major connections to the nervous system. The pineal gland and the posterior lobe of the pituitary gland are outgrowths of the brain. The suprarenal medulla developed as a modified sympathetic ganglion and is supplied directly by sympathetic nerve fibres. The anterior lobe of the pituitary gland receives chemicals (releasing factors) released into its blood vessels indirectly from the neighbouring area of brain (the hypothalamus). The other endocrine glands function independently from the nervous system (although their associated blood vessels receive sympathetic fibres).
Fig.8.67 Distribution of visceral and somatic nerves The body wall and the (parietal) layer of serous membrane lining it are supplied by somatic nerves, while the gut and the (visceral) layer of serous membrane around it is supplied by visceral nerves.
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Strangulation of a viscus
The blood supply to a viscus may be endangered from external compression. Strangulation (L. choke) affects veins earlier than arteries, being thinner walled (and with a lower blood pressure). Swelling from venous congestion may further aggravate the compression and ultimately the arterial supply is compromised. Strangulation of a tubular viscus (e.g. loop of intestine) irreversibly lodged in a tight hernial orifice (e.g. the femoral ring), occurs when its blood vessels are compressed. Strangulation may also occur from associated twisting of blood vessels to a viscus suspended by a long vascular stalk (e.g. torsion of the testis) or by a mesentery (e.g. volvulus of the sigmoid colon).
Fig.8.72 Public and private vascular supplies to lung The liver receives the hepatic artery and the portal vein (carrying blood to it from the gut via the portal venous
85
NERVOUS SYSTEM NERVE FIBRES AND REFLEX ARCS BRAIN AND SPINAL CORD STRUCTURE SPINAL NERVES AND FIBRE TYPES CRANIAL NERVES AND FIBRE TYPES NERVE GANGLIA SYMPATHETIC TRUNKS AND FIBRE PATHS NERVE PLEXUSES NERVE DISTRIBUTION AND BRANCHES VASCULAR SUPPLY OF A NERVE NERVE INJURIES AND NEUROGENIC PAIN NERVOUS SYSTEM
The nervous system consists of the Central Nervous System (CNS) and the Peripheral Nervous System (PNS). The CNS is made up of the brain and spinal cord. The brain consists of the forebrain (primarily the paired cerebral hemispheres), the midbrain and the hindbrain (pons, medulla and cerebellum).
Fig.9.1 Nervous system within body modules The brainstem is the (unpaired) midbrain, pons and medulla. The PNS is made up of the somatic and visceral (autonomic) nervous systems that are distributed via 12 pairs of cranial nerves and 31 pairs of spinal nerves. 86
Fig.9.6 Sites of synapses Cell membranes of synapsing neurons are separated by a gap, the synaptic cleft. A chemical transmitter released by arrival of electrical impulses at the pre-synaptic membrane diffuses across the synaptic cleft to affect the excitability of the post-synaptic membrane.
Fig.9.7 Components of a synapse Typically, synapses with dendrites are excitatory, while those with the cell body are inhibitory
Synapses
The central nervous system consists of the brain and spinal cord. The peripheral nervous system and ganglia are derived from cranial and spinal nerves (arising from the brain and spinal cord, respectively). An axon of one neuron meets another via a synapse (G. touch)
Fig.9.5 Major components of a neuron Although a neuron possesses only one axon, it may receive numerous synapses from axons of other neurons. These typically occur with the cell body (which surrounds the nucleus) and with prolongations of cell membrane termed dendrites (G. trees) near the cell body. 87
Receptors
A receptor (L. receive) is at the origin of a sensory nerve fibre. This is typically located on the end of the distal axonal extension. There are several types of receptors. Exteroreceptors are located in the skin and in the special sense organs. Cutaneous exteroreceptors are mechanoreceptors (for touch and pressure), thermoreceptors (hot and cold) and nocioceptors (for superficial somatic pain). Proprioceptors are located in somatic structures deep to the skin (in skeletal muscles, joints and bones). They include mechanoreceptors (for stretch, joint position and vibration) and nocioceptors (for deep somatic pain). Interoreceptors are located in internal organs. They include baroreceptors (for arterial blood pressure), chemoreceptors (for arterial oxygen tension) and nocioceptors (for visceral pain).
Fig.9.10 Major types of nerve fibres Visceral afferent fibres are non-myelinated and conduct slowly, conveying smooth muscle stretch and visceral (e.g. vague) pain. The functional fibre type of a motor nerve fibre corresponds to the type of effector. This may be somatic (for skeletal muscle) or visceral (for smooth muscle, cardiac muscle and glands). Somatic efferent fibres are large and rapidly conducting, while visceral efferent fibres are smaller and slower conducting.
Fig.9.9 Components of a neuromuscular junction In contrast to a receptor, an effector is not in direct continuity with a neuron. A motor neuron meets an effector at the neuro-effector junction. There is a gap (the junctional cleft) between the cell membrane of the neuron (exposed by local loss of endoneurium, neurilemma and myelin sheath) and that of the effector. The neuro-effector junction for skeletal muscle is termed a neuromuscular junction. At a neuromuscular junction, a chemical transmitter released by arrival of electrical impulses at the nerve terminal diffuses across the junctional cleft to excite a specialised area of skeletal muscle cell membrane (the motor end-plate).
Fig.9.13 An example of parasympathetic activation Fig.9.12 An example of sympathetic activation Sympathetic outflow is more divergent and diffuse than parasympathetic. For example, it is directed to almost all arterioles throughout the body, particularly those in skin and skeletal muscle (including of the limbs). Sympathetics primarily control smooth muscle tone of arterioles. Blood can be diverted to active organs according to need while blood pressure is maintained (ensuring adequate cerebral blood flow). 89
Reflexes
The nervous system is the sole control mechanism for skeletal muscle action. It also complements hormonal and local mechanisms in the control of smooth (and cardiac) muscle and of glands. In particular, it has the capacity to act almost instantaneously on specific distant targets. A reflex (L. bend backwards, as in feedback) is an active response to a stimulus that is involuntary and stereotyped. It is a negative feedback mechanism; the response feeds back on the stimulus (and progressively shuts it off beyond a certain threshold). A reflex is characterised by an active rather than a passive response. More energy is expended in the response than is provided by the stimulus (i.e. it is primed like a spring). Although modified by voluntary control, a reflex may occur without conscious awareness (i.e. it is automatic) and is stereotyped rather than random (i.e. it is pre-programmed along a specific path).
Neuroglia
The brain and spinal cord consists of nerve cells plus supporting cells. Blood vessels (being derived from mesoderm) supply the brain and spinal cord from the exterior and must penetrate them to reach deep parts. Neuroglia (G. nerve + glue) supports neurons in the brain and spinal cord. The majority of neuroglial cells (which also outnumber neurons in the CNS) are the astrocytes. These star-shaped cells have processes with foot plates that surround blood vessels. Some neuroglial cells are more like the Schwann cells that support peripheral nerve fibres. These myelin-forming cells are the oligodendrocytes.
Fig.9.18 Development of neural tube The brain develops from the expanded cranial end of the neural tube, while the spinal cord develops from its narrow caudal part. The cavity of the neural tube remains relatively wide throughout most of the brain (as its ventricles), but becomes very narrow in the spinal cord (as its central canal). Islands of ectoderm (neural crest) break away from the neural folds to form all of the sensory neurons in the PNS. Ganglia and Schwann cells are also derived from neural crest, as well as the suprarenal medulla (a modified sympathetic ganglion) and the inner two membranes covering the CNS.
Fig.9.22 Descending fibres to motor neurons Fig.9.20 Major motor pathways cross the midline A lateral column (containing the cell bodies of sympathetic neurons) lies in all thoracic, plus the upper two lumbar, segments of the spinal cord. 92 The descending fibres are primarily in the lateral funiculi and include the voluntary pathway (from the motor area of the cerebral cortex) plus many fibres to control skeletal muscle tone. There are also sympathetic pathways (primarily from the hypothalamus).
Fig 9.23 Ascending fibres from sensory neurons The ascending fibres convey most cutaneous sensation (via spinothalamic tracts), conscious proprioception plus fine touch (via the posterior columns) and unconscious proprioception (via spinocerebellar tracts). Within the funiculi, both descending and ascending fibres are arranged in laminae. In the anterior and lateral funiculi, fibres associated with caudal segments are superficial to those associated with more cranial segments. In the posterior funiculi, fibres associated with caudal segments are medial to those associated with more cranial segments. The left cerebral hemisphere controls movements for, and receives conscious sensation from, the right side of the body. Similarly, the right cerebral hemisphere is connected to the left side of the body. Most neural pathways in the CNS cross the midline.
Fig.9.25 Posterior and anterior nerve roots A serrated fold of pia mater (the denticulate ligament) within the subarachnoid space separates the posterior and anterior nerve roots. A swelling, termed a ganglion, is found on each posterior root. A posterior root ganglion comprises clusters of cell bodies of sensory nerve fibres (which unlike motor fibres have both proximal and distal axonal extensions).
SPINAL NERVES AND FIBRE TYPES Posterior and anterior nerve roots
There are 31 pairs of spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal). Each is attached to the corresponding spinal cord segment via nerve roots arising as a series of rootlets from the posterior and the anterior aspects of the spinal cord. Fig.9.26 Somatic afferent fibre paths In addition, posterior roots from T1 to L2 convey some visceral afferent fibres (which accompanied the visceral efferents but passed through a sympathetic ganglion without synapsing). These fibres convey visceral (slowly conducting) pain from thoracic, abdominal and upper pelvic viscera. Posterior roots from S2 to S4 convey visceral afferents from lower pelvic viscera.
Fig.9.28 Somatic efferent fibre paths In addition, anterior roots from T1 to L2 convey (preganglionic) sympathetic fibres and anterior roots from S2 to S4 convey (pre-ganglionic) parasympathetic fibres.
Dural sleeve
The union of an anterior nerve root with a posterior nerve root forms a spinal nerve. Each spinal nerve emerges from an intervertebral foramen. Nerve roots are invested by thin pia mater, continuous with that surrounding the spinal cord. As anterior and posterior nerve roots pass into an intervertebral foramen they also receive an arachnoid lined extension of dura mater (a dural sleeve). The dural sleeve merges with the epineurium of the spinal nerve.
Fig.9.31 Typical spinal nerve and its components Posterior rami of spinal nerves directly supply skin, intrinsic back muscles and joints of the dorsal aspect of the trunk and neck.
Fig.9.33 Distribution of a thoracic spinal nerve The segmental pattern of distribution from cervical, lumbar and sacral spinal nerves is disguised by their anterior rami linking to form plexuses. Fig.9.34 Levels of cranial nerve origin
Fig.9.42 Sympathetic ganglion and associated fibres Autonomic ganglia involve sympathetics and/or parasympathetics. Preganglionic fibres are myelinated, while postganglionic fibres are nonmyelinated (and of smaller diameter). Additional fibres may pass through an autonomic ganglion without synapsing in it. This applies to all visceral afferent fibres and even applies to some visceral efferent fibres. The latter may be postganglionic (having already synapsed in a more proximal ganglion) or preganglionic (to synapse in a more distal ganglion). 97
BODY SYSTEMS AND ORGAN STRUCTURE Paravertebral sympathetic ganglia Suprarenal medulla and paraganglia
The suprarenal (adrenal) medulla is a modified sympathetic ganglion (having also developed from the neural crest). It is supplied by (pre-ganglionic) sympathetic fibres and secretes adrenaline and noradrenaline directly into the blood stream. Clumps of (chromaffin) tissue similar in composition to suprarenal medulla (and neural crest derived) may be found nearby, along the abdominal aorta. These paraganglia can also secrete adrenaline. The largest are known as the para-aortic bodies.
Parasympathetic ganglia
Parasympathetic ganglia tend to be smaller and located more peripherally than sympathetic ganglia. They are typically situated adjacent to the viscera they supply. Parasympathetic post-ganglionic fibres are short, correlating with the more localised effects of parasympathetic stimulation. The major autonomic ganglia in the head with synapses that are purely parasympathetic have specific names. They are the ciliary ganglion (supplying the eye), the pterygopalatine ganglion (supplying lacrimal and nasal glands), the otic ganglion (supplying the parotid gland) and the submandibular ganglion (supplying submandibular and sublingual glands).
Fig.9.43 Ganglia on sympathetic trunk More than 20 pairs of ganglia with synapses that are purely sympathetic are located on the sympathetic trunks. These are termed paravertebral ganglia as they are also situated alongside the vertebral column. Sympathetic postganglionic fibres are much more numerous than preganglionic fibres and are typically long, correlating with the widespread effects of sympathetic stimulation (enhanced and prolonged by adrenaline). In addition to supplying arteries, sympathetic postganglionic fibres may form a plexus around arteries and accompany them to their peripheral destinations.
Fig.9.44 Types of sympathetic ganglia Preganglionic parasympathetic fibres (from branches of the vagus nerve) also pass through these ganglia. They tend to synapse in (parasympathetic) ganglia located adjacent to the viscera. 98
NERVE PLEXUSES
A plexus (L. braid) is the linking together of nerves (or of vessels). A nerve plexus involves the intermingling (but not joining) of axons from different nerves connected by continuous sheaths of fibrous tissue. In this rearrangement of bundles there is no mixing of electrical impulses (unlike vascular plexuses where the fluid contents mix within the interconnected lumens). The largest nerve plexuses are created from linking anterior rami of certain spinal nerves. In a similar way, although on a smaller scale, communicating branches can also occur between neighbouring nerves, particularly their cutaneous branches.
Fig.9.52 Limb buds and supply from anterior rami Limb buds arise only from the ventral aspect of the trunk (i.e. in front of the coronal morphological plane) and are supplied only by anterior rami. Posterior rami are not involved in their associated nerve plexuses (or the cervical plexus) as posterior rami are distributed to the back (and the back of the neck) rather than the ventral aspect of the trunk.
Somatic plexuses
Fig.9.54 Divisions of plexus and supply of compartments The anterior rami of the brachial plexus unite to form trunks, each dividing into two divisions, the anterior for distribution to flexor compartments and the posterior for distribution to extensor compartments. The divisions (after reuniting to form cords) provide the major peripheral nerves to the limb as terminal branches of the plexus. Branches to proximal muscles (surrounding the plexus) may arise directly from components of the plexus (anterior rami, trunks or cords). Fig.9.55 Nerve fibre types and their distribution Somatic efferent fibres are distributed to skeletal muscles. Visceral efferent fibres are sympathetic and primarily vasomotor. These fibres are distributed to blood vessels in muscles, bones, joints and skin. Sudomotor fibres (to sweat glands) and pilomotor fibres (to arrector pili muscles) are also distributed to skin.
Autonomic plexuses
Viscera are supplied by sympathetics and parasympathetics (including visceral afferent fibres accompanying either of them). These fibres tend to converge, forming plexuses near the viscera. The major autonomic plexuses in the thorax (cardiac, pulmonary and oesophageal), the abdomen (coeliac and mesenteric) and the pelvis (hypogastric) contain all of the above visceral nerve fibre types. In the abdomen and pelvis these plexuses surround major arteries supplying the viscera. In addition, purely sympathetic plexuses occur along arteries in the head, neck and limbs.
Hiltons law
Peripheral nerves link somatic structures to create functional units. There is a relationship between structures supplied by a particular nerve (according to Hiltons law). A nerve which supplies a muscle producing movement at a joint also supplies sensation to the joint and skin overlying (the insertion of) the muscle.
Fig.9.59 Protective withdrawal reflex and biceps jerk This draws the bones together, reducing the degree of stretch and protecting the joint from injury. Stretch of the flexor aspect of the capsule (e.g. of elbow joint) from hyperextension elicits a reflex contraction of flexor muscles (e.g. biceps brachii) producing flexion at the joint. A painful stimulus to skin elicits muscle contraction that tends to move the associated part away from the threat. Such superficial somatic (cutaneous) reflexes may be involved in a generalised withdrawal reflex. Contact with a sharp object (e.g. to skin on the sole of the foot) elicits reflex contraction of muscles (e.g. calf muscles) producing plantar flexion at the ankle joint, withdrawing the foot (particularly when accompanied by contraction of flexor muscles at the hip and knee joints).
Fig.9.58 Sequence of peripheral nerve branches The musculocutaneous nerve in the arm supplies a muscular branch to biceps brachii (a flexor at the elbow), then an articular branch (to the flexor aspect of the elbow
Fig.9.60 Protective back muscle spasm Inflammation of the meninges (meningitis) is accompanied by neck stiffness due to reflex spasm involving extensor muscles of the cervical spine as well as referral of pain (headache). Guarding and rigidity of the anterior abdominal wall protects underlying viscera when inflammation has spread to involve the parietal peritoneum (peritonitis).
Blood-brain barrier
The CNS receives blood supply from its periphery. The cerebral and the spinal arteries run on the surface of the brain and the spinal cord invested in pia mater. Their branches penetrate the white and grey matter, progressively getting smaller. The deepest areas of the CNS tend to have the most precarious arterial supply (particularly as these branches do not link with each other). Capillaries in the brain and spinal cord allow water to pass freely across the endothelial membrane with ease. However, their endothelium is impermeable to many substances, while others cross slowly. In addition, these capillaries are peculiar in being almost completely surrounded by the footplates of astrocytes (star-shaped neuroglial cells). This unique permeability barrier of cerebral capillaries has been termed the blood-brain barrier by physiologists and tends to protect the brain from toxic substances. A few areas of the brain are outside the blood-brain barrier. These small zones either have chemoreceptors (monitoring chemical changes in the plasma) or secrete hormones. The blood-brain barrier does not fully develop until early childhood. It also may be affected by brain disease (e.g. infection or tumours) and certain drugs may enter it (e.g. a few antibiotics), while others do not. There are no lymph vessels in the CNS.
BODY SYSTEMS AND ORGAN STRUCTURE NERVE INJURIES AND NEUROGENIC PAIN Types of nerve injuries
A peripheral nerve lesion impairs motor and sensory (including reflex) functions (and in the long term may lead to muscle wasting). Mild injury causes a transient loss of function. A peripheral nerve may be injured by laceration, traction or compression. Compression may directly damage nerve fibres (e.g. from a crush injury), compromise the blood supply to the nerve (e.g. from entrapment) or both. Large nerve fibres within a peripheral nerve are the most susceptible to pressure. if the gap of damage is bridged and scar tissue negotiated, many axons may regenerate along functionally different endoneurial tubes. This may be minimised by careful realignment of nerve fibre bundles in the surgical repair of a severed nerve.
Axonal degeneration
Interruption of an axon results in degeneration of the entire axon distally (including associated degeneration of its myelin sheath) and (for motor neurons) is coupled with subsequent muscle atrophy. This is termed antegrade degeneration. There is also a variable degree (depending on severity) of degeneration proximally. This ranges from a short distance of axon, to the cell body itself and (for severe injuries) may even include neurons that synapse with its cell body. This is termed retrograde degeneration. This is demonstrated in both antegrade and retrograde degeneration. A neuron influences the vitality of its connections.
Axonal regeneration
Nerve cells are highly specialised and have lost the capacity to divide. Although the cell bodies of neurons in the CNS or PNS may not be replaced, axons in peripheral nerves may regenerate. This is provided they have a track to regenerate along (created by the endoneurium). In contrast, axons in the CNS do not have tubes of connective tissue and do not tend to regenerate. In a peripheral nerve, gradual regeneration can occur (at a rate of approximately 2 mm/day) provided the endoneurium is intact. Disruption of the endoneurium, with or without perineurium and epineurium (in addition to the axons), results in variable degrees of permanent impairment. Even 104
Fig.9.64 Neuralgic pain With limb amputation, inadvertent stimulation of fibres associated with the stump may result in pain (phantom pain), and/or abnormal sensation (phantom limb), attributed to the absent extremity The anatomical causes of pain (based on its possible sources) are somatic, visceral and neurogenic. Somatic and visceral pain directly arise from pain receptors within their respective tissues, while neurogenic pain arises indirectly from abnormal activity in nerve fibres that transmit pain.
ARTERIAL SYSTEM ARTERIES AND BRANCHES ANASTOMOSES END ARTERIES NEUROVASCULAR SUPPLY OF A VESSEL ARTERIAL SYSTEM
The arterial system arises from the ventricles of the heart. It is divided into two separate systems.
Fig.10.5 Foetal umbilical artery blood is deoxygenated Arteries throughout the foetus have deoxygenated blood mixed with oxygenated blood.
Structure of arteries
Arteries consist of a cylindrical wall surrounding a central channel, the lumen (L. light, as at the end of a tunnel). The inner layer (intima) of the wall is connective tissue lined by endothelium (G. within + nipple i.e. an inner surface lining). The middle layer (media) contains concentrically arranged smooth muscle fibres and elastic fibres. The outer layer (adventitia) is primarily composed of collagen fibres. The adventitia also contains vasomotor nerve fibres and even vasa vasorum (L. vessels of vessels).
Arterioles
Arterioles are small branches that feed the capillary bed. They have the largest ratio of wall thickness to lumen calibre, which is maintained by smooth muscle tone controlled by vasomotor nerves. Vasomotor nerves are almost exclusively part of the sympathetic nervous system (although parasympathetic nerves also supply arterioles associated with erectile tissue). Arterioles act as resistance vessels. Control of changes in their calibre regulates blood flow and blood pressure. The greatest drop in blood pressure occurs across arterioles.
Capillaries
The thinnest walled vessels are capillaries (L. minute hairs) consisting of a single layer of endothelial cells (plus basement membrane) permeable to water, electrolytes and gases as well as cellular nutrients and wastes. Capillaries act as exchange vessels, creating a microcirculation. Water moves across capillary walls according to the difference between hydrostatic pressure (decreasing from the arterial to the venous end of a capillary) and osmotic pressure. There is net water movement out of the arterial end and into the venous end of a capillary. 106
Sinusoids
Capillary permeability varies at different sites and in different organs. It is also dramatically increased as part of the inflammatory response to tissue injury (producing leakage of fluid into the tissues, with swelling). Sites often subject to great hydrostatic pressure (e.g. the limbs) have less capillary permeability, minimising fluid leaking out of the vascular system. Certain organs (e.g. endocrine glands), where the capillary membrane is involved in transport of large molecules (e.g. hormones), have greater capillary permeability. Sinusoids (L. space-like) are specialised capillaries with a larger calibre and more sluggish flow. They are found particularly in components of organs with haemopoietic and defence function (i.e. liver, spleen and bone marrow). In these tissues, sinusoids have a modified endothelium with a discontinuous or absent basement membrane (and greater permeability) and phagocytes (G. eat + cells) that scavenge particles including old blood cells. The presence of sinusoids enables newly formed red and white blood cells to pass into the vascular system (as well as certain white blood cells to pass out of the vascular system).
Arterial branches
In the trunk, arterial branches are classified as parietal (to the body wall) or visceral (to viscera). Arteries often give many branches with a change in direction (and reduction in calibre) tending to occur where a large branch is given off.
Rete mirabile
A rete mirabile (L. net + wonderful) is a capillary bed located between two arteries. In certain animals arteries may break up into capillary beds, and then arise as arteries again. Retia mirabilia occur only at special sites (e.g. in the testes of marsupials or base of the brain in grazing animals) for special functions (e.g. temperature regulation influencing spermatogenesis or assisting venous return when the head is dependent, respectively). In humans, retia mirabilia only occur as microscopic collections termed glomeruli (L. little balls of thread) within the cortex of the kidney (between each pair of afferent and efferent arterioles). Their special function is the filtration of plasma. Unlike typical capillaries, those of a rete mirabile are not designed primarily for exchange of gases, cellular nutrients or wastes.
Fig.10.10 Parietal and visceral branches of arteries in trunk Where arteries divide into terminal branches, the larger branch tends to be more directly in line with the main trunk, with the smaller at a greater angle. Arterial branches to somatic structures (e.g. in the limbs and body wall) may be regarded as cutaneous, muscular, arteriae nervorum (to nerves), nutrient (to long bones) and articular (around joints). 107
Avascular structures
Structures not derived from mesoderm are avascular (they do not have capillaries). Tissues that do not possess capillaries include epidermis (ectoderm derived) and all other surface epithelia (primarily endoderm derived). Capillaries are also absent from hyaline cartilage.
Fig.10.13 Systemic pressure is higher than pulmonary Almost all the arteries in the body (other than pulmonary arteries) are derived from the aorta (and even include bronchial arteries supplying walls of the airways, lymph nodes and visceral pleura). Systemic arteries transport oxygenated blood. The lung has two circulations: pulmonary (via pulmonary arteries) and systemic (via bronchial arteries). Systemic arterial blood pressure is higher than pulmonary arterial blood pressure (and much higher than venous blood pressure).
Fig.10.12 Development of arteries from networks Many of these narrow, while others remain as the preferred channels and subsequently become the major arterial pathways. However, the capacity to open narrower paths (e.g. after occlusion of the preferred channel) remains. There is also the capacity for considerable anatomical variation of arterial patterns as there is often more than one avenue that may become a preferred channel. Variations of arteries or their branches include origin, number, course and distribution.
Haemorrhage
Haemorrhage (G. blood + gush) is loss of blood from a blood vessel. Haemorrhage may be arterial, capillary or venous and is typically due to external injury of the vessel wall. It also occurs with rupture of a weakened vascular wall. Vessels constrict and, if possible, plug (by platelet aggregation) the wall defect, minimising blood loss. Blood clotting or platelet defects predispose a patient to haemorrhage, as does increased blood pressure (which also accentuates bleeding).
Fig.10.15 Contrast between arterial and venous bleeding Haemorrhage can be external (and visible) or internal (hidden in a body cavity, compartment or space).Although blood tends to spurt from elastic and muscular arteries due to the pulsatile flow at higher pressure, large thin-walled veins oozing at lower pressure can cause equally severe blood loss. Blood loss and drop in blood pressure may cause symptoms (e.g. fainting). Internal haemorrhage may also cause pain due to pressure in the surrounding compartment. However, large compartments (e.g. muscle compartments of the thigh) or body cavities can accumulate dangerous volumes of blood without a significant rise in local pressure (and pain).
Arteriosclerosis
Changes tend to occur in arteries as they age. Arteriosclerosis (G. artery + hardness) is hardening of the arteries due to increased fibrous tissue and even calcification in the wall. Aging is accompanied by a 109
Fig.10.16 External and internal haemorrhage Compression may need to be applied upstream from the damaged vessel at strategic sites (e.g. where it runs over bone and can be compressed). Elevation, when possible (e.g. of a limb) will reduce hydrostatic pressure. The definitive treatment of a damaged vessel (particularly a large artery or vein) may involve ligation or surgical repair. In severe haemorrhage, fluid replacement or blood transfusion (via a major vein) may also be required to prevent shock (inadequate perfusion of tissues) and maintain blood pressure.
True anastomoses
Links directly between branches of muscular arteries are typically of large calibre. These are termed true anastomoses.
Fig.10.19 True anastomosis Adjacent (branches of) arteries tend to anastomose with each other. The more branches the greater the potential for anastomoses. The labial branches of the facial artery are continuous with their counterparts from the other side of the body, forming a true anastomosis around the lips. A midline incision through the lips tends to result in arterial blood spurting from both sides. Other examples of anastomoses include the cerebral arterial circle (of Willis) at the base of the brain, the palmar arches in the hand and the plantar arch in the foot.
ANASTOMOSES
An anastomosis (G. through + mouth) is a linking of tubular structures, such as blood vessels (lumen to lumen, i.e. mouth to mouth). When it occurs without an intervening capillary bed, it offers an alternative (collateral) route. 110
Potential anastomoses
Links directly between arterioles are typically of small calibre. These are termed potential anastomoses as they have the capacity to enlarge their calibre.
Arteriovenous anastomoses
Arteriovenous (AV) anastomoses are direct communications between small arteries and veins without an intervening capillary bed. The wall is thickened and the lumen diameter can be varied (via neural control of the smooth muscle tone). They are located in areas where there is intermittent blood flow. Arteriovenous anastomoses occur in exposed parts, including the skin of the nose, lips and ears. Fig.10.20 Potential anastomosis
Fig.10.23 AV anastomoses and temperature regulation Arteriovenous anastomoses are involved in temperature regulation, enabling blood to be shunted between superficial and deeper cutaneous vessels. Fig.10.21 Anastomoses within a muscle
Glomus tissue
At special sites arteriovenous anastomoses occur in the form of tiny clusters of interconnecting vessels termed glomera (L. balls of thread). They are most numerous in the skin of the fingers and toes, particularly digital pads and nail beds. A localised collection of glomus tissue also occurs at the origin of the internal carotid artery (carotid body), at the origin of the internal jugular vein (jugular body) and at the tip of the coccyx (coccygeal body). The carotid body has a high blood flow enabling it to function as a chemoreceptor monitoring the partial pressure of dissolved gases in the plasma. The roles, if any, of the other two are unknown.
Erectile tissue
Arteriovenous anastomoses also occur in erectile (cavernous) tissue, where they are associated with vascular spaces (venous sinuses) arranged like a honeycomb and capable of expansion. Erectile tissue is present in the nasal mucosa, where it warms and humidifies inspired air. Erectile tissue is especially prominent in the penis and clitoris. A tube of dense connective tissue (tunica albuginea) surrounds a mesh of venous sinuses in the corpora cavernosa of the penis. 111
END ARTERIES
An end artery is an artery isolated from others. Its branches do not appear to link with those of another artery. The territory it supplies is dependent on that single vessel.
End organs
An end organ is a body part or organ that is isolated from others. It tends to be supplied by a single artery or at least via a single avenue of arterial supply. End organs are particularly vulnerable to having their arterial supply cut off. Fig.10.25 The anatomical end artery to the retina
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Vulnerability to vasoconstrictors
Vasoconstrictor drugs (e.g. adrenaline) should not be injected into the digits or penis. These drugs can produce intense arterial spasm resulting in death of tissue in these terminal body parts. Fig.10.31 End arteries in a developing long bone
End tissue
Fig.10.30 The vermiform appendix and its end-artery The spleen is a solid organ suspended within the abdominal cavity by its attachment at the splenic hilum where it receives the splenic artery. The brain and spinal cord are suspended within the cranial cavity and vertebral canal, respectively, while the heart is suspended within the 113 Within an organ, the furthest area from its arterial source may be regarded as end tissue as it tends to be supplied by terminal arterial branches. End tissues within end organs are most vulnerable to having their arterial supply interrupted.
Pulmonary embolus
Emboli originating from systemic veins (e.g. deep veins in the calf) pass through the right atrium and ventricle, then into the pulmonary arterial system, to occlude a pulmonary artery or branches of it in the lung. Pulmonary emboli may also arise from the right side of the heart.
Vascular tone
Vascular smooth muscle tends to be in a state of continuous partial contraction (tone), modulated by (visceral) motor nerves. This is most significant in arterioles, the vessels primarily involved in the regulation of blood flow and blood pressure.
Vasa vasorum
Fig.10.38 Vasa vasorum of aorta The endothelium and intima receive nutrition directly by diffusion from blood in the lumen of a vessel. However, the media and adventitia (particularly of elastic and muscular arteries) require a blood supply from vessels of their own, termed vasa vasorum (L. vessels of vessels). Vasa vasorum include arteriae vasorum as well as venae vasorum.
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VENOUS SYSTEM VEINS AND TRIBUTARIES VENOUS VALVES AND VENAE COMITANTES VENOUS SINUSES AND COMMUNICATIONS VENOUS SYSTEM
The venous system comprises three separate major systems.
Fig. 11.3 Components of systemic venous system The portal venous system drains blood from the gut into the liver where it branches into a capillary bed, then forms the hepatic veins. These veins, in turn, drain into the inferior vena cava (IVC).
Fig.11.1 Venous system within major trunk modules The pulmonary venous system drains into the left atrium of the heart and is made up of pulmonary veins.
Structure of veins
Veins are more numerous than arteries. However, like arteries, veins consist of a tubular wall surrounding a central channel, termed the lumen. The wall comprises an (inner) intima lined by endothelium, a media with smooth muscle and an (outer) adventitia. Fig.11.5 Venous tree and changes in its dimensions
Fig.11.8 Layers of venous wall Veins have thinner walls and larger lumens than arteries, correlating with their lower pressure (and slower rate of flow) and greater volume. Veins act as capacitance vessels. They contain most of the blood volume.
Fig.11.10 Systemic venous systems The azygos (G. not yoked i.e. unpaired) vein is a partial bypass between the superior and inferior vena cava (helping equilibrate pressure between them). It is primarily located in the thorax. In addition to draining the posterior abdominal and thoracic wall, azygos vein tributaries receive vertebral veins. Vertebral veins include internal and external vertebral venous plexuses (networks located inside and outside the vertebral canal). Blood cells produced in the vertebral column enter the circulation via them.
VENOUS VALVES AND VENAE COMITANTES Role and structure of venous valves
Venous valves (L. flaps) are folds of endothelium lining veins, typically with a pair of cusps. They allow blood to flow in one direction only, thus directing venous return towards the heart.
Fig.11.15 Numerous valves in long veins of limbs Valves are particularly numerous in long veins. They break up what would otherwise be a continuous column of blood into shorter units. Each valve in the series takes a share of the hydrostatic pressure (which is considerable when standing upright). Valves are also present in veins (termed perforating veins) connecting superficial and deep systems. Their valves direct flow from the superficial veins to the deep veins and are most important in the calf where blood is pumped upwards against gravity by muscles surrounding the deep veins.
Venae comitantes
Venae comitantes (L. veins + accompanying) are a pair of companion veins wrapped around an artery. These veins also intercommunicate.
Venous flow
Venous return is directed towards the atria of the heart (via systemic veins to the right atrium and via pulmonary veins to the left atrium). Venous flow is due to blood pressure, contraction of adjacent skeletal muscles and the oscillation of intra-thoracic pressure with respiration. Fig.11.19 Muscular venous pump
Fig.11.20 Thoracic venous pump Descent of the diaphragm during inspiration, in addition to creating a negative intrathoracic pressure, shortens the inferior vena cava emptying it (into the right atrium of the heart from below) while the superior vena cava lengthens and fills. During expiration the converse occurs as the superior vena cava shortens and empties (into the right atrium from above), while the inferior vena cava lengthens and fills. The thoracic pump therefore augments venous return from both caval systems (if not from below in inspiration, then from above in expiration). 121
Fig.11.18 Vascular venous pump The connective tissue around the vascular bundle tends to resist the expansion associated with each arterial pulsation, compressing blood within the pair of veins. Venous flow is directed proximally due to the presence of venous valves (even though the arterial flow is in the opposite direction).
Fig.11.21 Blood trapped in trunk by valves above and below Thus, raising intrathoracic and intra-abdominal pressure (coughing, straining) shunts blood into the vertebral system (via the azygos system from the caval systems). Conversely, inspiration creates a suction that shunts blood from the vertebral system to the caval systems. Fig.11.23 Haemorrhoids and prolapse with straining
Fig.11.27 Calf muscle venous pump Fig.11.25 Effect of incompetent valve in perforating vein A dilatation of a vein at the site of a venous valve may also result in impairment of valve function with the potential for a domino effect further along the vein. This occurs particularly with long veins subjected to periods of high hydrostatic pressure (e.g. superficial veins of the lower limb in prolonged standing). Varicose veins may therefore be both cause and effect of valve incompetence. Repeated contraction of the calf muscles (e.g. by raising the heel and flexing the toes) promotes venous return by enlisting the muscular venous pump and minimises pooling of blood.
Fig.11.28 Venous sinus between the two layers of dura These venous sinuses are unique in that they are enclosed by dense connective tissue. Tension in the fibrous walls keeps the sinuses open despite the negative intracranial venous pressure, which would otherwise collapse them when standing upright.
Perforating veins
Links between veins are generally termed venous communications. Communications between superficial and deep veins in the lower limbs are termed perforating veins. They perforate the deep fascia (via openings in it). Valves are present in perforating veins (of particular importance in the calf) directing flow from superficial to deep. 123
Portal-systemic anastomoses
Communications between the portal system and the systemic system have the special term portal-systemic anastomoses. The portal venous system is valveless so flow may occur in either direction.
Emissary veins
Communications between intracranial and extracranial veins are termed emissary (L. out + send) veins. They arise from the dural venous sinuses and exit via foramina in the skull.
Fig.11.32 Major site of portal systemic anastomosis The two major sites of portal-systemic anastomosis are at the lower end of the oesophagus (with the azygos system) and at the anal canal (with the inferior vena caval system). Fig.11.30 Emissary veins pass via foramina in the skull
Venous plexuses
Just as venous tributaries tend to be more numerous than arterial branches, they communicate more freely (and have even more capacity for variation). Tributaries of veins tend to form intercommunicating networks where they are particularly numerous. These networks are termed venous plexuses.
Fig.11.33 Venous plexus in spinal canal Many venous plexuses are found around pelvic viscera (e.g. bladder, rectum and vagina) accommodating to changes in shape of these organs. They are also extensive as a cushion in the sole of the foot and within the vertebral canal (where they help cushion the spinal cord). 124
11. Venous System and Veins Deep vein thrombosis in the calf
The deep veins of the calf are predisposed to thrombosis if surrounding muscles are not contracting regularly (particularly in postoperative, postpartum or bedridden patients and from long aeroplane flights). A potential avenue of spread for infections of the face is to venous sinuses in the cranial cavity via (valveless) emissary veins that communicate with them. This may lead to a septic thrombosis (e.g. cavernous sinus thrombosis).
Fig.11.34 Deep vein thrombosis in calf from stasis Stasis and pooling of blood in soleal venous sinuses occurs if not emptied by regular contraction of the calf muscles. A thrombus in a deep calf vein, especially one that propagates proximally, may dislodge (or part of it may break off) to become a thromboembolus. Pulmonary thromboembolism (occlusion of a pulmonary artery or major branch of it in the lung by a thromboembolus) is a potential consequence of deep vein thrombosis originating in the calf and is life-threatening. Thromboemboli are carried via the inferior vena cava and the right side of the heart into the pulmonary arterial system. One or more arteries subsequently become occluded, as they become progressively narrower by branching. Thromboemboli are more common in veins than arteries because of the more sluggish flow. Usually these are small and are filtered by the lungs without damage. Organs supplied by systemic arteries are protected as all venous blood passes through the pulmonary capillary bed before proceeding to systemic arteries.
LYMPHATIC AND HAEMOPOIETIC SYSTEMS LYMPH VESSELS LYMPH RETURN LYMPH NODES LYMPHOID ORGANS AND TISSUES LYMPHATIC AND HAEMOPOIETIC SYSTEMS
Fig.12.3 Interstitial fluid filtered via lymph nodes The volume and the protein content of lymph vary from site to site. They are particularly high where capillaries are most permeable (e.g. from sinusoids of the liver). Lymph carrying foreign material is transmitted via lymph vessels to lymph nodes, where it is filtered and brought in contact with defence cells.
Lymphatics
Lymph capillaries drain into progressively larger tributaries termed lymphatics. Those from the skin drain into lymphatics located in the subcutaneous tissue. Although these vessels have thicker walls than lymph capillaries, they are still at low lumenal pressure (and are therefore easily compressed). They possess a basement membrane, circumferential smooth muscle cells and pacemaker cells (producing spontaneous rhythmic contractions). Lymphatics resemble veins and venous tributaries. However, as well as having thinner walls, they are more numerous (and more variable than veins and their tributaries). This correlates with their development from even more extensive networks (creating more opportunity for variation). Lymphatics have valves (formed by infolding of the endothelium) for one-way flow. The flow is directed ultimately to the venous system.
Lacteals
Intestinal lymphatics are termed lacteals (L. milk). This is because they contain chyle (L. juice), lymph rich in lipid molecules absorbed after a meal. Lacteals do not accompany veins (as intestinal veins are part of the portal venous system to the liver). Instead, they accompany the artery of the midgut (an unpaired branch of the aorta). As a result, large lipid molecules (primarily triglycerides in the form of chylomicrons) are conveyed to systemic veins via a large lymph collecting duct. The other nutrients, in contrast, are absorbed from the small intestine directly into portal venous blood.
Lymph trunks
Lymphatics are tributaries of lymph trunks. These larger lymph vessels typically accompany major blood vessels. The paired jugular, subclavian and bronchomediastinal lymph trunks collect lymph from the head and neck, upper limb, and thorax, respectively. The jugular lymph trunk accompanies the internal jugular vein and the subclavian lymph trunk accompanies the subclavian vein. The bronchomediastinal lymph trunk is atypical in that it runs independently of blood vessels. The unpaired intestinal lymph trunk and paired lumbar lymph trunks drain the abdomen, pelvis and lower limb. These lymph trunks accompany the aorta or its branches.
Lymphatic pathways
As well as having a similar structure to veins, lymphatics have a common direction of flow with them. Lymphatics also tend to accompany veins.
Fig.12.9 Relationship between lymphatics and veins Although superficial lymphatics accompany superficial veins, deep lymphatics do not always accompany deep veins. In the abdominal cavity, lymphatics accompany arteries to their origins from the front of the aorta (rather than accompany the portal vein to the liver).
12. Lymphatic System and Lymph Vessels LYMPH RETURN Mechanisms of lymph flow
The pressure within the lymphatic system is much lower than that of the cardiovascular system and for many lymph vessels throughout the body lymph flow is often against gravity. Lymph flow is dependent on three potential pumps coupled with the presence of one-way valves. The vascular lymph pump is provided by rhythmic contraction of the smooth muscle wall of lymph vessels, intimate contact with veins and the common direction of flow (milking effect). The muscular lymph pump is from contraction of adjacent muscles (squeezing effect). The thoracic lymph pump is due to the oscillation of intrathoracic pressure with respiration (sucking effect).
Cisterna chyli
The thoracic duct typically originates in the abdominal cavity from a small sac termed the cisterna chyli (L. reservoir + juice), lying adjacent to the aortic opening of the diaphragm. The cisterna chyli receives the intestinal lymph trunk plus the lumbar lymph trunks. However, the thoracic duct often arises directly from a confluence of these lymph ducts without the presence of a cisterna chyli.
Fig.12.13 Major direct path of lymph to the venous system Lymph is directly returned to the venous system via the thoracic duct (on the left) and the right lymphatic duct. These empty into large central veins (typically the origin of the brachiocephalic veins) at the junction of the neck and thorax.
Fig.12.12 Quadrants of body drained by thoracic duct At its origin the thoracic duct drains lymph from almost the entire body below the diaphragm (from intestinal and lumbar lymph trunks via cisterna chyli). At its termination it typically receives lymph from the left upper quadrant (after collecting the associated jugular, subclavian and bronchomediastinal lymph trunks). The thoracic duct (or the origin of the left brachiocephalic vein) is therefore the major direct pathway for lymph from three quadrants of the body. The right lymphatic duct (or the origin of the right brachiocephalic vein) is the major direct pathway for the right upper quadrant, of the body. 129
Lymphovenous communications
There are numerous small communications between the lymphatic system and the venous system. These are via peripheral connections between some lymphatics and veins, as well as via veins that emerge from the hila of lymph nodes. There are also numerous communications between the thoracic duct and tributaries of the azygos veins in the thorax. A significant proportion of fluid return is by these routes.
Fig.12.16 Stages of lymphatic spread Predicting the path of tumour cells carried by lymphatics is complicated by the possibility of: 1. Occlusion of some lymphatics by tumour cells (altering the direction of spread) 2. Variation in, as well as overlap of, lymph drainage territories 3. Posture and external compression influencing lymph flow (being at low pressure) 4. Lymphovenous communications via direct peripheral connections and via veins emerging from lymph node hila (providing potential avenues for short circuit) 5. Certain tumours producing growth factors generating new lymph capillaries which subsequently link with existing capillaries
Lymphoedema
Fig.12.15 Paths of lymph return to venous system Lymph capillaries normally take up fluid that has leaked from blood capillaries, which would otherwise accumulate in the interstitial compartment (between intravascular and intracellular fluid compartments). Although there are many lymphatic and lymphaticovenous communications, with multiple avenues of lymph return to the venous system, extensive lymphatic obstruction may prevent sufficient lymph return. The abnormal accumulation of tissue fluid (oedema) due to this mechanism is termed lymphoedema. Causes include surgical removal of lymphatics (e.g. from a radical mastectomy for breast cancer) and parasitic occlusion of lymphatics (e.g. elephantiasis of the lower limb and external genital organs from filarial worm infestation and subsequent inflammation).
Lymphatic spread
Tumours and infections can spread by lymphatics, particularly as tumour cells and microbes tend to be carried along with the lymph. However, since lymph drained from any particular organ tends to pass through at least one set of lymph nodes (prior to reaching the venous system), tumour cells or microbes carried in it are exposed to defence cells at these sites. Lymph nodes tend to enlarge in response and may also become tender (particularly with infection) or firmer (particularly with tumour involvement). 130
LYMPH NODES
Lymph nodes (L. knots) are multiple, discrete, encapsulated collections of lymphoid tissue lying along the course of lymph vessels.
Fig.12.19 Major palpable lymph node groups The major palpable lymph node groups are typically subdivided into superficial and deep groups, each located adjacent to a major vein.
Fig.12.20 Drainage of lymph from superficial to deep Lymph drains from superficial nodes to deep nodes.
Thymus
Tonsils
Fig.12.21 Thymus with its lobes The thymus is a lymphoid organ, which reaches its greatest absolute size at puberty (although its greatest relative size is at birth). It is located primarily in the thorax (extending up into the neck) and receives a blood supply from neighbouring vessels. Special immature lymphocytes (T cell precursors) from the bone marrow are transported via the blood stream to the thymus where they develop and differentiate. Those that would otherwise attack host cells are recognised and removed there. The particular lymphocytes (T cells) released from the thymus into the circulation are involved in mobilising certain defence cells against a foreign agent (cell mediated immunity). After puberty, the thymus in particular (together with lymphoid tissue in general) involutes with age.
Fig.12.23 Waldeyer's ring (of tonsillar tissue) The (palatine) tonsils plus other collections of tonsillar tissue (nasopharyngeal and lingual) encircle the pharynx (as Waldeyers ring) in the mucosa at the junction of the upper digestive and respiratory tracts. Lymph vessels drain them to deep cervical lymph nodes (particularly the tonsillar lymph node, palpable just below the angle of the mandible).
Peyers patches
Lymphoid tissue in the terminal small intestine forms aggregates termed Peyers patches. These tend to be arranged longitudinally in the ileum (along the antimesenteric border), while the lymphatics draining them pass transversely.
Spleen
Fig.12.22 Spleen with its blood vessels The spleen has a rich blood supply, large vascular spaces and sinusoids. The spleen filters blood picking up antigens, responds to them and releases lymphocytes into the blood stream. The spleen also removes old red blood cells from the circulation and is a store of red blood cells. 132 Fig.12.24 Peyer's patches in small intestine .
Chapter 13: Regions of the Human Body Chapter 14: Arrangement of Body Regions Chapter 15: Body Compartments and Fascial Planes Chapter 16: Body Wall and Cavities Chapter 17: Neurovascular Pathways
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The majority of regions are paired, including all regions of the limbs with some additional regions of the trunk, head and neck. The remaining regions being along the midline of the body are unpaired. From a geographic perspective, a module is like a country while regions are like its states.
Regional anatomy is concerned with the situational (extrinsic) properties of an organ its position and relations. Position refers to spatial relationships of an organ to the body as a whole, while relations are those to its immediate neighbours.
Body regions
A cluster of neighbouring regions may be grouped into a common module. The human body can be conceptualised as being made up of (or divided into) 8 modules containing a grand total of 72 regions.
Although arbitrary, regions (with clearly defined borders) are necessary for precise localisation of any specific organ. Regional anatomy also enables accurate description of the course for a structure (e.g. a nerve or a vessel) passing from one region to another, as well as relations at any point along a pathway. The first step in a clinical diagnosis is to determine the (anatomical) site of a lesion. This is typically expressed in terms of the region it is situated in and its proximity to a key bony or soft tissue landmark contributing to a boundary of the region. Landmarks can also be apertures (through or across boundaries) allowing pathways between one region and another.
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REGIONS OF HEAD REGIONS OF NECK REGIONS OF BACK REGIONS OF THORAX REGIONS OF ABDOMEN REGIONS OF PELVIS REGIONS OF UPPER LIMB
Fig.13.2 Cranial regions of head
6. - face 7. - parotid region 8. - deep styloid region 9. - infratemporal region 10. - pterygopalatine fossa
Fig.13.3 Facial regions of head 11. - mouth 12. - tongue 13. - nose 14. - pharynx 15. - larynx
Fig.13.1 Regions of head 1. - scalp 2. - temporal region 3, - cranial cavity 4. - orbit 5. - ear 135
REGIONS OF BACK
The back may be divided into 3 regions, which span its entire length from the 1st thoracic vertebra to the tip of the coccyx. These may be arranged into (2) muscle compartments and the vertebral column (with its enclosed vertebral canal). 1. - superficial compartment of back 2. - deep compartment of back 3. - vertebral region of back Fig.13.5 Regions of neck The anterior triangle surrounds the larynx and lower part of the pharynx, which although extending into the neck are regarded as regions of the head.
Fig.13.6 Triangles of neck Their continuations (trachea and oesophagus, respectively) are located in the root of the neck. The root of the neck is covered by the lower third of sternomastoid muscle while the sternomastoid region is covered by its upper two thirds. The vertebral region of the neck includes the cervical vertebral column as well as the enclosed vertebral canal (and associated pairs of intervertebral foramina). 136 Fig.13.8 Regions of back The superficial compartment includes the skin of the back and extends further laterally than the deep compartment, which in turn overlaps the much narrower vertebral region. The superficial compartment contains extrinsic back muscles while the deep compartment contains intrinsic back muscles.
REGIONS OF THORAX
The thorax may be divided into 8 regions arranged as (3) thoracic wall regions and (5) thoracic cavity regions. Fig.13.12 Thoracic wall regions The thoracic cavity, made up of paired pleural sacs with the mediastinum between them, contains the thoracic viscera.
Fig. 13.13 Subdivisions of mediastinum The pericardial sac occupies most of the middle mediastinum. A lung is located in each pleural sac while the heart is in the pericardial sac.
Fig.13.10 Regions of thorax 1. - anterior thoracic wall 2. - posterior thoracic wall 3. - the diaphragm 4. - pleural sacs 5. - anterior mediastinum 6. - middle mediastinum 7. - posterior mediastinum 8. - superior mediastinum
REGIONS OF ABDOMEN
The abdomen may be divided into 4 regions arranged as (3) abdominal wall regions and the abdominal cavity. The abdominal wall regions are primarily the large muscular and posterior abdominal walls. The anterior abdominal wall includes overlying skin while the posterior abdominal wall is directly in front of the lumbar vertebral column and hipbones (classified as part of the back and lower limb, respectively). The inguinal canal is at the lower 137
Fig.13.17 Regions of pelvis 1. - posterior pelvic wall 2. - lateral pelvic wall 3. - pelvic floor 4. - pelvic cavity 5. - anal triangle of perineum 6. - urogenital triangle of perineum
Fig.13.15 Regions of abdomen 1. - posterior abdominal wall 2. - anterior abdominal wall 3. - inguinal canal (and scrotum) 4. - abdominal cavity.
Fig.13.16 Position of abdominal cavity within trunk The abdominal cavity is separated from the thoracic cavity by the diaphragm but is continuous with the pelvic cavity below the pelvic brim. Fig.13.19 Pelvic wall regions
REGIONS OF PELVIS
The pelvis (L. basin) may be divided into 6 regions arranged into pelvic walls, the pelvic cavity and the two triangles of the perineum (L. discharge). The pelvic wall regions are primarily the lateral and posterior pelvic walls (formed by the lesser pelvis). The posterior pelvic wall is directly in front of the sacrum and coccyx (classified as part of the back). The pelvic cavity is enclosed by the pelvic walls and located above the pelvic floor. Its contents include pelvic viscera and the peritoneal cavity. The pelvic cavity is continuous with the abdominal cavity above the pelvic brim, but is separated from the perineum by the pelvic floor, which in turn contains openings for certain viscera. 138
Fig.13.20 Subdivisions of perineum The perineum is covered by skin with cutaneous orifices for the urogenital tract and for the (lower) digestive tract.
Fig.13.21 Regions of upper limb 1. - pectoral region 2. - axilla 3. - anterior compartment of arm 4. - cubital fossa 5. - anterior compartment of forearm 6. - carpal tunnel 7. - palm of hand 8. - palmar aspect of digits 9. - scapular region 10. - deltoid region 11. - posterior compartment of arm 12. - posterior compartment of forearm 13. - anatomical snuffbox 14. - dorsum of hand 15. - dorsal aspect of digits Fig.13.23 Regions of lower limb 1. - femoral triangle 2. - sub sartorial canal 3. - anterior compartment of thigh 4. - medial compartment of thigh 5. - anterior compartment of leg 6. - lateral compartment of leg 7. - dorsum of foot 8. - dorsal aspect of digits 9. - gluteal region 10. - posterior compartment of thigh 11. - popliteal fossa 12. - posterior compartment of leg 13. - tarsal tunnel 14. - sole of foot 15. - plantar aspect of toes
UNPAIRED REGIONS & MIDLINE OF BODY PAIRED REGIONS & BILATERAL SYMMETRY FLEXOR AND EXTENSOR REGIONS BOUNDARIES OF REGIONS APERTURES BETWEEN REGIONS UNPAIRED REGIONS & MIDLINE OF BODY
The mid-sagittal plane is the most important reference plane. It represents the midline of the body. 30 regions are unpaired (while the remaining 42 are paired). Unpaired regions are located in the midline although they may be divided into two halves by the midline. These regions are confined to the head, neck and trunk.
Bilateral symmetry
Animals, being capable of independent movement, tend to have bilateral symmetry (in contrast to the myriad of forms evident in plants). This is particularly important in humans to maintain balance in (bipedal) gait and locomotion. Symmetry facilitates movement and is exhibited by the skeleton and its associated muscles, especially in the limbs.
Fig.14.2 Bilateral symmetry in a coronal section Even within the head, neck and trunk unpaired regions have bilateral symmetry, being divided into two halves by the midline.
Fig.14.1 Major body cavities in a mid-sagittal section The body contains two main cavities, both of which are in the midline. The two main cavities in the body are the ventral cavity and the dorsal cavity. The ventral cavity is partitioned by the diaphragm into: -.a thoracic cavity, above it - an abdomino-pelvic cavity, below it These are not empty spaces, being occupied mainly by thoracic and abdomino-pelvic viscera, respectively (as well as their surrounding membranes and fluid). The dorsal cavity is divided into: - a cranial part (the cranial cavity, in the head), - a vertebral part (the vertebral canal, in the neck and the back continuous with the cranial part)
Fig.14.5 Territories within a segment of the trunk The exception is the (superficially located) extrinsic muscles. They have migrated onto the dorsal aspect (and retain their nerve supply from ventral rami).
Fig.14.3 Flexor and extensor regions in the trunk and limbs Course antigravity extensor muscles tend to occupy compartments on the dorsal aspect covered by hairier skin with tougher dermis.
Fig.14.7 Supply of limb buds from anterior rami Anterior rami of cervical and lumbosacral spinal nerves supply the upper and lower limbs, respectively (although indirectly via peripheral nerves derived from plexuses). 141
Fig.14.8 Supply of musculature within a limb bud Flexor and extensor regions therefore become situated on opposite aspects of the respective limbs, (flexor regions are anterior in the upper limb but posterior in the lower limb) The nerve supply for both flexor and extensor regions in the limbs are derived from anterior rami of spinal nerves. A limb plexus divides into anterior and posterior divisions, with their nerve fibres distributed (via associated peripheral nerves) to flexor regions and extensor regions, respectively. Fig.14.10 Imaginary lines between bony borders in thorax In view of the rotation of the limb buds, anterior divisions of the lumbosacral plexus supply posterior compartments of the lower limb and posterior divisions supply anterior compartments.
BOUNDARIES OF REGIONS
Regions are demarcated from each other by their boundaries. These may be bony or soft tissue or a combination of both.
Bony boundaries
Fig.14.11 Key soft tissue boundaries in upper limb Fig.14.9 Key bony boundaries in upper limb Bony boundaries of regions may be bony features, prominences or borders. For example the apex of the axilla (bounded by the medial border of the first rib, the clavicle and the superior border of the scapula) demarcates the upper limb from the neck. 142 Soft tissue boundaries of regions may also include borders of connective tissue thickenings (e.g. intermuscular septa, retinacula, tendons, ligaments). Medial and lateral intermuscular septa separate the anterior from the posterior compartment of the arm. The flexor retinaculum demarcates the carpal tunnel (between the anterior compartment of forearm and the palm of the hand).
14. Arrangement of Body Regions APERTURES BETWEEN REGIONS Major and minor apertures
Pathways between regions are through gaps in their boundaries termed apertures. Pathways between regions may be via both major and minor apertures. For example, the diaphragm has major apertures (centrally) providing pathways to and from the abdominal cavity and minor apertures (around the periphery) providing pathways to and from the abdominal walls.
Fig.14.12 Key structures exiting from spinal apertures Apertures may be major or minor. Major apertures are clearly defined openings (e.g. between or within bones), while minor apertures are avenues across boundaries (e.g. over or under a muscle) or through a boundary (e.g. by piercing a muscle) where an opening is not readily apparent. Many structures may pass through a major aperture Fig.14.15 Major and minor apertures in the diaphragm
Fig.14.13 Major apertures from neck For example, the superior aperture of the thorax transmits many viscera, vessels and nerves to and from the root of the neck. Generally only one or two structures pass through a minor aperture. For example, the radial artery, median nerve and ulnar artery each leave the cubital fossa to enter the forearm via a different avenue (passing over, through or under pronator teres muscle, respectively).
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COMPARTMENTS AND LAYERS MOBILE AND FIXED FASCIAL PLANES COMPARTMENTS AND LAYERS
Regions are typically in the form of compartments with clearly defined boundaries.
Fig.15.2 Layers within compartments of arm The roof of a compartment is composed of superficial structures (skin, subcutaneous tissue and deep fascia) that can be in the form of concentric layers (e.g. around a limb). The floor is composed of deep structures (bones and joints). The contents of compartments (between the roof and the floor) provide the intermediate group of structures and may also be in layers. This particularly applies to muscle compartments. Muscles in a superficial layer tend to be prime movers. They tend to span greater distances between their attachments (moving levers through greater arcs) or at least exert greater leverage. Muscles in a deep layer are usually shorter and tend to be fixators. Their role is more for stabilising rather than for generating power and range of movement. The key supply lines (major nerves and vessels) tend to run in the intermediate layer. Branches from them are well placed to pass superficially (cutaneous branches), deeply (articular branches) and to adjacent structures (muscular branches). Fig.15.1 Compartments and layers of leg Compartments have boundaries (composed of walls, a roof and a floor) and contents.
Fig.15.3 Plexus divisions and type of compartment supplied The deep muscle compartment (for intrinsic back muscles) on the dorsal aspect of the trunk, is an extensor compartment, and is supplied by posterior rami of spinal nerves. In the limbs, flexor compartment muscles are located anteriorly in the upper limb and posteriorly in the lower limb. They are supplied by anterior divisions of the associated nerve plexuses. Conversely, extensor compartment muscles are located posteriorly in the upper limb and anteriorly in the lower limb. They are supplied by posterior divisions of the associated nerve plexuses.
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15. Body Compartments and Fascial Planes Flexible and rigid compartments
At least one of the walls surrounding a compartment (particularly if transmitting a major vessel) is generally flexible, or at least has a sufficiently large aperture, to allow for expansion. However, unyielding walls may almost completely surround certain compartments. These compartments may be absolutely rigid bony cavities (e.g. cranial cavity) or relatively rigid fibro-osseous tunnels, canals and foramina (e.g. carpal tunnel, vertebral canal, intervertebral foramina). The contents of a rigid compartment may be cushioned by fat (e.g. around the dural sac in the vertebral canal, within the median nerve in the carpal tunnel) or fluid (e.g. cerebrospinal fluid within the dural sac in the cranial cavity and vertebral canal). The anterior compartment of the leg is particularly prone to this condition (termed 'anterior compartment syndrome').
Fig.15.6 Disc bulging into intervertebral foramen Swelling in rigid compartments increases the pressure and ultimately leads to compression of its contents. Even a small degree of swelling tends to give considerable pain. Further increase of compartment pressure compresses vessels (initially veins then arteries) and nerves. An emergency surgical operation to decompress the compartment may need to be performed (e.g. a laminectomy, to relieve spinal cord or spinal nerve root compression). Swelling (in 'mini-compartments') where skin is bound down to underlying structures (e.g. palm, nail bed, ear, nose and anus) may also be extremely painful. Drainage (e.g. by an appropriate incision) suddenly releases the pressure and typically brings rapid relief.
Fig.15.4 Rigid compartments in the spine Major vessels tend not to run through a rigid compartment (e.g. carpal tunnel).
Compartment syndrome
A compartment with rigid walls is a confined space and a potential site for compartment syndrome.
Fig.15.8 Mobile plane between fascial sheets While major vessels and nerves may course along them, few cross mobile fascial planes as they would otherwise overstretch or have their own mobility restricted.
Fig.15.10 Paths of vessels and nerves in fascial planes Fig.15.9 Vessels parallel to a mobile fascial plane Vessels and nerves may course parallel to mobile planes for long distances (e.g. where fascial coverings of muscles slide against each other and where subcutaneous tissue glides over deep fascia or periosteum). Mobile fascial planes are exploited in anatomical dissection and in surgical operations as they are easier to separate and there is less chance of damaging vessels or nerves. Vessels and nerves also course from fixed (concave) areas to mobile (convex) areas across the face. The facial artery enters the face from the neck by passing across the lower border of the body of the mandible (to which the investing deep fascia of the neck attaches). Branches of the facial nerve emerge from within the parotid gland (fixed by the parotid deep fascia which encloses it) prior to radiating across the face (in the subcutaneous tissue).
Fig.16.3 Supply lines to abdominal wall and cavity In contrast, visceral nerves and vessels supply the viscera (and are directed towards them in the cavity). They also supply the visceral layer of an associated serous membrane (e.g... visceral pleura or peritoneum).
Hernia
A hernia (L. rupture) is an abnormal protrusion of an anatomical structure through an opening, defect or area of weakness (in its containing walls).
Fig.16.2 Layers of anterior abdominal wall The body wall in the trunk is arranged in layers. The anterior thoracic and abdominal walls have skin on a layer of subcutaneous tissue, in turn, on layers of muscles or aponeuroses (rather than an unyielding layer of deep fascia). The anterior thoracic wall even has bones (sternum and ribs) and associated joints, in addition to muscles (the intercostals). The parietal layer of a serous membrane lines the interior of the body wall. Viscera are located internal to the body wall where they are more protected, occupying the cavity enclosed by the wall. 147
Fig.16.7 Herniation through a rigid opening Strangulation is more likely to occur if the opening has rigid edges.
Fig.16.5 Herniation from straining Rarely, but importantly, a sudden change in pressure gradient by performing a lumbar puncture in raised intracranial pressure may cause (potentially fatal) herniation of part of the brain through the (rigid) foramen magnum into the spinal canal. Serious complications from herniation include direct compression (of a vital structure), obstruction (of a hollow viscus) and strangulation (choking of vascular supply). Fig.16.8 Strangulation of a herniated loop of gut
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Fig.16.12 Subdivisions of the ventral cavity of the body The two pleural cavities and the pericardial cavity are separate closed cavities within the pleural sacs and pericardial sac, respectively. The peritoneal cavity is a single cavity within the peritoneal sac of the abdominopelvic 'cavity' (providing continuity between the abdominal 'cavity' and the pelvic 'cavity'). The peritoneal sac is subdivided into greater and lesser sacs (communicating via the omental foramen). 149
Fig.16.13 Pleural and pericardial sacs In males, the scrotal cavities are extensions of the peritoneal cavity (via the inguinal canal on each side) that normally become separate from it just prior to birth (by closure of the processus vaginalis).
Prolapse
A prolapse (L. falling) is the descent of an organ from its normal position. Organs affected include those supported within a large body cavity (e.g. uterus, rectum). Prolapse of an organ is due to weakened supports (e.g... from stretching during childbirth or from aging) coupled with gravity and aggravated by straining.
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NEUROVASCULAR BUNDLE COURSE THROUGH A REGION RELATIONS WITHIN A REGION NEUROVASCULAR BUNDLE
Nerves and vessels tend to accompany each other as components of a neurovascular bundle.
Fascial sheath
Large vessels and nerves are typically enclosed by connective tissue as a discrete fascial sheath forming a tube around them.
Fig.17.1 Components of a neurovascular bundle Smaller vessels and nerves also tend to be surrounded by connective tissue, although this may not be in the form of a tubular sheath when passing via fixed fascial planes (e.g. within intermuscular septa).
Fig.17.4 Venae comitantes and heat conservation Venae comitantes are located in the limbs, particularly distally.
Fig.17.2 Neurovascular bundle in the calf Within a neurovascular bundle, the vein and lymph vessels are located more peripherally. In addition, the fascial sheath of a neurovascular bundle tends to be thin or absent around the vein and lymph vessels (or have a vacant compartment next to it) allowing room for expansion. 151
Fig.17.6 Course of popliteal artery behind knee A course is described from origin to termination according to convention. Thus, arteries and their branches course from proximal to distal, while veins and their tributaries course from distal to proximal. Nerves and their branches course from proximal to distal (even those that contain only afferent fibres).
Tortuous arteries
Many arteries are tortuous and accommodate movement (e.g. facial, splenic), protrusion (lingual) or expansion (uterine) of the organs supplied.
Fig.17.11 Boundaries and key contents of femoral triangle The boundaries of a (3-dimensional) region have the following pairs of relations to its contents: - anterior/posterior - superior/inferior - medial/lateral In typical regions, one pair of boundaries form the roof and floor, the remainder form the walls. However, boundaries may receive different terms for regions of a different shape. The femoral triangle has a (anterior) roof and (posterior) floor, a (superior) base and (inferior) apex, medial and lateral borders.
Fig.17.10 Tortuosity of uterine and lingual arteries However, any artery may ultimately become tortuous because of loss of elasticity through aging.
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Fig.17.14 Vulnerability to nerve severance or entrapment In addition, nerves may be endangered by external compression from tight or inappropriate splints and casts. This is applicable to nerves closely related to both skin and bone (e.g... common fibular nerve around neck of fibula). Although compression may directly damage nerve fibres (e.g... from a crush injury) it primarily compromises blood supply to the nerve.
Chapter 18: Growth and Development Chapter 19: Normal Variation Chapter 20: Anatomical Variation in Structure Chapter 21: Anatomical Variation in Position Chapter 22: Pathological Changes
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Although anomalies are not normal they are not diseased. However, certain anomalies may have a decreased functional reserve, or a predisposition to disease. Others may impinge on or compress neighbouring structures. Encountering anomalies, particularly when not anticipated, can pose problems during invasive procedures or surgical operations.
Some are also associated with the presence of other anomalies. Anatomical variation is not uncommon, although for certain anomalies there is a different incidence across different population groups (e.g. sex, race). Careful dissection of an entire body on average uncovers about 50 anomalies. With closer examination (e.g. by tracing fine branches of vessels) the number detected is potentially much greater (e.g. as vascular patterns, like fingerprints, are unique for each individual). Thus, each human body should be regarded as special and assessed on its own merits. Anatomical variants may be partial or complete, single or multiple and, if affecting a paired structure, unilateral or bilateral. If multiple, they may be reciprocal and even compensatory. Anomalies found on physical examination or by imaging may be of clinical significance per se or when misdiagnosed as being pathological.
Pathological (G. disease) changes have impaired function in addition to abnormal structure. Pathological variation may be congenital or acquired. Congenital malformations have a genetic and/or developmental basis, while acquired disorders are more likely to be caused primarily by environmental factors (e.g. physical, chemical, organisms), although genetic factors often contribute. Either way there is abnormal structure with abnormal function that is not healthy (health being the state of optimal physical wellbeing with the absence of disease). It is vital for a clinician to distinguish typical from atypical, normal from abnormal, and health from disease.
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Fig.18.3 Three-layered germ disc in 3rd week Mesoderm forms all connective tissues (including bone, muscle, fascia, dermis and the sheaths of peripheral nerves). Mesoderm also forms vessels (only mesodermderived structures are vascular).
Fig.18.1 Development in 1st week A fluid-filled cavity develops, creating a blastocyst (G. germ + bladder). This has an inner cell mass, the embryoblast and an outer cell mass, the trophoblast (G. nutrition + germ). The latter implants into the uterine wall at the end of the first week. During the second week a bilaminar germ disc, the dorsal lamina becoming ectoderm and ventral lamina becoming endoderm, develops from the inner cell mass. Ectoderm subsequently forms epidermis (and skin appendages) and nerve cells. Endoderm forms the epithelial lining of the digestive tract (gut) and of the respiratory tract (which buds out of the foregut). Fig.18.4 Longitudinal folding due to neural tube In the 3 to 8 weeks, all the major organ systems start to develop (organogenesis). During this period of dramatic structural change, birth defects tend to occur. The embryo folds both longitudinally and transversely. Cephalocaudal folding occurs due to development of the neural tube while lateral folding occurs due to development of somites. During the early embryonic phase, features appear from more primitive ancestors. Early human embryos appear almost identical to those of other vertebrates. Further modifications, including disappearance of certain features, occur progressively with the embryo becoming more recognizably human by the end of the embryonic phase. 157
rd th
nd
week
Fig.18.5 Transverse folding due to somite development Development of the upper lip, nostrils, external ears and eyelids make the face more human looking. The limbs have elongated and fully formed hands and feet are present. Primary centres of ossification appear in long bones and during this time the limbs rotate to the foetal position (elbows pointing backwards, knees forward).
Features of a foetus
Fig.18.8 Position of limbs and spine in a foetus
Fig.18.9 Least dimensions presented by skull at birth The skull has the largest circumference of any part of the foetus and presents the major obstacle to passage along the birth canal. The foetal skull is elongated in an antero-posterior direction. During childbirth the foetal head normally rotates and flexes to present its smallest diameters as it negotiates the changing dimensions of the maternal bony pelvis between its inlet and outlet. The 158
Foetal circulation
The placenta, forming part of the internal lining of the uterus, is the site of exchange between maternal and foetal blood vessels, providing oxygen and nutrition (while removing carbon dioxide and wastes) throughout prenatal life. The umbilical cord is the connection to the placenta.
Fig.18.10 Umbilical vessels and bypass channels Before birth, oxygenated blood is received from the placenta via the umbilical vein and deoxygenated blood returned to it via the umbilical arteries. The immature liver and lungs are bypassed by temporary vascular channels (ductus venosus and ductus arteriosus, respectively). Blood is also shunted from the right atrium of the heart to the left via a temporary opening (foramen ovale) between them.
Fig.18.12 Changes in body dimensions A neonate has a relatively larger head and shorter lower limbs than an adult. This is also reflected in surface area. The head is about 18% of a neonates surface area while only 9% of an adult's.
Fig.18.11 Remnants after closure of vascular channels At birth, respiration via the lungs occurs with the very first breath. Also at birth (with oxygen supplied by respiration from the lungs), the foramen ovale closes and the bypass channels are obliterated, becoming ligamentous remnants (ligamentum venosum and ligamentum arteriosum, respectively). The umbilical vein and arteries are also obliterated, becoming ligamentous remnants (ligamentum teres and medial umbilical ligaments, respectively). 159
Fig.18.14 Fontanelles in a newborns skull The cranial bones become united at fibrous joints termed sutures. The frontal bone is in two halves, joined in the midline at the frontal suture. The external auditory meatus consists of only a cartilaginous part. The tympanic membrane is superficial and prone to be damaged unless care is taken during examination with an otoscope. The mastoid process is not developed, exposing the facial nerve, which is endangered in a forceps delivery. The mandible is small, with two halves joined in the midline at the mandibular symphysis (mental suture). Generally no teeth are present at birth.
Features of a child
Childhood may be divided into two phases, early childhood (years1-6) and late childhood (about years 7-13). In childhood the remaining secondary centres of ossification appear, as well as primary centres in short bones (of the hand and foot). Fig.18.15 High larynx in a neonate The tongue is short and broad and is located entirely in the oral cavity. The larynx lies much higher than in the adult (enabling the newborn to simultaneously swallow while continuing to breathe).
Fig.18.17 Body of mandible sectioned in a child Paranasal sinuses start to develop at the beginning of the second year keeping pace with progressive eruption of the maxillary teeth, contributing to changes in the shape and size of the face. Development of the pelvis allows the bladder and intestines to sink into it. This is associated with a flattening of the anterior abdominal wall.
Fig.18.20 Genital organs start maturing last Changes at puberty include ossification of the remaining secondary centres and maturation of secondary sexual characteristics, including the external genitalia. Sex differences in the skeleton become more apparent. In males there is increased growth in width of the shoulders while in females the pelvis widens. In the male, onset of secondary sexual characteristics is associated with changes in the larynx (and deepening of the voice), in the skin and distribution of hair on the body. In females the menarche (G. month + beginning) marks the time of the first menstrual period. Adolescence is associated with a sudden and rapid increase in growth in height. The adolescent growth spurt is earlier in girls than boys, but in both sexes lasts for approximately 2 years, after which increases in height continue, although at a slower rate. In girls, most growth in height is completed by the age of 18 years and in boys by 20 years. Typically, the earlier puberty begins the more rapidly it develops and the earlier it finishes.
AGE DIFFERENCES AND AGING SEX AND BODY BUILD DIFFERENCES FUNCTIONAL DIFFERENCES AGE DIFFERENCES AND AGING
Fig.19.1 Age changes in the mandible Normal variation due to age differences parallels the stages of normal (prenatal and postnatal) growth and development until maturity (which for most organ systems is reached by adulthood). Humans tend to survive beyond adulthood unlike wild animals, which are often killed by younger and healthier ones before effects of aging have time to develop. Reduction in organ size termed involution (L. to wrap up) may occur prior to the onset of old age. Fig.19.3 Distribution of bone marrow types in an adult
Menopause
The menopause (G. month + pause) is the cessation of ovarian and uterine cycles. Although occurring at a variable time in different women, a normal ovarian cycle is rare beyond the age of 50. Diminution in the secretion of oestrogen leads to atrophy of the ovaries, shrinkage of the uterus and atrophy of the breasts. A reduction in fat surrounding the breast causes the skin to wrinkle and sag. Post-menopausal osteoporosis occurs rapidly due to lower oestrogen levels, which results in bone removal exceeding bone deposition. At a critical level, postmenopausal osteoporosis is associated with a high risk of fracture.
Prostatic enlargement
The prostate gland tends to enlarge with age. Eventually, elderly men tend to have associated enlargement of the bladder due to increased thickness of its muscle wall (hypertrophy). This is a consequence of urethral obstruction (distal to the bladder neck) caused by enlargement of the surrounding prostate. There is no abrupt cessation of spermatogenesis, although there is a gradual reduction in hormone production from the testes. The stage of decreasing 162
Senescence
Senescence (L. growing old) refers to the changes that take place in the elderly. Adulthood may last for 40 years (from about age 20 to 60 years) while old age is from about 60 years to death. Normal life expectancy in western societies is approximately 80 years (females slightly greater than males). Normal aging processes may merge with pathological changes (especially degenerative disorders). Bone mass decreases gradually with loss of collagen and of calcium. Osteoporosis (G. bone + porous) results in thinning of bony trabeculae with an increase in susceptibility to fracture and delayed healing. Thinning of articular cartilage exposes underlying bone to increased stress while loss of water in the nucleus pulposus of intervertebral discs produces narrowing of disc spaces and loss of height. Soft tissues tend to calcify and skeletal muscles atrophy. Sutures of the skull begin to fuse. Teeth deteriorate through gum disease (gingivitis) and tend to fall out. Alveolar bone is exposed and the body of the mandible is resorbed (especially in the edentulous). Skin loses its elasticity and pigmentation. Hair of the head tends to become grey and may fall out. This occurs particularly in males although coarse hair appears, especially in the nostrils and external ear. There is loss of elasticity throughout the cardiovascular system, including arteries, which also become harder (arteriosclerosis) and more tortuous. The weight of the brain tends to decrease especially the frontal lobes with fissures becoming deeper and wider than in the young.
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Fig.19.6 Postural variation in position of organs The surface markings and vertebral levels for organs based on anatomical descriptions of a recumbent cadaver may be vastly different to those in a living person standing upright. The curvatures of the spine and the arches of the foot are affected by lying, sitting or standing. Other effects of posture include distension and pooling of blood in veins.
Somatotyping
Somatotyping (G. body + form) is a method of describing adult physique. Mesomorphs are muscular with little subcutaneous fat, while endomorphs and ectomorphs are at opposite ends of a continuum possessing greater to lesser amounts of fat. Excess body fat is termed obesity. It is common in many western societies.
FUNCTIONAL DIFFERENCES
Normal variation in size, shape or position of organs may occur due to functional differences. The major physiological factors influencing anatomy are posture, phase of respiration and pregnancy. These particularly apply to mobile or expansile viscera. Other factors include exercise (e.g. on skeletal muscles and the cardiovascular system), presence of contents (e.g. food and fluid in the gastrointestinal tract) or activation (e.g. of erectile tissue).
Fig.19.7 Movement of organs during breathing During inspiration the lungs expand and viscera directly below the diaphragm, particularly the liver (and gall bladder), spleen and kidneys, are pushed downwards as it descends.
Fig.19.9 Bloody Norm made me put this in when I was totally fucked
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SIZE OR SHAPE FEATURES OR ATTACHMENT PRESENCE OR PERSISTENCE ABSENCE AND DISAPPEARANCE FUSION OR SEPARATION NUMBER OR DUPLICATION
Fig.20.2 Variation in size of arterial branches
Fig.20.1 Abnormally long appendix The size of muscle bellies relative to their associated tendons is also variable. Palmaris longus has evolved a small belly in conjunction with a long tendon. It is now vestigial, with considerable variation in the degree of disappearance of the belly (and even its position along the tendon). Another example of a regressive variation is plantaris in the leg, which also has a small belly relative to the length of the tendon. Peroneus tertius is becoming more developed in humans (a progressive variation). Length of a duct (e.g. the cystic duct) is also variable. The cystic duct may be longer than normal (joining the common hepatic duct at a lower level) or shorter than normal. The 12th rib may be abnormally long or short. An abnormally long appendix produces no functional impairment. However, it may be of clinical significance when inflamed, making diagnosis more difficult (especially if it comes to lie adjacent to other structures and irritates them).
Fig.20.3 Horseshoe kidney A horseshoe kidney may be endangered, particularly if encountered unexpectedly during surgical procedures. Part of the head of the pancreas may encircle the duodenum, creating an annular (L. ring) pancreas.
Fig.20.5 Gynaecoid pelvic type and variants in females The android (about 30%), anthropoid (about 20%) and platypelloid (about 2%) types, have obstetric significance. Being of different internal dimensions, labour can be delayed or obstructed.
Fig.20.7 Azygos lobe of right lung Variations in the lobes of the liver also occur (a multilobed liver is normal in many animals). The uterus can be bi-cornuate may also occur (multiple horns are normal in the uterus of animals with litters). Deep notches of the spleen (creating multiple lobes) are associated with early branching of the splenic artery.
Fig.20.6 Anomalous bony features Although rib elements are present in cervical and lumbar vertebrae, ribs normally occur only in the thoracic spine. A cervical rib (about 1%) may arise from the (costal element of the) transverse process of the seventh cervical vertebra. This anomaly is associated with a higher 167
Fig.20.9 Presence of fabella in a radiograph of the knee A sesamoid bone may also be present in the tendon of peroneus longus (about 25%) and in the tendon of tibialis posterior (about 22%). The persistent frontal (metopic) suture (about 8%, although more common in certain races) may be complete or partial. It is normally present during development (generally disappearing by the age of 8 years) and has no functional significance (but may have clinical significance if confused with a fracture).
Absent vessels
A large anastomosing branch of a neighbouring artery may replace an artery and take over its territory. The dorsalis pedis artery may be absent (about 10%) with its territory taken over by the perforating branch of the peroneal artery. The lateral thoracic artery may be absent and its territory taken over by neighbouring branches of the axillary artery. Posterior communicating branches of the arterial circle of Willis (at the base of the brain) may be absent. The median cubital vein (linking the cephalic with the basilic vein) may be absent it is replaced by a median cephalic and a median basilic vein, which join forming a V.
ABSENCE OR DISAPPEARANCE
Fig.20.16 Os tibiale externum in a radiograph of the foot The patella develops from multiple centres of ossification. One of these may remain unfused, creating a bipartite patella. Small accessory bones may occur within the sutures of the skull. These are termed sutural (or wormian) bones. The zygomatic bone may ossify in two parts, creating the os japonium (about 0.2%). The occipital bone may also ossify in two parts, creating the inter-parietal bone or os incae. These accessory bones are more common in certain races. The os odontoideum is a nd separate tip of the odontoid process of the 2 cervical vertebra. Accessory bones cause no functional impairment but have clinical significance if mistaken for a fracture on X-ray. As they may be bilateral in about one in three individuals with the anomaly, X-ray of the corresponding part on the opposite side provides confirmation in such cases.
Fig.20.14 Sacralisation of L5 and lumbarisation of S1 Partial or complete separation of the first sacral vertebra from the rest of the sacrum (about 5%) is termed lumbarisation of S1. If complete, there is an additional lumbar vertebra (from five to six).
Accessory bones
Accessory bones are created by failure of a centre of ossification to fuse with the rest of the bone. The os acromiale (about 8%) is an atavistic (L. ancestor) epiphysis. This is a phylogenetic remnant of a discrete bone in certain animals. The epiphysis for the tip of the acromion remains separate from the rest of the scapula.
Fig. 20.15 Os acromiale Accessory bones in the foot include the os trigonum (about 8%), a separate lateral tubercle of the talus bone and the os tibiale externum (about 4%), a separate tuberosity of the navicular bone. The os trigonum is the homologue of the lunate bone in the hand (representing the phylogenetic os intermedium seen in certain animals). 170
Accessory nerves
An accessory phrenic nerve can occur in addition to the phrenic nerve (which arises from the cervical plexus). It is a small nerve that arises from the nerve to subclavius and may accompany the phrenic nerve and even join it. The accessory obturator nerve (about 0.8%) is an additional branch from the lumbar plexus.
Fig.20.20 Complete and partial duplication of ureters Bifid ribs (about 1%) can arise by duplication of part of the rib body. A double aortic arch encircling the oesophagus and trachea is a rare anomaly caused by retention of part of the original embryonic arterial pattern (six pairs of arches associated with the primitive aorta). It is a normal feature in certain other animals (e.g. frogs). A double vagina (or vaginal septum) and/or double uterus (about 0.1%) are uncommon human variants. However, multiple uterine horns occur in mammals that produce litters.
SITE OR ORIENTATION SIDE OR COMMUNICATION ORIGIN OR BRANCHING COURSE OR RELATIONSHIP DIVISION OR DEPTH ENDING OR DISTRIBUTION SITE OR ORIENTATION Incomplete ascent or descent
During development migration may occasionally fall short of the normal site. The kidney ascends from the pelvic cavity during development and migrates to its normal position on the posterior abdominal wall, adjacent to the suprarenal glands (which develop separately). Its vascular supply changes as it ascends by progressively receiving (and losing) vessels from the nearest major arteries and veins. A pelvic kidney (about 0.1%) falls well short in its ascent. Its (segmental) arteries arise primarily from the adjacent part of the aorta (or common iliac arteries) and its veins drain primarily to the adjacent part of the inferior vena cava (or common iliac veins). In contrast, the suprarenal gland remains in the normal position.
Fig. 21.2 Variations in orientation of appendix Other anomalies include transverse (about 2.5%), preileal (about 1%) and retro-ileal appendix (about 0.5%). The uterus is normally anteverted as the long axis of the cervix is directed more anteriorly than the long axis of the vagina. A retroverted uterus is a common variant.
Fig.21.3 Left-sided inferior vena cava There is also an association with some degree of visceral transposition (e.g. the heart being situated on the right side of the body) or vascular transposition (e.g. reversal of the azygos venous system with the azygos vein on the left, the hemiazygos and accessory hemiazygos veins on the right). These have clinical significance as unexpected findings on physical examination, imaging or at surgery.
Situs inversus
Rarely there may be a complete situs inversus (about 0.01%) where the thoracoabdominal viscera are in mirror image to normal. The heart may be situated on the right side of the body, termed dextrocardia (in an additional 0.01%). Patients with Kartageners syndrome present with situs inversus, respiratory infections and male sterility. The common factor is a defect in motility of cilia on all ciliated cells.
Fig.21.4 Aberrant left vertebral artery An aberrant cystic artery (to the gallbladder) arises from neighbouring arteries and not from the right hepatic (its usual origin). Anomalous origins include from the left hepatic artery (about 6%), the common hepatic artery (about 2%) or the gastroduodenal artery (about 2%). An aberrant dorsal pancreatic artery arises from the coeliac trunk instead of the splenic artery. Arteries that normally arise from a common trunk may instead arise independently. An aberrant right hepatic artery can arise from the superior mesenteric artery (about 12%) instead of the common hepatic artery. A branch of the thyrocervical trunk may arise directly from the subclavian artery. Aberrant circumflex femoral arteries can arise directly from the femoral artery instead of the beginning of the profunda femoris artery. Aberrant perforating branches can arise from the femoral artery rather than the profunda femoris artery. An aberrant posterior circumflex humeral artery can arise from the subscapular artery (about 20%) instead of the axillary artery and an aberrant profunda brachii artery can arise from the posterior circumflex humeral artery (about 7%) instead of the brachial artery. Aberrant arteries may also occur in addition to, rather than instead of, the normal artery. Such aberrant arteries are termed aberrant accessory arteries.
Fig.21.6 A normal and an aberrant obturator artery A few classic' patterns (described in textbooks as the standard) are themselves atypical or present in less than 50% of cases. It is contentious as to which pattern is anomalous. For example, a complete superficial palmar arch in the hand (linked to the superficial palmar branch of the radial artery) occurs in fewer than 30% of cases. A classic thyrocervical trunk is present in fewer than 50% of cases. A classic branching pattern of the axillary artery occurs in only about 10% of cases. Even a classic circle of Willis (at the base of the brain) is present in just over 50% of cases.
Fig.21.5 Scope for variation during arterial development The pattern of preferred channels produces alternative pathways (e.g. where the same set of arteries may supply a particular territory but via different routes). These variations tend to be reciprocal (i.e. if one branch is smaller, another is larger to compensate). Branches may also arise at a more proximal or more distal site along an artery. Ultimately every individual has a unique branching pattern for each vessel, as there is no requirement at this level for symmetry. Like fingerprints, even the branches of the central artery of the retina (as seen in examination of the optic fundus) are peculiar to each individual. Branching patterns often vary, particularly for arteries that anastomose with other arteries. Any alternative path may become the preferred channel. The inferior epigastric and obturator arteries normally anastomose via their pubic branches. An aberrant obturator artery arises from the epigastric artery (about 30%) where a large pubic branch replaces the normal origin from the internal iliac artery or is additional to a normal obturator artery (i.e. an aberrant accessory obturator artery). 174
Fig.21.8 Superficial ulnar artery from a high division A high division of the axillary artery (about 4%) or of the brachial artery (about 6%) can occur. The high division may either be due to persistence of the superficial brachial artery (the brachial artery dividing subsequently into radial and ulnar arteries) or division directly into radial and ulnar arteries. The roots of the median nerve normally pass in front of the axillary artery, however with a high division of the axillary artery one branch passes in front of them. The median nerve normally passes in front of the brachial artery in the arm. If the brachial artery disappears, instead of the superficial brachial artery, the median nerve remains deeply located (about 12%). Where there is a pair of brachial arteries in the arm (about 10%) the median nerve passes between them. The popliteal artery normally divides at the distal border of popliteus however it may divide at its proximal border (about 2%).
Fig.21.7 Retro-oesophageal right subclavian artery 10% of aberrant obturator arteries pass medial to the femoral canal rather than lateral to it and are regarded as endangered aberrant obturator arteries (about 3% overall). Because it lies along the free margin of the lacunar ligament, the artery is potentially endangered in femoral hernia surgery (where the lacunar ligament is cut).
Arterial dominance
The pattern of vascular distribution is compensatory. If one territory is larger (from arterial dominance) a neighbouring territory tends to be smaller. The heart is supplied by the left and right coronary arteries. Typically, the right coronary artery provides the posterior interventricular branch also known as the posterior descending artery (PDA). It supplies territory beyond the posterior interventricular groove. This is termed right dominance.
Fig.21.10 Normal coronary arteries (right dominance) The left coronary artery may provide the posterior interventricular branch/PDA (about 10%), termed left dominance. When both coronary arteries contribute equally to the PDA, it is termed balanced (about 5%).
Fig.21.11 Angiogram of dominant left coronary artery Other variations even include a single coronary artery, which provides all branches. The sino-atrial nodal branch may arise from the left coronary artery (about 45%) and the atrio-ventricular nodal branch from the left coronary artery (about 10%). The area of myocardial infarction from a coronary occlusion in a particular individual is dependant on the pattern of distribution and degree of coronary artery dominance. This is of particular significance regarding supply of the conducting system and the associated risk of a life-threatening arrhythmia.
Fig.21.9 Asymmetrical distribution of cerebral arteries Generally blood from the two arterial systems: internal carotid and vertebro-basilar) does not mix, but the anastomosis provided by the communicating arteries enables the potential for alternative paths in occlusion affecting one or more of them. The clinical features of a stroke from such occlusion are therefore influenced by the anatomical arrangement of the circle of Willis.
Functional impairment
There is a fine line between the anatomical variation of anomalies and the pathological changes of congenital malformations. In contrast to anatomical variation (with abnormal structure or position but no functional impairment) pathological changes have impaired function, even if not immediately evident. The abnormalities most difficult to classify are those present at birth without functional impairment, but with a diminished functional reserve. A structural abnormality (e.g. a patent foramen ovale or horseshoe kidney) that remains symptomless throughout life as an incidental finding (e.g. on imaging or at post-mortem) is considered to be an anatomical anomaly. In contrast, a structural abnormality (e.g. an atrial septal defect or polycystic kidney) that is symptomless at birth but later manifests functional impairment is considered to be a congenital malformation.
Spontaneous abortions
About 50% of conceptions do not result in a live birth but spontaneously abort early (and if prior to implantation, undetected). At least half have severe chromosomal abnormalities. Malformations occur when organ systems are forming (between the third to eighth weeks) and most major malformations spontaneously abort. About 20% of perinatal deaths are also due to congenital malformations. Genetic mutations and chromosomal abnormalities are solely responsible for about 15% of malformations. Environmental causes are solely responsible for about 10% and include physical agents (e.g. radiation), chemical agents (e.g. drugs) or organisms (e.g. certain viruses). The remainder (about 75%) are from multifactorial or unknown causes. Fig.22.1 Defective closure of interatrial septum
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Fig.22.3 Spina bifida However, spina bifida occulta (about 2%) is minor affecting the neural arch of one or more vertebrae and often not detected. Fig.22.5 Polycystic kidney Aqueductal stenosis in the brain may cause congenital hydrocephalus, with accumulation of cerebrospinal fluid and enlargement of the cranium. Stenosis of the pulmonary or aortic valves in the heart may occur and in coarctation of aorta (about 0.1%) a constriction is located near the ductus arteriosus. Certain structures may fail to form. These include digits and even limbs. An absent or rudimentary brain is known as anencephaly (about 0.1%) and in bilateral renal agenesis (about 0.03%) both kidneys are absent. Congenital absence of lymph vessels in a lower limb (Milroy's disease) results in lymphoedema. An absent uterus (about 0.02%) and even vagina may occur. Certain structures may form defectively. Chest deformities (about 0.1%) may result in funnel chest (depressed sternum) or pigeon chest (protruding sternum). Congenital dislocation of hip may be due to defective formation of the acetabulum of the hipbone. It requires recognition (and splinting) prior to weight bearing to prevent long-term effects. Talipes (club foot) results in a deformity. In polydactyly there is an extra digit or digits and in syndactyly two or more digits are fused. Failure of development of a centre of ossification in the body of a vertebra results in hemivertebra with associated scoliosis of the spine. 178
Fig.22.4 Tracheo-oesophageal fistula An abnormal passage may remain from defective closure of the trachea from the oesophagus as a serious tracheo-oesophageal fistula (about 0.05%). An auricular pit,
Fig.22.8 Acute lobar pneumonia Fig.22.6 Scoliosis due to a hemivertebra Failure of development of epiphyses of long bones produces an achondroplastic dwarf. Microcephaly of the head and micrognathia of the jaw may occur. Certain genetic disorders (e.g. adrenogenital syndrome from congenital adrenal hyperplasia) and chromosomal disorders (e.g. Down's syndrome, Turner's syndrome and Klinefelters syndrome) also produce defective formation of organs as secondary effects. The two types of inflammation are acute and chronic. Acute inflammation is characterised by the cardinal signs of redness (rubor), swelling (tumor), heat (calor) and pain (dolor). This response is due to increased blood flow from vasodilatation (hyperaemia), leakage of fluids and plasma proteins from increased vascular permeability (exudation) and passage of certain white blood cells from the blood to surrounding tissues through the vessel wall (emigration). The possible sequelae of acute inflammation are restoration to normal (resolution), passage along anatomical pathways (spread), abscess formation (suppuration), scar formation (fibrosis) or procedure to chronic inflammation. Spread may be direct (e.g. along fascial planes), lymphatic (via local lymph vessels to regional lymph nodes (containing collections of defence cells that filter lymph prior to its return into the venous system) or blood (via local veins prior to circulating around the body). An abscess (L. 'to go away') is a localised collection of pus (dead tissue, defence cells and micro-organisms) due to massive emigration of certain white blood cells. A scar is due to the production of collagen fibres from connective tissue cells that proliferate after damage associated with acute inflammation. Chronic inflammation may follow acute inflammation if the causative agent remains (e.g. persistence of a foreign body) or may occur from the outset with an organism of low virulence. There is infiltration of certain defence cells together with the proliferation of connective tissue.
ACQUIRED DISORDERS
There is a fine line between normal variation and pathological variation regarding acquired disorders. The normal variations most difficult to classify are those due to aging. The normal changes associated with senescence merge with certain degenerative disorders. There is even a fine line between congenital malformations and acquired disorders. The most difficult to classify are those birth defects that do not manifest themselves until later in life, and those acquired conditions that have a primarily genetic basis.
Traumatic disorders
Trauma is the disruption of tissues by physical injury. The nature of the traumatic condition is dependent on the type of anatomical structure involved: skin or mucous membrane ulceration (loss of epithelial continuity), soft tissue laceration (tearing) or contusion (crushing), muscle or tendon strain, ligament sprain, bone fracture or joint dislocation. For certain of these (e.g... muscle strains or ligament sprains) the degree of disruption may be classified as microscopic (first degree), partial (second degree) or complete (third degree).
Degenerative disorders
Degeneration is the effect on living cells by injury. The cells primarily affected are those embedded in the vascular and connective tissues of an organ. These specific cells (parenchymal cells) are most sensitive to direct harm from the injury while the vascular and connective tissues react to the injury (via an inflammatory response). The cause of the injury may be direct (e.g. by a physical, chemical or organism agent) as well as indirect (from associated inflammation). Parenchymal cells are also sensitive to injury from lack of oxygen. Effects on cells range from injury of the cytoplasm (cell damage) that is reversible (e.g. hydropic swelling, fatty change) through to injury of the nucleus, resulting in cell death (necrosis) that is irreversible. The sequel of necrosis is generally repair, involving surviving parenchymatous cells (via regeneration) and the connective tissues (via fibrosis). Certain highly specialised cells (e.g. nerve and muscle) have lost the capacity to divide (and thus replace necrotic cells). Other possible sequelae are deposition of calcium in damaged tissue (calcification), dissolving dead tissue (lysis) with cyst formation and infection of a necrotic part (gangrene). 179
Inflammatory disorders
Inflammation is the response of living tissues to injury. The cause of the injury may be physical, chemical, organismal or autoimmune. The inflammatory response is produced by vascular and connective tissues, directed towards protection. However, it may result in some collateral damage (and in autoimmune conditions the body is tricked into attacking a particular normal host tissue).
Fig.22.9 Cirrhosis of the liver Where continuous damage occurs, some necrosis and repair may even take place simultaneously (although associated with a degree of disruption of normal architecture) in the organ (e.g. cirrhosis of the liver from chronic alcoholism). Apoptosis (G. 'dropping off') is programmed cell death, particularly associated with aging. Other degenerative conditions involve extracellular infiltrations into surrounding tissues including protein deposition (e.g. amyloid) around blood vessels of certain organs and pigmentation from products of red blood cell breakdown (e.g. haemosiderin, bilirubin) or from inhalation of particles (e.g. carbon, silicone) into the lungs.
Mechanical disorders
Mechanical disorders, as distinct from traumatic (where there is tissue disruption from physical injury), involve a physical cause altering structure and/or impairing function. These include compression from the outside (e.g. by a surrounding structure) and collapse from the inside (e.g. of a lung). Other mechanical disorders include obstruction of a hollow viscus. This may be associated with an abnormal dilatation (of the wall and lumen) proximal to the obstruction. Hernia (L. rupture) is an abnormal protrusion of an anatomical structure through an opening, defect or weakness. Prolapse (L. falling) is the dropping of an organ from its normal position (e.g. due to weakness of its supports, coupled with gravity).
Fig.22.10 Carcinoma of the colon Secondary neoplasms are also termed metastases (G. beyond + standings). A carcinoma (G. 'cancer' + 'swelling') is a malignant neoplasm derived from epithelial cells (whether of a surface lining or of a gland), while a sarcoma (G. 'flesh' + 'swelling') is derived from connective tissue or muscle cells. Other disorders of growth include atrophy (a decrease in size from wasting), hypertrophy (an increase in cell size), hyperplasia (an increase in cell number), dysplasia (abnormal cellular development) and metaplasia (transformation of mature cells into an abnormal form). Fig.22.12 Hydronephrosis of kidney The cause of a disorder may be the consequence of another. A mechanical disorder may be a sequel of a traumatic disorder (e.g. injury to one organ may produce compression of an adjacent organ) or of a neoplastic disorder (e.g. a carcinoma may obstruct a hollow viscus producing a dilatation proximal to it). In each of these cases the normal anatomy is altered. Understanding of normal and abnormal anatomy is the basis for recognising clinical manifestations of disease processes.
Circulatory disorders
Circulatory disorders include an accumulation of blood within the vessels of an organ (congestion), an accumulation of extravascular fluid (oedema), bleeding from vessels (haemorrhage) and an inadequate perfusion of tissues throughout the body (shock) A haematoma (G. blood + swelling) is a localised extravascular collection of blood. A localised dilatation of an artery due to a weakness in its wall is termed an aneurysm (G. widening). 180
Chapter 23: Surface and Functional Anatomy Chapter 24: Radiographic Anatomy and Imaging Chapter 25: Sectional Anatomy, CT and MRI Chapter 26: Ultrasound Imaging Chapter 27: Endoscopic Anatomy Chapter 28: Clinical Procedures Chapter 29: Postmortem Examination of Organs Chapter 30: Cadaver Dissection
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SURFACE REGIONS SURFACE MARKINGS AND EXAMINATION SURFACE MAPS OF SUPPLY TERRITORIES FUNCTIONAL ANATOMY AND TESTING SURFACE REGIONS
Fig.23.1 Surface of modules Each body module includes some external surface. 183 Fig.23.4 Surface region on back of trunk
PRACTICAL PERSPECTIVES
1. - pectoral region 2. - axilla 3. - anterior compartment of arm 4. - cubital fossa 5. - anterior compartment of forearm 6. - carpal tunnel 7. - palm of hand 8. - palmar aspect of digits 9. - scapular region 10- deltoid region 11. - posterior compartment of arm 12. - posterior compartment of forearm 13. - anatomical snuffbox 14- dorsum of hand 15. - dorsal aspect of digits
Fig.23.8 Surface regions of lower limb 1. - femoral triangle 2. - subsartorial canal 3. - anterior compartment of thigh 4. - medial compartment of thigh 5. - anterior compartment of leg 6. - lateral compartment of leg 7. - dorsum of foot 8. - dorsal aspect of digits 9. - gluteal region 10. - posterior compartment of thigh 11. - popliteal fossa 12. - posterior compartment of leg 13. - tarsal tunnel 14. - sole of foot 15. - plantar aspect of toes
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23. Surface and Functional Anatomy SURFACE MARKINGS AND EXAMINATION Skin features and body build
lower limbs = 4x9%, upper limbs = 2x9%, head and neck = 1x9% Total = 99% (+ genitals the remaining 1%).
Bony landmarks
Fig.23.10 Fig.23.9
Fig.23.13 Fig.23.11
Fig.23.14
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23. Surface and Functional Anatomy Sites where motor nerves are superficial
Fig.23.15 Postural variation in position of organs The surface markings and vertebral levels for organs based on anatomical descriptions of a recumbent cadaver may be vastly different to those in a living person standing upright. The curvatures of the spine and the arches of the foot are affected by lying, sitting or standing. Other effects of posture include distension and pooling of blood in veins.
Fig.23.17
Fig.23.16 Movement of organs during breathing During inspiration the lungs expand and viscera directly below the diaphragm, particularly the liver (and gall bladder), spleen and kidneys, are pushed downwards as it descends. Physical examination of abdominal organs includes attempting to palpate them on full inspiration.
Fig.23.18 Sites for palpation of arteries against bone The usual site for clinical examination of an arterial pulse is where the radial artery lies on the distal end of the radius just deep to skin of the wrist.
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Fig.23.19 Palpating the radial artery against bone Other sites where arteries may be pressed against bone include the common carotid artery on the carotid th tubercle (of the 6 cervical vertebra) and the facial artery on the body of the mandible. Although the femoral artery is not directly related to bone, it is large and is close to skin just below the mid-inguinal point (at the base of the femoral triangle) where its pulsation may also be palpated.
Fig.23.22
Fig.12.17 The final sentinel lymph node Palpation of both left and right supraclavicular (groups of cervical) lymph nodes should be performed in the routine examination of the thorax. Palpation of the left supraclavicular lymph nodes should be performed in the routine examination of the abdomen (and is mandatory if there is suspicion of cancer in an abdominal organ).
Fig.23.20 188
23. Surface and Functional Anatomy SURFACE MAPS OF SUPPLY TERRITORIES Cutaneous nerve supply Ligament integrity Ligament stress test
Extensive ligament damage produces great impairment of function and increased potential for instability.
Fig.23.24
Fig.5.21 Stress test for cruciate ligaments of knee joint Ligament integrity may be tested clinically by stressing the ligament (putting it on stretch) and comparing the observable movement between the injured and uninjured sides. With a ligament sprain, pain tends to be exacerbated by stressing the ligament.
Arterial supply
Fig.23.26
Lymph drainage
Fig.23.27
PRACTICAL PERSPECTIVES
to determine which structures may limit movement (or produce pain). Muscle strength is gauged by the degree of active resistance required to prevent movement.
Assessing muscle tone and wasting Skeletal muscle tone and its assessment
Skeletal muscle tone (G. tension) is measured as resistance to stretch. Muscle tone is under reflex control. It is dependent on a nerve supply (both motor and sensory) and is modulated by the recruitment of more or fewer motor units. Skeletal muscle tone may be either increased or decreased by certain lesions of the nervous system. Assessment of skeletal muscle tone involves resistance to stretch of a major muscle group ideally through its full range of movement (with increasing velocity). This is an important step in a neurological examination.
Testing reflexes
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Fig.23. Phases of the walking cycle The line of gravity moves forwards in the direction of motion. At one phase of the cycle (mid-swing and midstance) it passes through both limbs. At all other phases it passes between the limbs.
Fig.23. Stabilisation of the pelvis during locomotion Gluteus medius and minimus muscles prevent excessive tilting of the pelvis (supporting the trunk above it) towards the unsupported side during locomotion.
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PLAIN RADIOGRAPH PRODUCTION RADIODENSITIES OF TISSUES RADIOGRAPHIC VIEWS PROPERTIES OF PLAIN RADIOGRAPHS BONES ON RADIOGRAPHS JOINTS ON RADIOGRAPHS OTHER STRUCTURES ON RADIOGRAPHS CONTRAST RADIOGRAPH PRODUCTION CONTRAST STUDIES OF VISCERA CONTRAST STUDIES OF CLOSED CAVITIES CONTRAST STUDIES OF VESSELS DIGITAL SUBTRACTION ANGIOGRAPHY PLAIN RADIOGRAPH PRODUCTION
The production of a plain radiograph involves beaming X-rays through an object onto a recording medium.
X-ray source
X-rays are produced in an X-ray tube, which is the central component of every X-ray machine. It consists of an air-evacuated glass cylinder in which a tungsten filament (cathode) and anode are located. A high potential (voltage) difference (up to several hundred kV) is applied between the cathode (which is also heated) and the anode. Electrons are ejected from the cathode and are attracted to the anode.
Fig. 24.2 An X-ray tube When these highly accelerated electrons collide with the anode, their kinetic energy is transformed to heat and radiation, including X-rays. The X-ray beam exits through a window (usually rectangular) bounded by lead collimators.
Recording media
On specially designed receptor materials (X-ray film and image intensifier screens), X-rays produce a short, tiny burst of light for every X-ray photon that is absorbed. This flash of light is recorded as a single dot on the X-ray film, or as a single impulse in a digital image. An X-ray image comprises millions of such dots. The X-ray film is still the most commonly used recording medium in radiography. Once exposed, the X-ray film is called a radiograph (or an X-ray image). Unexposed film consists of a plastic sheet covered with an emulsion sensitive to the visible light (photo-sensitivity) and X-rays (radio-sensitivity). The exposure to the X-ray radiation, followed by the interaction with a developer, results in chemical changes characterised by deposition of the metallic silver in the emulsion, which produces blackness on the film. The intensity of blackness on a radiograph is directly proportional to the intensity of radiation which reaches the film. 192
X-rays
X-rays are electromagnetic waves of radiation of a very short wavelength (only about 1/10,000 the wavelength of visible light). In the electromagnetic spectrum, the shorter the wavelength of radiation, the greater the energy of radiation.
Tissue radiodensities
Capacity of a tissue to absorb or scatter X-rays depends on its electron density, because X-ray photons are absorbed or deflected primarily by electrons. The closest easily measurable physical parameter to electron density is physical density (i.e. mass per unit volume, usually 3 expressed as grams/cm ), which is not only related to the physical state of the tissue but also to the atomic number of the elements which form it. When describing degrees of Xray attenuation, density of living tissue is termed tissue radiodensity. The greater the tissue radiodensity the greater the attenuation of X-rays. This results in fewer X-rays reaching and interacting with the X-ray film (or other recording medium).
Radiodensity spectrum
On the basis of their (plain film) radiodensities, tissues can be classified into four groups from the least to the most dense: - air - fat - soft tissues - bone
Fig. 24.3 Tissue radiodensities on a plain film The air density includes gases (which are normally present in some hollow viscera) as well as air in air sinuses. Soft tissues include all body fluids, muscles, water, cartilage, liquid bowel contents and parenchymal organs. Bone density includes teeth. A fifth non-anatomical density, often seen in radiographs, is that of metal, which is much denser than bone (e.g. total hip prostheses, fracture fixation plates, prosthetic heart valves, etc). Other commonly used prosthetic and medical device materials include plastics and silicones, which have densities close to that of soft tissue (but often have a radiodense stripe or marker to make identification easier).
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RADIOGRAPHIC VIEWS
Images of the same structure from different angles are termed radiographic views (or projections). Radiographs are two-dimensional images of threedimensional structures positioned between the source of Xrays (the X-ray tube) and the film. Not only is the anatomy collapsed into a flat image on the film but structures are superimposed on each other without indication of their order. Each view provides an image of an object from a different angle. An object is usually radiographed in at least two projections at right angles to each other. This enables the viewer to construct a 3-dimensional mental image from the complementary pair of flat (2dimensional) radiographs. It also enables superimposed (overlying) structures to be identified as separate entities.
Radiological interfaces
An interface is created when different anatomical structures lie in contact with each other. A radiological interface is created when tissues of different radiodensity lie adjacent to each other. Depending on the positioning relative to the path of the x-rays, these radiological interfaces may or may not be visible on a radiograph.
Lines on a radiograph
Lines (or edges) may be seen on a radiograph when radiological interfaces are parallel to the path of the Xrays.
Fig. 24.6 Views from beam via back and front Fig. 24.5 How a line is formed on an image Side-on projections are known as lateral views. 194
Fig. 24.7 Standard views of lumbar spine In addition to these, a number of oblique projections can also be used enabling certain features of a body part to be visualised. The X-ray tube is always perpendicular to the middle of the film. The optimal degree of required obliquity varies for different structures.
Looking at a radiograph
The image, whether an AP or PA view, is looked at as if facing the patient. The patients right is on the observers left and vice versa. R and L are marked on a radiograph to indicate the respective side. For lateral and oblique projections, abbreviations indicate which aspect of the body is adjacent to the film. Right lateral (R lateral) view indicates that the right aspect of the imaged body part is placed against the film. Right anterior oblique (RAO) view indicates the positioning of the right antero-lateral aspect of the body against the film. Fig. 24.8 Geometric and motion unsharpness Because of natural magnification of the image with increasing object-film distance, geometric unsharpness is worst for structures furthest from the film (and, by corollary, closest to the X-ray tube). For the same reasons, the greater the source-object distance compared to the objectfilm distance, the less is the geometric unsharpness. In part, this is why chest X-rays are taken with a large sourceobject distance. Motion unsharpness is the result of the edge moving while the film is being exposed. Motion unsharpness produces the X-ray equivalent of photographic blur when a fast moving object is photographed with a long exposure. Therefore, radiographs of moving objects (such as the heart and pulmonary vessels) are taken with as short an exposure as possible. For the same reason, a patient may be asked to keep still, not to breathe, or not to swallow during certain exposures.
PRACTICAL PERSPECTIVES
reducing X-ray exposure parameters (to reduce patient Xray dose) will eventually produce a non-diagnostic image. When the anterior aspect of the body (or a part of the body) needs to be least magnified and distorted on a radiograph, a P-A view is chosen. For example in a routine chest X-ray, the heart and lung hila (both nearer to the anterior thoracic wall) are of more interest than the spine. The patient is positioned with the front of the chest leaning against the X-ray film (while the X-ray source is located behind the middle of the patients back).
Fig. 24.11 Summation from superimposed structures The combined optical density (as seen on the final image) of several superimposed structures is the sum of the optical densities produced by each structure individually, because the X-ray beam is attenuated by each structure independently and in turn. The increase in optical density on the film produced by several overlapping structures is termed summation. For example, the vertebral column and mediastinal soft tissue structures are superimposed on a frontal chest X-ray, and where superimposed they produce a whiter area (i.e. summation takes place). In order to avoid interpretation difficulties resulting from the superimposition and summation phenomena, multiple projections are routinely used with the object often radiographed in at least two projections commonly at right angles to each other.
BONES ON RADIOGRAPHS
Bones, being very radiodense, are easily identifiable on a plain X-ray film because of their contrast with surrounding structures. Each type of bone has a particular radiographic appearance.
Fig. 24.12 Long bones on an image (elbow) Parts of the shaft circumference are parallel and other parts are perpendicular to the X-ray beam. Four interfaces are visible, two with soft tissues surrounding the shaft and two with the medullary cavity filled with soft tissue (bone marrow). The ends of a long bone are predominantly cancellous bone organised into groups of parallel struts (representing weight bearing paths) known as trabeculae. Compact bone is reduced to a thin superficial covering (subchondral bone) that usually supports the articular cartilage.
Fig. 24.15 Flat and pneumatic bones (skull) Certain skull bones have air-filled cavities (the paranasal sinuses), appearing as paired, clearly demarcated lucent areas (air radiodensity) of variable size.
Fig. 24.13 Short bones on an image (wrist) Underlying cancellous bone is organised into a system of weight bearing trabeculae. Irregular bones often have a complex radiographic appearance, with their parts and surfaces superimposed on 197
PRACTICAL PERSPECTIVES
Margins of every normal bone on a radiograph (regardless of size, shape and complexity) should appear as sharp, clear and continuous lines demarcating the edge of the bone from the surrounding tissues. Trabecular patterns within cancellous bone should form clear and continuous parallel lines where present. Optimal bony alignment (and immobilisation to maintain it) is crucial in fracture management. A radiolucent gap seen on the radiograph of a growing bone between the primary and secondary ossification centres (or between epiphysis and metaphysis in long bones), represents the epiphysial (growth) plate. The radiolucency is due to soft tissue epiphysial cartilage that is end-on to the X-ray beam. Zones of calcified cartilage form thin but distinguishable white (radiopaque) lines clearly demarcating the epiphysial plate from surrounding bone tissue.
Ossification centres
In the developing skeleton, primary centres of ossification (except for the short bones of the wrist and foot) appear well before birth. Further development and growth of certain bones occur until the end of adolescence. Secondary centres of ossification (epiphyses) appear at different ages in cartilaginous parts of developing skeletal elements. They appear on radiographs as small and irregular (often nodular) radiopacities representing calcified cartilage in the centre of cartilaginous bone ends. These islands of calcification quickly become ossified, expand in size and develop denser margins and trabecular cores. As they grow they replace the hyaline cartilage of the epiphysis (with hyaline cartilage remaining only on articular surfaces).
Epiphysial lines
Growth of bones finishes with closure of the epiphysial (growth) plates. Calcified cartilage from the margins of the epiphysial plate extends into its middle converting it to bone. With time, this area becomes thinner and merges with nearby trabeculae. However, a fine line of compact bone, termed the epiphysial line, usually persists throughout life.
Epiphysial plates
Fig. 24.20 Sesamoids and accessory bone (foot) Sesamoid bones occur in certain tendons, where they pass across bony convexities. In addition to the patella (the largest sesamoid bone), they are found most frequently in 198
JOINTS ON RADIOGRAPHS
Bony articular surfaces may be directly observed on a plain X-ray film of a joint. Other joint components of soft tissue radiodensity are indistinguishable from each other. However, articular fat pads (fat radiodensity) can be seen.
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be considered. Soft tissue structures around a joint that typically present as uniform soft tissue density are the joint capsule, surrounding tendons, bursae and muscles, and also any overlapping neurovascular bundles. Only joint fat pads will be visible as fat density structures (if large enough, and if the interface with other soft tissue structures is parallel to the beam).
Fig. 24.28 Context for a contrast radiograph The passage of contrast material is often followed in real time during the duration of contrast examination to observe the patterns of its distribution.
Contrast enhancement
Since body fluids (and non-gaseous contents of hollow organs) cannot be distinguished from their surrounding walls on a plain radiograph, administration of contrast material is required to see them. This is achieved by filling body cavities or lumina of viscera and of vessels with materials of different radiodensity. The resulting change in radiographic density between the lumen and walls of the imaged organs (or body parts) allows their visualisation. Contrast material can be introduced into just about any body cavity or potential space. Intravenously administered contrast material, (different to that for non-vascular administration), is concentrated in various parenchymal body organs depending on its biochemical properties, and so may opacify these organs, making them more visible against adjacent soft tissue. The most common example is contrast opacification of the kidneys, making the renal parenchyma and collecting systems visible in turn (intravenous pyelogram or intravenous urogram).
Upper GI studies
Several different studies examine the upper digestive tract, each tailored to one specific part. Fluoroscopy is used to demonstrate the pharynx (pharyngogram), oesophagus (barium swallow), stomach (barium meal) and small intestine (small bowel series) with only liquid barium as contrast (for single contrast study), or liquid barium and gas-producing crystals or liquid or even injected air (for a double contrast study).
Lower GI series
The large intestine is examined (in single or double contrast) using a barium enema. Liquid barium is run into the colon via a rectal tube (under fluoroscopic vision). To obtain double contrast, extra barium is then evacuated and air insufflated into the colon to distend it. The patient turns
PRACTICAL PERSPECTIVES
or stands to best demonstrate successive parts of the large intestine in turn. Double contrast barium enema optimally details the large intestinal mucosal lining. Appropriate patient preparation in order to achieve a clean colon is an absolute prerequisite for this examination. invasive radiological approaches (e.g... ultrasound, contrast studies, CT and MRI) are not conclusive.
Fig. 24.32 Retrograde pyelogram Cystography is an examination of the urinary bladder and it is often performed with urethrography in males to assess the functional anatomy of the lower urinary tract. Following catheterisation, the bladder is filled with contrast material and examined using fluoroscopy. The second part of the examination involves removal of the catheter followed by fluoroscopic examination of micturition. Fig. 24.31 Oral cholecystogram Endoscopic Retrograde Cholangiopancreatography (ERCP) is a contrast radiographic examination in which the contrast material is injected directly (and retrogradely) into the biliary and pancreatic ducts by use of a fiberoptic endoscope. Although, this examination offers excellent demonstration of ducts, it is performed only when less 202
Hysterosalpingography
Hysterosalpingography is a contrast radiographic examination of the uterus and uterine (Fallopian) tubes. A vacuum cup device (with a small cannula) or a specially designed catheter is attached to the vaginal opening of the cervix and contrast material is directly introduced into the uterine cavity. The contrast medium then fills the tubes and spills into the peritoneal cavity.
Peritoneography
Peritoneography is used occasionally to look at location and distribution of peritoneal compartments, and to diagnose difficult peritoneal hernias. Contrast material is injected into the peritoneal cavity under fluoroscopic control.
Fig. 24.33 Hysterosalpingogram This examination can also have a therapeutic effect on female infertility by opening the uterine tubes previously occluded by adhesions.
Arteriography
Arteriography refers to the contrast examination of arteries in general. Specialised arteriography includes angiocardiography, aortography, cerebral and coronary angiography. These are concerned with contrast examination of the heart chambers, thoracic and abdominal aorta, intracranial and coronary arteries, respectively. Contrast medium is injected via a catheter inserted into a peripheral artery (e.g. femoral or brachial) and passed retrogradely to the origin of the desired artery, or even into cardiac chambers. Arterial blood flow directs the distribution of the contrast medium from the catheter tip. Angiography of certain solid organs (e.g. kidney, liver) includes three phases: arterial, capillary and venous. The capillary phase enables visualisation of the organ parenchyma. Associated veins are also commonly sufficiently opacified in the last stage of arteriography (after the contrast medium passes through the capillary system of an organ whose arteries are opacified).
Myelography
Myelography is performed by injecting the contrast media (usually opaque myelographic contrast material, rarely gas) into the spinal subarachnoid space. The contrast material is introduced either via a lumbar puncture or via a cervical lateral puncture under direct fluoroscopic vision. The patient is carefully turned and tilted to distribute the contrast through the CSF in a way that will show the suspected abnormality, and may then proceed onto CT scanning after a variable time delay.
Contrast arthrography
Contrast arthrography utilises a gaseous medium (pneumoarthrography), positive contrast medium (opaque 203 Fig. 24.35 Arteriogram (abdominal aorta)
Venography
Venography is the contrast examination of veins (peripheral and central). A venous catheter is inserted (and positioned) into a peripheral vein. The injected contrast medium is carried in the direction of venous blood flow towards the heart, opacifying lumina of the veins along this path.
Lymphography
Lymphography includes the contrast examination of lymph vessels (lymphangiography) and of lymph nodes (lymphadenography).
Fig. 24.37 Lymphogram Both the media and the application approach are unique. Oily iodine contrast media are utilised because of their longer retention by the lymphatic system. 204
SECTIONAL ANATOMY CT IMAGE PRODUCTION TISSUE PROPERTIES IN CT PROPERTIES OF CT IMAGES ADDITIONAL CT TECHNIQUES MR IMAGE PRODUCTION TISSUE PROPERTIES IN MRI PROPERTIES OF MR IMAGES SPECIAL MR IMAGING SECTIONAL ANATOMY
Images of sections may be correlated with those from CT and MR and are presented with the same left-right orientation as plain film radiography. An image is viewed as if facing the patient; the patients right is on the viewers left and the patients left is on the viewers right. Historically, for axial images, this has been called the view from the feet. The same convention applies to coronal slices (right on the left and left on the right). However, no convention exists with sagittal images. Fig. 25.2 Sagittal section (left parasagittal)
Fig. 25.3 Coronal section Fig. 25.1 Axial section (mid-thoracic level)
Sections in coronal planes pass between the right and left sides of the body, parallel to the coronal suture of the skull. They are also oriented longitudinally but are perpendicular to sagittal planes.
CT IMAGE PRODUCTION
Computed tomography (CT) is a radiologic technique which utilises X-rays to produce cross-sectional images of the patient.
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PRACTICAL PERSPECTIVES
Each reconstructed slice consists of voxels (3 dimensional brick-shaped pixels). The size of the digital Xray detectors and the number of angular projections determine the smallest possible size of the voxel within each axial slice (dimensions in the X and Y directions, i.e. the short sides of the brick). The size of the voxel i n the Z direction (craniocaudal direction, the long side of the brick) is the width of the X-ray beam.
Fig. 25.4 Context for CT images The formation of CT images is a multi-step process with the equipment design reflecting the order in which this takes place.
CT image acquisition
The two major components of any CT scanner are the gantry (shaped like a donut) and the patient bed, which slides through the middle of the gantry. The gantry contains a mobile X-ray tube which continuously rotates around the gantry opening, and an array of many small digital X-ray detectors lying opposite the X-ray tube. The X-ray tube produces a thin, fan shaped X-ray beam. The width of the beam (also the width of the slice) is controlled partly by physical tube collimators, and partly by electronic detector masking. The beam traverses the patient and is read by the detectors on the other side of the gantry opening. Fig. 25.6 A CT voxel Each CT voxel has a value, traditionally displayed as a shade of grey. The value in each voxel is a measure of tissue radiodensity in the corresponding voxel in the patient. CT can measure radiodensity with exquisite accuracy, and can detect extremely subtle radiodensity differences in adjacent voxels.
TISSUE PROPERTIES IN CT
As in plain radiography, when a fan-shaped X-ray beam penetrates the body during Computed Tomography (CT) examination, it interacts with different tissues. Depending on the tissue radiodensity, some X-rays are absorbed, some are scattered.
Tissue radiodensities in CT
While plain radiographs have four groups of radiodensities, CT images provide a greater range of shades that allow differentiation between many tissue types.
Fig. 25.5 Components for CT image production The X-ray tube continuously rotates around the patient (at the speed of 1 revolution per second, or faster), and images from many angular projections are collected during any one revolution. These images are analogous to multiple overlapping photographs in panoramic photography, but are only slice-thick. The patient bed (with the patient lying as still as possible) is moved through the gantry, presenting successive parts of the patient to the X-ray beam, so that contiguous slices are acquired.
Fig. 25.7 Tissue radiodensities in CT imaging Traditionally, tissue radiodensity as measured by CT is expressed in Hounsfield Units (HU) or CT units. On the HU scale, the attenuation value for water is zero. Positive values are for structures with higher attenuation than water (soft tissues and bones) while 206
CT image reconstruction
The resulting huge volume of data from the image acquisition process is passed to the CT computer for image construction.
Windowing in CT
The limited capacity of the human eye to differentiate between different shades of grey limits the total number of shades of grey that can be displayed on a CT monitor or on CT film at any one time. The number of shades of grey that can be usefully displayed is far smaller than the number of different Hounsfield Unit values that are measured by a CT scanner. In order to fit the large dynamic range of the measured Hounsfield Units into the narrow dynamic range of the human eye, only select portions of the dynamic range are displayed, and may be stretched or compressed into only a few steps of grey. The process of displaying the HU range of interest is called windowing. Window level refers to the mid-value of the HU range to be displayed with the limited shades of grey, while window width describes the extent of this range. In general, to display a particular tissue optimally, the window level should be comparable to that tissues usual HU number, and the window width can then vary depending on how many other structures need to be included. A narrow window shows great detail in the structure of interest, but everything above the window will be presented as uniform white, and everything below as uniform grey. A wide window displays many different tissues as grey, but there is little differentiation between them. Optimal window level and width vary for each tissue. For optimal display of mediastinal soft tissues, the window level is around 40 HU, and the width is 400 HU. For lungs, however, the window level is around -700 HU and the width is 1000 HU. These values are usually displayed on the image.
Fig. 25.8 Attenuation values (in HU) and grey scale A CT image is simply a tissue density map (expressed in HU) in that particular slice. Although CT images can be displayed in any colour scale of the users choice, by tradition they are displayed in the same way as radiographs: radiolucent tissues are black, and increasingly radiodense tissues are progressively white.
PROPERTIES OF CT IMAGES
The images displayed on a monitor following CT scanning consist of a matrix of picture elements (pixels). Each individual pixel on the screen represents the HU value of the corresponding tissue voxel in the patient.
CT resolution
In-slice CT spatial resolution is limited by the size of individual X-ray detectors, and the number of angular
PRACTICAL PERSPECTIVES
projections that are collected. CT spatial resolution in the cranio-caudal (Z axis) is limited by slice collimation (whether physical or electronic). CT spatial resolution, although impressive, is much coarser than of plain film. CT contrast resolution (the ability to tell different tissue radiodensities apart) is extremely high, and well above that of plain film. Similar to plain radiography, it is limited by image noise.
ADDITIONAL CT TECHNIQUES
Rapid progress in digital technology and engineering, as well as routine utilisation of contrast media, led to the refinement of routine CT techniques and development of targeted CT techniques. Fig. 25.11 High resolution CT (of lungs)
Multislice CT
With the development of CT X-ray tubes, detector technology and electronic collimation, detector arrays are evolving to allow acquisition of multiple slices with each tube rotation. Four and 16 slice CT scanners may become superceded by new 64 slice machines. Multislice CT dramatically decreases the total examination time, because fewer tube revolutions are required to cover the same cranio-caudal distance. This is of particular use with patients who have difficulty holding still (e.g. short of breath, or children) and in trauma cases.
Helical CT
Helical CT imaging involves constant advancement of a patient through the gantry with a continuously revolving Xray tube. This is equivalent to helical motion of an X-ray tube around the patient. Helical CT images are of a continuous volume of tissue, rather than a single slice at a time, hence the term volume scanning. It eliminates gaps between slices in a conventional CT and allows multiplanar and 3-D reconstructions (e.g... of the skull). Because CT slices are continuously acquired, the total data set is volumetric, and the reconstructed axial slices can be reformatted into coronal, sagittal or oblique slices with little information loss. Almost all new CT scanners are helical and helical CT is rapidly replacing conventional CT.
MR IMAGE PRODUCTION
Magnetic Resonance Imaging (MRI) produces high quality cross-sectional images of the patient in any plane (horizontal, sagittal, coronal and/or oblique). MRI (unlike radiography and CT) avoids using ionising radiation. Fig. 25.10 Contrast media in CT (abdomen) It is based on recording radiofrequency signals emitted from within the body (rather than on the transmission of Xrays through the body).
Thin section CT
High-resolution computed tomography (HRCT) refers to thin-section CT. In HRCT the beam collimation is the thinnest possible, often as thin as 0.5 to 1.0mm. This means that voxel depth (Z axis) is the thinnest possible, and partial voluming artefact that degrades in-slice resolution with thicker slices is minimised. However, it is impossible to scan an entire body with 1.0mm slices (this will produce at least 1000 images to look at the torso alone), and of necessity such thin slices are taken with a spacing, often 10mm. Hence, this is a sampling study that is most frequently used to examine lung parenchyma in fine detail for diffuse lung disease where only representative tissue slices are sufficient. 208
Contraindications to MR Imaging
Implanted electronic devices and potentially mobile ferromagnetic material are contraindications to MRI. Any implanted electronic device can either be disabled by the magnetic field of an MR scanner or generate current loops which can cause burns. In particular, pacemakers usually stop functioning in an MR scanner, potentially leading to asystole and death. Pacemakers, neurostimulators and bionic ear implants are absolutely contraindicated in MR scanning. No electronic implant should even enter the MR scanning room. Metallic implants can be ferromagnetic (i.e. move in a magnetic field) or not. Generally, firmly implanted joint prostheses and other orthopaedic hardware will degrade the MR image to useless in their vicinity, but can enter the magnet. However, freely mobile metallic implants must be considered ferromagnetic till proven otherwise. In particular, cerebral aneurysmal clips or coils can not enter the MR scanning room until cleared as MR compatible. Metallic intraocular foreign bodies can cause severe damage if they move in the magnetic field. These can be detected with a plain X-ray. Ferromagnetic objects (e.g. oxygen cylinders, hand tools) may be drawn into the magnet and become unintended projectiles. In MR examination, the patient is placed on the moveable table, which slides inside a narrow tunnel barely large enough to contain an average human body. Patients with claustrophobia may not cope with the procedure and obese patients may not even fit in the tunnel.
Fig. 25.13 Emission of RF signals from body The variable magnetic field leads to radiofrequency electromagnetic waves being emitted from the body. These are recorded by receiver coils, the location of their source is decoded, and spatial maps of several magnetic properties of the body are slowly built up with successive pulse-receive cycles.
Magnetic properties
Just like with CT, MR imaging creates volume maps of several physical properties of the tissues being imaged. CT creates a map of only one such property: tissue radiodensity (which in turn reflects electron density in the tissue). MR imaging can image three fundamental tissue properties: proton density, and two others, called T1 and T2 constants. All tissues have the properties of T1 and T2 constants, which relate to how quickly magnetization returns to steady state after being altered by the RF pulses sent in by the transmitter coils. T1 weighted sequences show fatty tissues as bright and fluids as dark, while T2 weighted sequences
PRACTICAL PERSPECTIVES
show water and fluid as bright. Modern T2W sequences ('fast spin echo T2W') also show fat as bright. These include Cerebrospinal Fluid (CSF), mucus, urine and bile, or in case of a pathological process, oedematous mucosa and non-clotted blood.
PROPERTIES OF MR IMAGES
The image occurring on a video monitor following MR imaging consists of a matrix of picture elements (pixels). Each individual pixel on the screen represents the degree of signal intensity for the corresponding voxel in the body translated into a different shade of grey scale.
SPECIAL MR IMAGING
By using contrast media that have magnetic properties, the MR images of blood vessels and vascular organs can be enhanced. Alternatively, manipulation of MRI data can display only the structures that move quickly. This enables imaging of blood vessels without an application of any contrast media.
Proton movements
Dedicated MR sequences allow selective demonstration of moving protons, and in particular of flowing blood. In these dedicated sequences, moving blood can be either bright (white blood sequences) or have no signal (black blood sequences). The vast majority of MR angiography (MRA) and MR venography (MRV) is based on white-blood sequences, sometimes following contrast material administration. This imaging approach enables 3-D reconstruction of vascular tree images.
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Ultrasound reflection
Ultrasound is a high frequency vibration transmitted as a series of longitudinal waves through the body. When it travels through the tissues, the vibration interacts with them. The most important form of interaction for creation of US images is reflection, which occurs when the US waves cross boundaries of tissues which are of different acoustic densities. The reflected US wave is picked up by the transducer, and the location and distance of the boundary is calculated. These boundaries (interfaces) form the ultrasound image are built up by an ultrasound machine.
PROPERTIES OF US IMAGES
Ultrasound images can be printed to paper or film, or displayed in real time on a monitor. By convention, US data is displayed as shades of grey, while flowing blood is colour-coded.
Fig.26.4. Routine US at 18 weeks of pregnancy Ultrasound examination during pregnancy may be obtained by moving the transducer across the abdomen. It is performed to assess the foetus as well as the position of the placenta.
Colour Doppler
Colour Doppler imaging detects moving blood and its direction but provides no information about its spectral properties. The velocity of motion commonly presented as an intensity map. By convention, flow towards the transducer is coloured red, while flow away from the transducer is coloured blue (although any colour scale could be chosen).
Fig. 26.3 Echocardiograms Most ultrasound probes are either curved or linear. Curved probes produce a wedge-shaped image but with a 213
PRACTICAL PERSPECTIVES
Fig. 26.5 Colour Doppler images (right kidney) Colour Doppler information can be superimposed on real-time grey scale structural imaging to provide a composite image ('duplex scanning').
Pulsed Doppler
In pulsed Doppler imaging, a continuous narrow beam of US is used to 'listen' along one chosen direction in a small target volume. The reflected US beam carries information about the flow velocity within the target volume as a function of time as well as spectral information about all its velocities (i.e. the spread of different velocities and their relative prevalence within the target volume). The sound equivalent of pulsed Doppler US is the familiar arterial 'whoosh'. The visual image is a very accurate representation of the flow waveform and is used for vascular physiological analysis (e.g... to derive peak systolic velocity, diastolic velocity etc.).
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Bronchoscopy
The respiratory tract to the segmental bronchi can be viewed through a bronchoscope passed via the nose. Vocal cord function is also assessed. Fig.27.3 Tract viewed at gastroscopy 1. 2. Upper end of oesophagus with folds (from surrounding cricopharyngeal sphincter) Lower end of oesophagus (with folds from surrounding functional sphincter) and line of epithelial transition to gastric type Body of stomach (with rugae) Pyloric antrum and canal with orifice (and surrounding pyloric sphincter) Smooth part of first part of duodenum (duodenal cap) Second part of duodenum with circular folds and duodenal papilla (for bile duct and main pancreatic duct)
Fig.27.1 Tract viewed at bronchoscopy 1. 2. 3. 4. 5. 6. Inlet of larynx and vocal folds Trachea Tracheal bifurcation Right main bronchus Right upper lobe bronchus A segmental bronchus
3. 4. 5. 6.
Cystoscopy
The lower urinary tract including the bladder (and ureteric orifices) can be viewed through a cystoscope passed via the external urethral meatus. The urethra in a male is much longer than that in a female. Particular care is taken to ensure the cystoscope negotiates the change in direction of the urethra at the bulb of the penis (to smoothly enter the narrow membranous urethra). This is achieved by manoeuvring the penis.
Fig.27.5 Tract viewed at colonoscopy 1. 2. 3. 4. 5. 6. Rectum (with superior, middle and inferior rectal valves) lined by a characteristically thin mucosa Sigmoid colon Splenic flexure of colon (with shadow of spleen seen through the wall) Transverse colon Ascending colon and caecum (with ileocaecal valve) Caecal pole (with mucosal folds and orifice of appendix)) Fig.27.7 Tract viewed at cystoscopy (male and female) 1. 2. 3. 4. 5. 6. Penile urethra Bulbar fossa in urethra (and opening to membranous urethra) Prostatic urethra (with urethral crest and seminal colliculus) Internal urethral meatus (and uvula of bladder projecting into lumen) Trigone of bladder Right ureteric orifice
Laparoscopy
The peritoneal cavity and abdominopelvic organs can be viewed through a laparoscope introduced via a small incision through the anterior abdominal wall, typically at the umbilicus. The peritoneal cavity is a potential space normally occupied by only a thin film of fluid (between parietal and visceral layers of the peritoneum). The viscera separate from the anterior abdominal wall when gas is introduced to distend the space.
Thoracoscopy
The pleural cavity, lung and mediastinal structures can be viewed through the relevant side of the thoracic wall. At the beginning of the procedure, the lung is partially collapsed by entry of air into the pleural cavity. This potential space is normally occupied by only a thin film of fluid (between parietal and visceral layers of the pleura). As it collapses, the lung separates from the thoracic wall. The lung is re-inflated after the thoracoscope has been removed.
Fig.27.11 Body cavity viewed at laparoscopy 1. Left lobe of liver (lifted, showing left subhepatic space), stomach (with greater omentum) and spleen, diaphragm and left subphrenic space Diaphragm and right subphrenic space, right lobe of liver and fundus of gall bladder Anterior abdominal wall and small intestine Uterovesical pouch of peritoneal cavity (between uterus and bladder), uterine tubes and ovaries (with follicles) Rectouterine pouch of peritoneal cavity (between rectum and upper part of vagina) and fundus of uterus
2. Fig.27.9 Body cavities viewed at thoracoscopy 1. 2. 3. 4. 5. Right sympathetic trunk descending on the posterior thoracic wall (crossing intercostal veins) Right lung (middle and lower lobes) and anterior costodiaphragmatic recess Right dome of diaphragm and posterior costodiaphragmatic recess Upper lobe of left lung and lateral thoracic wall Left phrenic nerve on pericardium over left ventricle 3. 4.
5.
INCISIONS WOUND CLOSURE SYNOVIAL CAVITY PUNCTURE BODY CAVITY PUNCTURE INJECTIONS NERVE BLOCKS ARTERIAL PUNCTURE VENEPUNCTURE INTRAVENOUS CANNULATION INCISIONS
An incision is a surgical cut through skin. Incisions are made to remove skin lesions or to provide access to deeper anatomical structures. For surgical exploration of body cavities, incisions are also made through the other layers of the body wall. Skin characteristics of the region (including relaxed skin tension lines) should be assessed with functional and cosmetic implications considered.
PRACTICAL PERSPECTIVES
pressure difference enables effective circulation at the tissue level.
Fig.28.3 Elevation to reduce bleeding Those with high venous pressure (e.g. legs and feet) heal slower due to a more sluggish microcirculation. Areas with a poor arterial supply (e.g. skin over the tibia) do not tend to heal well. This is accentuated in patients with impaired arterial flow (e.g. from arterial occlusion) or impaired venous flow (e.g. from varicose veins). Fig.28.4 Incision via layers (anterior abdominal wall)
Fig.28.5 Sites where vital nerves are superficial Nerves that are superficial and vulnerable at specific sites include the: - facial nerve branches (on face) - accessory nerve (in posterior triangle of neck) - ulnar nerve (behind elbow and at wrist) - median nerve (at wrist) - recurrent thenar branch of median nerve (in palm) - common fibular nerve (behind knee) All of the above nerves contain motor fibres, with significant functional impairment to muscle action resulting if inadvertently severed.
Fig.28.6 Vessels and nerves endangered on abdomen Internal organs (e.g... abdominal viscera) may even be endangered if an incision is made too deeply.
WOUND CLOSURE
A wound is an injury involving a break in the skin, produced by either an incision or a laceration (traumatic tear).
PRACTICAL PERSPECTIVES
prevent disfigurement. Edges heal better when they are slighted everted. Sutures should be tied away from the wound edge.
Fig.28.8 Eversion and alignment of wound edges Excess tension (e.g... sutures tied too tight) impairs blood supply to the wound (especially its edges), causes pain and delays healing. Impaired blood supply may even result in the wound breaking down.
Fig. 28.11 Optimal compression from dressings Sutures should be left for a greater time in areas under tension with a poor blood supply (or other factors delaying healing). If there is doubt, they can be removed in stages rather than all at the one time (and risk wound disruption). However, if sutures appear too tight (and causing inadequate blood supply) they should be removed early.
Fig.28.9 Suture tension and tissue blood supply Although many areas can tolerate some tension to bring wound edges together, in certain regions (e.g. lower leg, foot, palm and fingers) only minimal tension is permissible. Areas already under considerable tension (e.g. over the tibia) require particular care. Excessive tension may require mobilization of a skin flap or even skin grafting.
Fig.28.12 Layers of a laceration and associated injuries Bleeding from wounds, even in highly vascular areas (e.g... scalp) is usually controlled by pressure applied to each side of the wound. Small spurting arteries can be clamped (with artery forceps) for a couple of minutes and larger spurters ligated, if necessary. Bleeding will tend to stop from compression by the sutures when the wound is closed. The wound should be explored by searching for any foreign bodies. The site, number and depth are assessed (including by x-ray where appropriate) before attempting removal. Use of a tourniquet may be considered to provide a bloodless field. 222
Fig.28.10 Postoperative elevation to minimise swelling Post-operative swelling will further increase wound tension. Swelling can be minimized by elevation (which reduces hydrostatic pressure). Tension from muscle action can be minimized by immobilization from a splint. Firm dressings may reduce wound tension and swelling, but if too tight will impair blood supply.
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INJECTIONS
Intradermal (ID) injections are given directly into the dermis of the skin. Subcutaneous (SC) injections pass through the skin into superficial fascia. Intramuscular (IM) injections penetrate into muscle.
Fig.28.15 Depth and optimal angle of injections The more superficial the injection, the flatter the plane of entry, to prevent the needle from penetrating too deeply. For an ID injection, the needle is of narrower bore and the volume injected to raise a small bleb within the skin is much smaller. For a SC injection in a thin person, the skin and subcutaneous tissue may be pinched to ensure the correct layer is injected.
NERVE BLOCKS
A nerve block involves infiltrating local anaesthetic around a nerve to interrupt conduction (temporarily). Within a peripheral nerve, small fibres (mainly pain fibres) are most affected by local anaesthetic agents. Larger fibres are affected to a lesser degree (hence touch sensation may remain). Although anaesthesia may be achieved by infiltration directly around certain structures (e.g. in a wound) much more local anaesthetic agent is required than with a nerve block. Directly injecting certain areas (e.g. palm or sole) may be painful and injection of fluid into tight, confined compartments may also raise pressure in the compartment, compromising vascular supply to its contents. Fine needles reduce the rate of injection and the volume required. Dental syringes have cartridges and fine needles, allowing easier control of the volume injected. However, they preclude aspiration and should only be used for superficial injections. The point of the needle must be moved while injecting to avoid inadvertent intravenous injection of a large bolus.
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Fig.28.19 Compressing circulation to hand Adequate collateral circulation to the hand is tested by compressing both the radial and ulnar arteries at the wrist until the skin of the palm has blanched. One artery is released with blushing in the entire palm indicating adequate collateral supply from that artery. The test can be repeated for the other artery to assess adequacy of collateral supply from it.
Fig. 28.21 Radial artery puncture Compression of the artery immediately after removal of the needle or cannula is mandatory to minimise bleeding. Firm pressure is maintained (through a gauze swab) for at least 5 minutes.
Technique of venepuncture
The needle should be directed along the chosen vein at a reasonably flat plane of entry (10 -15 degrees) through the skin, bevel upwards. It is inserted to at least 5 mm. into the interior of the vein.
Fig.28. 23 Superficial venous patterns in cubital fossa Being a flexor region, the skin is not as tough as on the extensor aspect of the limb and after the procedure compression of the vein can be easily assisted by elbow flexion.
Fig.28.25 Venepuncture in the cubital fossa For obtaining a venous blood sample, aspiration should be performed gently; otherwise the vein (being at low pressure) will tend to collapse. Failure of the procedure may occur because the needle has missed the vein (the needle can be withdrawn slightly and the procedure reattempted) or penetrated right through the vein (the needle can be slowly withdrawn while gently aspirating, until the vein is re-entered). After the sample is obtained, the tourniquet is released and the needle withdrawn. Compression of the vein (through a swab) immediately after removal of the needle will minimise bleeding and bruising. Gentle pressure is usually required for only a short time. 227
Fig.28.24 Inadvertent injection into an arterial variant Intravenous injection of a general anaesthetic agent or vasoconstrictor should not be administered at the cubital
INTRAVENOUS CANNULATION
Intravenous cannulation is performed to infuse fluid, transfuse blood and administer drugs. Typically a peripheral vein is chosen, but a central vein (e.g. internal jugular or subclavian) should be utilised to monitor central venous pressure, infuse certain drugs or supply parental nutrition.
Fig.28.26 Intravenous cannulation on dorsum of hand The needle (with surrounding cannula) should be directed along the chosen vein (located in the 228
POSTMORTEM EFFECTS ON TISSUES ORGANS IN-SITU AT AUTOPSY EXCISED VISCERA AT AUTOPSY POSTMORTEM EFFECTS ON TISSUES
The colour, texture and shape of organs at postmortem more closely represent their living state than in embalmed cadavers (due to the effects of embalming fluid). However, postmortem tissues are more friable and may be obscured by blood. They are also not disinfected and tend to deteriorate (particularly at room temperature). During autopsy, organs are first examined in-situ. Viscera are also examined following excision and in cut section (demonstrating their external and their internal appearance, respectively).
Anterior thoracic wall removed ORGANS IN-SITU AT AUTOPSY Skin and abdominal wall incised
After the body is placed in the supine position, a line of incision to expose contents of the thoracic and abdominal cavities is planned. The skin and muscles covering the anterior thoracic wall and those of the anterior abdominal wall are incised and reflected. This reveals the sternum and rib cage (with intercostal muscles) in the thorax and opens the peritoneal cavity below the costal margin. Within the abdomen, the liver and stomach are exposed, together with the fatty membrane (greater omentum) covering most of the intestines. The ribs are cut laterally and the front of the rib cage removed, by cutting it from the diaphragm. This opens the pleural cavities and reveals the lungs. The pericardium (located between the pleural sacs) is also exposed.
Fig.29.3 Intestines with mesenteries removed The transverse colon and most of the small intestine (jejunum and ileum) are excised along with their mesenteries. This reveals the duodenum and descending colon.
PRACTICAL PERSPECTIVES
The pericardium is removed, revealing other structures located in the mediastinum. The mediastinum is the region of the thoracic cavity between the pleural sacs. The first two parts of the aorta (ascending and arch) are visible, with the third part (descending aorta) obscured by the oesophagus. Pulmonary veins are also seen passing horizontally. The diaphragm is lifted, revealing the superior surface of the liver and the upper part of the stomach. The ascending colon has also been displaced upwards, to reveal the caecum and appendix.
Heart excised
The heart is removed by cutting all the great vessels at the reflections of the serous pericardium.
Fig.29.7 Retroperitoneal unpaired viscera All remaining contents of the thoracic cavity are removed, revealing the thoracic vertebral column. The liver (with the gall bladder), stomach and spleen are excised, revealing the duodenum and pancreas. The ascending colon, descending colon, duodenum and pancreas are retroperitoneal as their (dorsal) mesentery became absorbed during development.
Fig.29.5 Parietal layer of serous pericardium The parietal layer of the serous pericardium is reflected onto the heart (to become the visceral layer) via two connecting roots for the great vessels. One set of reflections is for the arteries (pulmonary trunk and ascending aorta) while the other set is for the veins (superior vena cava, inferior vena cava and the pulmonary veins). The right pulmonary veins are demonstrated while the left pulmonary veins have been removed.
Fig.29.8 Paired viscera on posterior abdominal wall The diaphragm, ascending colon (with caecum and appendix), duodenum and pancreas are all excised. The paired viscera (kidneys, suprarenal glands and ureters) on the posterior abdominal wall are exposed, together with the inferior vena cava. The left renal vein is seen passing across the abdominal aorta before draining into the inferior vena cava. The descending colon is displaced laterally and is seen crossing the pelvic brim to become the sigmoid (pelvic) colon. The peritoneal cavity of the pelvis is continuous with that of the abdomen. 230
29. Postmortem Examination of Organs EXCISED VISCERA AT AUTOPSY Hollow viscera excised and in cut section Solid viscera excised and in cut section
Fig.29.9 Excised hollow viscera 1. Oesophagus 2. Trachea and main bronchi 3. Heart 4. Stomach 5. Gallbladder 6. Duodenum 7. Jejunum and ileum 8. Caecum (with appendix) and abdominal colon 9. Bladder (with ureters) and deferent ducts 10. Vagina and uterus (with uterine tubes) 11. Sigmoid colon, rectum and anal canal Fig.29.11 Excised solid viscera 1. Thyroid gland 2. Lungs 3. Liver 4. Spleen 5. Pancreas 6. Suprarenal glands 7. Kidneys 8. Ovaries 9. Testes (with epididymes) 10. Prostate gland (with seminal vesicles)
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SURGICAL INSTRUMENTS
Fig.30.2 Surgical instruments used for dissection Fig.30.1 Cadaver supine on a dissecting table Dissection utilises surgical instruments to manipulate tissues and is performed layer-by-layer (from superficial to deep) commencing with a skin incision.
Scalpels
Scalpels are used to make incisions and to clean visible surfaces (e.g. muscles) by piecemeal removal of fat. They have a handle and a blade, each of which come in various sizes. The larger blades are more useful for incisions and removal of skin or of deep fascia, while the smaller blades are more useful for very fine dissection (e.g. clearing connective tissue from a small vessel). Scalpel blades become blunt with use and need to be changed regularly (with great care). The scalpel handle is notched obliquely on one side; which abuts the oblique end of the blade and the two may only be correctly fitted on that side.
SKIN INCISION
A fresh, sharp blade is applied to the scalpel handle to begin dissection. Larger scalpels are generally chosen for skin incisions on an embalmed cadaver, due to the force required to penetrate the skin (which might snap a small scalpel blade). An incision is made with the scalpel blade held perpendicular to the plane of the skin, contacting it along the blades edge (rather than just with the point).
Forceps
There are a variety of forceps. Plain (non-toothed) forceps are used for grasping tissues other than skin and may be used in fine dissection to separate tissues.
Fig.30.4 Holding tissue forceps correctly Toothed forceps are used for grasping cadaver skin, (that has been fixed by embalming fluid). However, toothed forceps should not be used on living skin to avoid localised trauma. Other special types of forceps are artery forceps, used for clamping vessels (and for changing scalpel blades). They have a ratchet, enabling the joints to be locked at various tensions. Bone forceps are strong and heavy, used for fragmenting and removing bone. Plain and toothed tissue forceps should be held like a pen, but controlled between the thumb and middle finger for optimum ease and accuracy.
Scissors
A pair of scissors can be activated by inserting the distal phalanx of the thumb and of the ring finger into each loop. The scissors may then be guided by the index finger, which is positioned over the joint for fine control and steadied by the middle finger.
Fig.30.6 Incising the skin (on leg) The epidermis and dermis (approximately 2mm deep) are pierced. In thick skin, on the palm of the hand or sole of the foot, the epidermis is greatly thickened and much tougher. These areas require a more forceful incision, so special care must be taken to avoid injury. Once the blade enters the (fatty) subcutaneous tissue, a reduced resistance is felt.
SKIN REFLECTION
Fig.30.5 Holding tissue scissors correctly Large scissors with round-tipped blades can be used to separate tissues by inserting their blades closed, then gradually opening them. Curved blades enable these scissors to be controlled from an angle (not in the plane of dissection) so that they do not obscure the field of view. Small, pointed scissors should be used for very fine dissection or trimming surfaces and edges of soft tissue. 233 Skin may be reflected after two incisions meeting at a right angle have been made. The skin at the junction of the incisions is gripped firmly (using toothed forceps) and traction applied to it, while the blade of the scalpel progressively frees dermis from underlying subcutaneous tissue. This is done using small strokes, rotating the blade so it cuts parallel to the plane of the subcutaneous tissue. Reflection along this plane avoids damage to structures in the subcutaneous tissue.
PRACTICAL PERSPECTIVES
Skin flaps are reflected, rather than removed, so that they can be replaced following dissection to keep underlying tissue moist.
Fig.30.9 Incising and reflecting deep fascia Deep fascia is removed from the field of dissection and, in this case, incised along its attachment to bone (where it becomes continuous with the periosteum). In general, deep fascia is easily removed from underlying muscles except where it merges with intermuscular septa. At some sites, muscle may be attached to deep fascia by its associated connective tissue (surrounding epimysium, aponeurotic expansions or tendinous prolongations).
Fig.30.8 Detaching subcutaneous tissue Cutaneous nerves and superficial veins receive their fine branches (or tributaries) from the skin. The main nerves and veins are preserved and may be followed until they pierce the deep fascia. The remaining fat is reflected and removed. 234
Fig.30.11 Opening scissor blades to separate structures Neurovascular bundles tend to course along mobile fascial planes, in parallel with them. Branches tend to pass along fixed fascial planes (e.g. intermuscular septa). The fascial sheath of a neurovascular bundle is thinner around veins, enabling them to expand. This may be removed (usually using a fine scalpel and forceps) and structures within the bundle separated by inserting closed scissors, then gradually opening the blades. Deep arteries in the periphery are surrounded by venae comitantes (pairs of veins with numerous intercommunicating branches). These in turn also communicate with superficial veins by communicating veins, which pierce the deep fascia.
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III n t r o d u c t iii o n n t r o d u c t o n n t r o d u c t o n Viscera Cells C h a p t e r C h a p t e r 4 C h a p t e r4 4 Extracellular matrix Osteoblasts Osteoclasts Compressive Tensile Calcium Collagen Hyaline Fibro Elastic 244
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III n t r o d u c t iii o n n t r o d u c t o n n t r o d u c t o n Normal variations Atypical Anatomical variations Abnormal Normal Function Anomaly Partial Complete Single Multiple Unilateral Bilateral Reciprocal Compensatory Pathological changes Impaired function Congenital Acquired C h a p t e r 8 C h a p t e r 1 8 C h a p t e r1 1 8 Growth Development Prenatal Embryonic Foetal Zygote Morula Blastocyst Embryoblast Trophoblast Bilaminar germ disc Ectoderm Endoderm Trilaminar germ disc Mesoderm Organogenesis Longitudinally Transversely Neural tube Somites Crown-rump length Amniotic fluid Gubernaculum Crown-heel length Oxygenated Deoxygenated Ductus venosus Ductus arteriosus Foramen ovale Ligamentum venosum Ligamentum arteriosum Ligamentum teres Medial umbilical ligaments Neonate
S Se ec cttiio on n3 3
III n t r o d u c t iii o n n t r o d u c t o n n t r o d u c t o n Region Position Relations Module C h a p t e r 3 C h a p t e r 1 3 C h a p t e r1 1 3 Paired Unpaired Bony Soft tissue Apertures C h a p t e r 4 C p t e r 1 4 Ch ha a p t e r1 1 4 Unpaired Ventral Dorsal Thoracic Abdomino-pelvic Cranial Vertebral Paired Bilateral symmetry Rotate Boundaries Apertures Compartments Boundaries C h a p t e r 5 C h a p t e r 1 5 C h a p t e r1 1 5 Prime movers Fixators Compartment syndrome Laminectomy Fibrous septa C h a p t e r 6 C h a p t e r 1 6 C h a p t e r1 1 6 Body wall Parietal Hernia Compression Obstruction Strangulation Serous sac Mesothelium Parietal Visceral Mobility Motility Prolapse C h a p t e r 7 C h a p t e r 1 7 C h a p t e r1 1 7 Neurovascular bundle Axial artery 246
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III n t r o d u c t iii o n n t r o d u c t o n n t r o d u c t o n Surface Anatomy Functional Anatomy Radiographic Anatomy Plain Radiography Contrast Studies Sectional Anatomy Computed Tomography Magnetic Resonance Imaging Ultrasound Imaging 247
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Index
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