G R V
r i 9 . 9 & s r s i n h a a t si r e p . p i v
At las of Huma
Anatomy
General Anatomy and Musculoskeletal System 15th Edltton by F: P;Nh:n
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URBAN l5l FISCHlER tahir99-VRG & vip.persianss.ir
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User's Guide to the Book lntrocUct:ory JllgM: • The introductory pages provide ell rel9\18nt anatomical informations concerning the subject of the chapter. Important de18ils and connections ere explained easily to understand. • The Dissection Unk for each chapter comprises brief and concise tips essential for the dissection of the respective body region. • Exam Check Usts provide all keywords for possible exam questions. Atilt JllgM: • The menu bar on top indicates the topics of each chapter. the bold print shows the subject of the respective pages. • Important anatomical structures in the figures are higtVighted in bold print. • Small supplement sketches located nex:t to complex views show visual angles and intersecting planes and, thus, facili18te orientation. • Detailed figure captions explain the relationships of anatomical structures.
• Bullated lists in figure captions as well as in 18bles help structuring complex facts and provide a better overview. • Figures. 18bles. and tex:t boxes are interconnected by crossreferences. • Cres5-references link the figures to the separate Table Booklet with tables of muscles. joints. and neNes. thus providing a sufficient anatomical knowledge for the exam. • Oinical RemaOO; boxes provide dinical background knowledge concerning the anatomical structures illustreted on the page. • The dissection link on the page indicates if a tip for dissecting the illustreted anatomical region is available on www.e-sobotta. com. Appendix: • List of abbreviations, general terms of direction and position can be found at the end of the book.
Perfect Orientation -the New Navigation System
--
Upper Extremity
...
The subject of this page
r-::--:--:---:::---~~~~
- 1 - - i The menu bar with the terms printed in bold indiea1es the subject of the currant page.
Slcetches facilitate orientation in complex ligures by showing visual angles and intersecting planes.
Important anatomical structures are primed in bold.
Figure captions explain anatomical connections concerning the illustretad structures.
-·----· .. _ .,......,... ..... _ ,-~-. . . , . . . _ , .·.. _
.....__"'
____ ..,. .. lioillroo _ _
CJI"'"-i~l"'~"'.............. .,__,.. ... .,....._......,_ ................... ... ,............... .......,....,_,_ -"'"""-· -----~~
For pages with this dissection link de18iled dissection tips can be found on www.e-sobotta.
__
___ __.. _____ ____......... ....._ _____ ... ___ ............... ................ __...,..._ ............................
1--+--- :..~=-.::::-~~ l'oet.l ........ -c..-,-=::::.:... _.,_ _ ::..::::::~-:-.::-::.:::~.:=: _ ...,...,.. _.,____ .... .._
..., _...
~_
........
...,.._
The Clinical Remarks boxes desaibe medical contax:ts to the anatomical structures illustr91ed on the page. Mostly, these dinical aspects are also of high relevance for the exam.
com.
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The following contents can be found in the other two volumes:
5 Viscera of the Thorax Heart --+ Lungs --+ Oesophagus --+ Thymus --+ Topography --+ Sections
en c
6 Viscera of the Abdomen
0
Development --+ Stomach --+ Intestines --+ Liver and Gallbladder --+ Pancreas --+ Spleen --+ Topography --+ Sections
"'~
..."'ccu
...
.E
-~.
7 Pelvis and Retroperitoneal Space Kidney and Adrenal Gland __, Efferent Urinary System __, Genitalia __, Rectum and Anal Canal --+ Topography --+ Sections
8 Head Overview --+ Skeleton and Joints --+ Muscles --+ Topography --+ Vessels and Nerves -+ Nose --+ Mouth and Oral Cavity --+ Salivary Glands
9 Eye Development -+ Skeleton .... Eyelids __, Lacrimal Apparatus -+ Muscles of the Eye __, Topography __, Eyeball -+ Visual Pathway
10 Ear Overview __, Outer Ear -+ Middle Ear Hearing and Equilibrium
-+
Auditory Tube
-+
Inner Ear
-+
11 Neck Muscles
-+
Pharynx __, Larynx __, Thyroid Gland __, Topography
12 Brain and Spinal Cord General __, Meninges and Blood Supply __, Brain .... Sections __, Cranial Nerves -+ Spinal Cord
tahir99-VRG & vip.persianss.ir
Paulsen, Waschke
Atlas of Human Anatomy Latin Nomenclature General Anatomy and Musculoskeletal System
Translated by T. Klonisch and S. Hombach-Kionisch
tahir99-VRG & vip.persianss.ir
tahir99-VRG & vip.persianss.ir
Atlas of Human Anatomy General Anatomy and Musculoskeletal System
G R V
15th edition Edited by F. Paulsen and J. Waschke
r i 9 . 9 & s r s i n hby T. Klonischiaand Translated a t sWinnipeg, Canada S. Hombach-Kionisch, r e p . with 700 Figures p 597 Coloured Plates i v
ELSEVIER URBAN &FISCHER '-------------'
URBAN & FISCHER Miinchen
tahir99-VRG & vip.persianss.ir
Editors
Prof. Dr. Friedrich Paulsen
Prof. Dr. Jens Waschke
Dissecting Courses for Students
More Clinical Relevance in Teaching
In his teaching, Friedrich Paulsen puts gffNit emphasis on the fsct that students csn ectliBI/y dissect on csdsvsrs of body donors. *The hands-on experifmce in diss6ction is extremely important not only for the three-dimensions/ undsrstending of snetomy snd ss the basis for virtue/ly every medics/ profession, but for many students also clfNirly addresses the issue of deeth end dying for the first time. The members of th8 dissection tfNim not only study snstomy but also 188m to dHI with this special issue. At no othsr time msdicel studtmts W/1/ have such a close contact to their classmates and tSBChers sgsin.M NThe dissection links in the at/as /sed to on/ins images thst are re/svsnt for the dissection. You cen print thsm and ts/cs thsm slang. The offered dissection tips are not instructions, but make sure that )lOu srs oriented exceptionslly we/lend not 'cutting in th8 darlc:M
From Msrr:h2011 Oft PnJfessor JMS ~ is Chsitrn8n Of
Professor Friedrich Paulsen lbom 1965 in Kiell passed the 'Abitur' in Brunswick: and trained successfully as a nurse. After studying human medicine in Kiel, he became scientific associate at the lnstiMe of Anatomy, Department of Oral and MalCillofacial Surgery and the Department of Otolaryngology, Head and Neck: Surgery of the Christian-Aibrechts-Universitiit Ki el. In 2002, together with his oolleagues, he was awarded the Teaching Award for outstanding teaching in the field of anatomy at the Medical Faculty of the University of Kiel. On several occasions he gained work: experience abroad in the academic section of the Department of Ophthalmology, University of Bristol, UK,. where he did research for several months. Fmm 2004 to 2010 as a University Professor, he was head of the Macroscopic Anatomy and Prosector Section at the Department of Anatomy and Cell Biology of the Martin-luther.JJniversitllt HalleWiltenbarg. Starting in April2010, Professor Paulsen became the Chairman at the Institute of Anatomy II of the Friedrich-AiexanderUniversiti.it Erlangen. Since 2006, Professor Paulsen is a board member of the Anatomical Society and 2009 he was elected the general secretary of the International Federation of Associations of Anatomy (IFAA).
Deparlt'riQnt I at th911'6fitut9 ofAnlltomy end Cs/1 Biology at ths Ludwig-Maximilians-UnNersitiit (LMUJ Munich. "For me, teadling at the depsrtmsnt of V9{1Qtativs anatomy. whirJl is 1'9S{l01lSib19 for the dissection courses of both Munich's largs universities LMU andTU, emp/lasizBs the importsnce of tHching anatomy wnh clfJllf clinical rsl9vsncs·, says ..19ns li'ofJsdlke. NThe clinic81 aspects in the Atlas introducs stlldsnts 1D 8tlltomy in the first semsststs. At the same time, it indicates the importllnce of this subj9ct for futl¥9 clinical prectice, as undsrstanding human snetomy tn98IIS more thtJn just memorastion of structur9S.M
Professor Jens Wesch Ia! (bom in 19741 habilitated in 2007 after graduation fmm Medical School and ccmpleting a doctoral thesis at the University of Wuerzburg. From 2003 to 2004 he joined Professor Fitz-Roy Curry at the University of California in Davis for a nine months research visit. Starting in June 2008, he became the Chairman at the lnstiMe of Anatomy and Cell Biology Ill at the University of Wuerzburg. In 2005, together with his oolleagues, Professor Waschke was awarded the Alben Koellilalr Teaching Award of the Faculty of Medicine in Wuerzburg. In 2006, he was awarded the Wolfgang Bargmann Prize of the Anatomical Society. His main research area concerns cellular mechanisms that control the adhesion between cells and the cellular junctions establishing the outer and inner barriers of the human body. The attention is focused on the regulations of the endothelial barrier in inflammation and the mechanisms, which lead to the formation of fatal dermal blisters in pemphigus, an autoimmune disease. The goal is to gain a better understanding of cell adhesion as a basis for the development of new therapeutic strategies.
His main research area concerns the innate immune system. Topics of spedal interest are antimicrobial peptides, trefoil factor peptides, surfactant proteins, mucins, corneal wound healing, as wall as stem cells of the lacrimal gland and diseases such as eye infections, dry eye, or osteoarthritis.
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All business correspondence should be made with:
Elsevier GmbH, Urban & Fischer Verlag, Hackerbri.icke 6, 80335 Munich, Germany, mail to:
[email protected] This atlas was founded by Johannes Sobotta t. former Professor of Anatomy and Director of the Anatomical Institute of the University in Bonn, Germany.
Addresses of the editors:
Professor Dr. mad. Friedrich Paulsen lnstitut fur Anatomi e II (Vorstand) Universitiit Erlangan-Nurnbarg Universitiitsstra P..a 19 91 054 Er1angen Germany
Garman editions:
Professor Dr. med. Sabine Hombach-Kionisch Professor Dr. mad. Thomas Klonisch Faculty of Medicine Department of Human Anatomy and Cell Science University of Manitoba 745 Bannatyna Avenue Winnipeg Manitoba R3E OJ9 Canada
1"' edition: 1904-1907 J. F. Lehmanns Verlag, Munich 2"d-1 1th edition: 1913-1 944 J. F. Lehmanns Verlag, Munich 12'h edition: 1948 and following editions Urban & Schwarzenberg, Munich 13'h edition: 1953, editor H. Becher 14'h edition: 1956, editor H. Bachar 15'h edition: 1957, editor H. Becher 16'h edition: 1967, editor H. Becher 17'h edition: 1972, editors H. Farner and J. Staubasand 18'h edition: 1982, editors H. Ferner and J. Staubesand 19'h edition: 1988, editor J. Staubesand 20'h edition: 1993, editors R. Putz and R. Pabst Urban & Schwarzenberg, Munich 21"' edition: 2000, editors R. Putz and R. Pabst Urban & Fischer, Munich 22"d edition: 2006, editors R. Putz and R. Pabst Urban & Fischer, Munich 23'd edition: 2010, editors F. Paulsen and J. Waschke Elsevier, Munich
Bibliographic information published by tha Deutsche Nationalbibliothak
Arabic edition
The Deutsche Nationalbibliothelc: lists this publication in the Deutsche National bibliografie; detailed bibliographic data are aveilabl e in the Internet at http://www. cl-nb.de.
Chinese edition (complex characters)
Professor Dr. mad. Jans Waschke lnstitut fur Anatomi a Ludwig-Maximil ians-Universitiit PettenkoferstraP..e 11 80333 Munchan Germany Addreues of the translators:
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Table of contents General Anatomy Orientation on the Body SurfacaAnatomy Davalopmant
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Muskuloskeletal System Vassals and Narvas
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Imaging Techniques
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o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o
Integumentary System
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4 6 12 14 22 32 36
Trunk SurfacaAnatomy Development Skelaton Imaging Muscles
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Vassals and Narvas Topography, Back Famala Breast
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Topography, Abdomen and Abdominal Wall
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42 44 46 68
74 96 104 114 118
Upper Extremity SurfacaAnatomy Development Skeleton Imaging Muscles
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o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o
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Topography Sections
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130 132 134 156 160 194 239
Lower Extremity SurfacaAnatomy Skeleton Imaging Muscles
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Topography Sections
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246 248 290 296 326 369
Translators
Prof. Dr. Thomas Klonisch
Prof. Dr. Sabine Hombach-Kionisch
Professor Thomas Klonisch (bom 1960] studied human medicine at the Ruhr-U niversitiit Bochum and the Justus-Liebig-Universitiit (JLU] Giessen. He successfully completed his doctoral thesis at the Institute of Biochemistry at the Faculty of Medicine of the JLU Giessen and became a scientific associate at the Institute of Medical Microbiology, University of Mainz (1 989-1991]. As an Alexander von Humboldt Fellow he joined the University of Guelph, Ontario, Canada, from 1991-1 992 and. in 1993-1 994, continued his research at the Ontario Veterinary College, Guelph, Ontario. From 1994-1996, he joined the immunoprotein engineering group at the Department of Immunology, University Collage London. UK, as a senior research fellow. From 1996-2004 he was a scientific associate at the Department of Anatomy and Cell Biology, Martin-Luther-Universitiit Halls-Wittenberg, where he received his accreditation as anatomist (1999], completed his habilitation (2000]. and held continuous national research funding by the German Research Council (DFG] and German Cancer Research Foundation (Deutsche Krebshilfe]. In 2004, he was appointed Full Professor and Head at the Department of Human Anatomy and Cell Science at the Faculty of Medicine, University of Manitoba, Winnipeg, Canada, where he is currently serving his second term as department chairman.
Teaching clinically relewnt anatomy and clinical case-based anatomy learning are the main teaching focus of Sabine Hombach-Kionisch at the Medical Faculty of the University of Manitoba. Since her appointment in 2004, Professor Hombach has been nominated annually for teaching awards by the Manitoba Medical Student Association.
His research areas concern the mechanisms employed by cancer cells and thai r cancer stem/progenitor cells to enhance tissue invasiveness and survival strategies in response to anticancer treatments. One particular focus is on the role of endocrine factors, such as the relaxin-like ligand-receptor system, in promoting carcinogenesis.
Sabine Hombach (born 1963] graduated from Medical School at the Justus-Liebig-Universitiit Giessen in 1991 and successfully completed her doctoral thesis in 1994. Following a career break to attend to her two children she re-engaged as a sessional lecturer at the Department of Anatomy and Cell Biology of the Martin-Luthar-Universitiit Halls-Wittenberg in 1997 and received a post-doctoral fellowship by the province of Saxony-Anhalt from 1998-2000. Thereafter, she joined the Department of Anatomy and Call Biology as a scientific associate. Professor Hom bach received her accreditation as anatomist in 2003 by the Garman Society of Anatomists and by the Medical Association of Saxony-Anhalt and completed her habilitation at the Medical Faculty of the Martin-Luther-Universitiit Halle-Wittenberg in 2004. In 2004, Professor Hom bach was appointed Assistant Professor at the Department of Human Anatomy and Cell Science. Faculty of Medicine of the University of Manitoba. She has been the recipient of the Marek European Thyroid von Basadow Research Prize by the Garman Endocrine Society in 2002 and received the Murray L. Barr Young Investigator Award by the Canadian Association for Anatomy, Neurobiology and Call Biology in 2009. Her main research interests are in the field of cancer research and environmental toxicants. Her focus in cancer research is to identify the molecular mechanisms that regulate cancer call migration and metastasis. She employs unique call and animal models and human primary cells to study epigenetic and transganarational effects facilitated by environmental chemicals.
Preface In the preface to the first edition of his Atlas, Johannes Sobotta wrote in May 1904: ·Many years of experience in anatomical dissection led the author to proceed with the presentation of the pari pharal nervous system and the blood vassals such that the illustrations of the book are presented to the student exactly in the same manner as body parts are presented to them in the dissection laboratories, i.e. simultaneous presentation of blood vassals and nerves of the same region. Alternating descriptive and image materials are distinctive features of this atlas. The images are the cora piece of the atlas. Apart from tabla legends, auxiliary and schematic drawings, the descriptive material includes short and concise text parts suitable for usa of this book in the gross anatomy laboratory.· As with fashions, reading and study habits of students change periodically. The multimedia presence and availability of information as wall as stimuli are certainly the main reasons of ever changing study habits. lhasa developments and changing demands of students to textbooks and atlases, which they uti lisa, as well as the availability of digital media of textbook contents, is accounted for by editors and publishers. Apart from intarvi aws and systematic surveys of students, the textbook saotor is occasionally an indicator anabli ng the evaIuation of expectations of students. Detailed textbooks with the absolute cia im of completeness are exchanged in favour of educational books that are tailored to the didactic needs of students and the contents of the study of human medicine, dentistry, and biomedical sciences, as well as the corresponding examinations. Similarly, illustrations in atlases such as the Sobotta, which contain exact naturalistic depiction of real anatomical specimens, fascinate doctors and associated medical professions for many generations throughout the world. However, students sometimes perceive them as too complicated and detailed. This awareness requires the consideration of how the strength of the atlas, which is known for its standards of accuracy and quality during its centennial existence featuring 22 editions, can be adapted to modern educational concepts without compromising the oeuvre's unique characteristics and authenticity. After careful consideration. Elsevier and the editors Professor Reinhard Putz and Professor Reinhard Pabst, who were in charge of the atlas up to its 22nd edition, came to the conclusion that a new editorial team with the same great enthusiasm for anatomy and teaching would meet the new requirements bast. Together with the Elsevier publishing house, we are extremely pleased to be charged with the new composition of the 23m edition of Sobotta. In redesigning, a very clear outline of contents and a didactic introduction to the pictures was taken into account. Not every fashion is accompanied with something anti rely new. Under didactical aspects we have revisited the old concept of a three-volume atlas, as used in Sobotta's first edition, with: General Anatomy and Musculoskeletal System (vol. 1], Internal Organs (vol. 2), and Head, Neck, and Neuroanatomy (vol. 3]. We have
also adopted, although slightly modified, the approach mentioned already in the preface of the first edition, i.e. combining the figures in the atlas with explanatory text which is an old trend being currently back into fashion once more. Each image is accompanied by a short explanatory text, which serves to introduce students to the image, explaining why the particular preparation and presentation of a region was selectad. The individual chapters were systematically organised in terms of currant subject matter and prevailing study habits; omitted and incomplete illustrations - particularly the systematics of the neurovascular pathways- ware supplemented or replaced. The majority of these new figures are conceptualised to facilitate studying the relevant pathways of blood supply and innervation by didactical aspects. We have also reviewed many existing figures, reduced figure legends, and highlightad keywords by bold print to simplify access to the anatomical contents. Numerous clinical examples are used to enhance the "lifeless anatomy", present the relevance of anatomy for the future career to the student, and provide a taste of what's to coma. Introductions to the individual chapters received a new conceptual design, covering in brief a summary of the content, the associated clinical aspects, and relevant dissection steps for the covered topic. It serves as a checklist for the requirements of the Institute of Medical and Pharmaceutical Examination Questions (IMPP) and is based on the German oral part of the preclinical medical examination (Physikum). Also new are brief introductions to each topic in embryology and the online connections of the atlas with the ability to download all images for reports, lectures, and presentations. We want to emphasise two points: 1. The "new" Sobotta in the 23m edition is not a study atlas, claiming completeness of a comprehensive knowledge and, thus, does not try to convey the intention to replace an accompanying textbook. 2. No matter how good the didactic approach, it cannot relieve the students of studying, but aid in visualisation. Anatomy is not difficult to study, but very time-consuming. Sacrificing this time is worthwhile, since physicians and patients will benefit from it. The goal of the 23m edition of Sobotta is not only to facilitate learning, but also to make learning exciting and attracting, so that the atlas is consulted during the study period as well as in the course of professional practice. Erlangan and Wuarzburg, summer 201 0, exactly 106 years after the first edition. Friedrich Paulsen and Jans Waschka
Acknowledgements First, we would like to express that the work on the Sobotta was axciti ng and challenging. During stages, at which one could see the progress of development of individual chapters and newly developed pictures with a slight detachment, one obtained satisfaction, was alated with pride and identified oneself evermore with the Sobotta. The redesign of Sobotta is obviously not the sola work of two inexperienced editors, but rather requires mora than aver a wall-attuned team under the coordination of the publisher. Without the long experience of Dr. Andrea Bailmann, who supervised several editions of the Sobotta and exerted the calming influence of the Sobotta team, many things would have bean impossible. We thank her for all the help and support. Ms. Alexandra Fmtic, who is also part of the four-member Sobotta team, pursued the first major project of her ca rear and tackled it with passion and enthusiasm. Her liveliness and management by motivation have enlivened and cheered the editors. We express our gratitude to Ms. Fmtic. We like to reflect back on the Sobotta initialisation weak in Parsbarg and weakly conference calls, in which Dr. Bailmann and Ms. Fmtic supported us in the composition of the Sobotta and presented an admirable way to marge the variety of two personalities to achieve a si ngla layout. Without the assertiveness, the ca lis for perseverance and the protective hand of Dr. Dorothea H ennessen, who directed the project of tha "23rd edition of Sobotta" and always believed in her Sobotta team and the tight schedule, this edition would have not bean published. Like a number of previous productions, the routi nier Renate Hausdorf lad tha successful reproduction of tha atlas. Other paopla involved in the aditi ng process and the success of the 23rd edition of tha Sobotta and whom we sincerely thank are Ms. Susanna Szczapanak (manuscript editing), Ms. Julia Baier, Mr. Martin Kortenhaus and Ms. Ulrika Kriegel (editing], Ms. Amalia Gutsmiadl (formal text editing], Ms. Sibylla Hartl (internal production), Ms. Claudia Adam and Mr. Michael Wiedom (formal figure editing and typesetting). Ms. Nicola Neubauer (layout development and refining tha typesetting data] and tha students Doris Bindl, Derkja Hockertz, Lisa Link, Sophia Pappa, Cornelia Ri ppl and Katherine and Florian Stumpfe. For the compilation of the index, we express our gratitude to Dr. Ursula Ostarkamp-Baust. Spacial thanks ara expressed to the illustrators Dr. Katja Dalkowski, Ms. Sonja Klebe, Mr. Jorg Mair and Mr. Stephan Winkler, who in addition to revising existing illustrations have developed a variety of excellent figures. Priv.-Doz. Dr. rar. nat. Helmut Wicht, Sankanbarg Anatomy, GoatheUniversitiit Frankfurt/Main, has revived the lifelessness of the introductions to the chapters indited by the two editors through his unique style of writing. We express our gratitude to Priv.-Doz. Dr. rar. nat. Wicht. A big help to us was the advisory council, which in addition to the former editors Prof. Dr. med. Dr. h. c. Reinhard Putz, Ludwig-Maximilians-Univarsitiit Munich, and Prof. Dr. mad. Reinhard Pabst, Hannover
Medical School, and colleagues Prof. Dr. mad. Pater Kugler, JuliusMaximilians-Universitat Wuarzburg, and Prof. Dr. rar. nat. Gottfried Bogusch, Charitlfl Benin, supported us strongly with advice and critical comments. We would like to specifically emphasise tha effort of Ms. Renata Putz, who corrected the manuscript very carefully; her comments were of crucial importance for the consistency of the work in itsalt and with the aar1iar editions. For support with corrections and revisions, we express our sincere thanks to Ms. Stephanie Beilicke, Dr. rer. nat. Lars Briiuer, Ms. Anett Dikar, Mr. Fabian Garreis, Ms. Elisabeth George, Ms. Patricia Maaka, Ms. Susann Moschtar, Mr. Jorg Pakarsky and Mr. Martin Schicht. For assistance in creating clinical figures, we express our gratitude to Priv.-Doz. Dr. mad. Hannes Kutta, Clinic and Polyclinic for Oto-RhinoLaryngology at the University Hospital Hamburg-Eppandorf, Prof. Dr. med. Norbert Kleinsasser, University Clinic for Oto-Rhino-Laryngo-Pathology, Julius-Maximilians-Univarsitiit Wuarzburg, Prof. Dr. mad. Andreas Dietz, Head of Clinic and Polyclinic for Oto-Rhino-Laryngology at the University Leipzig, Dr. med. Dietrich Stoevesandt, Clinic for Diagnostic Radiology at tha Martin-Luthar-Universitiit Halle-Wittanbarg, Prof. Dr. mad. Stephan Ziarz, Director of the University Hospital and Polyclinic for Neurology at the Martin-Luther-Universitiit Halle-Wittenbarg, Dr. mad. Barit Jordan, Hospital and Polyclinic for Neurology at tha Martin-Luthar-Universitat Halls-Wittenberg, Dr. mad. Saadattin Sat University Hospital for Ophthalmology at the Martin-Luthar-Univarsitiit Halle-Wittenberg, Mr. cand. med. Christian Schroeder, Eckemforde, and Mr. Danis Hiller, Bad Lauchstiidt. We also would like to express our thanks to our anatomical mentors Prof. Dr. med. Bernhard 'Tillmann, Christian-Aibrechts-Universitiit Kiel, and Prof. Dr. mad. Datlav Dranckhahn, Julius-Maximilians-Univarsitiit Wuarzburg, whom we not only owe our anatomical training, the motivation for subject matter, and the sense of mission, but also have been great role medals in their design of textbooks and atlases, as wall as in their teaching excellence. Our deepest gmtitude to our parents, Dr. med. Ursula Paulsen and Prof. Dr. mad. Karsten Paulsen, and also Annalias Waschka and Dr. mad. Dieter Waschka, who intensely supported and sustained the Sobotta project. Karsten Paulsen, who passed away in May 2010, studied anatomy as a medical student from tha 4'" edition of Sobotta. Dieter Waschka used the 16'" edition of Sobotta and continues to attain knowledge with medical literature even during retirement. The 23rd edition is dedicated to our fathers. Last but not least, we thank our wives Dr. mad. Dana Paulsen and Susanna Waschka, who not only had to share us with the Sobotta in the last year, but also were on hand with help and advice on many issues and have bean strongly supportive.
General Anatomy Orientation on the Body . . . . . . . . . . .
4
Surface Anatomy . .. . . . . .. . . . .. . . . .
6
Development .. . . ... ... . ........... 12 Musculoskeletal System ........ .. . 14 Vessels and Nerves ................ 22 Imaging Techniques . . . . . . . . . . . . . . . 32 Integumentary System ............. 36
AnatomyReveal the Concealed What Anatomy Is
Linguae Anatomiae
"
The language of this classical discipline "Anatomy" (Linguae anatomiae) is predominantly Latin and (latinized) Greek. In the past 50 years, some English terms were added. The anatomic Termini technici (terminology) are usually marvellously gmphic, concrete, and vivid. Even a word monster like "Cartilago arytanoidea" means simply (nothing more than) "the cartilage which looks like a gravy boat". This cartilage is located above the larynx and really looks like a boat-shaped pitcher to serve gravy. At times one needs visual imagination which anatomists do not lack. One does not need to be afraid of terminology, but mther enjoy its diversity. This is done most successfully when this terminology is translated into one's own language and imagination.
"Anatomy(... ) dissects organisms into their(... ) constituents( ... (, examining their axtamal, sensorial percaptibla properties and their internal structure. It is the study of death to make conclusions about life. Anatomy manually destroys an ideal creation in order to rebuild it mantally and to virtually recreate a human being. There is not a more glamorous task for the human mind." Josaph Hyrtl (Anatomist, 1811-1894). Although anatomy deals with death, it is devoted to life. It is not about death but mther about the comprehension of the human body which functions as a unit. The body donors are models only. There are two othar medical fields which deal with dead bodies: forensic medicine and pathology. Pathologists are interested in causes of diseases. Forensic medicine deals in particular with doubtful causes of death. Whereas the sole purpose of anatomists is to understand the living human body on a continuum from the embryonic stage to old age. Eyes and hands are most important tools of the anatomist.The findings revealed by hands, tweezers, scissors, scalpels, and the visualization of these structures by aye is called gross or macroscopic anatomy. Structures in gross anatomy not discernible by the nakad eye can be visualized by microtomes or light and electron microscopes. This field is called microscopic anatomy. Organization and classification are basic aspects of systematic anatomy. The body is precisely classified according to systems. The bone system for axampla includes not only bones, but also bony parts and associated terminology. On the other hand, tissue systems are organized according to types and subtypes. Topographic anatomy is the study of regions or divisions of the body and emphasizes the relations between various structures in that region. The relationship of form and function is tarmed functional anatomy. Topographic anatomy and functional anatomy are the supreme disciplines of the physician and lead the path to clinical anatomy. This serves as practical application for diagnosis and therapy. Lastly, comparative anatomy serves in evolutionary phylogeny. It is of interest to biologists and compares bodies and body parts of different creatures. Histology is a subdivision of microscopic anatomy and is dealing with the composition of organ tissues which are multicellular in structure. Cytology. the study of calls, focuses on structure and function of the single cell. Embryology, which mainly uses the microscope for examination of tiny embryos, describes the development of an organism (individual development, ontogenesis). Dissection and analysis is the trade of the anatomy, but its real goal is to mentally assemble all parts into a functioning whole. This goal of understanding the structural design and shape of biological structures and conceptualizing it as a unified structure-function relationship can also be called morphology.
2
Body Donations - The Legacy Dead human bodies are essential for carrying out lessons in dissection. These bodies are made available by body donations. The body donor bequeathed hislher body to an anatomical institute. This has to be done in person as a last will declamtion during the lifetime of the donor. Next of kin are not authorized representatives in this legal matter. Every body donor has personally contacted an anatomy institute during hislher lifetime and, in the last will, donated hiS/her body to the institution for teaching and research after death. The body donor usually receives a donor card which always needs to be at hand. When death occurs the body is brought to the anatomy institute and is used for lessons in dissection, for clinical preparations, for demonstration, or for surgery courses as well as for scientific studies. Following the courses and examinations, the mortal remains are usually cremated and buried in the cemetery of honour of the university. The memorial or funeral service is attended by family members, students, and instructors of the faculty. Depending on institution and/or state/province, there are different regulations for the exhibition of bodies and organs. For example, body donors or organs of body donors can be exhibited in an anatomical collection for presentation and teaching purposes, if this is expressed in the bodydono(s will. Reasons for body donations are diverse, and body donors represent all parts of society. The widely held assumption that body donors donate to be granted an inexpensive funeral is proven to be wrong. Many universities charge a fee for body donations and this has not resulted in a reduction of body donations.
Clinical Remarks----------, Human anatomy is the basis for the education of physicians, dentists, and other health professionals. The anatomical knov.iedge is constantly applied in daily patient care and must always be r&freshed. The curricula of biomedical studies and education continue to encompass more scientific knowledge. The EIJCisting subjects have to be covered in fewer lectures, since competing subjects and new technologies require a greater amount of the limited wniculum hours. Training competent clinicians and specialists in health-ralstad medical professions can be achieved effectively by supplementing anatomical facts with clinical examples. This also leads to an application.criantad Ieeming and incr&ases the motivation of the student. However, the extensive and tim&-consuming study of anatomy should not be neglected. Intrinsic and firm anatomy knowledge can then be applied to the benefit of the patient.
-+ Dissection Link Dissection is done by hand using a scalpel (non-disposable scalpels I) and anatomical tweezers. Structures and organs as well as their topographic relationships are axs mined in this fashion. The nature of the tissue differs regionally. Areas with a lot of adipose tissues that can be removed bluntly by hand alternate with connective tissue which can be stripped off with the aid of scalpel only. As pert of the preparation, different cavities era (I)CJIOSed which are filled with air, liquid, or said constituents. The tissue of the organs (parenchyma) may - depending on the fixation - be hard, soft, spongy, tender, or elastic. Protected nerves and blood vessels are located in different layers of the body. and their dissection can be of varying difficulty. In some locations these are easily removable, in other regions they may adhere to adjacent tissues. To illustrate the muscles, mobilization by loosening the tight surrounding connective tissue sheaths !muscle fascial is required. To prevent damage, spacial attention needs to be paid to nerves and blood vessels entering and exiting the muscle. Partial severance of surrounding ligaments is needed to open joints. In contrast some structures such as the inner ear can be exposed with a hammer and chisel or saws and milling machines. The preparation requires a lot of patience, manual dexterity, and spatial imagination. One gains great experiences and valuable insights which are not offered by any anatomy textbook or atlas. These include the three-dimensional understanding of tha structures of the human body, the controntation with death, but also teamwork.
EXAM CHECK LIST • Main axes • main plana& • directions and positioning of body parts • directions of movement • radiological terms of sectional planes • ganaral embryology • genaral surface projection of inner organa • skeletal overview • bona structure • bone devalopmant • bony connections • type of joints • examination of joints • muscle types • muscle mechanics • cardiovascular system • greater and l881er blood circulatory system • portal ayGem • overview: lymph system • spinal nerve • ovarview: central, paripheral, and autonomic nervous system • skin and finger naila • imaging technique&: radiograph, ultrasound, MRI, and scintigraphy
cr.
3
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Axes and planes
c
b
FigL 1.1a to c Planes and • • · • sagittal plana (Planum sagit tale). encompasses sagittal and longitudinal axes b transversa plana =horizontal plana (Planum transversale!, enc~ passes transversa and sagittal axes
Main ADs
c frontal plane =caonal plane (Pfan\ITI frontalel; anoompesses longitudinal and transverse axes
Main Planes ~------------------------------------~ median !sagittal) plane
symmetry plane, divides the body into two equal halves
is positioned perpendicular to longitudinal and sagittal axis
sagittal plane
runs parallel to the median (sagittal! plane
is positioned perpendicular to sagittal and transverse axis
transverse plane
any c~ional plane of the body
frontal plane
parallel to the forehead
sagittal aids
is positioned perpendicular to transverse and longitudinal axis
transverse aids longitudinal or vertica axis
Direction of Movement
extension
stretching of the torso or the extremities
Rlldiologiclll y.,..
Anatomical Terms
fieldon
bending of the torso or the extremities
sagittal section
sagittal plane
abduction
moving extremities sway from the torso
coronal section
frontal plane
adduction
moving extremities towards the torso
axial section
transverse plane
elevation
lifting of arms above the horizontal plane
Radiology terminology in im119ing pm«KiJras (co,..:~uted tomogrupl'rf and 11'1119"atic
rotation
turning extremities inwards and outwards around a longitudinal axis
own nom~~nclatura
circumduction
spinning motion
r&~~onai1CG imagi~l defines the wee main anatomictl
4
pia!l* a& HC!ioM with tl*r
Musculoskeletal system -+ Vessels and nerves -+ Imaging techniques -+ Integumentary system
Directional information and relationships
u~ mad lana antafcr
Ltlea mad lana PQIUrlar
UMe~emds--~~~ UMa~-~~~~
dlltal
• FigL 1.2• •nd b ~for arilm.tion, cir«tiOIRII inlarm..ion •nd r....lanshlps. • ventral viaw b dorsal view
1Winl of Dhctlan and Pasltlanlng of lady Parts aanial or superior
towards the head
apical
pointed or belonging to the tip
caudal or inferior
towards the sacrum
basal
pointed towards the base
anterior or ventral
towards the front or abdomen
dexter
right
posterior or dorsal
towards the beck
sinister
left
lateral
sideways, sway from the midline
pro>Cimal
towards the torso
medial
centered, towards the midline
distal
towards the end of the limbs
median or medianus
witl'in the median plane
ulnar
towards the ulna
intermedial
positioned in between
radial
towards the radius
oentral
towards the interior of the body
tibial
towards the tibia
peripheral
towards the body surface
fibular
towards the fibula
profundus
located deeply
volar or palmar
towards the palm of the hand
superficial or superficialis
located superficially
plantar
towards the sole of the foot
external or extemus
located externally
doml
(extremities) towards the back (dorsum} of the hand or the foot
internal or internus
located internally
frontal
towards the forehead
rostral
(literally translated: Ntowards the beak") towards the mouth or tip of the nose (exclusively used for directional and positional information related to the head)
5
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Parts of the body
Membrum lnt.IUI
1.3
Flf. 1.3 and Fig. 1.4 Surface anatomy ot 1he male ( ~ Fig. 1.3) 1nd the temele <~Fig. 1.4); vemral 'Yisw. Anatomical terminology generally refers to the upright position with the face directed forwarzd, arms positioned sideways, palms pointing towards the body or forward, legs positioned beside each other with feat pointing forward.
6
1.4
The body is divided into head (Caput), neck (Collum), torso (Truncus) with chest !Thorax), abdomen (Abdomen), peMs (PeMs), back (Dorsum). end upper (Membrum supariusl and lower (Membrum infariusl extremities. The extremities divide into the upper arm (Brachium), forearm (Antebrachium). hand (Manus) end upper leg (Femur), lower leg
Musculoskeletal system -+ Vessels and nerves -+ Imaging techniques -+ Integumentary system
Parts of the body
Membrum 8Upii'IUI
Membrum lnfwful
1.5
1.8
F~. 1.5 1nd Fig. 1.6 Surface 1natomy ot 1he mile ( ~ 1nd temale (~ Fig. 1.6); dorst~l view.
F~. 1.5)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . During 11111mnlllis (from ancient Greek. <1\ICliN~ enlfmfli!ISis = The history is usually taken before physical examination takes place, memory) - taking a medical history - the history of a patient is carefully examined with reference to current symptoms. A detailed medical history includes biological, psychological, and social Bltpects. This gathered information often permits conclusions rega~ ing risk factors and causal relationships. The anamnesis does not have a direct therapeutic goal, ahhough talking about end clarifying the issi.Jes may have a salutary effect.
but in an emergency immediate treatment is required and taking the medical history is postponed. The goal of the accurate medical history is to narrow down the possible differential diagnoses. This process of elimination is based on key symptoms and exclusion c~ teria. Following the medical history, further investigations are often necessary to effectively diagnose a medical condition.
7
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Regions of the body
Regia axil---.;;:......... Regla~mM8-~--~~
AaglotncHI- - --t-o
Roglo ~n~bllallll Roglo abdamlrlllllllleralll
Fig. 1.7 Boctr Nglont; van1ral view. The body surface is divided into n~gions for better desa'iption end orientation. Regio: region; Trigonum: triangle.
8
Development
-+
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Regions of the body
Raglo-HI antar1a
- -'1---
Aeglo antlllndliii)Oitellcr _
__,,..
Fig. 1.8 Boct, Nglons; dorsal view. The body surface is divided into regions for batter daSO'iption and orientation. Regio: region; Trigonum: triangle.
9
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Inner organs, surface projection
~~~+------o~~----~~~~~~~~~~~ ~--------~-------4~~~~~~~~
IN--------Gallta' ~"'f------- SPI8n [UenJ
-------1--'lr
~-------~,:===~~-~~~~~~ '+--------Je)mum r+-------- DucxJenum Aen
-------+-.....,
H-------Oalcn-----~1-"":3~!11
•
FigL 1.S. and b PrGjaction of inner organ1 anta ~ bodf surface. Projection of inner organs on1o the ventral abdominal wall (a) and onto tha dorsal wall of the trunk (b): esophagus, thyroid gland (Glandula thyroidea), Ylind pipe lll'lldleal, lung (Pulmo), heart !Cor), diaphragm, liver
b
(Hepar), stomach (Gaster), spleen (Splen (lien)). pancreas, duodenum, jejunum. kidney (Ran), colon. ileum, appendix (Appendix vermiformis), and rectum (Rectum).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Even without technical instruments. an examiner is able to obUiin orientation on individual organs and their projection onto the body surface of the patient through practice. Auecultation (to auscultate originates from the Latin word NauscultareN and means listening) is pert of the physical examination and includes the listening to the sounds of the organs typically done Ylith a ste1tlos
10
to best or shake) is performed for diagnostic purposes and involws tapping the body surface of the patient. Percussion induces vibretions of the tissue beneath the surface of the body. The resulting sounds provide information about the state of the tissue. Thus, the size and position of an organ (e.g. liver) or the air content of the tissue (e.g. lung) can be assessed.
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Inner organs, surface projection
~----
Hapar ----~
...
'J....:.~---Guta'----+-lt~~ ~r----- Vllllea blllarls
s•n~~~~====~~~~~B;~ Cdon-
~.:>-+-----
•
Rp. 1.10. and b ProJec'lan of lnnw organs onto ~he body ..rrace. Projection of inner organs on1o the right wall of the torso (a) and on1o 1he left wall of 1he torso (b): lung (Pulmo). heart (Cor),
diaphnJgm, liver (Hepar), stomach (Gss1arl, gall bladder (Vesica biliaris), spleen (Splen (l.ienD. colon, kidney (Ran). small intes1ine (lntestinum 1enue). appendix. (Appendix. vermiformis). and rectum.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Through knowledge of 1he proJection of the internal organs onto the body surface. disease specific symP1oms can already be linked to organs during physical examination. In addition 1o 1he petien1's history, first clues of 1he diseased organ(s) involved can be deduced.
F« example, appendici1is (inflamma1ion of 1he appendix !Appendix varmiformisD is usually acoompenied by discomfort in the right lower abdomen.
11
Surface anatomy
Orientation on the body -+ Surface anatomy -+ Development
-+
Development
h
. ~ :.
- - - - - '·, \, ,
--.........
,
',,
'"\,
... ,
.
6
'
\
...
\
the ampulla of the oviduct. The fusion of the pronuclei of the ovum and sperm into e single diploid nucleus creates the zygote
eG
,
:~ I
l
'
,' I
'
,,'' ~~
a
-
-------------· (g)
_a ____ a_a _______________ _
Figs. 1.11a to i First - k of embryogenesis: fartilization and implantation. [211 Within 24 hours after ovulation Ia), fertilization (b] noiTTially occurs in
\\
12-. 4-. 8- and 16-c:ell stages; d-h) generate a cell aggregate (Morula) which is transported into the uterine cavity. At approximately day 5 after fertilization, the morula develops into a fluid-filled cyst !blastocyst; il which implants into the uterine mucosa at days 5-6. (c). Subsequent cell divisions
Morula
a
Syncytlobtiphablut
0;'"-~'-
Epiblast} Embr}'l:lblut Hypoblast
(Embryoblast)
Trophoblast
b
Cytobtiphablast
Blastocyst cavity
Syncytiobtiphablast Amniatic cavity Germ plllte Blastocyst cavity
li'Dphoblast
c
Figs. 1.12a toe First and - n d - k of embryogenesis: bilaminar embryonic disc. [211 Upon differentiation of the morula (a] into the blastocyst, the latter generates an inner cell mass lembryoblast) and a larger fluid-filled (blastocyst cavity] outer cell layer !trophoblast; b). Through interaotions between maternal tissues and the trophoblast cells the uteroplacental circulation is formed (c-e). The embryoblast develops into
12
e
the bilaminar embryonic disc with ectoderm (columnar cells at the dorsal surface of the embryoblast] and entoderm (cuboidal cells at the ventral surface). The ectodeiTTI forms a dorsally located cavity which becomes the amniotic cavity. The ventrally located blastocyst cavity becomes the primary yolk sac which is lined by entoderm. At day 12, the secondary yolk sac (yolk sac proper) forms. The original blastocyst cavity is lined by extr&-embryonic mesoderm.
Musculoskeletal system -+ Vessels and nerves -+ Imaging techniques -+ Integumentary system
Development
Pl'lmftlve node
Chorda dcnalls
Cloacal membrane
BuocopharyngeaJ membrane
- -ifi'ff--+-_,.
Entoderm
h
Ectoderm
Figs. 1.13a and h Third week of amhryoganasis: gastrulation. 1211 Development of the trilaminate embryonic disc initiates with the appearance of the primitive streak at the dorsal surface of the ectoderm. At its cranial section, the primitive streak is demarcated by the primitive node (a). Cells migrating out of the primitive streak form the intraembryonic m•odarm located between the top of the yolk sac and the ectoderm of the amniotic cavity (gastrulation). Some of these cells form the notochordal pro-s which extends towards the cranial part of the embryo where the prechordal plata has formed (adhesion between ectoderm and entoderm without an intervening mesoderm
M~enn
layer). The notochordal process develops a lumen (notochordal canal) and becomes the notochord (Chorda dorsalis; primitive stabilizing structure of the embryo) which regresses later in development (h). Relics of the notochord can be found in the Nuclei pulposi located within the vetrebral discs. Some mesoderm cells migrate cranially past the prechordal plate to create the primordial heart. The three germ layers (ectoderm, mesoderm, entoderm) are the building blocks for the d lopment of all organs. Further information on the germ layers participating in specific organ formation can be found in embryology textbooks.
13
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Skeleton
·~""""-- NIIXIIII. :--~--- NandltKia
--irt--
-i-'in-- - oa-
~~~~~-7~--~~~-o.~
088a(3J)I--~~
088am~a--~~wn
OeladiQtaum [PhllllnQee]
~<1---FI)I.Ia
1-&i?f----l))la
~~--o-tanll ftlll~~----o-~11.
1-\H \11111 - - -o - dlgltcnm (Ptal.,g•J
Fig. 1.14 Skeleton, Systii1NIIklletale; ventml view. [1 0) The bones of the skeleton are grouped according to their shape end structure: • lang .b~ (Ossa Ionge), e.g. hollow bones of 1tle extremities, like femur end humerus • llltort bon.. !Ossa brevia), e.g. carpal end tarsal bones • flat bon• (Ossa plena}, e.g. ribs, sternum, scapula, pelvis, bones of the skull
14
• ail'4illld bonee (Ossa pneumetica}, e.g. frontal bone, ethmoid bone, maxilla, sphenoid bone • irng11llr bona (Ossa irregularia, cannot ba grouped with 1tla other bones), e.g. vertebme, mandible • MMmoid bonu (Ossa sesemoidee, bones embedded in tendons), e.g. patella, Os piriformis • ~~CCa~Gry bonu (Ossa eccessoria, accessory bones not commonly found in all human skeletons), e.g. lMUrel bones of 1tle skull, cervical rib
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Structure of bones
. ~ UI'Mep~ll
Eplphylll praxlmda ~
~~~~~proximal IS
.\
.l -. '
Apophyllll
~SIDI1amlaiiPClf!QI08a .·.~I.
Fig. 1.15 Long bclnea {hollow bclnea), Os longum. Section through the proximal part of the femoral bone of an adult. Periosteum of the diaphysis has been removed and folded sideways. Dorsal view. Sectioned femoral bone displays two distinct types of bones with no clear separation between them: • Substantia compacta or corticalis (compacta, compact bone, very thin in the epiphysis, substantial in the diaphysis) and • Substantia spongiosa (spongiosa, spongy or cancellous bone, substantial presence exclusively in the epiphysis and metaphysis). In the diaphysis, the compaeu appears as a solid mass; the spongiosa in epi- and metaphysis creates a three-dimensional network of delicate branched bones ttrabec:ulae). Depending on the physical forces applying, they are divided into traction or compression trabeculae. The space in between the trabeculae is filled with blooe}forming bone marraw (young person) or fatty lipids (old person). The orientation of the individual trabeculae is parallel to the lines of tensile and compressive stress generated within the bone. (In the femur, these forces are prox.imal and eccentric, adding additional bending stress to the bone.) A long evolutionary process resulted in a light bone, combining maximal mechanical robustness with minimal bone deposit.
- - - --
-
- - - - I~Umtllllamellu ....,----VOU
-
Pllrloetllum
----Oitoanwtth cancsntrtclamallu
VOU
fie. 1.16 StructuN of e long hollow bone, Os langum. The basic histological structure of both a mature compact bone and a mature spongy bone is similar and represents a lemeller bone. The mature bone is composed of lamellar concentric units, named on.o•, most frequently found in the compacta of long bones. In spongy bones, the lamellae are primarily oriented parallel to the trabecular surface. In the compact bone, lamellae of bone matrix with central blood vessels create osteons, a system IHAVERS' system) of five to 20 bony
lamellae (lpecielllmellae) which are grouped concentrically around a HAVERS' canal and can be a few centimeters in length. Collagen fibres show perpendicular orientation in adjacent lemeiiH of en o.tteon. Remnants of previous osteons, called lirt~MIIIIImellae, are located between ostaons. The outer and inner surface of the compacta is composed of lamellae surrounding the complete bone. These are called outer and inner circu.,....ntill lemeiiH.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The friCture of a bone leads to the formation of two or mora fr~~~r ments with or without dislocation. Apart from pain, true signs are abnormal mobility, grinding sounds with movement (crepitation). axis misalignment an initial muscle stupor Oack of muscle activity), and corresponding rediogrsph findings. Ideally, healing of a fracture involves complete immobilization and weight-bearing restrictions. S~» cassful h ..ling of 1 frectuN is achieved when the fonmer1y injured bone regains its full weight-bearing capacity and long bones have reformed the medullary cavity. The primtuy fracture healing ax.du-
sivaly occurs with narrow, irritation-free frscture gaps and does not involve callus fonmation, as is achieved surgically by osteosynthesis with plates and saews for optimal alignment of fractured ends. As part of the primary fracture healing, the fracture gap is bridged by capillaries from opened HAVERS' canals which are surrounded by osteons spanning the gap. The MCOncllry flllcture healing often forms a slightly thicker aiLII which is gradually converted into fun<> tional bone mass.
15
Surface anatomy
Orientation on the body
Surface anatomy
-+
-+
Development
-+
Bone development
~ 18.40.Y
J~--------~--------1&Y
, ~-------18.-18. y
16....18. y
EW; amllrycu'fc week EM; amllf)'llnlc maLa! LN; mcuttl dli'a w ;:r-ctli'a
17.-1&. y
7.-8. EW
- +I+-
20.-24. y @;j~--7....8. y
8.N
6.-7. y
2.-4. y
~i
__JW~·t 3.-4.Y
~~~a~1r
15.-21. y
1.-2.v ~ l
s,...6.Y ~ ;' ~1.17
08 8C8$lheldlllnl3.-8. M 081unatum 3 ....8. Y 08 tl'aPNium s.... e. Y 08tl'apeZddll~n~3.-7. Y
1.18
08 Pllllbm• 8.-12. y 08111CJJ.Wm1.-4. Y 08 ham IliUm 2....6. N 08 captat~n~2.-4. N
llllue7.EN
Cllcaneu8 6.-8. EM 08 naviculare 4. Y 08 cuboldllum 1Q. EM
up.,..
Fig. 1.11 and fie. 1.18 Oaliicltion of ttt. skeleton of the t-o Rg. 1.17f •nd lower mrell'it!M t-o Rg. 1.18f; position of the epiand apophysial ossification centres and chronological sequence of the formation of these ossification centres. The timing for these bone nucleation sites to appear holds clues as to the stage reached in skeletal development and, thus, to the individual skeletal and bone age. We distinguish ossification centres formed around the shaft (diaphysis) of the cartilage modal during the fatal pari-
9
l!::::-
6.EN 8. EN a.EW
08 aJnllifannB modlllill 2.-3. Y 08 aJnllifannB ntamaclklm 3.-4. Y 08 aJnell'llfrtMIIIIterale 12. N
od, resulting in the diaphyses (cilphJseal ouificltion} from ossification centres which in part form during the second half of the fatal period and in the first years of life within the cartilaginous epi- and apophyses tepJ. and apophytMI ostllc:Mion). No further increase in body height occurs once the cartilaginous epiphyseal gaps ossify and disappear (synostosis). Thereafter, isolated bona nucleation sites are no more 'iisible in the X.111y image.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . For treatment plans and the prognosis of orthopaedic diseases and deformities during childhood. the determination of skeletal age end
16
any existing growth reserves are of great importance.
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Joints
Fig. 1.19 FibrGUI joint, Junctura fibrau [Syndesmolil]. Fibrous joims between bones are found in sutures of the skull. syndesmoses (e.g. fibrous connections between the titia and fibula or the radius and ulna). and gomphoses (e.g. fibrous anchoring of the teeth in their alveolar sockets of the maxilla and mandibula).
Fig. 1.20 ClrtilaginoLII joint, Juncture cartileginee [Synchclndro-
slsJ. Cartilaginous joints connect bones through hyaiM carSaga (synchondrosis, e.g. connection between 1. rib and daviclel or ftbrocarSaga (symphysis. e.g. Symphysis pubica).
Oapu.fallltfc1.41Ufa{==Memllrlne
Jaln!IJDXI
IIYftCIYIIIIIe Plcu~
Fig. 1.21 Oluclus joint, Juncture GIIIMI8 [Synastculis). At the osseous joints bones are fused as exemplified by the sacrum.
Fig. U2 Synovill ftrue} joint, JIII'IICture synovilil [Atticulrio ~ ncMIIt. Dlerthro...J; schematic sectional view. (according to 11 JJ Hyaline cartilage at the bony ends covers the subchondml bone. The joint capsule encloses the joint cavity and consists of an outer fibrous membrana (Mambmna fibrosa} and an innnar synovial membrana (Membmna synovialis). The synovial membrane secretes the synovia into the joint cavity which acts as the grease of the joint VIlhan the freedom of motion of a joint is restricted by an exceptionally strong join1 capsula, this joint is called amphiarthrosis (e.g. small carpal joints of the hand and foot; Articulatio sacroiliacal.
Fig. 1.23 Structure of the joint ClpiUie. [24) The join1 capsule is composed of the Membmna fibrosa and the Membmna synovialis. The Mlmbrene fi)rau consists of tough fibrous tissue. The MembreM synoW!b is composed of the following layers: a superficial loose layer of A calls (type A synovialocytas or M calls, specialized macrophages which metabolize the metabolic compounds produced by the calls in the joint cartilage). 8 calls (type B synovislocytas or F cells, active fibroblasts which produce and secrete the outer collagen and protaoglycan aggmgates. i.e. hyaluronic acid of the synovia) and the subsynovial connective tissue rich in capillaries, fibroblasts, and lipocytes. Collagen fibres within the articular cartilage are arranged in arcades (BENNINGHOFF's arcades).
17
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Types of joints
f
• d
e
C¥J
---~
FiaL 1.248 to a JoinU, Juncturee synovilles [Articullrtion81, DlarboMI). Joints I.ISUSIIy increase the range of motion significantly. They are classified acoordng to 1tla shape of 1tlair articulating surtaces and/or 1tla freedom of movement they allow. Basad on 1tla main axes of motion, we distinguish uniaxial, biaxial. and multi axial join1s. • llinae joint, Articuletio qindrice (Ginglymus): uniaxial joint, permits flexion and extension b conaid joint, Articulatio conaidee: uniaxial joint. permits rotational movement e pivot joint, Articulatio trGchaidea: uniaxial joint, permits rotational movement
18
d conct,llr joint, .Atticua.tio owidee, Atticuktio elliptloidea: biaxial joint, permits flexion, extension, abduction, adduction, and restricted rotational movement • saddle Jo~ Mlcul~lo Mllarb: biaxial join1, permits flexion, exte~ sion, abduction. adduction. and restricted rotetional movament f spheroidal or bal and toeket Joint, Mlculetlo tpheroldee: multiaxial joint, permits flexion. extension, abduction. adduction, end rotational movement a plane joint, Miculetio plane: joint permits simple gliding movements in different direc1ions
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Range of joint movement
( a
b
Figs. 1.25a and b Documentation of the range of joint movement: nautraJ.null method. The neutral-null method is a standardized goniometric method to determine the active range of movement in a joint. An upright position with arms hanging down to each side is considered the zero degree starting
position when examining the joints (a view from the front and b from the side). The extent of achievable movement from this null position is expressed in degrees of angle measured. First the active range of movement away from the body is determined, followed by the active range of movement towards the body.
Eld8nsloniFiaXIan 0'-20'-140'
Figs. 1.2611 to c Documentation of the range of joint movement: Examples. a The normal healthy knee joint has the following range of movement 5° extension and 140° flexion (not shown). The angle of the ankle joint in relation to the foot is considered the null position. This allows for a 20• extension and 40° flexion under normal conditions (not shown). The normal range of movement in the knee joint is 5•-o•-140• (knee stretched, null position, knee bent), that of the ankle joint is 20•~•-40• (dorsal extension, null position, plantar flexion). b stretching of the knee impossible (see Clinical Remarks box) c complete stiffness of the knee (see Clinical Remarks box)
b
oo•
Eld8nsloniFiaXIan
o•-20•-2a•
c
140"
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - . Limitations of joint movement are associated with a decreased range of movement. A contraction is indicated if the joint mobility is restricted or the neutral position of a joint is not reached. The neutral-f'lull method is used to document exactly the mobility of the impaired joint. For a limited mobility of flexion contractura the motion formula reads for example, 0°-20°-140° [-+ Fig. 1.26b: extension of the knee is not possible, null position is not achieved, the
knee is in 20• flexion, but can be further bent to 140°). A complete stiffening of the knee due to ossification (ankylosis) results in the knee being fixed in a 20• angle of flexion. The movement formula is o•-2o•-2o• (-+ Fig. 1.26c: knee extension is not possible, null position is not achieved, the knee is bent at 20• and cannot be bent further).
19
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Types of muscles Sllrallum tlntum
~~··
~Ina
}
} synovlals tendlnll Vqlna Sllrailum 11Yft0111ale, tend INS
1 Itie o1 toroe ol11lerroscle 2 Vlrtual~evtr .m ctttle mUIICie 3 uls ol1'01a11Cn ctttle Jotlt
...,. tafldl.-
3
Fig. 1.27 Orp.._lan pmclpll af skeltrtlll mu...., exemplified by ttt. hredlill miiiCII, M. brachilliL Skeletal muscles move bones in their joints and have a fixed point of origin (Oligo) and a flexible point of insenion (lnsertio). They are surrounded by a fascia. The belly of 1tle musde (Venter, Gaster) connects with the bone through a tendon. The amount of force a muscle can transfer onto a joint depends on the length of 1tle lever !Vertical disUince of the vector forca of the muscle and 1tla rotational axis of the joint lever arm of force). The length of the lever varies depending on the joint position and is known as virtusllevar.
=
Rg. 1.28 Strudur• of • tllndon shedl.. YagiM tenclnls.. V.gm .,OYialil, -..mplified hy • finaw. Tendon sheaths reduce friction during movement and protect tendons which are deflected by musdas and bones. The composition of a tendon is similar to that of a joint capsule. The inner layer of 1tle tendon sheath (Strstum syna.~iale, Pars tendinea} is pan of the tendon, whereas 1tle outer layer (Stra1um synovial a, Pars parietalisl is part of the Stratum fibrosum of the tendon sheath. The gap between both layers (Cavitas synovia lis) contains synovial fluid (Synovia). Small blood vessels reach the tendon vis Vincula brevia and longs (small ligaments from 1tle mesotendineum).
Fig&. 1.298 to 1 Typu of muiCI& Micros<:opically, fibres of skeletal muscles exhibit typical cross-striations. Basad on their shape skeletal muscles can be divided into: • single head, parallel muscle fibres (Musculus fusiformisl b double head, parallel muscle fibres (Musculus biceps) c double belly, parallel musde fibres (Musculus biventer! d multi-head, flat muscle (Musculus planus) • multi-belly musde with tendinous intersections (Musculus inters&<> tUS)
f unipennate musde (Musculus semipennatusl f
I
g bipennste muscle (Musculus pennstus)
Definition----------------------------.. From a functional viewpoint, passive and active musculoskeletal systems can be distinguished: • The pauiwe miiiCUiollulfetlll system includes bones, joints, and ligaments. The skeleton creates the shape of the body, is an attachment point for muscles, and forms body cavities that oon-
20
Ulin and protect inner organs. Joints provide flexible connections between bones. • The actMI muiCUiolblatal system consists of the skeleUII muscles which move 1tle bones in 1tle joints and can be controlled voluntarily.
MuiiCUIDebleeal ~ -+ Veo~Nie S'ld ne~VH -+ lmeglro 111Chnk!UM
-+
lntegumerrtery eyftem Musd9 blomecheni~;S
'-''*' _"' _
_, _ _ _ .....
........,_,,...... snt.ttya..-.......,.,.o, ........ , " " ~tl)(11 1hn a. a...,. p~ Nil'llo""'*' ~ h mi.Mtt tli:lw
..S thl d'P. '4 ~·I a•~olftt,..,..lth *-a err a
,..,.. ,...... e 1\a C'I:IU leQ'M d
•• n"t..ldi& 1'b'lll p:tiiiiOMd ,_. ~ tl) . . . di'le6:w\ «f tt-.. fitlnlf. ............ ~ ef.
1llnlb'l 11111 b,..... fi:IQitol t. ~wllr\ t. M fclrw c:lll fw
tH&~,......flwu IF.J.-..1 fttnlllrrGrt ~. li:lwww, .._, ,.,..,.. .._
,.,......~ tDt.llilt'ldln h ~boca
ftai:W'Itl!dl"'.,._ fOHp.fltlfl'l&ter'tlcill ~ M/TI, ti'IOolobclklel ..,.. .ttdtrW~.tJ/1/y~dtMOOI'III:I'IIIIia b'l:lt it *•'*t'lldkl'h .-,,lin 1tw tll"llb'' fg,rQif:y ~" rN.wd "' ...
....w
fllcaOQt•ltldfw.,.....,.,._....bl:afTitaa:.elll...a..e.ct tilt 1'1&..,•• t'!lido'a" ... .,.,...,.. tnr,),
--r=l! {,
t{J
... , .... ....,................,.....,ti'UdMf!fhflltltlwjti'lt Wldhl'r••"""Witttn(r.cf~ ~IQ»nD
_.err alewt-.Hdt K$:1......_,
err
n.~ewt wm 11 .... ttlt C8f'lll'e t'WIDIIW H pol'if ...._... . tcrc:a ldl. ftJt ~ cotTpiM"ik m t.l'l'lCHtd ~ .. d. joinl. • 'l'rl.lllldiii"''WAtuM' .tl'l.t~ Q:lmkllf ~ llrolw•rm Q:I«WWa111i:n\a. Ttwllrclhc:lll ,.....,... 11!'1'1 . . . . . CI'I!M~~ t!'lt CI'Girl n:lb tel"ft t.t ~ ot 1'1& JOI". Air .......... ~ . . .etm II. n'Oitii!MI
tcC:IIIIIiltnM-
at.,....
~ftfiOI'tah M. lll'll:tioodloit.tll'dft .... ~it,.....
b'v nl .,...,... .,.......,., IMr•rm. ~ 'lltltrt l'l'IMI'f fQIIIIIt
............ O'IIHI!'I'.ed ....... tt.lbilinll' CO'I'\~wlmMI In N dll'!ldDrl ella~ t:lt'tle
21
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
The cardiovascular system
Un.tlpul..
Fig. 1.32 Ovem.w af ~he arurl.. of 1he sysUimic circuletion. The function of arteries is to transport blood from the heart to the periphery of the body 01' into 1tle lungs. We distinguish arteries of the elastic type (e.g. aorta, arteries dose to the heart) and arteries of 1tle muscular type (most of 1t1e arteries, e.g. As. brschialis and femorslis). Blood travels 1tlrough arteries with ever more narrow diameter to reach arterioles and enter into a capillary networlc: where the exchange of oxygen takes place between the blood and the tissue.
*
t.;J.Il;;:ttt--
1l'ilil11il p~lrior pul..
1\=• r - - Doreellepedle pul..
in women: A. CMirica
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In many parts of the body, large and mediumoized arteries run near 1tle body surface. The pulse can be felt by pressing 1tle artery against e harder underlying structure. The most distal palpable pulse and thus far1tlest from the heart is the pulse of the A. dorsalis pedis
22
on the dOI'sum of the foot. The examination of the arterial pulse reveals many clues abou11tle frequency of the heartbeat, differences of blood flow in the upper end lower extremity, end holds genersl dues abou11tle cirrulation of the blood in a particular body section.
Musculoskeletal System -+ Vessels and nerves -+ Imaging techniques -+ Integumentary system
The cardiovascular system
V.Jugl.fn exana \L Jugl.fn antafcr \L Jugulorla lnt.na
v. tn.cl'facep!alca daJdm v. 8Z)'gCit Ca
PreNntaltlon Gfvelne 111ft 81111: deep
~ht ~: tupertlclal
lllfttlcleof1he '-!:deep ct llle head: aul*ftclal
~ht aide
1.33
Fig. 1.33 end Ra. 1.34 OveMiw of 1M veins of the aystemic circulation , ... Fig. 1.33) end venous velva C... Fig. 1.34). Veins transport blood from the periphery of the body back to the heart. They expand easily and fune1ion as reservoirs. The veins of the systemic ciroulation transport deoxygenated blood, those of the tung circulation transport oxygenated blood. Most wins are concomitant veins, meaning they run in palllllel with corresponding arteries. Compared to the arteries, their course is variable and the blood pressure is significantly lower. Veins, capillaries, and wnoles are part of the low pi'UIUN aystem of blood circulation. Most of the time. veins transport blood against gr'BIIitational force. Thus, larger veins of the extremities and the lower neck region possess valves (venous valves! to SI.Jpport the venous blood flow back to the heart. ~rt from the valves. mu~ etas and the arterial pulse (only Yhlen venous valves are present} also affee1 the venous blood flow. Atrcws pointing upwards indicate the direction of blood flow. When blood acrumulates (arrows pointing downwards) the valves close. Most parts of the body contain a INI.,.&cill venous system in the subcutaneous fat pad which communicates with a deepw venous system running parallel to the arteries lboth systems ere separated by venous valves so that blood can only trawl unidirectionally from the superficial to the deep wins).
" in woman: V. ovaries
23
Surface anatomy ~ml~, pulmonary, eng fetal biOO
··--
.,.
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fNI!It to t'l6 t.1l ~ W WI open~ CN!IIe In the~ ~......,. H llft"'*'"*'ll. fl"dtll ¥o*di,..,N~tnd..,...
• DIJi:tl.l.l.......,.tARNmO
•
O\.IIIM~l£101'..uJ1 ~'n\ni.II~WJ!il
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Al ..... POtn. b~M.IIr ~«t(~
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t!'ICII'IWnnlfttQII'\...,_to.,.=•*MV*"' tiDe!~.
.,.,. .......... 8lil';h ~ ~"' ~011'111. w Of8l\ fJI'..ItU ww.oa.tBOTAL.UD n I'IMI.fted.,.. ~ 1'1& Me N~ .... fl'ttw»:yMi~tnd~a~.,,IIOod fnm h.., M'OII'l'lki~ .. I'IMIIdfNIIrly .... hhwnll . .
IJitiiAIIilf l:lb:ld tniN"f It WtCII¥,.., 100 l'fl"lifll .. nm mPit'f
hRrt-..,
WI!' .. ~..... ,,...,.., lrnl:l . . aiii'IMI\1'1'1!*11 . . . . ~. \rPto
l:tlt:*lltliOt:ftdWI'flll'.a........,..eot'15 .,,_,.WI~ A» qMII!IIl ai ....._ fil'ller'llyafalrr ~M.......,. il'woNIIIh ~Of
............ ~ . . hftr1l,go « "' ~..., .. Q"'lllt lrl ....,.,I' ICIh t!'lll......e.wn I'M.Itlln,_ocd.lllilcln t1:
'TI'I& trl'll!lllattlll'lelal'ld ......_ 01
1'16,.......f"hhlltty deterftft w
'IIIIIO.AWi,,.,,,._,li\N~~N(fi~~H
cd.rnrO.~htts.....,.~tll_...,.,....,aot!W'I'IHt. Olfi&!IIY tied '
iiGI!I'I..,.....,...f t *IJII!IIIIIIed tJii H • ...
&a'U.W)',t. ~ 8(J'(..uD,t.4,d
••• MAHT\US' 4llt .... MAHT\US' lliJmll'll
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Portal vein system
\( renall8 tlrfll!l'a
V.m.~ntarlcalnfartat
fie. 1.36 PGrtal vein, V. partH hepatil.. and infWior wna cava, V. cna lnfwfar; semi-sdlamatic representation; tribu18rias to inferior vena cava in blue; tributaries to the portal vein in purple. Potential portal-systemic anastomoses are encircled in black. The portal-venous circulation constitutes a special part of the systemic cirrulation. Here, two separate capillary beds (intestine, liver) are ronnected in sequence. Prior to reaching the systemic cirrulation, venous
blood from most unpaired abdominal organs (stomach, parts of the intestine, pancreas, spleen) is d111ined into the portal vein and from hare into the liver. This way, most of the nutrients ebsorted through the intestinaltrect first reach the liver and are metabolized there. Not until the blood has passed the liver, is it drained '.lie the liver veins r.Jv. hepaticas) into the inferior vena cava and the systemic circulation.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In patients with liver cirrhosis significantly less blood flows through the liver due to higher resistance of the liver end therefore incr...ed partal vein p.......,.. Bypassing the liver, the remainder of the blood flows through portocaval anastomoses directly into the systemic circulation. However, the vains in the anastomosis region are structurally not well suited to acrommodate the ina-eased blood
flow end will form wricole wina. This can lead to oesophageal varices in the region of the gestro-oesophageal junction, to the rare formation of a Caput medusae (Medusa head) in the region of pareumbilical veins, or it can result in the occurrence of varicose veins in the anal canal. Especially oteOpha1J8111 wric. can easily be injured during food uptake and cause lif&threatening haemO!Thagas.
25
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Lymphatic system
tnlnqe WI D.lctusl)'mphlllcu8 duUr
-
Orarlage via OUCIU8 thoracic us
Fig. 1.37 Overview cl the lymphatic syatem. Stsrting in the body periphery, lymph capillaries collect imerstitial fluid Oymph) and transport it '.lis collecting ducts into lymph veaela and lymph nodes. Lymph nodM responsible for 1tle collection and filtration of a particular body region are called regional lymph nodes. Those lymph nodes aocepting lymph fluid from differen1 lymph nodes are called collector lymph nodes. Finally, the lymph reaches two major lymphldlc duc:ts. the Ductus thoracicus and Ductus lymphaticus dexter, which drain the lymph into the venous blood of the systemic circulation. The major pal1 of 1t1e lymph
26
drains into the left venous angle (Angulus venosus, located between V. jugulalis imerna sinistre and V. ~bclavia sinistral via 1t1e Ductus bra· cicua. The Ductus lvfnphaticull dater drains the lymph collected from the right upper quadrant in1o 1tle right venous angle (located between V. jugulatis interne dextra and V. subcla'iia dextne). In addition to the lymph vessels and lymph nodes 1tle lymphoid ti~e also includes lymphatic organa (thymus, bone marrow, spleen, tonsils, mucosa-essociated lymphoid tissue IMALTJl. The lymphatic '31/S" tam has important functions in immune responses and resorption of lipids.
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Lymph nodes
Fig. 1.38 Lymph nodU wfth In- end outealna ~ph WSMis; •mMM:hem.tic H~P........tltion. Lymph nodes are part of the lymphatic system and considered secundary lymphatic organs. They come in various shapes (mostly
lens- or bean-shaped with a diameter of 5-20 mm). The body contains about 1,000 lymph nodes and of those 200 to 300 are located in the neck alone. Functionally, lymph nodes are part of the immune system and play an important role in the defence against infections.
Fig. 1.39 Lymph nodes; schematic croswection. (according to [2)) This cross-section of a nepresentative lymph node shows in-and outgoing lymph vessels (Vasa efferentia end Vasa efferentia). blood supply, and compartmentalization of ttle lymph node into B region !secondary follicle), T region (pamconical zone) with postcepillary or high endothe-
lial venules, follicular end interdigitating dendritic cells. medullary sinus, intermediate sinus, and subcapsular or rorticel sinus (With cellular romposition shown). " Reticular cells lining the sinus wall also reside within the sinus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The IXIIm~n
of lymph noda is an important aspect of the physical examination of e patient. The examination includes the palpable lymph nodes of ttle neck, the axilla. and the groin. The enlargement of lymph nodes can be e sign of inflammation (lymphadenitis)
or malignant disease (e.g. metastasis of a malignant tumour or a genemlized disorder of the lymphatic system such es HODGKIN's disease).
27
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Nervous system
Fig. 1.40 and Fig. 1.41 Ora•nlzMion of 1M 1111"¥0111 system; ventral(-+ Fig. 1.401 and dorsal view(-+ Fig. 1.41). (according to 1211 The nei\IOus system is composed of the central (CNS; brain, spinal cordi and peripheral nei\IOus system lPNS}. The PNS is mainly cernposed of spinal nerves (with oonnec1ions to the spinal C«d} and cranial nerves (Wi1h connections to the brain). The nervous system is involved in complex functions that include the regulation of the activities of the musdes and the intestines, the communication wi1h the environment and the inner self, and memoriz-
28
ing past experiences (memory). The nei\IOus system is also essential for conceptualizing imaginations (thinking), generating emotions, and adapting quickly to changes in the surrounding world and the body interior. We distinguish the alrtonom~ (visceral, regulating the activities of the intestines, predominantly involuntary) and the .omatic (innervation of skeiEJ181 muscles, cognitive perception of sensory input) IHII'VOIIS ~m. Both systems interact with and affect each other. Apart from the nervous system, overall body functions are also regulated by the endocrine system.
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Spinal nerves
N.ll'tmDI1all8
R. artanaua an1afct
Nn.lplnlll81: It'!. C8rVIcallle lt'!.lllarclcl lt'!.llnlllal• lt1.amllla8 N. CCICC)VIIU8
Rg. 1.42 ~ nrpl'nlntatfan of • spml nerve Cspml cord
•amant} -..mpified by two ifHINCic n.ws; view from above in
an oblique lateral angle. The human body has 31 pairs of spinal nerves (eight cervical. twelve thoracic, five lumbar, five saat~l pairs, and one coccygeal pair). Each spinal nerve is composed of an anterior root (Radix. anterior) and a dorsal root (Radix posterior). The cell bodies (Perikaryal of motor nerves are located in the grey matter within the spinal cord. Their ax.ons leave the spinal cord forming the anterior root. The perikarya of sensory
nerves are located in the dorsal root ganglia !Ganglia sensoria nervi spinalis). Their processes enter the spinal cord via the dorsal roots. Rami communicantes connect the spinal cord with the sympathetic chain of ganglia (Ganglia trunci sympathic:i) of the sympathetic trunk (Truncus sympathicus). All branches of the dorsal spinal nerves as well es the ventral branches of the thOI'acic spinal nerves T2 to 111 hew a segmental arrangement. The other ventral branches converge to form plex.us (Plexus cervicalis, brachialis,lumbosacrslis).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Excessive alcohol consumption. Diabetes mellitus, vitamin 8 deficiency, intoxication with heavy me181s and drugs as well as impaired blood perfusion can result in disturbances of peripheral nerves. This
can lead to palsy or excessive ex.c:i18tion of nerve cells (neurons). PolyntrurofM'hy resembles a clinical scenario in which many nerves ere affected.
29
Surface anatomy Auton om!~ nervous S'f.'Uim
,..,.a.,, ,,,............
~(2:1)
prthdc:hcJI!iCWIH<4anf~ Th6 IWitl& <* ellh.. . . 0
1
IW\tO.a.,...,.,
...
~ ~ the INII!II'Iaft ot
N tJrlttlllloOitJffiJMMOfl.-rt ai N _...., «
. . . .~"'~~.-db~ttcrfflt~ .. thll.,.._ liln. t . IWOIII~ f'bw .,.,._ CPI ........... ~Wild\ ....:11hl* P'.. tc> . .. , .Gllfl'l. Nt' 'ftlllllllf N~tttio~CIOOU'td.ftrot!Wii
....
'*-*~tlltllttdiWido'III'Wii'll6W~141)i,.., . . . . . . .
'nw~l'lln'OUJ~OWlllibttGC tw WI~ llfiiW1I'O'
W
•OfN~flr'ldil\
........... w~htrwk ~ Hn. ftlt'IO, TMm-..Cif tt.tllrw'lllltlrtdiiJ*'lc:lllh~-h!le~nl..-.u.
ht'IICiel afth.ttt ••••• k:z •tt kl::wW hhtnlrubmftl N_,.8f*"'ll«
_,.,_,.QIII'I-
(#I,flbMti)1Jrllit~tll1*t*- H ..... tf'll¥..,....~~i0flio I'JN'CQI ¥1+tttNI"'I fti1CitQ"lt 11:1 hl'r&IQ!rt (llljjJII'W. 'nw ~ *-ld lmlkt .... ~ • ...,, ......
thrtle:....,..,.
PI!• ,._.
.,_1, lhS ,._,.,~llth& ....... OII'I&~l . .li'IH:IU!Ir. 'Thtti .............................. H~dHi~~ V'IIICW)If It OliliiW'cf"' 1111~CIIIflkiw Wid~
c~~~~------------------------------------.
-·g.
..
.-c....
. . . . . .. ,. . .,
~
I
...........
NI•tde~*"art
TI'Mt ~~ P'fiWif ·~ cs..
tlnd1lrv ~~ ... 401 ~IIW)Qit lrl crtt. . _ _ (W, ~ ,_,QCII1hly II\ c:tart. tl'llllflba Cl' PNWlti!Dfh ~ <~~ ~ ,..,.. e
~
tadla• n
Clttw . . . . . te.... a.t. . . . ··--~~--
'*"'
,.,... Pfll\ •
~~.
Dllpo"*tt 0\haifMMd ~
Clf"' l&l1lnll"''tJ.....,.,. ~ c:k:rcln crf"' ~
~.....,_ ea3al hn:tSot\«Oiht~rrwy........
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Autonomic nervous system
~[il~-Pons--~ ~~fiij~ ~~~
~
Ganglion OlrVIcale ti.4*11.18
~~_...-N.aculamalalfl801~
N. faclal8 IVIO
m.- "'ill ~-.llmH-¥-- H. glattcphaly~el.l8 I.DQ
N.a.dlac18 cenlcalll mac:ll18 _ _ ~llan
_
cenlcathct'8dalm
(all.tum]
Fig. 1.44 Rep......trion of 1fle Svmpatflicul, Par• ~pathica. The entire sympathetic chain of ganglia and their interganglionic connections located to both sides of the venebrsl C
Fig. 1.45 RepNMrrtlrtion of 1M P•ruympathicull, Par• paruympaUM. The parasympathetic fibres (purple) normally run together with other nerves fibres.
31
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Radiography, fluoroscopy
ScllpJie, Angl.fUII IUparlar
Calla I A.pulmcnalllllllnllltra V. CIIW.IUparlar
BIIUI'C8.110 11'1CheU, C&llna tl'aCheU ltuncus pumonallll
Scapga. Margo medial a V.pulmcnall8
Brcnc!UilR!c. .lll dexter
r;..,.....:.....+ -
v.pulmcnaJIII
!IP"'~--~r ""ntrlcl.fUIIIInlltar
•
..
Fig. 1.46 Conventional radiograph tx·ray), owervilw of 1M 1ftoro:. 1271 Radiography is ona of the most frequently used imaging techniques in hospitals and local clinical prac1ice. Familiarity with the imaging temnique is essential in understanding how such images ere being generated and what type of radiographic image is viewed. Simple radiogaphic images of tha thorax are among 1hose most frequently generated. With a patient standing upright, the X-rays pass through the thorax.
in a postarior-entarior (PAl direction (patient faces radiographic film). In the lying position, the X-rays pass through the patian1 in an anteriorposterior (API direction. A good radiographic image of the thorax. displays the major bronchi and blood vessels of the lung. the cardiomadiastinsl conture. the diaphragm, the ribs, and the peripheral soft tissue. " conture of the breast (mammal
v.teln rumllellll II
cacm
Fig. 1.47 Conventional radiograph tx·ray), colon fluoro.ecopy llftw .blrfum twlllowtat.IBI In a radiograph. hollow organs. such as arteries, veins. and intestinal loops, are poor in contrast and need to be filled with a substance that absorbs X..rays to increase contrast. These substances must not be toxic to the patient. A frequamly used substance to increase rontrast of the gsst~ntestinel tract is the insoluble, non-toxic. high density salt barium Sl..llfste. For applicstions in vassals iodinKontaining molecules are usually employed. These substances are safe and well tolerated by most patients and can also be used to image the kidneys, ureters, and bladder (intravenous urogram (IVU). intravenous pyelogram (IVP)) as they are ex.creted by the kidneys.
32
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Scintigraphy and ultrasound
fie. 1.48 Scintig,aphy, tw:intigram of 1he 1hyraid gland. [27) In sdntigraphy, gamma rays (a form of electromagnetic rays) are used to generate an image. Gamma rays are produced as a result of the decay of unstable atomic nuclei, YAlereas X-rays are excess energy released during the bombardment of atoms with electrons. The gamma
ray eminer has to be administered to the patient. The radio-isotope tedlnetium-99m (99mrJ is most frequently used and injected as a cocktail together with other molerules. Upon irjection, images era generated by a gamma camera, depending on how the radiopharmacon is absorbed, distributed, metabolized, or exaeted by the body.
Memb!Um tlfellus
Fig. 1.49 Sonography, uMrasound lm•a• af a fwtut at w.ek 28 of pragn1ncy; lateral '.liew. Examinations of the body employing ultrasound era common in all medical speciahies. Ultrasound represents a series of high-frequency sound waves (not an electromagnetic beam) generated by electric impulses in piezo-electric crystals. These sound waves are reflected from
inner organs and their content (fetus in the uterus), registered by the same piezo-electric element, and transformed back into electrical impulses by the crystal. This information is then analysed by a computer end presented on a screen. This way, the m0118ments of the eKtremities of the fetus and the opening of the mouth can be viewed as a live image.
33
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Computed tomography (CT) and 3-D CT angiography
ecnct.. ....... media Ooncha nals lrfwlal'
Fig. 1.50 Computed tamography, coronal camputed tomagram
ten afthuln~~~a. 1111
Computed tomogrsphy (CT) was developed by Sir Godfrey Hounsfield in the 1970es and has undergone ccnstsnt refinement. The computed tomograph generstes a series of sectional images through the body in
the trsnsverse or, as shown here. the coronal plane. The patient rests on a table and. YAlile cirrulating the body, an X-ray tube takes one sectional image after the other. Once ell images have bean acquired, the individual sectional images are calrulated by a computer applying c~ plex mathematical algorithms.
P&n abdcmtlalls aortae (Acl1ll. abdominal Is] A. llllca cannu6111lalnlltra
llllca ntsr. . alnll!ra
Fig. 1.51 3-D CT analography, S.D CT analoaram afd~nt structuru Clf 1fle abdoman and palvil (Yolun'HH'endlring technlqua, VR1l darlvld fram muHidltectar CT tectlont. 1271
Modem computed tomogrsphy technology (e.g. 64-lines volume spirsl multilayer CT) provides new dimensions and indications for CT diagnostics and guarsntees minimal dosage exposure for patients. CT angiogrsphy is based on the same multilayer CT technology. In a
34
blood vessel, the region of interest is scanned during fast intravenous injection of a iodine-contsining substance to increase contrast of the struc1ure. The resulting sectional images of branctling vessels are then assembled by a computer to generste a 3-0 image. " dinicalterm: A. femoralis superlicialis
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Magnetic resonance imaging (MRI)
capeura lnterna. Cfus ant8111.18 Nuele1.181entl'orml8, PI.Umen LdlUs temporal It
fie. 1.52 Magnetic .-ananee tamagraphy tMRI) ar imaging !Mill, ulalltraRSVWM} m•anetlc retonai'ICIImall' af the brlln (1'2-weighted). [27) In magnetic rasonance imaging patiems are a.xposad to a powerful magnetic field. This causes all protons of hydrogen atoms in the body to align with the magnetic field which effec1ivaly transfonms these hydrogen pr01ons to become miniature magnets. Than patients are
briefly exposed to rediofrequancy pulses to systematically change the alignment of these pr01ons. VIlhan returning to their original posi1ion, the pr01ons emit a weak mdio wave that is detected by the inS1rument. The strength, frequency, and time it takes for the protons to retum to their original position is an important infonmation rontained wi1hin the emitted signal and analysed by a computer to generate an image.
Pllcal~larlll
llbla
Llg.palallle
Rg. 1.53 Magnetic raonance tamagraphy, tlglttll magndc ....anai'ICI image {MRI} Gf I knll fT2-weiahtld}. [27) Altering the sequence of impulses used to exdte protons allows for different charac1aristic features of these protons to be analysed. These charaC1eriS1ics are called -w.lgtrtmg• of an MRI scan. Altera1ions in pulse frequency and scanning parameters result in T1-waighted (fluids:
dark. fat: bright; e.g. join1 effusion dark) and T2-waighted (fluids: bright, fat: grey; e.g. the conspicuous HOFFA's fat pad between the patella and tibia) images. Thus, specifically T-weighted images emphasise particular tissue compartments. MRI can also be used to genemta angiograms of the peripheral and central drrulation. " HOFFA's fat pad
35
Surface anatomy
Orientation on the body
-+
Surface anatomy
-+
Development
-+
Nails
.
'""~ ,., ----{\
Margo lib«
H}pen)'Cifum Carpu8u~ula
Nail wall
ll'll.trlxun;ull
UJI"&IIa
Epanychtlm
L161Uia
\alllumun;ula
Fig. 1.54 Distal fingw phalallll with nail. The nail (Unguis) is a convex-shaped, translucent keratin plate on the upper side of the distal phalanx. of the finger end toe. It serves to protect the tips of the fingers and toes and supports the grasping function of the fingers. The nail embeds into cutaneous slits (nail grooves, ValIum unguis) and its lateral margin is coverad by the cutaneous nail wall or fold on bo1h sides of the nail. The epithelial layer extending from the nail wall at the base of the nail onto the dorsal nail plate is called eponychium. The neil plate is anchored here to the nail bed. the skin beneath the nail plate.
fie. 1.55 Diltal finger phlllmc; nail partially removed. The epithelium located beneath the free margin of the nail at the tips of the phalanges is called hyponychium (also known as MquickN). Beneath the epithelial hyponychium lies the fibrous base of the nail bed Yltlich is tightly connected with the periost of the distal phalanx. The proximal hyponychium forms the nail matrix (Matrix unguis) which generates the nail plate. The Lunule is the visible pert of the nail matrix.
l 'fluVal bet·=m~~ Nallbtd
Phalanx d1118118
(H~~:::i;l;r- AIUCIAa.110 lnte~Pflalangee. d1118118
Fig. 1.58 DINI ftngw phalanx; Phlllnx distillIt; sagittal section. The nail bed comprises the region between the nail end the distal phalanx. It consists of epithelium (Hyponychium and Matrix unguis) and the underlying dermis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Whit• spots under nails are due to defective fusion of the nail plate with the nail bad. Changes in light reflection at these points cause the nail plate to appear milky-white (similar to the Lunula). The lack of fusion may have different reasons. for ex.ample it occurs through physical tllluma, it may rasult from certain medication, or it is linked to various diseases. llritth naila signal lack of biotin (vitamin H). Biotin is required for the formation of keratin, the main component
36
of the nail plate. Numerous systemic diseases era associated with nail changes. Rlr ex.ampla, psoriasis leads to the formation of 1m1ll pitt, ollr tpOU and sometimes crunmly 111llt up to a complete nail ct,strophy. Following skin end nail injuries. the nail can be oolonized by fungi tonydtomycotb}. Treatment of fungal infections of the toenails is ohen lengthy.
tahir99-VRG & vip.persianss.ir
Musculoskeletal system
-+
Vessels and nerves
-+
Imaging techniques
-+
Integumentary system
Skin
a
b
c
Fig. 1.57 Skin layws.lntegui'MIItum cammun.; thalry •~I; C: rutis, composed of epidennis (E) and dermis (D); SC: subcutis; Fs: superficial fascia; Fm: muscle fascia; M: muscle; rc: Retinaculum cutis; ES: eccrine sweat glands. HE-staining, magnification: 22-fold. 121 The skin (cutis} is composed of the epidermill and underlying dermis (fibro-elastic connective tissue with capillary plexus, specialized receptors, nerves, immune cells, melatoni~roducing cells, sweat glands, hair follides, sebaceous glands, smooth muscle cells; thickness varies depending on the body region). Beneath the dennis lies the Slbadls (subcuteneous fat tissue).The skin is the largest organ of the body (a pprox. 2 m2l and serves many functions: it protects against mechanical injury, is a thermoregulator and a sensory organ, and prevents excessive fluid loss.
Figs. 1.51111o d Hairy~ Ia and c. .b..:k of ftngerl and balrleu akin lb and d, finger tip); E: epidennis; P: papillae; pD and rD: papillary and reticular dermis; AR: rete ridges; ES: eccrine sweat glands; SgD: sweet gland efferent duct. The dotted lines indicate the margins between the dermal layers {Stratum papillare and Stratum reticulare). HE-staining. Magnificetion: 45fold, inset 100-fold. (c, d [2Jl The top panel shows scanning electron microscopy images of the surface of the dermal Stratum papi IIare after the epidenn is has been digested and removed. The bottom panel shows the corresponding histological schematic uverview images of sagittal sections through epidermis and dermis. The insert on the left image displays a tangential rut through the epidermis (purple) and the papillary dermis [pink!.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , The denno-epidermal connection is ensured by a number of different proteins end structures which are responsible for the adhesion mechanisms between these two zones. Genetic defects of some of th9SB proteins and structures lead to injuries inflicted by shear forces resulting in creeks which may be associated with the form~-
tlon of biiiDrs (Bullae) and, in some cases, involve large detachment of the epidermis. Detachment of epidermis can also be caused by auto-antibodies against components of adhesive structures (bullous pemphigoid, pemphigus).
tahir99-VRG & vip.persianss.ir
Surface anatomy
Orientation on the body
-+
Integumentary system
Hair
Fig. 1.59 Hail'll, Pili; longitudinal section throu!t' the human scalp [24) Hairs are the products of keratinization of the epidermis. They originate from invaginations of tha epidermis wtlich form follicles that contain mitotically active cells (matrix cellsl at the base. Matrix cells differentiate to become keratinized cells which form the shaft of the hair. Postnatally. we distinguish two types of hair: • Vlllut hair (fluffy hair) is soft, shon. thin, largely without pigmentation. and does nat oontain a medulla (follicles are located in the dermis); similar to fetal lanugo hair, venus hair covers most of tha body in children and women. • Tarminll hair (long hair) is firm. long, thick. pigmented, and contains
a medulla (follicles reach into the subcutis); it constiMes the hair of the head. eye brows, pubic region, arm pits, and beard (in men). The body distribution of terminal hair differs among ethnic groups. Hair protects from U'J.!ight and oold and serves to convey sensations of touch.
Fig. 1.60 Structur11 of 1 hair follicla; longitudinal section. [25) Hair originates from hair follides which are cylindrical invaginations of the epidermis into tha dermis or subcutis. The hlir follicular .bocfr consists of a hair bulb and the hair papilla. Each hair follicle receives a tuft of blood vessels to sustain its growth and is associated with a sebaceous gland Chalr-tl.baeeous gland unit} and a smooth muscle IM. ari'IICtDr pili}. The laner is responsible for the erection of the hair(~ pathetic activation) by indenting the epidermis to form small pits (goose bumps). The following str\JC1ures can be identified in e hair: • a fully keratinized hlir lhlft with the epithelial inner and 01.11ar root sheaths • non-kemtinized hlir root sepemted by the keratogenous zone (hair cells kemtinizingl from the kemtinized hair shaft • hair .bul.b with its expanded base contains mitotically active matrix cells (ragenemtive part of the hair) • dermal hair papilla. the cell- and blood vessel-rich dermal part YAlich invaginates into the hair bulb from beneath • hair Infundibulum represents the surface opening of the follide and contains the pilosebaceous canal of the hair-sebaceous gland unit • epithalial root 1hllth of the hair YAlich is divided into en inner and outer root sheath: cellular layers of the Inner root sheath are (from hair medulla outward): cuticle. HUXLEY's end HENLE's layers; the outer root sheath is oomposed of multiple layers of bright, nonkemtinized cells YAlich begin to keratinize in the infundibular region of the hair and integmte into the epidermis. Genetic predisposition and pigmentation (melanin content) determine the hair colour. Once the production of melanin ceases. the hair turns from gray to white.
38
tahir99-VRG & vip.persianss.ir
Trunk Surface Anatomy . . . . . . . . . . . . . . . . .
42
Development . . . . . .. . . . . .. . . . .. . . .
44
Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . .
46
Imaging ...........................
68
Muscles . . . . . .. . . . . . . . . . . . . . . . . .. .
74
Vessels and Nerves . . . . . . . . . . . . . . .
96
Topography, Back ................. 104 Female Breast .............. . .. . ... 114 Topography, Abdomen and Abdominal Wall ................ .. . 118
tahir99-VRG & vip.persianss.ir
Ventral and Dorsal Body Wall It has become common practise and is also logic, to study the walls (Paries) of the trunk (Truncus) separately from the content of the cavity, the internal organs, since both parts follow different structural principles. If one takes the view that the body wall is a structure composed of bones and muscles which surround the internal organs, then it consists of chest (Thorax), Abdomen, and Pelvis. According to this definition, the shoulder girdle (-+ p. 135) is not part of the Thorax. since it is only resting on the thoracic walls. whereas the pelvic girdle (-+ p. 264) is an integral and definite part of the trunk, as it holds and protects the organs of the lower abdomen.
Skeleton The trunk (and the neck) is supported by the vertebral column (Columna vertebralis). The vertebral column is composed of single vertebrae and continues throughout the entire length of the trunk. Its most caudal section, the coccyx (Os coccygis), consists of a variable number (4-7) of rudimentary vertebrae. The tip of the tail piece of the coccyx points towards the posterior wall of the Rectum. In the pelvic region, five large single vertebrae are fused by synostosis, resulting in a very rigid vertebral column segment. In contrast, the five lumbar vertebrae (Vertebrae lumbales) enable flexion, extension, and lateral rotation of the vertebral column. The twelve thoracic vertebrae (Vertebrae thoracicae), which articulate with the twelve rib pairs, are notably less mobile. The superior ten rib pairs (Costae verae et spuriae) are connected to the Sternum, the two inferior pairs (Costae fluctuantes) do not extend to the Sternum. Ribs, thoracic vertebrae, and sternum form the bony thorax or rib cage (Thorax). The ribs are easily palpable on both sides of the Sternum. Starting from the top of the rib cage, the first rib (Costa prima) is not palpable because it is hidden under the clavicle (Clavicula). The second rib (Costa secunda), however, is palpable. Counting the ribs, alongside with the use of auxiliary reference lines, helps identify specific locations on the Thorax. For instance, in an imaginary saginal line passing through the middle of the clavicle and the fifth intercostal space that is below the fifth rib, the beat of the cardiac apex is palpable. This is where the apex of the heart is "knocking" on the chest wall from the inside. The cartilaginous costal arch (Arcus costalis), which connects the seventh to tenth rib with the Sternum in an arch-shaped fashion, is also well palpable. It is the landmark for the inferior thoracic aperture, which constitutes a wide opening of the Thorax towards the Abdomen. The thoracic cavity is partitioned by the dome-shaped, steep and upward projecting diaphragm (see below). Abdominal organs, such as stomach, liver, spleen, and others, are located below to the diaphragm and "beneath the cartilage" (Regiones hypochondriacae). The pulsation of the Aorta abdominalis is palpable in the Regia epigastrica between the cartilaginous rib arches and immediately inferior to the xiphoid process (Proc. xiphoideus stemi).
Muscles The muscles of the abdominal wall are voluntary, like those of the extremities. Muscles are classified into two major groups: muscles acting exclusively on the abdominal wall and muscles of the extremities (arising from the abdominal wall and acting on the shoulder girdle and
40
the extremities). According to their location and function, the muscles of the wall of the trunk form four major groups: the autochthonous muscles of the back, muscles of the lateral and ventral wall of the trunk. muscles of the diaphragm, and muscles of the pelvic floor. The autoc:bthonous musdes of tha back. which consists of numerous single muscles, are located to both sides of the vertebral column. Arranged in two powerful muscle strands, these muscles are oriented in a predominantly craniocaudal direction from the occiput to the pelvic girdle via the neck. thorax and loins. With the back extended, these muscles are particularly visible in the lumbar region. Overall, these muscles are effective in facilitating an erected spine posture, hence they are called M. erector spinae. The adjective "autochthonous" means "rooted or native" - during ontogenesis, all voluntary muscles of the body emerge bilaterally to the vertebral column, precisely the region of the autochthonous muscles of the back in adults. The muscular progenitor (precursor) cells (myogenic progenitor cells) of all other muscles migrate from this region across the ventral side of the trunk towards the extremities. Thus, one should name these "allochthonous" muscles, since they arise from cells "coming from outside". The muKias of tha lateral and ventral wall of the trunk exist as multilayered intercostal muscles (Mm. intercostales) of the thorax. They assist in respiration. The flanks of the Abdomen (Regiones laterales) contain flat, likewise multilayered muscles, which are also known as lateral abdominal muscles (Mm. obliqui and M. transversus). The anterior abdominal wall is formed by tough tendons (aponeuroses) of these lateral muscles. The straight abdominal muscle (M. rectus abdominis) extending longitudinally from the symphysis to the chest is ensheathed in these aponeuroses ("six-pack belly"). Together, these muscles rotate and flex the trunk. Beyond this, these muscles also control the tension of the abdominal wall, assist in expiration as well as in vocalization for speech and singing, and increase abdominal pressure. The diaphragm (Diaphragms), the most important muscle of respiration, is voluntary, even though one is not aware of its actions. The diaphragm is located in the interior of the trunk, arises from the margins of the inferior thoracic aperture (see above) and forms a large thin-walled dome with the apex pointing towards the thoracic cavity. During contraction, the dome flattens and this leads to an increased volume of the thoracic cavity facilitating inhalation. The muscles of tha pelvic foor (Diaphragms pelvis and urogenitale) are also voluntary (pelvic floor exercise). They bear the weight of the visceral organs (caudally the bony pelvis is open). These muscles originate from the inner lower margins of the bony pelvis to form a funnel that tapers down towards the caudal end[-+ p. 196 and 214).
Breast (Mamma) The breasts (Mammae) are located on the female thorax - more precisely: they ride on top of the M. pectoralis major, a muscle of the shoulder girdle. Their major component is subcutaneous adipose tissue and only a small part consists of glandular tissue (Glandulae mammariae). Each mammary gland comprises 10 to 20 single glands (Lobi) and each gland sends its own efferent duct to the mammilla (Papilla mammaria). Only during breastfeeding (lactation period) -or in the presence of a malignant breast tumour- the glandular tissue proliferates, which should only serve the production of milk. Men also have tiny rudimentary mammary glands. They can also accumulate abundant adipose tissue in the breast region on top of the M. pectoralis (gynecomastia).
tahir99-VRG & vip.persianss.ir
Clinical Remarks------------, Anomali.e s in the region of the thoracic wall (e.g. Pectus excsv&tum (funne l chasti, Pectus carinarum [pigeon chest or carinate chest]) as we ll as congenital anomafies and defonnities of the mamma (e.g. amastia, apla.sia, athelia, polythelia. polymastia, mammary hypertrophy) may occur. The feminization of the male chest (~nwstl•l can have different undertying causes. of tha •artie .,.mus causes the formation of arterial circulatory bypasses which involve arteries of the ventral well of the trunk tAa. thoraclca interns, epigastricae superior and inferlorj. This leads to an increased arterial diameter and pulsatile force resulting in the formation of erosions at the caudal aspect of the ribs in the vicinity of the dilated intercostal arteries. Hernias are a common disease in the region of the ventral abdominal well. A t a breach point in the ventral abdominal well (hernial canal), a hernial sse csn form in which abdominal viscera can protrude and be trapped (hernial content). Men usually have congenital or acquired inguinal herrias. The constriction or blockage of the upper or lower Vena cava leads to the fonnBtion of - 1 analllmo... via superficial and deep veins of the abdominal wall with visible enlargement of the epifascisI veins. Deviations from the scrotal position of the testis can occur in cases of mal._neua t.tiL
Steno"'
-+ Dissection Llnlc After preparation of the skin, the M m. trapezius and IB'Iissimus dorsi as well as the Fascia thoracolumbalis are elCPQSed. The M. trapezius is separated at its origin; the M. IB'Iissimus dorsi is separated in an ~ shaped manner near its origin. After dissection of blood and nerve vessels of the muscles, the Mm. levstor scapulae and rhomboidei are exposed and the Trigonum lumbale fibrosum is defined. Following the removal of the origin of the M. latissimus dorsi, the structures passing through the axillary gaps are exposed. The Mm. serrati posteriores are exposed after removal of the Mm. rhomboidei at their origin. Subsequently, dissection of the M. erector spinae and the deep (internal) neck region occurs. Upon completion, the Mammae on the ventral side of the body ara dissected and removed, the epifascial pathways are traced to thigh and upper arm, and the dissection of the axilla and MOHAENHEIM's fossa is completed. After rem
EXAM CHECK LIST • Columna vartabralis: davalopmant and lkslstal componants • Vertebra prominena • atrueture of a vertebra • Os aacrum • Os cocev11is • vartabral connaetions • autochthonous musclas of tha back • narvaa and blood ve11ala: location crl' apinal ganglia and spinal narvaa, innervation rag ion of Rr. dorsales, N. occipitalis major, A vert.a bralie, and Plaxus vanosi vartebrales • surface anatomy • palpable skeletal prominences • MICHAELIS' rhomboid • organization of the layers crl'tha nedt ·Trigonum suboccipitale • morphological buia of lumbar puneture and epidural anaesthesia • basic davalopmant crl' the thorax· Angulus sterni • medioclavicular Iina • anterior and posterior axillary lines • scapular Iina ovsina of tha skin and lymphatic drainage • skalatal components and conneetions • thorax • Mm. intarcostalu • diaphragm • intercostal nerves and blood vessels • A thoracica intema • collateral ci rcu latory ro utas as a reau It of aortic stan osis • Vv. thoracicae internaa • Vv. thoracoepigastricaa • cavocaval anastomoses • mamma • basic development of the umbilicus • abdominal muscles • segmental nerves and blood vsuels • N. subcostalis • Plexus lumbalis • Nn. iliohypogastricus, ilioinguinalis, and genitofamoralia • Vasa epigastrica • Canalia inguinalis • external genital organs
41
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Back
Vllltallrap!Omlnen~ ~ Aa'omlon~ SpfnaSCij:l!Aa& - - - - - -
- - - N. giWILII miiXImLII
42
Fig. 2.1 Back, Dorsum, surf.ce relief cl the h.a:. The contours of the back provide useful landmarks to determine different regions of the vertebral column. muscles. the approximate position of the end of the spinal cord, and the position of organs (e.g. ki~
ney). Bony lsndmstils ere the Proc. spinosus of the Jlh cetVicsl vertebra (Vertebra prominensl, the &a"Omion, the Spina scapulae, the Angulus inferior scapulae. end the Proc. spinosus of the !1' lumber vertebra.
Fig. 2.2 Regiontlend orientation lines of the hack. The back and neck region have the following distinct topographic regions: Regio cel\licslis posterior (Regio nuchalisl. Regiones venebralis.
scspulstis. infrsscspularis. dehoidea. lumbalis. secrslis. and glutealis. Useful orien18tion lines of the back include the Linea medians poste~ or. persvenebrslis. scspularis. and axillaris posterior.
tahir99-VRG & vip.persianss.ir
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Thoracic and abdominal wall
Splrw.llllal an1a11ar aupaler
Fig. 2.3 Surface Hllitf af 1M chat end 1M abdominal wei af 1 young wamen. Lsndmatils assist in the orientation at the vantml side of the trunk. like
e.g. the costal arch (Arcus oostslis), the umbilicus (Anulus umbilicslis). and the Spina iliaca an1erior S~Jperior. Additional landmarks are shown.
N. pactcrala!TIIjar ----..,;---1....._-
N. rectuallbdcmlnla M.IUC1ua -.,1'111, l~btandl'l-.
Fig. 2.4 Surface relief af the cht8t end the abdominal well cf 1 yo~mgmen.
Lsndmatils on the vantml side of the trunk.
43
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles
-+
Development
W8ek4
Fig. 2.5 Development of the walls of the trunk: organization of the somitas at weak 4. [21 I All elements of the supportive and muscular systems of the ventral and dorsal trunk originate exclusively from the middle germ layer !Mesoderm). The mesodellll condenses on both sides of the Chorda dorsalis and the neural tube to follll somites and unsegmented lateral meso-
dellll. At week 4, a ventromedial section of each somite differentiates to become a ICierotome. Migrating cells of the sclerotomes on both sides of the neural tube and the notocord (Chorda dorsalis) meet to form primitive vertebrae. Derivatives of the lateral section of each somite are the myotome and the dermatome which contribute cells for the development of the muscles and skin, respectively.
week5
Week7
eplnalle, R.vantl'llllill
a
b
c M. rectUIIIbdamlnls
Figs. 2.6a to c Development of the walls of the trunk: differentiation of epimere and hypomara from rnyotomas. [21 I The striated skeletal muscles of the trunk originate from dellllatomyotomes in the lateral section of the somites and starts differentiating at week 4. During week 5, a larger ventral group of mesenchymal cells, the hypomare, separates from a smaller dorsal cell population, the epimere. The hypomere is the origin of the Mm. scaleni, prevertebral neck muscles, infrahyoid muscles, Mm. intercostal as, subcostales, transversus thoracis, oblique abdominal muscles, Mm. rectus abdominis, quad-
ratus lumborum, pelvic floor muscles, and sphincter muscles of the anus and urethra. The autochthonous muscles of the back (M. erector spinae) derive from the epimere. In the region of the abdominal wall, the hypomere differentiates into the oblique and rectus abdominal muscles at week 7; the epimere folllls part of the autochthonous back muscles. Epimere and hypomere receive separate nerve innervation: these are the Rr. ventrales and Rr. dorsales of the spinal nerves for the hypomere and epimere, respectively.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The absence of indillidual muscles is often without clinical relevance. Varying degrees of severity of movement disorders are associated with uni- or bilateral absence of the M. pectoralis or the Mm. trapezius and serratus anterior.
44
The prune-bally syndrome, which is very rare, presents a complete lack of abdominal muscles and the organs are palpable through the entire skin. Larger muscle defects in the abdominal wall are associated with the formation of hernias.
tahir99-VRG & vip.persianss.ir
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Development W8ek6
N. spinalis, R. ventralis Myotome
lnt8rsegrnental vein
-+---caudal
~~~~~~
Intersegmental artery
&davmme
N. spinaJis, R. ventralis
Fig. 2.7 Development of the wall of the trunk: Nuclei pulposi as remnants of the Chorda dorsalis in the adult vertebral column. [211 From the beginning of weak 4 of development. migrating calls from the scarotoma assemble around the neural tuba. A fraction of calls encircles the Chorda dorsalis and differentiates to become the vertebral body. The Chorda regresses to become the small jelly-like Nucleus pulposus in the centre of the intervertebral discs.
N. spinalis
a
Wllek 10
--£:3~1--Nucl
pulpoMJs
Vertebral body
ll'le sternal bars fuse craniocaudally
lnl!erBegmental bloodwssel
N. spinalis
a
b
Figs. 2.8a and b Development of the ribs and the sternum. [2 1I The sternum develops from two sternal bars which derive from parallel condensations of mesenchymal cells in the ventrolateral body wall (a) and fuse cranio-caudally in the median plane (b). Ossification of the Proc. xiphoideus occurs late at 20-25 years of age. The ribs in the region of the thoracic vertebral column and the Procc. costales of the neck and lumbar vertebrae derive from sclerotome cells that have migrated ventrolaterally. Dorsally they are connected with the vertebrae and ventrally they connect in part with the Sternum (ribs I to VII; true ribs,. Costae verae). The ribs VIII. to X fuse ventrally and connect to the sternum in an arch via their own cartilage (false ribs, Costae spuriaaJ. Ribs XI and XII are exclusively connected with the vertebrae and end freely (Costae fluc:tuantasl in the ventral chest wall.
b
Fig. 2.9a and b Development of vertebral bodies from two adjacent _,arotomas. [21 I Sclerotomes divide into a cranial and caudal section. A myotome is associated with a sclerotome and receives innervation by a spinal nerve. In between the sclarotomas and the myotomes course the intersegmental blood vessels (week 6, a). The individual vertebrae are formed by the fusion of a caudal with a neighbouring cranial sclerotome section. Each spinal nerve associated with a myotome becomes sandwiched during the fusion of the cranial and caudal sclerotome sections and exits through a Foramen intervertebrale. Intervertebral discs develop between the primordial vertebrae (b). Muscles derived from a single myotome (e.g. M. rotator brevis, -+ Fig. 2.781 can move two neighbouring vertebrae into opposite directions. The functional unit of all structures participating in the motion of two neighbouring vertebrae is called a motion segment.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , A spina bifida represents a cleft dorsal vertebral column as a result of failed fusion of a single or multiple vertebral arches. A combination of incomplete closure of vertebral arches and exposure of underlying neural folds is called rachischisis. Paralysis occurs if the spinal cord is also affected. If the cleft in the vertebral arches is covered with skin, it is called spina bifida occulta. A wedg•lhapad vertebra (hemivertebra) results if a vertebra lacks one of the two ossification centres. Fusion of two vertebrae and degeneration of the interverta-
bral disc creates a block vertebra. Failure of fusion of the lateral sternal bands often results in a gap formation in the Corpus stemi or the Proc. xiphoideus. Clinically, such gaps or holes are insignificant. Accessory ribs are common in the cervical and lumbar region (cervical and lumbar ribs). In the lumbar region, accessory ribs are usually clinically insignificant, however, in the neck region they may lead to a compression of the Plexus brachial is or the A. subclavia (-+ p. 47 and p. 54).
45
tahir99-VRG & vip.persianss.ir
tahir99-VRG & vip.persianss.ir
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Ribs
Calum CCIII&a, Ofa cdll c:aae
'lWiweulum cOitae
VIII
Fig. 2.12 Ribs.. Co sue; ribs I to lit cranial view: rib VII: caudal '.liaw. Ribs Ill ~o X are typically shaped. The head of the lib !Caput ()OStael is wedgiH\haped and possesses two artirular surfaces (Facies aniculares capitis ()OStae). The Tuberculum costae has one Sl.lrface (Facies articulalis tuberculi costae). The V.. A.. and N. intercostalis run in close proJtimity to the Sulcus costae. AA invagination at the ventral end of the body of the rib (Ccrpus costae) facilitates contact with the rib canilage.
Ribs I. I. XL and XI deviate from the typical lib strue1ure.Rib I is
stumpy, broad, and shows the strongest cur'.ling; the head has only one articular S~Jrtace. Rib II displays only an outline of a Sulrus costae and a Tuberositas musruli sermti anterioris marks the origin of theM. serm1:\Js anterior. The heads of ribs .XI and .XII contain only one artirular surface. These two ribs fail to contact with the costal arch. show pointed ventral ends, and have no Tuben::Yium ()OStae.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . lib anamaiiM are common: • A eervtcal rib is observed in approximately 1% of the population. The lib primordial at the J'd' cer'.lical venebra (C7l is enlarged. Apart from isolated enlargement of the Proc. transversus, uni- or bilaterally, additional ribs may be present which can be connected to the sternum. The pressure of a cer'.licallib on the lower roots of the Plexus brachialis can cause sensory loss and motor deficits in the innervation region of the N. ulnalis.
• Two..fHNtded rb arise from two panially fused ribs. • In blftd ribs the anterior part of the lib divides into two parts. • Widening of the intercostal arteries in the Sulcus costae during stenosis of the aortic isthmus reS~Jits in pnassure atrophy of the rib bone which is called lfOiion11 (u...,..} of the rib.
47
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
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Vertebral column
'lwt*w
lu,.._ 1-V
Oll.cftlm
2.14
2.13
Fig. 2.13 and Fig. 2.14 V.rteb111l column.. Colwnn• vwtllbralll; ven1ral (... Fig. 2.131 and dorsal(... Fig. 2.14) views. The vertebral column accounts for 40% of 1he heigh1 of a human, a quarter thereof baing due to the intervertebral discs. The vertebral column is romposed of 24 presacral vertebrae (seven cervical vertebrae. twelve thoracic vertebrae. five lumbar vertebrae) as well es 1WO
synos1otic parts, the sacral lOs sacrum) and the coccygeal bone lOs coccygis). Tha thoracic vertebrae connaC1 with 1he 1Walva rib pairs, tha sacrum articuiB1es wi1h 1he Ossa coXIJe. In 1he upright posi1ion, the physical forte increases from cranial to caudal along the vertebral rolumn.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . S.CNiizrion raters 10 the fusion of the ~ lumber vertebra with 1he Os sacrum (only 23 presacral vertebrae remaining). When 1he 1op sacral vertebra remains separated from tha remainder of tha Os sacrum 125 presacral vertebrae!. the condition is called lumballza· tion. Radiograph aXIIminB1ion reveals six lumber vertebrae and four
48
sacral vertebrae. VIlhan 1he sacrum hes five vertebrae, there is an addi1ional sacralizB1ion of the first coccygeal vertebra. Fusion of 1he firs1 cef\lical vertebra IA11es) wi1h the skull is called Ulimil.tion of
"Jedat.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Vertebral column
------Lwnblrlardcllle
811cnl ~· _ _ ____,.,.
fie. 2.15 Vertebral column, C.,lumna vett:e.bralis; view from the left side. When viewed in the sagittal plane the vertebral rolumn has a chamcteristic curwture: • oervicallordosis lventml convex curvature) • thoracic kyphosis (dorsal ronvex curwturel • lumbar lordosis (ventml convex. curwture) • sacral kyphosis (dorsal convex curvature) Lordosis end kyphosis ere tha medical terms for vantmlly end dorsally directed ronvex curvatures of the vertebral rolumn, respectively. In the
first few months attar birth, all sections of the vertebral rolumn show a dorsal convex. band. The cervical lordosis develops with the ability to sit upright and the lumbar lordosis forms when learning to walk. The vertebml curwtures form only after the pelvis has tilted forward as a result of the bipedal walk teamed at the age of 1-2 years. Prior to this ability to walk upright, ell sections of the vertebml rolumn show a dorsal convex curwture.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Excessive curvature of the spine in the frontal plane t~eoliolil} is always pathologic. This growth deformity of the spine resuhs in fix.ed lateml curvature, torsion, and rotation of the vertebral rolumn which cannot be straightened physiologically by the use of muscles. Sco-
liosis is one of the oldest known orthopedic conditions. Despite intense scientific and clinical eHOI'ts, to this day many of the problems associated with sooliosis are not resolved satisfactorily. Due to unequal leg length, the majority of the population has a mild S()Oiiosis.
49
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
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Atlas and axis
Fcni!Wimll!grlllm
Fig. 2.16 Bue of occipital bane, 0. occipitale, regian of 1M Fan~man IIIIISJIUm and 1M ~Mal eanctyta far 1M uppw IHNtd jclint; caudal '.liaw. The ocdpital oon~es are located bilaterally to the F«aman magnum.
Rg. 2.17 1tt Cervical vertebra, Atlls; cranial '.liew. The atlas does not possess a vertebral body. During development the latter fused with the axis to form the Dens. The anterior vertebrsl arch IArcus anterior atlantis) is positioned anterior to and artirulates Ylith the dens. At the posterior vertebral arch (Arcus posterior atlantis), the Proc. spinosus is replaced by a small Tuberrulum postarius. The upper articular facets of the atlas are fre~antly sepersted into two sections. C~ pared to other vertebrae, the atlas has a slightly longer transversa pro-
cess. " variant: Canalis arteriae vertebralis
Fig. 2.18 1tt Cervical vertebra, Atlls; caudal '.liew. The Fovea dantis articulates with the Dans axis and is located on the inside of the Arcus anterior atlantis. The Fades artirulares infariO!'es are shallow, concave, and tilted in a 3t:r' angle to the trsnsverse plana. The Foramen transversarium is typical for cervical vertebrae and facilitates the pessege of the A. vartebrslis.
Fig. 2.19 1tt and 2"" cervical Wl'f:a.brae, A111s end Alllil; median section; view from the left side. The median section permits the inspection of the vartebrsl canal. Atlas and axis articulate via the Fovea dentis and the Fades articularis anterior in the Articulatio atlanto.axialis medians. The Arcus posterior atlantis is oonsiderably smaller in relation to the Arcus vertebrae of the axis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Degenerative changes of the cervical vertebrae are common Ylith advanced age and present as ~eodtandre~~ls lrrterwrtebra· lis with dorsal spondylophytes which can lead to narrowing of the vertebral canal Ylith resulting compression of the spinal cord. Arthrosis in the zygapophyseal joints and the uncovartebral gaps 1~ Fig. 2.241 Ylith formation of osteophytes ~Its in narrowing of the F«aman intervartebrale and/Or the Foramen transvarssrium with symptoms resembling spinal nerve oomprassion as well as in pressure on the A. vartebralis and the sympathetic nerve plexus.
50
llaleted fractura of the .tllrrtel archie occur espedally as e re~lt of motor vehicle accidents. The inddence declined in recant years due to improved safety measures in vehicles (air bag). Fractures must be distinguished from Atlas variants. In contrast to variations such as the occurrence of e Canalis artetiae vartebrslis or abo normalities like the assimilation of 1M Atlu (fusion with the cranial base). cleft farmations in 1M region
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Cervical vertebrae
Proc. " - - ·
2.20
2.21
fie. 2.20 and Fig. 2.21 2!"'1 cervical vartebra, A:DI; ventral I-t Fig. 2.201 and dorsocranial (... Fig. 2.211 views. A distinct feature that sets the axis apart from the other cervical vertebrae is the dans. The front and rear side of the dans are covered with articular facets (Facias articulares anterior et posterior). The articular facets of the Procc. articulares supariores are sloped to the outside and
the Procc. articulares inferiores are positioned in an oblique angle to the frontal plana. Starting with the 3 101 cervical vertebra, the articular facets of the Procc. articulares supariores also assume an oblique position in relation to the frontal plane. The transversa process of the axis !Proc. transversus) is short and the spinous process (Proc. spinosus) is frequently split in two.
C
FaciMirbM!Uinlls
Fig. 2.22 P cervical vartebrH, Vert:a.bra cervicail ¥, cranial '.liew. The !f" cervical vertebra exemplifies the typical structure of the an~ to 61" cer'.lical vertebrae. With the exception of the J'h cer'.lical vertebra, the Proc. spinosus has two pointed ends. The Proc. transversus is short, has a Foramen transversarium and ends latarally in aTuben::ulum anterius and in a Tuberculum postarius, Ylith the Sulcus nervi spinalis located between them. The Foramen vertabrala is large and triangular. The vertebral body is longer in the transverse axis than in the sagittal axis and similarly wide at the front and back.
Fig. 2.23 J1l' cervical Wl'f:a.bra, v...te.bra c...W:.il VII; cranial '.liew. The 71' cer'.lical vertebra has a long transverse process Ylith a Tuberculum postarius only and a long and undi'.lided spinous process.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The odontoid fra"'ura or the fracture of the Pars interarticularis (the se><:alled hanged man's fracture) presents the risk of cervical cord compression and is mostly seen as a ~It of motor vehicle
accidents. An odontoid fracture can also affect small children and is difficult to diagnose.
51
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
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Cervical vertebrae
Fcnman II'IIIIWanllufum
$Jill... , . ••twwwlbilbialle SIACUII neM ll!llnall8
52
fie. 2.24 ~to Tl' cal'1lklll wrtebraa, V.l1abraa earvtcala I~VII; ventral 'oliaw. The 3711 to att~ oervical vertebrae have a typical structure, whereas 1t1e 1"'. 2nd, and ]ttl cervical vertabrse de'oliate from this structure. The upper surfaces display a lip projecting upward at either side (Unci corporis).
The Unci corporis are also named Procc. uncinati and articulate in the Articulatio (Hemiarthrosis) uncovartebralis with the lateral and caudal parts of the Corpus vertebrae of the above vertebra.
Fig. 2.25 1"' to Tl' carvical wtt:a.braa, V.l1abraa cttvicalu ~VII; lateral dorsal ..new. The long and undivided spinous process of the 7"' cervical vertebra can be easily palpated in 1tle neck and is therefore also named Vertebra prominans. However, this cervical venabrs can be confused with the
1• thorscic venabrs which has an evan more pronounced spinous prooess. The articular facets (Facies articularis superior or inferior) of a vertabrsl process (Proc. anicularis superior or inferior) articulate with the rorresponding partner in the Articulatio zygapophysialis.
* so-called uncovertebral gaps
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Thoracic vertebrae
lncii&Jra vatetnlll ~ Prac . .tlculorla lnfarlct Prcc..
Fig. 2.28 Vwtebra: ex~~mple dtltllllng 1M struetura of ~h• 5"' aanial view. The vertebral arch !Arcus vertebrae) is divided in the Pedirulus arcus vertebrae and the Lamina arous vertabrse. Coming off the arch are bilaterally the Procc. transversi and dorsally the Proc. spnosus. Articular facets are located aanially and caudally and participate in the formation of the vertebral joinfs (Zygapophyseal joints). The lateral cranial and caudal aspects of the vertebral body each possess a fovea for the articulation of the costal head (Fovea cos1ales superior and inferior). In thenticulatio costotrsnsversaria at the Proc. transversus, the Fovea oostslis artiruates wth the facet of tt1e Tuberrul~n~ costae of the corresponding rib. ~horacic ve~abra;
Fig. 2.27 ffl' 1ftoi'IICk verta.bre, V.~abra 1floraelc. VI; view from the left side. View of the artirular facets for the cos1al heads IFoveae costales S~.Jpe rior and inferior). the articular facets of the zygapophyseal joints positioned almost in the frcrrtal plane IProcc. articulares S~.Jperior and inferior), the facets (Foveae costales) for the articulation with the Tuberrulum costae of the ribs, the Incisura vertebralis inferior and the Proc. spinasus pointing sharply downwards.
* also: annular rim
Proc.
tnnt-·
Fig. 2.28 10111 1hclracic verta.bre, V.~abrailloracic. X; ventral view onto the vertebral body with superior and inferior intervertebral surface. The articular facets of the Procc. artirularas extend beyond the vertsbrei body cranially and caudally.
Fig. 2.29 12111 ~horacic ve~abra, Vwte.tn'll ~hot8Cicl XI; view from the left side. The 1~ ttloracic vertebrs has a singular bilateral Fovea oostslis and displays structural similarities to a lumbar vertebra: the inferior artirular processes point lstarslly. In addition, this vertebra possesses Procc. mamillaras and accessorii. "
area of the vertebral arch between the upper and lower articular process (se><:slled isthmus =intersnicular portion)
53
Trunk
Surface anatomy
-+
Development
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Skeleton
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Imaging
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Muscles
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Thoracic and lumbar vertebrae
lncl811'8. wrtelnlllllrtellcr
Fig. 2.30 1Qih to 121" 1horacic verta.brae, Vett:a.braeihoracicae X-XI. and 1• tiD ~ lumbllr verta.brae, Verttlbrae lumblll.. HI; lett
dorsal view. The lumbar vertebrae are larger and s1ructurelly more rompact to withstand the increased rompression forces imposed by the body weight The Procc. spinosi are short, podgy, and point almost s1reight back-
ward. The atthes of the lumbar vertebrae are the origin of the Procc. costal as (derived from the primordial ribs fused with 1he venabraal, the variably large Proce. accessorii, the Procc. articulares superiores (sup. por1ing the upper anicular fece1s, Facies anicularesl. the Procc. mamillares (remnants of 1he Proc. trensversus), and the Proce. aniculares infariores Yli1h 1he lower articular facets (Facias anicularas).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . • Posterolatarel disc herniations or osteophy1es caused by os1aoarthri1ic-media1ed degenere1ion of venebrel join1s can lead to the narrowing of._ Foraii'HII'IIntervertebrale and to compression of 1he spinal nerve roo1s with resulting defici1s. • Lumbllr ribs can cause pain due to their close topogrephic rei~ 1ionship 10 the kidneys.
54
• CtMYIIge of the latWIII verta.bralarch causes saparetion of the Procc. articulares inferiores Ylith 1he posterior part of the atth and the Proc. spinosus from the remainder of the vertebra (known as
tpOnct,folylil). • The bony separa1ion of the isthmus(-+ Fig. 2.29) can cause vert. bral slippage (lflondylolilthaeis).
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Lumbar vertebrae
..
a,. ..mblr verte.bre, Vltte.bre lumbllia Ill, af en elct.t, madlen SIC6Dn; view from the left side. The articular facets of tha Procc. articulares superiores are facing each other (that is the reason why they are not clearly visible from the sidel fie. 2.31 pen~e~n:
and articulata with the inferior articular processes of the adjacent higher vertebra. " ossification of ligamentous attachments
2.33
fie. 2.32 end Fig. 2.33 4"' ..mblr verte.bre, Vltte.bN lumbllia IV; cranial(_. Fig. 2.321 and ventral(_. Fig. 2.33) views. Tha Pediculus arcus venabrsa is proportionally vary large in C
brs has a massive body (Corpus vertabrse) with pronounced upper and lower intervertebral surfaces (facies intervertebrales superior and inferior). The articular facets of the zygspophysaal joint extend beyond the cranial and caudal part of the vertebral body. " also: superior vertebral end plate "" also: inferior vertebral and plate
55
Trunk
Surface anatomy
-+
Development
-+
Sacrum
BulaOIIIIIa-
Flgt.. 2.34 ~o 2.38 S.CNm, Os sacrum; dorsal (_. Fig. 2.34), vemral (-+ Fig. 2.351, and aanial (-+ Fig. 2.361 ..news. The dorsal surface ffllclesdortlllls) displays five longitudinal aests of different intensity formed by the fusion of the corresponding vertebral processes. The Crista ..crail medilna results from the fusion of the Procc. spinosi, the Crtsa taeralls medialis cooesponds to the fusion of the Procc. articulares, end the Q
56
2.35
Skeleton
-+
Imaging
-+
Muscles
-+
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Sacrum and coccyx
Prac . .tlcullnl euperlot ...........
Rg. 2.3'7 Sacrum. Os sacrum; view from the right side. The lateral view shows the Facies articularis, Yltlich is part of the joint wth the Os coxae !Articulatio sacroiliacs). The Tuberositas ossis sacri is located at its dorsal aspect and serves as an insenion region for ligaments.
Fig. 2.38 Saerwn.. Os sacrum; median section; view from the right side. " In adults, remnants of the intervertebral discs can remain. In addition, incomplete fusions of sacml vertebrae are frequently found.
fie. 2.39 Sacrum. Olucrum; differences in sax. Men have a slightly longer and narrower sacrum than women. The shape of the sacrum female contributes to the wder shape of the female pelvis which is advantageous during parturition.
Fig. 2.40 Saerwn, Os ucrum; differences in sex. The male sacrum is bent mons than the female sacrum.
Ccmu caccygeum
fie. 2.41 Coccp, O• coccygis; ventral cranial view. The coccyx is formed from thnee to four vertebrae but can also be made up of five rudimentary wrtebme as is shown here. The COCi¥< is connected to the Os sacrum via the Comus coccyges and the rudimentary venebml body.
Fig. 2.42 COccp:.. Os coccygila; dorsal caudal view. The size of the ooccygeal vertebrae decneases from aanial to caudal. Of all coccygeal wnebme, only the 1tt coccygeal wnebm resembles a typical vertebral structure.
57
Trunk
Surface anatomy
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Development
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Skeleton
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Imaging
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Muscles
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Sternum
Mlnratum lltlml
In ciiU ra CCII!allll
lnciiiUra C01181111111
lnciiiUra CCIItallll
2.43
Fig. 2.43end Fig. 2.44
St:ern~n; ventral (... Fig. 2.43) and lataml Fig. 2.441'1/iaws. The Stemum is composed of the Ma~brium and the Corpus stemi. and of ttla Proc. xiphoideus. Its upper end forms ttla Incisura jugulalis which is the ventral upper margin of the upper thomcic apanure and aniculatas with the cla'llicles through ttl a Incisurae cla'lliculares and with
(-+
the ribs Ito VII 'Ilia the lncisume COStales. Manubrium and Corpus stemi are connected by the Symphylb [Synehondi'OIIsJ menubrlo"wna· lia. whereas ttle Corpus stemi and Proc. lCiphoideus aniculate through the Symphytlt xlpiHmwnells. The Proc. xiphoidaus can be divided.
* angle of LUDWIG ILUDOVICUSI
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Bone marrow biopsies can be obtained from ttl a stemum. ttl a peMs. and the iliac crest. The application of atarnel puncture for diagnostic biopsy of bona marrow has become rare and has bean replaced by iliac crest puncture. Sternal puncture servas to evaluate bone marraw ()EIIJS in haamatopoiatic diseases. The puncture site is located in the median line of ttle Corpus stemi between the attachments
58
of the ribs II and Ill. The region of the costostamal connections and the lower two-thirds of the Corpus stemi are aclllded from atarnel puncture due to possible presence of synchondroses and potential Fillure .twni conpnite (opening in the stamum) as a result of incomplete fusion of ttla paired stemal bands. Needle puncture in thase areas oould lead to injury of the haan (~ p. 45).
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Sternum
c.ti&IQO allltalslll
Fig. 2.45 Stwnum and oJtg.-. of cal1111gmus partt af ~he ribs. Ca11ileginea coatelu; frontal section. Only part of 1tle costostemal insertions are true joints. Synchondroses ara common (ribs I, VI and VII).
Fig. 2.41 S~ernoc:lntculer Joints.. Ar1kuldonlt sternoclnlcull· ,_.ventral view; right frontal section through 1tle joint. The stemodavicular joint is a functional ball and to~ Jo~ Ylith three degrees of freedom in movement. It contains a DiiCUiarticull· rll of fibrous cartilage. dividing the joint into two chambers (dlthllllmlc joim). The shape of this joint is a reflection of 1t1e demands of muhiexi-
al mobility and vary diverse mechanical stresses during different joint positions. Because the discus is able to absorb high shear forces. the articular facets can be kept small. The Ligg. sternoclavicularia anterius and posterius. interclaviculare and costoclaviculare strengthen the joint capsule.
59
Trunk
Surface anatomy
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Development
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Skeleton
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Imaging
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Muscles
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Ligaments of the vertebral column
Ollla.l8 --=---"~~-+,...-, l~tnlls
Rg. 2.47 Llpments af ~h• vel11bral column Ullng ~t. aample af ~ krw•ifHiracic vetf:l.bral column; ventml view. The anterior longitudinal ligament Cl.lg. longltudli'la.. amerfus} ranges from the Tuberoulum anterius of the Atlas to the Os sacrum. It is fixed to the anterior surfaoe of the vertebral bodies and to the intervertebral discs (Disci intervertebmles). This ligament increases the S1Sbilityof the vertebral column during mention.
Rg. 2.48 Ugamentt af ~h• vetf:l.bral colwnn using ~h• aampll of~ loW8I' ifHiracic 1nd upJ*" lumbar vel11bral column; dorsal view. The poS1erior longitudinal ligament U.i(g. longitudinal• post.U.} is a rontinuation of the Membrana tee1oria and extends to the Canalis saaalis. It is fixed to the intervertebral discs end the rims of the intervertebral surtaces and serures the intervertebral discs (Disci intervertebnJIes). This ligament ina-eases the S1Sbility of the vertebral oolumn during
ftalon.
60
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Ligaments of the vertebral column
Rg. 2.49 Co•owrtllbral Joints, Artkullrtlona costcMirtCn~la; trsnsverse section through the lovver part of the costovertebrsl joint; aanial view.
The costal heads articulate with the thorscic vertebts/vertebrae in the Mleu~lo apHis COitH. With the exception of the ribs I, XI and XII, this is a tw~hambared joint (dithalamic joint). Each costal head articulates with the upper and lower rim of two adjaoent vertebrae and, through a ligament (lig. capitis costae intraarticulare; not 'iisible). the
Rg. 2.50 Co.....-Jons of 1M wnebn~lardtes.: ventral'iiew. In between the vertebral arches stretch the segmental Ligg. ftiMI (yellow colour results from the high rontent of elastic fibres oriented perpendicular to each other). They form the dorsal demarcation of the Fo-
intervertebrsl disc is fixed to the Crista capitis costae. In addition, the rib articulates with the Proc. transversus of the aanial vertebrs in the Artleullrtlo co•crtnnsver~~~rlll (exception are ribs XI and XII). This involves the Facies articularis tubarouli costae of the rib and the Fovea costalis processus transversi of the vertebraltrsnsverse process. The weak joint capsules are strengthened by different ligaments (-+ Fig. 2.50).
remina intervertebrelia. The Ligg. flave are always under tension and support the musdas of the back when erecting the vertebral column from all flexed positions.
61
Trunk
Surface anatomy
-+
Development
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Skeleton
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Imaging
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Muscles
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Ligaments of the vertebral column
Oil CUll ~lnll8
62
Fig. 2.51 Ligamanu of~ wrtebrll cclumn and~ COif:o'Wirt• bral Joints. Artleu~larteS co"owrtebralls; view from the left side; latersl parts of the anterior longitudinal ligament removed. The joint capsules of the Artirulstiones capitis ()()51ae are strengthened
by the Ligg. capitis oostae rsdista; the joint capsules of the Artirulationes costotransversariae are supported by the Ligg. costotransversaria (Lig. oostotransvarsarium latarale and Lig. oostotrsnsversarium
Fig. 2.52 Ligamanu of~ wrtebrll cclumn and~ COif:o'Wirt• bral Joints. Artleu~larteS co"owrtebralls; dorsal view. The dorsal part of the joint capsules of the Articulationes trsnsverssrise is strengthened by the Ligg. costotransversaria lateralas and superiora. The Ligg. intertransverssria guarsntea additional stability.
" The Lig. supraspinal& is the median pert of the Fascia thomcolumbalis.
S~.Jperiusl.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Motion segment
Fanunan lnB\utallrala
Llg.lanllltudlnalll.-tlle
Ug. lntenplnale
MJII.IIIIboeus
Dllcul
{
fie. 2.53 Lumbar motion ....,.nt; median section; view from the lett side. The interwrtebml disc (Discus intervertebrelis) is composed of a central gelatinous nucleus (Nucleus pulposusl, a remnant of the Chorda dorsalis, end a ligamentous ring (Anulus fibrosus), which surrounds the Nudeus pulposus. The Anulus fibrosl..ls is the non-ossified remnant of the epiphysis of the vertebral body("). Its main attachment is to the Corpus vertebrae at the bony rim and the hyaline cartilaginous lining ("")of the intarvenabml surface and the Lig. longitudinale postarius. Additional,
although weaker, fixation is provided by the Lig. longitudinale enterius. A Discus interwrtebralis acting as Symphysis interwrteb1111is connects two neighbouring vertebrae. The Ligg. flsva interspinal& and supmspinale provide the connection between the vertebral ardles. In the thoracolumbar region, the Lig. interspinale projects into the Fascia thoracolumbalis. " annularrim "" hyaline cartilaginous lining of the interwnebml surface
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The inherited (HJ.A.827 positive) ankylosing spondylitis tBEKHTEREV'• di11111} involves e progressive ossification of the Anulus fibrosus of the imerveneb111l discs, the veneb111l joints, the Ligg. capitum costarum radia1S and eos101111nsverseria end Ligg. longitudinale anterius and interspinalia. In the early stages, in most
cases only the sacro-iliac joints are affected. Despite the limitation in flexing motions, the outline of the back seems normal initially. However, progression of the disease coincides with the back becoming flattened like a board. In addition, there is a significant restriction of chest wall excul'l!ions along with restrictions in raspi111tory capacity.
63
Trunk
Surface anatomy
-+
Development
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Skeleton
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Imaging
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Muscles
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Cervico-occipital joints
Allfcl.fllfo-oocx:~ll. --~'~\~ \\
Clpll.falll1k:l.falfa
Fig. 2.54 C.~ltlll Joints wHh dNp llpments; dorsal view. The Membrana tectoria is 1tle cranial extension of the Ug. lalllltudlnall po1teri111 and covers the ligaments and the joint capsule of the
Articulatio atlanto-axialis mediana (nat visible). Lateral between Os occipitsle and Atlas the joint capsula of tha Articulatio atlantooccipitalis and between Atlas and Axis the joint capsule of 1tle Articulatio atlantoaxialis latsralis are visible.
FaclcullcngltuclniiM}
Ug.~m-llt ~a;::crorme Fuclcullcngi!Uclnakle
Nn. corvlc:lllrM, Aladtx.
Fig. 2.55 Cervico-occipitaliNNiitioMI , . n with intwmeciml Mlllmo-alll faint and carrapondlna lg.....ms; sagittal section through tha median plane; view from the left sida. A section through 1tle articular connection between Dens axis and anterior arch of tha Atlas is shown. This is pen of the so-called lower head joint composed of the Articulationes atlantoaxiales laterales and 1tle Articulatio atlantoaxialis medians as opposed to the upper head joint which consists of 1t1e Articulationes atlantooccipitales. Above and below the Atlas, the joint capsule receives support through the Mlm-
64
.briM Mllrrtooccipitalis anterior and the upper part of the ug. longitudinale superius, raspectively. On the posterior side of 1tle dens, 1tle joint capsule is strengthened by the Fasciculi longitudinalas and the ug. transversum atlantis ijointly named Llg. cruelorm• Mill mit) as well as the Membr1na u.ct:oril which covers the ug. cruciforme atlantis. The Membrana tectoria is covered by the Dura mater spinalis. The M•m· .briM Mllntooccipitalia poatMor extends between the Os occipitale and Atlas at the dorsal aspect of 1t1e vertebral canal.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Cervico-occipital joints
Ale. . ~
'llltlcl.lllll!lo llllllll..,_...ls llltenllls
Fig. 2.58 Carvico-acipital joints with deep ligaments; dorsal view; after ramOVBI of the Membrana tectoria. Centrally located is the Llg. cruclorrne atlantis composed of the Lig. transversum atlantis and the two Fasciculi longitudinales. Behind this ligament the Llgg. alarlll (Winged ligaments) are located which origi-
natB from th a tip and the lateraI surface of the Dens axis (-+ Fig. 2.57); they project upwards in an oblique angle. On the left side, the joint capsule of the Articulatio atlantoocd pita lis and the Articulatio atlantoaxial is are shown. On the right side, the joint capsules hove been removed and the joint cavity is visible.
Fig. 2.57 C.rvlc:o-occlpltal Joints wlll'l dHP ligaments; dorsal view; after removal of the Membrana tectoria and Lig. cruciatum atlantis.
One can see the Ugg. alalia(-+ Fig. 2.561 which frequently project to the Massee latereles of the Atlas and the thin Lig. apicia dentill.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , Rupture of the Ug. trensversum atlantis and/or the Ug. crucifonne atlantis can lead to the dislocation of the Dens axis into the vertebral canal and, thus, into the Medulla oblongata. This will result in spinal cord contusion or trenssection of the struc-
tures !broken neck). The nerve centres for respiration and blood drt;ulation are destroyed, which will result in immediate death. Occasionally, a missing Dens axis or incomplete formation of the odontoid may causa an atlanto-axial subluxation.
65
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
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Muscles
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Cervico-occipital joints
Menaal'lll
VeiUin Olr\llcal18 Ill
Fig. 2.58 C.~ltlll Joints wHh llpments •nd upper cervic.l vertebr•l col~n; ventral '.liaw. The Llg. langltudiMII •merfus is located in the midline. The M•m·
extends from 1t1e occipital bone to the Atlas. The joint capsule of the Aniculatio atlantooccipitalis is shown on the ride side and removed on 1tle contralateral side.
Fig. 2.59 C.~ltlll Joints; dorsal view. Dorsal view onto the Membrana atlantoocx:ipiUIIis posterior and the Lig.
terior atlantis. The joint capsule of the Aniculatio atlantoaxialis lateralis between Atlas and Axis is shown on the rida side and removed on the contralateral side.
atlantooccipitale laterale between the Os oocipitale and 1tle Arcus pos-
66
.br•n~~ Ml•~tt.lls •merlor
Vessels and nerves
-+
Topography, back
-+
Female breast
Topography, abdomen and abdominal wall
-+
Intervertebral discs
lh:ue eorporte I,Jinle. unc:frlatue] Ar&lhaflbt'cala --1*"~-
• Eplpi!)'811UI1Uilrll _
___,;_.~
Anulue flbroeue Eplpllyall 81'&1111111 N.aplrlllllt,-_...· ~1
llillcl- puiJIC*III
Gangllan--I.ITI
•
navlllfllnalll
b
Flp. 2.toa and b lntervel1tbral dl~a. Dllcllntervel1tbrala. a Cervical intaNenabral discs. Disci intervartebrales carvicales; frontal section; ventral view. In the lateml areas of the cervical intervertebral discs so-called uncovartebral gaps (**) start forming already during the first decade of life. Between 5 to 10 years of age, the gaps become manifest and assume a joint-like character, hence their name uncovertebral joints. While providing increased flexibility of the cervical venabml column at a younger age, later on these uncevertebral joints may rupture rompletely and,
thus. can impact negatively on neck mobility(... Clinical Remarks). b Lumbar intervertebml disc. Discus inteNenebmlis lumbalis; median section(... Fig. 2.531; view from the left. "
"*
hyaline cartilaginous lining of the intervertebral surface as part of the non-ossified portion of the vertebral epiphyses so-called uncovertebral gap
Anum tlbra1111
Dleeut
Intel walbilbialle
{
NUCleUs pupoeus
Fig. 2.81 Lumbar lntervel1tbral dllc, Dkcutlirttii"¥Wtebralll lumbalis; cranial view.
The inteNertebral disc (Discus intervertebralisl is composed of a central jelly-like nucleus (Nucleus pulposus), a ramnant of the Chords dorsalis, and a fibrous ring IAnulus fibrosusl surrounding the Nucleus pulposus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Degenerative alterations of the inteNertebral disc occur most frequently in the lumbar and the cervical regions of the vertebral column. This can rasult in disc protrusion or disc prolapse (lllpptMi dille, herniated Nucleus pulposus). The disc tissue shifts usually to the posterior and lateral side, rarely posteromedially, into the ver-
tebral canal resulting in compression of the spinal nerve roots (tpl1'111 radicullr •dro11111). Most ohen. the segments S1, L5 end L4 ara affected. In the cervical vertebral rolumn, a slipped disc may oocur upon rupture of the Discus intervertebralis, emanating from the uncovertebral gaps.
67
Trunk
Surface anatomy
-+
Development
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Skeleton
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Imaging
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Muscles
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Cervical region of the vertebral column, radiography
Axii,Carp.l8w- - - - - - - - - - - - - - -
Angutuamandlbutu
-----------,r.-
Uigua - . , . . . . - - - - - - - - - vartetn. cenlcallllll,
Capua-.
-
f -- - - - : :
OfiiCUII ~lnlle
Plac. aplnaa~a
- - - - - - --+-
Pedcuh.18 arcue wrtelll'at
Fig. 2.62 C.Mall wrtebr... V.l1tlbrae eervtcala; late111l radiograph of the caNical pan of the vanabml oolumn; upright position; the Clentral beam is directed onto the 3n1 ceNical vaneb111; shoulders era pulled downwards.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Kyphotls is dEJfined as a vanebrel column curved dorsally convelC. In the thoracic vanebral oolumn. this slight ourwtura is physiological, however, in the CleNical and lumbar vanebrel column it is always pathologic. A pronounced kyphosis leads to hump formation (gibbus) and is present in various forms (e.g. in early childhood as humpback; in adolescence as juvenile or edoleectnt kypholil
68
!SCHEUERMANN's disease); in adults through loss of elasticity and disc degene111tion as Mnie kypholil). Congenital kyphosis usually results from hemi- or fused veneb111e. A strong norlilhysiological lordosis is called hypMordOiilsnd occurs particularly in the lumber vanebral column.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Thoracic region of the vertebral column, radiography
Fig. 2.83 'Dtonu:~ wrtebrH. Vwtebrae1ftoraeleae; amerior-posterior IAPl radiograph of the thoracic part of the vertebral oolumn; uprisj\t position Ylith Thorax in inspiration; cen1ral beam is directed onto the SU' thoracic vertebra. "
intervertebml disc space
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Due to the dense capillary network Ylithin a vertebra, the vertebral oolumn is frequently a loc.tion for metllltala of malignant tumours. The normal bone matrix of affected vertebrae is destroyed end the mechanical bone properties have vanished. Therefore, even
minor strain leads to collapse of vertebrae. Often vertebral fragments enter the vertebml canal or the intervertebral fommina and result in injuries and compression of the spinal cord and the spinal nerves.
69
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Lumbar region of the vertebral column, radiography
--lumbaiiii,CarpuaWitalltwl
Fcnmtna tnurvtrtebl'ala
Arcue Wltllbrat, Peclculue arcue Wltlllltwl
lnclllft Wltalnllelrttrlef
..
Proc. 81UcUIIII8lnftrlef Ploc. trtiCIAarlll tUpe!!CI'
.... O.lh.m, a-llaca
l'l'omcmcrlJm _....:...._ _ __ OeaacnJm - - - - - - - - - -
Fig. 2.64 u.nbar YlrtlbrH, V.rtebr11 lumbllel; latent! mdiograph of the lumbar pan of 1t1e vertebral rolumn: upright position; central beam is directed onto the 2"• lumbar vertabm. The anterior edges of the lower lumbar vertebrae are oblique as an initial sign of degenerative changes and pathological alterations.
*
intervertebral disc space *" region of the vertebral arch between the superior and inferior articular processes (isthmus intemrticular ponion) ***The terminal points indicate 1tle position of 1tle XII. rib, Yhlich is poorly visible in this ropy of the mdiogmph.
=
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . O.tteoporolis is a metabolic bone disease (osteopathy) Yhlich is characterized by localized or universal reduction of bone tiSlM.Ie without changing the external shape of the bone. The etiology is mostly unknown. This condition mostly affects women {Ner 55 and men over 70 years of ega. Genetic predisposition, low physical ac-
70
tivity, malnutrition, and unfevoumble estrogen levels contribute to the development of osteoporosis. As a l'elM.Ilt of the weakened bone structure, fractures such as vertebral fractures, distal radius fractures, and femoral neck fractures occur frequently.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Lumbar region of the vertebral column, radiography Co81aXJI \oW!etn.lumballll, Capua Wltlltna
Fig. 2.615 Lumblr wrtebrH, v..tebrulumbales, 1nd ucnrm. 0. Rerum; AP-rediograph of the lumbar part of the vertebrel rolumn and sacrum; upright position; centre! beam is directed onto the ztd lumber vertebre. " intervertebral disc space
Fig. 2.18 Lumblr wrtebrH, Vwtebl'll lumbiiU; radiogreph Ylith beam in an oblique engle; upright position. [8) The e)Cj)Eirienced radiologist can recognize a dog-like figure (*Scotty dog", dotted lines) in this oblique radiogreph image. The centre! pert represents the interarticular portion. The clinical term refers to the superior and inferior articular facets of the zygapophyses! joints [-> Fig. 2.29). " interarticular portion
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Fri~UI'IS In ~hi raalon of . . lntlr1r1kular p01'1fon CIMhmut, lead to a change in the Scotty dog figure, such es dog collar. caused by a zone of lysis. Mostly as a result of sport injuries, damage occurs particularly to the Pats intererticularis at the level of L4 and L5 (isthmus). In the absence of a fracture of the ventral Pars intererticularis,
the crenial vertebra shifts over the caudal vertebra as a result of congenital or degenerative changes of the position of the articular facet. All the above-mentioned conditions (including a fracture of the Pars intererticularis) are termed •pondwfoilthtlil (vertebral slippage).
71
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Vertebral column, CT
C&nllago lhyroklea M. -..oclsldl>-
mlllllllldeuB 'MIIIIbra ceMcallll v;
earp.. v.tabras !)!cue CCli'JK)I18
Pnx:.tm....,..,...
lU>Bft:uum llrlliBII,. Dille,. lnlarwltsbniJIII
-.acaMcaJIII VI,
earp.. Pnx:. ..tlcuLamina _ . W11elne
Fig. 2.67 C.rviCIII part of tiWI vertebral column; computed tomographic (Cl} cross-&ection at the level of the intervertebral disc between the 4111 and 5 111 cel'llical vartebrae.
Fig. 2.88 C.Mc:al part af th• vwtabral column; computed tomographic (Cl} cross-section at the level of the sth cel'llical vertebra.
• endotracheal tube and endoscopic instrument
Acrta, Pan abdcmlnaJIII
Dlllcu•
V. CIMI.Infartcr
V. cava lnferlcr
Acrta, Para abdcmiralil
~--·
Ccrp.I•WIII:abrE
M.peaaormjcr Ran
M....... IT$
Foramen lni8IVSielnle
Proc• .-!lcullrtS114*!Df
AnlciA11o Z)1111)011tr,'slalls Ploc. .-tlalllrts lnll!l1or PICC. mamllllrlo Mm. dllnl
Proc.opln. . . FMcl• th....:clumbaJII
Fig. 2.81 Lumbar part f1l tiWI vertebral column; computed tomographic (Cl} CI'OS!Wiection at the levaI of the 2"~ end 3n1 lumbar vertebrae.
Padlc:IJ. . IIC. . Wlll:abnla
Ug.tlawm Ploc. C08Ials Ploc. anlcullrts lnler1ar Ploc. anlcullrts IIU parlor Ug. lntllnlplnale Mm.danll FIIIICia tllarzDI~mbaJis
Fig. 2.70 Lumbar part of tha wrhbral coklmn; computed tomographic {Cll cross-&ection at the level of the pediculi of the 3'd lumber vertebra.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , Some genetic diseases era associated with differences in vertebrae count. The KLIPPEL-FElL synclram• is a heredi1ary disorder of the cel'llical spine with spinal fusion (generally of otlas and axis Of of the 5'h and 6"' cervical vertebrae) during the early embryonic s1age. Characteristic features are a decreased nee k. Iength and often a eort-
72
genital elevation of scapula due to spinal fusion. Spina bifid&, lower placement of ears, and abnonnalities of heart and other organs aocompany this disease. A vertebra that emerges from only one side of the associoted sclerotome is termed a harnivertebra.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Vertebral column, MRI
\oW!etn.lumbalal,
CapuaWitalltwl
Fig. 2.71 Lumbllr part of 1tle wrtlbrel column; magne1ic rescnance tomographic image (MAl) of the thoracic and lumber part of 1he vertebral column and the sacrum. MRI is a sui1Sble imaging technique 10 view in1arvartabml discs, the spinal cord, and 1he epiduml space (Spatium epidurals).
Olnal8 wrtelnllll 'With cerellrclptlal flulcl1111d Cauda eql.fna
Fig. 2.12 Medill dille prGiepse; T2-waigh1ad magna1ic resonance tomographic sagittal image (MAO in the lumbar part of 1he vertebral oolumn. [8)
Fig. 2.73 Medill diiC prGIIpu; T2-waigh1ed magnetic rescnance tomographic axial image (MAO in the lumber part of 1he vertebral c:olumn.[S)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Aging decreases 1he ability of 1he Anulus fibrosus and Nucleus pulposus 10 ra1Sin wa1ar which leads to forma1ion of small creeks in the Anulus fibrosus (dtondrosll}. No1able are radiographic reduction in heigh1 and pa1hologic instabili1y with increased mobility in 1he motion segment. Gradual height reduction of 1he disc and 1he resulting reduction in mechanical buffer function lead 10 increased strain on adjacent superior and inferior in1ervartebral ~rfaces of 1he vertebral
bodies. On radiographic images, the tclerotk proceu is reflected by an increase in radia1ion densi1y (olteochondi'Oiil). Further. it ~Its in the forma1ion of os1eophytes (bony spurs) at 1he vertebral bodies. which are also visible in radiographs. Vlli1h the radial creeks in 1he Anulus fibrosus increasing, in1ervertebral disc 1issue can leave the intervertebral space (dilc prGiepse;-> Figs. 2.72 and 2.73).
73
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Superficial layer of muscles of the back
N. rtlcmbdcleua mljct
M. obUqws el~Um1.18 abdomlnlll
Oe sacrum, Facie~~ dCI'IIflls
Fig. 2.74 Superficilllayer af 1M trunk..nn 1nd inlnk-ehouldet girdle mutdls; dorsal view. The Mm. trapezius and latissimus dorsi represent the largest part of the superficial layer of muscles of the back. The M. tnrpalus secures the scapula and thus the shoulder girdle and can move the scapula and clavicle backwards medially towards the vartebrel rolumn. The Partes descandens and ascandens tum the Angulus inferior of the scapula medially. The Pars desoandens acts as an adductor and SI.Jpports the M. serratus anterior in the elevation of the shoulder.
The M. llltiuimll& dor1i is the largest muscle of the human body with respect to the S~.Jrtace area. It lowers the elevated arm, adducts the arm. can move the arm from an adducted position medially and beckwards, rotates the arm inward, and assists in eJCpiretion. M. latissimus dorsi end M. taN8 major devalop at the same time. The latter pulls the arm medially end backwards, supports adduction, end inward rotation of the arm.
I-+T27,281
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . A portion of the M. lltiuim111 dorlii can be used to COYir dlflcts of 1fMI w1l af 1fMI trunk es well as to reoonstruct the mammary after resection of mammary carcinoma. F« this purpose e suitable
74
-+ di•••ction linlc
pedicle flap, on which the A. and V. thorecodorselis ere segmented and transferred, is prepared. The M. piCf:ol'lllilmljor (ventral trunk well) is often used as pedicle flap graft to cover f1cill d..-.cta.
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Superficial layer of muscles of the back
fie. 2.75 Deep layer cl the tru..-erm end trunk..houlder girdle muscle.t: dorsal 'lliew. After remCMII of the M. tmpezius. the Mm. 19118tor scepulae. rhomboideus minor and rhomboideus major are 'llisible on 1t1e right side. The M. II'Wetor Kapulae can lift the scapula and simultaneously tums the Angulus inferior of the scapula medially. M. rhomboideus minor and M. rflombGidMa m1jc:lr fix the scapula to the 1t1orax and pull it towards 1t1e spine. After the remCMII of the three muscles and the M. latissimus dorsi the Mm. Hmltll posterlara ~r and lilfwlor become 'llisible. The M. serratus posterior superior lihs the upper ribs upv.9rds and supports inspiration. The M. serratus posterior inferior broadens the lower thomcic aperture and stabilizes the lower ribs during the contraction of the Pars costalis of the diaphmgm. Thus, this muscle also suppon:s inspir~ tion.
The Facie thoraco..mbelia oonstiMes e dense aponeurosis. This tough fibrous strue1ure surrounds the autoch1tlonous (in1rinsic) erector spinae musdes of the back and forms an osteofibrous tube together wi1tlthe vertebml column and the dorsal side of 1tle ribs. Its superficial lamina serves as origin for the M. latissimus dorsi end the M. sermtus posterior. This lamina is firmly attached to 1tle tendon of the M. erector spinae. It sepemtes the M. splenius cervicis from the M. tmpezius end 1tle Mm. rhomboidei in its aanial see1ion and merges wi1t11tle Fascia nuchae. The deep lamina is shown in-> Fig. 2.76. The areas of the ntgonum lulllbale superlus (GRYN FELrs triangle in TA) and the Trigonum lumbele inr.iua (PETrrs triangle) ens the sites for GRYNFELT's and PETJrs 1111'1\ber hernia.
-+ di•••ction linlc
75
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Deep layer of muscles of the back
M. MTIIIJ8 poeurlartupa'lef
M.ll~oc:otalle thorac:ll
M.lonul..rrnue thorac:ll
Fig. 2.78 Superficial layer of 1fte dNp talltoc:Mhonout} mutc!M ofifle back; dorsal '.liew. The autoch1tlonous musdes of 1tle beck are collectively named M. er«tot tpinH. It is di'.lided in1o a medial and a IB1eral1rec1. Each 1rsct is composed of different systems(-+ Fig. 2.771. TheM. eree1or spinae
76
-+ di•••ction linlc
eX1ends from 1he sacrum to 1tle occipital bone. The abdominal muscles and the M. erector spinae 1ogether act es a fune1ional uni1 (bow-1endon principle).
I-+T181
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Deep layer of muscles of the back, schematic diagram
Oblique t)ll14lm
llleral
M. llacclla.. ·carvlcl8 -lhcncl8 ·l~.mbarum
/' }f'"J:--...=:'-------M. mJhrld1.18**
medial
maclllll
-cenrlcll -Uicncl8 -lumbanJm
lateral
Mm. rotatcnl8 10~1"* -C*'I'Iclll
medial
-UIC1'81Ci8 -lumlla'Um
medial
Mm.lmnpl·cenlc:ll •thcncll ·lumbanJm
-------i~S:':::T
Nm.-l:lr8\'lae"*
"
fie. 2.77 Deep (autactrtflonoLII} mLIICIIa of 1M .b.:lr; diagram of the different muscle groups. The autochthonous muscles of the beck. oollectively named M. erector spinae. am be divided into a longitudinal erector system and an oblique system. as wall as in a lateral and medial tract. The lateral tract divides into an intartransvarsal system (Mm. intartran5versariil. a sacrospinal system (M. iliooostalis, M. longissimus). and a spinotransvarse system (M. splenius carvicis. M. splenius capitis!: • The intartrll'llft'MIII system serves as stabilizer. facilitates banding sideways and extension among transversa processes of the vertebrae. • The tlla'Otplnal ~ erects the spine. causes extension, and facilitates sidc:Hlending and rotational movements of the trunk on the ipsilateral side.
medial
-canrlcll -Uicncl8 -lumbanJm
• The tpinotNniVWH aystam acts as e stabilizer according to the bow-tendon principle and, together with the short neck muscles, supports all movements generated in the joints of the ceNicel spine and head. The mecill tract divides into e spinal system (Mm. interspinales. M. spinalis! and a transvarsospinal system (Mm. rotatores braves, Mm. rotatores longi, M. multifidus. M. semispinalis). Functionally. the tpinal ~am is important for extension and torsion; the trlnsvei'!IOiplnal ~am stabilizes end rotates to the contralateral side. " spinotransverse •• transversospinal
77
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Deep layer of muscles of the back
Alias, f'l'oc.11'1118\W8U8 M. Clbllqulle capltlelnfel1or
Ugg.lnbnplnallll; ug. aupruptulill
Memmna lnten:l08181111 rtwna
Mm.IIMitorM eo1t1r111n longl
Fucla uu:ncdumbala Mm.l~l modlllille l~n~barum
N. abllquualnt«r&~a -.,-.r.
M. tl'all8Wr8US«
M. abl~cJJus 41Jamus alldomlrfs
Fig. 2.78 Mlllda of 1M back. Mm. dortl, and mlllda of 1M neck, Mm. suboccipitalel; dorsal view. Upon removal of the Mm. splenius capitis and semispinalis capitis, the short neck musdes (Mm. rectus capitis posterior minor, rectus capitis posterior major, obliquus capitis superior, obliquus capitis inferior) become visible. Also depicted here are the Mm. levatores costa rum YAlich are not part of the autochthonous muscles of the beck because they are innel\lllted
78
-+ di•••ction linlc
lllalumllalll
by Rr. ventrales of the spinal nerves. Contrec1ion of these musdes re-
sults in rotation of the contralateral side and side-bending movements on the ipsilateral side. Some authors also discuss a role of this musde group in inspiration. F« the organization of the other shown autochthonous musdes of the back see~ Fig. 2.77. I-+T181
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Deep layer of muscles of the back
M.leYator 00111ae leflgus
Mm. multffidl
Colla XII
)-,.-IJII~I--VIIrtabnlelumbalee,
Pracx:. ccaa•
Mm.l~l lltnl•l~n~borUm
Feecla thoncolllmballll (Lamlne~
Mm. mullltldl
Deep...,_
Fig. 2.19 cl the miiiiCI• of 1M back, Mm. doNi, in the reelan of the thcndc and lumbllr put of the wrtllbral col~n; dorsal '.liaw. On the right side, a cross-sec1ion through the caudal region of the M. arectOI' spinae is shown. The Mm. multifidi belong to the medial tract
Ug.lcngtuclnalt8111»11U8
and are located medially, together with the superficial and deep laaf of the Fascia ttloracolumbalis. On the left side of the body, the Mm. 1'018tores ttiOI'acis are '.lisible.
I-.T1al C4IIDil equlrw.
-r~mt&.t~:~-:-~~~
Pedlcuh• arc... - - } Arcus
Aen M. 1JK1U map -
Lamlnaa'CUI~ ~bru f-....Oill§
M. q18:1ra!ua tiiT&XIfum
CoD. XII M. Obi(JJU8 41Xttri1J8 abcicmtll8 M. rau•m ... dorll
Prac. aplnaaua
Rg. 2.80 A&rtodrthonous miii!Cia of 1M bade; transverse section at the laval of the 2nd lumbar venebre; caudal '.liaw. The autodlthonous muscles of the back are located in an osteofibrous tube which is fOI'med by the dorsal parts of the venebree at the inside and the Fascia ttlolllcolumbalis on the outside. The autochthonous
musdes of the back are divided into a lateral tract l"l and a medial tract ("").
-+ di•••ction linlc
79
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Neck muscles fie. 2.81 Shclrt muldea of the necl. Mm. luboccipitalee,; view from an oblique dorsal angle. Tha Mm. rectus capitis posterior major, obliquus capitis superior, and cbliquus capitis inferior create a triangle tvertebl'llllttrllngle). The M. rectus capitis posterior minor is locsted medially to the M. rectus capitis posterior major. Functionally, the four muscles direct precise movements of the head joints (Articulationes atlantooceipitalis and atlantoaxialis) and perform minute adjustments of the head in the atlanto-occipital and atlanto-axial joints. I-+T181
N.lnlpl:zkla
a.mllplnaJis capl1fs
M. NCtue Clplt!e pciiWfor ITIIfar M. obllcp~e CIPIIIIIIJMikr
Fig. 2.82 Mlllda of 1M blek. Mm. dortl, and mlllda of 1M neck, Mm. tuboccipitalet; dorsal view.
To view the short muscles of the neck, the Mm. splenius capitis and semispinalis capitis on the right side were removed. The M. rectus capitis posterior minor has its origin at the Tuberculum posterius of the Atlas and inserts medially at the Linea nuchalis inferior. The M. rectus capitis posterior major originates at the Proc. spinosus of the Axis and inserts laterally to the M. rectus capitis posterior minor at the Linea
80
-+ di•••ction linlc
nuchalis inferior. The M. obliquus capitis superior originates at the Proc. transversus of the Atlas end inserts above end laterally to the M. rectus capitis posterior major. The M. cbliquus capitis inferior has its origin at the Proc. spinosus of the Axis end inserts at the Proc. transversus of the Atlas. I-+T181
Vessels and nerves
-+
Topography, back
-+
Female breast
-+
Topography, abdomen and abdominal wall
Neck muscles
Fig. 2.83 Mlllda of 1fHI neck. Mm. tubocc:IPitiiiM.: dorsal view. The Mm. rectus capitis posterior major. obliquus capitis superior. end obliquus capitis inferior create the margins of the vertebralis triangle fTfiaonum erterile vertlbrelil}. At the base of this triangle the A. vertebral is crosses the hrus posterior atlantis.
I =Tuberculum pos1erius of the Atlas II = Proc. spinosus of tha Axis
Fig. 2.84 MlltdU of 1fHI back. Mm. dorsl,end mlltdU of 1fHI neck. Mm. coli; view from the left side. Upon dissection of the M. splenius capitis (rest displaced cnmiallyl. the latersl view of the neck reveals from anterior to posterior the Mm. scaleni medius and posterior as well as autochthonous muscles of the back with the latersl (Mm. iliocostalis cervicis, longissimus ceNicis. splenius cervicis, longissimus capitis) and medial (Mm. semispinalis thoracis. semispinalis capitis) tracts. With the removal of the superficial muscles of the beck in the neck region the Ug. nuchae and pans of the M. trapezius become visible at the midline.
M. eca1enue medlue
-+ di•••ction linlc
81
Trunk
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles -+
Muscles of the thoracic and abdominal wall
Llgg. CCIItmlphckSaa"'
M. obllcplll atemue lbdclmlnle
Flll'lle lntln:nlrel•
Fig. 2.85 MUida of ~M ~hcndc and abdomNI waiL Mm. 1hcnacia and Mm. abdominis.eul*ficill ..,_.;ventral '.liew. The V. cephalica runs between 1t1e margins of 1t1e M. deltoideus and M. pactomlis major to tha Trigonum clavipectorale (MOHRENHEIM's fossa) whene it goes deep to join the V. axillaris. The lower margin of 1tle M. pactomlis major constitutes the anterior axillary fold, the anterior margin of 1tle M. latissimus dorsi cneates 1tle posterior axillary fold; 1tle M. sermtus anterior forms the floor of the axilla. The M. pacwrab ml,lor functionally participates in 1t1e anteversion (= flexion) of the arm in the shoulder joint and is a strong adductor and medial rotator. In addition, this muscle can pull the shoulder forward and downward with the arm in e fixed position end assists in inspiration.
82
-+ di•••ction linlc
In 1tle abdominal region, 1tle rectus shea1t1 is formed by the aponeuroses of the oblique abdominal musdes. The outmost oblique abdominal muscle, M. o.blqiiiiiS aldtii'IUS abdomlnh. sends its aponeurosis into the outer layer of the rectus sheath. In 1tle midline, the aponeuroses join in 1tle Linea alba. The caudal suspensory ligaments for the penis, Ligg. fundiforme and suspensorium penis, are shown. Lateml 1tlereof the Funiculus spermaticus and co~ tmlatemlly the Anulus inguinslis superficialis with Crus mediale, Fibrae intercrumles, and Lig. reflexum ana visible.
1-+ T 15,24,25,28 I
Vessels and nerves -+ Topography, back -+ Female breast -+ Topography, abdomen and abdominal wall
Muscles of the thoracic and abdominal wall
M.su.u. matmue
Fig. 2.81 Mutcles of ~he ~horadc and abdominal wal.. Mm. Mm. abdominil; from the right side. The lateral view demonstrates the female breast (Mamma) riding on the M. pactomlis major. The lateral abdominal wall displays the seml1ad in1erposition of 1tla muscular origins of the M. obliquus extemus abdominis wi1tlthose of the M • ..,...us anterior. The M. latissimus dorsi covers lhasa muscular samnions from dorsal. The M. obliquus aternus abdominis extends from lateml posterior aanial to medial an1erior caudal. The muscle fibras coming from 1tle ~horecilend
..new
lower ribs run almost vertical to the Labium extamum of the Crista iliaca. The remaining musde fibres enter into a sheet-like aponeurosis which panicipates in the formation of 1t1a ractus shea1t1 (Vagina musculi racti abdominis). At the 1tligh, 1tle Fascia glutea and 1tle Mm. gluteua IMJdmus and ~nsor faciH latH radiating into 1t1a Tractus iliotibialis era visible.
I-+T24,25,27,28
I
83
Trunk
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Muscles
-+
Muscles of the thoracic and abdominal wall
A.axllarla
M. 8811111118 anterior
c.-n1
M. pecta"aiB major, IW8 abdomlnaiB
Fig. 2.87 Muscles of the thar'IICic wall; Mm. thoracls; ventral view. TheM. pectorals major was removed on both sides, and theM. pectoralis minor was also removed on the left side. On the right side of the body, the course of the neurovascular bundle is visible below the M. pectoralis minor. Although the M. pectora&. minor is considered a musde of the shoulder it does not insert at the upper extremity but at
the Proc. coracoideus. TheM. pectoralis minor originates from ribs Ill to V and participates in depression and rotation of the scapula.lhe vary variable M. stemalis is a not infra quent variant located on top of the M. pectoralis major.
I-+T13,15,241
Cola. VIII M.amma.m.ur----+--~~~
It lnlen:oalalle poalilr1cw A. l'*'-11111s posteltor
M._.... ........., FMcla---+-r--"-:--::,;1~
N. lnlllrcolllllllll (T8)
Puhna
...
M. h18rcoetal8 - - -+--.;,_--:i!i.l-....,.;.,
Pleura vlllceralle [pumonalls]
..-.,
...... pMialllllll, .... caafllllll; 1'88<:111 endatllarac:ICII
........... j811111111s, Pan! dllphragmallca
1'8'11 C081alls dlaplngmllls
Hepa'
Palloneum...,.,rala Pe111oneum pariii1Bie ReceeeUI COMXIdlllplngmallcU8
Fig. 2.88 Muscles of the thar'IICic wall; Mm. thoracls; frontal section through two intercostal spaces. The following structures are penetreted during pleural puncture: CutiS/ Subcutis, Fascia musculi se1111ti, M. se1111tus anterior, Fascia thoracica e~ttema. M. intercostalis extemus. M. intercostalis intemus. Fascia irtterrostalis interne, Fascia endothoracica, Pleura parietalis. Pleural punc-
tures always are conducted at the upper margin of the rib because the neurovascular structures (V., A., N. intercostalisl run belaw the rib. " position of the needle during pleural puncture
I-+T131
Vessels and nerves
-+
Topography, back
-+
Female breast -+ Topography, abdomen and abdominal wall
Muscles of the thoracic and abdominal wall
~l h \
II
.
> )
Mm• .,11MWIIIIiihii lllllllml
Mm• ......._.... ...........
Fig. 2.89 Posterior - • of the thoracic CIIVit.y, Cavell tlloracia; ventral view. The Mm. intercostales atemii project from posterior aanial to anterior caudal. They initiate at the Tubercula costarum and reach forward to the parasternal cartilage [not visible!. These muscles act in concert with the Mm. intercartilaginei [not shown) by ea-ting tha ri:le during inspiration. The Mm. lntercostales ~ernl project from posterior caudal to anterior aanial. They initiate at the Angulus costae end reach the sternum (not
visible). They act during expiration by dapi'IIUing the riba. An exception are the muscular parts loce1Bd between the ca rti laginous parts of the ribs !Mm. intercartilaginei) which support inspiration. Not shown ere the muscular elements of the Mm. intercosteles intemi stretching across multiple segments, known as Mm. subcosteles. 'htlich serve the same function ss the Mm. intercostales intemi.
1-+T 11-131
/
I
--~\.It. ) \
I
.'
) I
Mm. h11!rcoatala8 lnteml
Rg. 2.90 Anblrlor - • at the tllorlldc cntty, Cavell thorada; dorsal view. The view onto the inner side of the anterior thoracic well displays the sternum and the muscular bundles of theM. tra__._ tha111ds. They originate at the lateral side of the sternum and of the Proe.
xiphoideus and insert on the inside of the costal cartilages 2to 6. The M. transversus thoreci s supports expiration. The posterior side of the Manubrium stemi serves as origin for the M. stemothyroideus and M. stemohyoideus.
1-+T 13
85
Trunk
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles -+
Abdominal muscles
\lqtna m1.18CUII recti abdcmtllt, l.alrina 81111!11cr
Mm. rtta'co81aiM trumt
N. ollllqu~ Glll8mU8 llbdamlnllt
M. obllqwe llnibllmle ebdomlnle
M. pynmldllte
Fig. 2.91 Supelficillend middle layer of 1M abdominel mLIICiu, Mm. ebdamlnll; ventral view. On the right side, the superficial leaf (lamina anterior) of the rectus sheath (Vagina musculi recti abdominis) has bean opened and the M. I"'Ctuu ebdaminil becomes visible. This muscle is separated into three to four lntarsectiones tandineae which aaata the SCH:~JIIed six peck contour when exercised properly. The M. rectus abdominis serves to bend the trunk forward and sideways. The caudal pan of the rectus sheath contains the small triangular M. pynmldalls which originates from the Os pubis and projects into the Linea alba. The M. pyramidalis is a rudimentary pouch muscle (from a comparative anatomical standpoint, the kangaroo possesses a strongly developped M. pyramidalis).
86
-+ di•••ction linlc
On the left side, the M. obiq11111 tadwnLII ebdaminil hes been detached and folded medially aaoss the rectus sheath. The larger part of this muscle ends in an aponeurosis which contributes to the superficial leaf (lamina an1ariorl of the rectus sheath. Functionally, this muscle participates in the forward and sid!H:lending movements it lateral rotetion of the upper torso. It is an element of the oblique and transversa muscular abdominal girdle. and creates a functional unit with the musdas of the opposite side as wall as the Mm. obliqui in1arni and transversi abdominis.
1-+ T 13-15, 24 I
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Abdominal muscles
M.--.tla
M. ollllqULII -!'&Ia abdamlnll
M. obllqula 11n1t1mua lbdomtnle
Fig. 2.92 Middle layer of 1he abdomin1l miiiCias, Mm. abdom.-.1..: ventral view. On the right side, the M. obliquus ex:ternus abdominis is largely removed. Beneath lies theM. obllquus Internus abdom.-.ls. Its aponeurosis contributes to formation of both the superficial !Lamina anterioo and the deep (lamina posteri0111amina of the rectus sheath. The M. obliquus intemus abdominis projects from lateral caudal to medial era-
nial and, like the M. obliquus ex:temus abc:lominis, it participates in the oblique and tlllnsverse muscular abdominal girdle and supports forward and side-bending movements and lateral rotation of the upper torso.
I~ T 13-15,241
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Abdominal muscles M. recti.IS abdcmtlls M. I)K1CI'alls maJor
M. v.--llldomlnle
Funlc!Aus spe~mw.tleus-
Rg. 2.93 Deep layer ofb abdomln1l miDCias. Mm. abdom.-.ls: ventral view. On the right abdominal side the M. transversus abdominis is shown. In addition, the anterior lamina {lamina anterior) of the rectus sheath Mr gina musculi recti abdominis) and theM. rectus abdominis have been
removed. The tnmsition from muscle fibres to the aponeurosis of the M. tnu• wrsua abdominil forms a semilunar line (linea semilunaris). This aponeurosis contributes to the major part of the posterior lamina !Lamina posterior) of the rectus sheath. Caudally of the Linea {Zonal arcuata, the aponeurosis of the M. transversus abclominis participates in the formation of the Lamina anterior of the rectus sheath 1~ Fig. 2.961. The
aponeurosis radiates into the Unea alba. The M. transversus abdominis is mainly exerting a constrictive force which results in increased intraabdominal pressure and supports forced expiration. In its upper section (from sternum to Linea !Zonal arcuatal, the deep lamina (lamina posterior) of the rectus sheath is formed by the aponeuroses of both the M. obliquus intemus abdominis and the M. transversus abdominis. Below (from Unea !Zonal arcuata to Os pubis), the Lamina posterior only consists of Fascia transversalis and Peritoneum parietal&.
I-tT 13-151
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . A rare SPIBEUAN hemi1 can occur at th& lateral margin of the
Linea arcuata bordering on the Unea semilunaris.
88
- dl•••ctlon llnlc
Surgical scars in th& abdominal wall can be the starting point for lnclllon1l hlml11.
tahir99-VRG & vip.persianss.ir
Vessels and nerves ..... Topography, back ..... Female breast ..... Topography, abdomen and abdominal wall
Muscle function
c
Figs. 2.94a to c Directions of motion of the trunk. a side-bending movements (lateral flexion) of the trunk Banding to both sides up to 40" is normal (0"/40°). Vertebra prominans (CVII) and Sl serve as reference points when determining the angle in the upright and maxi mal lateral flexion position. The lateral flexion is supported by the Mm. obliquus axtarnus abdominis, obliquus intamus abdominis, quadratus lumborum, iliocostalis, psoas major, longissimus and splenius. b Forward (flexion) and backward bending of the trunk (extension) in the vertebra I joints The range of motion is between approximately 100° flexion und 50° extension. Astra ight li na between th a acromion of the scapula and the Crista i liaca of the femur is used to determine these angles. Flexion of the trunk is supported by the Mm. rectus abdomi nis, obliquus externus abdomi nis, obliquus intemus abdominis, and psoas major. The Mm. iliocostalis, psoas major, longissimus, splenius, spinalis, semispinalis, multifidus,
trapezius, and levatores costarum participate in the dorsal flexion of the spine. c rotation of the trunk Bilateral anterior to posterior rotation of the trunk by approximately 40° is possible. A line connecting the acromion of the scapula on both sides serves as a reference axis. Ipsilateral rotation of the trunk is supported by Mm. obliquus intemus abdominis, iliocostalis, longissimus, and splenius. Rotation of the trunk to the contralateral side is achieved by the Mm. obliquus extemus abdominis, semispinalis, multifidus, rotatores, and levatores costarum. The vertebral joints in individual sections of the vertebral column restrict the range of movement. As for the entire vertebral column, bending forward (flexion) and backward (extension) of approximately 100°/0°/500, a side-bending (lateral flexion) of 0°/40°, and a torsion (rotational movement) of 40"/0°/40" are possible; these serve as normal reference values to assess movement restrictions.
Fig. 2.95 Objac:ti¥8 assessment of movement restrictions in the lumbar section of the vertebral column (method by SCHOBER) and the thon~cic part of the ,.rtebral column (OTT"s sign).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , Method by SCHOBER: To objectify movement restrictions of the lumbar spine, the patient is asked to stand upright and the examiner places his/her right thumb on the tip of the Crista sacral is mediana and the index finger of the same hand on the Proc. spinosus of a lumbar vertebra about a hand width (1 0 em) above. With maximal flexion, the distance between the two points usually increases by 5 em (4-6 em).
OTT"s sign: Mobility of the thoracic spina is determined in the same manner. The origin of measure is the Proc. spinosus of the -,m cervical vertebra (Vertebra prominens) and is traced 30 em caudally. With maximal flexion, the distance between these two points usually increases by 8 em.
89
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles -+
Abdominal muscles, rectus sheath
1ltla aubc"""-, Panniculus adlpoeus
M. rao::lla llbdDmlnlll
Lin• alia
A.; vv. eplg.at:l(e) 114*b(lll) M. ctlllquua ulllmua abdomlnll, AplliiiiU.....,
Vaglnamii8CIII I'IICtlllbdomlnla
Vagina miiiCIIII recti llbdDmlnla, Lamina anterlar
•
M. oblt~ws lntemusllbdolrjnls M. cbllquusi!Jdernus abdcmhl8
M.~olltx:lamhll
b
c M.IIBIISWIIIUS abdomlnls
M. giW~Ua medius Fuda thamcclumballl, Lamina augerfll:llllo'
Fall:Ill lhonK:olumballs, Lamina prafll'u:lll
Rp. 2.91.a to c Structure of tha rectus shallth, Yllghl musa~ll recti abdominiia; cross-s&el:ion; caudal view. The Mm. rBC!us abdominis and pyramidalis are embedded in a tough fibrous tube (Vagina musculi rBC!i abdominis) which is formed by the aponeuroses of the oblique abdominal muscles !Mm. obliquus eldernus abdominis, obliquus intemus abdominis, and transversus abdominis) as well as the Fascia transversalis and the Peritoneum parietal& at the inside of the ventral abdominal wall. All aponeuroses radiate into the Linea alba. lhe upper section of the rectus sh ealh is different from the lower section.The border between both sections is the u (Zon•l arcu.... In the uppanaction, the anterior lamina (Lamina anterior) of the rectus sheath is formed by the aponeurosis of the M. obliquus extemus abdominis and the anterior part of the aponeurosis of the M. obliquus inter-
90
nus abdominis; the posterior lamina [Lamina posterior) is composed of the posterior part of the aponeurosis of the M. obliquus intemus abdominis, the aponeurosis of theM. transversus abdominis as well as the Fascia transversalis and the Peritoneum parietale (a, b). In the IGwar section. all three aponeuroses locate in front of the M. rectus abdominis (c). Here, the posterior side of the rectus sheath is very thin and composed exclusively by the Fascia transversalis and the Peritoneum parietal&(.... Fig. 2.93). The umbilicus is a potential weak spot in the anterior abdominal wall which is thinner in the region of the umbilical pit and the Papilla umbilical is as compared to other parts (b).
1-+ T 14-18. 18. 42 I
tahir99-VRG & vip.persianss.ir
Vessels and nerves -+ Topography, back -+ Female breast -+ Topography, abdomen and abdominal wall
Abdominal wall, CT 'I 2.B7a 2.97b
,-;...(
J
" M. ll'llnllll8nlua abdamlnls, Aponeuroels
M. lltlllquua 61demua abdomlnls, Aponeuroels
M. cbl"',.lllllemua abdamhlll M. abllquua lnternua abdDmhlll M. trana\wllua abdamlnlll
M. cblqu,. lrtornua abdomlnll, Apa1'1111J1Dalll; M. ll'lln111181'8US abdomlnls, AponaLI'OIIa
M. cbllqwa ntamu11 abolamolnlll....._
M. lltlllquua 61demua abdomlnls, Aponauroels
Osllklm
b
Flp. 2.97• and b MuKies of th• abdoml. .l waiL Mm. abdominis; computed tomographic (CTJ aoss-sections.
The oblique and rectus abdomil"llll muscles can be distinguished in CT scans. TheM. erector spinae and theM. quadratus lumborum are also clearly visible.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Umbllcal htlml8s occur in newborns and adults. In newborns the umbilical papilla has not yet formed, whereas in adults the connective tissue of the umbilical papilla separates due to an excessive expansion of the abdominal wall during pregnancy or
adiposity. The hernial canal is the umbilical ring IAnulus umbilicus). An omphiiiDct!la (congenital umbilical hernia} is a birth defect resulting in the persistence of the physiological umbilical hernia during the fetal pllfiod.
91
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Inside of the ventral abdominal wall
M. rectu8 abdcmlrls
Plk:a wnbllk:allll llfllralle
Rg. 2.98 PosteriDr apect of 1he anteriDr abdominal wall: dorsal view. On the right side, the fascia and the peritoneum covering the diaphragm and theM. tranSV&I'sus abdominis have been removed. On the posterior aspect of the ventllll abdominal wall different folds (Plicae), pits (Fossae), and ligaments (ugamenta) are noticeable. The Ug. fllclfonne heptltls !sickle-shaped liver band) extends between the diaphlllgm and the liver and inserts in a right angle at the posterior aspect of the ventral abdominal wall. It extends to the umbilirus and represents the developmental remnant of the mes&nteJY of the umbilical vein. The umbilical vein occludes immediately after birth and remains visible as a round ligamentous cord (Lig. t~n~a hepetia) at the free border of the Lig. falciform a hepatis. Bekrw the umbilicus are visible the Plicllumbilicalia medilna (median umbilical fold; contains
92
the remnants of the Urachus -the fibrous remnant of the allantois that stretches from the top of the urinaJY bladder to the umbilicus). lateral thereof the Plicae umbilical• medial• (medial umbilical folds; contain the remnants of the As. umbilicalesl. and fanhest lateIllI the Plicae umbilical• llrt8ralea {lateral umbilical folds; oontain the Vasa epigastrica inferior!. The Fossae supravesicales, inguinales mediales. and inguinales latelllles are located between the folds. The Foal inguineliallterail corresponds to the inner inguinal ring located beneath; the Fotsa InguinalII meclallslocates at the same level as the outer inguinal ring.
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Diaphragm and posterior abdominal wall
Centrum tllndlneum
Fig. 2.99 Dilphragm. Dilphragm•, and muldM of 1M abdDmlnal wall, Mm. lbdomlnh; vemral view. The diaphragm is composed of a cemral tendon phJte (Centrum tendineum) with attached muscles which hav& their origin at the sternum (Pars sternalis), the ribs !Pars costalis), and the lumbar region of the vertebral column {Pars lumbalis). Upon removal of the retrop91'itoneum, the paravertebral location of the Mm. iliopsoas {composed of a M. psoas major and M. iliacus each), the M. quadratus lumborum, and, as a variant, the M. psoas minor are shown. Both the M. psoas mljor. originating from the Fossa iliaca, and the
M. ililcua insert at the Trochanter minor of the femur. The M. psoas major represents the strongest flexor of the hip. The M. psoas major can move the upper torso from a lying position into an upright sitting position and participates in the rotation of the trunk. TheM. qu.cfratus lwnborum originates from the Labium intemum of the Crista iliacs and inserts at the XII. rib and at the Procc. cos tales of the 1• to 4111 1umbar vertebrae. This muscle is able to depress the XII. rib and participates in the forward flexion of the trunk. * FALLOPIAN ligament or POUPART's ligament I ~ ns, 1s. 19, 42 1
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Diaphragm 1 (1\'lggrNmllllllmoc:OIIblie}: A.; \t.1han.clea lilllmll,
stlllter, R.l)tlrMCOIIlOomllllll8
Hlll:ull oe.ophageu.: OIIICI)tlagus; ltuncl \'IIQIIM ant1111ar et P<*IIIICf
A. ptnnt:a lrhrtlr
N. tPII/ICIIIICUS miiJCI' Pars coetlllle dlllptlragmlllllt
Pars lumbella dlllptlragmlllllt, d&lltnJII'\, (Pin -.Ill)
en.
Llg. -..tum m.cll1le Llg.~n:~~lltum
l l l t l • l - -'\.' M. ql.lldrltuslumboNn
Rg. 2.100 DJaplnam. Dlaphn11ma: caudal view. Th& diaphragm comprises the Centrum t&ndineum and the Partes sternales, costales, and lumbales. The Trigonum ltemocostale {LARREY's cleft) is located between the Pars sternalis and the Pars costalis, and th& Trigonum ..mbocoltale (BOCHDALEK's triangle) between the Pars costalis and the Pars lumbalis. The Pars lumballs is divided into a Crus dextrum and Crus sinistrum, each of which is separated further into Crura medial&, intermedium. and laterale. The Crus dextrum is attached to the lumbar vertebral bodies of L1to L3 and the intercalating Disci intervertebrales; the Crus sinistrum is attached to the lumbar vertebrae L1 and l:l and the inter-
calating Discus intervertebral&. The Crus mediale dextrum forms a loop around the oesophagus (Hiatus oesophageus). The tight and left diaphragmatic crura are connected by a tendinous arch (Hiatus aorticus) at the level of the vertebral column. At the Hiatus aorticus the aorta enters the abdominal cavity. The Lig. arcuatum medial& (psoas arcade) demarcates the diaphragm from the M. psoas major, whereas the Lig. arcustum laterale (quadratus arcade! separates the diaphragm from the M. quadratus lumborum.
Llg.~n:~~lltum
llltlrlle"*
M.ftnswrsus &bdomln18
M. qJIKirlll~aal~.mbonJm
Rg. 2.101 Dlaphn~gm. Dlaphn~gma. with dllrphragmltlc ~~Pt~r tui'IIS and muld• of 1he post8rior abdominal wal; ventral view. The diaphragm is a double dome-shaped incomplete separation between the thoracic and abdominal cavity 1~ Figs. 2.99 und 2.102).
94
- dl•••ctlon llnlc
..
.... ••
dinical term: BOCHDALEK's triangle quadratus arcade psoas arcade
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Diaphragm
Oo81a VIJ--+....Jffl Oo81a VIII--t--ill
N.
Fig. 2.102 Dilrphragm, DiiiPflragm.. and oblique mUICiee of1he abdDmlnal wall, Mm. lbdomlnh; frontal section; ventral view. The thin and dome-shaped diaphragm is shown. The Partes costales originate laterally from the XI. rib and project into the Centrum tendineum. The diaphnagmatic dome positions between the 5"' and 6111 inter-
v. rt1INOOIUIIIt;
(T8l
costal spaces during normal breathing. The lateral abdominal wall is composed of the oblique musdes of the abdominal wall (Mm. obliquus externus abdominis, obliquus intemus abdominis, and transversus at> dominis).
b
Fip. 2.103.1 and b Axiellliding hernia) Ia) and para-oeeophageal hiatal hernia (b); sdlematic drawing. 1171
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . DIIIPflragmltlc hernlls ana classified as congenital {Hernia diephragmatica spuria) and acquinad {Hernia diaphragmatica vera). If the herniated organs are covered by peritoneum (hernial sac), it is called a true hernia. The congenital form usually presents as a gap in the diaphragm through which abdominal organs (stomach, intestine, liver, spleen) pass into the thorax. Commonly, congenital hernias (usually OCOJrring at the physiological weak points of the diaphragm in the Trig~ num stem
Acquired diaphragmatic hernias are usually sliding hernias or paraoesophageal hiatal hernias {-+ Fig. 2.103). In a hiatal hernia the stomach partially passes through the physiologic slit-Maped ope~ ing of the diaphragm for the passage of the oesophagus !oesophageal hiatus). With an axial sliding hernia, the cardia is pulled through the diaphragm into the thorax. Thena are also mixed forms. AA especially sevena form is the upsidedown stcmach {thoracic stomach, large parts of the stomach have slipped into the thoracic cavity assuming an upside-down position).
sac.
95
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Arteries of the ventral wall of the trunk
A. carolla commu~a al~atra
~ii:=~;~~i~=~=~==} ecoecro~nl l e ~
Allie e.cramlale
A. ttu..
~~~llrc:~- Rr.l*tonles A. Ill~
~~ --~Ji~..~~~~;
A. thonldc:alliblln• A. U!anlclcaeupertar A. pertcatllll.coplnnlca
Rr.Rr.atemlliiHt pe!!'oraJUe
A. ttu:nc:llllnlllma A. perbrdii!QCIIIh!Wibl
fig. 2.104 Arteries of the wntr•l w•l cf the trunk. The ventral wall of the trunk receives arterial blood lhrough branches of the Aa. subclavia. axillaris. iliaca extema. and femollllis. The muscles of the abdominal wall receiv& blood through segmentally arranged Aa. lumbales derived from !he aorta abdominalis (not shown!.
* clinical term: LARREY'sdeft .. clinical term: A. mammaria intema
96
.,....._ofthe A. thor•cial int. . • • • • • •
Rr. mediastinales Rr. thymici Rr. bronchiales Rr. trachealas A. pericardiacophrenica Rr. sternales
• Rr. perlolllntes - Rr. mammarii mediales • Rr. interoostales anteriores • A. musrulophrenica • A. epigastrica Sl..lperior
tahir99-VRG & vip.persianss.ir
Vessels and nerves
-+
Topography, back -+ Female breast -+ Topography, abdomen and abdominal wall
Arteries of the thoracic wall
Fig. 2.105 Arteriee of the thorMic -••· The intercostal arteries create anastomoses between the A. thoracica intema and the Pars thoracica aortae. • clinical term: A. mammaria intema
BranchM of the Pllrs tho..-.. aorlait [AartathoraciceJ • Aa. intercostales posteriores - R. dorsalis - R. cutaneus medialis - R. cutaneus lateralis - R. spinalis
- R. oollateralis - R. cutaneus lateralis - Rr. mammarii laterales
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Stllll08ia of the aortic illlhmu.. a narrowing of the aorta in the aortic arch, results in the formation of a vertical and a horizontal bypass circuit: • Vllltlclll bypau circuit: between the Aa. subdaviae and iliacae extemae via the Aa. thoracicae internae, epigastricae superiores and epigastricae inferiores (within the rectus sheath) and in the abdominal wall via the Aa. musculophrenicae, epigastricae inferiores, and circumflexae ilium profundae
• horizontal bypliu .circuit: between the Aa. thoracicae intemae and Aorta thoracica via Rr. intercostales anteriores and Aa. intercostales posteriores to supply the thoracic and abdominal organs. The enlargement ofthe intercostal arteries leads to the formation of rib usures (erosions) (-o Clinical Remarks p. 47). The bypass circuits contribute to the maintenance of blood supply to parts of the body wall and lower extremities (a difference in blood pressure between upper and lower extremities is usually still measurable).
97
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Veins of the ventral wall of the trunk
Fig. 2.106 Veins of tt. ventral wall of the trunk. The veins of the ventral wall of !tie trunk. genenJte a superficial {shown on !tie right side of !tie body! and a deep (left side of the body) system of anastomoses between Vv. cavae superior and inferior.
98
•
clinical term: LARREY's cleft
"" clinical term: V. mammaria interns
Vessels and nerves -+ Topography, back -+ Female breast -+ Topography, abdomen and abdominal wall
Azygos system
881Rlls medana
Fig. 2.107 Azygoasystem. The azygos system drains blood between the V. iliaca intema and the V. cava superior. Hidden from view by the V. cava inferior, the V. lumbalis ascendens on the right side connects the V. azygos with the V. iliaca
communis dextra. There are also direct connections of the Vv. lumbales ascendentes with the V. cava inferior. Integrated into this venous system are the Plexus venosus sacral is and the Plexus venosi vertebraIss eldemi and intemi as well as the Vv.lumbales.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Venous congestion of the V. cava superior, the V. cava inferior, or Vv. iliacae communes results from a thrombosis, a mass formation and/Or an invasion of tumours and can lead to the development of bypass circulation between the V. caVIl superior and V. cava inferior
IC8V0Cb11lanut-): • be1ween V. iliaca eldema and V. cava superior via V. epigastrica inferior, V. epigastrica superior, V. thoracica intema, and V. brachiocephalica
• between V. femora lis and V. cava superior Ilia V. circumflexa ilium superficialislepigastrica superficial is, V. thoracoepigastrica, V. axillaris, and V. brachiocephalica • between V. iliaca intema and V. cava superior via Plexus venosus sacralis, Plexus venosi vertebrales eldemi and intemi, V. azygos and V. hemiazygos • between Vv. lumbales and V. cava superior via Vv. lumbales ascendentes, V. azygos and V. hemiazygos PartocaVIII •nutom- I~ Fig. 6.70, Vol. 2).
99
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Arteries and veins of the thoracic wall
R.~lle.mrtor
A. ,_ulophrenlc:a
Fig. 2.108 Arteries of1fle thonlclcwall. 181 Ao11B and A. 1horaciCll intema communicate 1hrough 1he Aa. intercostBIes postetiores and 1he Rr. imercostales anteri01'6S. The A. muscul~ phreniCll. a branch of the A. 1horacica intema. runs benealh the costal arch. These vessels provide blood to the lhoracic and abdominal wall. " clinical term: A. mammaria intema
V. bracMOQ8Ph&JIC& tl~811'8.
Y. 1~111 a'ltlrtor
Fig. 2.109 v.inl of thtl thoracic wall. [8) Vv. CliVBe superior and inferior are connected by the Vv. lumbales. hemiazygos, and azygos. Additional anastomoses exist between the azygos system and the Vv. thoracicae intemae via 1he Vv. imercostales posteriores and anteriores. The veins drain the blood of 1he thoracic and abdominal wall. " clinical term: V. mammaria intema
100
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Arteries and veins of the ventral wall of the trunk
Flr.lnten:altalee· -
A.; V. mUKUiaplnnlca
M.111Ct.. uxtamlnll
,1M.- --+-- v. eplgatrle& rrfwlef
" ...___A. I I - atllm8
fig. 2.110 Veelell at 1M poet•ior •IIJ'HICt of the ventral well of the tn..lr; dorsal view. The epigaS1ric vessels (Vasa epigastrica superior and inferior) run at the posterior side of the M. transversus abdominis and become visible upon removal of the rectus sheath in the upper two thirds of the abdominal cavity and upon removal of the Fascia transvarsalis in the lower third of the abdominal cavity. The A. thoracica interna on the lett
side of the body is covered by the M. transversus abdominis. Upon entering the rectus sheath through the Trigonum S1ernocostale of the diaphragm, the A. 1horacica intema becomes the A. epigaS1rica supe~ or. The A. epigastrica inferior derives from the A. iliaca externa. " clinical term: A. mammaria interne • • clinical term: V. mammaria interna
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The A. thoracica (mammaria) intema and the V. saphena magna are commonly used as grafts in coronary llypels surgery for revasar larization of a heart with severe cor0111ry stenosll {narrowing of
the coronary arteries). Bypass circulation in stenosis of the aortic iS1hmus _. page 97, cavocavalanastomoses _.page 99.
101
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Lymph vessels
Fig. 2.111 Superftclal ~ph vessels and regl0111llymph nodes of the ventr•l w•l af theinlnll:. The axillary lymph nodes (Nodi lymphoidei axillares, including the Nodi lymphoidei brachial as and pecto!lllesl collect the lymph of the ~ tir& upper extremity, of large parts of the ventral wall of the trunk up to the watershed at the level of the umbilicus, as well as of the back up to the respectiveWlltersh&d <~Fig. 2.1121. The ...,.rficiel inguinal ~ph II'IOdM (Nodi lymphoidei inguinalas superlicialesl consist of a vertical and horizontal group. They collect the lymph of the entire lower extremity, of the ventral wall of the trunk up to the watershed at the leva! of the umbilicus, as well as of the external genitalia (including the penis}, the perineal and anal region. In women, the lymph vessels of the Corpus uteri and the uterotubal junction that pass through the inguinal canal with the Lig. teras uteri 1~ Fig. 2.114) d!llin their lymph into the superficial inguinal lymph nodes. In men, the lymph of the testis is drained to the para-aortal lymph nodes (not shown).
Fig. 2.112 Superficial lymph ,...... af the pollt8rior w•l af the trunk. Abow the umbilicus, the lymph is d!llin&d into the axillary lymph nodes, whereas below the umbilicus the lymph is drained into the superficial inguinal lymph nodes.
102
Vessels and nerves -+ Topography, back -+ Female breast -+ Topography, abdomen and abdominal wall
Lymph vessels
Rg. 2. t13 SUperftcllll lymph - 1 • and regional lymph nodes of the female external genitalia a well a the perineal and anal region; caudal view. The lymph of external genitalia, perin91Jm, and anal regions drains into the superficial inguinal lymph nodes. Initial lymphatic stations are the Nodllympholdellnguhlla superfldales supllf'OIII8dlales.
-1•
Fig. 2.1 14 Suf*ficiel end deep lymph and regional lrmph nodlls af Yllglna, Vaghl. uterus. Ut8ru~ uterine IFAU.OPIANI tube, Tuba uterlna. and ovary, OVIIrlum; ventral view. • The lymph of the upper 1wo thirds of the vagina is drained into the pelvic lymph nodes, the lower third drains into the inguinal lymph nodes. • The lymph from the ovary, the FALLOPIAN tube, and part of the uterine fundus and corpus is drained alongside the A. ovarica, located in the Lig. suspensori1n1 ovarii, into the Nod lymphoidei l1n1bales.
• The second part of lymph from the uterine fundus, corpus, and cervix reaches the Nodi lymphoidei iliaci alongside the A. uterina. • A third fraction of the uterine lymph from the fundus and corpus drains alongside the Ug. teres uteri into the Nodi lymphoidei inguinales superficiales (highlighted in yellow).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Inguinal lymph nodes are of clinical significance in inflammation and malignant tumours. Their enlargement is a first indication of a pathological process located in their lymph draining tributary. In women,
it is important to remember that one possible meblstlltic route from the uteNS is via the lymphatic ducts along the Lig. teres uteri through the inguinal canal to the inguinal lymph nodes.
103
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Innervation of the skin of the back
N. oa:~tala miner {Pimcua anlcalllt)
t - - t - - N . cutaneua bnEtlll -.Ita a~per!Or
(N.IIXII-)
C&
T2
Rr. a.tblnellllteral• (Nn.epnllille, Nn.lntercaltalea)
N. cutaneua femOifa illleratllt (PIIIxua klmlllllta)
N. cutane~a femclfa pa~Wiat (PIIIxua tumblllta)
Rg. 2.115 Setmerrtllllnnervatlon of the slim (dennftomes) and cuuneoua nerwa of 1he .b.lct; dorsal view. Cutaneous n91VEJS frequently receiv& nerve fibres from multiple spinal nerves, thus, the dermatome and the region of innervation of the cuts-
104
neous nEKVes differ. The darlc: blue line on the right indicates the demarcation between the innervation area of the Rr. posteriores (dorsales) and Rr. anteriores {ventrales) of the spinal nerves.
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Vessels and nerves of the back
N. cutaneus bractllllaerlll81nfwlor
Fig. 2.118 V..Mh and I'HII'YIS of 1he btlck: dorsal visw; superficial muscles and shoulder girdle were removed on the left side. • wssels and netV&S in the medill axillry space (triangular axillary space): A. and V. circumflexa scapulae !margins: Clllnial M. teres minor, caudal M. teres major, lat&llll Caput longum of the M. triceps brachii) • vessels and nerves in the llt81"111 axillary space (quad!llngular axillary space): A. and V. cireumflexa humeri posterior, N. axillaris (margins: cranial M. teres minor, caudal M. teres major, medial Caput longum of the M. triceps b!llchii, latellll humellll shaft)
• vessels and nerves in the 1rlclps lilt A. and V. profunda b!llchii, N. radialis (margins: cranial M. teres major, medial Caput longum of the M. triceps brachii, lataral humaral shaft)
.. ""
......
vessels and nerves in the triangular axillary space vessels and nerves in the quad!llngular axillary space vessels and nerves in the triceps slit
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Vessels and nerves of the neck
N. ~lt•h mlnOJ
M. U'8Pei!IU8
Rr. clltlnel poeWI-
(1\h, Ulorlclel,
At.~)
Fr. CUW!ella.terale8 pec:UJ1'81118
o-~n. tluaclc~ Nn.
Fig. 2.117 V...ll •nd .,.,.,.. of 1118 occipital n~gion, Regie> occlpltall. posteriDr neck. RigiD CII"VVcclls posterior llfteglo nuchalls)L •nd upper region of 1he IHick: dorsal view. Up to the scapular line, the skin of the back receives segmental innervation by the Rr. posteriores (dorsales) of the spinal nerves {Rr. cutanei posteriores). The N. occipitalis majorfrom C2 and the N. occipitalis tar-
106
~ dl•••ctlon llnlc
rturc011:118e)
tius from C3 {not shown) prOIIide cutaneous innervation for the poste~ or neck and occipital region IRr. mediates of the Rr. posteriores (dorsales)). TheN. occipitalis minor derives from the Plexus cervicalis (Rr. antetiores [ventrales)) and is part of the Punctum nervosum (ERB's nerve point). The course of the N. accessorius lXII in the neck and shoulder region is also shown.
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Vessels and nerves of the neck
N. occtpltlltle mejar
v. Wlltelnll8
A. anlcala prafunda
R. pn:lfundua (A. tnuuwena col~
Fig. 2.118 Veuellend nerv• of 1M occipital region, Regio occfp...lls. end posteriDr neck. RigiD cerv!Clllls posteriDr; dorsal view.
To demonstrate the deep neurovascular tracts. the Mm. trapezius. sternocleidomastoideus, splenius capitis, and semispinalis capitis were detached and partially removed. On both sides of the posterior aspect
of the neck the short neck musdes {Mm. recti capitis posterior minor and major as well as the Mm. obliqui capitis superior and inferior) are shown. These musdes create the margins of the vertebrells triangle (Trigonum arteria& vertebralis). Besides arteries and veins, the Nn. oocipitalis major and suboccipitalis as well as the Nn. accessorii lXII are shown.
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Nerves of the neck and the deep posterior cervical region
M. I'8CI18 capltll pa111e11ar mtnar
Fig. 2.119 NlrvM of 1M poeterior nect. Regio cerviclil posterior; dorsal view. The N. occlpltals m1}Dr represents the R. posterior from C2 and pnr jects into th& occipital region. Th& R. posterior from C3 projects crani-
N. Cl!Mcala [C7J,
ally as N. occipitlil tartiul into the Lig. nuchae. Ascending from the vertebralis triangle, which harbours the A. vertebralis, the A. posterior from C1 innervates the short neck muscles as N. subocclpllalls.
N. aplnatlll. Gangllan aer.:wtlm
Fill n.clctAn PQII1811ora
Rg. 2.120 VM18IIInd . .I'YM of 1be deep posterior niCk. Reglo CII'Yiclllls posterior. 1nd contllnt of 1he vertebral canal; dorsal view. The vertebral canal was accessed from dorsal and the occipital bone is
108
- dl•••ctlon llnlc
remo~~ed to view the Dura mater with opened Sinus sagittalis superior and Sinus transversus. The ascending part of the A. verta.brllia between the cervical vert&brae can be seen.
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Cauda equina and lumbar puncture ~,...--VIIItellft lurrcall8 11,
Prcc. ec«aa8
---Pl--us
Wlltelnllalnter111a paatelfat
Rr. dcnal• ~V.Iumbell)
l~ua
medlallalumbannl
Llg.lllalumbale
Rg. 2.121 Vessels and Mrves of tM openlld vertebral canal of the lumbar section of the wrtabral column, Aegio lumb.lil; dorsal view.
Qwdeequl'le
Fig. 2.122 Lumbar puncture, direction of the puncturing needle.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . To obUJin cerebrospinal fluid for diagnostic purposes or to administer drugs into the subarachnoid space, a lumbar punctlre is performed below the 2n11 lumbar vertebra, usually between the Proc. spinosus of L31L4 or L41L5, to prevent spinal cord injuries. At the same level lies the Cauda equina; here. the subarachnoid space is the widest
(lumbar cistern). The puncture needle is inserted through the Ligg. supraspinal& and interspinal&, the epidural space, the Dura mater, and the arachnoid until the needle enters the subarachnoid space 1~ Fig.2.122).
109
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Spinal nerve and Foramen intervertebrale
nuncua sympa.Ult:u., Gangllan truncl!¥"patl1lcl
A. c:ommunlc:arw R. men1ln11'"",
Fig. 2.123 Spinal....,., N.tpinail,. in 1tla1honlcic region; caudal view. The stem of the spinal nQ(Ve is only a few millimeters long {Truncus nervi spinalis) and is created by the merger of the Radices anterior and posterior. The Truncus dMdes into the larger R. anterior un the thoracic region as N. intercostalis) and the smaller R. posterior. The latter divides into a medial {R. medialis! and lateral {R. lateralis} bninch which innQ(VIJte the autochthonous muscles of the back IMm. dorsi) and, with their terminal ends, provide cutaneous innQ(Vation of the back (Rr. cu-
tanei medialis and lateralis). The R. communicans is the connection between the spinal nerve and the sympathetic trunk (Truncus sympathicus). The R. meningeus of the spinal nerve projects back into the vertebral canal and innervates the ligaments of the vertebral column and the meningeal membranes covering the spinal cord. The N. intercostalis runs along the underside of the rib (not shown) in a ventral direction, innervates the Mm. intercostales externi and intemi, and provides Rr. cutanai lateralis and anterior for the innervation of the skin.
nuncus 11IIM t~Pl'lals (1..3)
Dlecualnterv•telllalll, Anl.f .. ttbral..
Fig. 2.124 Spinaiii'MitV8, N.tpinail,. in tilelumb.lr region of the Yll'tebrll column: view from the left side. 111 Upon its passage through the Foramen intQ(Vertebrale, the spinal nerve dMdes into the Rr. anterior, posterior, meningeus, and communicans.
Fig. 2.125 Spil'lll MIW,. N. spinelil, in the lumb.lr region Clf the vertebral column; sagittal section at the level of the Foramen intervertebnile; view from the left side. 11 I At the leva! of the Foramen intervertebral& the Radices anterior and posterior have not yet merged to form the spinal nerve. They are still surrounded by the Dura and immersed in cerebrospinal fluid. Shown are the ventrally located Discus intervertebralis and the dorsally located Ug. flawm with the adjacent zygapophyseal joint.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Posterolateral disc herniations, spondylophytes, or tumours can lead to a narrowing of 1he intervert:e.brel foramina with compression
110
of the spinal nerve roots which results in deficits of nerve functions.
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Spinal nerve
langtudlnale ants\~ a
Rg. 2.128 NlrYH of 1M vertebral colann. Colan.. Yel"tebrlllll; view from !he right side in an oblique angle. Branches of the spinal nBNe are shown which project to adjacent struotures. These include the R. men.-.geus for the sensory innervation of the meningeal membnmes of !he spinal cord, smaller branches derived from !he R. posterior for the Capsula articularis of !he zygapophyseal joints, and the Rr. communicantes albus and griseus connecting wilh the Tn.ncus sympathicus.
The R. communlcllns albuiJ contains preganglionic sympalhetic fibres from the lateral column of the spinal cord for the Truncus sympalhicus. The R. communicans griMLIII contains postganglionic sympathetic fibres of the sympalhetic trunk which project back to the spinal nerve. Autonomic nEHVe fibres from !he sympalhetic trunk innervate the Disci intBNertebrales and ligaments of the vertebral column.
A. cr.caneuumlllor
Nl\. tpllllllec Nn.C8MNn.-.:lcl Nn.lumbale8 Nn. 88ICI'8Ie8
N.c:ocey;-
Rg. 2.127 Structure of a spinal nerve. N. spinalis. end spinal cord •ament. IXImplified by two thoracic ll'ltlr'VM, Nn. thoracici; oblique superior view. Each spinal nerve is composed of an anterior root {Radix anterior! and a posterior root (Radix posterior). The cell bodies (perikarya) of motor nerve fibres ara located in the gray matter of !he spinal cord and exit through the anterior root; the perikarya of sensory nerve fibres ara lo-
cated in !he dorsal root ganglion (Ganglion sensorium nervi spinalis) and the fibres enter !he spinal cord via the dorsal root. Rr. communicantes connect !he spinal cord with the chain of ganglia of the Truncus sympathicus {Ganglion trunci sympathicij. The dorsal branches of !he spinal nerves ar& arranged in a segmental order; with the exoeption of the intercostal nerves 2 to 11, the other ventral branches cr&ate plexus.
111
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Blood vessels and nerves of the vertebral canal
ll'uncLa necvlaptnalll, R.
Fig. 2.128 Content of the vert:abral canal, C.nalil verte.btalis; cross-sec1ion at the level of the 5111 cervical verteb111; Clllnial view. The spinal cord is surrounded by the Dura, the Arachnoidea and the Pia mater spinalis and immersed in cerebrospinal fluid in the subarachnoid space (Spatium subarachnoideuml. In the vertebllll canal, this dullll
tube and the exiting roots of the spinal nerves are surrounded and protected by adipose tissue with embedded venous plexus (Plexus venosus vertebralis intemus anterior and posterio, and nourishing blood vessels. See epidural anaesthesia ~ page 331, Vol. 3.
Flklm termln1le
Ganglion trunci aympe.U1lcl
11'unC1181181VIsptnalls, R. antllfor
Fig. 2.129 Content of the vert:abral canal, C.nalil verte.btalis; cross-sec1ion at the level of the 31d lumbar verteb111; c111nial view. Below the 1"'/')!"llumbar vertebra and before exiting the vertebral canal. nerve roots from L2 onwards, including the N. coccygeus, run caudally as a loose bundle of fibres surrounded by the dural sac. This entire
112
collec1ion of nerve roots is named Cauda equina. Located in between the nerve fibres and originating from the Conus medullaris of the spinal cord is the thin and thread-like Filum terminal&. See lumbar puncture~ pages 109 and 331, Vol. 3.
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Vessels and nerves of the vertebral canal Dlft..-eptlde tpllllllle eniJIIrlor, R. n.dlculllll an1e11ar
~H+I......,
lli--7--
Pleixua_a_._...la lnterrlla .rlllrler
Fig. 2.130 Thor•cic n~gion of the vertebt1l column with tpin.l cord, Medul.. splnall-. and IVIII'PIIthltlc1nmk. Truncus synrpethlct~!J; ventllll view. The Spatium epidural& is shown which surrounds the v&rtebtal canal
with its meninges. It contains the Plexus venosus vertebralis intemus anterior and the Rr. spinales of the A. inten::ostalis posterior embedded in adipose tissue. The A. spinalis anterior runs on top of 1tle spinal cord.
Rg. 2.131 VHa of the vertebnll can.L C.n.ll vertebr•lls: view
posterior via Vv. intervertebrales. The latter plexus drains 1tle blood (in the lumbar region of the vertebtal column) into the paravertebtal Vv. lumbales ascendentes (in the thoracic region of the vertebtal column run the Vv. azygos, hemiazygos, and hemiazygos accessoria). These veins also collect blood from the Plaua vena.ua vertebr1ia extef'o nus1rrterlor which dlllins 1tle anterior side of the vertebllll bodies and the intervertebllll discs.
from the right side in an oblique dorsal angle. The vertebral canal is filled with a dense network of veins which form the Piau• venot1 Y8i"':e.bnnles lnternl 1nter1Dr 1nd posterior. Located in the Spatium epidutale, this venous plexus covers 1tle meninges which surround 1t1e spinal cord and the Cauda equine. The two plexus are connected wi1t11tle PIIXIIII venOIU!I vertebr•ll extemus
113
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Overview and development
M. pectanllllt ma,lar
Plplllll m1rmnn1
fig. 2.132 Breat, Mlmme; lateral view.
Fie. 2.133 Breat,. M1mme; ventral view.
Rg. 2.134 Mlk line. The d&v&lopmant of the mammary gland initiates in the milk line {mammary ridge), a strip of thickened surface ectoderm formed in embryonic week 61hat extends from the axillary pit to the inguinal region. With the exception of the area above theM. pectoralis major. the location for the development of the future breast {Mamma), the rest of the milk line normally regresses.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The absence of the nipples (athell) or breasts (lmlltll. m•mmary aplllie) are rare congenital anomalies that can occur uni- or bilaterally. Supernumerary nipples or breasts are called polythelie or ~astla, respectively. This is usually hereditary and can also affect men. Typically, the rudimentary glandular tissue in male breasts does not develop further after birth. When breast grow!h occurs in men
114
(possibly due to hormonal disorders), this condition is called gyn• comlltie. Some female breasts are too large (memmary hypertrophy), which can be associated with shoulder and back pain. In such cases. a breast reduction surgery is indicated. Too small breasts or the absence of breasts can necessitate breast augmentation with surgical insertion of silicone prostheses.
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Female breast
Fig. 2.135 BI'Mtt. M1mma; ven1ntl view. The breast is composed of the mammary gland {Glandula mammatia) and a iibrous stroma filled with adipose tissue. The breast has up to 20 individual glands (Lobi), each possessing a separate efferent lactiferous duct opening onto the mammary nipple (Papilla mammaria).
The branched lac1iferous ducts terminate in groups of alveoli (Lobuli). During pregnancy, the glandular tissue transforms into the lactating breast. • clinical temn: COOPER's ligaments
Ductua llldftlllt
Fig. 2.136 BrMIIt, Mlmm.; sagittal section. Strong ligaments lligg. suspensoria mammaria, COOPER's ligaments) derived irom the Fascia pectoralis of the M. pectoralis major support the breast in its normal position. • clinical temn: COOPER's ligaments
115
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Blood supply and lymphatic drainage
''
Lewll ' L8wl
A. ttl-crumlllle, A. pec:blnlle Nodi ~ldllllldiiii'M C8lltniiM
'
''
' ~'"' rr'. • '
Rg. 2.137 Blood IIIIPPtv of tt. fem1le brelst.lynrphdc dl'lln1g1 ptlltlll• of tt. film lie breiIt, 1nd location of l'lgioMI lymph nodM. The approximately 40 axillary lymph nodes do not just filter the lymph of almost the entire upper extremity but also collect two thirds of the lymph from the Mamma and the major part of the lymph fluids derived
from the thoracic and upper abdominal wall. The Truncus subdlvtus collects the lymph of the axillary lymph nodes and drains it into the Ductualympheticua dD.tlr' and the Ductull thor1cicua (not shown) on the right and left side, respectively. " dinical term: ROTIER's lymph nodes
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . From a clinical topographic and onoosurgical viewpoint, lymph nodes of the female breast are categorized into three levels. The M. pecto-
ralis minor acts as a boundary: • Levell lies laternl to the M. pectoralis minor. • Level lilies caudal to the M. pectoralis minor. • Levell lilies medial to the M. pectoralis minor.
116
The parastemallymph nodes of both sides are interconnected. The lymph of Levell is drained to Level II and via Nodi lymphoidei axillares apicales into Level Ill, and from here into the Truncus subclavius.
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Clinic
Fig. 2.138 Radiograph of the Mlmme (mlmmognrphy) of • 47.,..MIId 'W'OII'IIID. Mammography is a radiological examina1ion used for the early diagne> sis of mammary carcinoma, 1he most frequen1 tumour in women.
Fig. 2.139 Radiogr•ph of • Mlmme lm•m11'10W8plry) of • 23-y•r-old women. 1191 Normal mammary parenchyma shows poorly demarc.a1ed whi1e condensations primarily located beneath the region of the nipple (Mammilla). In young women, breast tissue can be extremely dense due to scarcely distributed adipose tissue.
Fig. 2.140 freqllllf'ICV of m~mmerycarclnomeln reletlon to the location in ~ntage.
Rg. 2.141 Memmotr•phy of • mellgn.nt breat cancer.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In Europe, breast cancer mortality ranges from 12-19% of all female cancer dea1hs. Thus, breas1 cancer is the leading cause of cancer dea1hs in most countries of the European Union. followed by lung and ooloree1al cancer. In women, breast cancer is the leading cause of death be1w&en the age of 35 and 55 years. In about 60% of all cases the upper O\J1er quadrant of the breast is affec1&d 1~ Fig. 2.140). Breast carcinoma originating mostly from the epithelium of 1he Due1us lae1iferi (ductal camnoma) me1astasizes mainly imo the axillary lymph nodes. less often in1o re1rostemal {parasternal) lymph nodes.
The firs1 lymph node located in the lymph drainage tributary and to receive lymph is referred 1o as Mntinel I= the one 1furt kHPI gu.1rd) lymph node which is usually also 1he first lymph node of metastatic colonization. The number of affec1&d lymph nodes in the 1hr&e hierarchical levels is directly rela1ed 1o 1he survival ra1e. Breast cancer of 1he medial quadrants can me1astasize via the imerconnect&d parasternal lymph nodes to the comralateral side.
117
tahir99-VRG & vip.persianss.ir
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Innervation of the skin of the thoracic and abdominal wall
Fig. 2.142 Segi1'MII'Ibl HI'IIIOty ini'I8Nation of the ventral thoracic
end ebdomhll wall Cdennltomas,, Skin regions receiving sensory fibres from a single spinal nerve are named dermatomes. The mammilla is located within dermatomas T4 to T5; the umbilicus is located in dermatome T10.
Fig. 2.143 SegmentalseniOI'y innervation ofihe thoracic end
abdomhll wal. On the right side, the spinal nerves responsible for the innarvation of the dermatomas are shown {... Fig. 2.1421. HEAD's zones represent skin areas which refer to distinct viscera as a result of cross-connections between the somatic and autonomic nervous system in a corresponding spinal cord segment. These aossconnections of the somatic and autonomic nervous system are due to the segmented {metameric) body structure. HEAD's zones for referred pain relate to specific inner organs. The HEAD's zone of a specific organ can stretch across multiple dermatomes but has a specific point of maximal reflex.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Shinglas (herpes zoster) is the most common infection of the peripheral nervous system. Herpes zoster leads to an acute neuralgia, which is limited to the dellTIIltome of a specific dorsal root of a sensory spinal or ctanial nerve. An initial infection with the varicella zoster virus caused chickenpox. Shingles are the result of a reectivation of the dormant virus. There is a vesicular exanthema (formation of blisters), which is restricted to the innervation of a sensory root ganglion or cranial sensory nerve. Initially, the patient suffers from
118
intense burning and localized pain, followed three to five days later by exanthema. An irritation of the corresponding internal organ of a HEAD's zone 1~ Fig. 2.1431 can initiate a viscerocutaneous reflex resulting in pain in a specific, mostly ipsilatetal zone (zone of hyperalgesia). This phenomenon is called referred peln. The pain can sometimes spread to neighbouring segments or the affected body side (generalization).
tahir99-VRG & vip.persianss.ir
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Vessels and nerves of the trunk
Nn. thcn.clc:l, Nn. lll1ercaetlllelt
Rr. a.ttaneiiiiDrlcll-. pectanaJ•
M. oblqwa eoctem.. abdamlrfa
Nn. li'Jot'IK:IC~ Nn. ~oecal88, Rr. c:ulanellllt8nle8 pec:U)t'lliM 111
I~
} 1\h.lhorlclc:l, lin. "'· a.rtlllei8/1Urlarlle abdcmtlale8
-f,~~~~~~--1~~~~r-~~~(lt==n2
N. genllziamcnJII, R. femcnllt
M. rectue abdcmtlls
Fig. 2.144 Epifalcill•nd deep v....ll •• well•• .,.,.,.. ofihe wntr•l wall of the trunk of • 'W'Omlln; ventral view. On the right side of the body. the Fasciae deltoidea. pectoralis. thoracica. abdominis. and lata with their epifascial neurovascular structures and the mammary gland are shown. The Mamma receives its blood supply from the Rr. mammarii mediales of the A. thoracica internaand from the Rr. mammarii laterai&S of the Aa. thoracica lateralis and thoraoodorsalis.
On the left side of the body. the superficial fascia was removed to provide a clear view of the muscles. The rectus sheath is opened, the M. ractus abdominis is cut in the middle; its parts are faded up- and do~ ward. On the posterior aspect of the M. rectus abdominis the Vasa epigastrica superior and inferior are seen. " dinical term: A. mammaria intema
Trunk
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Relief of the inside of the ventral abdominal wall
Plea ~n~bllcalla ITIIICIIIIW.
"'lea UIT&:IIIcalllt medialis
Anutuatngutnalla proftlndua
fig. 2.145 v.ntralabdominll wal of a newborn; insid& vi&w. Th& descensus of the 1eS1is into the scrotum is completed in a mature newbom.
"'lea umbllcalllt -.Ita
Extending across th& Anulus inguinalis profundus, th& Proc. vaginalis peritonei of the Peritoneum parietal a descends slightly into the inguinal canal.
.&11-~<---A.;IL ~lnfellar
~'f( ~;v.:.r--- l...tlcllw ITIIIICIIIarum
~:l};j~'f--- N. femcntls Anukls t~gutnatts pn:Nlcl.ls
Rg. 2.148 Ventral abdominal wal; inside view. Th& Fossa inguinalis mEidialis, Fossa inguinalis la1eralis, Lacuna vasorum, and Lacuna musculorum are shown. To demonstrate the neurovascular passage ways, the Peritoneum parietale and the Fascia transversalis were removed on th& right sid& of 1he body.
120
" clinical term: HESSELBACH's ligament • • clinical1erm: HESSELBACH's triangle
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Inguinal canal
Fig. 2.147 SUI*'ficill inguinal ring. Anu... inguinalia supetficilil: vemral viWN. The Crus medlale and Crusllrtlrale as part of 1he aponeurosis of the M. obliquus extemus abdominis and interoonnecting Fibtae intercrurales constitute 1he margins of the superficial inguinal ring. The caudal margin is the Ug. reflexum as part of 1he Ug. inguinale.
On 1he tight side of the body. 1he aponeurosis of theM. obliquus ex:lernus abdominis was reflected and provides a dear view on the M. o.b&quus liltemus abdomlnh. Muscle fibres of 1he M. obliquus intemus abdominis split off as M. cnmater and, as a superficial muscle layer, accompany the Funiculus spermaticus into 1he scrotum.
AniA1.18InQUtlaiS II'Ofl.lleiJS
Rg. 2.148 Walls and content of the inguinal canal. C. nail inguinalil,. right tide; ventral viWN. [1 I The inguinal canal is confined by the aponeurosis of the M. obliquus ex:lemus abdominis in 1he front. caudally by 1he Ug. inguinale, posteriorly by the Fascia tran&versalis, and cranially by the free margin of 1he M. transversus abdominis.
Ug. retlex1m
N. genltdemcnlll, R.genltall8
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The e~emaateric rafla is the conttaction of 1he M. cremaster and resulting el&~~ation of the testicle on the same side when touching 1he inside of the thigh. It is a physiological extrinsic reflex. The afferent fibt&S course in 1he R. femotalis of theN. genitofemoralis, the efferent fibres project in the R. genitalis of 1he N. genitofemoralis. The Anulus inguinalis profundus is the hernial anal of indirect in-
guinal hernias. The Fossa inguinalis medialis {HESSELBACH's triangle, ->Fig. 2.146) is the hernial canal for direct inguinal hernias. whereas 1he Septum femoral& in 1he Lacuna vasorum is the hernial canal for femoral (thigh) herniaL
Rumpf
Surface anatomy _. Development _. Skeleton _. Imaging _. Muscles _.
Inguinal canal
1 PllrftaiiUKm p.-!ltllle
M. ObiQW8 4I!Ctllm1.18 abdomtll&
- - - - M. ollllqu1.18 -.,ueabdamtn18, Aponeui'0818
Fig. 2.149 lnguinll Col nil,. Can alii inguin1lil,. and tplr'I'Ritic cord, Funiculus spermlltlcw. right tide; ventllll view. 1101 The approxima181y 4-6 em long inguinal canal penet!lltes 1tle ventllll abdominal wall abov& the inguinal ligament in an oblique angle from a posterior-la1ellll-clllnial to an anterior-medial-caudal direction. The inner opening is the Anulua inguinllil profundul which is formed by the Peritoneum and Fascia trctnS'IIElrsalis as the posterior demart:ation and by the M. tlllnsversus abdorninis and Lig. inguinale as Cl"8nial and caudal margins, respectively. The outer opening is 1tle Anulua intuinalia ~~~Pt~rficialil with 1tl& aponeurosis of th& M. obliquus extemus abdominis and 1tle Lig. inguinale {Lig. reflexuml being the anterior and caudal margins, respectively. Locat&d in the inguinal canal is the Funiculua
122
8plr'l'l'loltic. On its Fascia spermatica extema, theN. scrotalis anterior of the N. ilioinguinalis reeches 1tle anterior part of the scrotum. Like 1tle M. transversus abdominis, theM. obllquus lnternus lbdomlnh is positioned superior to the Funiculus spermaticus and contributes muscle fibres IM. cremesterl that cover the Funiculus spermaticus. The M. cremaster has its awn fascia {Fascia cremasterica). reaches onto the testis between Fasciae spermaticae externa and intema. and plays an important role in regulating 1tle tempelllture for spermatogenesis to ocrur.
" transversus tendinous arch •• clinical term: GIMBERNArs ligament
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Inguinal canal
M. obl~l.l8 lmerl1lslbdomln18
N. genltGfemonlll, R. genital II
FMcla
..,,lllll:llca
at.~~ a
----
teatlcUartl; P f l a l 8 - pemplniWI'IIIs
M. crarmftllr ---...,!;;;;~~-,\::~'-
Fig. 2.150 Content of the spermatic cord, Funiculua tplt'l'l'loltic, and coverings of tMtl-.lllft llde; ventral view. 1101 Covered by the Fascia sperma1ica extema, the M. cremaster, and the Fascia spermatica intema, th& apermatic cord contains th& Ductus d~ ferens, the A. ductus deferentis, !tie A. testicularis Ia direct branch of the Aorta), the Pl&xus pampiniformis {drains into lti& V. tastirularis and from ltiere on the right side into th& V. cava inferior and on the left side into the V. renalisl, !tie R. genitalis of the N. genitofemoralis, and the Vestigium processus vaginalis {obliterated Proc. vaginalis testis which guid&d the testicular descent from lti& abdominal cavity into !tie sc~ tum,~ Fig. 2.1511.
The teltia is covered by the serous Lamina viscera lis (epiorchium) and the Lamina parietalis (periorchium) which are separated from each oltier by a gap, the Cavum serosum saoti. Epiorchium and periorchium are connected at the mesorchium. The other coverings listed from the inside to the outside are the Fascia sperrnatica intema, muscle fibres of the M. cremaster with Fascia cremasterica, and the Fascia spermatica extern a. Both tastes reside in the scrotum (not shown) which contains the protective dartos fascia (Tunica dartos!. Myoepithelial calls in !tie Tunica dartos cause the scrotum to contract, a process involved in testicular thermoregulation and important for normal spermatogenesis to ocrur.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Accumula1ion of fluid in the Cavitas serosa scroti is called hydroce•. Cys1s in the Proc. vaginalis testis lead to dilation of the Funiculus spermaticus and are called funirular hydrocel& {Hydrocele funiculi sperrna1icil. Retantion cysts of the epididymis are called spennatocelet.. Malformation of the mesorchium {attachment zone of testis and epidittvmisl can lead to testicular torsion !common in puberty) wilti strangling of the venous retum to the Plexus pampiniformis and fol-
lowed by strangling of the A. testicularis wilti risk of aseptic nea-osis of the testis. Bacldlow of blood in the Plexus pampiniformis is called varicocele, which occurs in 80% of all cases on the left side (because !tie left V. testicularis drains into !tie left V. rena lis). Frequent causes are the obstruction of drainage, as in kidnay tumours. varicocelas can lead to infertility.
Trunk
Surface anatomy
~ Development~
Skeleton
~
Imaging
~ Muscles~
Development of the inguinal canal
l
GdlemiiCIIIum teella
Rg. 2.151 Delcentus teds from week 7 fpott co11ceptlon) until birth. In the male fetus, the testes are relocated during the fetal period from the abdominal cavity along the Gubernaculum testis and beneath the Peritoneum parietal& of the dorsal abdominal wall into the scrotum. The
Peritoneum parietal& creates an invagination IProc. vaginalis peritoneil that stretches from the inguinal canal into the scrotum and becomes positioned superior to the testis. With the exception of a remnant on the testis (Tunica vaginalis testis), the Proc. vaginalis peritonei obliterates shortly after birth.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The descenut of the testes into the scrotum is a sign of foetal maturity at birth. Maldleclnsul tastil oro..us in about 3% of all newborns. The testicle can lie in the abdominal cavity or in the inguinal canal (testicular retention, cryptorchidism, ectopic testis!.
124
Due to elevated temperature (spermatogenesis occurs at 35 °Cl, an ICtopic tMtia location can result in infertility and an increased risk of malignant transformation.
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Inguinal hernias
1 F~e14ftW181calla 2 F~ lngul1111lla medialis 3 F~lngul1111lla -.!Ia
Rg. 2.152 Structure of the ventral abdominal wall and the CCM~ringa of the epermatic cord. Funicu... tpennaticus, end
teeti.. Teetia; schematic diagram. For didactic reasons, the inguinal canal, the spermatic cord, and the scrotum are drawn in the same plane. (according to [1)) The Descensus testis causes the testis to lie in a pouch of the abdominal wall which extends into the scrotum. Therefore, scrotum and spermatic cord possess the same structure as the abdominal wall. The Fascia of the M. obliquus extemus abdominis continues as Fascia spennatlca u.tema onto the Funiculus spermaticus. Beneath lies the M. cremaster which splits from theM. obliquus intemus abdominis and
is covered by the Fucla crematel'kll. The next deeper layer contains the F8ICil spermatice intenNI as part of the aponeurosis of the M. transversus abdominis which covers the content of the Funiculus spermaticus. With the exception of a remnant in the testicular region {Tunica vaginalis testis with Lamina parietalis = periorchium and Lamina vis<:eralis =epiorchiuml, the Pro c. vaginalis peritonei is obliterated and has become the Vatlalum processus veglnells Ia fibrous cord; left side of the image). On the right side of the image, the Proc. vaginal is testis failed to dose but persists (Proc. vagina lis peritonei persistensl and, thus, causes an opan connection between the abdominal cavity and the Cavitas serosa scroti. 2
Pertcneum Flllda lnlllnllll'llllllll .....,._ __
1F~•~Icalla
2 F~lngul1111lla medialis 3 F~lngul1111lla -alia
Rg. 2.153 lnguhll hernias; schematic dlllwing. Left side of the image: lateral, indirect hernia; right side of the image: medial, direct hernia. (according to [1 D Indirect ln.,.lnal hernias enter the inguinal canal in the Fossa inguinalis lateralis through the Anulus inguinalis profundus. Direct 1118ulnel heml11 penetrate through the muscle-free Trigonum inguinale (HESSELBACH's triangle) in the Fossa inguinalis medialis
which is a weak spot in the ventral abdominal wall. Here, the posterior abdominal wall consists only of the Fascia transversalis and the Peritoneum parietal& (Paries dorsalis tenuis canalis inguinalis).
• ....
......
intestinal loop in hernial sac peritoneal cavity newly formed peritoneal hernial sac
125
Trunk
Surface anatomy .-.•...-. Topography, abdomen and abdominal wall
Plexus lumbosacralis
Plnlumballl dlllphrqrm.tlll, 018deidrum
-~~~~~~~
Ug.II'CI.III.tl.llllll.tllt'a»----:-i--'::"~~ .11'
N.II!Dhypoval'lrf-
N.IIIomgulnalll
M. OblQUU8
lmemu• abdcml~s
"'·-· abdOml~•
N. genltllfemonlll, -..J---..;;....~t:--r/7 R.ternonlla N. genltllfemonlll,
R.genltlllla N.~
R. tenlt811a} N. Cl.l'llinMa
ternorfallltlnlla
R.temcnlla
N.tenlto-
femcnlla
N. obtUratorlus, A. antellor
Rg. 2.154 Posterior abdominal w.l with Pllxus lumbosacralls: ventral view. The Plexus lumbosacmlis is composed of the Plexus lumbalis IT12, L1-L3 IL4)) and !tie Plexus sacralis IIL41 L5, S1-S51. The Plexus lumbalis is important for the innervation of the wall of the trunk. Shown are the segmental organization and !tie course of !tie Rr. anterlores (ventraiHJ of the spmal nerves of 1he Plexus lumiHIIII which innervate the abdominal muscles, the inguinal region, and the thigh. These are from cmnial to caudal the Nn. subcostalis (intercostalis XIII. iliohypogas-
126
- dl•••ctlon llnlc
tricus CT12. L1l. ilioinguinalis IL11. genitofemoralis IL1. L2) with R. femoralis and R. genitalis, and the N. cutaneus femoris lateralis (L2. L3). The N. femoollis ILH.41 exits !tie vertebnll column l'lld, when completing its passage through the Lacuna musculorum, provides Rr. cutanei antetior&s for the inneNation of the skin of the thigh. Also shown is the N. obturatorius Ill1I L2-l4) entering !tie Canalis obtumtorius.
Upper Extremity Surface Anatomy . . .. .. . .. . .. . .. . . 130 Development . . .. . . . . . . . . . . . . . . . . . 132 Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Topography ....................... 194 Sections .. . .. .. . . .. .. . .. . . .. .. . .. . 239
The Upper Limb Grasp the Concept The upper limb (Membrum superius) consists of the pectoral girdle (Cingulum membri superioris or pectorals) and the arm (Pars Iibera membri superioris). Both parts merge in the shoulder area (Greek: ·amos". Regia deltoidea) and the axilla (Fossa axillaris).
Shoulder Pectoral Girdle In contrast to the pelvic gird Ie. the pectoral girdI e is not a rigid ringshaped bony structure but is rather very mobile in itself and with respect to the trunk. Its structure consists ventrally of the collarbone (Clavicula) and dorsally of the shoulder blade (Scapula). The proximal end of the Clavicula articulates with the sternum (Articulatio sternoclavicularis). This medial part of the clavicle, which confines the Fossa jugularis laterally, is easily visualised and palpated. Tracing the clavicle laterally one reaches the acromioclavicular joint (Articulatio acromioclavicularis), in which the clavicle articulates with the acromion, a forward-positioned process of the Scapula. During circulating and swinging motions of the arm, one can feel the movements of the pectoral girdle with respect to the trunk. The Scapula. which is attached dorsally to the thorax, has no further articulations with the trunk. Various muscles of the thorax. neck, and head (M. trapezius) guide the movement of the Scapula.
The Scapula contains the glenoid cavity of the actual shoulder joint (Articulatio humeri). The shoulder joint- a ball and socket joint- is very mobile due to its limp capsule, but also vulnerable to dislocations (luxations). Normally numerous muscles, including those of the rotator cuff, support the shoulder joint. The "shoulder", as it is commonly referred to in everyday language, is a transition area of the Pars li bera and the Cingulum and is referred to as the Regia deltoidea. The Regia deltoidea is named after the M. deltoideus, which covers the shoulder region. Below the shoulder joint, the axilla (Fossa axillaris) is located as a deep pit, which opens caudally. The muscular anterior border of the axilla is created by the M. pectoralis, and the likewise posterior border of the axilla is formed by theM. latissimus dorsi and theM. teres minor. The hairy axillary skin forms the roof of the pit and protects the large axillary neurovascular structures which, embedded in adipose tissue, emerge from the upper thoracic aperture and the neck to supply the lim b.
Arm The Pars Iibera membri superioris consists of the upper arm (Brachium), the region of the elbow (Regio cubitalis), the foreaiTI'I (Antebrachium), the wrist region (Regia carpal is), and the hand (Manus). On the medial side of the upper arm, contraction of theM. biceps reveals a longitudinal groove, the Sulcus bicipitalis medialis. The pulse of the A. brachial is is palpable in the sulcus and, when certain pressure is applied, one can feel the shaft of the bone of the upper aiTI'I, the Humerus. However, forceful palpations may induce unpleasant sensations as theN. ulnaris and N. media nus run parallel alongside the A. brachial is. The teiTI'I of the elbow region, Regio cubital is, originates from the Latin verb "cubitare" (to lie). During antiquity when lying down at the
128
table one leaned on one's elbows. More accurately: one leaned on the Olecranon of the Ulna, a bony process, which is noticeable on the dorsal side of the elbow joint (Articulatio cubiti). Both bony humps (Epicondy1us medialis and lateralis), palpated medially and laterally of the Regia cubitalis are part of the Humerus. These epicondyles serve as the origin of extensor muscles to the wrist, which are positioned laterally, as opposed to the medially positioned flexor muscles to the wrist. The N. ulnaris runs in a groove behind the medial epicondyle. Dorsal impact on this nerve can cause painful sensations. In the elbOIIV joint, the humerus articulates with both bones of the forearm and the latter two articulate with each other. On the forearm, Antebrachium, the Ulna is palpable along the side of the fifth digit. Bulky muscles hide the Radius in its proximal aspect; distally however, towards the thumb, its shaft is palpable. During turning movements of the forearm and the hand (pronation and supination), which also involve the elbow joint, the Radius rotates around the stationary Ulna. Radius and Ulna are joined syndesmotically by the Membrana interossea, but proximally and distally they are connected by the foiTI'Iation of joints. The wrist area, Regia carpalis, receives its nama from the carpal bones, the Ossa carpi, which align in two rows at the base of the hand: a proximal and a distal row. These bones interlock in a complicated and thre&
Clinical Remarks--------__, The d~n Ouxation) of the should• joint is mora commoo than in any other joint of the body. Also, the_, of the tendons of the rGtii•CII' cuff miDCIIs due to lifting the arm and the entrapment of attactlad tandons under the acromion is a commoo disease. Depending on lifestyle, sooner or latSI' this disease leads to impairments. Many luind iniuriN require surgical raconstitutioo to restore the function. Evidence of the significance of the hand is the fact that there is a separate speaalisation for hand surg8
-+ Dl•••ctlon Llnlt Musculoskeletal systems are d-.cted in leyertl (stratigraphically) from superficial to daapSI' structures. In contrast to the lag, the arm can usually be dissected from both sides (VBntral and dorsal) without turing CNSI' the body. First, the apifascial veins and cutaneous n81'V8S within the subcutaneous adipose tissue are exposed. The V. cephalica and V. basilica are traced from the wrists to the upper arm. In the elbow region, these run alongside of the cutaneous nerves of the forearm. The cutaneous nerves of the upper arm and forearm are to be exposed before opening the fascia and displaying indillidual muscles. The dissection of the axillary fossa with the nerves of the Plexus brachialis and the branches of the A. a>dllaris requires special skills and is labour-intertsiva. In this region only soma of the lymph nodes are displayed. The coures of individual n81'V8S and blood vassals and their branches are systematically exposed and traced to achieve a complete dissection which facilitates understanding of the topography and function of nao..r ravascular pathways. Dissection of the hand should be coosidSI'ad early in the dissection process. Elcposure of the numerous small hand muscles and the branches of artSI'ies and nerves in this ragioo is time consuming.
EXAM CHECK LIST • Bones: apophyaea and origins, insertions of muscles (also the small mueclet1 of the hand)· rotator cuff· joints with ligamenta lin particular a.h oulder and elbow) • muecles end their courae, function, innervation • Plaxua brachialia and ita petipharal nei'V&I including their innervation and courae • nerve lesiona and clinical symptoms • arterias and their branches, couraa and pulaas • couraa ofvaina •lymphatic drainage including Nodi Jymphoidai of the axilla and levels • topography: axilla and hand • carpal tunnel • tran~v&rse aactiona: Brachium and Antebrachium • surface anatomy
129
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Surface anatomy
M.llloeps InchII
OlgHLB mtnnu•
3.1
Ocnum man La
Palex
DlQHue rnedue Olgllus 8/lulalte OlgHua mtnlmLB Proe.~ldNI (Uinl)
M.trk»p8 InchI
3.2
Clinical Remarks---------.. Rg. 3.1 •nd Fig. 3.2 Surfllce relef of the •nn. right sld-.: ventral 1... Fig. 3.1) and do!'sall... Fig. 3.21 view.
130
Th& surface relief of the arm is d&1EIIT11ined by the musdes and by some of the skeletal elemems. The palpable parts of bones help with orientation during the physical exam.
Muscles _. Topography _. Sections
Fascias of the arm
M. tn.cl'fcm:Uall8
M. ftucr Clllpl n.cld•
M. u.tllr.a' digiti ml~ml
M. fti!ICOI' cap! utnarte
Aeltnacutum m1.18CUIOrUm MteniiClfUm
3.4
Fig. 3.3 and Fig. 3.4 Facia of 1he upper arm, F..cia .brachii, and fllscfa of the forearm. Facia antebrachl. right llde; ventral (-+ Fig. 3.3) and dorsal I-+ Fig. 3.41 view. As shown in the illustration, the surface relief is determined predominamly by the various muscles. The muscles are covered with their own fascias and bundled to muscle groups. These group fascias are covered
by a common fascia, the fascia of the upper arm and the forearm, which resides underneath the skin. After dissecting all important subcutaneous structures such as the cutaneous nerves and the epifascial veins, the subcutaneous adipose tissue is removed to display the fascias.
131
Upper Extremity Development
132
Surface anatomy
-+
Development
-+
Skeleton
-+
Imaging
-+
Vessels and nerves ~ Topography, back ~ Female breast ~ Topography, abdomen and abdominal wall
Muscle function
Figs. 2.9"- to c
• sidfK)ending Bending to both sides (CVII) and Sl sBNe as the upright and supported by the abdominis. quadratus and splenius. b Forward (flexion) and the vertebral joints The range of mo1ion is extension. A stlllight line between of the femur is used to supported by the Mm. obliquus intemus psoas major. lnnniqq;.,.,,,
of the scapula and the Crista iliaca angles. Flexion of the trunk is obliquus extemus abdominis. major. The Mm. iliocostalis, spinalis. semispinalis. multifidus.
trapezius, and levatores costa rum participate in the dorsal flexion of the spine. c rotation of the trunk Bilateral anterior to posterior rotation of the trunk by approximately 40" is possible. A line connecting the acromion of the scapula on both sides serves as a referance axis. Ipsilateral rotation of the trunk is supported by Mm. obliquus internus abdominis. iliocostalis. longissimus, and splenius. Rotation of the trunk to the contralatellll side is achieved by the Mm. obliquus extemus abdominis. semispinalis, multifidus, rotatores. and levatores costa rum. The vertebral joints in individual sections of the vertebllll column restrict the range of movement. As for the entire vertebral column. bending forward {flexion) and backward (extension) of approximately 100°/0°/50", a side-bending (latellll flexion) of o•140•. and a torsion (rotational movament) of 40"/fY'/40" are possible; these serve as normal reference values to assess movement restrictions.
Fig. 2.95 Objectiw a .....ment of I1'IOWei1MI'It rllbictionl in 1111 lumbar NCtlon of 1he vertebral column IIIM'IItod by SCHOBERI and 1he thoracic part of 1he wrtebral column (OTI's signI.
89
Vessels and nerves ..... Topography, back ..... Female breast ..... Topography, abdomen and abdominal wall
Fig. 2.92 Middle layer of the abdominal muscles, Mm. abdominis; ventral view. On the right side, the M. obliquus externus abdominis is largely removed. 8 eneath Iiss the M. obliquus internus abdominiL Its aponeurosis contributes to formation of both the superficial (Lamina anterior) and the deep (Lamina posterior) lamina of the rectus sheath. TheM. obliquus intarnus abdominis projects from lateral caudal to medial era-
nial and, like the M. obliquus extemus abdominis, it participates in the oblique and transversa muscular abdominal girdle and supports forward and side-bending movements and lateral rotation of the upper torso. --t T 13-15, 24
--t
dissection link
87
Muscles _. Topography _. Sections
Shoulder blade
lnc:illnlla(IU._ M-;o IUperlar
M-;o
medialis
CM!tM glenoldlllle
3.15
Rp. 3.13 to 3.15 Shoulder blltde. SapuiL right tide; dorsal (-> Fig. 3.13), lateral(-> Fig. 3.14), and ventral{-> Fig. 3.15) view. The shoulder blade is a flat bone with three margins and three angles.
The dorsal T-shaped protrusion, the Spina scapulae, serves as ani~ portant apophysis for the attachment of muscles.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The N. npraiCipullrll passes through the lnclsur11 sapulle, which is bridged by the Lig. transversum scapulae superius <~Fig. 3.28). Ossification of the ligament can result in compreulon
of the nEH"'& with weakening of the dependent muscles IM. SI.Jpraspinatus and M. infraspinatus). These musdes are important for abduction and extemal rotation of the arm.
137
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Humerus
Rg. 3.18 Bone of the upper •rm. Humerus. right llde; ventral view. The humeral head forms an angle of 150•-1so• with the axis of the humeral shaft Ccollodl!rpbyiMI •ngle). In addition, 1tl& head shows a
138
nrt:rotorslon of 15°-30° and a posterior rotation relative to the axis through the distal condyles. The Tuberculum majus and the Tuberculum minus are located laterally and medially on the proximal shaft, r&speclively.
Muscles _. Topography _. Sections
Humerus
Colum anlllomlcum
l
~)
I
Tendnau.r,_uOM: 1 M. 814ft1Ptlll11t 2 M. tlftupt~atus 3 M.ta.mli!OI'
8ulcua l'llfVI Ulra'll
1\'octllee. humeri
3.17
Rg. 3.17 and Rg. 3.18 Bone of the upper ann. Humerus. right tide; dorsal(-> Fig. 3.171 and proximal(-> Fig. 3.18) view. The Sulcul nervi radillil spirals around the dorsal shaft of the Hu-
merus guiding 1tle N. radialis. The posterior side of 1tle Epicondylus medialis shows the Sulcul nervi ulneria where theN. ulnaris may be irritated mechanically {"funny boneN).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . As a result of falls. fractures of the Humerus are reiiJ!ively common. Supplying blood YMMis (Aa. circumflexae humeri anterior and posterior) and the N. axillaris which loop around the Humerus may
be damaged in proximal fractures<~ p. 2001. The N. radialis may be injured during fractur• in 1he shift •r• or surgical treatment of such fractures(-> p. 2031. resulting in a clinically obvious N. radialia
lesion {radial nEKVe paralysis!. In this re9on, 1tle n&t'\le may also be damaged by compression (•JHirk bench paratpts• or •s.turday night JHII!IV"'). Diltal fractures may cause demege to 1tre N. uln• rll in 1tle Sulcus ulnaris 1~ p. 201). Since the nEKVe is extremely exposed at this location, lesions of theN. ulnaris in this area represent the most common nerve lesions of the upper extremity.
139
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Ulna
lncllura tractf8111fa
Proe.
ooronold-..I!IJL--Incleure l'lldlllle
FaciM medale
Pnx:.lltylakl- ulrat
3.19 3.21
3.20
Figa. 3.19to3.21 Uln-. Uln• rightlide;ventral {->Fig. 3.19), Fig. 3.201, and radial I~ Fig. 3.211 view.
dorsal<~
140
Matching an isolated Ulna to on& side of th& body is aided by th& position of the Incisura radialis which points laterally.
Muscles _. Topography _. Sections
Radius
ClfUradll, ClrcurnfereraaullcuColuml'lldll
1\Diroeltlla radii
~radii
Corpuaradll - --IH-
Fulee polterlat ---11~
3.22
3.24
3.23
Fip. 3.22 to 3.24 Raciua,. Radiua right tide; v&ntral (~ Fig. 3.22), dorsal 1~ Fig. 3.231, and ulnar 1~ Fig. 3.241 view. Matching an isolated Radius to one side of the body is aided by !tie
position of the Proc. styloideus radii which points laterally. The Incisura radialis, however, points in an ulnar direction. " groows and bony crests for the extensor tendons
141
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Skeleton of the hand
O.~um
O..dlgltorum
Fig. 3.25 Sbleton of 1he hind, o..a m1nL11, right tide; palmar view. The hand IManusl consists of the wrist {Carpus with Ossa carpi), the metacarpus (M&tacarpus with Ossa m&tacarpi) and th& digits {Digiti with Ossa digitoruml. Digits consist of several phalanges. The bones of
142
th& wrist form th& Sulcus carpi which builds th& base of the carpaltu~ nel (-+ Fig. 3.1251. The carpal tunnel is bordered by the scaphoid !Os scaphoideuml and the tn~pezium lOs tn~peziuml on the radial side and by the pisiform {Os pisiform&) and the hamate (Os hamatum) on the ulnar side.
Muscles _. Topography _. Sections
Skeleton of the hand
Fig. 3.26 Sbleton of 1M hind, o..a m1nua, right tide; dorsal view.
The wrist (Carpus! comprises a proximal and a distal raw. From radial to ulnar the proximal row contains scaphoid (Os scaphoideum), lunate (Os lunatum! and triquetrum lOs triquetrum!. The pisiform {Os pisiform&! is adjacent to the triquetrum on the palmar side. S1rictly speaking, the Os pisiform& is not part of the Ossa carpi but serves as a sesamoid bone
{Os sesamoideum) for the tendon of the M. flexor carpi ulnaris. The distal raw comprises of the trapezium (Os trapezium!, the trapezoid !Os trapezoideum), the capitate lOs capitatuml. and the hamate lOs hamatum). For many years, stud ems have used mnemonics to help them memorising the sequence of the carpal bones: Some Lovers Try Positions That Thr:ry Can't Handle.
143
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Clavicular joints
Dllcue lrt!CUIII'II
Fig. 3.27 Mecilll cllvictlllr joint, Atlicullrtio ltlr'I'Kidnicullril; vemllll view of bolh joints. The medial clavicular joint is the only articulating conn8C1ion of the upper extremity with the skeleton of the trunk. The socket of the sternum and !he ball of the clavicle are separated by a Discus articularis of i~ brous cartilage which functions in balancing the traction force of lateral
144
movements. The strong ligaments comprise the Ligg. stemoclavicularia anterius and posterius spanning both bony oomponents on the ve~ tllll and dorsal side, and !he Lig. imerdaviculare oonnecting both cl~ cles cranially. The Lig. oostoclaviculare spans between the cartilage of rib land !he sternal end of !he davida; !heM. subclavius extends to !he acromial end of the davide.
Muscles _. Topography _. Sections
Clavicular joints
Ug.-lnlcu..., Ug.canoldlum
Fig. 3.28 Labar•l cllrviet~lllr joint, Art. 81Ct'0miodaviculllril,. right !Ide; ventntl view. The lateral clavicular joint connects the clavicle and the Scapula. The frequently present Discus articularis of fibrous cartilag& incompletely separates the cavity of the joint. The joint capsule is supported by the Lig. acromiodaviculare. In addition, the Lig. cotacodaviculare helps to
stabilise the acromioclavicular joint. This ligament consists of two separate ligaments, which independently connect the coracoid process with the Scapula. The Lig. conoideum reaches the Tuberculum conoideum medially. The Lig. trapezoideum inserts laterally on the inferior and acromial aspect of the clavide along the Linea trapezoidea (-+ Fig. 3.12).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The sternoclavicular joint is well protec1ed from injuries by its strong ligamentous support. However, injurile to 1he •e~omiocllrvicullr
)oint. also called AC joint, oocur frequently (e.g. as a result of a fall; -> Fig. 3.57).
145
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Shoulder joint
M. blc:.pe bnchll, Clput r~um, Tenc:lo
3.29
M. blc:.pe bndlll, ClpUt ronaum,lllnclo
uo Fig. 3.29 •nd Fig. 3.30 Shoulder joint. AttictJIIItio humeri,. rilht !Ide; section in the scapular plane, ventral I~ Fig. 3.291and hJtellll view omo the joint socket<~ Fig. 3.30). The Cavitas glenoidalis of the Scapula together with the glenoid labrum (Labrum glenoidlllel of fibrous cartilage form the socket of the glenohumeral joint. It is a classical ball and socket joint where the humeral head articulates with the glenoid fossa of the Scapula. The joint capsule !Capsula articularis) originates from the Labrum glenoidal& and includes at the superior aspect of the Labrum glenoidal& the tendon of Caput longum of the M. biceps brachii. Originating from the Tuberculum suplllglenoidale, the long head of the biceps projec1s lhrough the
146
shoulder joint. while the long head of the triceps (Caput longum of M. triceps brachiil has its origin at the Tuberculum infraglenoidale outside of the shoulder joint capsule. The capsule inserts at the Collum anatomicum of the Humerus, leaving Tuberculum majus and Tubero..llum minus extllHirticular. Inferiorly, the joint capsule extends to form a fold {REIC6SSUS axillaris). Various ligaments {-+ Fig. 3.31) and inserting te~ dons of the rotator cuff muscles {-+ Figs. 3.34 und 3.651 support the joint capsule on the posterior, superior, and anterior side. The roof of h lhouldlr comprises the Proc. coracoideus, the Acromion, and the connecting Lig. coracoacromiale.
Muscles _. Topography _. Sections
Shoulder joint
Ug.-mlllle
Rg. 3.31 Shoulder )Dint. Articulatio humeri. right llde; vemral view. The joint capsule (Capsula articularis) is supported by various ligaments and by tendons of !he rotator cuff muscles. The Ug. coracohuiMI"'IIe is positioned crnnially, originates from the Proc. coracoideus. and tadiates into the posterior aspect of the capsule. The Ugg. glenohulllel"elle consist of different collagen fibre systems and stabilise the anterior part of !he capsule. Since !he tendons of the rotator cuff muscles also radiate into the capsule from anterior, superior, and posterior direc-
tions, the weakness of the inferior joint capsule is evident. The Ug. coracoecromille, together wilh the Pro c. coracoidaus and the Aaomion. fotm the roof of the shoulder outside of the joint capsule. The roof of the shoulder functions as an additional Sl..lpport for !he glenoid fossa by stabilizing the humeral head superi0t1y against pressure from the arm. The structu1111 elements of the shoulder roof also limit elevation of the arm abolle the horizontal plane IEIIMJ!ion), unless the Scapula is rotated, too.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The glenoid fossa of the shoulder joint is relatively small. Thus, !his joint has a large tange of motion but is also prone to injury. Disloca-
tions lluatlons) of the shoulder joint are among the most common dislocations of the body{... p. 159).
147
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Shoulder joint
Fig. 3.32 Shoulder joint. Articulatio humeri, right lic:le; dorsal view.
Fip. 3.a3e to c Renga of I1'ICMIIII1HI'I in 1flelhoufder joint with and wttftout contributions of 1fte clavtcular Joints. (according to 11D. a,.b The shoulder joint is a .bell and 80Cket joint with three degrees of freedom of movement and the highest range of movement of all joints of the human body. When motions are exdusively performed in the glenohumeral joint. the extent of abduction and anteversion is restricted by the shoulder roof {thin lines). But if considering combined movements of shoulder and davicular joints. allowing the Scapula to rotate. then a much higher range of movement is possible (thick lines). This also allows for the elevetion of the arm above the horizontal plane. Rotation of the Scapula is mediated by the M. serratus anterior and M. trapezius and already becomes effective at the beginning of abduction of the arm. To determine rotational movements of the shoulder joint !see c below) the forearm. which can be viewed like an indicator. has to be positioned in a 90" flexion of the elbow. \IIIith the arm extended, one mostly detects a combined rotation of the shoulder joint and the forearm. RllniJI of IIKMIIII8IIt In the shoulder Joint elone:
c
148
• abduction-adduction: goo_ 0°-400 e anteversion-retroversiOn: goo_ 0°- 4Q0 • external rotation-internal rotation: 60°- 0°-70° Ringe of movement in .,.. lhoulder end clavicular joinU com· .bined: • abduction-adduction: 180°- 0°- 40° • anteversion-retroversion: 170°-00-40° • external rotation-internal rotation: 90°- 0°-100°
Muscles _. Topography _. Sections
Shoulder joint
........bac:rom...
M.~.--.Tendo
fig. 3.34 Shoulder joint. .Articelllrtio humeri, right tide; lateral view. Several muscles comribute to ltle stabilisation of ltle shouldar joint through insertion of their tendons into the joint capsule. These muscles are collectively called ltle rotator cuH: M. subsclrpularh supports the joint capsule from ltle ventral, M. supr..pinalul from ltle superior, and M. infr..pinltua and M. ur• minor from the dorsal aspect. Thus, the inferior aspect is the weakest part of the joint capsule. Several synovial cushions (Bursae) are associated with the shoulder joint. Some of them communicate with the joint capsule and form ex-
tensions of the joint. The Bursa subooracoidea which is positioned u~ demeath ltle Proc. coracoid &US frequently communicates with ltle Bursa subtendin&a musculi subscapularis. The latter cushions ltle tendon of theM. subscapularis(... Fig. 3.31) and often also communicates with the artirular cavity(... Fig. 3.641. The Bursa subacromialis is positioned on top of the supraspinatus tendon and is connected with the Bursa subdeltoidea. Thus, these two bursae together form the accessory subacromial joint. These bursae enable a frictio~free movement of ltle head of the Humerus and of the tendons of the rotator cuff muscles beneath the Acromion.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Degenaraliw altellltions affecting the tendon of M. suplllspinatus are common. Patients present with pain when lifting the anm. Abduction between 60-120" causes compression of the tendon u~ darneath ltle roof of ltle shoulder (hplngement syndrome). In
addition, degenarativ charges due to calcifications in ltle accessory subacromial joint can be the cause of painful restrictions of shoulder movements.
149
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Elbow joint
c..... ..tlcullrte, -~::.to;\~ MembniM. flbftlaa
Ug.colllillllrlle Ug. colllltlnle l'lldllll
ullwe
3.38
Fig. 3.35 Artlculltlng bona of the elbow Joint. Artlculdo cubiti: vemral viw.v. Artirulating areas covered by hyaline cartilage are illustrated in blue.
Ulra
Ug. colllltlnle urn an,
flnanlellcr)
3.37
Rp. 3.38 to 3.38 ElboiN )Dint.. Articulatio cubiti. right llde; Fig. 3.36), medial(~ Fig. 3.37). and dorsal 1~ Fig. 3.38) viw.v. The elbow joint is a composite joint (Articulatio composita), with the Humerus. the Radius and the Ulna articulating in three partial joints. • .Articulltio humeroulnlril: hinge joint with the Trochlea humeri forming the ball and the lncisulll trochlearis of the Ulna forming the socket • .Articulltio humeror1dillia: multiaxial ball and socket joint involving the Capitulum humeri lballl und the Fovea articularis of the Radius !socket) • Artlculltlo radloulnerls proxlllllllll: pivot joint involving the Orcumferentia articularis of the Caput radii (ball) and the Incisura radialis of the Ulna (socket). ventral<~
150
The joint capsule !Capsula articularisl encloses the cartilaginous articulating surfaces of all three bones. The capsule is reinforced by accessory ligaments. Two collt8r1l ligamants are responsible for lateral stabilisation of the elbow joint. Medially, the Lig. collatelllle ulnare connects the Epicondylus medialis of the Humarus with the Proc. coronoideus (Pars anteriol1 and the Olecranon (Pars posteriol1 of the Ulna. The Ug. collateral& 111diale originates from the lateral aspect of the Epiccndylus lataralis and radiates out to join the anwr ligamant (lig. anulare llldiil Yhlich is attached to the anterior and posterior side of the Ulna to loop the Caput of the Radius. The anular ligament allows for guided rotational movements in the proximal radio-ulnar joint.
Muscles _. Topography _. Sections
Elbow joint UD"
b
figa. 3.398 and .b Range of movement in the elbow joint. (according to 1111 The &lbow joint enables two distinct movements: hinge movem&nts between Humerus and Ulna and between Humerus and Radius and rotational movements between Humerus and Radius and between Radius and Ulna. Thus, the partitions of the &I bow joint function as hinge rotation Joint (trochoginglymus) when acting together. The joint between Humerus and Ulna is larg&ly guided by bones. In contrast to the inhibition of arm flexion by soft tissues of the flexor muscles, exte~ sion of the arm is limited by the bony structure of the Olecranon. The transverse axis of movement in the &I bow joint is positioned within the Trochl&a humeri (a).
The rotational movements are guided by the Lig. anulare radii (b). Rotation of the Radius around the Ulna not only requires movements in the proximal but also in the distal radiC>Yinar joint (... Fig. 3.44). Starting from the neutral-null position and 'hith the thumb pointing upwards the rotational movement in the radiex~lnar joint can result in supination {palm facing upwards) or pronation (palm facing downwards) of the forearm. Despite the fact that the articular surfaces of the humerCX~Inar joint have the shape of a multi-exial ball and socket joint, the humeroulnar joint is functionally confined to hinge movements. The circular anular ligament firmly ties the Radius to the Ulna and prevents abdu~ tion and adduction movements.
Range af movement In the elbow )oint: • extension-flexion: 10"-0"-150° • supination-pronation: 90°- 0"- 9()0
Fig•. 3.408 and b HUETEirs triangle. In the extended position of the elbow joint, the epicondyles of the Humerus are in line with the Olecranon {a). In flexed position, however, the epicondyles form an equilateral triangle IHUETER's triangle, .b). The Huetefs triangle has radiological r&l911ance since fractures and disloca-
tions may result in dlllliations from this triangular orientation of the &picondyles. "dinical term: HUETER's triangle
151
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Conjunctions between the bones of the forearm
Rg. 3.41 and Rg. 3.42 ConJunctions of the bones of the right foreann lilsupi!Wtlon c~ Rg. 3.41) and prondon position (... Fig. 3.42J; ventral view. The bones of the for&arm are connected by the tough Membrana interossea antebrachii whose collagen fibres are predominantly oriented
from the Radius proximally to the Ulna distally. Proximally, the Chorda obliqua courses with an opposite oriantation. The figures demonstrate the rotation of the Radius around the Ulna. Radius and Ulna are positioned in parallel during supination of the forearm but they cross during pronation of the forearm.
Olilcnlnon
Articulatio rlllllol*lilrtl
proDI'IIIII Llf.IIIUIIn radii -~~:;;;~~~---::::~ Pnx:. c:aranoldeu•
Fig. 3.43 Proximal radiHIInar joint. Articulatio racioulnaria and ventral view. The proximal radio-ulnar joint is a pivot joint and part of the elbow joint. The common axis for both the proximal and the distal radiCH.~Inar joints is the diagonal axis of the forearm connec1ing the Caput radii with the Caput ulnae. JII"C)Dnalll~. right llde; proximal
152
Fig. 3.44 Diltal radio-ulilar joint. Articulrio rldioulilaril dllhllt; distal and dorsal view. The distal radiCH.~Inar joint is a pivot joint as walland is located adjacent to the proximal wrist joint. This joint comprises the Caput ulnae and the Incisura ulnaris of the Radius. In the proximal wrist joint the Facies articularis carpalis of the distal Radius and the artirular disc of the distal radiCH.~Inar joint articulate with the proximal carpal bones.
Muscles _. Topography _. Sections
Joints of Carpus and metacarpus
Fig. 3.45 Joints 1nd ligamlll'lb of 1M right hand, Articulltianes 1nd Llgamentl m1n111. right side; palmar view.
AltiCUIIII!o ndl~lle
Fig. 3.48 JointB of the right Clrpullnd metac.rpua,. Articulatio..... c.rpl, right lldrt; viaw from palmar, section parallel to !he dorsum of the hand. In addition to smaller joints between the different bones of the carpus and metacarpus lhese consit of two wrist joints. • The proximll wrillt joint (Articulatio radiocarpalis) is a condyloid joint and connects the bones of the forearm {socke1) with the carpus ijoint head). Between Ulna and Os triquetrum resides a Discus articulatis {- Fig. 3.44).
• The diltll wrilt joint (Articulatio mediocarpalis) also functions as a condyloid joint. Carpal bones of the proximal row articulate with carpal bones of the distal row. • The Articulltian• cerpometlcarpalee 11-V between carpal and metacarpal bones and the Artlcula6Dn• lntermltlearpaln between the bases of the metacarpal bones are tight amphi-erthroses allowing only very limited movements. In contrast, the Siddle joint of the 1humb !Articulatio carpometacarpalis pollicisl is highly mobile and allows flexion and extension as well as abduction and adduction movements.
153
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Joints of carpus and metacarpus U18ments ofC.rpus and M81:11c8rpus
• Ligg. radiocarpalia palmare and dorsale. and Lig. ulnocarpal& palmar& • Ligg. collateralia carpi radiale and ulnare: from the Procc. styloidei • Ligg. intercarpalia palmaria. dorsalia. and interossea • Lig. carpi radiatum: ligaments radiating from the Os capitstum • Lig. pisohamatum: continuation of the flexor carpi ulnaris tendon to the Os hamatum
Ugg. CIIIJIOrneblclrpllllll dcnllll
• Lig. pisometacarpale: continuation of the flexor carpi ulnaris tendon to the Ossa metacarpi IV and V • Ligg. carpometacarpalia palmaria and dorsalis • Ligg. metacarpalia palmaria, dorsalia. and interossea
Fig. 3.47 .Joints and IIIJIIII'HN'Its of tM hand. Ar1kullltloneiJ and LiQ~~menta manu11, right side; dorsal view.
Range of II'IO'W'IIII'Ient In 1he wrllt Jc*rts. (according to [1)) Proximal and distal wrist joints function as condyloid (elliploic:t) jointa and comribute both to the movements of the hand. Thus, the axes of movements for both joints are described as combined axes through the Os capitatum. Abduction of Radius and Ulna oCOJrs mainly in the proximal wrist joint with a combined dorsopalmar axis of movements running through the centre of the Os capitatum (a). The palmar flexion is predominantly mediated by the proximal wrist joint. and the dorsal extension by the distal wrist joint !mnemonic, b). The transverse axis of these mOV&ments also runs through the centre of the Os capitatum. Most other joints of the carpus and metacarpus are amphi..:trthroses and their range of motion is negligible. In contrast. the Siddle joint of thliflumb shows a great freedom of movements allowing not only flexion and extension but also adduction and abduction. These movements can be combined for circumduction and op~ sition of the thumb, both of which are important to grasp objects. Fig•. 3.481 and b
Range of movement in tM carpel joints: • ulnar abduction- radial abduction: ao·- o·-ao· e dorsal extenSiOn- palmar flexion: 60°-0°-60° Rane- of movement In 1he saddle Joint of 1he thumb:
• extension-flexion: 30°-0°-40° • abduction-adduction: 1o·-o·- 4()•
154
Muscles _. Topography _. Sections
Finger joints
Ugg. palm .-fa
Ug. colllllllnle
Rg. 3.49 FlniJII' JolntiJ. Al1kullti01'1M dlgltorum. right side: la1eral view, sagit1al section. They comprise th& m&1acarpophalang&al and in1erphalang&al joims. The metac.rpophlllngHI Joints !Articulationes m&1acarpophalangeales) are condyloid join1s in which th& dis1al parts of the me1acarpal bones anicuhrte with the bases of the proximal phalanges. The m&1acarpophalangeal joim of the thumb, however, is a hinge joint. The praxim1l •nd diltal inblrphlllngMI joints {Articula1iones imerphalangeae manus proximales and dis1alesl between the heads and 1he bases of 1h& respec1iv& digi1al bones are hinge joints.
I
b
Fi$J. 3.50 Lig1menta of the finger joints, ArticulltioMs digiti, rlaht side; la1ert~l view. • Ligg. collateralia: medial and lateral • Lig. palm are: ventral • Lig. me1acarpale 1ransversum profundum: connec1s palmar ligaments at the m&1acarpophalangeal joints (... Fig. 3.45).
Fip. 3.51e to c Renge of I1'IO¥IIIMI'It in 1M finger joinb. !according to 1111 The metacarpophalangeal joints allow flexion and extension as well as radial and ulnar abduction. Rotational movements are only possible p~ sively if fingers are in extension. The saddle joim of the thumb exclusively enables hinge movemems. The same applies for the proximal and dis1al interphalangeal joims which exdusively enable flexion. Ringe of I1'IO¥IIIMI'It in the metec.lrpophlllnglll joints: • dorsal extension-palmar flexion: 30"- o·- go• • ulnar abdUC1iorH'8dialabduction: 120- 401"- o·- (20- 40)" Ringe of movement in the proximel inblrphellngMI jointtc • dorsal extension-palmar flexion: o·- 0"-100" Ringe of movement in the diltel interphlllngeel joints: • dorsal extension-palmar flexion: o•- 0"- 90°
Clinical Remarks---------.. .Ab.tlr'tMir6Dns 1nd terms commonly used in the dinical setting: • MCP joint = metacarpophalangeal joim • PIP joint =proximal interphalangeal join1 • Dl P join1 = distalln1erphalangeal joint
155
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Shoulder joint and humerus
Cia~Ia
•·- ---....-------,--OMt.glenalc!da _ _ _ _ ____:._Colllmtci!PliU
Rg. 3.52 Shoulder Joint. Ar11culdo hull'lll'l. right side; rtldiograph in anteriopostetior (AP) beam projection.
• Fig a. 3.53a and b Rldiogrephalhowing fracblr• of 1he Huii'III'UI. a fnlcture of the lhlft of the Humerus. which may result in injury to the radial nerve. [8)
b
b Fracblre of 1he head of the H..nen.11, which may result in injury to the axillary nerve. 141
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Conventional radiographs ar& suitable for the identification of fr8c. 111r• and dillocations (luxations)leading to alterations in the position of skeletal elements. Injuries to the ligaments, however, cannot
156
be detected by radiographic imaging but instead require the use of ultrasound or magnetic resonance imaging (M Rl) as diagnostic tools.
Muscles _. Topography _. Sections
Elbow joint
HUmllrU8
Fo-Oiecnnl
lncllura tnx:hllllllfa
Rid I..
Clinical Remarks---------.. Fig. 3.54 •nd Fig. 3.55 Elbow joint. Attiet~lrrtio et~biti,. right IIide; radiographs in anteriopos1erior(AP; ~Fig. 3.54) and lllteral (~Fig. 3.551 beam projections.
In the extended position of the elbow joint. both epicondyles of the Humerus are in line wi!h the Olecranon of the Ulna. Fractures or dislocations may result in dellilltions from the normal position {-+ Fig. 3.40).
157
Upper Extremity
Surface anatomy ~ Development ~ Skeleton ~ Imaging ~
Hand
Fig. 3.56 Hand,. Manua. right tide; radiograph in anterioposteriOI'
lAP> beam projection.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The fracture of the distal Radius is the most common fracture occurring in humans. The diagnosis of a distal Radius fracture based on the radiographic image requit&S profound knowledge of the radiological anatomy of the wrist joint. Fractures of the carpus frequently involve the SC8phold bone. Concomitant injuries of the supplying blood vessels may result in
158
necrosis of the scaphoid bone and show a reduced bone density in radiographic images. In addition, injuries may cause degenerative alterations such as arthrosis of the hand and finger joints. Typical radiological signs of artflroeia are the development of bony outgrowths (osteophytesl and destruction of the articular surfaces.
Muscles _. Topography _. Sections
Dislocations of the shoulder
+ Fig. 3.57 Injury of 1he •e~omiocllvicullr joint (•lhoulder 111P81'11tlon·). (aoc:ording to 11 D After dislocation (luxation) of 1he acromioclavicular joint and associated rupture of the Ligg. coracodaviculare and acromioclavicular&, 1he lateral part of the clavicle is pulled up by 1he M. trapezius and 1he shoulder "drops« (Weight of the arm). The cfastllc:atlon of the severity is done according to TOSSY: • I O'W'IH'8Xtent1Dn of the ligaments • I pertill rupture of the ligaments • II compllrt:e rupture of bolh components, the Lig. coracodaviculare and the Lig. acromioclaviculare. This TOSSY-111 injury requires surgical stabilisation.
Fig. 3.59 Reposition of • cillocmed lhoulder. (according to [1)) The procedure aocording to ARLT requires the injured arm to be positioned over a cushioned back of a chair. The physician pulls 1he flexed arm in the direction of the Humerus until the head of the Humerus pops back into 1he glenoid fossa.
Fig. 3.58 Dilloc.ltion IIUIIlltion) of the shoulder joint. !according to 1111 Dislocation of 1he shoulder is the most common luxation in 1he body. The shoulder joint is prone to luxation because of the weak bony and ligamentous guidance for 1he movements of the head of Humerus. The most common (90%1 form is the Luxatio subcorac:oidea (as shown on the right side) with positioning of the Humeral head beneath the Proc. coracoideus. The contour of 1he shoulder ldornel is reduoed and the upper arm appears longer.
Fig. 3.60 Luxatio subcor•coidu. [4) This type of luxation means that the head of the Humerus snaps to a position beneath the Proc. coracoideus. The dome of the shoulder is reduoed and the arm appears longer.
159
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of shoulder and arm
M. uten.:1r c.-pi n.dllllllo~ ..
M.III»Ccf cap! radllll8 M. pal'nal!slcflgl.l8
Fig. 3.61 v.ntr•l mllldla of the shoulder •nd vemllll view.
160
•nn. right side;
Muscles _. Topography _. Sections
Muscles of shoulder and arm
Fig. 3.62 Dotul muacl• of h
lhouldlr and arm, right tide;
dorsal view.
l-tT24-381
161
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Muscles of the arm
M.UII'Mmtncr M.-ma,Jar
M. obUquus utemus alldomtnts
M. tn.chlcm:Uelta
M. eld»n8
M. ftlliCOf cap~ radialis
M. abdue10f pomcta longus \\Ill~~-
M. 6lll8n8cr pol lela bnMa
M.ldclue110r pol leis
Rg. 3.83 Muscles of 1M arm and 1horax. right side: l11te1111 view.
l~n4-3al
162
Imaging
~
Muscles _. Topography _. Sections
Rotator cuff
M. oon.oobradlllll8 M. blcepa bra:l111, Caput llr8Y8
M.111ceps Inch!~ C&putlcngum
fie. 3.&1 Shoulder joint end shoulder mi.IIICIM, right -"fe; latetal view after rerTKM~I of the M. deltoideus and the Caput humeri. l-tT28.28
I
Fie. 3.85 MIIICfas of the rotator cuff: lateral view. The extensive tang a of movement in the shoulder joint is an essential prerequisite for the touch and grip function of the upper extremity. Based on the strong guidance by muscles and the highly flexible positioning of the Scapula, the shoulder joint only requires little support by bones and ligaments. However. when neuromuscular problems arise, such as in nerve injuries or with a dysbalance between the rotator cuff muscles. the contact of the articular surfaces cannot be guatanteed anymore. Dislocations occur when shear forces act tangentially to the Cavitas glenoitialis. in particular during a fall. The tendons of those muscles directly adjacent to the shoulder joint radiate into the joint capsule and form a tough rotator cuff around the head of the Humerus. Among these muscles are the M. sub8cepullril (venttal}, theM. IIIPf..pinltua (superior). M. infratpinltul (dorsal superior), and the M. teras minor (dorsal inferior!. With the exception of theM. subscapularis, which inserts on the Tuberculum minus. and in addition to their connection to the joint capsule, all muscles of the rotator cuff inselt B1 the Tuberculum majus. The M. deltoideus is not part of the rotator cuff because there is no connection to the joint capsule.
I_.na,28 I Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In addition to their role in the various movements (kinematics), the relevance of the rotator cuff muscles is to ensure the correct position of the humeral head in the glenoid fossa (statics!. Elevation of
the humerel heed occurs as a result of muscular imbalance. especially a relative weakness of the adductory (inferior) parts of the muscles.
163
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Muscles of the shoulder girdle
Rg•. 3.8811 and b Muscles of the shoulder girdle. a M. trapezius .b M. levator sc.pulle and Mm. momboidei The shoulder has two func1ional muscle groups. The muscles of the shoulder girdle originating from the Scapula or clavicle primarily move the shoulder girdle and only indirectly move 1he arm. In contrast, the muscles of the shoulder originating from the Humerus directly move the arm. These muscle groups can be subdivided acrording to their position. The donal muscles of the shoulder girdle comprise the M.
tlllpezius. the M. levator scapulae, and the Mm. rhomboidei. Ventral muscles are the M. serratus anterior. the M. pec1oralis minor, and the M. subclavius(... Fig. 3.68). Fixation of the Scapula to the trunk is pr&dominantly accomplished by the M. levator scapulae and the Mm. rhomboidei, with additional support from the M. serratus anterior and the M. trapezius. The dorsal musdes of the shoulder girdle are also illust111ted as superficial muscles of the back (... pp. 74 and 75). The ventral musdes are also shown with the ventral wall of the trunk 1... pp. 86-88).
I-+T271
164
Muscles -+ Topography -+ Sections
Muscles of the shoulder girdle
M.~lsmlnor
Figa. 3.86c and d Mu~~~~:lell of the lhoulder girdle. c M. sarratus arrtariDr
d M. pactoral• minor end M. subclavius M. serratus anterior, M. pactOilllis minor, and M. subclavius belong to the ventral muscles of the shoulder girdle. The main function of the M. sem1tus anterior and the M. trape2i us is the rotation of the Scapula, a requirement for the elevation of the arm above the horizontal plane. In addition to its function in lowering the Scapula, theM. pectoralis minor supports the elevation of the ribs when the arm is fixed, thus, ~
ing as auxiliary muscle of inspiration similar to theM. serratus anterior. The M. subclaltius acts as an active strap in the stabilisation of the sternoclavicular joint. The dor.;al musdes are also illustrated as superficial muscles of the back(-+ pp. 74and 75). The ventral musdes are shown with the ventral wall of the trunk(-+ pp. 86-881.
165
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the shoulder
b
•
Figs. 3.67• to c Mllldea of the shoulder. • M. lllltlalmus dorsi .b M. infr81pinatua, M. t.,.. minor, M. ur•m~jor c M. eubscepullris In contrast to muscles of the shoulder girdle, shoulder muscles direc11y act on the arm. They can be subdivided into a dorsal and a ventral group of muscles and an additionalla1eral group of muscles which is defined as a part of the dorsal group in some textbooks. The group of dorNI shoulder muscles comprises the M.latissimus dotSi, M. infraspinatus, M. teres minor, M. teres major, and M. subscapularis, the only muscle of this group positioned on the ventral side of the Scapula.
The M. llltiuimua dorsi enables a strong retroversion movement of the anteverted arm !such as raising the trunk to the arm when climbing or performing chin-ups). However, with the arms fixed its ac1ion aids in the compression of the thorax {e.g. when coughing; patients with COPD develop a strong M. latissimus dorso. The M. aublt:lpullris is the most important medial rotator of the arm and its action is necessary in order to cross when crossing the arms behind the back. Its functional antagonist is the M. Infraspinatus e~ abling a strong lateral rotation of the arm. M.teres major and M. teres minor are functionally less important on their own but support the action of the other shoulder musdes.
I-+T281
166
Muscles _. Topography _. Sections
Muscles of shoulder and shoulder girdle
d
Fig a. 3.67d to f Mllldas of the shoulder. d M. IUPf'IIIPinltua e M. deltoideus f M. pector•il major The group of lltenll shoulder muscles comprises the M. supraspiniJ!us and the M. deltoideus. The M. pectoralis major is the only one in a ventr•l position. The M. pector•lis m.1jor is the strongest muscle for anteversion and adduction of the arm. Its action is essential to cross the arms in front of the trunk (Ventrally). In addition to the M. IIJ!issimus dorsi, theM. pectotalis major supports a strong retroversion movement of the arm when started from an anteverted position. The M. deltoideua is the most important abductor of the arm and sup.. ports all other m011ements of the shoulder joint through its functionally distinct parts. The M. supr1~ supports the action of the M. deltoideus in abduction.
I_.ns..261 167
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of shoulder and shoulder girdle
M. 8CIIIIIn.. medkla
.... dlltoldlua M. blcept IHactlll,
Cllput la~um
M. eUIIclll'lllue Mm. rt118n::o11:81• lnteml M • ..,...llllllrfor
Mm. lnterco81ale8 uteml
M.1*1C1'8118 maJor
Fig. 3.68 Muaclee of 1he shoulder girdle end the shoulder, right side; ventral view, corresponding ribs are labeled wi1h Roman numerals. This ventral view mainly shows the ventral muscle group of the shoulder girdle IM. serratus anterior, M. pectoralis minor, and M. subclavius!. Of the dorsal group, only the M.levator scapulae and part of the inser-
tion of theM. trapezius are illustrated. TheM. pectoralis minor is reflected anteriorly to provide a better view of the M. serratus anterior and its origins on ribs I to IX The abduction position of the arm allows a good view of the M. subscapularis which broadly oovers the ventral area of the Scapula.
M. blclllpl bra:lil { C8put lo~llll--------..!
Caputm-
Fig. 3.69 Poeition of 1fle M. supraspin.ltul in rellltion to the roof
of the shoulder. Acromion and Proc. coracoideus form the roof of Ule shoulder. They are connected by the ug. coracoacromiale. Prior to its insertion into the joint capsule, Ule tendon of M. supraspinatus courses beneath Ule roof
168
of the shoulder. Therefore the tendon can be compressed in abducted position of the arm and frequently painful degenerative conditions of the suprespinatus tendon are observed.
I-+T28,2~U91
Muscles _. Topography _. Sections
Muscles of shoulder and shoulder girdle
Ug. ccncaclll:v1cullt&, ug.lnlplmlkllllnl
M. om~us. VIHUr lnfwlar M. _ , . antellar
M. bf0el)8 bra.clil, Clput IOf'GUm
M. trfcepa bi'IICIII, Ceput langum
M. _ , . antertar
Qu~uwuii'-Yt~~-
M.tlllw
M. trfcepal!nctll, caput langum
3.71
Rg. 3.70 and Rg. 3.71 MIIICias of the shoulder girdle and 1fte lhoulder, rightlide;ventral 1- Fig. 3.70) and dorsal(- Fig. 3.71) view.
Except for ltieir origins, !tie muscles of the shoulder girdle are removed to visualise the shoulder muscles. The ventral view particularly shows the complete course of !tie M. subscapularis and the M. teres major. From its origin at the Angulus inferior of !tie Scapula, !tie latter a-osses the Humerus anteriorly before inserting on the Crista tuberculi minoris. On the dorsal side of the Scapula, !tie M. suplllspinatus is in part covered by !tie M. trapezius and courses {not visible here! under the roof of the shoulder to insert on the upper portion of the Tuberoulum majus. Benealti are !tie insertions of M. infraspinatus and M. teres minor.
This illustration also visualises the axillary gaps between M. teres major and M. teres minor with the Humerus as their lateral border. Both muscles diverge in a Y-shaped way from their origins on the Scapula and leave a gap which is divided by !tie long heed of the M. triceps blllchii into a medially positioned triangular axillary ..,_. (Spatium axillare medialel and the laterally positioned quadrangular ollary Jpaee (Spatium axillar& lateral&). The !medial) triangular axillary spaoe serves as passage for the A. and V. circumflexa scapulae to the dorsal side of the Scapula. The (lateral) quadrangular axillary space is traversed by !tie N. axillaris and by the A. and V. circumflex.a humeri posterior.
I_. T 25,28.28. 30 I 169
Upper Extremity
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+
Muscles of the upper arm
Caput-·
3.7211
Figs. 3.72a and b Ventral muscles oftbe upper ann. right side; ventral view. a M. coracobrachialis end M. brachlalls b M. biceps bradlii The ventrally positioned M. coracobrachialis hfls its origins at the Proc. coracoideus and i~ serts medially at the Humerus. In contrast to the other two ventral muscles of the upper arm. its action is restricted to the shol.llder joint contributing to movements of adduction. medial rotation, and antevllfSion without a major impact on these movements of the arm. Originating distally from the anterior surface of the Humerus. the M. brachia lis inserts into the joint capsule and the Tuberositas ulnae. TheM. brachia lis exclusively acts on the elbow joint by supporting its flexion.
In contrast to theM. coracobrachialis and M. brachialis, both the M. biceps brachii and the M. triceps brachii (-+ Fig. 3.73) span two joints and thus are able to promote movements in the shoulder and the elbow joints. The M. biceps brachii is the most important muscle on the dorsal side of the arm. The Caput breve of theM. biceps brachii originates from the Proc. coracoideus and has similar functions as the M. coracobrachialis. The Caput longum originates from the Tuberculum supraglenoidale of the Scapula and functions as abductor of the arm. However, its most important action is on the elbow joint. With its major insertion at the Tuberositas redii, theM. biceps brachii seNes as the most impDI'tant ftavr In the ·~ Joint and the strongest . .pinetor of the forearm in a flexed position.
Fig. 3.73 Dort~o~l mlddes of the upper erm. M. triceps brKhl and M. enconeus. right side; dorsal view. TheM. triceps brachii is positioned on the dorsal side of the upper arm. Its Caput longum originates from the Tuberculum infraglenoidale, whereas the Caput laterals and Caput rnadials have a broad origin on the dorsal side of the Humerus. In addition to its supportive function in adduction and retroversion of the shoulder joint, the M. biceps brachii is the mDet important ext__,r of the albDw joint due to its common insertion on the Olecranon. This function is supported to a ceria in extent by the action of the M. anconeus which spans from the Condytus lateralis of the Humerus to the Ot sera non and the dorsal side of the Ulna.
I-+T29,30 I
170
Muscles _. Topography _. Sections
Muscles of the upper arm
M.IIUJ)I'UI)IIli\US
M. cmol!yOICieUt, venter rn'ei!Cf
M.~lem~Tendo
M.-mapr
M. bleeJNa bndlll, Cap.rt lqum
M.lrtcepe lnchl, Cap.rt medllle
fig. 3.74 V.ntr•l mulldee of 1fle upper •nn. right tide; wn1ral view. The M. co!llcobrachialis is positioned ventllllly to !he M. biceps blllchii. The short head (Caput breve) of the M. biceps brachii origina1es from the Proc. coracoideus. !he long head !Caput longuml from the Tuberculum supraglenoidale. In acldi1ion to i1s principal insertion si1e a1 the Tu-
berositas radii, the Aponeurosis musculi bicipitis brachii radiates into the fascia of !he foreatm (Fascia antebrachiil. The M. brachialis is positioned beneath !he M. biceps brachii and is only visible with its muscle belly on bo1h sides of the biceps 1endon.
I_. T29,30 I 171
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Muscles of the upper arm
M. lrtoepe tn.cHI, Olp.rt medllllt
Fig. 3.75 V.ntr•l mulldle of 1fle upper •nn. right tide; ventral view; after removal of the M. biceps bracnii. The M. biceps brachii was removed to demonstrate the underlying M. brachialis. TheM. cotacobtachialis is easily identified since it is pierced
172
by the N. musculocutaneus, the netW which innervates all three mu~ cles of the ven1ral side of the upper ann IM. biceps brachii, M. coracobrachialis, and M. brechialis).
I~T29,ao
I
Muscles _. Topography _. Sections
Muscles of the upper arm
M.tllrwlllllllor
M. lllll:lllelmua doni
M. trf~ bnlc:flll, Ceput lo~um
Fig. 3.76 Donl81 muaciM of 1he lhoulder and upper arm, and ventral muscfes of 1he upper arm. right side; dorsolate!lll view. The M. triceps brachii almost completely covers the posterior aspect of the upper arm. Visible here are Caput longum and Caput lateral& which both cover the Caput mediale. All lhree heads of this muscle have a common insertion a1 the Olecranon. TheM. 1riceps brachii is separa1ed by 1he Septum intermUSCI..IIare lateral& from the flexor muscles {M. brachial is, M. biceps brachiil on the ventral side of !he upper arm. The
radial extensor muscles of the forearm have 1heir origins on 1he lateral aspect of the distal upper arm. From proximally to distally, lhese co~ prise !he M. brechioradialis, M. extensor carpi ~t~dialis longus. and M. extensor carpi radialis brevis. The following shoulder musdes are also visible here: M. deltoideus, M. teres major, M. latissimus dorsi and M. supraspinatus.
173
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the upper arm
M.
Fig. 3.n Dots~~l muldea of 1he lhoulder •nd upper •rm, right !Ide; dorsolatellll view; ltle Caput laterale of ltle M. triceps brachii was cut. The Caput longum of theM. triceps brachii originates from the Tuberculum infraglenoidale of the Scapula. The Caput laterale originates proximal and la1ernl of 1h& Sulcus nervi radialis. When the Caput late tale is cut open, the Caput m&diale can be seen which originates from 1he Humerus distal and medial of ltle Sulcus ni!Ni llldialis. In addition, the
174
-r.:w
aupl radlalalcngua
trilngullr and the quadr•naul•r specea !axillar, eaps) are '.lisible between ltle M. teres minor and M. teres major (-+ Figs. 3.70 and 3.71), which are sepalllted by the Caput longum. Distal of theM. tiii'6S major the 1riclpa Illit is visible which is used by theN. radialis to reach the dorsal side of the Humerus.
Muscles -+ Topography -+ Sections
Muscles of the forearm
d
b
Flp. 3.'7811 to d Vantnll mllldas af the fGnlllrm. right slda; ventral view. The flexors of the forearm are positioned on the ventral side. They are separated by the radial and ulnar nBYrovascular bundles into a superficial and a deep group of muscles. Each of these two groups consists again of two layers, thus, four distinct layers can be separated: • superficial layer • middle layer • deep layer • deepest layer a superftclallayer From radial to ulnar, the Sl.flerficiaI layer consists of M. pronator teres, M. flexor carpi radialis, M. palmaris longus, and M. flexor carpi ulnaris. All these muscles have their origin at the Epicondylus medialis of the Humerus and function as flmcors of the elbow Joint and, with the e>tception of the M. pronator teres, also of the wrist. TheM. p..-tor • - crosses the diagonal axis of the forearm and therefore is the most impartant proneter, together with the M. pronator quadratus in the deepest layer. TheM. palmaris longus may be missing uni- or bilaterally in up to 20% of the people and functions in stretching the palmar aponeurosis in addition to flexing the wrist. When acting together with its antagonist on the extensor side, the M. flexor carpiulnaris mediates
ulnar abduction and the M. flexor carpi radialis enables radial abduction.
b middlelqer TheM. flexor dl.-mrum superftclalls makes up the middle layer. The tendons of its four parts insert on the palmar aspects of the middle phalanges of the second to fifth fingers. Thus, this muscle also flexes the middle interphlllangeal joints and, with lesser strength, the metaCIIrpophalangeaiJolnts. in addition to its support in flexion of the elbow and wrist joints. c deepla.,.r The deep layer comprises the M. flexor polkilllongus on the radial side and theM. fiBXDr dlglterum profundus on the ulnar side. Both muscles originate from the ventral aspect of the bones of the forearm As their tendons reach the palmar aspects of the distal phalanges, they do not act on the elbow joint but flex the wrist and the di...l interphalangeal joints Df fingers and thumb and to a lesser extent the metacarpophalangeal and proximal interphlllangeal joints. d diiBpBSt layer Beneath the tendons of the long flexor muscles of the forearm theM. pronator quadratus connects the ventral aspects of Radius and Ulna.
I-+T31.321
175
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the forearm
M. blcepe tnchl
M. tlacrCirJII uln.ta
M. abductor poUiclelongua
Rean.:uhJll muaculeriJll elt1ien801'Um
Rg. 3.79 Superflcf1lllyer of 1he verrtrll muscles of 1he forllnn. right IIide; ventrnl view. From radial to ulnar. th& sup&rficial musd& lay&r of th& for&arm consists of M. pron81or teres, M. flexor carpi radialis, M. palmaris longus, and M. flexor carpi ulnaris. Parts of th& M. flexor digitorum sup&rficialis of the middle lay&r are visible between the M. palmaris longus and M. flexor carpi ulnaris and between the tendons of the other muscles. The redial
176
group of muscles of the forearm functionally belongs to the extensors of th& wrist and lies on the radial side in relation to the superficial flexors.
Muscles _. Topography _. Sections
Muscles of the forearm
M. fllllllor dlgttorum eupert!CIIIIe
M. abcludcr pollclalong..
M. ftMlr pol lei• long..
M. fie..- Cllpl redlllll, Tendo
M. b!W:Illen.dlallll, Tendo
Fig. 3.80 Mlrtdlllayer of 1he verrtnll muscles of 1he forelnn. right tide; ventral view; M. flexor carpi rndialis and M. palmaris longus were partially removed. The M. pronator teres is visible in its full length after removal of 1he Aponeurosis musculi bicipitis brnchii and reflection of the M. brnchioradialis. Beneath 1he superficial flexors, the middle layer of ventral mu&cles of the forearm is visible which consists of 1he four muscle bellies of theM. flexor digitorum superficialis.lts whole dimension can only be appreciated upon removal or deviation of the M. flexor carpi llldialis and M. palmaris longus, as illustrated here. The Caput humeroulnare of 1he
M. flexor digitorum superficialis originates from the Epiccndylus medialis of the Humerus and from the Proc. corcnoideus of the ulna. Its Caput rndiale has its origin at the anterior aspect of the Radius. Strictly speaking, 1he different musde bulges of M. flexor digitorum superficialis are not positioned exactly in one plane. Thus, this illustration only shows the muscle parts for the 1hird and fourth fingers which cover the muscle parts of 1he second and fiflh fingers.
177
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the forearm
M. blc8pe tn.chl, Tenc:lo
M. fl&lllll' pollcl•lang..
Fig. 3.81 Midd'- layer of the ventr•l miiiCIIa of the forMrm, right 11•; ventllll view; M. flexor carpi radialis, M. palmaris longus, and M. pronator teres were almost completely removed. In contrast to th& illustration in - Fig. 3.80, th& M. pronator t&r&s was also cut to demonstrate the origins of the M. flexor digitorum superii-
cialis. Th& Caput humeroulnare originates from the Epicondylus medialis of the Humerus and from the Proc. coronoideus of the Ulna. The Caput radiale has its origin at the anterior aspect of the Radius.
I_.T:n I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Abnormel incre... in mUlde tone in th& form of ap.111ticity may occur after stroke or damag& to th& central nervous system {CNS). An increase in muscle tone may also oc.cur without major injury with dptDnie. Spasticity often affects entir& muscle groups. However. dystonia may affect selectively indMdual flexor muscles, such as in
178
writer's cramp, and sometim&S only a single musde belly such as of the M. flexor digitorum superticialis. To enable targeted treatment. such as the inhibition of signal transmission at the motor end plates by injection of botulinum toxin, a very precise understanding of the function and the topoglllphy of the muscles is necessary.
Muscles _. Topography _. Sections
Muscles of the forearm
\1\.;~~!lotli\i:,;....- Sepblm
htsmUICIA_.
tnchl medllle
M. ft~ dlgltarum aupelflclda
M. f'lllllor poll lela IDngua
M. lltW:Illen.cllllt, Tendo
Fig. 3.82 Deep •nd deepeltllayer of 1M ventral muaciN of 1M forearm. right side; ventral view; after removal of !he superficial flexors. With the removal of all superficial flexors. the deep flexors become visible as shown here. The M. flexor digitorum profundus has its origin at the anterior aspect of !he Ulna and the Membrana interossea antebrachii. TheM. fleXOI' pollicis longus Ol'iginates from the anteriOI' aspect
of the Radius and in up to 40% of all cases with an additional Caput humeroulnare from the Epicondylus medialis and !he Proc. ooronoideus. The M. pronatOI' qu&dratus is covered by the tendons of the flexor muscles and connects Radius and Ulna at the distal fOI'eann.
179
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the forearm
Fig. 3.83 Racill mllldla of the for•rm, right aide; dorsal view. From proximal to diS1al. !he radial group of muscles comprises !he M. brachiotadialis and the Mm. extensores carpi tadialis longus and brevis. These muscles originate from the latetal aspect of the Humerus and run anterior to the transversal axis of !he elbow joint which makes them flexors of this joint. The M. brachioradialis inserts at the distal end of the Radius and. thus. only spans one joint. Its function depends on the given position of !he forearm and may support supination or pronation. The Mm. extensores carpi radialis longus and br&vis function as ext~ sors of the wriS1 joints and enable radial abduction.
l-tT331 Fig a. 3.848 to c Don~~~l miiiCies of the forearm. right llcle; dorsal view. • auperficilllayer All superficial extensors have a common origin at the Epicondylus lateralis. Excessive use of !he extensor tendons may cause intensive pain in the elbow rtennis elbow"). From radial to ulnar, this muscle group comprises the M. extensor digitorum. M. extensor digiti minimi. and M.
180
extensor carpi ulnaris. TheM. extensor digitorum and M. extensor digiti minimi llldiate into the dorsal aponeuroses of digits two to five. Therefore. these muscles serve as extensors of the wriS1, the metacarpophalangeal joints. and the proximal interphalangeal joints. As the dorsal aponeurosis ends at the middle phalanges, these musdes do nat participate in extension of the distal interphalangeal joints. .bend c deep layer From radial to ulnar, the distal layer consiS1s of the M. abductor pollicis longus. M. extensor pollicis brevis, M. extensor pollicis longus, and M. extensor indicis {... Fig. 3.840). TheM. abductor pollicis longus abducts in the saddle joint of the thumb, and !he Mm. extensores pollicis brevis and longus extend this joint as well as the interphalangeal joint of the thumb. The M. extensor indicis extends the metacarpophalangeal and the proximal interphalangeal joints of !he index finger. Proximal. the deep layer of extensor musdes comprises the M. supinator 1~ Fig. 3.84cl which winds around !he Radius. It is the strongest supinator during extension of !he elbow joint.
Muscles _. Topography _. Sections
Muscles of the forearm
Olllc:ranon
M.anccn-
M.-pollcl•-
M. 6lll8n8cr pol~-· 'lllnc!o
Altfna.cullm muacuJcrum .u.naorum
Fig. 3.1115 Supt~rficiellllylr' of 1M dorul muaclle of 1M fonNnn and dlltll JHirt of upper arm. right side: latellll view. The latellll view best shows the radial group of muacles.. From proximal to distal there are the M. brachioradialis, and the Mm. ex:tensores carpi radialis longus and brevis. Further to the ulnar side, the superficial exflniOr' muld• are positioned (M. extensor digitorum, M. extensor digiti minimi, and M. extensor carpi ulnaris). Distally between these muscle groups the distal parts of the deep extensor mi.IICIM
are '1/isible (thus, they are not completely covered by the superficial extensors!. In this illustration, the fascia of the M. anooneus at the distal part of the upper arm was removed. The M. anconeus belongs to the extensor muscles of the upper arm.
181
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Muscles of the forearm
M.anconeua
M. -CIIIplrw:tllllll-
M. -.tlln_. llgltl mlnlml
M. abductcf pc411c:l810ngi.IS
~I-7'o.~ ---,,------
Rg. 3.88 Superflcf1lllyer of 1he dorMI muscles of 1he fOI"Nnn 1nd dilltll part of upper •rm, right IIide; dorsal view. The tupt~rficiai1Xt8nll0r' mlllcf• of the forearm comprise the M. extensor digitorum. M. extensor digiti minimi. and M. extensor carpi ulnatis.
182
M. uteneor carp! radialis ll!WIS, Tendo M. uten.ar aupl n.dlllllalangu~t, Tendo
On 1tle ulnar side, the M. flexor carpi ulnaris of 1tle superficial flexor group is adjacent to 1tle M. extensor carpi ulna tis.
l-+n41
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the forearm
M.ancaneua
M. atlln_. dll!lllorum, llnclr.a
M. ~c.pl ndallelong.., Tendo
Rg. 3.17 Deep layer of tr. donal muscles of the for•rm. right tide; dorsal view; after partial removal of the Mm. ex:I&I'\SOI'6S digitorum and digiti minimi. Removal of the superficial extensors of the forearm enables the view of proximal parts of the d&ep extensor musd&S. The de&p layer consists proximally of the M. supinator, and distally from n~dial to ulnar of the M. abductor pollicis longus, M. extensor pollicis brevis, M. extensor pollicis longus, and M. extensor indios. The Retinaculum musculorum ex:tensorum forms six oaeaftbrous tunnels for the passage of the extensor musdetendons to the dorsum of the hand. This illustration shows the third, fourth, and fifth osseofibrous tunnel cut open.
Oueoflbrous tunnels on the dol'tllm of the henct. from radlel to ulner: • first tunnel: M. abductor pollicis longus and M. extensor pollicis brevis • second tunnel: Mm. extensores carpi radialis longus and brevis • third tunnel: M. extensor pollicis longus • fourth tunnel: M. extensor digitorum and M. extensor indios • fifth tunnel: M. extensor digiti minimi • sixth tunnel: M. extensor carpi ulnaris
183
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the forearm
:;--T-- Llll· clll111111n,lel'lldlale
- +--- Ulg.enul11191'11dll
M. fluclr Clllpl ulnalfa
M.lbdudDr polllcle longue
M. attllniiClr Clllpl IAnalfe, Tendo ----,.-''"
Caput ut>• ----,11-ifr:o M. sdlln- pol lela-· Tencla
M. e.x11N18Cf C3J)I radlabllnW, Tendo
Rg. 3.88 Deep layer of 1he dorNI mUICIM of the foreerm. right tide; dorsal view; after complete removal of the superficial extensor muscles. Superficial extensor muscles have been completely removed to visualise the origins of the deep extensor muscles. The M. supinator origins from the Epicondylus lateralis of the Humerus, the radial ligaments llig. collaterale rtJdiale and Lig. anulara radii) and from the Crista m. supinatoris of the Ulna. The muscle then winds around the Radius above and below the Tuberositas radii. Both muscles on the radial side {M. abductor pollicis longus, M. extensor pollicis brevis) originate from the dorsal
184
side of Radius and Ulna and from the Membrana interossee antebrachii. Their tendons pass through the first osseofibrous tunnel. The two muscles on the ulnar side (M. extensor pollicis longus and M. extensor indicisl originate exclusively from the Ulna and the Membrana interossea. Their tendons pass through the third and fourth osseofibrous tu~ nel, respectively. The illustrtJtion here shows all osseofibrous tunnels opened.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the forearm
M. bloepe bradlll
M. pctnall8 longue
Rg. 3.89 Foreann. Antebracfllum.ln supi!Wtlon position, right tide; ventral and palmar view. Atrovvs indicate th& traction v&Ctors for th& most important supinators. In g&neral, all muscles capable of promoting pronation or supination Cf0181fle dilgonalaxil ofthefcnann (-+Fig. 3.81 which COO'espondsits rotational axis. In addition, all important supinator and pronator muscles lnMI't on 1fle Radius. Important supinators are !tie M. biceps brachii (from a fl&x&d position), M. supinator (with extended arm), and M. brachioradialis (from a pronated position). The M. supinator is pierced by the Ramus profundus of !tie radial n&rv& {N. radialis) which may be compressed at this location with resulting paralysis of the deep extensor muscles{-+ p. 203).
Fig. 3.90 For•rm. Antebrachium. In pronltlon position. right side; ventral ..new n&ar the elbow and dorsal view near th& hand. Arrows indicate the traction vectors for the most important pronators. The most important pronators are !tie M.pronator teres, M. pronator quadratus, and M. brachioradialis (from a supinated position). The M. flexor carpi radialis and M. palmaris longus also wealdy promote pronation. TheN. m&dianus passes between the two heads of theM. pronator teres but is rarely compressed at this location (-+ p. 205).
1-+ T32,a3,351 185
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
-t
Development
-t
-t
Skeleton
Imaging
-t
Ten dons of the dorsum of the hand
M. ___, polllc:lt brftll, Tendo M. awn_.pollc:l•long.., Tendo
.
M.~.-
n
M.lntwc.eu. dana! ill I
Rg. 3.91 Tendons of tr. dorsum of the hind. Dorsum 1111nus. right IIide; dotSal view. The tendons of the extensor musclas run beneath the Retinaculum musculorum ex:tensorum to reach the dorsum of the thumb and the dotSal aponeurnsas of the digits. The distinct tendons of the M. ext~ sor digitorum are linked by intertendinous connections {Con nexus intertendinei) which limit the separate mobility of each iinger. There are no intrinsic muscles at the dotSUm oi the hand.
186
According to their developmental origins and innervation, the Mm. interossei dorsalas belong to the palmar muscles. VIlhan the thumb is extended, tendons of the M. extensor pollicis brevis and M. extensor pollicis longus iorm the borders of an indented space which is referred to as the anatomical snuH box I'Tabetiilr•).
I-t T34, 35,37 I
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Tendinous sheaths of the dorsum of the hand
M. exl»nnClr ciQn
Rg. 3.92 Dorsal c.rpal tendinous shNthl.. V•glnae tenclnum. of the dorsum of the hand, right tide; dorsal view. Beneath the Retinaculum musculorum ext91'\S0rum the tendons of the extensor muscles are positioned in six. osseofibrous tunnels 1... Fig. 3.87). The respective tendons are covered in mostly individual tendinous sheaths to reduce friction during movements of the tendons between the retinaculum and the bones of the wrist. Exf81'1110r mUICIII of 1hl finllr' joints: With the exception of the tendon of the M. extensor pollicis longus, which reaches the distal phalanx. the tendons of the Mm. extensores digitorum, extensor digiti minimi, and extensor indicis insert together with the middle tract of the doi'S!ll aponeuroses c~ Fig. 3.91) at the middle phalanx and therefore cannot extend the distal interphalangeal joints. However, tendons of the Mm. lumbricales and to some extent
of the Mm. interossei palmares and dorsales radiate into the lateral tracts of the digital dorsal aponeuroses. They reach the dorsal side of the transverse axis of the distal interphalangeal joints and act as exte~ sors thereof. This explains why the Mm. lumbricales are the main ex.t91'\S0rs of the distal interphalangeal joints. • meucarpophelangeel joints and proximal interphlllngeal Jolrrtl: M. ex.tensor digitorum, M. extensor digiti minimi, M. exte~ sorindicis • diltal int8rphlllft8811 joirrtl: Mm. lumbricales, weakly also Mm. interossei pal mares and doi'S!lles • carpomeucarpal joint of the1flumb: M. extensor pollicis brevis • proxhal and dlltllllnterphallngeal Joints of 1fle thumb: M. extensor pollicis longus
187
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Muscles of the hand
M. palmaris b!wl8
Rg. 3.93 Superflcfelllyer of muscles In 1he ptllm of the hend. Pelme menua, right IIide; palmar view. There are 1flrM groups of miiiCias in the palm of the hand. On both sides of the palm. muscles of the thumb and the fifth finger form the thenar and hypothenar. respectively. Between the two groups are the muscles of the palm of the hand. These three groups are arranged in three coniMICVIIve mulde leyers. The neurovascular structures b~r tween these layers need to be considered when dissecting the palm of the hand (~ pp. 235-237}. Located most superiicially is the palmer eponeurosls (Aponeurosis palmaris! which consists of longitudinal and tranS'I/erse fibres; the latter being prominent just below the metacarpo-
188
phalangeal joints lUg. metacarpals transversum superiicialel. The palmar aponeurosis is fixed proximally to the Retinaculum musculorum flexorum und stretched by the M. palmaris longus. Distally, it is fixed to the tendinous sheaths of the finger flexors and to the ligaments of the metacarpophalangeal joints. At the thenar, the M. abductor pollicis brevis is located on the radial side and the M. flexor pollicis brevis is located Ulnar to the abductor muscle. At the Hypothenar. theM. palmaris brevis and M. abductor digiti minimi are superficial.
1-+T 31, 36-38 I
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the hand
M. ll8i10'CIIPI ut~n, Tendo
r:-T;::lfriHilill~4...- M. ~~- dlgltonlm pnlfllndue, lllndl-
M. abdlctor dghl mlnml
M. oppon- digiti mlnlml
M. abdlctar dlghl mlrfml
Mm. 1m-e1 dcll'8alll8
M. lldliJctor polllcla, Cap.rt-ln'l
M.
Rg. 3.94 lntennedllte layer of mLBCia In the ptllm of the hind. Palma manu.. right lide; palmar view; after removal of the palmar aponeurosis and the superficial muscles. The three muscle groups of the palm of the hand (Palma manus) are arte~ng&d in three consecutive layers. When the superficial muscles are removed, the muscles of the intemnediate layer are visible. These comprise the M. opponens pollicis and M. abductor pollicis at the Thenar, and the M. flexor digiti minimi and M. opponens digiti minimi at the Hypothenar. both of which are positioned llldial to the superficial M. abductor digiti minimi. In the palm of the hand, the tendons of the M.
flexor digitorum superficialis (cut in this illustration) insert at the middle phalanx with a split tendon.The tendons of M. flexor digitorum profu~ dus pass through the split tendon to reach the distal phalanx of the fingers. The tendons of the M. flexor digitorum profundus seNe es origin for the four Mm. lumbricales which also belong to the intermediate layer of muscles !for the function of Mm. lumbricales ~ Fig. 3.1 01 ). The tendon of the M. flexor pollicis longus inserts at the distal phalanx of the thumb.
1-+ n2. 38-38 1
189
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Tendinous sheaths of the palmar hand
M. opponens polllc:l8
M. aiXfuctor dlahl mlnlml
M.ftucf dlghl mlliml bnMs M. CllPOilllll8 dlahl mlnlml
M. at!Ci.lc1cr polllc:le,
ClpLt 1l'll'lmlnum
Yaglr.e~dlgltorum
111111111
Rg. 3.96 Pal11111r. carpaL. and digital tendlilous lhellths. V.gln• tendlnum. of the hend, right tide; palmar view.
a Rp. 3.9811 to d V.rlllnts of palmar tendinous shed~~. In contrast to the situation in the dorsal aspect of the hand. tendons of the finger flexors usually have only two tendinous sheaths. The radial tendinous sheath surrounds the tendon of the M. flexor pollicis longus and reaches to its distal phalanx. The ulner tendinous sheath surrounds
c
d
all tendons of lhe Mm. flexores digitorum superficialis and profundus at the wrist and reachas the distal phalanx only at the fifth digit. The othar fingers have independent tendinous sheaths surrounding the flexOI' tendons.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The arrangement of the tendinous sheaths is of clinical importance as IHicterlallnfectlons !phlegmon) quickly spread in the tendinous shea1hs. An inflammation invoMng the ulnar tendinous shea1h can
190
spread to the fifth fingar.lnadequate antibiotic therapy may result in stiffening of the entire hand.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the hand
M. abductcr pol lela long.., 'TllncUrwe
Aeelnac:ullm muec:ulorum llilcclum
M. ftucr poll lela - · Caput profundum M. oppanena polllcll
....
M. opponena dlgll ml'ltmt
~
danallal
Vl'lcull
'VIncula tlrdnum { Vl'lcuklm biiiYit
Fig. 3.97 Deep lay11r of muaclee of 1fle p.~lm of 1M hind, Palm.~ man111. right U.; palmar view; after removal of the tendons of 1he long flexors of the fingers. The three muscle groups of the palm of the hand are arranged in three consecutive layers. Upon removal of 1he tendons of 1he long flexors the muscles of the deep layer become visible. The Mm. interossei and Mm. lumbricales are fle)(l)(S of the metacarpophalangeal joints (for course and func1ion of Mm. interossei ~ Figs. 3.98to 3.1 001. The tendons of the Mm. interossei and Mm. lumbricales are positioned at the
palmar side to the transverse axis of the metacarpophalangeal joints. Thus, the Mm. interossei and, to a lesser extent, also the Mm. lumb~ cales are the main flexors of 1he metacarpophalangeal joints. The illustration shows hallv the tendons of the deep flexors pierce through the tendon gaps of 1he superficial flexors.The tendons are attached to the phalanges by small ligaments Mnrula t&ndinuml.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Knowledge of 1he function and 1he course of 1he fle)(l)( muscle tendons at the fingers is important when 8dmining cuts. The M. flexor digitorum profundus is aHected if flexion of 1he distal interphalangeal joints is impossible. If, however, flexion of 1he proximal
interphalangeal joints is reduced while flexion of the distal interphalangeal joints is possible an isolated injury of M. flexor digitorum superfic:ialis is indicated.
191
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Muscles of the hand
Rg. 3.98 Mm. lntero.,el pal1111res. right side; palmar view. Th& thr&e Mm. int&rossei palmar&s originat& from th& ulnar aspect of th& Os metacarpi II and from the tadial aspect of the Ossa metacarpi rv and V. They insert on the same side of the corr&Sponding proximal phalanx of th& fingers and tadiate into th& lat&ral ttacts of th& dorsal ape> neurosis (arrows).
Ra. 3.99 Mm. lnterOSMI dor~~~la, right side; dorsal view. Ths four Mm. int&rossei dorsales have their origin with two heads from the opposing surfaces of ths Ossa metacarpi 1-V. They ins&rt on both sides of the proximal phalanx of th& middle finger, on the ulnar side of the ring fing&r, and on the tadial sids of the index fing&r. A small portion of their tendons also merges with the lateral ttacts of the dorsal aponeurosis. Thus, these muscles are flexors of the metacarpophalangeal joints and extensors of th& proximal and distal interphalangeal joints. RaxDr muscla of 1he lnterphllangNI Joints: Each joint has a predominant flexor muscle. The exclusive flexor for the distal interphalangeal joints is theM. flexor digitorum profundus. • metac.rpophlllniJINII Joints: Mm. interossei palmar&S and dorsales, also Mm. lumbricales, but weaker • proximll interph1l1nge11 jainbi: Mm. flexor digitorum superficialis • dlltlllnterphlllniJINII Joints: M. flexor digitorum profundus
I-+T371
192
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the hand
Mm.l-el clanalilll
Fig. 3.100 Schem..ic drawing of the positiona of the Mm. lnterosMI and their ~~dons on abduction and adduction of the fingers. (according to 1111 According to their course described on _. p. 192, the Mm. interossei doi'SIIIes spread the fingers (abduction! and can move the middle finger
medially and laterally. In contrast, the Mm. interossei palmares adduct the fingers. Their effec1s on the movements of flexion and extension can be deduced from the course of their tendons in relation to the transverse axis oi the finger joints and is explained on _. pages 191 and
Fig. 3.101 Mm...mbric.IH,. right side; palmar view. The two llldial Mm. lumbricales originate with one head, the two ulnar Mm. lumbricales with two heads from the tendons of M. flexor digitorum profundus. All muscles insert on the radial side of the proximal phalanx of the fingers 11-V and their tendons merge with the hJtellll
fibres oi the dorsal aponeurosis of the fingers. Thr:ry weakly flex the metacarpophalangeal joints and extend the proximal and distal interphalangeal joints.
192.
I-+T371
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tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Plexus brachialis
C4
C6
* Nn. lll)lnllllle, Rr.1111:1111Dre8 +a Tf~cua eupertar b Tr~cua mecUua
e Truncl.l81rfw!Dr
•a
Fuclcuklalll.tllralll
e
Fuclcukla mecUelll
oe
b Fuclculua pc11brtar
C7
f'llr8 • eupn.ciiMcu- : I
' I
: '' -------------::: ' :' ' :' Pilla ' nfnu:IIMciA- 't
1 N.l)tlrenlc1.18 G"'eXU8 08Mcallll 2 N. denial II SC~P!Me 3 4 5 8
T1
Fir. muaciA. . . N. .Up
N. rlllllllle
Rg. 3.102 Brar:Nal plaxus. PIIXIII bnldllall• {C5-T1l: segiMI'Ital arrangement cf nervea, right lic:le; ventral view. Innervation of the upper extremity is derived from the Plexus btachialis. The bl'tlchial plexus is formed by Rr. anteriores of spinal nerves of the low91' cervical and upper thoracic spinal cold segments (C~T1). First. the Rr. anteriores combine to form three tnmluJ {Trunci) which then rearrange at the level of the clavicle to form three cord!l !Fasciculi). These are named according to their position in relation to the A. axillaris as lateral, medial, and posterior colds. N91Ve fibres from CS and C6 assemble into the Truncus superior. from C7 into the Truncus medius. and from C8 to T1 into the Truncus inferior. The dorsal divisions (Divisiones posteriores} of all three trunks form the posterior cold !Fasciculus posterior; fibres from C~T1 ). The ventral divisions {Divisiones anteriores) of Truncus superior and Truncus medius continue as latetal COI"Cl !Fasciculus lateralis; lateral of A. axillaris; nerve fibres from C5-C7), the venttal part of Truncus inferior continues as medial cord {Fasciculus medialis. medial of A. axillaris. nerve fibres from C8-T1 ). Und9/'standing this struc1ure of the brachial plexus allows to easily memorise and de-
duct the composition of the different peripheral nerves. with a few exceptions only. The Plexus btachialis has two topogtaphical parts: Thesupracii'Wicullr part !Pars supraclavicularis) comprises the trunks and those peripheral nerves derived from the trunks or the Rr. anteriores of the spinal nerves {C~T1 1. The l~raciiMcular part !Pars infraclavicularisl consists of the fascicles (fasciruli). The nerves of the arm I~ Fig. 3.1 03) branch off the inftaclavicular part. Nerves to the shoulder, however, btanch off the supraclavicular part.
Pars supracllvicullria: • • • • •
N9/'ve btanches for the Mm. scaleni and M. longus calli (C5-0ll N. dorsalis scapulae (C3-C5) N. thotacicus longus (C~71 N. suprascapularis (~6) N. subclavius IC5-C61
l-tT22,23
I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Severe injuries of the shoulder and arm {motorcycle accidents. malposition at binh. improper positioning during surgery) can lead to lesions of the Plexus brachialis. Depending on the sHeeted trunks one distinguishes: • Upper brar:Nal plaxus pal'llpls IERB's palsy. roots cf C5-C8) with paresis (patalysis) of the abductors and latetal rotators of the shoulder. and the upper arm flexors as well as theM. supinator. As a result, there is an adduction and medial rotation of the arm with extended elbow joint but normal hand function. Path~ mechanism: increase of the distance between neck and shoulder.
194
• Lower brachill piiXIII perafvsil (ICLUMPKE's palsy, roots of C8-T1) with paresis of the long flexors of the fingers and shon muscles of the hand, partially with HORNER's syndrome (mi~ sis. ptosis. enophthalmus} due to additional lesion of the cervical sympathetic chain Y
Muscles _. Topography _. Sections
Nerves to the arm derived from the Plexus brachial is
Rieclcutua maclllta
P f - bndllllla,
Pllrlllnhcllwlculllrta
{
Feldc:ulua ~ Rleclcutuat..,.lla
~~~~---~+-~~tt~
N. madl~na --'-~~-t1.1t.ltrt~--_:_
___ N. cu'llrleul bndlll madIaiii
N.alllllrb
A. IUI*ftC~I8 - --ill
R.lll'Q1'UI'Idua --<+-~
/Jf,l:....fH--T- - N.lnterc.aeulantebfactlll-
/Jr:f-- - A. dcnala (N. ullllll8)
1111-+-- - A. pal'nal!a (N. utlllll8) R. profundua (N. ulrall)
Nn. dlgtlle8 P8111'1&1'88 ccmmunee--ff::6f11'F:l11Jrfl:-lrlr - - - R. aupedlclda (N. utnllla)
\Wil6-- - Nn. dlgtallle palm~n~t ccmmu~
Rg. 3.103 BracNal plaus. PIIXIII bnlchl1lls (C5-T1); nerves of the arm, right IIide; ventral view. The n&Nes of the ann derive from the infraclavicular part of the brachial plexus. The Fasciculus posterior gives rise to the N. axillaris and the N. radialis. The Fasciculus lateralis contributes to the N. musculocutaneus and the late!lll root !Radix latellllisl of the N. medianus. The Fasciculus medialis gives rise to theN. ulnaris, the medial rootiRadix medialis) of theN. medianus, and the cutaneous nerves of the medial upper ann {N. cutaneus brachii medialis) and fonaarm IN. cutaneus antebrachii medialis).
Parslnfrlcllvfcularll: Faciculua postlrior IC5-T1): • N. axillaris {C5-C61 • N. radialis IC5-T1l • Nn. subscapulares IC5-C7l • N. thoracodorsalis {C6-C81 Faclculuslllt•rall IC5-C71: • N. musculocutaneus (C5-C7) • N. medianus, Radix lateralis {C6-C7) • N. pectoralis lateralis IC5-C7l Faciculua medialiaiC8-T1): • N. medianus, Radix medialis (C8-T1) • N. ulnaris (C8-T1l • N. cutaneus brachii medialis (C8-T1) • N. cutaneus antebracnii medialis IC8-T1) • N. pectoralis medialis IC8-T1l
195
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Innervation of the skin
N. m•~-. N. cutaneus
1/11111tnchlla.terall8
--'-:-:------~--
:=::}
Nn.lntercaatalea
Rr. CI.Unelllta'alil8 peclanlille
1 N. uMtt {=nwneclclaQnltlleelalprcprea --- - '
N.ll~ac:Mals
comml61ea R~~~~------------~
3.104
N. cut1neu1 bndlll medialII
N. c:u'llin-lrltllnctlll {R mldlalle R DOean~t--'
c:utan-tndlll~}
N. a.nan- bractllllltlnllslnfllrlar N. radii! II N.c:utaneu8antelnct111~
R
euperflclall8}
R canmunlcans utl&rl8
N. radlllla
Nn. dlgllalee ~
d~==}
N. cu'III*M bndlll midlalla
3.105
Rg. 3.104 and Fig. 3.105 euta..ous nerves of the upper extnmJ. ty, right side; ventral(-> Fig. 3.104) and dorsal(-> Fig. 3.105) view. All nerv• of the infraclavicular part of the Plexua .br8cllialia contribute to the sensoJY innervation of lhoulder and ann. The h:rtellll aspect of the shoulder is inn&n~ated by the N. axillatis. The lateral and dorsal sides of the upper arm, !he dorsal side of the forearm, and the dorsal side of !he radial 211.1 fingers are innervated by !heN. radialis. TheN.
196
N. '*'IIIII
'----------R.dcnall8 N. cuteneua...........,ll medllllla
musculocutaneus conveys sensoJY innervation to !he lateral aspect of the forearm. TheN. cutaneus brachii medialis and N. o..rtaneus antebrachii medialis innervate the medial aspect of the arm. The N. medianus (palmar side of the radiai3Y.I fingers! and N. ulnaris (palmar side of !he ulnar 2¥.t fingers) inneNate !he hand.
l-tT231
Muscles _. Topography _. Sections
Innervation of the skin
C3
T3
T3
T2
T1
3.107
Rg. 3.108 end Fig. 3.107 Segmental cutaneous lnnei'V'don upper aldremity, right side; ventral 1... Fig. 3.106) and dorsal(... Fig. 3.107) view. Specific areas of the skin are innetVated by one single spinal cold s~ ment. These areas of the skin are termed dermetomee. As peripheral cutaneous nerves of the arm contain sensory netVe fibres from seve1111 (dermetOd'IIM) of h
spinal cold segments, dermatomes are nat exactly congruent with the cutaneous area supplied by the paripheral nel\l&s {... p. 196).1n contrast to the belt-like orientation of the dermatomes of the trunk, dermatomes of the arm are oriented along the lon$aitudinll axis {see DEMIIopment.... Fig. 3.7).
l-tT231
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The demarcation of dermatomes is of great signifiCI.Ince in the dia~ nosis of herniated dilcl and narrowing (lltllnotil) of itle Y8t'tabnll anal and intervertebral foramina for exiting spinal netVes: while the segment C6 inneMtes the radial forearm and thumb. C7 supplies
the third finger and the adjacent halves of the fourth and second fingers. Sensory innervations of the fifth finger and the ulnar side of the forearm are linked to segments C8 and T1. respectively.
197
Upper Extremity
Surface anatomy -+ Development -+ Skeleton -+ Imaging -+
Nerves to the shoulder from the Pars supraclavicularis of the Plexus brachialis
M• .ra~US antet1cr
Fig. 3.108 N. dorulia SC~~p~~lae(C3-C51, right lide; dorsal view. TheN. dorsalis scapulae innervates the Mm. rhomboidei and M.levator scapulae, both of which fix the Scapula to the trunk and pull it medially and superiorly. The N. dorsalis scapulae is the most cranial nerve to branch off the Plexus brachialis, it pierces through theM. scalenus medius, and runs dorsally along the inferior border of the M. levator scapulae (indicator muscle).
CVII
Fig. 3.109 N. thoracicuslong. . IC5-C71 and N. subclavius(CSC61. right side; lateral view from the right side. The N. thoracicus longus innervates theM. serratus anterior which is responsible for the elevation of the arm. This nerve pierces the M. scalenus medius and courses underneath the Plexus brachialis and Clavicula to the lateral side of the thorax to descend along the outer surface of the M. serratus anterior. The N. subclavius innervates the corresponding muscle which actively stabilises the stemoclavicular joint. The N. subclavius runs adjacent to the M. subclavius and often sends a branch to theN. phrenicus raccessory phrenic nerve"). The nerves to the shoulder derive from the Pars supraclavicularis (-+ Figs. 3.1 08 to 3. 11 0) and the Pars infraclavicuIaris (-+ Figs. 3. 111 to 3.1131 of the Plexus brachial is. Nerves tD the dloulder from the Pars supradavicularis: • N. dorsalis scapulas (C3-C5) • N. thoracicus longus {C5-C71 • N. suprascapularis {C4-C6J • N. subclavius {C5-C6)
I-+TZZ.231
Fig. 3.110 N. supracapularls IC4-C8J. right side; dorsaJ..;ew. The N. suprascapularis innervates the M. supraspinatus (supports abduction) and M. infraspinatus (most important lateral rotator of the armI). TheN. suprascapularis derives from the Truncus superior, runs dorsally along the cla..;de, and reaches the dorsal aspect of the shoulder blade by traversing the Incisura scapulae underneath the Lig. transversum scapulae superius.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . I.Mions of the shoulder nerves from the Pars supradhicularil: • N. dorselis ICIIpulae: The Scapula is displaced laterally and slightly protruding from the thorax. Art isolated injury is rare because of its sheltered position. • N. tboraclcus longus: Elevation is impossible I The medial border of the Scapula protrudes wing-like from the body (Scapula alata; winged scapula). This lesion is relatively common when carrying heavy loads on the back {Mbackpacker's palsyu) because this nerve can be pinched under the cla..;cJe.
198
• N. aupraiiCIIpularil: Affects lateral rotation {M. infraspinatus is the most important muscle) and, to a lesser degree, abduction {M. supraspinatus). In addition to injuries of the lateral neck, pinching of nerves in the suprascapular notch (Incisura scapulae) is also possible. • The isolated lesion of the N. subclavius is very rare and has no clear dinical symptoms.
Muscles _. Topography _. Sections
Nerves to the shoulder from the Pars infraclavicularis of the Plexus brachial is
Nn. 8Ub1C8f1UIIrea '-
Fig. 3.111 Nn. subtlcapull,.. (C5-C7), right side; ventral view. Both n&/Ves inneMte theM. subscapularis (most important medial rotator of the arm 1). The Nn. subscapulares are well pro1ected since they branch off the posterior cord and immediately descend to the anterior side of the Scapula.
Fig. 3.112 Nn. pector•lesllt.,.lil (C5-C7) •nd medillisiC8-T1), rlaht side; ventral view. The terms Nlateralis" and "medialis" are related to their origins from the lateral or medial cord, respectively. not to their topographical position lthe N. pectoralis medialis is often positioned lateran. Both nerves innervate the Mm. pectorales major and minor. TheM. pectoralis major is the most important muscle for the adduction and antEMit'sion of the arm.
CVll
Fig. 3.113 N. 1hot1codoruliiiC6-C8), right •ide; dorsal vi9W. Together with the corresponding artery, theN. thoracodorsalis courses to the medial side of the M. latissimus dorsi and innervates this muscle and theM. teres major. The nerves to the shoulder derive from the Pars S~.Jpraclavicularis (... Figs. 3.108 to 3.110) and the Pars infraclallirularis (... Figs. 3.111 to 3.113) of the Plexus brachialis. Nerves to 1fte shoulder from 1fte Pers lnfrecllvll:ularb: • Nn. subscapulares (C5-C7) from Fasciculus posterior • N. thoracodorsalis IC6-C8l from Fasciculus posterior • N. pectoralis lateralis IC5-C7) from Fasciculus lateralis • N. pectoralis medialis (C~T1) from Fasciculus medialis
I-+T22.23I Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of 1he shoulder nerv11 from 1he Pars infraclaviet~llril: In general. isolated injuries of individual infraclavicular nerws of the brachial plexus are rare due to their sheltered location. • Nn. subscepull,..: Weak medial rotation of the Humerus • N. thorecodoi'MIIs: Impaired adduction of the retroverted arm. Arms cannot be crossed behind the back. The posterior axillary
fold is collapsed. Considering the size of the M. latissimus dorsi, the symptoms are mostly minorI • Nn. pectoreles: Impairment of adduction and anteversion. The arms cannot ba crossed in front of tha trunk. The anterior axillary fold is collapsed.
199
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
N. axillaris
N.alllllle M. tiii'H miner
-:!:11'-+-- - N. c:u'III*M lnctlll llillllrelle..,.rtar
Fig. 3.114 CourN,. motor 1nd NRIOf'y innervation ofihe N. axlll1rll. right llde; dorsal view. The N. axillaris originates from the Fasciculus posterior. traverses the quldl'lniJIIIIr tp1C8 in the Axilla together with the A. arrumflexa h~r meri posterior and courses around the Collum mirurgicum of the Humerus to ream the dorsal side of the arm. The axillary nerve innerwtes the M. deltoideus (most important abductor of the arml and the M. teres minor. The sensory terminal branch {N. cutaneus brachii lateralis superior !purple)) emerges at the inferior dorsal border of the M. deltoideus and inneMtes the lateral aspect of the shoulder.
C5
ca C7
C8 T1
Fig. 3.115 Segmental organlllrtiDn of 1he N. axlll1rls. right tide; ventral view.
Rg. 3.118 l.ellon of the N. allllrll: par•lpll•nd ftl'ophy of 1fle M. deltoideuL
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the N. axllllrll: The N. axillaris may be injured in proximal humeral fractures and shoulder luxations. Abduction of the arm
is severely impaired and sensory input from the lateral side of the
200
shoulder is lost Long-lasting injury causes muscle atrophy. such that thedomeshapeof the shoulder is gone(... Fig. 3.116).
Muscles _. Topography _. Sections
N. musculocutaneus
Fig. 3.118 Segmental orgenilation ofihe N. mUICI.IIocutane.., rlaht llde; ventral view.
l-tT22.231 Fig. 3.117 Course. motor and MRSOry lni'NII"V8tlon of tha N. mUICIIIOCIIUI'MIIIII (D5-C7). right IIide; ventrnl view. Originating from the Fasciculus lat&rnlis. the N. musculorutaneus plercH 1he M. COI"'Icobracfllall. descends distally between the M. biceps brnchii and M. brnchialis, and appears with its sensory branch (N. eutaneus antebl'achii lateralis [purple)) between these two muscles
at the elbow. The N. musrulocutaneus provides motor innervation to the three ventral muscles of the upper arm and sensory inn91Vc1lion to the radial forearm. Because the N. musculorutaneus pierces the M. coraccbrachialis. finding the nerve during dissection helps to get oriented in dissecting the Plexus bl'achialis {... Figs. 3.148and 3.149).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . l..elioM of 1he N. m~~~Ce~locutaneua: The N. musculorutaneus is at risk during shoulder luxations. Aexion of the elbow is significantly reduced as a result of injury. but remains weakly preserved because the radial group of the forearm extensors {innervated by the N. radialis) and the superficial flexors of the forearm {innervated by the N.
medianus) also promote flexion in the elbow joint. Supination of the flexed arm and the biceps reflex are weakened due to the paralysis of the M. biceps brachii. The sensory deficit on the radial forearm can be mild, because overlap ocrurs with the inn91Vc1lions of the medial and the dorsal sensory nerves.
201
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
N. radialis
N. cu'lll'lew bndlll illlllllnle lniWfor
fig. 3.120 Segmental organilation of 1he N. radialis,. right •ide; ventllll view.
fig. 3.119 Course, motor and IIII'IISOty innervation of the N. radlallslC5-T1), right side; dorsal view. Sensory cutaneous brancnes are shown in purple. The N. radialis derives from the Fasciculus posterior and reacnes the dorsal side of the Humerus through the •trlcepsstt• (~Fig. 3.771 between the Caput longum and Caput latelllle of the M. triceps blllctlii. BllfoN winding around the Humerus in the Sulcus nervi mdialis. theN. radialis sends motor blllnches to the M. triceps blllctlii and a sensory branch to the dorsal side of the upper arm. The sensory bmnch to the forearm branches off during its course in the Sulcus nervi radialis. The N. radialis then enters the cubital fossa from latellllly between theM. brachiomdialis and M. brachialis (radillillnnal). and divides into a R. superfieialis and R. profundus. Before this division. motor branches to
202
the M. bmcnioradialis and Mm. extensores carpi mdialis longus and brevis branch off. Together with the A. llldialis. the R. suparflclalll descends beneath the M. blllchiollldialis. Further distally, the R. superficialis courses to the dorsal side of the hand for the sensory innervation of the skin between the thumb and the index fingEr !Spatium interosseum; autonomic area II and the dorsal side of the radial 2¥.1 fingers. Inferior to the elbOIN, the A. profund111 pierces the M. supinator (lupinltor a•l) and reaches the dorsal side of the forearm to provide motor innervation to all extensor muscles of the forearm. The M. supinator reveals a sha~ged tendinous arch (arcade of FROHSE). The terminal branctl is the N. interosseus antebrachii posterior which provides sensory innervation to the dorsal wrist joints. Slnlory autonomic area: first interdigital space.
Muscles _. Topography _. Sections
N. radialis
Autorx~mlc.,. of Ill& N. ,.dllllla
Fig. 3.122 Proximal lesion of 1fte N. n~dlllls: "'wrllt drop• with sensory deficits in the first intettligital space.
Clinical Remarks---------..
N.~.m.bnlchl
pollblrtcr
Fig. 3.121 Locations of common N. r•dillial•ions (C5-T1), right !Ide; dorsal view {marked by bars!. The skin areas of sensory inneJVation are highlighted !purple shading!. Sen10ry 1utonomic •r. .: first intettligital space
1 proxlmaiiHion in the axilla 2 intermediate INion near the lh.lft of Humerua
foau (b)
00 or
et~bital
Lesion a of 1he N. r1dialis: Thare are three types of lesions: • Prc»cmmlllalon in the region of the 1dll: In the past, oft&n caused by crutches; however, presemly this type of injury occurs mainly due to improper positioning in the OR. In addition to the symptoms associated with damage in the area of the humeral shaft impairment of the M. triceps with reduction of &!bow extension exclusiv&ly occurs with proximal lesions. This also aff&cts the triceps tendon reflex and causes loss of sensation on the back of the upper arm, as these nerve fibr&S branch off before entering the &.Ileus neJVi radialis. • Intermediate llllon in the region of the humer•l shaft or .allow: caused by a humeral shaft fracture or crush injuries (oontusion) against the Humerus. In the elbow region, Radius dislocations or proximal fractures may contribute to the intermediate lesion as well as a compr&Ssion by the arcade of FROHSE. Lesions in the region of the humer•l shaft , ... Fig. 3.121, 2a) r&Sult in a "'wrllt drop• (... Fig. 3.122) due to impairment of all forearm extensors, including the radial group as w&ll as an impairment of the finger and thumb extension and supination of the extended arm. In addition, a sensory deficit occurs at the back of the forearm, in the first interdigital space !autonomic region), and on the back of the radial 2¥.z fingers. If only the R. profundua is pinched while passing through theM. supinator{... Fig. 3.121, 2bl, sensory deficits are missing and the lack of inneMtion of the wrist is negligible. A -wriat drop' does not occur since only the finger extensors are impaired, whereas the Mm. extensor&S carpi llldiales as part of the intact llldial muscle group can sufficiently stabilise the wrist. Due to active insufficiency of the flexors which cannot be compensated for by extension of the wrists, a ltrong flit cloture II not 1chltmlble. • Diltlllation of the R. M.!plrficialia in the wrilt regions due to a distal Radius fracture {most common fracture in humans): The sensory deficit is confined to the first interdigital space and to the back of the radial 2Yz fingers. Motor deficits are absentI
3 dlltiiiHion near the wrllt Joints
203
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
N. medianus
M.llfOna.tlll'
tln6---~..:.:... ~
M. f!eiCill' Clllpl n.dllllt -....:....-.....,..,_,.r-1J/
C5
-1--11-- - M . ftela' dl!lltcrum al4*flclala JIAI~-11--- N • . . . . _ . . enllllllradlll entlllrtcr
ce C7
cs T1
Ra. 3.124 Segmentlll organlllltlon of 1fle N. meclanus.. right side; ventral vi91N.
Fig. 3.123 Course, motor and MII'IISOty innervation and locationl of IMioM of1he N. medilnua (C6-T1), right sidl; ventral view. Sensory cutaneous b!llnches are shown in purple. The N. medianus originates from a lateral and a medial root which derive from !he corresponding cords, and initially descends along !he medially side of !he upper arm in the Sulcus bicipitalis medialis without providing any branches. The nerve then enters the cubital fossa from medially and traverses between both heads of M. pronator teres into the intermuscular layer between the superficial and deep flexor mu&cles of the forearm. Wilh the exception of the M. flexor carpi ulnaris and !he ulnar part of M. flexor digitorum profundus, the N. medianus innervates all flexor muscles of the forearm. The deep flexors are innervated by the N. interosseus antebrachii anterior which also provides sensory innerva1ion to the palmar side of the wrist joints. The N. medi-
204
anus then enters the palm of the hand via the arpeliu'lnel (Canalis carpal is) between the tendons of the flexor muscles. In the palm of the hand, the median nerve dMdes into three Nn. digitales palmares co~ munes. These provide motor innervation to the muscles of the thumb (except for the M. adductor pollicis and Caput profundum of the M. flexor pollicis brevis) and the two redial Mm. lumbricales. Their terminal branches provide sensory innervation of the respective palmar side of the redial 3Y.t fingers and the dorsal side of the distal phalanges. Sensory autonomic area: distal phalanges of the second and third fingers. Common locdons of lesions !marked by bars): 1 proximal lalon in the Sulc1.11 ~!tills meclalll (a} and in !he cl.lbitll foul (b) 2 dlltlllellon near the wrllt Joints and the carpal tunnel
Muscles _. Topography _. Sections
N. medianus
'WIItlna communla
tlndtnum mueculanlm t'laonlm
Rg. 3.125 Carpal tunnel, C.nells cerpalls. right side; distal view; transverse section at the level of the carpometacarpal joints. Tog91h&rwith the catp!ll bones the R91inarulum musculorum flexorum forms the carpal tunnel which is traversed by the N. medianus and the t&ndons of the long flexor muscles(~ Fig. 3.164). Inflammatory mac-
tions of the t&ndinous sheaths or swellings in the area of the catp!ll tunnel may result in compression of the N. medianus. Functional deficits caused by compression of the N. medianus in the catp!lltunnel are ref&rred to as carpel tunnel syndrome.
Rg. 3.128 Proxl11111lleslon of the N. medlenus: •hand of .btlnediction• with sensory deficits at the distal phalanx of the second and third fingers.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of tl» N. medianus: There are proximal and distal lesions:
• Proximal lations in the area of the Sulcus bicipitalis medialis 1- Fig. 3.123, 1a; e.g.cuts) or in the cubital fossa(~ Fig. 3.123, 1b}: In the cubital fossa, theN. medianus may be pinched by distal fractures of the Humerus, employing incorrect procedures during phlebotomy or intravenous injections, or at its passage between the two heads of the M. pronator t&res {pronator syndrome; median nerve entrapment syndrome}. Only the proximal lesion presents with the •hand of benlclctlon• position, charac1arised by the inability to flex the proximal and distal interphalangeal joints of the first, second and third fingers<- Fig. 3.126}. The reason is the absence of innBI'IIlltion to the superficial fing&r flexor and the radial component of the deep finger flexor. All other symptoms are similar to those of the distal lesion. • Dilltallllliona in the wrillt region (sud'! as "rutting the arteriesN
in a suicide attempt) or by compression of the N. medianus in the carpal tunnel (CIIrpal tunnel8yndrome): These do not result in a "hand of benediction" because the motor branches of the finger flexors already separate at the fomarml However, this lesion presents with an •ape hand'" displ~ng thenar atrophy and an adducted thumb due to the predominating effects of the M. adductor pollicis (innervated by theN. ulnaris). Grasping an object between the thumb and the index finger is impossible because of the inability to oppose the thumb (deficit of M. opponens pollicis} and the distal phalanges of both fingers cannot approximate. In addition, the impaired ability to abduct the thumb IM. abductor pollicis brENis) does not all
205
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
N. ulnaris
N. uln.-ia, R. dor•h
M.fiiiiO'pollclatnvf.,
Olput pn:lfunlllm
R.~el1llll
Ra. 3.128 Segmerrtll org1nhltlon of 1111 N. uln1rll, right llde; ventral view.
I~T22,231
Fig. 3.127 Course, motor 1nd MII'IISOty inMr'Vlltion 1nd locetionl of IHiola of 1he N. ..n1rls (C8-T1). right llde; ventral view. Sensory cutaneous b!llnches are shown in purple. The N. ulnaris originates from th& Fasciculus medialis and courses along the medial upper arm in the Sulcus bicipitalis medialis. After piercing the Septum intermuscular& brachii medialis. the N. ulnaris ap.. pears on th& dorsal side of th& Epicondylus medialis and runs directly adjacent to the bone in the Sulcus nervi ulnaris IN funny bone"). Th& N. ulnaris has no branches in the upper arm. In the forearm. it courses together with the A. ulnaris ben&ath th& M. flexor carpi ulnaris to the wrist and enters the palm of the hand through the GUYON's canal. Its R. dorsalis n&aehes the dorsal side of the hand and supplies sensory innervation to the ulnar 211.1 digits. In the forearm. the ulnar nerve pr
206
of the M. flexor digitorum profundus. In the palm of the hand. the A. profundus bnmches off follo'hing th& deep palmar arterial arch to provide motor inneMiion to the muscles of the Hypothenar. all interossous muscles. the ulnar Mm. lumbricales, M. adductor pollicis. and the deep head of the M. flexor pollicis brevis. The R. superiicialis provides motor innervation to theM. palmaris brevis and continues as sensory R. digitalis palmaris communis. which divides into the final branches inneMiing the palmar side of the ulnar 1Y.t digits land the dorsal sides of their distal phalanges). Slnlory 1utonomic •rea: distal phalanx of the fifth finger Freq111nt loc.tlons of lellonslmarked by bars): 1 proxim1llasian at the Epicondylus medialis (Mfunny bone") 2 distil lesion in the area of GUYON's ca1111
Muscles _. Topography _. Sections
N. ulnaris M. fleiG' dlgttmum al4*ftclllll, lllndlrwe
(Lig. Clrpl pelmln)
Ugg.~apalmarta
0. Cllpltatum
Fig. 3.129 GUYON's canal, right IIide; distal view; transwtSe section at the level of !tie metacarpophalangeal joints. The GUYON's canal is formed by the Retinaculum musculorum flexo. rum and its superficial separation, the Lig carpi palmare*. TheN. ulna-
tis, togeltier with the A. and V. ulnatis traverse the GUYON's canal <~Fig. 3.164). Swelling or chronic pl'eSSIJre in this area may cause a compression of the N. ulna tis (GUYON's canal syndrome).
N
Fig. 3.130 Proximal and dhtlllellons of1fll N. ulnarll: '"clawed hind'" with impaired sensation at the distal phalanx of the fifth finger.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Lations of 1111 N. ulnarll: Although proximal and distal lesions are distinguished. a dear clinical differentiation between them is not possible: • Proximal l•iona in the area of the Sulcus nervi ulnatis ('"fun· ny bone*), usually due to chronic compression when leaning on the arm: This is the most common nerve lesion of the upper extremity. • Dilltal llllioM in the region of GUYON's canal, usually due to chronic pressure. Both cases present with a '"clav..
langeal joints and for extension in !tie distal interphalangeal joints. Bringing the finger tips of the thumb and fifth digit in oontact is impossible because of the deficit of M. opponens digiti minimi with resulting inability to oppose the fifth digit. The FROMENT's llitn (holding a sheet of paper between the thumb and index finger) proves that the lack of adduction of the thumb is co~ pensated by flexing its distal phalanx IM. flexor pollicis longus is innervated by the median nerve). Senaory dlficita occur in the palmar side of !tie ulnar 1~ fingers. Sensory symptoms may be absent. if !tie lesion only affects the R. profundus, such as in compression injuries in the palm ijackhammer).
207
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Arteries of the arm .Art-- althe Upper Extremity Brenclles of111e.A. lllllllerls: • A. thotacica superior (inconsistent) • A. thotaooacromialis • A. thotacica lateralis • A. subscapularis -A circumflexa scapulae -A. 1horaoodorsalis • A. circumflexa humeri posterior • A. circumflexa humeri anterior A.c:frc1JT111- - - - -.pfc.- ;, humed arartcr
\ -- - - - - - A . calllleralllt
ul'l-
A. calllleralll media
tul*!or
- -T----ll'-!
Branch• of the .A. brechielis: • A. profunda brachii -A. collateral is media -A. oollateralis radialis • A. oollateralis ulnaris superior • A. oollateralis ulnaris inferior Branch• of the .A. redilllis: • A. recurrens radialis • R. carpalis palmaris • R. carpalis dorsalis ~ Rete carpale dorsale ~ Aa. metacarpales dorsales~ Aa. digitales dorsales • R. palmaris superficialis ~ /Vcus palmaris superfic:ialis • A. princeps pollicis • A. radialis indicis • Arcus palmaris profundus ~ Aa. metacarpalas palmares
I~-'--- R.
- - --u
pcatelfor
·..-9----A.rec..rena
ul'larte 1~+-+--A. W..rte
1..1-t-
-:-- A . ~ c:ammunllt
Branch• of the .A. ulnerls: • A. recurrens ulnaris • A. interossea communis - A. interossea anterior - A. oomitans neNi mediani - A. interossea posterior mit A. interossea recurrens • R. carpalis dorsalis • R. carpalis palmaris • R. palmaris profundus ~Arcus palmaris profundus • Arcus palmaris superficialis ~ Aa. digitalas palmares
Rete ertlculere cubiti:
Collllterel erter• (A. collateralis media. A. oollateralis radialis, A. oollateralis ulnaris superior, A. oollateralis ulnaris inferior! and NCUrrMt .,...... (A. recurrens radialis. A. recurrens ulnaris. A. interossea recurrensl contribute to a collateral circulation in the elbow area (Rete articular& cubiti). R.
ft-ffM~~--ALd9~ palmlrM c:ammuMe
Ra. 3.131 Arteries of the upper extremity, rtgtrt llde; ventral view. The .A. axillril is a continuation of the A. subcl
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In a comple1e physical exam, the pulses of the A. radialis and A. ulnaris are palpated on the radial and ulnar side of the proximal wrist. respectively, to exclude an occlusion of the blood v&ssels by •rterlosclarolls and blood clots (emboli). The existing wscular network
208
of collateral and recurrent arteries allows for the ligation of the A. brachilllil in 1118 cubital foul in case of injury, without jeopardizing the blood supply to the forearm.
Muscles -+ Topography -+ Sections
Veins and lymph vessels of the arm
v.: thanlcaeplgllalca - - --aftloir-rloft-1'\\ 111-;f+- - - - (HIIdul-lcull)
a
b
Flp. 3.132a and b Superficial Ia) and deep lb) wins and lymph
veuels. right lide; ventral view. The superficial venaua ayatem of the ann consists of two major lines which collect v&nO\Js blood from the hand: On the doi"Sillside of the thumb, the V. cephallc:a anlllbrachll collects blood from the dorsal venous network of the hand and runs on the radial ventral side of the foreann to the cubital fossa 1o join the V. basilica antebrnchii via the V. mediana cubiti. On the upper ann, the V. cephalica courses in the Sulcus bicipitalis lateralis and merges in the Trigonum clllvipectornle (MOHRENHEIM's fossil) with the V. axillaris. In the upper arm, this superficial vein may be very weak or missing. The V. basilica antebrachi begins on the ulnar dorsum of the hand,
continues on the ulnar ventral side of the forearm and enters the Vv. brachiales at the Hiatus basilicus on the distal portion of the upper arm. The 11UJ141rlicial epiallllial lymph CD!lectors form a radia I, ulnar and medial bundle in the foreann. In the upper arm, the medial bundle follows the V. basilica and drains into the axillary lymph nodes. The dorsolateral bundle courses along the V. cephalica and additionally drains into the supraclavicular lymph nodes. The regional lymph node stations for both systems are positioned in the axilla (Nodi lymphoidBi axillares). There are only few lymph nodes in the cubital fossa !Nodi lymphoidei cubitales). The deep~ system and the deep subfascial lymph collectors accompany the respective arteries.
209
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Lymph nodes and lymph vessels of the axilla
Donolllteral ~ _ of lyn1lh eolllc:tonl In the upper In!
__,--,_/1
Fig. 3.133 Superficilllymph YMI8II and lymph nod• in the axlla, fosSil axlll1rll. 1nd the literal Will of the thora. Reglo thoracfce laten~lls. right side; ventral view. In the upper arm, the superficial epifasciallymph collectors 001'\Stitute a medial bU'Idle along the V. basilica and a dorsolatellll bundle along the
210
Ptllilla
mammalla
V. cephalica, both of which connect to the axillary lymph nodes. The axillary lymph nodes !Nodi lymphoidei axillaresl nat only serve as regional lymph nodes for the arm but also for the wall of the upper quadrants of the trunk, namely thorax and back.
Muscles _. Topography _. Sections
Axillary lymph nodes
'
'
'
''
'
Lawll ', LAwai II '. I.JM!IIII
'
A. axman
V. axlllll1a
vv. mammariU medallle
Fig. 3.134 L.wels of lymph node IHnlrchy In the axiiL fotN axillaria,. right tide; ventral view. The adipose tissue of the axilla harbours up to 50 lymph nodes {Nodi lymphoidei axillaresl which collect lymph from 1tle arm, the upper thoracic wall including 1tle breast, and 1tle wall of the upper back. Because of their clinical relevance in breast cancer,these lymph nodes are categorised in three levels in topographical relation to the M. pectoralis minor. Superficial and deep lymph nodes ar& associated with all 1tlree levels, but often their affiliation with either level is not clear. However, 1tle apical lymph nodes from level II I collect lymph from all other lymph nodes in this region and seMI as 1tle last lymph node station prior to 1tle Truncus subclavius which drains into 1tle Ductus ltloracicus !left side) or into the Ductus lymphaticus dexter {right side; topography of 1tle axillary lymph nodes-> Fig. 3.147).
Levell of IDdlllry lymph nodes: 1.8Vel L llnferfor group lateral of the M. pectoralil minor: • Nodi lymphoidei paramammarii {lateral of the breast) • Nodi lymphoidei axillares pectorales (along A. and V. thoracica lateralisl • Nodi lymphoidei axillares subscapulares (along A. and V. subscapularis and thoracodorsalisl • Nodi lymphoidei axillares laterales (along A. and V. axillaris} Livelli. Intermediate group above and below 1fte M. pectorals mhw: • Nodi lymphoidei interpectorales (between M. pectoralis minor and M. pectoralis major) • Nodi lymphoidei axillares centntles (beneath M. pectoralis minor) LevellII, -..peri or group medial of the M. pectorelis minor: • Nodi lymphoidei axillares apicales lsubfasc:ial in the Trigonum clevipectorale =MOHRENHEIM's fossa)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Palpation of the lymph I'IOdM is part of a complete physical examination. The physician should keap in mind that axillary lymph nodes are the regional lymph nodes of the arm as wall as of the wall of the upper trunk. Because of the high incidence of breast cancer {about one in ten women acquires breast cancer, but it may also affect men), any palpable axillary lymph node enlargement in a woman is considered indicative of potential breast cancer. Currently, the surgical removal of axillary lymph nodes (lymph-
acleMctomy) as part of the surgical treatment in breast cancer
patients is discussed controversially since it is not proven 1tlat 1tlis procedure, in addition to removal of the primary tumour, increases the survival rate in patients. However, 1tle diagnostic lymphadenectomy to determine potential metastases (staging! of the tumour is of great importance and requires knowledge of the topography of the axillary lymph nodes.
211
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Superficial vessels and nerves of the axilla
Nn. tupt'81Ci1Yic:ulln81rarmlldll
>-----14----:...,_-
M. pectaniii81T11jor, Fa8Cia
·~~~~----~--~c~am~
~WIIal88)
Rg. 3.135 Eplf81cfll YNIMIIs and l'l8l"ftoS of 1he all II, foal axillria, and tl» llteral1horacic wal, Regio 1horaciclllt8ralil, right IIide; ventral view. Next to the superficial axillary lymph nodes !Nodi lymphoidei axillares superficiales), blood vessels and nerv&s are located in the axilla and in
212
- dl•••ctlon llnlc
the latenJI wall of the 1horax. The V. thoracoepigastrica is variable and descends at the level of the anterior axillary fold formed by the M. pectoralis major. A branch of the A thoracica lateralis may acoompany this vein. Cutaneous branches of the Nn. intercostalas exit from the respective intercostal spaces into the axilla {Rr. cutanei laterales pectorales).
Muscles _. Topography _. Sections
Superficial vessels and nerves of the upper arm and shoulder
v. Clflhlllce
Rg. 3.138 Eplfatcfal wins and nerves of the shoulder, Reglo delloidu, of the uppt1r arm, Rlgio brachi anterior, and ~bital foeu, Regio ~bitllia anterior, right IIide; ventral view. In lhe upper arm. lhe V. cephallal ascends in the Sulcus bicipitalis lateralis and runs betwe9/'l the origins of theM. deltoideus and M. pect~ Illlis major. In the cubital fossa, it connects wilhthe V. basilica via lhe V. mldlana cubiti. In the inferior part of the upper arm. the V. IHIIIIIc8 courses in the Sulcus bicipitalis medialis and pierces through the Fascia blllchii to 91'11er one of lhe Vv. brachiales. Several cutaneous bll!nches of lhe N. cutai'IIU!I bracflll medialis pen81ra1e the fascia at the
N. wtlnilullndlll medlelll
level of lhe axilla to distribute along the medial aspect of the upper arm. There are connections to the Nn. intii'CIOSt:o.bradlillel of the Nn. interrostales. In the dstal part of the upper arm. the cutaneous branches for the forearm exit the fascia. The N. cutllneus errt:l.bntchll medialis aooompanies the V. basilica. and theN. cuteneua errt:l.bntchi llrt8ralil descends next to the V. cephalica. As the sensory terminal blllnch of theN. musculocutaneus running between the M. biceps brachii and the more deeply positioned M. brachialis. the N. cutaneus antebrachii lateralis pieroes lhe fascia between these two muscles. TheN. cutaneus antebrachll potterfor appears further latellll.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Due to the accessibility, the V. caphllicl is frequently used for the implantation of cardiac pecamahra and port lly'llt8ma (for application of chemotherapeutics or parenteral nutrition!. Central venous
c:ethltera (CVC, • antral line•) may be inserted through the V. c~ phalica into the superior V. cava.
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Superficial vessels and nerves of the upper arm and shoulder
A.; V. drcumfl&~~a humeri pcaterlar
pomrtar}
N. w11wi- tnchll ,.~.........__ N. w11w1- tnchllllltlnlllalnflntar N.n.dllllll
V.ceplldca ~i+lffif1E--
Rg. 3.137 Eplf81cfll YMIMih and l'l8l"¥'eS of 1he lhoulder. Reglo delloidu, of the upper arm, Rlgio brachi post8rior, and cubital foeu, Regio et~bitalia posterior, right tide; clorsolatetal view. The N. cvtai'IIMB brlchl llrtlralls IIIJHnlor is the terminal sensory branch of the N. axillaris. It pierces the fascia at the inferior margin of the M. deltoideus which is inneNated by the axillary neNe. N. cutan•
214
- dl•••ctlon llnlc
N. w11w1- .mlndlll poetwtor
(N.raddll}
us brachll llteralls Inferior. N. cutaneus brachl posterior and N. cutaneus antebrachi posterior are terminal branctles of the N. tadialis and pierce through the fascia late tal to theM. triceps bractlii. The exit of the N. cutaneus antebrachii posterior is often localised between the M. triceps btactlii and the venttally located M. btactlialis.
Muscles _. Topography _. Sections
Veins of the cubital fossa
V.blllllllce
v. bllllllc:a (A. brectlllllla . .pert'lclll... VIr.)
Rg•. 3.138.1 to c V.rlltlon• of the eplaldal veRI In the cubital font, Regio cubitalia ant8rior, right lidl; ventral view. The V. cephalica may wry substamially in the upper arm <~ Figs. 3.1388 and b). Occasionally, the V. medians cubiti is missing, and instead, the V. eephalica antebrachii and V. basilica antebrachii communicate via in-
direc1 connections with a V. medians antebrachii on the anterior aspect of the forearm c~ Fig. 3.138c). Of importance is the potential existence of an additional A. brachialis superficialis in the cubital fossa with a course in pan~llelto the veins.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The veins in the cubital fossa are importan1 for drawing blood and for intravenouaadminiltration of drugs. Because of their extensive variability, it is recommended to examine the exact course of the veins and palpate them. If an arterial pulse is palpated, one should
consider the existence of a suparlicial A. brachialis. Drugs should not be injected into the artery, because some substances may have toxic effects upon intllHirterial injection due to lack of dilution.
215
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Superficial vessels and nerves of the forearm
A. eupedlelalle (N.I'IIIIalll)
IL ceplldca antetnchl
3.139
Fig. 3.139 and Fig. 3.140 Epifascill veina and ....,.. of 1he foreann, ftetlo antebracllll anterior and Reglo antebrachll posterior. and of the cubital fossa, Reglo cubllalls anterior. rltht side; ventral 1- Fig. 3.139) and dorsal 1- Fig. 3.140) view. At ltle dorsal side of the thumb, the V. cephal lea antabrachll emerges from the superficial venous network {Rete venosum dorsale manus) and then courses on the radial and ventral side of the forearm, whereas the V. basllca antebrachll continues from the ulnar dorsum of the hand to the ulnar ventral side of the forearm. In the cubital fossa, boltl veins usually communicate via the V. median• cubiti. The cutaneous nerves of the forearm radiate wiltlltleir branches to boltl sides of the
216
- dl•••ctlon llnlc
3.140
forearm. Upon exiting the fascia, theN. cutaMUII antebrachii media· lis runs adjacent to the V. basilica; theN. cutaneus antebrachllatera· lis starts its course together wiltlthe V. cephalica. The N. cutanaus antebrachi postlriar pierces the fascia between the M. triceps brachii and M. brachialis. At the distal forearm, ltle R. superftclllll of the N. radialis pierces the fascia benealtlthe tendon of ltle M. brachioradialis and thus reaches the dorsum of the hand. Similarly, the R. dotulil of theN. ulnarll exits benealtlthe tendon of theM. flexor carpi ulnaris to reach the dorsal side. The palmar branches of N. medianus and N. ulnaris proximal of the wrists are usually not easily shown in the dissection.
Muscles _. Topography _. Sections
Superficial vessels and nerves of the dorsum of the hand
N.l'lldrarle, R. auperflclllll
N. ullllltl, A. dorlllll
Fig. 3.141 Epifllllcill YIUIIIand nlr'YI8 on tiMI dorsum of 1he hind. Dorsum m1nus. right side: dorsal view. At lhe dorsal side of the thumb. the V. cephlllc8 antebrachll emerges from the superficial venous netwotit on the dotSum of the hand, and the V. bldlca 1ntebrachll emerges on lhe veins from on ulnar dorsum of lhe hand. Above the proximal wrist joint. lhe R. superficilil of
1he N. ntdilil pierces the fascia beneath the tendon of the M. bradlioradialis. Its dMsions, the Nn. digitales dorsales, convey sensory innervation of lhe llldial 2~ digits. The ulnar 2~ digits are innervated by lhe R. dots~il of the N. ulneria emerging beneath the tendon of the M. flexor carpi ulnaris.
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Trigonum clavipectorale Fa:lcukla palltelfar
F818C1CIA1.18IIIteral8 Fuclcutua medda
M.aubciiMua
N. l)e(:tonll8 medals
A.ll'lcncloacnmlllle,
Rr.pedonl• M. pectot'lllll ll'llfar, Pant d1Mcullll8
Fig. 3.142 Trigonum clllvlpectoraJ. IMOHRENHEIM's fossa) on 1he right side. The Trigonum clavipectorale is a small triangular space betw&en the clavicle and and the origins of 1he M. pectoralis major and M. deltoideus. To rewallhe Trigonum clavipectorale during dissection, 1he origin of the M. pectoralis major is separated from the clavicle and reflected laterally and the Fascia clavipectoralis is removed. At 1he trigone, 1he V.
Rg. 3.143 Branches of 1he A. 1horlcoacromlalll. thoracoacromialis are: • Rr. pectorales to the Mm. pectorales • R. clavicularis to 1he M. subclavius • R. deltoideus to the M. deltoideus • R. acromialis to the Rete acromial&
na. four tarminal bt'llncb• of the A
218
~ dl•••ctlon llnlc
cephlllca pierces the Fascia clavipectoralis to empty into 1he V. axillalis. In addition, the A. thOI"'ICCHHCC"'mlalll emerges from 1he A. axillalis and divides into four terminal branches. The Nn. pectoral• medialis and lllrteralls which originate from the respective cords of 1he brachial plexus course together wilh the arterial brancttes to 1he pectoral musdes which they supply.
Muscles
-+
Topography
-+
Sections
Axillary fossa v. lll..._...,lgeltr1ca V.lllllllarlll v.~
M. pacl
M. aemdus anterlar
N.lllomclr:ua langua
Fig. 3.144 Axillary foaa, Fossa Dllarls, right Bide; laterocaudal
les deriw from the Nn. lntercostala, cross the axilla, and run along-
view.
side theN. cutaneus brachii medialis. TheN. thoracodonlalia courses together with the corresponding blood vessels to the medial side of the M. latissimus dorsi. Further ventral, the N. thoracicua longua descends on the lateral aspect of the M. serratus anterior which it innervates.
The anterior and posterior borders of the axillary fossa are the M. pectoralis major and the M. latissimus dorsi, respectively, bo1h of which are fom1ing the axillary folds. In the axillary fossa, all three cords of the Pars infraclavicularis of the Pla18 bnlchilllia surround the A. oilarill while covered verrtrally by the V. axlllarls. The Nn. lntercostobrachla-
A.-Fig. 3.145 Arteria of the llloulder, right Mle; wntral view. Brandtas of the A. axllarls: • A. thoracica superior: variable on the Mm. pectorales • A. thoracoacrornialis {..... Fig. 3.143) • A. thoracica lateralis: lateral of the M. pectoralis minor • A. subscapularis: divides into the A. thoracodor.illlis to the M. latissimus dorsi, and the A circumflexa scapulae which traverses the
triangular axillary space and anastomoses (•) with the A. suprascapularis. • A. circumflexa humeri anterior: anastomoses (**) with the A. circumflexa humeri posterior which traverses the quadrangular axillary space. The R. acromialis of the A. thoracoacromialis may also anastomose with the A. suprascapularis (*-*).
-+ dissection link
219
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Axillary fossa
M. pectcnlll map
V.cephalca
A.; v. thorllclca llltwllllt
N. Ulcn.clcus longus
Fig. 3.146 Axillary follll, Foaa axillllril, and latenll1horacic waiL Reglo 1honlclce lateralII. right llde; lateral view. Compared to ~ Figure 3.144, the M. pec1o!lllis major is split to visualise the M. pectotalia minor underneath and the anatomical structures appearing in the Trigonum clavipectorale. The A. thoracoacromlalls and its branches are visible at the upper border of M. pectoralis minor. The associated Rr. pectorales course together with the Nn. pectorales of the Plexus b!llchialis towards the Mm. pecto!llles major and minor
220
~ dl•••ctlon llnlc
which they inneNate. The M. pectoralis minor seNes as an important landmark for the classification of axillary lymph nodes 1~ Fig. 3.134). The A. and V. thoraclca laterals course at its lateral border and lateral thereof, the A., V. and N.1horacodanalil descend to reach the medial aspect of the M. serratus anterior they supply. The V. tho!llooepigastrica shows variable dimensions (here shown as a strong vessel) and is not accompanied by an artery during its course in the subo..rtaneous adipose tissue of the latellll thoracic wall.
Muscles
-+
Topography
-+
Sections
Axillary fossa
M. scalenus medkls
M.omahyalcleull, \lenta' IIUpeRlr
A;V.~coll,
R. •Lperflclolll
M. pec1Drals miiKI'
Nod l)mpholdel -.....,..c:;;.JII cervi...... antericnoo a...,orflclolllllt pmfun::ll
M. pec1DIBIIB major
N. muscuiDcUIBneUs V. )Jgularla N. mlldlonUB
N.ul...-
1hncl •bGIIIvluB Ill brunchormdlllllllnalla slnl...,
Nadl lymphlllciBI llllllalwllllanlles N. culaneUB bnlchl mlldlolll
Fig. 3.147 AJdllaryfosA, Fossa axlllarls. and llrtllral thoracic
-11, RegiD thGracica lateralia, left lidtl; ventral viEIIN. In contrast to .... Fig. 3.146, the left side is shown to demonstrate the confluence of the axillary IJmph , . _.. in the Ductus lhoracicus. The M. pectoralis minor is split for a better visualisation of the axillary lymph nodes. With respect to their topographical relation to the M. pectoralis minor, the axillary lymph nodes are organised in thr• lllvllls (.... Fig. 3.134). The fir5t level (lateral of M. pectoralis minor) contains the Nodi lymphoidei axilla res pectorales alongside the A. and V. thoraci-
ca lateralis and, further lateral, the Nodi lyrnphoidei axillares subscap~r Iares and the Nodi lyrnphoidei axillares laterales next to the V. axi llaris. The second level (at the level of M. pectoralis minor) depicts the Nodi lymphoidei axillares centrales beneath the muscle. Medial of M. pectoralis minor,the third level is positioned as a last filter station prior to the junction with the Truncus aabclaviua. The latter conveys the lymph from the left thorax via the Ductus thoracicus to the left venous angle between V. jugularis intema and V. subclavia.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The Ductus thoraclcus carries the lymph of the entire lower body (including abdominal and palvic organs) and empties into the left venous angle. Before doing so, it receives additional lymph via the Truncus bronchomediastinalis sinister from the left thorax, via the
Truncus subclavius sinister from the left arm, and via the Truncus jugularis sinister from the left head and neck region. Therefore, metastases of malignant tumours in the abdomen may manifest in the left supraclavicular lymph nodes VIRCHOW'a node.
-+ dissection link
221
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the upper arm
Faeclcutuatlltlnlla
N. tharacodanda
N. cutaneus bractlll medialis
A.bnlchlda
Fig. 3.148 Blood vaaela end nerves of the exillery f - . , FOUl axlllrts.. and of 1he medlllllde of the upper arm. Reglo bnlchl anterior, right side; ventromedial view. To show the infraclavicular part of the Plexua.btacllillia, theM. pectollllis major was cut near its origin on the Crista tuberculi majoris and removed. Proximally, the three "m" ar& shown. The Faciculua let.,. lia and Faaciet~lua medielil position to both sides of the A. axillaris and form a M-shaped structure of nerves which serves as helpful orientation during dissection. The lateral strok& of the "m" is formed by theN. musculocutaneus which is easily identified piercing the M. coracobrachialis. The medial and lateral roots of theN. medianus form the
222
- dl•••ctlon llnlc
middle part of the NmN. and the medial stroke of the NmN is fotmed by the N. ulnaris. While the N. medianus descends in the Sulcus bicipitalis medialis to reach the cubital fossa from medial, the N. ulnaris runs on the posterior side of the Epicondylus medialis. The Faeciculua poeterior was mobilised from its position behind the A. axillaris. One of its peripheral nerves, the N. axillaris, traverses the quadrangular space together with the A. circumflexa humeri posterior. Then, the Fascio..llus posterior continues as N. llldialis which courses together with the A. profunda brachii through the triceps slit to reach the posterior aspect of the Humerus.
Muscles _. Topography _. Sections
Vessels and nerves of the upper arm
Fig. 3.149 Atleriee and nervea of the axillary f01111, F08&I IIXIIarts.. and of 1he medial Ilea of the upper arm. Reglo brachll anterior, right !Ide; ventromedial view; M. biceps brachii hold apart. The M. biceps brachii was lifted off lat&l'ally to show the course of the N. miiiC4IIocvt:llneus. The latter pierces and innBMJtes the M. con~ cobtachialis and descends between theM. btachiotadialis and M. btachialis supplying motor innetVation. At the distal upper arm, the sen~ ry terminal bn~nch {N. cutaneus anteb!llchii laten~lis) appears between the two muscles and continues on the radial side of the forearm. The
N. medilnLII descends together with the A. brachialis in the Sulcus bicipitalis medialis to naach the cubital fossa. The N. ulnarb continues together with the A. collaten~lis ulnaris superior to the posterior side of the Epicondylus medialis. The A. collat&l'alis ulnaris inferior frequently bn~nches proximal of the elbow as a thin vessel from the A. brachialis. The N. aillaria branches off the Fasciculus posterior proximally and ttaverses the quadtangular axillary space. The N. radilil oourses toge1her with the A. profunda b!llchii through the triceps slit.
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the upper arm
M.-ma,lar
N.l'll. . ., N. Clll'llnllullndlll poella'lcr
A. callmn.. racl ...
N. c:u'llwl- brechllllltwallelrftrtcr N. Ndllllle, N. c:u'llwl-ll'ltellnlctlll polblrlor
Rg. 3.150 Arteries end nerves of the ........ tide of the upper erm, Regio .brldlii polrt8rior, right IIide; dotSOiateral view. The Caput longum and Caput latetale of the M. triceps brachii were sepantted to show the triceps lilt between both heads. The N. radl• Iii and A. profunde bracllii traverse this gap to course in the Sulcus
neNi redia lis of the Humerus. The motor branches of ttle N. radialis for the inneNation of the M. triceps and the N. cutanaus brachii posterior already sepatate a1the level of the triceps slit HowEMII', theN. cutaneus bntchii lstentlis inferior and N. cutaneus antebrachii posterior leave the N. tadialis from the Sulcus nervi tadialis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In a humeral shaft fracture with injury to the N. radialis the function of the M. triceps brachii usually remains unaffected. The motor nerves to inn&rvate the M. triceps as well as the N. cutaneus btachii posterior already branch off the N. ntdialis at the passage through
224
- dl•••ctlon llnlc
the triceps slit. The N. cutaneus brachii lst&ralis inferior together with the N. cutaneus antebrachii posterior may be affected by this injury because they separate in the region of the Sulcus nervi tadialis.
Muscles _. Topography _. Sections
Vessels and nerves of the upper arm u;. tnlniMN'IInl ecapullle aupertla
~~"+--
N.c:u11m- bnc:hll
lltenlllllllrftrtcr
(N.n.ddll) ~~,\1---
A. colllltenlla media --W.:~'o:ISA'rl A. col~l•l'lldllllla, --~":--~~PH~~
A. collatenllandlall., R. antellor
R. pcatellor
N. cl.taneul antetnchllllerala (N. m~aa.~lac:u1luleu~)
Rg. 3.151 Ar1ertH and nerves of the shoulder. Reglo deltoldea. and 1he llrterallil» of 1he upper arm. Regio .bnlchii dof'Mii ... right tide; dorsola1etal view. This illus1nl1ion depicts again the localisation of the branches of the N. r•dillia. The triclpa slit was elongated through keen edged sepamtion of the Caput longum and Caput lateral& of the M. triceps blllchii. The motor branches of the N. radialis for the innervation of the M. triceps and theN. eutaneus b!'aehii pos1erior already separate a11he leval of the triceps slit. However, the N. cutaneus braehii latellllis inferior and N. cutaneus antebrachii posterior leave the N. llldialis in the Sulcus nervi tadialis. The A. profunda b!'achii runs toge1her with the N. tadialis and splits into A. collateralis media Ito Epicondylus medialis) and A. collateralis radialis (concomitant with the nerve). This illuS1ra1ion also demonstrates 1he billlry sp.~ces wi1h 1raversing
structures. N. axillaris and A. circumflexa humeri pos1erior pass through the quadmngular axillary space. The A. circumflexa scapulae traverses the 1riangular axillary space 1o the dorsal side. In the Fossa inftaspinata, the A. ciroJmflexa scapulae (derived from A. axillaris) fonms an important anaS1omosis with the A. supraseapularis (derived from A. subclavial. Fnaquently, anaS1omoses with the A. dorsalis scapulae !from A. subclavia, not shown! also exist. These arterial anastomoses allow for a oolla1eral arterial circulation 10 supply 1he arm, thereby bypassing a proximal occlusion of the A. axillaris. The A. suprascapularis traverses above the Lig. transversum scapulae superius 10 the Fossa supraspina1a of the Scapula. However. the N. suprascapularis t!llverses beneath the ligament through the lncisu!ll scapulae. Nerve and artery are then bridged by the Lig. transversum scapulae inferius during 1heir 1tansition into the Fossa infraspinata.
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dl•••etlon llnlc
225
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Vessels and nerves of the forearm
M. blcepa ln.chl
M.brai::Mals
N.
med•u• -......:~---'d
N. ullllllt; A. Ql41a8r1118 1Anarl8 tuperlcf
Allenewoeis mutctlt
blelptls tnchl
M. tlilcor C3P1 radllll8 M. flllxar C3pl ulnalfa
M. flucr polllclala~ua
R. dcnlll8 G'l· ulnarll)
Rg. 3.152 Superficial arteries and I'I8I"VVS of 1he forearm. Reglo antebrachii ant8rior, right side; ventral view. The N. medianua runs together with the A. brachialis to the cubital
fossa from medial. The A. b!llchialis splits into A. llldialis and A. ulnaris, both of which descend to the respective sides of the wrist. Palpation of
226
~ dl•••ctlon llnlc
arterial pulses is predominantly performed on 1tle A. llldialis just above the proximal wrist joint. The A. ulnaris and concomitant N. ulnaris are both covered by the M. flexor carpi ulnaris as demonstrated at the distal forearm.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the forearm
A..recurrenaradllllla
• +-+-- N.ulraf• •-..!-+-- A. uln.t•
Rg. 3.153 Superficial arteries and I'I8I"VVIS of 1he forearm. Reglo antebrachii anmrior, right lide; ventral view; M. b!'achioradialis and Aponeurosis bicipitis antebrachii W81'e removed. The M. brac:hioradialis and the insertion of the M. biceps b!llcnii to the Fascia antebrachii (Aponeurosis musculi bicipitis antebrachii) have been removed to visualise the b!llnching of the A. braciAIIs and to show the course of the A. and N. llldialis. As a b!llnch of the A. b!llchialis, the A. nui1lil continues its course beneath the M. brachioradialis and reaches the llldial side of the wrist. The A. racurrans radialis ascends beneath the M. b!llchiollldialis to the arterial network of the elbow (Rete articular& cubiti) and engages in an anastomosis with the A. colla-
teralis radialis 1"1. The A. ul•rll branches off below the M. pronator teres and descends next to the N. ulnaris beneath the M. flexor carpi ulna tis to the ulnar side of the wrist. Between M. brachioradialis and M. brechialis (radial tunnel! the N. redllll enters the cubital fossa from lateral and splits into R. superticialis and R. profundus. The A. •uperfi· clllls runs adjacent to the A. radialis and de'\liates to the dorsal side in the distal third of the forearm. The R. profundus inn&MJtes and pierces the M. supinator (alpin1tor anaQ. The sharp-edged tendinous arch (arcade of FROHSE) at the entrance to the muscle may compi"6SS the nerve.
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227
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the forearm
N. radds, A. pntund ...
A.utn.-fa
A. recurretW ulrw18 M. flela' catpl n.dllllllt
A. Ulllllls, A. C81P8fl8 donlall8 A. radiale, A. pal'nlrl8 IUI*fk*l8
Rg. 3.154 Deep erterles end nerves of the for•nn. Reglo em. .brllchii enterior, right lide; ventral view; M. pronator teres and M. flexor carpi radialis were split and theM. palmaris longus was removed. Once the superiicial flexor muscles of the forearm are separated, the proximal branch&S of the A. uln1ril are visible: the A. interossea communis descends as a strong vessel, and the A. recurrens ulnaris as-
228
- dl•••ctlon llnlc
cends beneath the M. pronator teres. The N. medlenus appears bEttween both heads of theM. pronator teres to enter the space between the deep and intetmediate layers of the flexor muscles of the forearm. At the distal forearm, the tendon of the M. flexor carpi ulnaris was cut to show the branching of the R. doraelia of N. ulneria and its course to the dorsum of the hand.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the forearm
N. radlalle, R. lli'OfUnc:fl.l8
14. rec:urren. radlllle
M. blcepe bn.chl, Tllntfo
N.n.dlalle, R. 8~18
M. tlilcor pollc18101l!U8
Rg. 3.155 Deep arteries and I'NII"¥'M of 1he for..nn. Raglo antebr•dlii •nt.rior, right IIide; vemml view; all superficial flexor muscles wer& r&moved. After removal of all superficial flexor muscles, including !he M. flexor digitorum superficialis, the complete course of theN. medianus is visible. It descends dis11111y in !he midline of the forearm between the deep and superficial flexor muscles and is commonly accompanied by a lhin
R. dcnllle Olf, ulnarll)
anery (A. comitans nervi medianil. At !he proximal forearm. !he N. interosseus antebrachii anterior branches oH providing motor innervation to the deep flexor muscles and sensory supply to the wrist joints.The A. interossea anterior accompanies this nerve, and the A. interossea posterior traverses through the Membrana interossea antebrachii to the dorsal side.
_. dl•••etlon llnlc
229
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the cubital fossa and elbow
A.brKhll.
~'F#-f--
N. radllllle, R. pnlf\nill
N.l'lldlalla, A. l...,ertfCIIIIa
A.ra,lals M. _,.,dlgblnJm
M.-carpl,.dllllla-
3.156
Olllcnlnan
M. ft&xcr dlgblnJm prdundua
3.157
Fig. 3.156 and Fig. 3.157 Arteria a and nervas of the .abow; Regie> ct~bltllllsanterlor. right side: IBtellll (radian view 1~ Fig. 3.156). .Arterlas and l'MII"VVS of the elbow'. RigiD cubltalls posterior, rtaht lide: medial (ulnar) view(-> Fig. 3.157). These illus1ra1ions demonstrate the course of the nB!Ves of the arm after splitting the diva!'se superficial flexors and ex:t9!'\SOI'S. Together with the A. brachialis, the N. medilnua enters the cubital fossa from medial. The N. radialis enters the cubital fossa from latellll between
230
- dl•••ctlon llnlc
the M. brachioradialis and M. brachialis (radial tunnel) together with the A. collatellllis radialis. Here it divides into the two terminal bll!nches. The R. superlicialis continues beneath the M. blllchiollldialis • The R. profundus reach&S the dorsal side through the M. supinator (atplnator anal). The N. ulnarls is directly adjacent to the bone in the Sulcus nervi ulnaris where it is easily irritated (•funny bone•). Then. the N. ulnaris cours&S beneath the M. flexor carpi ulnaris to the flexor side of the forearm.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the forearm
I '
.
I
,\
~~Jt~J'"
N. IAilllfs
N. ,...... R. profundlll
A. I " ' * ' - poeblrlor
M. abduct« polllci81cngl.l8
M. elllen8ar polllcl8-
M. ~ciQhl mlnm~ Tendo
N.l'lldlllll, R.~c:l1lll A. I~ &mellor R. donal• (N. ulllllfll)
fig. 3.158 DMp en.riM end ll'lllr'VM of 1M for. .rm, Ragio antebracbll posterior, right tide; radial view. The M. extensor digiti minimi is deviated to the side to shaw the course of the R. profund• of 1M N. radielia which dascends with the A.
interossea posterior between the superficial and deep extensors. At the redial side of the wrist the R. superftclalls of the N. radialis appears from beneath theM. bnu:hioredialis and enters the dorsum of the hand.
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the forearm
A.lntiiii'C I I I I I'8CIImfl8
A.lnllll ~II I I ~GC'
M.eupl-
M.-cupl,.dllllla-
M. at11enecr dlglc!um
R.~nantr.~~•.
M. ab
N. lnterv..ew am.lnlchll ~
Membnnal~
N. radllll8, A. tuperllclals M. ellten8ar palllc:l8-
M. ut8!180f pollc1810nQU8, Tendo
Rg. 3.159 Deep erterles end rHII"¥'M of 1he forelnn. Reglo entebr•cbii poaterior, right side; radial view. The M. extensor digitorum was lifted sideways to show the btanches of the R. profundus of 1he N. redial Is and of the A. lnterOIIIM poste. rior. Following its ttansition through the supinator muscle. the R. profundus of the N. radialis inneMtes all superficial and deep
232
- dl•••ctlon llnlc
extensors of the forearm and terminates as sensory N. interosseus antebrachii posterior at the wrist. After its passage through the Membtana interossea antebrachii, the A. interossea posterior btanches off the A. interossea r&OJrrens YA'Iich reaches the arterial network of the elbow {Rete articular& cubit~ underneath the M. anconeus.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Arteries of the hand
Fig. 3.180 Arteries of 1he hind, Merus. right tide; palmar view. The palm of the hand is supplied by the A. radialis and A. ulnaris which usually both contribute to the two palmar arterial arches. The A. radii· Is terminates in the deep pelmer erterllllerch (Arcus palmaris
profundus.~ Fig. 3.161land contributes a communicating branch to the superficial palmar arterial arch (Arcus palmaris superficialisl. wheneas, the A. ..neril terminates in the superficial p.almllr ertwl arch 1~ Fig. 3.162) and provides a branch to the Arcus palmaris profundus.
Fig•. 3.1811 to d V.rlltlon• of the deep p.almer erterlalarch. The deep palmar arterial arch gives rise to the Aa. metacarpales palmares which supply the palm of the hand including the Mm. interossei. Frequently, in the interdigital spaces the weak Aa. metacarpales palmares join the digital arteries which derive from the superficial palmar arterial arch. The deep palmar arterial arch is usually closed but the A. interossea anterior may be connected 1"1.
Rp. 3.1828 to c V.rlltlon• of the superficial palmar erterlal arch. The superficial palmar arterial arch feeds the Aa. digitales palmares for the second to fifth digits. The thumb (A, princeps pollicisland the radial side of the index finger {A. radialis indicisl are supplied by direct branches of the A. radialis. In summary, the A. radialis supplies the palm of the hand and the radial1 !1.1 digits, and the A. ulnaris supplies the ulnar 3¥.t digits. Frequently, a complete superficial palmar arterial arch is missing. In these cases, the A. radialis and A. ulnaris have separate supply zones.
233
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy _. Development _. Skeleton _. Imaging _.
Vessels and nerves of the palm of the hand
11Ji:.ll=f'7-- N. utln, R. palmalll ~~llr+~~-.4!~-
N.utrale A. utn.ta
M. palmaris bMII8
S.:::,.....-,M !.Mir":~t----J~,-T.__-
N. utlllllt, Rr. p a J Nn. dlgbiN patm-pi'Cip'l
A. dlgblll palm .-fa eommunla Aa.dlgltlllN palnwea proptlla
Fig. 3.163 Superficialartarilland ll'llltvll ofthl p.~lm ofthe hind, Palma manus. right side; palmar view. In the palm of the hand, blood vessels and nerves are well protected by the p.1lmar aponaurotia (Aponeurosis palmaris). Proximal of the metacarpophalangeal joints and between the longitudinal fibres of the apo-
234
- dl•••ctlon llnlc
neurosis, the Nn. digitales palmares derived from theN. medianus and N. ulnaris and the ramifications of the terminal digital bnmches of the As. digitales palmares communes are visible. ks the N. ulnaris and A. ulnaris run superficially in the GUYON'• canal,. they may be injured or compressed at this location.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the palm of the hand
M. fluor cwp raclall, 'Tllnclo
A.l'lldl1lt., R. palnwb ..JMl'flcllh
N. ulrwte, A. protundue
A. utllllls, A. palmaris proMCils
N. dlgltlllll palnwb IIII'OPI'IUI A. oammunlean8 CIJTl nero.o ulllllll
N. midi-.., --:lfi;Y
N. dlgblll palna'fl
IF'-ir;'
c:ommunl1
A& dtgltllN patm-commun.
Fig. 3.164 lnmrmedilrt8111yera of 1t18rias •nd nerves of the pelm of the hind. P1h1 m1nus. right side: after removal of the palmar view; palmar aponeurosis. The ~~~Pt~rficill palmar 1t18rill 1rch (Arcus palmaris superticialis) is essentially f01med by the A. ulnaris and frequently anastomoses with a branch from the A. radialis (R. palmaris superficialis). The Aa. digitales palmares for the ulnar 3~ digits branch off the superficial palmar arterial anch while it crosses the tendons of the long flexor muscles of the
fingers. The N. ulnlril accompanies the A. ulnaris through the GUYON's can1l. Distal of the Os pisiform&, the N. ulnaris aready splits into its R. profundus and R. superficialis and continues along this dire~ tion. The R. superficillil divides into Nn. digitales palmares for sensory innervation of the ulnar 1~ digits. The radial 3~ digits are supplied by respectiv& branches of theN. medilnua which enters the palm of the hand through the carpal tumel (Canalis carpalis) ben&ath the Retinaculum mUSOJiorum flexorum.
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dl•••etlon llnlc
235
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Vessels and nerves of the palm of the hand
M. appanena polllcll M. ftucr polllcll _,.,Caput .,perflclllilt
Areul Plllrn.tl ~·
N. Utlar18, R. ~~~~ 'r\L.JIU~:--- N. ut..-18, A. proftlndue
M. abductar digiti mtrfmt
Mm. tntan:.et patmaree
M. &dcfuctllf potlcl8 A& tnetllcii'JNII• PlllnwM
Mm. t1e1ccn1e ctgnorum, Tendines
Mm. llmb!lcalll8
Fig. 3.185 Deep at18riea and ll'll8r'VM of 1he palm of 1he hand,. Palma manus. right side; palmar view; tendons of 1he ilexor musci&S and Mm. lumbricales w&re remowd and the M. adductor pollicis was split. The deep palmar arterial an:h !Arcus palmaris profundus! dariv&S from the A. radialis and communicates with the R. palmaris profundus of the A. ulnaris. This arch is positioned beneath the M. adductor pollicis and in front of the bases of the Ossa m81acarpi, thus, iurther proxi-
236
~ dl•••ctlon llnlc
mal than the superficial palmar arterial arch. The deep palmar arterial arch releas&S the 1hin Aa. metacarpai&S palmares and courses over 1he Mm. interossei togelher with 1he R. profundus of 1fle N. ulnarbl which inneNatas the hypothenar musclas, the Mm. interossei, and the two ulnar Mm. lumbricales. The arteries supplying 1he 1humb lA. princeps pollicis) and the tadial side of the index finger (A. tadialis indicisl ar& also btanches of the A. radialis.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the dorsum of the hand
M. extelllar palllcll tnv111
M. ai:Dlctar palllclllangu., lllndo
A. melacllplll8 clcnall8 1
M. - - pallcllla~Uit, Tendo
M. adeilctor pclllc18
Fig. 3.166 Atleriee and nervea of the dorsum of the hand, Dorsum manu-. right side; dorsal view; after removal of the long tendons of the ext&nSOr muscles. Both. the A. radialia and A. uln1ril s&nd a R. carpalia dorulia to the dorsum of the hand where they communiC81e. The radial branch is usually stronger and predominan11y supplies the Aa. metacarpales dorsales
for the dorsum of the hand and the Aa. digitales dorsales for the digits up to the proximal interphalangeal joints. The intermediate and distal phalanges are supplied by the palmar digital arteries. Before the A. radialis courses betw&en both heads of the M. interosseus dorsalis I to reach the palm of the hand, the A. metacarpalis dorsalis I dinacUy branches of the A. tadialis.
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Vessels and nerves of the dorsum of the hand
N. radiale, N. cutan-111t811n.chllll081*1or
M. opponena pol lela
M. ~poll lela lclngua, '!IInde) Nn. digital• c:ICnellla A. metaaupalla dcnalllt
M. adduc:tar pol lela
IlL lm-Je donlllle I
Fig. 3.167 Atlerile •nd nervea of the dorsum of the hind, Dorsum manus,. right side; radial view. The illustllltion demonstllltes the course of 1he A. radl•ll• in the aree of the wrist. At the proximal wrist joint. the A. radialis is positioned between the tendons of the M. brachioradialis and M. flexor carpi llldialis. After traversing beneath the Retinaculum musculorum extensorum. the A. radialis provides the R. palmaris superficialis which communicates with the superlicial arterial palmar arch. The A. radialis then Cl'osses underneath the tendons of the ext9!'\SOI' muscles passing
238
~ dl•••ctlon llnlc
through the first osseofibl'ous tunnel (M. abductor pollicis longus and M. extensor pollicis brevis, _. Fig. 3.87) to reach the Fovea raclalll {Ta~; between the tendons of Mm. ext&nsor6S pollic:is brevis and longus) and delivers a R. carpal is dorsalis. After having crossed beneath the tendon of theM. extensor pollic:is longus. the A. llldialis releases the A. metacarpalis dorsalis to the thumb and passes between the two heads of theM. interosseus dorsalis I into the palm of the hand. Occasionally, a superficial variant exists and the artery crosses the extensor tendons superficially.
tahir99-VRG & vip.persianss.ir
Muscles -+ Topography -+ Sections
Hand, sagittal section
A.
••Ia
!-
1a poa.rior
M. exl8nsor dlgtarum
M. lllx:luciDr pallclllang,., 'lllndl.M. _,..,.. pallcllllang,., 'lllndD
M. ft&lCDI' dlgltarum pmlundus, Tendnee
Radlu•
Rlltlr-=uum musc:ularum flelwrum M. ftlllllll' dlgltarum aupa!lclalls, 'lllndlnea
ifi-1...,1H:!' - - - M. I1UrC8!18U8 palmaris II
'"1-1'-+.it-- - M . l - 8 dcnalls Ill fWI:ffi!l---A.II. . . . . .I.. donal.. Ill
Fig. 3.188 Arteri• olille hllncl, Manus. right llide; ulnar view; Sllgittal section at the level of the Ulnar plane of the third digit. At the distal foreaiTTl, the Aa. interosseae anterior and posterior run on both sides of the Membrana interossea antebrachii. The metacarpus is supplied from palmar and dorsal by arterial netwolts (Rete carpale palmare and dor.~~~lel which derive from the A. mdialis and A. ulnaris. The metacarpal and digital arteries of the dorsum of the hand derive
from the dorsal arterial network. At the volar side of the hand, the m~ tacarpelarteries originate from the deep and the digital arteries from the superficial palmar arterial arch. Each finger receives a total of four digital arteries (palmar and dorsal at the mdial and ulnar side, respeotively). The dorsal digital arteries only reach to the middle phalanx.The middle and distal phalanges are supplied by bmnches of the palmar digital arteries.
239
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy
~
Development
~
Skeleton
~
Imaging
~
Upper arm, transverse sections i
/,"'
(ft.J.
t
-
t~1;u~~ \ M. ln.chllla
Sepum lltllnnUICUIIn ln.chl - -
A. oollta'als ulllllls tUI*!CI'
N.radllllla N.ulrall
M. !rtc:epe tn.cHI, OlpJt langum
M. 1rtc:epe tn.chl~ Caput medlale
Fig. 3.189 Upper arm, Bl'lldlium, right lida; distal view; transverse section at the level of !he middle part of !he upper arm. The CI'OS$-section clearly demonstrates the two muiCie groups of the upper arm. Located on the ventral side are the flexors of the elbow joint. The M. biceps brachii is positioned anterior to !he M. brachialis which originates furth91' lateral. The ins91'tion of theM. coracobrachialis on the medial humeral shaft is delineated. The heads of the M. triceps bnlchii oocupy the posterior side of the upper arm. NlurO'VliiCullr structur• course in two p.~uageweys.The N. medianus togeth91' with the A. brachialis and concomitant Vv. brachiates are
located in the Sulcus bicipitalis medialis and anterior to the Septum intermuscular& brachii mediate (medial passageway). The V. basilica has already pierced the fasda and is shown just before merging wilh the V. brachialis. The N. ulnaris traverses the Septum intermusculare brachii mediate further distal to reach the posterior side of the Epicondylus medialis. Laterally. in the Sulcus n&Ni radialis the N. radialis winds around the humeral shaft together with the A. profunda brachii (dorsal passageway! and descends between !he M. bl'achialis and M. triceps brachii.
Rg. 3.170 Upper •rm. Brachium. right side: distal view; magnetic resonance imaging cross-section (axial MRII at the level of the middle part of the upp91' arm.
240
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Forearm and carpus, transverse sections
\t medllna ant81H'adlll
A.l'lldlallll -
-+----H,Ff-N•
M. fl~dlgltaum prafundl.l8
N.l'lldlllla, R....-f'lcllh
una
M. 8lttiHliiCr CIIJ)I ndals ~1.18 N.l~ .m.lnchll.m.IGC'
M. 8llt8n8ar pdllc:l8lang1.18
N.l~ .mlnc:hll JIO'hr!GC"
Memnnalnten:.ee.
Fig. 3.171 Forearm, Ant:abrachium, right IIide; distal view; transverse sec1ion atltle level of the distalltlird of ltle forearm. The forearm displays five neurovascular pasAIIIWIIP which are located between the superficial and deep layers of the flexors and extensors. respectively.The A. and V. radialis together with the R. superficialis of ltle N. radialis course beneath ltle M. bntchioradialis {radial neurovascular passageway). In the midline. between the superficial and intermediate layers of the flexors, theN. medianus and a delicate concomitant artery (A. comitans
nervi mediani) are positioned (medial neurovascular passagaway). 8&nealtlthe M. flexor carpi ulnaris, the N., A. and V. ulnaris are located (ulnar neurovasrular passageway!. The A. and V. interossea anterior and the N. interosseus anterior course anterior to the Membrana intEI!'ossea antibrachii finterosseal neurovascular passageway). The A. and V. interossea posterior and the N. intEII'OSSeus posterior are located between the superficial and deep extensors (posterior neurovascular passageway!.
Relnacui~MT~ m~a:Uiorum ftucrum
Thenar N.mldl-r
A.;¥;; N. ulr.le**
M. fl_.polllelelongue, Tenelo IIIII. f'lllllor Cllpl ndlllll, lllnelo O.lnlpeltlm
M.lllductor
pollk:IIIIO~ut, Tenelo·~;i~~~~~i~
i!l!!'iJ:ll!ffl~~~';:-;7~- Mm. f'lllllcnl dlgltorum, TendlnH ~~~~~r,~~~---06~~m
M. e~palllc:l8 - · lllndo-
Mm.--CI/I)I ndU., lllncllnH M. - - polllcltlcu~ua,
Rg. 3.172 C.rpu•. right side; distal view; transverse sec1ion at the level of the distal row of carpal bones. The palmar side of the carpus has two neui'OW'MCelllr .,....,..,.,.,. of clinical imporlllnce. The carpal bones together with the Retinaculum musculorum flexorum form the carpal tunnel (Canalis carpi). TheN. m&dianus traverses the carpal tunnel togeltler with the tendons of the long flexors of the digits. Therefore swelling of the tendinous sheaths
may result in compression of theN. medianus (carpal tunnel syndrome, ~Fig. 3.125).TheA .• V. and N. ulnaris run above ltle retinaculum in the GUYON's CIRII where they are vulnerable to compression due to the superficial location (distal lesion of the N. ulnaris _. Fig. 3.1291. " carpaltunnel "" GUYON's canal
241
tahir99-VRG & vip.persianss.ir
Upper Extremity
Surface anatomy .-.•...-. Sections
Metacarpus and third digit, transverse sections
Aa. dlgtaille palman. camlftln.; N.medlal1lS
M.abductDr ct;nlmlnml M. CI)I)Onen8 dl;nlmlnlml M. abductDr pc~llclalongua
M. Cl)pcll*l8 POIICIS·--1..../Gi
08 mecac:.p~ poUicl8 --+~....:..
J.•J··~~""'"t--0...-pv
~~~stf-- M.tlllolccf dlgkcl'um proti61CilS. Tend I'!•
M. extenlar dlgtt ml'ltmt
M.l'"*'-.18 palm&rl8111
M.tran:-Ja danda rv M.I-I!Nt dcnaltal A. ..-carpalII palmn 0. mala:alpll'ldlcla M.tran:-ua palmalllt
M. ~sdanllb II 08 tnetacapllll
Rg. 3.173 MltllcarpuiJ.: transverse section at the I&Vel of the middle of the third metacarpal bone. This section demonstrates the position of the muscles in the palm of the hllnd which are grouped in three layers I~ pp. 1~1931. Sl4*ficilllv, theM. abductor pollicis, M. flexor pollicis brevis, and M. abductor digiti minimi cover the other muscles of the Thenar and Hypothenar. respectively. The lntermedllrte layer harbours the tendons of the long flexor muscles of the fingers. Also. the Mm. lumbricales
originate from these tendons. The deep layer of the palmar muscles is formed by the Mm. interossei palmares and dorsales. Here it is obvious the palmar interosseal muscles lie indeed nearer to the palm of the hand than the dorsal muscles. In addition, this illustration also clearly shows the position of the digital arteries (Aa. digitales palmares communes) and the sensory terminal branches of theN. medianus which run ventrally to the flexor tendons I~ Fig. 3.1641.
N. dlglals dan ale
M.lla.dlgttarum pralundua, Tendo
Rg. 3.174 Third dlgtt. Digitus medius IIIII: transverse s&C1ion through the shaft of the middle phalanx. The tendon of the M. flexor digitorum profundus has pierced the tendon of the M. flexor digitorum supetiicialis and both tendons are positioned within a common tendinous sheath (Vagina t&ndinum digiti). The
242
dorsal arteries and nerves a1 the middle phalanx are much thinner than the corresponding palmar structures. Thus, the middle phalanges are predominantly and the distal phalanges are exclusively supplied by palm1r brancltes lA. digitalis palmaris propria and N. digitalis palmaris proprius)(-+ Fig. 3.168).
Lower Extremity Surface Anatomy . . . . . . . . . . . . . . . . . 246 Skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Topography . . . . . . . . . . . . . . . . . . . . . . . 326 Sections. . . . . . . . . . . . . . . . . . . . . . . . . . . 369
The Lower Limb the Erect Gait The bipeda I upright gait not only influenced the intellectual and sociocultural development of humans but also resulted in significant changes of the human anatomy. In humans, the lower extremities- as seen in hominids- are locomotion and support organs, however, with a more stable and wider pelvic girdla and longer lags: The extensive pelvic bones bear the weight of the upper body and support the viscera of the abdominal cavity, enabling prolonged standing without much effort. The ability to take larger steps results in accelerated locomotion. Speed and greater range of action caused already the quadrupedal mammals to develop limbs which migrated ventrally underneath the body. The front (upper) extremities were rotated dorsally while the rear (lower) extremities were rotated ventrally. Hence, in humans the extensors of the thigh and lower leg are positioned anteriorly, whereas the upper arm and forearm extensors are located posteriorly. The joints of the free extremity such as hip, knee, and ankle joints are supported by stable ligaments. They ensure steadiness while standing and relieve the muscle groups on buttocks, knee, and calf. which are responsible for bodly posture. The stanca stabilizing foat of humans- in contrast to the grasping hand-like foot in hominids- has led to less mobility of the joints, especially of the interphalangea I joints of the toes; the muscles of the foot contribute to stabilization of the foot and bracing of the plantar arch rather than enabling the fine-tuned movement of individua I toes.
Pelvic Girdle In contrast to the shoulder girdle, the pelvic girdle (Cingulum membri inferioris or pelvicum) is an almost rigid bony ring. Dorsally it consists of the sacrum (Os sacrum), which is a constituent of the spine. The sacrum is unpaired and it connects bilaterally through minimally flexible joints (Articulationes sacroiliacae) with the paired pelvic bones (Ossa coxae). The Ossa coxae form two bony half shells which join ventrally beneath the Mons pubis at the fibrocartilaginous Symphysis pubica. This resembles a bony floorless basin, where the muscles and ligaments form the pelvic floor. Each pelvic bone consists of three single bones which are connected by synostoses once growth is completed: the ilium (Os ilium, cranial), the ischium (Os ischii, caudodorsal) and the pubis (Os pubis, caudoventral). When investigating the soft tissues of the pelvic girdle, the following picture emerges: At the ventral aspect. the inguinal region (Regio inguina lis) is positioned on either side of the Mons pubis. In the tender inguinal canal. blood vessels, muscles, and nerves (and the spermatic cord in males) descend from the interior of the abdomen to the leg (and scrotum, respectively). The pulse of the femoral artery (A. femoral is) is palpable slightly lateral to both sides of the Mons pubis in the Regia inguinalis. The actual hip region (Regio coxae) is located more laterally. Dorsally, the bilaterally curved buttocks of the gluteal region (Regio glutealis, "ho glutos": the buttocks) rest on the bony pelvic girdle. Their convexity resulted from the adaptive evolution of the gluteal muscles due to the transition to the bipedal gait. Both buttocks are separated by a deep natal cleft (Crena ani) and the gluteal fold (Sulcus gl utea lis) separates them from the thigh.
244
Lower limb The Pars Iibera membri inferioris consists of the thigh (Femur), the knee (Genu), the leg (Crus), and the foot (Pes). The thigh (Femur) is supported by the identically named bone, which is the largest long bone of the bodly. In the hip joint [Articulatio coxae), the ball-like head of the Femur articulates with the hemispherical socket of the Os coxae. The range of movement of the hip joint, especially the extension, is restricted by powerful, almost centimetre-thick ligaments which are incorporated into the capsule. Since the Femur is well surrounded by muscles, one can only palpate the two (epi-)condyles (bilaterally superior to the knee) and the greater trochanter rochanter majoo in the hip region.
rr
In the knaa ragion [Regio genus), the thigh bone and Tibia form the knee joint (Articulatio genus). The kneecap (Patella) is the ventral part of the knee joint and articulates with the Femur through its posterior surface. The knee is primarily a hinge joint between Femur and libia. In a flexed position, it also allows for a certain rotation of the leg. The posterior region of the knee, the popliteal fossa (Fossa popliteal, is soft and placable when the knee is flexed. Deep in the fossa, branches ofthe N. ischiadicus and the A. poplitea descend from the thigh to the leg. Therefore, the pulse of the A. poplitea is hardly palpable in a flexed position of the knee. The lowar lag (Crus, lag) is supported by a medially and anteriorly located libia and a laterally positioned Fibula. The head of the Fibula is easily palpable distal to the knee joint (of which the Fibula is not a part). TheN. fibularis communis descends subcutaneously and dorsal to the head of the Fibula. Damage to the N. fibularis communis can occur at this point, e.g. due to pressure of a poorly padded cast. At the transition to the foat (Pas). one can easily palpate the bilateral ankle bulges (Malleolus lateralis and medialis). The Malleolus lateral is (of the Fibula) is always positioned lower than the Malleolus medialis (of the libia). Just inferior and posterior to the Malleolus medialis a bundle of blood vessels, nerves and tendons descends from the dorsal aspect of the Crus to the sole of the foot. The pulse of the A. tibialis posterior is palpable near the Malleolus medialis. Both malleoli of the libia and Fibula articulata with the Talus, forming the ankle joint [Articulatio talocruralis). It facilitates elevation and depression of the foot. The digital extensor tendons project on the dorsum of the foot. Between them, the pulse of the A. dorsalis pedis is palpable. The skeleton of the foot includes the Tarsus, the Metatarsus, and the phalanges (Digiti). There are seven tarsal bones (Ossa tarsi), the Talus being positioned on top. Just below the Talus lies the heel bone (Calcaneus) to which the ACHILLES tendon (Tendo calcaneus) attaches at its posterior surface. At the medial side, the navicular bone (Os naviculare) lies inferior and anterior to the Talus. The above mentioned three bones form the talocalcaneonavicular joint [Articulatio talocalcaneonavicularis). It permits rotating the foot inwards (supination) and outwards (pronation). Theremaining tarsal bones, the three cuneiform bones (Ossa cuneiformia) and the cuboid (Os cuboideum). are interconnected by tight and almost immobile joints. The Metatarsus is supported by five long bones, the Ossa metatarsi. Together with the tarsal bones, they form the arch of the foot. The flexible arch of the foot is mainly supported by muscles and tendons located in the sole of the foot (Pianta pedis). The toes I to V (Digiti) are formed by shorter long bones, the phalanges. One starts counting at the great toe [Hallux, Digitus primus); in analogy to the thumb, the Hallux has only two phalanges.
Clinical Remarks--------__, CongMillll dlformiti• such as hip dysplasia or clubfoot occur frequently and require therapy during early childhood to en&ble walking and to warrant normal development. Among the chronic degMeratid ~-.such as arthrosis, which affect eldery persons w ith variable sii'Verity and which contribute to a substantial amount of the costs in the public health sector, the hip joint (coxarthrosis) and the knee joint (gonarthrosis) are more frequently affected than the joints of the upper extremity. This is caused by the high impact on the weight-bearing joints that is in part due to the erect bipedal posture, but also to civil isatiol}o based conditions such as obesity. In addition, traumatic injuries at work or during recreational activities affect the long bones and predominantly the joints of the lower extremities (injuries to the ligaments and menisci) and frequently require a surgical recol}o struction. The primary goal here is to restore the ability to walk and, thus, prii'V8nt secondary diseases caused by immobility such as thrombosis and pulmonary infections.
-+ Dissection Llnlc The musculoskeletal system is dissected in -.yars (stratigraphically) from superficial to deep structures. Venlnll dlssec:tlan: Firat, the epifascial structures in the subcutaneous adipose tissue are exposed. This involves sii'Veral cutaneous nerves of the Plexus lumbalis and at the distal leg around theN. fibularis superficialis from the Plexus sacra lis. Then follows the dissection of the V. sapnsna magna ascending from the anterior aspect of the medial rna~ leolus via the medial aspect of the knee up to the Ccnfluens venosus subinguinalis in the groin. The fasda is opened to expose the individual muscles. Immediately beneath the inguinal ligament (lig. inguinale), the L.scunae musculorum and vasorum together with exiting neurovascular structures are dissected. From here, the A. and V. femora lis as well as theN. saphenus are traced to their entrance into the adductor canal (Canalis adductoriusJ. Next, the origin and the branches of the A. profunda femoris, the main blood vessel supplying the thigh, are dissected. Finally, the individual joints (e.g. knee joint) are exposed. Dorsal das-tlon: After exposure of the epifascial cutaneous nerves from the PI exus sa eraIis, the V. sa phana parva is traced from the posf:&. rior aspect of the lateral malleolus to its confluence in the popliteal fossa. Next, the opening of the fasda displays the individual musdes. In the gluteal region, theM. gluteus maximus is exposed and reflected, followed by the display of the deep musdes of the gluteal region. The Aegio glutealis with pathways is dissected. TheN. ischiadicus is traoed to its divergence and from there theN. tibialis and theN. fibularis communis with its branches are traced to the foot. The popliteal fossa is dissected induding blood vessels. In the leg, the neurovascular pathways are traced along the A. tibialis anterior and posterior to the foot. After the removal of the plantar aponeurosis on the Plants pedis, the individual layers of the short foot muscles are exposed and the assedated pathways are visualised.
EXAM CHECK LIST • Bonae with apophY'N far muacle origins and inaertiona • joints and ligament• (in particular: Articulatio genu1 with Ligg. cruciBt:a and coiiBtarale and meniac:i) • muac:lat and their eourae, function and innervation • nerve• with 1upply area, course and lesions • arteriat with branch at, courte and pulsea • veinl and their courte •lymphatic drainage and Nodi lymphoidei inguinaleeauperfici• le1 • topography: Lacunae mueculorum and va1orum, Regia glut&alit with intraglutaal injection, Canalit obturatorius, Canalis adductorius, foHa poplitea and Planta pedis· compartment syndrome • c~ectione: Coxa, Femur and Cru1 •surface anatomy
245
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Surface anatomy
Rllgb femCIISI/llellor
---!--M. ..tanla
- - - MlrQoll'll*'lor(l'l~
- - - Mllleolue medllllle (nlll)
Fig. 4.1 view.
246
Surface n~ilf of 1M lower .U.mity, right lidl; ventral
The surface relief of the legs is determined by muscles and skeletal elements. The skeletal elements which are palpable through the skin are important landmarks for the physical examination.
Muscles _. Topography _. Sections
Surface anatomy
o.-m---+
SulcuagkiiiMilllt---
-
--C.puttllul•
Fig. 4.2 Su,_. n~ilf of 1M lower atNmity, right lide; dorsal view.
247
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Skeleton of the lower extremity
FemLI'
-c - 1+--- Lcng uls of 1lllal thlft Tllla--+T-t--1:1
ArllciAIIIo 1aloCI'Iftlll Arllc1Aa11o calcaneoctmoiCM. 'lil•l:lo't""'-MiciAa11o tublalalls """'--Arllc1Aa11o 1alocalcanecnlvleul&rl8 ~~~1::::- Anlculltlo cune
01g111 pedis, 088a dlgi1CfiJTl: - Phallnx praxmall8 - Phallnx medii. - Phallnx dllla..
fig. 4.3 Bonee end joinm of the lower extremity, Membrum lnhrtus. right tide: ventral view. Whereas the shoulder girdle consists of two bones !Scapula and Oavicula), the pelvic girdle (Cingulum pelvicum) is formed by two hip bones (Os coxae! and the sacrum lOs saaum). Thigh and leg form e laterally open angle of 174•. referred to as Q.engle.
248
In the knock-lnH deformity {Genu valgum) the Q..:~ngle is smaller, in the bowleg deformity (Genu varuml it is larger. For the development of the lower extremity~ pages 132 and 133.
Muscles ..... Topography ..... Sections
Skeleton of the lower extremity
normal Q-angle
Genuvalgum (knock-knee deformity)
Fig. 4.4 Mechanical axis of the lower extremity IMIKULICZ"s line). (according to 11 ]). Normally, the great joints of the lower extremity are positioned on a virtual straight line, the m echanica I axis of the lower extremity. This axis connects the centre of the femoral head with the middle of the malleolar mortice of the ankle joint.
Genuvarum (bowleg deformity)
In the knock-knee deformity (Genu valgum), the knee is shifted medially away from the mechanical axis, in the bowleg deformity (Genu varum), it is shifted laterally. The size of the arrows depicts the stress on the medial and lateral parts of the joint in relation to the mechanical axis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Since the whole body weight is transferred via the mechanical axis to the soles of the feet. the stress on the joints is even if the joints are aligned along the mechanical axis. Shifting of the knee joint in the case of a knock-knee (Genu valgum) or bowleg (Genu varum) deformity results in an uneven stress on both compartments of the knee joint (red arrows,-+ Fig. 4.4). As a consequence, degeneration
of the menisci or the joint cartilage may occur, causing arthrosis of the knee joint lgonarthrosis). A Genu valgum results in lateral arthrosis whereas a Genu varum causes arthrosis in the medial compartment. For substantial deviations from the mechanical axis, surgical corrections by removal of a bony wedge (osteotomy) may be performed.
249
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Pelvis
LIMet.mllllllla
O.llum
250
fig. 4.5 Pelvia, Pelvil; vantral cranial view. Sacro-iliac joint (Articulatio sacroiliaca) and pubic symphysis {Symphysis pubical connect the two hip bones (Ossa coxae) and the sacrum lOs sacrum). The resulting stable ring formation encompasses the viscera with its iliac bones and transfers the weight of the body to the lower extremities. The Lin.. tllrminalil begins at the pubic symphysis with the Pecten ossis pubis and continues through the Linea arcuata to the promontory
(Pn:lmontorium). The Linea terminalis encirdes the peMc inlet (Apef'o tur• pelvil superior) and separates the cranill faiH lllrga} pelvil {PeMs major) from the caudal true 111111111 pelvis (Pelvis minor). The promontory is the part of the vertebral column that protrudes farthest into the peMc inlet. The pelvic outlet lAperura plhil im.ior) is confined by the inferior margin of the pubic symphysis anteriorly, the isctlial tuberosities laterally, and the tip of the coccyx posteriorly.
fig. 4.6 and Fig. 4.7 Pelvil,. Pelvia,. of 1 wom~n C... Fig. 4.6) •nd of • man c~ Fig. 4.7). The shape of the peMs shows differences between the sexes. In men, the peMc inlet is rather heart..shaped. The smaller pubic angle is referred to as Angulus subpubicus I~ Fig. 4.411. In women, the peMc inlet is transverse oval in shape. In addition. the inferior pubic angle (Arcus pubis, ... Fig. 4.42), the distance between the ischial tuberosities. and the wings of ilium are larger than in men.
The following inner diameters are used to determine the width of the peMc inlet: the obstetric conjugate diameter (Diameter vera) between the posterior aspect of the pubic symphysis and the promontory. the transverse diameter (Diameter transversa) between the most lateral points of the Linea terminalis on both sides. and the oblique diameter {Diameter obliqua I and II) which connects the Articulatio sacroiliaca of each side with the corresponding most distal point on the Linea terminalis.
Muscles _. Topography _. Sections
Pelvis
e-o: a-c:: a-d:
Dllmelef (cUnt:al term: ConJ...a~ anlllclmlca: 11.5 em, fnlmu. p!l:lman~Euytothe •14*D' margl'l of the pubiC: tr,tmp!lyll8 Dlllm!Merwra:: 11 em, fromtheprornontoiYto u. poetellor &lll*t of the pubk: tYI!Iplly8iS Dllmelef dill; an de: 12.5 em, fnlm u. pnxnarmy to u. tlflllfor m-;ln rlu. pubk: trpnphylle
Ug.-.-ale
Fig. 4.8 PeMJ. Pelvis. of 1 wom1n; medial view; median sec1ion with illustration of th& div&rse straight inner diam&ters and their normal length which may, however. show interindividual variations.
The most important is ttl& Diameter vera connecting the posterior aspect of the pubic symphysis and the promontory.
!HI:
DlametwtraniMII'I&: 13.6 em, di8Wlot belween the moet lltlnlly po&tioned pclntt en e&eh enc1
of the u,_ tllnnlnalle.
Ra. 4.9 PeMI. Pelvts, of • woman wtth measurements; dorsal view. Another int&mal diameter with a certain significance is the transverse diameter !Diameter transversal. The different ext&mal diameters (Distantiae). however. are of insignificant practical reiEMJnce and ther&fore not shown.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Because the pelvic inl&t and th& tru& pelvis encompass the birth canal, ttl& determination of the pelvic diameters is of great importance during pretn•ncy to assess whether a vaginal birttl is possitr Ia. Th& most important diameter for the passage of the foetal head is ttle Dllmet:er Yll"'l (clinical term: Conjugata vera; at least 11 em). It can b& assess&d by vaginal examination of the Diameter diagonalis which spans from the inferior margin of the pubic symphysis to the promontory and is 1.5 em longer than the Conjugata vera. If an incongruity between the foetal head and the maternal birth canal is
suspect&d. the exact dimensions of the Conjugata vera are determined by magnetic resonance imaging IMRil. During caesarean section the Conjugata vera is routinely calculated to assess whether further vaginal births are possible. During pregnancy. the pubic symphysis and saao-iliac joints are loosened by the actions of the hormone relaxin which is produc&d in the placenta and the ovary. Thus. the Conjugata vera is dilat&d by approximately 1 em during parturition.
251
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Hip bone
Spn.lll- postwtor .up.tor .,..,.,'--__ Spll'llllll- postwtor llrftrtor
fig. 4.10 Hip bone, 0. coxee, right IIide; medial view. The hip bone consists of three parts, the ilium (Os llum), ismium lOs ilchium), and pubis (0. pubil). The ilium forms the false pelvis, ischium and pubis form the bony ring around the obturator foramen from
Crflltlllllla
{
~~:.-:;:
___
.,.:....,
Lalllum ut.smu1m-----1o
F
Corpu• 08118 Ill - - -.;,...._,
&rllnallllce ...-..rtor lnfwlor ----::~""'
U1lbU8 acelabiAI
AcltlbuiLim {
111cle8 Follllaacelabull
lnclslft aoetabull
Rg. 4.11 Hlp bone, Os coxae.. right side: ventral view.
252
posterior and anterior. respectively. The Feci• auricularia serves as articular surface for the sacrc:Hiiac joint. The Discus imerpubicus is attached to the Fecies symplrvsilil.
Muscles _. Topography _. Sections
Hip bone u~ atutea ll1tiiiiDr
Fsl.. 1111De
Urwa gtutee. lrlllflar
{ u~
atutea pcebiiiDr
Rg. 4.12 Hlp bone. Os coae. right llcle: dorsolateral view. All three parts of the hip bone, namely the ilium (Os ilium). the ischium
{Os ischium! and the pubis (Os pubis), contribute to the fonmation of the acetabular fossa (Acetabulum).
Raml.l8 oesta tscllll
Rg. 4.13 Hlp bone. Os COXM. of • e.,...r-old child. right side; latetal view. The three parts of the hip bone (Os ilium, Os ischium. Os pubis) are
linked by a Y-shaped cartilaginous synchondrosis in the Acetabulum. This cartilaginous synchondrosis ossifies between the age of 13 to 18.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . With high-energy trauma and high impact on the S1retched lowar limbs, a ftacture of the acetabular fossa may occur with dislocation of the femotal head (centtal fracture-dislocation of the hip). The development of the juvenile hip bone with ossification of the
cartilaginous synchondroses in the area of the Acetabulum needs to be considered for radiogtaphic images in children and adolescents to avoid confusion of the cartilaginous synchondroses with an ac&tabular fracture deft.
253
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Thigh bone
Collum temarta
Fig. 4.14 Thigh bone, Femur, right side; ventral view. Proximal at the femollll shaft the Trochanter major is positioned laterally and the Trochanter minor dorsomedially.
254
Fig. 4.15 Thigh boM, Femur, riaht side; dorsal view. The Unea aspelll serves as apophysis for the origin of the M. quadriceps femoris as well as for the insertion of seve!lll muscles of 1tle adductor group.
Muscles _. Topography _. Sections
Thigh bone
Fig. 4.17 Thigh baM, Femur, riaht side; proximal viaw; the proximal and distal ends of the femur are proj&Cted on top of eadl other. The f&mOfal neck is rotlbtd anteriorlr by 12-14° against the axis conn&Cting both f&mOfal condyles !transverse axis of the femoral condyles). This is referred to as torsion angle of the femur. In infants. this angle is approximately 300. If the torsion angle of the femur is larg&r, the l&g is medially rotated and the toes point inwards during walking. If the torsion angle of the femur is smaller than 12°, the toes point outwards.
Fig. 4.16 Thigh bone, Femur, right side; medial view.
Fig. 4.18 Thigh baM, Femur, riaht side; cross-section of the femoral shaft at mid-level; distal view. The out&r layer of solid Substantia compacta is followed by an inner lay&r of Substantia spongiosa and the central medullary cavity (Cavitas medullaris) Ymich contains the bone marrow.
255
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Thigh bone
Fig. 4.19 Proxim1l end of 1he femur, Femur, rilht side; dorsal view.
Fig. 4.20 Proximal end cf the femur, Femur, rigJ!t side, with llustrdon of the •nale of lilciiiWtlon of 1fle femur (neck-shaft •nalel The femoral neck forms an angle of 128' with the femoral shaft. This angle is referred to as the caput-collunHliaphyseal angle or angle. In the n9Wbom, the CCD angle meaSI..Ires 150". AA lncreaed CCO angle resul1s in a Coxa wlga, a decr•sed angle causes a Coxa var•.
ceo
ceo
Fig. 4.21 Proxlm1l end of 1M femur. Femur, right llde.. wHtl illu.ntion cf the apongiou structure in the c.u of •n incn...c:t angle of inclination (neck-eh.lft angle) (Cod wig a). Section a1 the level of the1orsion angle of the femur. Th9 spongiou nbecuiM are 1rajectorial, i.e. 1h&y align with the lines of maximal traction and compression forces {the so-called trajectories). Coxa valga causes higher compra.tlon forces and leads to a reinforcemen1 of 1he m9dial spongiosa 1rabeculae (*") and at the same lime to a redue1ion of the lateral spongiosa trabeculae 1"1.
Ra. 4.22 Proximal end cf the femur, Femur. rlgJ!t side. wtlh ilustration of 1fle tpOngicu structure in 1fle cue d• dect..sed •nail of inclination (n.a:-lhaft •nQie) (Coxa v•re). Section a1 the level of the torsion angle of the femur. In Coxa vara. increased tr•ctian forcee cause a reinforcemam of 1he lateral spongiosa trabeculae (") and at the same time a redue1ion of the medial spongiosa trabeculae 1*"). As a reS~.Jit of an increased bending s1ra-.1he corticalis at 1he inner side of the femoral neck is 1hickened.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Alterations of the caput-eollunHliaphyseal ICCD) angle may restrie1 movemen1s. In Coxa vara. reduc9d abduction is found. Changes in the forces acting on the articular surfaces of 1he join1 such as in Cod vala• or Coxa ver• may cause an increased attrition resulting
256
in arthrosis of the hip joint lcoxarthroll•l or the knee joint lgonerthrotlil). In addi1ion. Coxa vare predisposes 1o frecu.. of the femoral neck due1o 1he increased bending stress.
Muscles _. Topography _. Sections
Thigh bone
Rg. 4.23 Distal end of the femur. Femur. right side; lateral view. To understand the flexi~xtension movement in the knee joint (... Fig. 4.69) knowledge about the articular surfaces of the femoral condyles is important. In relation to the axis of the femoral shaft the articular surfaces are positioned dorsally (retropotlition). In addition. the curvature of the femoral condyles is more pronounced posteriorly !smaller llldius of rurvaturel than anteriorly (larger radius of curvature) resulting in a spirel curvature. This phenomenon is more distinct in the medial than in the lateral condyle(-+ Fig. 4.100).
Fig. 4.24 Diltal end of the femur, Femur, right -"fe; frontal section at the level of the joint bodies; ventral view.
Fig. 4.25 Diltal end of the femur, Femur, right •ide; distal view.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Since degenerative diseases of the knee joints (gonlrthrosll) are common and frequently require prosthetic surgery (total knee r• pllclment, TKRI. the knowledge of the anatomy of both articulating bones is of utmost importance. Recent studies have shown th1J11he
radius of curvature and the shape of the arlirular surfaces different on either side of the joint. Thus. knee joint prosthetic surgery aims at constructing articular surfaces with the closest possible similarity in shape to facilitate the natural movements of a healthy knee.
257
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Tibia
Matgomedlall8
SulCus mdealllla
l!llllecu medals
4.26
4.27
Fig. 4.26 to Fig. 4.28 U,ia. Tabil, right side; ventral (-> Fig. 4.26). late!lll <~Fig. 4.27), and dorsal I~ Fig. 4.281 views. The proximal articular surface is shifted dorsally from the axis of the tibial shaft Cretropolltlon). In addition. the articular surface is tilted dol'-
Rg. 4.29 llbla. llbla. and fibula, Fibula. right llde; proximal view. The articular surfaces of the oondyi&S (•) are collectively referred to as Ftlciee articllllril superior.
258
4.28
sally by 3°-7° (retroversion). The retroversion is more pronounced at the medial condyle than at the lateral condyle and is here especially distinet at the medial tim of the articular surface.
Muscles _. Topography _. Sections
Fibula
Collumftlulae
Fanunen nutlfcklm
Margo 8JUIIcrI
Mllll«**llat.llll F - malleoli - . I l l
4.30
4.31
Rg. 4.30 and Rg. 4.31 Rbula, RIMM, right llde: medial (->Fig. 4.30) and latetal 1- Fig. 4.31) views. 11\/hen positioning an isolated fibula, orientation is given by the fact that
the articular surfaces of the fibular head and of the malleus both point medially.
Mlllleolusll!erala
MlllloluiiNdlllla
Fig. 4.32 llbla, l1bla.. and fibula, Rbula, right llde; distal view.
259
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Skeleton of the foot
1 II Ill flf V
HIIIW: I,D~nus l)l!mue) Dtgluseec:undue Dtglu•leltiU8 Dtglu•qua~tu.
Dtglu• mlnmus ("'lntU8]
Fig. 4.33 Sbleton of 1he foot. 0... peel it, right tide; dorsal view. The foot {Pesl is organised in T•l'lllll with Ossa tarsi, Mlltmrsus wi1h Ossa metatarsi. and toes IDigHI) which consist of sevellll phalanges. The Tarsus comprises the Talus, the Calcaneus. Ule navicular {Os navi-
culare). Ule cuboid {Os cuboidauml. and the three cuneiform bones (Ossa cuneiformial. Oinically, the forefoot is distinguished from Ule hindfoot. Both ana separated by the articular line in the Articulationes tarsometatarsales.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The Articulatio tarsi transversa {dinical term: CHOPART's joint; blue) and the Articulationes tarsometatarsales {clinical term: LJSFRANC's fc*lt; redl ana preferred locations for surgical amputations in the
260
case of injuries. frostbite, or perfusion deficits wi1h tissue necrosis. In lllre occasions. h.uartfons may occur in Ulese joints.
Muscles _. Topography _. Sections
Skeleton of the foot
I II
Hill WI I.DlilhU81)1!ml.ll) Dlgkus te<:Undl.ll
Ill DlgtuatettiU8 IV Dlgtuaquartua V Dlgtua mlnmua ("'11111.18]
011 cunei!Wme ln'llllrmldlum
Fig. 4.U Skeleton of 1M foot. 0... pedil, riaht tide; plantar view.
261
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Skeleton of the foot
.Arilleullltkl _.., t n l n - (CHOPART'a joint)
nllll!c;ulare
- {~:--tal-,-~r---""r"--Shlatlnl -
-1-- - --+-'--:-->11
Celie- - 4 --t=~-n~~--~~----~~~
4.38
Rg. 4.35 and Rg. 4.38 Skeleton of the foot. 0.. pedis. right tide; medial 1- Fig. 4.35) and lateral 1- Fig. 4.36) views.
262
Th& Sinus tarsi is a hollow space which is formed by the Sulcus tali and the Sulcus calcanei.
Muscles _. Topography _. Sections
Talus and calcaneus
Prcc. laterals tall ~--SuiCU8 tendl~s
muecullfte.J«lrl8 hduclalangl
4.S7
4.38
Rg. 4.S7 and Fig. 4.38 Talus. T•lus. right side; dorsal (-+ Fig. 4.37) and plantar views(-+ Fig. 4.381. The trochlea is broader at its posteriOI' aspect than at its anterior aspect.
Sulcua tendlnll muacul
flbulal181~1
4.40
Rg. 4.39 and Fig. 4.40 C.lcaneus. C.lcaneus. right side; medial (... Fig. 4.39) and lateral views( ... Fig. 4.40).
263
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ligaments of the pelvis
Alllcullllo CCllCIUt
4.42
Rg. 4.41 and Rg. 4.42 Joints and lgaments of 1he male (-+ Fig. 4.41) end the female pelvia (-+ Fig. 4.42); vemral view. The pelvic girdle (Qngulum pelvicum) is a ring-shaped bony construction created by both the dorsal amphiarthroses of lti& sacro-iliac joints (Articllllrtiona UCfoiliiiC.Ie) and by the ventrally located pubic symphysis (Synrphpls publca). Each sacro-iliac joint is stabilised by the Ugg. Ha"'IIIIca anterlores v&ntrally, and by the Ug. lllolumiHIIe superiorly. The latter connects the Pmc:. oostalis of the lumbar vertebrae
264
IV and V 'hith the Crista iliaca. These strong ligaments only allow small tilting movemants of the pelvis of about 10". The pubic symphysis is bridged superiorly by the Lig. pubicum superfus,. and inferiorly by the Ug. publl:um lnferiiD. In both sexes the Foramen obturatum is almost completely dosed by the Membrana o.bUatoril which only leaves the C.nail o.bturatorlus as a passageway for lti& neurovasrular bundles to lti& inner side of the thigh IAN. obtumtoria. N. obtumtorius).
Muscles _. Topography _. Sections
Ligaments of the pelvis
Rg. 4.43 and Rg. 4.44 Joints and lgaments of the male Fig. 4.43) and the femala palvia (-+ Fig. 4.44); vemml cranial view. The almost horizontally oriemed Lig. sacrospinale connects !he sacrum with !he Spina ischiadica, dorsal of which !he Lig. saaotubemle courses obliquely to !he Tuber ischiadicum. Bolh ligaments compl~r ment the Incisura ischiadica major and minor to form the Foramen (-+
llchladlcum ma,Jus and minus. These openings constitute impol1ant passageways for blood vessels and nerves of the Plexus sacralis to the gluteal region {Regia glutealis). The space beneath the inguinal ligament llig. inguinale! is dMded by !he Arcus iliopectineus into the lateral Lacuna musculorum and the medial Lacuna vasorum (-+ Fig. 4.177) through which the neurovascular structures course to the anterior side of the thigh.
265
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ligaments of the pelvis
-
IIi I
4.45
Ug. publcum tlfellue
Spina llacai)OIItWICr suptr!Or
Llg.~
~ IIChllldlcum
mn..
4.46
fig. 4.45 end Fig. 4.46 Joinm end ligemenm of 1111 femele pelvil; dorsal <~ Fig. 4.451 and caudal views 1~ Fig. 4.461. On the dorsal side. the sacro-iliac joint is stabilised by !tie Llgg. MCI"'ilillc. poateriora and int8r01111e. Due to the strong ligaments on the posterior side of the pelvis. only small tilting movements of up to 1o• are possible.
266
Ug. publcum tlfellue
The almost horizontally oriented Lig. UCI'Oipinele oonnects the sacrum wilti the Spina ischiadica, dorsal of which !tie Ug. MCI'Otubanle courses obliquely to the Tuber ischiadicum. Both ligaments confine !tie Foremine ildlilldica mejLII and min111 as passageways for blood ves. sels and nerves of the Plexus sacralis to the gluteal region.
Muscles _. Topography _. Sections
Ligaments of the pelvis
-
4.47
Ug. publcum rn'elll.l8
~""""-- Artlc:uiiiUo •ac:roll-. Ug. sacnl4tlacum 8l'Mrll.l8
Fen men lldlllldlcum maJu• Ll'UIIUICUII!a
urwe t8nnlnalll {
Pecten 088111 """lit--~
4.48
fig. 4.47 •nd Fig. 4.48 Joinm •nd ligamenm of the female pelvil; oblique transverse s8C1ion; ventral caudal view<~ Fig. 4.47) and median section; view from the left side<~ Fig. 4.481. Illustrated is the sacro-iliac joint with its ligaments (Ligg. MCfoiliiCI anteriora, posteriora. and li'ltlrossel as well as the Ug. saC~ospln•
le, and Lig. sactotuberlle). The Lig. iliolumblle is not visible. The Lig. secrospinale and Lig. sacrotuberale confine 1tte fonlmlna llchlldlea ma)us and minus as passageways for blood vessels and nerves of 1tte Plexus sacralis to the gluteal region.
267
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ligaments of the pelvis
Fig. 4.49 Sact'O-IIIIIC Joint. Artlculdo Mcrolllllc8: frontal sec1ion; dorsal view. These strong ligaments, of which the Ligg • .acroililca •nterior• and lirtero•e• and Ug. lllolumiHIIe are visible here, stabilise the sacnr
iliac joint and enable the transmission of weight from ttl& trunk 10 the pelvic girdle. In particular, the dorsal Ligg. Mcroili11C8 interoau and posblriora broadly connect the Sacrum and Ilium.
Fig. 4.50 Pubic symphylit.. ~phylil pubice; oblique section; ventral caudal view. The connection of ttle pubic bones is a symphysis. The Dhcullnterpu.bicul consists of fibrous cartilage; only the surface area to the Facies
symphysiales of both pubic bones consists of hyaline cartilage. FolloiMng ttle first decade of life, an oblong gap frequenUy forms !Cavitas symphysialis). This gap of the joint is bridged S~.Jperiorly by ttle Ug. pubicum superiul and inferiorly by the Lig. pubicum inferiu&
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . P•in in 1M MCtO-ililc joint may be caused by injuri-.. c~egt~Mr• 1111'1 conditions, or rheumatic diseases which in part preferentially affect this joint {BEKHTEREV's disease!. Since the sacro-iliac joint is
268
innervated directly by branches of the sacral plexus, pain may radiate into the leg I~ p. 326).
Muscles _. Topography _. Sections
Hip joint
-
and the transverse !axial) plane is 40". The hip joint transfers the whole body weight onto the lower ex:lremities. Therefore, the joint capsule ICaJ*IIa articullril) is reinforced by strong ligaments. Cirrular fibres of the joint capsule SIJrround the femoral neck in particular on the dorsal side and are referred to as Zane orhicularil which ligaments of the capsule also join. The Lig. capitis femoris lacks a mechanical function.
fig. 4.52 and Fig. 4.53 Hip joint. Attictlllltio co••· right lide; Fig. 4.52) and dorsal!~ Fig. 4.531 views.
• Ua. IIIDfemorale !anterior and SIJperiorl: inhibits extension and ~
There are three major ligaments of the hip joint which surround the femoral head in a spiral manner. Their principle function is to limit the range of hip extension and to prevent the backward tilting of the pelvis:
• Lig. pubofemorale {anterior and inferior): inhibits extension, abduc-
ventral<~
acetabular
m
Rg. 4.51 Hlp )Dints. Artle«.~ldonas coxae; oblique transverse section; ventral cranial view. In the hip joint, the Acetabulum of the hip bone forms the socket. Together with the Labrum acetabuli, the Acetabulum covers more than half of the femoral head {Caput femoris). Thus, the hip joint is a special form of a baiHmd-socket joint referred to as cotyloid Jc*1t !Articulatio cotylica, enarthrosis). The anal• between the plane of the
duction and, thus, supports the small gluteal muscles tion, and lateral rotation
• Ua. llchlafemon~le lposterion: inhibits extension, medial rotation, and adduction
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Orthopaedic studies have shown that position and shape of the Acetabulum and the femoral head are important factors in degenerative changes of the hip joint rc:oxarthrosll). Premature degenerative changes may be induced by a flattened roof of the joint (hip dy!plala) which shows a smaller than usual angle between the
acetabullr rim and the horizontal plane as well as by a larger than usual roof of the hip joint. A larger roof of the hip joint may be caused by an anteriorly ex:lended acetabular rim in cases of a dorsally tilted Acetabulum lratrcwertion d 1fHI Acetabulum), or if the articular surface is located very deep in the Acetabulum ICo• profunda).
269
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Hip joint
Rg. 4.54 and Rg. 4.55 Hlp Joint. Articulatio coxae. rlaht side; vemral view; after opening of the capsule and partial 1~ Fig. 4.54) or complete(~ Fig. 4.55) exarticulation of the femoral head. Besides the extemalligamems IUa. llofemon~Je. Ug. pubofemor'llle, Lig. iachiofemorale) the internally located Lig. capitie fernorie is visible which lacks mechanical function in the joint. The Lig. nnwet~~~~m acetabull inferiorly doses the Acetabulum, and together with the Labrum acetabuli, which also consists of fibrous connective tissue. it seNes to guide the femon~l head.
•
o•
figa. 4.568 to d Range of moviii'MI'It in the hip joint. Atticulltio COXIIe. (according to [1)) The hip joim is an enar1hrosis
270
4.55
c
d
a much higher degree and exclusively limited by soft tissues. In addition, medial and late!lll rotation as well as adduction and abduction are limited by ligaments. Range of IIICMIRIIIIt: • extension-flexion: 10"- 0"-130° b abduction-adduction: 40°- 0"- 30° c and d lateral rotation-medial rotation: so·-o·- 40"
Muscles _. Topography _. Sections
Blood supply of the hip joint
R,__,cl&m}
R. ~·
4.57
~ cn:umflllxa femclll8lltlnlll)
R. dMcendlln•
4.58
Fig. 4.57 end Fig. 4.58 Blood supply of the hip joint. right side; vemral c~ Fig. 4.57) and dorsal I~ Fig. 4.581 views. In the adult. the A. clrwrnflau femoris medllls is the major blood vessel supplying th& f&mOI'al h&ad. In infants, how9Y81', the R. ecetabularts (from A. obtullltoria and A. circumflexa f&mOI'is medialis), which runs within th& ug. capitis fsmoris, providss th& major part of the blood supply to the femoral head. In th& adult, it suppliss only one-fifth to
one-third of the proximal epiphysis. However. the A. circumflexa femoris medialis suppliss the femoral head and neck via several smaller branchss coursing on the posterior side within the joint capsule. The A circumflallll f81'1'10fil lllrtareil mainly supplies the femoral neck at its amerior side. The Acetabulum is supplied from ventral and dorsal by the A. obturatoria and from cranial by the A. glut&a superior.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Th& arterial blood supply is crucial for th& int&grity of th& femoral head. Oxygen deprivation 6schaemia) results in necrosis of the femorelhead which. in the worst case scenario. requires the replacement of the h&ad by an endoprosthesil. Therefore. the supplying arteries need to be preserved during hip surgery. This is partirularly important in casss of arthrosis if not the whol& f&moral h&ad but only the artirular surface is replaced by a prosthesis {"cap prosthssisN). Therefore, the knowledge of the exact anatomy of the arterial supply has gained importanc& during the last years. On& has to consid&rthat the A. circumflexa femoris medialis ooursss on the post&rior side of the femoral neck where it is covened and well protected by the
short hip muscles of the pelvitrochanteric group. Hence. these mu~ cles should be preserved during surgery to avoid injury to the artery. Since the Aa. cincurnflexa femoris medialis and lateralis pass between the layers of the joint capsule they are at risk of injury in imracapsular frectures of 1he femorel neck. As a result an immediate replacemem of the femoral h&ad by an encloprosthesis is more commonly performed. It is suggested that the spontaneous necrosis of the femoral heed during early puberty (PERiliES' di.....) is also caused by a oompromised arterial supply.
271
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Knee joint
fig. 4.59 •nd Fig. 4.60 Plltelllt, Pmn-. right tide; wntral (-> Fig. 4.59) and dorsal(-> Fig. 4.60) views. The patella is a ,..mold boM (Os sesamoideuml within the tendon of the M. quadriceps femoris. It serws as a hypomochliDn by guiding
the tendon on its way to the insertion on the Tuberositas tibiae aver the distal end of the femur. This results in an increase of the '.lirtuallever arm and torque of !he musde.
RcltdoMiade
--t-+t--~mur
Attlcullltlo dblcflbullrill ---jt.......,~ \ prcoc)TIIIs
Clputflbullle
Callumflbullle
llbla
4.81
Rg. 4.81 •nd Rg. 4.82 KMe Joint. Articulatio genus. rtaht tide; ventral(-> Fig. 4.61) and clo!'sal 1- Fig. 4.62) views. [10) In !he knee joint the Femur artirulates with 'Tibia (Articelllrtio fiNnoro. tlblallst and Patella (Artlcullltlo femoroplltell•rls; - Fig. 4.2091. All bones are ensheathed by a common joint capsule. In the Articulatio femorotibialis. the femoral condyles constitute !he head and the upper articular surface of the 'Tibia !Facies articularis superior! and both tibial condyles form the socket of the joint.
4.82 The knee joint is a blcondylar )oint (Articulatio bicondylaris) which functions as a pivot·hinge joint {trochoginglymus) and possesses two axes of movement. The transverse axis for llld8nlion and flexion movements extends through both femoral condyles. The longitudinal axis for rotational movements is positioned eccentrically and perpendicular through the Tuberrulum intercondylar& mediale. For the range of movement in the knee joint - page 276.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In addition to the hip joint. the knee joint is strained by the weight of !he body. Thus. degenemtive changes (gon•rthi"'Ohl are a common disease of the knee joint frequently requiring prosthetic substitution of the joint bodies. Since the knee joint lacks a strong muscuar guidance. lil,lurles to the ligaments and the menisci are common. These may partly be treated minimally-invasive by erthro-
272
scopy, a process that requires profound knowledge of the anatomy of !he knee joint. Dysplasia of the Patella or the femoral Facies patellaris may cause repetitive patelar IIDartlons. In addition to the exercise of the respective M. vastus medialis or lateralis. the surgical correction with tightening of the joint capsule (capsulorrhaphyl or displacement of the Lig. patellae is the treatment of choice.
Muscles _. Topography _. Sections
knee joint
Fig. 4.83 and Rg. 4.84 Knee Joint. Articulatio genus. rlaht llcll; with cloled joint c.~peu,. (... Fig. 4.63), end after opaning of the c.peule (... Fig. 4.64); ventral view. The ligaments of the knee joint consist of extermlllglments which support the joint from the outside, and int8rnelligemtWita which are positioned within the Capsula fibrosa. Here, the external ligaments are illustlllted. They comprise the Ug. patelae as the continuation of the tendon of theM. quadriceps femoris, and the Retinlet~ll patellae me· dill,. and a.t.r•le. Both of these latter ligaments hav& superficial longitudinal and deep circular fibres and can be viewed as parts of the t~
don of the M. quadriceps femoris (Mm. vasti medialis and lateralisl. Medially and laterally, there are two collateral ligaments (Ligg. colllrf:e. r•lil tibilll and fibulare) which insert in the 'Tibia and Fibula. The joint capsule encloses the articular surfeces. The HOFFA's fat ped !Corpus adiposum infrapatellare) is positioned between the Capsula fibrosa and the Capsula synovialis. This adipose tissue is connected to the anterior cruciate ligament by a fold, the Plica synovialis infrapatellaris, and laterally possesses two Plicae alares. The knee joint is associated with sev&ral burue some of which communicate with the joint capsule as shown here for the Bursa suprapatellaris.
_. dl•••etlon llnlc
273
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Knee joint
M. glllltl'cla1emh•. Olput lllllnl&
Ug. collllilllnll tiUin Llg. poplltllum --'111m
Ug. coll.-.tiblllla
4.85
Fern!'- QlnctJ!us medialis -
Ug. meniiCDfllmcnle f1081*'1ue Ug. colllhnlle tiblllle
H--
-~~·~~~~
M. semlmembnlnoeue, Tendo
I..Jf. popllteum ollllqwm
Fig. 4.65 end Fig. 4.68 Knee joint. Articelllrtio genua. right tide; with ciDsed Joint cepsulel~ Fig. 4.85), end .tter open.,., of1he capsule(-+ Rg. 4.88); dorsal view. At the rear side of the knee joint, additional exblrnelligementa sup. port the joint capsule. The Ug. popllteum obllquum projects medially and inferiorly from the late!lll femoral condyle, and the Ug. popllteum en:t~etum courses in the opposite direction, thus, crossing theM. pop. liteus. Of the two collateral ligaments, only the Ug. colllrterele tlbllll is connected to the joint capsule. The Ug. colllrterell ftbullre is ..-peratad from the joint capsule by the tendon of the M. popliteus. After opening of the joint capsule several Interne! lgements are visi-
274
~ dl•••ctlon llnlc
ble. The anterior cruciate ligament U.i$1. crucietum enteri111} courses from the inner surface of the lateral femoral condyle in an anterior diret> tion to the Area intercondylaris anterior of the Tibia. The posterior cnr ciate ligament (Lig. crucilrtum poeblrilll} courses in the opposite direction from the inner surface of the medial femoral condyle to the Area intercondylaris posterior of the Tibia. The Ug. menheclfiii'IOl'llle enteri111 (not visible here) and the Li8· meniecofemorale polteriul connect the posterior hom of the latellll meniscus (Meniscus latellllisl anterior and posterior to the posterior cruc:iate ligament with the medial condyle and, thus, support the posterior cruciate ligament.
Muscles _. Topography _. Sections
Knee joint
Rg. 4.87 and Rg. 4.88 lmer Cmedllll) colat:eralllgament, Ug. collltwall mediale, in exbanlion C- Fig. 4.67), and fllxion Fig. 4.68); medial view. Only lhe posterior fibres of the inner colhrtellllligamentCUg. collat.,. le tibille) are connected to the Meniscus medialis. In flexion, the co~ tortion of the ligament fixes the Meniscus medialis in its position. In contlllst. the latellll collate!lllligament (Lig. colaterale ftbulare) is not
c-
connected to the Meniscus late!lllis. Because of lhe larger llldius of cur.tature of the femoral condyles in the front. the collateral ligaments are stretched in the extended knee. This position therefore does not allow for rotational movements. In a flexed position of the knee. lhe collateral ligaments are relaxed due to the smaller radius of curvature of the femoral condyles at the back. thus enabling rotational movements.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The collate!lllligaments stabilise the knee joint medially and laterally. The medial collateral ligament (clinical term: MCtJ in particular stabilises against abduction. the lateral collateral ligament (dinical term: LCU against adduction movements. Injuries to these ligaments in-
crease instability and laxity of lhe knee joint. This phenomenon is utilised during physical examination to assess potential injuries to the collateral ligaments.
275
Lower Extremity
So.rfaoe orwrtomy ... Sb!Joc.>n ... hnouilljj ...
Knee joint
... ..
•
•
.......... ........ •........'**'"''' •• ...-.te Mcch t1D
11:1 11'1& . . . )H"'• • . . .. . , . )lfll't .... Me l*a4,'ill'ill) ¥lfiiCft tu'loiot\I.~W lOa fl IIt''&, )Mrt: lltOIWIOIWi',._..W,_ t..o a . Ql rrmta" lt» liiWWCIIN>• tiH' • .-rl4141'1:1-..on IT'ICHIMW!ta boll\~~ •• 11'1& ~ .l:lritb'........W . . , 7, ''??~flkWIHIII; ....,.,..........
1\1'1&......,.
llr ~h ~II'O~I'It ITI~afttll 1'11111. Clll.$» b at'I'IIIM jlaiDitefi'IICke ell ,.,...,... eil N flrtall ~ b .,...........,. , . t'iltiM #ltllt tfl'll'lllitr\ n • «Wt~tV:p»ittl\ e..~t I'I'IIO'JM P»-
Wtbtr'R ~4.11,_ fliJIIIi!Qn h a W1W11t lllf W.'l'hll> r...t;:n IT'ICHIMW!t ......... ~ tal~ at'ld 1!1111 ... IT'ICIIo"'l"' ~ ¥!!'lid\ h ~ tC:II!.f> to 1!1' p»>W.Mp atd I'IM bA'I'\ il\ tl» ~
r•..,
*' l"I"'QQWW''II'Rr " ' ...... elf "' .-..wb W\drw llllllllwrt- -~ -·~lnwlll'l:fll&wll//llf'-1(f. 4rnca ...... hrndll ~
~~lilt CCI"'IIiid: ~ . . medlf tl'llll'tli:UI. liltlioM If> to t 210" ..... t.. i~..., to 141:t' ~ jli'IIW:II> tllnlb'l'lt h hlltnltltra 1'1'11..:1'• tl). ,.,... . . . , II ~!:Ia \G tEO". ll'nlfled Cf'P/Illf 80ft~ eda 1&10/'i. . . . . . ."" 1D 1M , . .
'""* *"""*
w
~b.J~bt~M''!M, • . ,flyllojroo1&-.~
"""""N .. neldlAfu'lf; .._..4rnca.-....,c:lfttlt!Ne.__ N~ti'Ncdillts81_ .... Cllrl'9.,._~~
~ ~- N.I..AiiMI~it~to· ...... fld:tr!t
..,...,~.._twn*tt""I'J')III"'I;ttwtlt~.-.
tiiNJI.....,.IT\ . . . l!ltiiiiCn. Abet den w MCldcn ft~I'T'IOet fG!'to
"*WJ~ttdllojN~~
liOtl'•*
srrw "" tf'lllp4J d ""......,.. n ....., ~· d ""FIPI'U' n Tllll • 1'1011 ......... It IIHlllti!IIW fWncnf ~ t.t jftiOOI
....,..,.,.
~ Q) I'QifrW tNrllr ~·~~~~·~*·"' 1111'011> 111'011> f»Fwtu I'QIIItw~M•ao•l~tbtlrmll'lfllphaleolh_,_
b a...l "*'lk:oM:illdll ~tl)'\..0"'•10"
d t (.&itfilr ~ a t'C:IdO~ HIS ftd h
tr'WIIISif ~ tflr'l'lliflt n itt
...
a
a
fiiWIIiOo-.JI~C'\oO"'oo140'"
Muscles _. Topography _. Sections
Cruciate ligaments
Menl8cus medllll8
Ug. crucllltum .r1111rtue
Fig. 4.70 Knee joint. .Articelllrtio genua,. right side, in go•.ftexec:t poeition; ventral viWN; after removal of the joint capsule and the collateral ligaments. The most important inner ligaments are the two cruciate ligaments. The ••muiDr crucilrbl ligament {Lig. cruciatum anterius) courses from the inner surface of the la1eltll femoltll condyle in an anterior direction to the Area intercondylaris anterior of the libia (from a superior posteri-
L~.
or IBteltllto an inferior anterior direction). The posterior erudite Ilea· ment {lig. cruciatum posterius) courses in an opposite direction from the inner surface of the medial femo~t~l condyle to the Area interco~ dylaris posterior of the Tibia (from a superior anterior medial to a posterior inferior direction). Although the cruciate ligaments are positioned within the fibrous joint capsule (intra-articular) they are outside the Capsula synovialis and thus atr•synOYill
cruclltum polblftl•
ug.aucllltumanlelfus
b
Rp. 4.711 to b Stablhlrtlon of 1he knee Joint. .Artll:cjdo genua. right IIide, through collrt8r•l•nd crucilrt8 ligaments in ext8nlion (•), end flexion (b); ventral viWN. The crucia1e ligaments together with the collateral ligaments form a functional unit. The collateral ligaments are tense only during extension
of the knee and stabilise the knee in this position against rotational as well as abductiorv'adduction movements. In contrast, distinct parts of the cruciate ligaments are tense during all positions of the knee joint: the medial components during extension, and the IBt<ll components during flexion.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . After lil,lury to the cruclate ligaments the Femur can slide in sagittal direction similar to a drawer: anteriorly with injury to the anterior Cl'uciate ligament {clinical term: ACL; ••nterior drawer"' test), posteriorly with injury to the posterior cruciate ligament !clinical term:
PCL; •posterior dr.wer'" test). This is tested in the supine position of the patient. The examiner sits (fixes) on the foot of the 9D"- flexed knee and pulls the leg anteriOI'Iy or pushes it posteriOI'Iy.
277
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Menisci
Llgg. m.nl.c:ot.rnonlla
~ lnl poltwfu•
Fig. 4.72 Menilci of the lknM joint, right side; cranial view. Both menisci are roughly C.shaped and appear wedge-shaped in crosssections. The medill meniiCUI is larger and anchored via the Ligg. menilcotibilill 1nteriue and potlteriue to the respectiv& Area interoondylaris of the libia. In addition, the medial meniscus is fixed to the medial collateral ligament. In contrast. the llrt8r1l meniiCus is a~ chored via the Ugg. menhcof8moral.. entlrlus and potterfus to the medial femoral condyle, but it is separated from the lateral collatert~lli-
• Figa. 4.731 to c Sliding renge of the mlll'llilci,. Menilci, during flexion. In flexion, both menisci are pushed posteriorly over the rims of the tibial condyles. The mobility of the lateral meniscus is higher due to the reduced fixation.
278
gament by the tendon of the M. popliteus (... Fig. 4.77). The posterior hom is only indirectly and flexibly fixed to the libia via the M. popliteus. Anteriorly, both menisci are connected through the Lig. traniV8I'SIIm genus. As a result. the range of movement of the lateral condyle is i~ creased in flexion. Both menisci are composed of fibrous carilage inside and dense oo~ nectiv& tissue outside.
c
• extended position b, c flexed position
Muscles _. Topography _. Sections
Menisci
A.lnMtor llhnlll• genu•
fig. 4.74 Atblrialsuppt, of tile meniiCi, MeniiCi, right side; cranial view. The external por11Dns of the Menisci are supplied through a perfm• nillc.l network of blood vessels that derives from the Aa. inferiores
medialis and lateralis genus and from the A. media genus (branches of the A. popliteal. The Internal portions are devoid of blood vessels and are nourished by diffusion from the syncMII ftufd.
fip. 4.158 to d s ..,.. in 1he development of menillc.l tMrs. [4) • development of a longitudinal tear b elongation of the tear from the posterior to the anterior hom and shift into the joint rbucket handle. tear, b') or
c additional radial tear {N parrot beak N; often leading to a posterior or anterior hom awlsion) d llldialtear, latellll C-shaped meniscus most commonly affected
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Menilctla injuriee are common. The medial menilcua is affected most commonly due to its fixation to bone and capsule. Acute injuries occur during sudden rotational movements of the weighted flexed knee and result in a painful inhibition of active and passive extansion. Chronic degenerative changes often occur as a result of
malpositions. If the injuries affect the well-arterialised periphery of the Menisci, spontaneous repair is possible. Lessions of the centllllporlions frequently require an arthroscopic removal of the tom parts to restore free movements. Despite treatment. frequently degenerative changes in the knee joint (gonartilrosls) can develop.
279
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Knee joint
(Buru eUIII'Mclllle pnlplltelllrte)
Ug. COII11.1181'alt 1blalt
Ug. popltteum oblq.~um
4.TI
Fig. 4.78 •nd Fig. 4.TI Knee joint. AttictJIIItio genua. right tide, with bursa•; l81eral <~ Fig. 4.761and dorsal I~ Fig. 4.77) views; illustration of the anicular cavity by injec1ion of a symhetic polymer. The knee joint is surrounded by up to 30 bursae (BurMe synovill•). Some bursae communic81e with the joint capsule, such as the Bursa supte~patellaris (anterior sup&ri011 beneath the tendon of the M. quadriceps femoris, or the Bursa subpoplitea (posterior inferior) beneath the
M. popliteus. Other bursae are positioned in places with exposure to higher pressure le.g. when kneeling! such as the Bursa prepetellaris or the Bursa infrapatellaris. Some serve as gliding surface for tendons of muscles such as the Bursa musculi semimembte~nosi or the Bursae subtendineae musculorum gastrocnemii medialis and late1111is (both not shown).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . With extensive mechanical stress (actMties in kneeling position) inflammation of the bursae may occur (bui'Bitil). In the case of chronic inflammatOIY capsular effusions such as in meumatic diseases (e.g. meum81oid ar1hritisl. enlargement and fusion of bursae
280
may OCOJr which appear as swelling in the popliteal fossa. A fusion of the Bursa musculi semimembte~nosi with the Bursa subtendinea musculi gastrocnemii medialis is referred to as BAKER'• cyat.
Muscles _. Topography _. Sections
Knee joint, arthroscopy
Fig. 4.78 Endollcopic ex~~mi!Wtion l•rtflrOIICOPY) of 1M lknM joint. Arthroscopy allows the minimally-invasive acx:ess to the articular Cllllity to assess the intrasynovial structures of the knee joint and to perfoon minor repairs. 1 arttlrtl8cape 2 l'l· and ~lrtj-hflulcl
3 cc«
4 oc:ularandadlllltWb'~Cillo trilltiHTl
6
amerc~~t~~ra~.-
e antefDmediii8.CICIMe
7 adllltlonllllnnument
• Llg. crucllltum ant~~rt~•
Fip. 4..79 a to c Knee joint, Atticulltio gen111, rigJ!t side; arthroscopic images. a distal view in the femoropatellar joint .b medial ..new onto the inner tim of the lateral meniscus c anterolatellll view onto the anterior cruciate ligament
......
.....
patellar ridge: ridge between medial and lateral articular surfaces clinical term: Recessus sup!llpatellaris groping hooks
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Atlhi'OICOpils are frequently performed clinical procedures of the knee joint. They serve as dlagn0111c tools. e.g. if a rupture of a meniscus cannot be excluded by MRI. They are also used for tr..t·
ment such as the removal of tom meniscus parts, the repair of cruciate ligaments (a-uciate ligament reconstruction!, or to remove floating bodies which painfully inhibit movements.
281
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ligaments of the leg
.,....._.~.....-_
M•mlnn• . . . lliiCNitll
4.80
Rg. 4.80 and Rg. 4.81 Ugamarrts of tha1lbla. Tibia, and 1he fibula. FiDull. right side; ventral(-> Fig. 4.80) and dorsal{-> Fig. 4.81) views. The proximal Ligg. capitis fibulae anterius and posterius create an amphiarthrosis (Atliet~llrtio tibiofibularis). Distally, both bones are fixed by the Ligg. tibiofibularia anterius and posterius in a syndesmosis (Syndetm011111111Dftbullrll). Between both bones, the Membrana lnt•
cruris serves as an additional stabiliser with dense connective tissue and collagen fibres, which predominantly course obliquely dow~ wards from the libia to the Fibula. Together with the inferior articular surface of the libia, the medial and lateral Malleus form the 11111leollr forte. The latter provides the socket for the ankle joint. OUN
"
malleolar fork
Fig. 4.82 Diltal end of the tibia, Tabil, and fibula, Fibula, right !Ide; distal view.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Proximal fractures of the Fibula in the region of its head and neck are referred to as MAISONNEUVE fracturas. Fractures of the distal end of the Fibula are called WEBER fracturM which are classified in three degrees (-o Figs. 4.107 to 4.109)
282
depending on the i11110Jvement of the Syndesmosis tibiafibularis. All fractures are treated surgically with plates and screws because minor alterations in the joint position of the ankle joint can cause degenenJtive changes larthrolll).
Muscles _. Topography _. Sections
Ankle joint
Llg. col..._.~ [.IIDIIMmiJ, ---l,.,~~ P1n tlbloCIII!ril pomrtcw Ug. colllltlnle medlllle l•IDideumJ, ,... tlblocelca'Me Ug. 1110c81c8neUm I)OIIQ8Rls
Rg. 4.83 Ankle Joint (tlllocnll'al Joint). Artlculdo tlllocrurall. right IIide, with liQ~~menta; dorsal view.
F'llrts of the Lig. collste1111e mediale (F'llrs tibiotalaris posterior, F'llrs tibiocalcanea) and the lateral Lig. talofibulare posterius support the joint from the posterior side.
Mal leal.. medllllll
Fig. 4.84 Diltal end of theii)i-. Tabil,. and fibull. Fibull. right !Ide; distal view.
Tibia and Fibula are connected through the Syndesmosis tibiofibularis and together form the malleolar fork. the socket of the anlde joint.
283
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ankle joint
Flbclla Pin ttblotalln
Pin tlblocak:llnlll. Pin ttblolalalfa antllrlat
I..Jg. collllllt'ale mldllll [deltoldeumJ {
Pin ltiaravlculortl
4.815
Ug. talocalcaneum ~m Llg. cuboklllaniiVIculllre dcnale
Mallllolualal8nlll
Ugg.m~la
4.86
U'an8Wr8a II'QfUnda
Ug. blfll'eltUm
Rg. 4.85 end Rg. 4.88 Ankle )Dint (talocrun~l fc*ltl. Articulatio talocrul'lllia,. right side, with ligaments.: medial {-> Fig. 4.85) and latetal (-> Fig. 4.86) views. The movements of the foot take place in the (uppeo ankle joint and in the Ooweo talocalcaneonavicular joint. The 01her joints of the Tarsus and Metatarsus are amphiarthroses which increase the nmge of movement of the talocalcanaoniJIIicular joint to a certain extent. In the ankle joint, the malleolar fork constiMes the socket and the trochlea of the
Talus the ball of the joint. Medially. both joints are stabilised by a fa~ shaped radiation of ligaments that is referred to as Lig. callat•ele mediele (deltoideum) and consists of four parts (Pars tibi01alaris anterior, Pars tibi01alaris posterior, Pars tibiocalcanea, and Pars tibionavirularisl which connect the respective bones. There are three single ligaments on the lat_..l side lUg. talaflbulare enterlus. Ug. taloftbulal'll posterfua. Ua. celceneaftbularel. These ligaments provide additional stabilisation of the talocalcaneonavicular joint.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Injuries to the ankle joint are more common than injuries to thetaligamentous support in the malleolar region is n01 very strong. Since the trochlea of the Talus is wider in the anterior than the posterior part {-> Fig. 4.37). secure guidance of the bones is only guaranteed in dorsiflexion ~extension) localceneonnlct~llr Joint because the
284
with distension of the malleolar fork. The most common ligamentous injury in the human is the tear of the lateral ligaments llig. talofibulare anterius and Lig. calcaneofibularel in hypersuplnatlon treume.
Muscles
~
Topography
~
Sections
Talocalcaneonavicular joint
aJneacubaldeum dcnale
---n.-..-- 0. c!Dllcleum
Ug.c:aJc:aneoc:!DliCMUm Clllcllllllana!CIA-} U Q• blf~m ,..._ _ _ Ug.
Artleull'llo tllloCllk:-cnMI:ul...
Llg. tlll~m 11rm~~v.-1m~
Ug. callllerale medal& (dellalcleum]
4.87
Fig. 4.89 TaiOCIICineonhicular joint, Articulrio talocaiCineorurwicularis. proximal fc*lt bodies.. right slda; distal view.
4.88
Rg. 4.87 and Rg. 4.88 TalocaiCineonnfcullr Jc*d, Articulatio talocalcaneonavicullrill. dilltal joint bodias, right tide; proximal 1... Fig. 4.871 and la1ernl (... Fig. 4.88) views after removal of 1he Talus. In the talocalcaneonavicular joint, Talus, Calcaneus and Os navirulare articulate in two independent join1s. The posterior joint (Articulatio subtlllarlst is formed by the pos1erior corresponding altirular surfaces of Talus and Calcaneus. This paltial joint is sepamed by the Ug. talocalcaneum intero~Uum, positioned in the Sinus tarsi, from 1he an1~ rior partial joint tArtlculatlo talocaiCineonnlcularh). In the anterior paltial joint, the anterior articular surfaces of Talus and Calcaneus articulate as well as the head of 1he Talus articulates wi1h 1he Os navicula-
re anteriorly and with the Ug. calcan80118Vtcullra plantllre inferiorly. A1 this contact point 1he latter shows an articular surface of hyaline cartilage and contribu1es to 1he plantar arch. Both parts of the join1 crea1e a func1ional unit and are often collectively referred to as Ar1ku· Lltio taiOCIICineonhiculeril. In addition to the ligaments of the ankle joints, there are several ligaments Ymich stabilize the skeletal elements of the talocalcaneonavicular joint. Besides the Lig. talocalcaneum interosseum, these are the Lig. talocalcaneum medial& and the Lig. talocalcaneum lateral& 1-+ Figs. 4.83 and 4.86). For the range of movement in the talocalcaneonavicular joint ... Figure 4.92.
285
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Joints of the foot
Ug. Clllc.l....v!CUI-pl~
Sllltenlacuklm tall
Rg. 4.90 Joints of the foot. Artlculltlones pedis,. right llde. wttfl lipments; plantar view. The remaining joints of the Tarsus and Metatarsus are amphiarthrous which only minimally contribute to !he movement of the foot. Together however, they extend the range of movement of the talocalcaneonavicular joint and transform !he foot into an elastic base. At the Tarsus. two joints can be emphasized which contribute to supination and pronation mOV&ments of the foot. The CHOPART"a joint (Articulatio tarsi transversa) is composed of the Articulatio talonavirularis and the Anicul81io calcaneocuboidea <~ Fig. 4.33). The USFRANC's Jc*1t (Articulationes tarsometatarsales) is the connection to the Metatarsus 1~ Fig. 4.33). These two anicul81ion lines have clinical rel811ance as important amputation lines. The metatarsal bones articulate in several separate joints. The metatarsal bones are connected proximally by the Articulationes lntarm•
286
tlrtii'SIIas and distally by !he I.Jt. metatar~~le1rlnsversum prclfundum. The joints of forefoot and midfoot are linked by strong plantar, dorsal. and interosseous ligaments. The CHOPARrs joint is stabilised dorsally by !he Ug . .bluratum which divides into two ligaments (Ug. calcaneonalliculare and Lig. calcanaocuboideum. ~ Fig. 4.87) and is opposed on the plantar side by !he Ug. c.lcaneocuboldeum plantara. Tog81her wilh the Ug. calcaneonallirulare plantar&, the I.Jt. plantare longum serves to stabilise the plantar arch. The latter is more superficial than the other plantar ligaments and spans from the Calcaneus to the Os cuboideum and the Ossa metatarselia II-IV. The digital Joints can be categorised in metataraophalln1111 joints (Artirulationes metatarsophalangealesl and in proximal and clltal Interphalangeal joints (Articulationes interphalangeae proximales and distales). The range of movement in all digital joints is limited by tight collateral ligaments (Ugg. collateralial and inferiorly by the Ligg. plantaris.
Muscles _. Topography _. Sections
Joints of the foot
M. til lA- [plftlneu~]langu., lllndo
M. Ublllla poltelfar, lllndo
Rg. 4.91 Joints of 11te foot.. Artlculltlones pedis.. right llde, wtth lipi1'MII'Ib; plantar '.li91N; attar removal of the Lig. plantar& longum.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The most common deformity in the first metatarsophalangeal joint is the hallux velgus.. in which the head of the first metatarsal bone deviates and protrudes medially, whereas the big toe {halluX) is adducted latetally. This condition may cause seV8!'e pain in the metatarsophalangeal joint and may cause soft tissue swelling. This frequently requires surgical correction. Current therapeutic a~
preaches attempt to correct the deformity by patalysing the adducting muscle IM. adductor hallucisl with injections of botulinum toxin. In the hammer toe deformity, the proximal interphalangeal joint is fixed in a flexed position. In cl.rw toe deformities, the metatarsophalangeal joints are hyperextended and the proximal phalanx may even slide above the metatarsals.
287
Lower Extremity
So.rfaoe orwrtomy ... Sb!Joc.>n ... hnouilljj ...
Ankle joirrt and o!her joints of !he foot
,)/
~
~
I' I'
,
•
~
-
' ~..
\J
I
I
.
.. .~'
I I
I
"-..! ...
•
·,
...
-
-
__ ,.. ....
.-.d..........
I ..
•
•
.........,........,_,., ..... ""* ac;a NfliOIWt~T•'IIIU N
All1181ofiM
• 00111"
toMi& ...... ,..,...1 f''S ""*d.tl~ N
, .,. . 1 :L a f)lllal: t Wlllol1-l*i•t • ":.,...O't-
'•l(e
• ..,.. -*'"*"' .. tl:l tt.,....
Muscles _. Topography _. Sections
Plantar arch
Talus
•
Oan!IK:t points tofbar
Rgs. 4.9411 and b BOOH of 1he plantar ardt. rtatrt side; dorsal lal and plantar (b) views. IJ\Ihile the heads of the metatarsal bones are positioned in the plantar plane, the Ossa cuneiformia, Os naviculare and Talus. particularly towards their posterior aspect, position themselves on top of their lateral skeletal parts, resulting in the Talus to be placed on top of the Calcan•
us. Thus, a medially open longitudinal arch is formed. The tr'IIISVIII'M arch of the foot is formed by the wedge..shaped Ossa cuneiformia and the bases of the metatarsal bones. Due to these arches, the foot has only three contact points with the floor: at the heads of the metatarsal bones I and V and at the Tub91' calcanei.
Rg. 4.95 Ugamerrts of 1he longltuclfnal plantar arch. rlatrt llde: madill viw.r. The ligaments of the foot passively maintain the longitudinal arch of the foot. They are actively supported by the tendons of the M. tibialis posterior and M. fibulatis longus(-+ Fig. 4.1481 and the short muscles on the sole of the foot. These supporting struc1ures provide the tension
band syltem to counteract the body weight. The ligaments can be categorized into three superimposing levels: • upper level: Lig. calcaneonaviculare plantare • middle level: Lig. plantare longum • low91' level: Aponeurosis plantaris
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Foot deformities are v91Y common. The most common deformity of the extremities is the congenital clubfoot in which the foot is fixed in plantarflexion and supination. This position is caused by an insufficient regression of this intrauterine physiological position (-+ p. 132). More frequently are the adult deformities caused by a
failure of the ligamentous support system. The acquired fllrtfoot buckles medially because the Talus is displaced inferiomedially. This in tum forces the heads of the metatarsal bones apart and results in floor contact of the metatarsal bones 11-V. This may cause painful compression symptoms at the sole of the foot.
289
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Pelvis
Alaoeelellll
Ostlmlm
lllbef 18ctllldlcum
Rg. 4.98 Pelvis of • men: radioglllph in an1eropos1erior (API beam projection; uprigh1 standing position.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Plain radiological images of the pelvis are taken frequemly. They help to diagnose frectures and melposlllons of the skeletal elements of the hip joint and the pelvic girdle. They also enable the detection of
290
degenerative changes (artflroeil) or local alterations of the bone. such as metata11.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Hip joint
Co!pus 01118 Ill
*
Colum femCifa TI'OC:IIIIllUif ITlljOf
Fig. 4.97 Hip joint, Articulatio COde, right lide; radiograph in anteroposterior lAP> bEHJm projection; upright standing position.
• clinical tenn: roof of the acetabulum "" clinical tenn: notch at the roof of the acetabulum
.~~~--~+-rncll~n lllchlldlca
mtlor
Fig. 4.98 Hip joint. Articulatio ccxae. right lide; radiograph in LAUENSTEIN projection (abdue1ion and flexion of the thigh in supine position).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Suspecting a disease of the hip joint. specialn~diogn~phic images in various joint positions can be performed. such as the LAUENSTEIN
proJection in abdue1ion and flexion of the thigh for a bettar assessment of the joint bodies.
291
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Knee joint
FM!Ur, Oondyll&lllteralls
=~medal&}
lllben:ut~n~
Erdnemla rtwoondylalls
lntercand)'lln lllenlle
Unee. eplp!lyltlllls
4.99 QxpuafemCIII
4.100
Rg. 4.99 and Rg. 4.100 KnN Jc*d, Articulatio genus. radiograph in anteroposterior lAP) beam projection(~ Fig. 4.99) and in lateral beam projection(~ Fig. 4.100); in supine position.
flbullle
It has to be considered that the contours of the medial and lateral fetTIOral condyles are not congnuent.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Conceming diseases of the knee joint. radiographic images are generally taken in two planes. The anteroposterior {API beam projection allows for the assessment of the anicular CIJIIity and the socket
292
of the libia. The femoral condyles, howEMI!', are better inspected in lateral beam projection. In addition to fractures. also malpositions, and degenerative diseases such as gonarthrosis can be diagnosed.
tahir99-VRG & vip.persianss.ir
Muscles -+ Topography -+ Sections
Knee joint M. VIIIIIUS 111181'1118
·-
Condylus
capsula allculnl;
M. gulnx:namlus, Tendo
Femw, Condylus rrwdala
L.lg. collalilrale
M. papllllu..
tl. . . M..lll_
Tendo
mlldlalla lbla,
Cordytl• medialis
F - arllc~llllo a.....,a.
Condylus llltlnla M. .~ lllllnlfll, (Carnu aniBrluB) CCJrpua adlpcaLITIInll'apalelln
4.102
Llg. pabtlllll
Fig. 4.101 Knee JHII. Articulatio genus. rl_.. lkle; magnetic resonance imaging (MRI) sagittal section; ventral view.
4.103 4.104
..
" ntercandyla..
Ug.cruclllllum
..-.;
--
L.lg. cruclalum pwlariua
Llg. crucllltUm ~
Alea lntercordylai'B
h ten:cnd)1alls
4.103
~
4.104
Fig. 4.102 to Fig. 4.104 KnM joint. Articulatio genua. right side; magnetic resonance imaging (MRI) sagittal sections; medial view. Compact bone appears dark with this imaging t echnique.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Injuries to ligaments and menisci of the knee joint cannot be imaged with conventional radiographic techniques which only detect bony structures. In case of suspected soft tissue injury, m•gnetlc , _
n•nce i11111ging IMAQ is perfom1ed. If this technique does not dearly exclude injuries, endoscopic diagnostic procedures (•rthroscopy; ... p. 281) should be considered.
293
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Ankle joint and talocalcaneonavicular joint
Fibula lblll.
Malleolus medllll8
4.105
Fibula
11bla
1\'octllee.tal Malleolus medlal8 Pr!x:. paetellor tall
AltiCUIIIII!o eutltllllrta
Columtall Clp.Jttall ArtiCUIItfo
SUIIC8ntaCUium tall
tii10CIIIc8t-II'WICUIIte :;:::::::::;::- - Os navlcUIIW
4.106
Fig. 4.105 and Fig. 4.106 AMie joint (talocfural joint), and talocalcllneonnlct~lar fc*d. Articulationes tllloauralll and talocalcllneonnlct~larlll,.
right side; radiograph in anteroposterior
lAP> beam projection(- Fig. 4.105). and in lateral beam projection 1- Fig. 4.106).
294
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Fractures of the ankle joint
4.108
4.107
Fig. 4.107 •nd Fig. 4.108 Ar*le joint (t•loctural joint), Articulatio talocruralls,. right side. with llllleol•r fracture CWEBER type B); tadiogtaph in anteroposterior (AP) beam projection{... Fig. 4.1071, and in latetal beam projection {... Fig. 4.1 08). [17) Fracture lines are marked with arrows.
MalleoiU8 medlllle
WEBER A
WB:IERB
WEBERC
Rg. 4.109 Clasllcdon of ankla Joint fraeturas according to WEBER typea A. B. •nd C.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Ftactures of the distal end of the libia are called WEBER fractur. . and- depending on the involvement of the Syndesmosis tibiofibulltris- further classified in three types: • WEBER A: The Malleus la1eralis is fractured beneeth the intact syndesmosis.
• WEBER B: The ftacture line goes through the syndesmosis which may be injured. • WEBER C: The ftacture is located above the tom syndesmosis. A WEBER C fracture results in a severe instability of the ankle joint.
295
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Fascias of the lower extremity
M.1111necrt.ca.
111.1»
Margofak:lfolml8
- -------E•I
M.glMiti'OalemiU8
Retfnacui~MT~ mLIICUiorum ~ma'4*f18
- +--
4.110
4.111
Rg. 4.110.nd Fig. 4.111 flllclae of 1he1hlgh. Fasci• IIIIU, tr.
lag, Felcila e~uril,. and the dorsum of the foot, Faacie doruil ptldill,. right lide; ventral(~ Fig. 4.110) and dorsal{~ Fig. 4.111) views.
296
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Muscles of the hip and lower extremity
M.ll~
{
M.II~s
M. peou mlljef -+.~
M.graclll
Rg. 4.112 Vent111l miiiCias of the hlp. thigh end leg. right llde.: vemral view.
1-+ T 42. 44. 45. 47, 48 I 297
Lower Extremity
Surface anatomy -t Skeleton -t Imaging -t
Muscles of the hip and lower extremity
M. gllt8U8 mll)dmus
M. g111811'0Cnemlus
Rg. 4.113 Donal miiiCIM of the hlp. thigh and leg. right llde; dotSal view.
l-tT43.48,4t
298
I
Muscles _. Topography _. Sections
Muscles of the hip and thigh
M. cblqUI.I8 llillt8ml.l81bdCITinl8
Rg. 4.114 MLBCfes of tt. hlp •nd thigh, right side: late!lll view. The Tr•ctua iliotibiail serves as reinfo~a~men1 of the fascia of the thigh (Fascia lata) and connects the ilium with the Tibia. It count&l'balances the body weight-induced medial forces on the thigh bone.
This principle is ref&l'red to as temlon blind effect.
299
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
Muscles of the hip and thigh
(M. pao• mt~. line»
fcnmen tnfraplr!fanne)
Foramen 18ctllldlc:um minus
llJbet llct111dlc:um
M. gt~UUS mum us M. blc»pe femcrlt, OIIPJt IOngum
M.lldcluc!Dr m~nta
Fig. 4.115 Mllld• of the hip •nd thigh., right side; medial view.
300
~
Muscles _. Topography _. Sections
Muscles of the hip and thigh
4.117a
I
M. adl:luctar langu.
4.118
Fig. 4.116to Fig. 4.118 v.ntral miiiCIM of1fle hip and 1fligh and medial mllldas of the thigh. right side: vamral view. The muscles of the hip and thigh are equally important to erect the body from the supine position, to maintain an upright position, and for the normal gait. The verrtnll musclas of the hip comprise the M. iliopsoas<- Fig. 4.116) which functions as most importantfttlll.or of the hip. Located at the lateral thigh, the M. tensor fasciae lata& 1- Fig. 4.117al functions as tantlon bind via its insertion on the iliotibial tract and protects the thigh bone from fractures by reducing bending stress. Together with theM. sartorius 1- Fig. 4.117a), theM. tensor fasciae lata& flexes the hip joint. Due to its innervation, the M.
I
tensor fasciae lata& is also counted among the dorsolateral hip muscles. The four-headed M. quadriceps femoris (... Fig. 4.117b) is the only ax· u.-or of 1he U.a joint and is essential to arect 1fle bocfr from a squatting position. Its M. rectus femoris spans two joints and also flexes the hip. Located medially. the muscles of the adductor group (Mm. adductores, ... Fig. 4.1181 are the most important adductors of the thigh and stabilise the hip during standing and walking.
I-tT42-451 301
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the hip and thigh
M.lr.,_ {
M.
~map
M.IIIIICUa ---,:Ffr-
M. 'VIIItua medii! Ia
Ug.palellu
Fig. 4.119 Ventral miiiCias of the hip and tlrigh, and medill mllldas of the1Ngh. right llde; vamral view; after removal of the Fascia lata ventral to the Tractus iliotibialis. The M. iliopeoala is composed of two different muscles which originate from the lumbar part of ltle vertebral column {M. psoas! and the Fossa iliaca (M. iliacus). Inferior to the inguinal ligament. only a short portion of both parts of the muscle courses to the common insertion site at the Trochanter minus. The M. urtoriua is ensheathed by a split portion of the Fascia lata and Cl'osses the anterior aspect of the thigh to insert at the medial aspect of the Tibia posterior to the transverse axis of ltle knee. Thus. it flexes the hip and the knee. Medially. the muscles of the edductor group are located on top of each oltler in several layers of which only ltle superficial M. pec1ineus,
302
M. adductor longus. and M. gracilis are visible. The four heads of theM. quedrlclps femoris IM. rectus femoris, Mm. vasti late1111is, medialis, and intermedius) lie distally and late111lly of ltle M. sartorius. Their co~ mon tendon incorporates the Patella as a sesamoid bone before the fibres continue as Lig. patellae to the Tuberositas tibiae. Most laterally, the M. teniOf f111ciH latae inserts in the Tractus ilia. tibialis. The common insertion of the Mm. sartorius, gracilis, and semitendinosus inferior to ltle medial tibial condyle is often referred to as the NPes anserinus superficialisN.
Muscles _. Topography _. Sections
Muscles of the hip and thigh
Rg. 4.120 Ventn1l miiiCias of the hlp •nd thigh. •nd mlldlal miiiCIM of the tlligh. right side; vantral view; after removal of the Fascia lata, theM. sartorius, and the M. tensor fasciae latae. After removal of the M. sartorius, the entrance to the •dduetor CIUI81 (Canalis adductorius) is visible which is demarcated dorsally by the M. adductor longus. In its anterior portion, the canal is covered by the Septum intermuscular& adductorium which connects the fasciae of the M. vastus medialis, Mm. adductores longus and magnus.
The four heeds of the M. qultdrlceps femoris (M. rectus femoris. Mm. vasti lateralis, medialis and intermedius) are located laterally to the a~ ductor canal. •
The fourth head of theM. quadriceps femoris. theM. vastus intermedius, lies beneath the M. rectus femoris.
1-+ T 42. 45, 481
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In the case of conditions such as spasticilt or dystonil, which involve a permanently flexed hip joint due to the contraction of the M. iliopsoas, standing in an upright position is impossible. Therapeutically, the M. iliopsoas is paralysed by injection of botulinum toxin which relaxes the muscle by blocking cholinergic synapses.
Considering the course of the musde, it is obvious that only a small portion of the muscle fibres can be blocked by injection from beneath the inguinal ligament. Therefore additional injections into the lumbar parts of the M. psoas major may be required.
303
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the hip and thigh
M.-=rt~a
M.Wituamedlda
Fig. 4.121 v.ntral miiiCias of the hip •nd tlligh, •nd deep medill mllldas of the1Ngh. right llde; vamral view; after removal of the Fascia lata, Mm. sartorius, rectus femoris, and adductor longus, and partial removal of th& M. iliopsoas at the ar&a of th& hip joint. The M. rectus femoris and a part of the M. adductor longus are reflected superiorly. After removal of th& M. rectus femoris, th& M. YMiua intllrmediua of th& M. quadric&p& femoris is visibl&. The resection of the M. sartorius and M. adductor longus reveals the deep adduo-
304
tor musd&s, the M. 1dductor brevia and parts of the M. 1dductor m1g1U1.
• common insertion of the Mm. sartorius, gracilis and semitendinosus
I~T42,45,461
Muscles _. Topography _. Sections
Muscles of the hip and thigh
M. vutu. llllenlll
M. 8lltllrlus, Tendo (PM anll«fl1l• 8Upe!\'lclall8)
{
Burw. aublencl~ muacull8lltllrll
M. gra.cll8, Tendo M. 1111mb!1dk'!c.ua, 1llndo
Fig. 4.122 Ventral miiiCias of the hip •nd thigh, •nd deep madill mllldas of the tNgh, right side: van1ral view; after almost compl81e resection of !he superficial and some of the deep muscles. Upon reflecting the superficial adductor muscles and the M. adductor brevis laterally, the M. adductor magnus becomes visible. Its upper portion is also referred to as M. adductor minimus. The M. adductor magnus and its tendon form the adductor hiltua (Hiatus adductorius) through which the blood vessels of the !high IAN. femoralis) pass to reach !he popliteal fossa. Proximal, !he insertion of the M. iliopsoas at the Trochanter minor is recognisable after resection of the M. pecti-
neus and M. adductor brevis. The C.naliaobturatoriua is displayed as opening wilhin the Membrana obtu111toria. It serves as neurovascular passageway between the small peMs and the thigh. Caudal of this opening, the almost horizontal fibres of the M. o.bturatoriua extarrue and the M. quadrftlls femoris are revealed, both of which belong to the pelvitrochanteric group of dorsal hip muscles (-> p. 306). These muscles are often not displayed during the dissection dasses and thus, their dasses is more diffirult to envision.
1-+ T 42-45,47 I 305
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the hip and thigh
M. gllt&Ut
maxml.8
M. gllt&Ut mtntmU8
M. gemeiiU8 1Uperlar
M. qf.ll(ftt'U8 femclrl8
4.124 4.123c
Rp. 4.1238 to c Donal miiiCIM of the hlp. right llcle: dorsal view. The dorsal muscles of the hip are categ«ized in a clorsolaternl and a peMtrochanteric group. The dorsolateral group comprises the Mm. glutei maximus. medius and minimus. According to its innSMJtion. the M. 18n101" faclae letae (-+ Fig. 4.117al also may be counted among this group. The M.gluteus maxim• (-> Fig. 4.123a) is the most important ext8n11Cr' and llt8ral rotator of the hip and for example necessary when climbing S1airs. In cont~t~st. the smeller gluteal muscles (Mm. glutei medius and minimus. -> Figs. 4.123b and c) are the most important ebductora and medial rotators of the thigh. Their action stabilises the hip during standing and walking and prevents the tilting of the peMs to the contrnlaternl side when standing on one leg (for the function of the small gluteal muscles and the TRENDELENBURG's sign-+ p. 3351. The pelvitrocbent8ric group (M. priformis, Mm. obturntorii intemus and extemus, Mm. gemelli superior and inferior, M. quadrntus femoris -+Fig. 4.123cl comprises exclusively llterel rotators.
306
Fig. 4.124 Doi'NI Cllchlocn~reL hllllltrlniJ) mllldls of the thigh. right side; dorsal view. The dorsal (ilchiocn~rel,. hamstring) ml.llld• (->Fig. 4.124) on the posterior side of the thigh originate from the Tuber ischiadirum and insert to both bones of the lower leg. These muscles span two joints and facilitate extension in the hip joint while serving as strclngat ftiiiCDI'S in the knee joint. In addition, the lateral M. bll:eps femoris functions in llt8rel rotation on both joints. whereas the medial M. semitendinosus and M. Rmlmembnlnosus function in medial rotation.
1-+ T 43,44,47 I
Muscles _. Topography _. Sections
Muscles of the hip and thigh
Rg. 4.125 end Fig. 4.126 Doi'MI muscles of 11te hlp end 'high, rigM side; dorsal view; after splitting of the Fascia lata (-> Fig. 4.1251 and separation of theM. gluteus maximus (->Fig. 4.126). The illustnrtion shows the superiicial and the deep origins and insertions of the M. glldeu~maximuL Superficially, the muscle originates from the posterior side of the sacrum, the Crista iliaca and the Fascia tho1'8Columbalis as well as deeply from the Lig sacrotuberale. Its muscle fibres course in an oblique way, whereas the M. glldeu~ mecius beneath has an almost vertical orientation. The M. gluteus maximus has superficial insenions at the Fascia lata and the Tractus iliotibialis and deep insertions on the Tuberositas glutea of the Femur. Separation and lateral reflexion of the M. gluteus maximus reveals the other pans of the M. gluteus medius and the pelvtlrochanterle muldes. The M. piriformis divides the Foramen ischiadicum majus into the Foramina S«!praplrlorme and lilfreplrtfonne which serve as important passageways for neurovascular structures from the pelvis. It should be noted that theM. obtur.t:ori• imerru• frequently continues as a tendinous structure from its deflecting point (hypomochlion) at the lnciSI.Jra ischiadica minor to its insertion at the Fossa trochanterica.
I_. T 43,44,47 I
4.125
Foramen { (Fcnmen ..,.piriforme) lllchlldlc:um ml!ue (Fcnmen llnhplrttorme)
Sl)tlal8cMidlca - --f'i:lHIIfi
r:-r,., lldllldlc:um
mn..
- --+•
M. ~UI ln1ilmul
Ug.IIIICI'OUielllll
BI6M. trochal!lelfca
m~.~~a~ll gt~te~ miiXIml
M. gklteU8 mllldmus M. adduc1a'm1QML8 ---+--~. M. aembnclk'lc.ua
- -+
4.128
M. adduda' mlrfmua
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the hip and thigh
M. geme11.. aupertar M.-~111111&
M. gemelh.18 lnfwlar
M.gh.«et.18mulm..
M. blcepa fllmortl, caput lan;um
M. Q11111'0CI'Uif111.., Caput lltnl•
Rg. 4.127 Donwll mi.IICIM of the hlp and 1111gb. right side; dorsal view; aft91' partial resection of the Mm. glutei maximus and medius. After cutting theM. gluteus medius in addition to the M. gluteus maximus, the M. gluteus mlnhus is visible. Collec1ively, the Mm. glutei medius and minimus ar& r&fMed to as 1m111 glutMI mllld-. Both muscles serve for hip abduction and stabilisation of the peMs during one-leg stand. The dorsal side of the thigh contains the hlmstring mlllelas which span from the Tub91' ischiadicum to the bones of the Iemar leg. Located
308
medially is the M. semltendiiiOSUIJ (named aft91' its long tendon) and beneath theM. Hmii1'HIIInbranGIUI {named after its flat tendon); positioned laterally is the M. bictlpe famaria. The Caput longum of the latt91' originates from the Tuber ischiadirum, whereas the Caput breve originates from the distal thigh (labium laterala of the Linea aspera).
Muscles _. Topography _. Sections
Muscles of the hip and thigh
M. Obt'lntcii1.18IM«I1lS. Teneio
au,. tloct1111118rtc1l mU~CUII giLD! medii
B11111.11iehlll.dlca mUICUII obt'Url.tcl111meml B~ trochanlelfca mU8CIAI glutei mulml
M. llopsoas, Tendo
M. gluteu8 muhn•
M. edductcr mlnlmue
M.gnclle
M. blclpe tei'IICiffa, Clput lon;um
Rg. 4.128 Deep dorMI muiCIM of1he hlp and thigh, right slcll; dotSal view; after almost complete resection of the superficial gluteal and hamstring muscles. Upon splitting the M. quadratus femoris, the deeper M. o.bU'Irtorfus extemus is visible; its course is often difficult to imagine. Removal of the long head of the M. biceps femoris exposes !tie deep components of the adductor group. The M. adductor magnus has two functionally independent muscle parts with distinct innervation. Its major compo-
nent originates from !tie inferior pubic n~mus (this part is sometimes referred to as M. adductor minimua) and the ischial ramus. The post&rior part derives from the Tuber ischiadirum and, according to its funotion and innervation, is counted among !tie hamstring muscles.
1-+ T 43,44,48.47 I
309
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the thigh
---M.gi'IICIIIe,ll!nl» M. 881111melltl!WloiMJ8, Tendo
4.129
M. YllltUSIII.teralls
M. MmlmlmllrlinOMJI, - -iH+-f..Jo'JIIl!\11\111.\
lllnl» (PM e.-In ~a profwu:l11)
M.gi'IICIIII, lllndo - -IH
4.130
Rg. 4.129 •nd Fig. 4.130 MIIICIM lil1he region of the knee Joint, right lide; medial(-> Fig. 4.129) and dorsal(-> Fig. 4.130) views. The common insertion of the Mm. sartorius, gracilis. and semitendinosus benealh the medial condyle of the Tibia is referl'8d to as NPes ansa-
310
rinus supetiicialis•. The deeply located insenion of the M. semimembranosus is called "Pes anserinus profundus".
I~T45-471
Muscles _. Topography _. Sections
Muscles of the leg
o-i-l,_.-:-'-+--
..
M. flbullu1a [peraneua] ,~
4..1331
4.132
Fig. 4.131 to Fig. 4.133 Mllldee of the leg. right side; ventral 1~ Fig. 4.131), lateral 1~ Fig. 4.132), and dorsal<~ Fig. 4.1331 views. The leg has three muscle groups. To understand their function. the position in relation to the axes of movement in the joints of the ankle and foot are imporlllnt. All muscles coursing anterior to the transverse axis of the ankle joint are ext..-.ors (dorsiflexors), all musdes dorul to this axis are flexors (pllntarflllllont) of the foot. All muscles with tendons coursing medial to the oblique axis of the talocalcaneonavicular joint function as supinatora and lift the medial margin of the foot. Muscles with tendons lat8ral to this axis lift the lateral margin of the foot and thus perform pronltlon. The ventral muscles of the leg function as extensors (... Fig. 4.1311. They extend the ankle joint and the talocalcaneonavirular joint. together with the other joints of the foot, they mainly support pronation. The M. tibilil anterior is the most important extensor (-+ Fig. 4.1311. whereas the M. extensor dlgHorum IIDngus and M. ttKtensor halucfsiiDngus also extend the toes. The lateral (fibular1 muscles of the leg(... Fig. 4.132) comprise theMm. flbul1rls longus 1nd bre'llh. They are the most important pronators
and function as plantarflexors in the ankle joint due to their tendons positioned behind the flexion-extension axis. Dorsally located are the true flexor muscles (plantarflexors) which can be divided in a superficial and a deep group. TheM. triceps sunte (-+ Fig. 4.133al is pal1 of the superficial dorsal muscles and comprises the two-headed M. ea11rocn1mlus and the M. IOieus beneath. The M. triceps surae is the strongest flexor and major supinator of the foot. TheM. pl1nterls is rather insignificant. The deep dorsal muscles (flexors; ... Fig. 4.133bl are largely equivalent to the extensors on the ventral side. The M. 1ibielil poftlrior is a fl&xor and a strong supinator. The M. flaxor dlgltorum longus and M. ftaor hllluciiiiDngua flex the phalangeal joints. A special role has the M. poplit8ua which stabilises the knee joint. Above the medial Malleolus. the tendon of the M. flexor digitorum crosses the tendon of the M. tibialis posterior (CIIi...,... cruril) and at the level of the sole of the foot, it aosses the tendon of the M. flexor hallucis longus ICIIiame pllntere).
I-+T48-51
I 311
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the leg
- - - T l b l l , Facl88 medialis
~-- M. ~blalsllltei!CI', Tencfo
M.
M. -dgllarlnl
Fig. 4.134 v.ntral•nd Llt8r•l mllldla cf the leg•nd 1he foot. right 11•; ventllll view. The M. tlblals •nterlor of !tie extensor group can be palpated near the margin of the Tibia. Since its tendon courses medial to the axis of the UJiocalcaneonavicular joint, it functions as a lallhough weak) supinator in contrast to the other extensors. The M. ext:eMOr digitorum longua derives from the proximal Tibia and Fibula. and the M. ext:enacr heiU. ell longus is located between the other two extensors at the distal leg. Occasionally, the M. extensor digitorum longus shows a separation that inserts at the Os metatarsi V and is confusingly called M. fibuleria tertlua. In the disUJI part, the tendons are guided by a reinforcement of
312
-ICI'
hllklcl81ang~a, Tendo
M. 41111811801' hllh.1CI81n\118
the fascia of the leg, the Retinaculum muaculorum llldeneorum. The retinacula of the foot function as retainers and prevent the tendons from lifting off the bones during extension of the foot. Bath muscles of the fibulatis group {Mm. fibula,.. long111 and brevia) belong to the lateral group and originate from the proximal and distal Fibula. Clinically, they are often referred to by their old name as peroneal muscles (fibula. greek: perone).
I~T48,49
I
Muscles _. Topography _. Sections
Muscles of the leg
M. t'llullrla J:plnlraiiJ lon;ua
- - - M. tlblllllll'ltlrfOI'
M•..._.,.dlglonlm lollll\ll
R~rum mu..uarum
t'llul.-tum .,__.mJ
M. ft1Br... dlgllcnJm langu~t, Tencl~
M. nbulllls [ll«oneue] urtlJs, Tendo
Fig. 4.135 Mllld• of t!MIIeg •nd 1111 toot. right IIide; lateral view. In the lata!lll view, all three muscle groups of !tie leg are visible. Latallllly behind the anterior group of extensors lie the fibularis muscles. dorsally lie the flexors. Since the deep flexors of the rear side are directly adjacent to the bones of the leg, only !tie superficial muscles (M. triceps surae), the M. gestrocnemius and the M. soleua,. can be seen. The tendons of the fibularis group are guided by the RetiniiCul• m111C411orum flbul1rlum. The M. fibularis brevis insei1S at the Os me-
tatarsi V. whereas the tendon of the M. fibularis longus extends benealti the sole of the foot and inserts at the Os metatarsi I and Os cuneiforma mediale. thus actively supporting the plantar arch. It should be noted that the M. 1Xt8n110t h1llucil long111 is found distally between the M. tibialis anterior and the M. extensor digitorum longus.
I_. T 48-50, 52 I
313
Lower Extremity
Surface anatomy -t Skeleton -t Imaging -t
Muscles of the leg
M. aemmemtnnoeu•--+-l+i~il'i
M.pllr!Wfa
M.IJ'&ICllls--+-Holt
fig. 4.136 Superficilllayer cf the dotul mUldea of the lower leg.. right side; dorsal view. The superficial group of flexors comprises !tie M. triceps 111rae and the M. plentaria. The strong M. triceps surae includes !tie two-headed M. gastrocnemii• and the subjacent M. soleus. All superficial dorsal muscles insert at the Calcaneus via the ACHILLES tendon {Tendo calcaneus). The M. biceps surae is the strongest flexor of the ankle joint
314
and the strongest supinator of the foot. even stronger than theM. tibialis posterior. If it is pe!Uysed, such as after a disc hemiBtion wi1h 1'89Uting injury to the spinal cord segment S1 or a lesion of !tie N. tibialis, standing on one's toes is impossible.
1-tTSO
I
Muscles _. Topography _. Sections
Muscles of the leg
M. f'laor dlgltoNn lOCIII"'
fig. 4.137 Supetficilllayer of the dorul miiiCIIa of the lower leg.. right side; dorsal view; after dissec1ing the origins of the M. gaS1rocnemius. After reflecting the M. pltrocnemiua inferiotly, the M. plentaril is visible proximal of the M. IOieul.. The muscle bellies of the deep fl~r xors are located further distally and are visible on both sides of the
ACHILLES tendon after removal of the Fascia cruris. Their tendons are guided by the Retinaculum miiiCCionlm ft8xanlm at the medial malleolus.
I-+T51
I
315
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the leg
Bini. t!j)tendl~ muec:ull gaarccnemll medals
M. flbuill18 (perane~]lang~
M. flexor IIIIIUCIIIOIIQUI
Deep..,_.
fig. 4.138 of the dots~~l mllld• of the leg, right lide; doi'SIII view; after remOIIBI of !tie superficial flexors. After removal of !tie superlicial flexors the deep muscles are visible. The M. ii)ielil poeterior is located be1ween both flexor musdes of the toes. The M. flexor dlgltorum longus originates furth8S1 medially followed by theM. tibillil potderior and further distal by theM. flexor hellucil longus. Their tendons meet beneath the medial malleolus where ltiey are covered by the Retinaculum muscuiDrum flexorum. In this course the tendon of theM. flexor digitorum longus crosses the
316
tendon of the M. tibialis posterior IChiasme cruril). Proximal. the M.
popliteus originates from !tie Cond~us Iaten~ lis and from the posterior hom of the lateral meniscus. The muscle inserts en the posterior aspect of the proximal 'Tibia and functions as a relatively strong mecill routor. Thus, the primary function of the M. popliteus is to edvely stabilile the knee and to prevent an extensive lateral rotation.
I~Ts11
Muscles _. Topography _. Sections
Muscles of the leg
line ..bltlln.-n. ITIUIQIII ll•tiOCUIIITlJI rnedlallll lkna mu..UI8M1lmem~I--"'"""~P·:a.?
fig. 4.139 DMp ..,_.of the doi'SIII mllld• of the leg, right IIide; dorsal view; after remOII!II of !tie superficial flexors and splitting of !tie M. popliteus. Upon splitting of the M. popliteus, the Bursa subpoplitea is exposed. This bursa frequently communicates with the joint cavity of the knee joint and is often ref91'red to as R....,.subpcplit8ua. Additional bur-
sae are present beneath !tie tendinous crigins and insections of the dorsal muscles !Bursa miiiCUII semlmembranotl and Bui'IH subtlndiiiiH muiCUiorum gastroc11emll medialis and let~r~llll. These also may communicate with the joint cavity(-> p. 280).
l-tT51
I
317
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Synovial sheaths of the foot
M. tlblllllll ants1ar, Tenclo
Allll'laculum muacularum flbullllfum
(percniiClrUm)
'llillllna c:Qilmunl• tandlnum muK~Uian~m
tllul.tum (Jieroneorum]
'lflltlna tandlnum ,._.11 alii-ttl d!gltDrum pedla lang I
M. tlblallall'lla1or, 'nlndo
M.lbdi.IC1Ilr dllilhl mlnlml
M. tllullrla ~~ tarti.., 'nlndo
M. ~ dlgltorum IDIIIJU', 'TWidlnaa M. ut8!18cr halllcls breYI8, Tendo
M.~hllluc:lalan;u ..
1Wido
fig. 4.140 Synoviallhuths, V.ginla undinum, of tha foot. right !Ide; dorsal view in relation to the dorsum of the foot. The Fascia cruris was removed except for the Retinarulum musculorum ex:tensorum. The 111tinacul1 of the foot serve as retaining straps and prevent the tendons from lifting off the bones during muscle con-
318
tractions. Each ex:tensor muscle has its own synovial sheath (Vagina tendinisl Ymich endoses all tendons of the respective muscle and serves as guiding tube as well as gliding surface. In oontn1st, the te~ dons of theM. fibularis longus and M. fibularis brevis have a common synovial sheath.
Muscles _. Topography _. Sections
Synovial sheaths of the foot
Flltfrw.cuklm muaciAarum 611te!'slrum hfelf..
'VIIIglna tendlnll miiiCUII t'lnortllllalluclalongl
M.llb
4..141
M. fiMat dlgllanJm-
tandlnll ,._.II m.-t1 llalluclllql M. fttllniCI' hallucl8 lltwl8
FlltfnaciAum m..c.-.rum -+----.~ llbullrlum (peroneoriJll)
M. exteniCI' dlgtaum long... lltndl-
M. ut"*ll' diQIIanJm t~Ws M. llbulalle [pe!oneu&] te!U.., Tendo
4..142
M. llbullllal)a'oneue] bre\118, Tendo
fig. 4..141 and Fig. 4.142 Synovilllheatha. V.gin.. tendinum, of the foot.. right side; medial<~ Fig. 4.1411 and IB1ellll <~Fig. 4.1421 views.
The synovial sheaths surround the tendons of all three muscle groups of the leg particularly where the tendons are fixed to the bones by the
retinacula. The Retinaculum musculorum flexorum forms the malleolar canal behind the medial malleolus YA'Iich serves as a passageway for the neurovascular structures IN. tibialis, AN. tibialis posteriori to the sole of the foot.
319
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the foot
Reltlaculum muacutarum flbullllfum [~)
- -1-+
M. 11llllll8111118rlef, Tenc!o
M.-hduclllcngu~t, Tendo
M. -.till!_. halluc:ll bnMe
Fig. 4.143 Mllld• of the dorsum of 1he foot, right tide; dorsal view. Beneath the tendons of the long extensor muscles, which have 1tlair muscle bellies at the ventral side of the leg, there are 1w0 short extensors. The M. exteraor dlgHorum brevis and M. nleraor hllucls brwil originate on the dorsal side of 1tle Calcaneus and their tendons insert from lateral into 1tle tendons of the long extensors and additio-
320
nally into the dorsal aponeurosis. Therefore, they oontribute to the extension in the phalangeal joints and the metatarsophalangeal joint of the big toe. The Mm. interossei dorsales are also visible, but 1tley are grouped with the plantar musdes {... p. 325).
Muscles _. Topography _. Sections
Muscles of the foot
M.llbllllllt anta1ar, ll!ndo
M. ___.llllluclllllnrlfll
Fig. 4.144 Mllld• of tiMI dorsum of 1M foot, right tide; dorsal view. The Retinaculum musculorum extensorum was split and the tendon of the M. extensor digitorum longus partially remowd to demonstrate the muscles of the dorsum of the foot. They comprise the short extensor muscles of the lateml four toes (M. extensor digitorum brevis) and of
the big toe (M. extensor hallucis brevis). These muscles originate from the dorsal side of the Calcaneus and project to the dorsal aponeurosis of the second to fourth phalanges or to the dorsal side of the big toe.
I-+T48.52.54I
321
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the foot
r-1cu11 longttudlnalee
Rg. 4.146 Pllrrtllr IIPOf'HIUroslll,. Aponeurosis pl1nt11rll. of th1 foot, right tide; plantar view. The plan18r aponeurosis is a plate of dense connective tissue with e strong medial and two weaker letellll parts. The FaclculllonaHucln• I • project from the Tuber calcanei to the ligaments of the metatarsophalangeal joints. At the level of the Ossa metatarsi they are connected
322
~ dl•••ctlon llnlc
by tlllnsverse fibres IFasciculi tralll¥81'111. These tlllnsverse fibres are collectively referred to as Lig. metatert~ele traRIYir•m superficilla. Two septa course from the planter aponeurosis to the bones, thus, creating spaces for three plantar muscle groups.
Muscles _. Topography _. Sections
Muscles of the foot
Pin eruclllormll } 'llll!gtna tllndlnle muecutt
- - - - - : - - - - Pllrs~mullrtl
Rg. 4.148 Superficial layer of plantllr muscles. right llcle: plantar view; after removal of the plantar aponeurosis. In contrast to the hand, the muscles of the sole of the foot do not set\19 for differentiated movements of indMdual toes but serve in IICtlvely brllcing the plantllr •reb as a functional muscle unit. The plantar muscles suppot1 the ligaments which accomplish a passive stabilisation. The plantar muscles are separated into three different groups !medial, intermediate and lateral) by two septa which project from the plantar aponeurosis to the bones. These groups are not easily separated during dissection, and it is easier to dissect four !layers of muscles.
tl-'1 llalluctaton;l
The muscles of the tupt~rflcl•lllayer comprise the M. •bductor hlllu· cil, M. fllxor di$litcrum brevia and M. abductor digiti minimi. The tendons of the M. flexor digitorum brevis are pierced by the tendons of the long flexors. At the level of the toes, the tendons of the flexor muscles have separate synovial sheaths (Vaginae tendinum) which do not communicate with those at the tarsal level. The synovial sheaths are reinforced by ligaments containing anular (Pars anularisland c:rucifotm {Pars c:ruciformis) components.
1-+TSZ-551
323
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Muscles of the foot
M. IIMlf dllilhl mlnlml M.lllductcr dlgiU mlliml
M. ~8 Pllnt&lf&lll
M. allduclar hducll
M. allduc:la' digiti mntmt
fig. 4.147 Middle layer of 1he plentar muaclee, right IIide; plamar view; after dissection of the M. flexor digitorum brevis. The muscles lie in four layers on top of each other. Upon resection of the M. flexor digitorum brevis. the muscles and tendon a of the second layer are visible. It consists of the tendons of the long flexors {M, flexor hallucia long• and M. fllxor digitorum longIll) and of two muscles of the intermediate group. The tendon of the M. flexor digitorum longus
324
serves as origin for the M. q•dratua plantae wtlich functions as an accessOfY flexor supporting the long flexor muscle. The tendon also serves as origin for the four Mm. lumbrlcala which insert from medial on the proximal phalanges of the toes (11-V).
I-+T53-ssl
Muscles _. Topography _. Sections
Muscles of the foot
Mm.lurmt:aillll peclai-IV
Caput lnln!Mnum}
M. ~adonellapadlalll
M. addUctor hill lucia
"'!ttm'----~IIJ! allllquum Mm.l~lpl.,._llletll M.~ado1'11811apadla1Y---I......,..
M. OIIPO'I- llgltl mlnlml
----~:...
M. 11M« hiii.ICislcngut, Tendo'* M. abducla' dQitl mnlml
Rg. 4.148 Deep and deepest layers of tt. plantar mu~elel. right !Ide; plantar view; after removal of bo1h superficial musde layers and the long flexor tendons. Within the deep layer the M. flaxor halluds bnMs and M. adductor halluds are located medially, the M. flaxor digiti m.,.lml brevis and the inconsistent M. opponens digiti minimi laterally.
The deepest layer comprises three Mm• .,..erouel plantares and four Mm. lntei"'SMM dorsales as well as the tendons of 11te M. tibia· lia postarior and M. fibullrillongut. " The a-ossing of 1he M. flexor digitorum longus tendon over the M. flexor hallucis longus tendon is also referred to as Chiasma plantare.
I_. T 51. 53-55 I
4.150
fig. 4.149 and Fig. 4.150 Mm. irrtllroaei dorsal• (-+fig. 4.149) and plarrtllrMI-+ Fig. 4.150) of the foot. right side: dorsal (-+ Fig. 4.149) and plantar 1-+ Fig. 4.150) views. The four Mm. intiii'OIINii dorulla (I-IV) are two-headed and originate from opposing sides of the bases of the Ossa metatarsi I to V. They insert on the proximal phalanges of the second to fourth toes in such a way that muscles I and II project medial and lateral to the second toe. whereas muscles Ill and IV course lateral to the third and fourth toe.
Thus. the muscles can flex the metatarsophalangeal joints, abduct the toes II to IV laterally, and additionally adduct the second toe. The 1hree Mm• .,..erossel plantares 11-1111 have only one head and originate from the plantar side of the Ossa metatarsi Ill to V. They insert on the medial side of the respective toes. They serve for flexion of 1he metatarsophalangeal joints and adduction of the toes.
1-+Tsa-ssl 325
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Plexus lumbosacralis
T12
L1
L2
N.lllolngiAralll (r12, L1)
Pl-lumball8
L3 N.
ltCfemcnlle (1.1 L.2) { R. famcnlll gen • R.gelilllll8 N. ci.Ginac.a I'Gmcrtt ll!anll• (1.2, L3)
L4
N. femonllia (1.2-1..4) L6
S1
N. glll'lew .uperkw(l4, L6; 81)
1hlncue Un~llll(l4-L6) S2
N.11U.U. lnfwflll'(l~ 81, 82)
N. iadlildicue (L4,L5;S1-q
r~--
Plsxua--ia
S3
comlftlnll N.ll:llllllt
S4
S6 Co
N.IIIOOCOO'.I'II81»
Rg. 4.151 Lumbosacral plexus,. Plexus llnbosacralls 0'12-85. Co1): segnental organisation of th& nerves, right side; ventral view. lh& lower &xtremity is inn&!Vclt&d by th& Pl&xus lumbosacrnlis. Th& plexus is composed of Rr. anteriores of the spinal neNes which originat& from the lumbar. sacrnl, and coccygsal ssgments of the spinal OOI'd and combine to form the Plexus lumbllls (T12-l4) and the Plaxus sacralls (L4-S5. Co1l. The segments ~o1 are also referred to as Pl&xus eoocyg&us. Both plexusss are connect&d by the TruncLIIIumbosecrals which conveys nerve fibres from the spinal cord segments L4. L5 from the Plexus lumbalis to the small pelvis. The functionally most important nerves of the Plexus lumbalis are the N. femornlis and the N. obtullltorius. The N. femoralls provides motor innervation to the ventllll muscle group of the hip and thigh (flexors in th& hip and extensors in the knee) and sensory innervation to the ventral aspect of the thigh and the ven-
326
tromedial aspect of the leg. The N. obtunrtarfus conveys motor fibres to the adductor muscles and sensory fibrss to the m&dial thigh. The strongest and longest brnnch of the Plexus sacralis is the N. ildliadicus. With both of its divisions IN. tibialis and N. fibularis) the N. ischiedicus provides motor innervation to the hamstring musdss (extensors in the hip and flexors in the kneel and to all musdss in the leg and the foot as wall as sensory innervation to the calf and foot. The Nn. glutei superior and inflrior innervate the gluteal musdss which represent the major extensors, rotators, and abductors of the hip. The N. pudendus provides motor innervation to the musdss of the parinaal region and sensory innervation to the external genitalia. The musdss of the pelvic floor are innervated by direct branches (*) of the sacral plexus.
I~T401
Muscles .... Topography .... Sections
Innervation of the lower extremity by the Plexus lumbosacralis
.,H.....-.'1--T--
N.gluiBu•...-
~~;.....,A---+--
N.gllaua lnr.tar
~~·.......l!~,..,-- N. pudardl• J"\~~9---,H-- N.~
llmara. pcm.rtar
Tt-+-+-- N.l.tlllldlcw
'---- N. 11111111• L.~~~~-- N. tlblllllrtll COIIII'IUI..
_____
Plauelumbllls (T12-L4J
__,
• motor branches to the M. iliopsoas and M. quadratus lumborum (f12-L4) • N. iliohypogastricus IT12, L1l • N. ilioinguinalis (T12, L1) • N. genitofemoralis (L1, L21 • N. cutanaus femoris lateralis (l2, L3) • N. femoralis (L2-L4l • N. obturatorius {L2-L4)
............ u~ 85. ~ Co _1..;. J _ ____.
4.15!
Fig. 4.15! •nd Fig. 4.153 Lumboucr~~l pl-.,~· lumbosacr•lls IT1Z..SS. CoU: nervas CJf the lower IDCtnmlty. right *le; wnlnll , .... Fig. 4.152) and dorsal,.... Fig. 4.153) views. The nei'II8S of t he ~alumbe&. (T12-L4) course ventral to the hip joint and innervate the inferior part of the anterolateral abdominal ~II and the ventral aspect o f the thigh. The branches of the Plexus sacrahs course dorsal to the hip joint. They innervate the posterior side of the thigh, the major part of the leg and the whole foot.
4.152
• motor branches for the pel'fitrocha~ teric muscles of the hi p IM. obtutatorio.Js internus. Mm. gemelli su perior and inferior, M. quadratus femoris, M. piriformis; I..A-S2) • N. gluteus superior «..4-51 l • N. gluteus inf erior (L&-82) • N. ischiadicus (L4-S3l • N. cutaneus femoris posterior {S1-S3) • cutaneous branches to the skin of the ischial t uberosity {N. cutaneus perforans, 52, S3) and coccyx (N. anococcygeus, S5-Co1) • N. pudendus (S2-S4) • Nn. splanchnici pel'fici (preganglionic parasympathetic fibres; S2-S4) • motor branches to the pelvic floor (M. IBVIItor ani and M. ischiococcygeus, S3, S4)
327
Lower Extremity
Surface anatomy
~
~
Skeleton
Imaging
~
Innervation of the skin
N. llahypagu!lfCLII, R. ci.Gineullllenllll
R. femcnllll
N.genltoftmcnlla { R.gentalll
N.lllolnguNIIe, Nn.. lla'OUIIe8111t1111Dn18
N. tiKMite cammunle, N. cutaneua aunut Iatini II (N.Iachlldlcull)
N.......,.., Rr. a.n:ane1 mJ!I8 medlllee
(N. fllmorallll)
4.154
4.155
-
Nn.tlmbal•
-
N.lllalf1pOgUtlfcua
-
Nn.aacnJ•
-
N. cutaneua film Oils lateral Is
-
N.genllofemoralll N.fllmcralll
Rg. 4.154 and Fig. 4.155 Cutaneous nerves of the IIDwer extremity, right side; ventral (- Fig. 4.154) and dorsal (- Fig. 4.155) views.
All nerves of !tie Plexus lumballl comribute to the sensory innervation of the inguinal n~gion and the ventr•l thigh. The lateral aspect of the leg and the dorsum of the foot are supplied by branches of the
-
N.cb!unllalfua N. cutaneua femOI!a pclltelfcr
-
IIIII
N. tlbullrll N.suralls
Plexus saaalis. The glut:NI n~glon is innervated by Rr. posterlora from the lumbar {Nn. clunium supariores) and sacral (Nn. clunium medii) spinal nerves. The dorsal side of !tie whole lower extremity and the sole of !tie foot are innervated by branches of the Plexus sacralis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The course of the nerves from the Plexus lumbalis and Plexus sacralis influences the pattem of referred pain originating in !tie area of !tie plexus. If the Plaxus lumballs is affected by haematoma or a
328
tumour, the pain is referred to the •ntwior •apect of the thigh. With compression of the Plaxus sacr•lll, !tie pain radiates to the doral side of the ltiigh and the leg lllchlalgla).
Muscles -+ Topography -+ Sections
Innervation of the skin
L4
4.156
Fig. 4.158 and Fig. 4.157 Stlgllllllltlll in. .rvation of the Kin 1~1 cf theiDwer exlnlmlty. right ~e; ventral (-+ Fig. 4.156) and dorsal (-+ Fig. 4.157) views. Distinct areas of the skin are supplied by a single spinal cord segment. These Cl.ltaneous areas are referred to as dermatomes. Since the peripheral cutaneous nerves of the lower extremity convey sensory fibres from several spinal cord segments, the borders of the dermatomes do
4.157
not correspond with the Cl.ltaneous area supplied by the peripheral nerves (-+ p. 3281. In contrast to the circular orientation of the dermatomes of the trunk. dermatomes on the ventral side of the lower extremity are obliquely oriented in a lateral superior to medial inferior direction. On the dorsal side they are oriented in a nearly longitudinal dlrwctlon. (see Development. -+ p. 133).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The localisation of dermatomes is clinically important in the diegIKMIIica of fnlquentlr occarring - o f disc prolapse. Disc herniation/prolapse occurs mosUy in the lower lumbar vertebral column and may compress the L4-S1 spinal nerve roots. Wlereas nerve
fibres from the U segment innervate the medial margin of 1he foot, the big toe and the HCOnd toe are supplied by the L5 segment. The whole lateral side of the foot. including the fifth toe, is supplied by 81.
329
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Plexus lumbalis
Iliacus
fllmonlle
PKUneus rec:tu8femarl8 lliL-.1-~--- M. eoturatoms utllmus
-1\-111.+-!H-- - - M. adeilctcl' 101l!U8
ll1.f'JNJf"1f1j~-f.--- M.IK!Cilctcl' IOil!Ua lf/1~--- ,u W811.18lnurmed1.18
M.
M. \'8811.18 medialis
Fig. 4.158 Course and target arM a of 1he l'llr'Y• of the Pllxua lumiHIIII IT12-1.4); ventral view; cutaneous branches are highlighted in purple. The N. iliohypogastricua and N. ilioinguinalia (further caudal) cross the M. quadratus lumborum behind the kidney and then pass between the M. transversus abdominis and the M. obliquus intemus abdominis to the ventral side. Both innervate the inferior parts of these abdominal muscles. The N. iliohypogastricus also provides sensory innEIIW1ion to the skin above the inguinal ligament. the N. ilioinguinalis provides sensory innervation to the anterior aspect of the external genitalia. The N. genltofemol'llll pierces the M. psoas major, crosses posterior to the ureter, and divides into two branches: The lateral R. ft111'10t'8lil enters the anterior thigh through the Lacuna vasorum and provides rutaneous inneMJtion inferior to the inguinal ligament. The medial R. genitalia courses through the inguinal canal to the Scrotum and conveys sensory fibres to the anterior aspects of the external genitalia and motor fibres to the M. cremaster in men. The N. cutai'HIUI femoris llrtlralls projects laterally through the Lacuna musculorum and provides sensory
330
fibres for the lateral side of the thigh. TheN. femoralis courses medially through the Lacuna musculorum and immediately splits fan-like into several branches. Rr. cutanei anteriores supply the skin on the ve~ tral side of the thigh. The Rr. musculares provide motor fibres to the anterior musdes of the hip (M. iliopsoas) and the thigh (M. sartorius and M. quadriceps femoris! and in part to the M. pectineus. Its terminal branch is the N. uphenus which enters the adductor canal (-> p. 351) and exits it through the Septum intermuscular& vastoadductorium at the medial side of the knee joint to supply sensory innervation to the medial and anterior aspects of the leg. The N. obturatorius initially courses medial to the M. psoas major and then passes through the Canalis obturatorius {-> p. 351) to the medial aspect of the thigh. One of its branches reaches theM. obturatorius extemus. TheN. obturatorius then divides into the R. anterior and the R. posterior (anterior and posterior to the M. adductor brevis) which convey motor fibres to the muscles of the adductor group. The R. anterior also provides cutaneous innervation to the skin of the medial thigh.
Muscles _. Topography _. Sections
Plexus lumbalis
Fig. 4.159 l.atior8 of Mr"¥U of 1he PIIXUIIumblil; van1ral view. Cutaneous branches are highlighted in purple. Frequent locations for lesions are marked by black bars.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the N. IIIDhypogatrlcus. N. llcWigulnllls and N. 81· nitofemoralil are rare due to their prot&Ct&d position. Howaver. their close proximity to the kidney and the ureter may result in p.1in radiating to the inguinal region or the external genitalia in certain diseases of the kidney (Inflammation of the renal pelvis, pyelonephritis, ureter concrementsl. The N. C\ltl. . . . femortlllltllr1lls may be pinched underneath the inguinal ligament by tightly fitting pants or may be injured during hip surgery with an anterior access. This may result in loss of sensation or pain a1 the lateml aspect of the thigh (IMI"'Igll para esthetical. Injury to the N. femorail most frequamly ()C().Jrs in the groin during surgery or diagnostic manoeuvres (e.g. cardiac catheteo. As
a result. the restriction of hip flexion and the imbility to extend the knee make it impossible to dimb stairs. The patellar tendon reflex (knee-jer1t reflex) is lacking and sensation on the anterior thigh and medial leg is absan1. The N. obblratoriua is at risk of injury when passing through the Canalis obtumtorius. Pelvic frectures as well as obturator hernias or extensive ovarian carcinomas may cause nerve lesions. Loss of function of the obturator muscles causes unstable standing, weakness with leg adduction and makes it impossible to cross one's legs. Sensory loss may occur at the medial thigh. Pain and pamesthesia may radiate and simulate diseases of the knee joint IAOMBERG'• knee phenomenon).
331
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Plexus sacral is
N.tibllllh --~+-14
N•...._ c:cxnmunl• --~,_-1:4
Rg. 4.180 Cou1118 and target ai'Ms of 1he rHII'Y8IJ of the Plexus taCf•lil (L4-S5, Co1). Dorsal view; cutaneous nerves ar& highlighted in purple. The N. glute~a superior exits the small peMs through the Foramen suptapirifomne and provides motor innB~Vation to the small gluteal muscles (most important abductors and medial rotators of the hip joint) and the M. tensor fasciae latae. The N. gluteus Inferior exits through the Fotamen infrapirifomne and innervates the M. gluteus maximus. the strongest extensor and external rotator of the hip joint. The N. lldlladlct~s is the strongest nerve of the human body. It consists of two divisions (N. tibialis and N. fibularis communis) which are combined to one common nerve for a variable distance only by a connectiv& tissue sheath (epineurium). The N. ischiadirus exits the peMs through the Fotamen infrapirifomne and descends to the popliteal fossa underneath theM. biceps femoris. In most cases, N. 1ibialil and N. fibullria commWiil separate at the level of the distal third of the thigh. Occasionally (12% of cases). both nerves already exit the peMs separately {high division) in which case the N. fibularis often pierces the M. pirifomnis. At the level of the thigh, the N. tibialis provides motor innervation to the hams1ring muscles and the pos1erior head of the M. adductor magnus. The N. fibularis innervates the Caput breve of the M. biceps femoris. Both portions of the N. ischiadicus together innervate all muscles of the leg and the foot and provide sensory innervation to the skin of the leg {except for the medial
332
aspect: innervated by theN. saphenus of the N. femoral is) and the foot. The N. cutaneuafemoria poftlrior exits the peMs through the Foramen infrapirifomne and btanches oH the sensory Nn. clunium inferiores for the skin of the inferior gluteal region. It descends in the subfascial layer to the middle of the thigh and provides sensory inn9t'llalion to the posterior thigh. TheN. pudendus has a complicated course. It exits the pelvis through the Fotamen inftapirifomne and, together with the corresponding blood vessels, Y
I~T401
Muscles _. Topography _. Sections
Plexus sacralis
*
N. cutaneua femalfa poaterlot
~d~-----~--~4
N. l'b!An commun• ----....:.....IJ-..J.!.A
Rg. 4.181 Letlola of 1he most Important l'KII'Y8I of the Plexus taCf•lil. OotSal view. Cutaneous btanches ar& highlighted in purple. On the right side, the potential injury, such as wrongly placed intragluteal injections. to !he nerves at the level of their exit from the peMs is
shown. On the left side, !he possible site of injury to !he N. ischiadirus due to ftactur&s of the pelvis or hip surgery is indicated. " lesion wilh wrongly placed intragluteal injection
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the nervee of 1he Plexua uct8lil - part 1 (part 2 ~ p.335) With a high dMIIon of the N. iscniadicus. !he N. ftbularh communil may be irritated when piercing the M. piriformis (piriformis
syndrome). The resulting pain may be very similar to the pain caused by a disc herniation. TheN. ilchildiet~a may also be injured during inttagluteal injections 01' by compression during extended sitting periods. after pelvic flllctures and in the case of hip luxations or hip surgery. The resulting petalysis of the hamstring muscles affects extension in the hip joint. but mor& importantly. flexion and rotation in !he knee joint. If the N. tibialis and N. fibula lis are damaged completely, all muscles of the leg and foot are patalysed and standing 01' walking is impossible. When lifting the leg, the foot cannot be dorsiflexed and dlllgs along the ground (foot drop). As a result, pa-
tients increase compensatory hip and knee flexion CMIPPIII• g•it). Standing on one's toes is not possible anymore since plantarflexion is lost. Cutaneous innervation is almost completely absent in the leg (except ventromedial) and foot {for isolated lesions of !he N. tibialis and N. fibularis ~ pages 336 and 337). Lesions of isolated motor branches to the pelvitrochanteric muscles or cutaneous branches ar& of no functional relevance. Motor branches to the muscles of the peMc floor and parasympalhetic nerves, however, may be injured during surgical procedures in the small pelvis. such as rectum and prostate surgery. hell •nd winery incontinent» may result from peMc floor insufficiency. Injury to the parasympalhetic nerves result in eractile dytlfunction in men and an equally il'llufficilnt filing of the cavernous .body of the clitoris in women.
333
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
lntragluteal injections
N.pudllnu
==t~~~~~~~"1~
Ug. 880f'081)1111»
334
Rg. 4.182 Surhce profectlon of 1M lbletlll contour and the N. llchllldlcus In the glutHI region. With wrongly positioned intragluteal injections in the M. gluteus maximus principally all neurovascular structures passing through the Foramen ischiadicum majus are at risk of injury. Only the A. and V. pudenda
intema and the N. pudendus are well protected as then course medially and pass through the Foramen ischiadirum minus to reach the ischioanal fossa. Therefore, injections should always be applied into the M. gluteus medius(-> Fig. 4.1631.
fig. 4.163 v.ntral intraglutul injection a (eccording to HOCHSlETIER) To avoid damaging of important neur0118scular structures in the gluteal region, intragluteal injections are performed within a triangular field between two splayed fingers and the Crista iliaca. The index finger is
placed onto at the Spina iliaca anterior superior and the palm of the hand over the Trochanter major. The only nel\18 remaining at risk is the motor branch projecting from the N. gluteus superior to the M. tensor fasciae latae.
Muscles _. Topography _. Sections
Plexus sacralis
•
Fip. 4.1&c. to c TRENDELENBURG'align 1nd DUCHENNE'agait with loa of function of 1he small glutMI muiCIM on the right side (b, c). • The gluteal muscles abduct the ipsilateral leg if the body weight is shifted to the other leg. In one-legged stand, the ipsilateral muscles stabilise the pelvis and prevent the tilting of the pelvis to the contralateral side.
c
b With functional insufficiency of the small gluteal musdes, such as in
c
hip dysplasia or wilh lesions of theN. gluteus superior, the pel\lis drops to the healthy side when standing on the leg of the affected side {TRENDELENBURG's sign). The pelvis of the healthy side is elevated by shifting the trunk towards the affected side (DUCHENNE's gait).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the nerYM of 1he Plexus Ma'llll - part 2 (part 1 -> p. 333) Due to its protected course, lesions of th& N. pudandua are rare. Symptoms are caused by th& malfunction of lhe perineal musdes and the sphincter muscles of the bladder and rectum and may r&sult in urt. .ry and feallilcontmlnce. SensotY loss in lhe genital region may cause dlsturiHinCM in sexual functlora. During parturition, loss of sensory function in the perinsogenital region is desired and a pudendal nerve block may be performed to reduce pain. Thereby, th& Spina ischiadica is palpated through lhe vagina and the N. pudendus is anaesthetised prior to its entranc& in th& ALCOCK's canal by injections approximately 1 em lateml and cmnial of lhe ischial spine. Wronglv pllced intr1muacullr injections in the gluteal region may injur& the n&urovascular structures which leav& the Foramina supraand infrapiriforme. Not only blood vessels but also lhe Nn. glutei sup&rior and inferior, theN. cutaneus fsmoris post&rior, and theN.
ischiadicus may be affected. The intmgluteal injection according to HOCHSTETIER is appli9d to theM. gluteus medius(-> Fig. 4.163). Lesions of the N. glute111 suparior cause paralysis of the small gluteal muscles (most impol1ant abductors and m9dial rotators of th& hip) and the M. tensor fasciae latae. Paralysis of the small gluteal muscles makes it impossible to stand one-legged on the affected side because the pelvis tilts to the contmlateral side (TRENDELENBURG's sign). With lesions of the N. gluteus Inferior the loss of function of the M. gluteus maximus compromises extension in lhe hip. With normal gait, this deficit can partly be compensated for by the action of the hamstring muscles. However, activities such as dimbing stairs, jumping, and a fast walking pace will not be possible. Lesions of the N. cut1n1111 fii'IKiril posterior cause sensory deficits on the posterior side of the thigh.
335
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
N. tibialis
111u•r• communra
Fig. 4.165 N. tibialia: •niiOfY innervation by cuuneouaii'Mir'YM (purple). and motor Innervation by miiiCUiar branches. right llcle; doi'SIII view. The N. illdlildicua often divides at the transition from the middle to the lower third of the thigh into the medial N. tibialis and the lateral N. fibularia communia. The N. tibialis innervates the dorsal muscles of the thigh (hamstring muscles and dorsal part of theM. adductor magnus). The N. tibialis cominues in the direction of the N. ischiadicus to pass the popliteal fossa and descends between the heads of the M. gasti'OCI'l&mius beneath the tendinous arch of the M. soleus (Arcua tendli'leus musct~l solei). It further courses together with the A. and V. tibialis posterior between the superficial and deep flexors to the me-
dial malleolus. In the popliteal fossa the N. cutaneua .._.,, medillil branches off to supply the medial calf and splits into the N. suralII for the distal calf and the N. cutaneus dorsells lateralls for the lateral margin of the foot. The latter often communicates with a cutaneous branch from the N. fibularis communis. When passing underneath the Retinaculum musculorum flexorum lmelleoler cenel), the N. tibialis splits into its two terminal branches {1\ln. planter• medillia and literail! for the innervation of the sole of the foot. Thus, the N. tibialis prOIIides motor innetVation to all flexor musdes of the calf and all pia~ tar muscles of the foot as well as sensory innervstion to the middle calf and, after forming the N. suralis, to the lower calf and the lateral margin of the foot.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . l.ellons of the N. tlblall ana rare, but may occur during injuries of the knee joint or after compression in the melleollr cenel to tibial fractures or injuries of the ankle joint (mediel tarselillnneiiiWI'Hfrome). The tarsal tunnel syndrome is characterised by burning pain sensations at the sole of the foot and loss of function of the plantar muscles. Aexion, adduction, or splaying of toes is impossible. Paralysis of the Mm. interossei and Mm. lumbricales results in the
336
claw foot deformity. Lesions at the level of the popliteal fossa a~ ditionally cause a loss of function in all flexors of the leg (negative ACHILLES tendon reflex). Plantarflexion is weak and only supported by the muscles of the fibularis group. An increased prcl'lltfon and doraiflaxian poeition of the foot is the result. Standing on one's toes is impossible.
Muscles _. Topography _. Sections
N. fibularis communis
N. cll'llnlu•-
..._..1•----r+-+
R. comrnun~ tllul.-!1 -----!?+
N. cutaneu••uru medd•(N. llblllii)---+H
M. l'b!Aari810~U8 - --f-11-+-11-
N . a l f t l l l - - - --'+
fig. 4.186 N. fi)ullril communil: IMII'IISOty innervation .by cu'llneousl'l8i'WI (purple). and motor lni'HII"fttlon .by mu~eular bnlncfles.. right U.; lateltll view. After the division of the N. ilcllildiet~l at the transition to the distal third of the thigh, the N. ftbullrll communis courses through the popliteal fossa and around the head of the fibula to the fibularis compartment. Here the neMI divides into its two terminal branches {Nn. fibulares superlicialis and profundus!. At the thigh, the N. fibula lis communis provides motor innetVation to the Caput br&v& of the M. biceps femoris only. Prior to its division into the terminal branches, the N. fibularis communis provides the N. cut....,. surae llrt:eralls for the skin of the lateral calf and another branch for the communication with the N. cutaneus su~t~e medialis.
The N. fibullrilauperficillil continues in the fibularis compartment and provides motor fibnes to the fibularis muscles. Subsequently. it pierces the fascia of the distal leg and splits into the two terminal se~ sory branches (Nn. cu'llneii dorsales medillil and int8rmediul) for the dorsum of the foot. The N. fibularil profundul enters the extensor compartment and de. scends together with the A. tibialis anterior to the dorsum of the foot. On its Wflll, it provides motor innervation to the extensor muscles of the leg and the dorsum of the foot. Its terminal branch and provides sensory innervation to the skin of the first interphalangeal space.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the N. ftbullrh communis are the most common nerve lesions of the lower extremity. Potential causes are fractures of the proximal fibula, tight skiing boots or casts. or crosslegged position. Loss of function of the extensor muscles results in a drop of the foot (footdrop). As a result. patients increase the compensatory knee flexion (steppage galt). Palsy of the fibularis muscles result in supination position of the foot. Sensory innervation is compromised for the lateral caH and the dorsum of the foot. The N. ftbullrll profundus may be affected in compartment syndrome as a result of a tltluma if the nerve and concomitant blood vessels are compressed by bleeding or swelling of the extensor muscles (anterior (tlbll[) compartment •drome). This frequent-
ly requines splining of the fascia of the leg lfasciotomyl. Pa~t~lysis of the N. fibularis profundus also shows with footdrop and steppage gait. but the sensory innervation is only compromised in the first interphalangeal area. In the anterior tarsal tunnel syndrome. the cutaneous branches underneath the Retinaculum musculorum extensorum are compressed with resulting numbness at the first interphalangeal space. Isolated injuries of the N. flbularllauparflclall (as in trauma of the fibularis muscles) are less common and cause a supination position of the foot due to the malfunction of the fibulatis muscles. Here. sensory innervation at the dorsum of the foot is compromised with intact skin sensation at the first interphalangeal space.
337
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Arteries of the pelvis and thigh
A.llacalntema
A. ct1:umflllollum pn:lfunca
\o.:::!~---------R.plmlcU8
.....1(----,....---':...._---- Ug.l'lgut11111e
~---J!f:::==i'r-------- Aa. pOOe!ldaeetctemae ~~\1~=------R,_,..I.t• R.anttllar
~c~~~mon.::::~::===-~------~'-~~~li~~ R. --~sna~--
Rg. 4.187 ArteriM of the pelwll•nd the1hlgh. rtaht tid.: ventral view. The A. profilnd• femoril is the main artery of the hip joint and the thigh. The other bmnches of the A. femoralis do not contribute to the arterial supply of the thigh. The A. profunda femoris branches off the A. femomlis Hem inferior to the inguinal ligament and divides into the A8. clrcunfleue femoris medlllls and llrter•llt. In the adult. the fe. mor•l heed is almost exclusively supplied by the A. circumflallll fe. morls medialis IR. profundus! which loops around the Collum femoris from behind 1~ Figs. 4.57 and 4.58). The R. profundus also supplies the
338
adductor musdes and the hamstring muscles. The R. acetabulatis anastomoses with the identically named branch of the A. obturatoria. The A. cirrumflexa femoris lateralis courses anterior to the femoral neck. It supplies the femoml neck and YAth seveml branches also the lateral hip muscles and the ventral muscles of the thigh. The Aa. perforantes are terminal bmnches which supply the adductor and hamstring muscles. All branches anastomose YAth each other as wall as with the A. obturatoria and the Aa. gluteae from the A. iliaca interna which is the basis for potential collateral circulations.
Muscles ..... Topography ..... Sections
Arteries of the pelvis and thigh
Arteries of the Lower Extremity
Brancm. of the A. - . . extern• • A. epigastrica inferior - A. cramasterica/A. liga manti teretis uteri - R. pubicus (anastomoses with A. obtl.-atoria) • A. circumflexa ilium profunda Br-t.s of the A. t.moralls: • • • •
A. epigastrica superficia lis A. circumflexa ilium superficial is Aa. pudendae extemae A. profunda femoris - A. circumflexa femoris medialis - A. circumflexa femoris lateralis - Aa. perforantes (mostly three) • A. descendens genus BrMChes of the A. poplitea: • A. superior medialis genus • A. superior lateralis genus • A. media genus • Aa. surales • A. inferior medialis genus • A. inferior lateral is genus
Branches of the A. tibialis anterior: • A. necurrens tibialis posterior • A. recunrens tibialis anterior • A. malleolaris anterior medialis • A. malleolaris anterior lateralis • A. dorsalis pedis - A. tarsalis lateralis - Aa. tarsales mediales - A. arcuata (,A.a. metatarsales dorsales 7 Aa. digitales dorsales; A. plantaris profunda 7 Arcus plantaris profundus) Branches of the A. tibialis posterior: • A. fibularis - R. perforans - R. communicans - Rr. malleolaras laterales - Rr. calcanei - A. nutricia fibulae and A. nutricia tibiae • Rr. malleolaras mediales • Rr. calcanei • A. plantaris medialis - R. superficialis - R. profundus (7 Arcus plantaris profundus) • A. plantaris lateralis (7 Arcus plantaris profundus with Aa. metatarsales plantares 7 Aa. digitales plantares)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . A complete physical examination includes palpation of the arterial pulses of the A. femora lis (in the groin), the A. poplitea (in the popliteal fossa), the A. dorsalis pedis (at the level of the talocalcaneonavicular joint lateral of theM. extensor hallucis longus tendon), and the A. tibialis posterior (behind the medial malleolus) to rule out occlusion of the respective blood vessels due to arteriosclerosis or emboli. Owing to the excellent blood supply of the Tibia (through Vasa nutricia) large fluid volumes may be infused via an intraosseous acceaa in emergency situations. Several arterial anastomoses contribute to collate,..l c:in:ulatiDns at different levels of the lower extremity. Although the anastomoses between branches of the A. profunda femoris and branches of the A. il iaca intema are variable, in
an emergency they allow for the ligation of the A. femoris proximal to the A. profunda femoris. In contrast, the collaterals of the Rete articulara genus around the knee are not sufficient to compensate for the ligation of the A. poplitea. The Rete articulare genus is formed by the recurrent arteries of the leg and the third perforating artery of the A. profunda femoris. The arterial network around the malleoli is well developed and usually warrants sufficient arterial supply to the foot if one of the Aa. tibiales is occluded. [The part of the A. femoral is between the branching off of the A. profunda femoris and the entry into the Canalis adductorius is clinically often referred to as A. femoralis superficialis.)
339
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Arteries of the lower extremity
'-dR'""":"'"-1--A.c~lnlfl&llll
femartll .......
.A-Ir:~--+- AL perfanantea O; II; II~
<1>-----..,f-- C..lllllldduc:tDrtlll
A. IUperlar - . I l l genua
-~~.:FJ~~;T-A. medlaganus
A. Inferior lll!eralla genua A. lnfellor medial I& gerua
A. tiblah pomrtor
A. ttblallalrlta1ar
A. W'88118 medlale -e...to,Ll.- - A. clclnella pec1a
4.188
Fig. 4.168 and Fig. 4.189 Am riM of 1M lower -.tNmity, right !Ide; ventral I~ Fig. 4.168) and dorsal I~ Fig. 4.169) views. The A. llaca externa branches off the A. iliaca communis anterior to the sacrc>iliac joint and continues beneath the inguinal ligament in the Lacuna vasorum as A. femoralt.. Following the passage through the adductor canal it is then referred to as A. poplitM {arterial supply of the knee joint). The A. poplitea descends underneath the tendinous arch of the M. soleus between the superiicial and deep flexors of the leg and
340
4.189
divides into the A. 1i:lialia poaterior which continues its course. and the A. 1lblalll anterior which pierces the Membnma interossea cruris to reach the anterior extensor compartment. The latter continues as A. dorulia pedia on the dorsum of the foot. The A. tibialis posterior provides the strong A. ftbularlsto the lateral malleolus and than continues through tha malleolar canal around tha medial malleolus to reach the sole of the foot where it provides two terminal branches (Ae. pllnta· ,.. medialis and laterall).
Muscles _. Topography _. Sections
Veins of the lower extremity
V.llllce.
e-..
v. eplgutlfcaa~lll
V. dn:lnlfl-llum aupetflclda
v. cln:Umflaxa femCIIII medlllllt V.aapllerR•~•
Y....._m..,_
Y.•--~n•
Fig. 4.170 Veins of t!MIIower extnmity, right side; ventral view. The deep vHis (dark blue)IICCOIIIJMIIIY' !tie respective erterles. In the leg, usually two veins course together with the respective artel'f, whe1'8as at the ltiigh and the popliteal fossa only one concomitant vein is found. The npelflclal Y4II'IOUI 'Y'tefn Oight blue! consists of two mein veins which collect the blood from !tie dorsum and the sole of the foot. The V. npbena megna originates enterlor to the medial malleolus and ascends on the medial side of the leg and thigh to the Hiatus saphenus (->Fig. 4.178). Here, the V. saphena magna receives tributaries from several veins of !tie inguinal region (see below! and enters the V.
femoralis at the femoral triangle. On !tie posterior side, the V. saphene pei'YI originates from !tie lateral margin of !tie foot posterior to !tie lateral malleolus and ascends en !tie middle of the calf to the popliteal fossa to enter the V. poplitea. The V. saphena magna and parva communicate through variable branches.
Tributlrila of the V. uphene megne It the flmorel triengle:
• v. epigastrica superiicialis
• V. circumflexa ilium superficialis • V. saphena accessoria • Vv. pudendae externae
341
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Veins of the lower extremity
t -
Fig. 4.171 Supetficilland deep vei1111 of 1M lowar exnmity with venous vetvw: org~nhlltlon prl~le. The extremities have a superftclel eplfasclel venous system and a deep subfalcill venoua system coursing together with the respective arteries. Both systems are connected by perfOillting veins (Vv. perforantaat. Venoul velves direct the blood flow from the superficial towards the deep wins causing the major part of the blood {86%1 to be
+---ecmmunle&Ung Win
drained 'iia the deep veins of the lower extremity to the heart. Among the many perforating veins, three groups are of dinical relevance: • DODD's perfOillting wins: intermediate third of the medial thigh • BOYD's perforating veins: medial aspect of the proximal leg (below the kneel • COCKETT's perforating wins: medial aspect of the distal leg
Rg. 4.172 Acute aural thrombosis wtth lerge thrombus (arTOWS) in the V. femoralia. [6)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Since the venous blood of the law&r extremity is predominantly drained via the deep veins towards the heart, deep venous1flrombosls bears the risk for potentially lethal pul1110111ry emboli caused by floating parts of the thrombus. Dilation of the superficial veins CVerlcosls) with formation of prominent and dilated superficial veins CVaricM) is a common condition. These are usually the result of a
342
connective tissue weakness with insufficiency of the venous valves. But they may also r&Sult from an occlusion of the deep veins due to thrombosis. This needs to be investigated carefully, sinoe surgical rem011al of the superficial varicose veins can only be performed when the deep veins are not obstructed.
Muscles _. Topography _. Sections
Lymph vessels of the lower extremity
Daraolmnl callllc:llng ayeem
fig. 4.173 and Fig. 4.174 Superficial ~ph vaaell of the lower «
drains into the lymph nodes of the popliteal fossa (Nodi lymphoidei poplitei superflclales and prafundll and continues into the deep ingtr inal lymph nodes INocllynrpltoldellngulnales prafuncll. The deep collecting systems directly drain into the deep popliteal and inguinal lymph nodes. While most of the venous drainage from the lower extremity occurs via the deep veins. the major part of the lymph is drained by the superficial lymph vessels.
343
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Lymph nodes and lymph vessels of the inguinal region
v.
88j)!lena _ . (medllllll)
OYw!IJTl lU>&IAW!na
~~~_,11! ...,..__ UWU8
fig. 4.175 and Fig. 4.176 Superficial ~ph nodM of1he inguinll region. Reglo lnguhllls ( ~ Fig. 4.175), and their trlbutarlls t~ Rg. 4.178). right side: vemral view. The inguinal region harbours four to 25 epifascial superficial inguinal lymph nodes (Noel ~oldll lngulnaiM tupt~rftclalls) which further drain into one to three inguinal lymph nodes medial of the V. femora lis (Nodi lymphoidei inguinalee profundi), and further into the Nodi lymphoidei iliaci extemi in the pelvis. The superficial inguinal lymph nodes form a verticlllmand along the V. saphena magna and a horizontalmand beneath the inguinal ligament.
The inguinal lymph nodes not only serve as regional lymph nodes for the major part of the lower extremity but also collect lymph from the lower quadltlnts of the abdominal well and the .beck. the plffnNI region and theat~m~lgenitalia <~Figs. 2.111 to2.114).1n addition, lymph from the lower perts of the Rectum and the VagiM and occasionally from the Uterus and adjacent uterine tubes (along the Lig. teres uteri) drains into the inguinal lymph nodes.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Palpation of the lymph nodes is part of a complete physical examination. The inguinal lymph nodes are regional stations for the major part of the lymph from the lower extremity. Only the drainage of the lateral margin of the foot and the calf occurs into the popliteal nodes as their regional stations which mostly cannot be palpated. Malignant cells from all regions and organs mentioned abov&.
344
including the Rectum and female reproductive organs. may thus form metastases in the inguinal region. In men. however, only the lymph from the external genitalia (penis, scrotum} drains into the inguinal nodes, but lymph from the testes travels '.lia the spermatic cord into the lumbar lymph nodes.
Muscles _. Topography _. Sections
Vessels and nerves of the inguinal region
~ (.~.\ ~J
N. cu'lll'lew ternorfalltlnlla
N.fllmoralll---- - -..,.-'\1
A.rel.-11~ --'C'""'11t-:~.,
fig. 4.177 LllcunM miiiiCellonlm end ve110n1m, right IIide; oblique •etlan at tr. lwei of the lngajnelllgemerrt: ven11'1'11 view. The space between Os coxae and the Lig. inguinlll {Fossa iliopactinea) is dMded by the Arcus IIIDpactlneu1. which spans between the inguinal ligament and the pelvic: bone, into the lat&rtll Lacuna musculorum and the medial Lacuna vasorum. The Lacuna musculorum is almost oomplately occupied by the M. llopsoas. The N. cutaneous fe-
mons lateralis is located lateral to the M. iliopsoas near the Spina iliaca anterior, the N. fem0rt1lis is positioned medial to the M. iliopsoas. Passing through the Lacuna vasorum from lateral to medial are the A. f811'101"11lls of the N. genltofemcnll. the A femorall1. and the V. fe.. mcnlls. Located most medially are the deep inguinal lymph nodes (Nodi lymphoidei inguinllls prof111'1di).
fig. 4.178 Hilrtus uphen• end UCtln.l vasorum, right lic:le; ventl'tll view; after remOIIBI of the anterior abdominal wall. of the Fascia iliaca and the abdominal viscel'tl.
The Hiatus saphenus is an opening of the Fascia lata through which the V. saphena magna passes prior to entering the V. fem0rt1lis. Located most medially are the deep inguinal lymph nodes !Nodi lymphoidei inguinales profundij the biggest of which is ref&n'ed to as ROSDIMUEu.ER's node.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The topowephy of the Foul ilioplctinee is of relevance for diagnostic and th&rtlpeutic interventions. From medial l"lnner"l to lateral. the large vessels are orien1ed in the following sequence: V. femoralis. A. femoralis and N. femoralis (iVAN). Since the pulse of the A. femort~lis is easily palpated, access to the V. femoralis is
gained by piercing the skin aboU11 em medial of the artery to insert a right ventricular cardiac catheter through the V. femaalis. The artery is accessed for left ventricular cathaterisation or for arterial blood gas analysis. TheN. femoralis lies lateral to the artery and may be damaged during these interventions.
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Superficial vessels and nerves of inguinal region and thigh
A.;V.~s~l8
Aa.; Vv. puclendu-
A.;
v. cln:Umflua I fum eupetftcllllll
Rg. 4.179 Eplfascfal YMI4Ih and l'l8l"ftoS of 1he lnguNI region. Regio inguinalil, th1 thigh, Rlgio flmoria ant8rior, and the lrnle, Reglo genus anterior, right side; ventral view. Duling the dissec1ion of this region pal1io.rlarly the course of the cutaneous nerves and the epifascial veins need to be considered. The N. llolngulnalll pierces the fascia aboYe the inguinal ligament. Just Clllnial to it, the R. cvtaneus anterior of the N. lllohypo;astrlcus is found. The V. Mphlna magna ascends at th& medial aspect of the thigh and enters into the V. femo!lllis through the Hiatus saphenus. Hera the vein collects several tributaries from the inguinal region I- p. 341). Most of th&se veins are accompanied by small branches of
346
~ dl•••ctlon llnlc
the A. femo!lllis. The R. femoralll of the N. genltofemorah passes through the Lacuna vasorum just lateral to the A femoralis. The N. cu'IIIIIUI femorlllltll'lllltllJVerses the Lac>.ma musculorum medially to the Spina iliac a anterior superior and innervates the lateral aspect of the thigh. The Rr. cutanai anteriorle of the N. r.notalia pierce the fascia at sev&llll locations to innervate the ventllll aspect of the thigh. Medial to the V. saphena magna, sevellll small cutaneous .brancha af thtl N. o.btwatoriua supply a variable area on the medial aspect of the thigh. Medial and inferior to the knee, the R. lnfrapatllarll of the N. saphenua passes through the fascia. Just above the patalla the thin A. descendens genus courses to the Rete patellare of the knee.
Muscles _. Topography _. Sections
Superficial vessels and nerves of the gluteal region and thigh
Nn. CIIIIIIUm.....,.. (1.1-cl)
Nn. clunlum m""ll (51-83)
Fig. 4.180 Eplfatdll vawels and nerves of the gluteal region. Regio glutulia.h thigh, RigiD femoril post8rior, and the popliteal fota, fosH popltM. rtght side; dorsal view. Thera are no important epifascial veins on the posterior side of the thigh. The V. saphena parva of the leg enters the subfascial V. poplitea in the popliteal fossa. The skin of the gluteal region is innervated by three groups of cutaneous nerves. The Nn. clunlum ~ {Rr. posterioras from L1-~) appear laterally to the autochthonous musdes
of the back abow the iliac crest. The Nn. clunlwn medii !Rr. postariores from S1-S3) traverse theM. gluteus maximus at its origin from the posterior side of the sacrum. The Nn. clunlwn Inferior• are branches of the N. rutaneus femoris posterior and YAnd around the inferior margin of the M. gluteus maximus. The N. cutaneua femoril polt.-iar descends in the middle of the thigh and pierces the fascia at midlength of the thigh to provide sensol)' innerwtion to the posterior aspect of the thigh.
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Superficial vessels and nerves of the leg
Y.--11-.!n•
N.~
mldlalle (!'f. t!blllle}
v. m-umlallleralla N. cutan- dorlllll mid IIIII
4.181
fig. 4.181 and Fig. 4.182 Epifascill vei• and ll'ltlr'YM of 1he lag, Regb cruris. and 1he foot.. Reglo pedis. right tide; medial 1- Fig. 4.181) and dorsolatetal <-Fig. 4.182) views. The V. Mphen a magna originates at !he medial margin of the foot anterior to the madial malleolus and ascends on the medial side of !he lag and thigh. At !he medial aspect of !he knee. the N. Mphenua pierces the fascia. Its major branch descends adjacent to the V. saphena magna and splits into the sensory terminal branches. Rr. cutanel cruris medlaiH. for !he innervation of !he ventral and medial lag and the medial margin of !he foot. The R. lnfrapatellariJ of the N. saphenus pierces the fascia ventral to the V. saphena magna and supplies !he skin b~r neath the patella. In the distal third of the late tal side of the leg, the N.
348
~ dl•••ctlon llnlc
4.18:2
fibularil ~Iii perforates the fascia to split into the two terminal cutaneous branches INn. cutanal doi'SIIIIs medialis and lntennediual which continue on the dorsum of the foot. On the posterior side of the lag, the V. saphana parva emerges from the epifasc:ial veins of the lateral margin of the foot and ascends posteriorly to the lateral malleolus on the dorsal side of the calf, pierces the popliteal fascia, and enters the V. poplitea. Adjacent !hereof courses !heN. cutan1111 surae medialis, a branch of the N. tibialis. which continues distally at !he distal third of the leg as N. aurail. It frequently communicates with the N. fibularis directly or via a communicating N. cutaneua aurae latera· lis. The terminal branch of !he N. suralis supplies as N. cutaneua dor· ..lillateralil the lateral margin of the foot.
Muscles _. Topography _. Sections
Superficial vessels and nerves of the dorsum of the foot
Mllllllah•medld8
N. cu'llln- dol'l81e medllle
\t margtlals medialis
v. margtlalsll!eralls
Fig. 4.183 Eplfatdll veins •nd ..nres of the dorsum of the foot. Don111m pedis, right side; dorsal view omo the dorsum of the foot The V. uphen• m1gn1 originates at the medial margin of the foot from the epifascial veins of the dorsum of the foot and, thus, is a continuation of the Arcus venosus dorsalis. The smaller V. 11phen• pt1rva originates from the latetal margin of the foot. At the latetal aspect of the
distal leg the N. ftbularts superflcllllls perforates the fascia and splits into the Nn. cutanel dorules medialis and lntennediiiiJ for the se~ sory innervation of the dorsum of the foot and the toes. The lateral margin of the foot is innervated by the N. cutllneus dorlllls lateralls of the N. sun~lis. Only the first interphalangeal space receives sensory innervation from the terminal branches of the N. fibuleril profundl&
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the thigh
\tllacae~tterne.
A. ct1:lnlflemllum pll:lfuncia ---!rn~-llll,.;...:~ M.lll.c1.8 ----~:!~~·
N. terncnlla - -H1ii-'Hl'i'l"
Y. Slllhen• ml!llPII A. muscularl8 G'f, temanllll
M.-medlda
Ug.p&tellat
Rg. 4.184 V8118lland ..I'YM of 1be 1hlgh. Reglo femoris am.rtor. right side; ventral view. After removal of the fascia, the individual muscles and the subfascial vessels and nerves are displayed in the femoral triangle ITrtgonum femOI"'IIa). The boundaries of the tlllingle are formed by the inguinal ligament (Lig. inguinala; proximal), theM. gracilis {medial), and the M. sartorius Oaterall. Beneath the inguinal ligament. the following structures enter the triangle from medial to lateral: V. femoralis, A. femoralis. and N. femoralis. The V. saphena magna enters the V. femora lis. The A. femorall re-
350
~ dl•••ctlon llnlc
leases smaller branches to the inguinal region 3-6 em below the inguinal ligament and as a larger b!llnch the A. profunda femoris. In the Fossa iliopectinea, the N. flmoralil creates a fan-shaped branching and divides into the N. saphenus, several Rr. musculares for motor i~ nervation of the ventral muscles of the thigh and the M. pectineus as well as the Rt. cutanai ant8rioratl providing sensory innervation to the skin of the ventral thigh. The large cutaneous N. saphanus continues the course of the N. femoralis beneath the M. sartorius. Medial to the Spina iliaca anterior superior, the N. cutanaua flmorillllt•alia enters the Lacuna musculorum beneath the inguinal ligament.
Muscles _. Topography _. Sections
Vessels and nerves of the thigh
N.~
M.-~1.18
A. cutlneua {N. Clbtul'lltortul)
M. &dcfuctor !!l1Qnl.l8
Rg. 4.185 Veaelland . .l'YM of tM1hlgh. Reglo femoris anterior, right tide; ventral view; after partial removal of the M. sartorius and splitting of theM. p9Ciineus. The A. and V. femonllls and the N. saphenus are exposed up to their &ntrance into the adductor canal (C.nalia adductoriua). The &ntrance of the adductor canal is formed by the Mm. vastus medialis and adduo-
tor longus and the Septum lntennu~eulare YIIJtoadduetarfum which spans betwaen these muscles and the M. adductor magnus. Owing to the splitting of the M. pectineus. the outlet of the C.nail obturatorius is visible. Here. the N. obtul'ltorfus and the A. and V. obturatorla exit the pelvis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In some eases of sp.~sticity, the muscle tonus of those musdes innervated by the N. obturatorius is so high that abduction of the legs and. thus. walking and standing are not possible. Injections of botulinum toxin into the adductor muscles reduce the spasticity and may relieve the symptoms. Botulinum toxin blocks the signal
transduction at the motor end plates. although, in sonne cases it is much more effective to irreversibly paralyse the N. obturatorlus by phenolln,Jectlons. This is performed by introducing the needle a few centimeters lateral to the pubic symphysis to reach the N. obtullltorius exiting from the Canalis obturatorius.
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the thigh
A. Cllmntclrfa
M.e.dcluc:la'M. &dcfuctor 10ngl.l8
M.lldductar IOngua
M. adduc:la' magnl.l8
A. aupllllor meclda genua
A. PQI)Itee.
Fig. 4.186 V...ll •nd .,.,.,.. of 1118 1fligh, Regio femoril anterior, right side; ventral view; after partial removal of 1he M. sartorius and M. rectus femoris, and splitting of the M. pectineus and M. adductor longus.The adductor canal is opened. The A. profunda femoris with its bnmches is displayed. This artery branches off the A. femoralis 3-6 em below the inguinal ligament and seN&S as main artery forth& thigh and th& femoral h&ad {... pp. 271 and 338l. The Aa. circum flax• femoris medialis and lllt81'11lll branch off the A. profunda femoris or occasionally derive directly from the A. femoralis. lh& A. cirrumflexa femoris medialis has a d&ep branch to su~
352
~ dl•••ctlon llnlc
ply th& femoral neck and head as well as the adductor muscles and the proximal parts of 1he hamS1ring muscles. There are anastomoses wth the A. obturlltorlll which contribute to the SIJpply of the acetabular fossa and the adductors. The ascending branch (A. ascendens) of the A. circumflexa femoris late!1llis SIJpplies the latel1ll musdes of the hip, the descending branch (R. descendens). descendens supplies the anterior ventral muscles of the thigh. The main trunk of the A. profunda f&moris descends further and pi'OIIides three Aa. perforanta to supply the deep adductor musdes and the hamstring muscles at 1he dorsal aspect of tha thigh.
Muscles _. Topography _. Sections
Vessels and nerves of the gluteal region and thigh
M. gtuteua medha, F.c!a
Nn.. cllnlum medllS'I-531
M.g~miiXImua
M. bl081l6 femcrl8
N. f!llul.ta communle
N. Cutaneu8 IIJ'U la.tellle (N. nbUIIIII cortrn u1'18)
M. blcepe femtnl, lando
nerv•
Fig. 4.187 Veuell•nd of 1M glutMI n~gion, Regio glut:ealls.ihe 1hlgh. Reglo femoris posterior. •nd the popltMI fosH. Fota popllt:N. right side: dorsal view; after remOIIBI of 1tle Fascia lata. The N. cwneus femoris posterior provides sensory innervation to 1tle posterior aspect of the 1tligh. It enters the groove between the M. biceps femoris and theM. semitendinosus at the inferior margin of the M. gluteus maximus and penetrates 1tle fascia at the midleng1tl of the 1tligh. This needs to be considered for the dissection. At the distal thigh, both muscles deviate from each other and define the borders of
the popliteal fossa (Fou.l poplitM). As a continuation of the A. and V. femoralis, the A. and V. poplitea enter the popliteal fossa after exiling the adductor canal. Here, they are joined by the temninal branches of theN. ischiadicus {N. tibialis and N. fibularis communis). In the popliteal fossa, 1tle N. flbul•rls communis courses most laterally and supetiicially. Located medially and deep YAthin the popliteal fossa are 1tle N. tibillil, V. popitee, and A. poplitM {NVA; from superficial to deep). The V. saphena parva ascends in the middle of 1tle calf and drains into the V. poplitea in 1tle popliteal fossa.
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the gluteal region and thigh
Nn. duntlm mecllll81-83)
fig. 4.188 V...ll and .,.,.,.. of 1118 glut8al n~gion, Regio glutHIII. the1hlgh. Reglo femorll posterior, and 1he popliteal foeu, FoMa poplitM, right lide; dorsal view; after removal of the Fascia lata and lateral deflec1ion of the Caput longum of the M. biceps femoris. The N. ilcllildiet~a descends under the guidance of the M. biceps femoris. At the level of the distal third or higher las shown herel. the N. ischiadicus dMdes into its terminal branches. The N. tibialis continues its original course and the N. fibularil communi• turns laterally to
354
~ dl•••ctlon llnlc
wind around the fibular head and enter the fibularis oompartment of the leg below the popliteal fossa. In the negion of the popliteal fossa, theN. cutai'MIUI aurae medilil branches off the N. tibialis, and the N. CIJo taii'II81111UI'H lllrterah bnmches off the N. fibularis communis for the sensory innervation of the calf. The N. rutaneus surae medialis co~ bines with a branch of the N. rutaneus surae lateralis to form the N. surals. At the thigh, the Ala. perforantes of the A. profunda femoris penetrate the M. adductor magnus lateral to the N. ischiadirus to supply the hamstring musdes.
Muscles _. Topography _. Sections
Vessels and nerves of the gluteal region and thigh
M. gh.tet• mear..M.g~miiXImua
N. gtll'llluatnflrtor
M. gemet..-rnfellar
A._....
(A. cln:umtl- femorta madIaiii)
---- - A. .up81tll:llllh
~ eln:ulll1ma t.morfa medlllllll)
N. cu'lll'lew temorlll poetlrtcr
N.IIChlldlcu• - - - -
M. biCIIIfll femalf., Caput langum - - - -
N. fblln ccmmunllt
N. cutan- 11ft& medllllt
tr.
Rg. 4.189 Ver.selland . .l'YM of gluteal region. Reglo glutMiil,. the1fligh. Regie) fernoria poaterior, and 1he poplit!NI foeu, Folu poplit... right side; dorsal view; after dissection of the M. glutaus maximus and Caput longum of the M. biceps femoris. The N. illdlildicus exits the Foramen infrapiriforme together with the N. cvtaneus femoris postii'IDr and the N. gluteuslilferlor as well as with the A and V. glutM Inferior. The N. pudendusand the A. and V.
N. a.rtanei.I811Urat ta.teralls
pudenda lntema also exit here, but immediately wind round the Ug. sacrospinale to enter the Fossa ischioanalis beneath the Lig. sacrotuberale through the Foramen ischiadicum minus. The N. gluteus inferiOI' supplies motor fibres to the M. gluteus maximus. The N. gluteus superior together with the A. and V. glutea superior exits the pelvis through the FOI'amen supn~piriforme but remains at the deap level beneath the M. gluteus medius which it innervates.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The topogn~phy of the gluteal region explains why lntramLBCUiar injection. must be applied into the M. ghmna medius, not into the M. gluteus maximus. Wrongly placed injections may cause
bleedings and injuries to the nerves which innervate the muscles facilitating movements in the hip {Nn. glutei superiOI' and inferior) and the leg (N. ischiadirus).
Lower Extremity
Surface anatomy -+ Skeleton -+ Imaging -+
Vessels and nerves of the gluteal region
M. oblk!ws ext8fnLB abdomlnla
M. gU!eus maxmLB M. glutaLB maxim,. M. plrtformla
N. w~an- fwnarle pgete~tar M. gemeiiLB superior M. obanla1us lrtemua M. gemeiiLB lnferlar
Rg. 4.190 V...ls and MrYIIS of the giiiiBIII region. Reglo glulealill. and the thigh, RegiD femGrilr pasterior, right lide; dorsal view; the Mm. glutei maximus and medius w&re cut and partially reflected, the N. ischiadicus was removed aft&r its exit from the Foramen infrapirifonne. After cutting and reflecting the M. gluteus medius, the N. glublua auperior is exposed which exits togeth&r with the A. and V. glulea
superior through the Foremen suprapiriforme and then courses laterally between theM. gluteus medius and the deeper M. gluteus minim us to theM. tensor fasciaelatae. It supplies motor fibres to all these muscles. Several branches of the A. circurnflaa femori8 medialis appear between the pelvitrochanteric hip muscles and anastomose with the gluteal arteries.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The topography of the gluteal region has particular relevance for hlp joinl._.rgary with dorsal access. To prevent injury to the A. cirrumflexa femoris medialis as the major blood vessel supplying the fe-
356
-+ dissection link
moral head, dissection of the peMtrochanteric muscles lin particular of the M. quadratus femoris and M. obturatorius extemus) should beavcided.
Muscles _. Topography _. Sections
Vessels and nerves of the popliteal fossa
V.allpherR
- --4- - Fuclactlll8
--------:--- v.....-..-
- - - - - - - . . . . ; - - - Dcnol.-.1 c:GIIec:ang ~m
4.191
M. blcepefemalla
4-192
Fig. 4.191 and Fig. 4.192 Vatsell and nerves of the popliteal
fosH. Fota popllt:N, right side: dorsal view; after partial (-Fig. 4.191) and complete(- Fig. 4.192) removal of the fascia. In the popliteal fossa the N. ftbullrls comm...ls is located most laterally and superficially, followed medially and deeply by the N. tibialis. V. poplitN, and A. popitM (NVA). The V. saphena p.II'Vll ascends in
the midline of the leg and drains into the V. poplitea in the popliteal fossa. The dorlolllteral lymph '¥8N8I system courses along the V. saphena parva, whereas the ventromedilllymph ¥811181 8y8tem aocompanies the V. Sll'pllena magM. The first regional lymph nodes for the dorsolateral collecting system are the Nodi ~pholdel poplitei -..perficieles and profundi 1- p. 343).
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Arteries of the popliteal fossa
M. bloepl flmarl8
Rg. 4.193 ArteriM of the poplltell fossa. fosM poplltee, right tide; dorsal view; after partial resection of the covering musdes. The A. poplitM supplies the knee joint and forms arterial networks with its branches above (Aa. superiorss medialis and lateralis genus) and below (Aa. inferiores medialis and lateralis genus) the articular cavity. These arterial networks contribute to the Rete artirulare genus on the ventral side of the knee. At the level of the joint, the A. media genus
branches off to supply the knee joint. The Aa. surales supply the muscles of the calf. Bei
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The portion of the A. poplitea between the branching off of the A. tibialis anterior and the origin of the A. fibularis derived from the
358
~ dl•••ctlon llnlc
A. tibialis posterior is clinically referred to as Truncua1ibiofibulariL
Muscles _. Topography _. Sections
Vessels and nerves of the leg
M.tlblllll.,_
M. tlblllll arartar, Tenclo
M. _,_cUgll:lrum Ia~..
Fig. 4.194 V..Mh and I'HII"¥''S of 1he leg. Reglo aurls anterior. right U.; ventral view; after spreading apart !tie extensor muscles. The superficial lymph vessels course as ventromedill collecting _... tem from !tie medial margin of the foot alongside the V. saphena
magna and as dorlolatlral collecting system alongside the V. sephena parv1. The deep lymph vessels accompany !tie arteries in the three muscular compartments as shown here for the extensor compartment.
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the leg
Fig. 4..195 V...llend nerva of the leg, Reglo crurllemerfor, rlaht side; ventral
A. tlt'ellor lateral is genus
A. tbllllls a!Urlor
M. 411Cteneor dliilltorUm lOll!~»
view; after removal of the Fascia cruris and dissecting the Mm. extensor digitorum longus and fibula lis longus. The A. tibillil emlrior descends in the eJttensor compartment between the M. extensor digitorum longus and M. tibialis anterior and continues as A. dorsalis pedis on the dorsum of the foot. After the A. recurrenstiblalls posterior branches off at the posterior side of the leg, the A. recurrens tibilillenf:e. rlor appears as the next branch after ti'IJ\Io ersing the Membnma interossea cruris. At the malleoli the AI. melllollra emlrior• m• dlalls and leterells contribute to the arterial network around the ankle that may provide a sufficient oollateral circulation in case of an ocdusion of one of the arteries of the leg. The N. fibuleris communis winds laterally around the head of the fibula. enters the fibularis compartment and then divides into its two terminal branches. The N. fibuleris .,. perficillil descends in the fibularis compartment provides motor fibres to both fibularis muscles and pierces the fascia at the distal third of the leg. The N. ftbularls profundus passes over to the extensor compartment and descends adjacent to the A tibialis anterior. It conveys motor innervation to all extensors of the leg and the dor~m of the foot. Its terminal branches corrvey sensory fibres to the first interdigital space.
N. ~bulniU.,..ricll.
-~llli'r-
Reltlacutum mueculerUm 411Cteneorum n1'wlls
A.m.lleot.-fallllllrfor tltlntll A. dor'lllllle pad II
Nn. dJtlteiM dcnetae paella
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The N. ftbularls communis may be injured near the fibular head (proximal fibular fractures. casts, crossed lags). The resulting paralysis of the extensor muscles causes the toes to drop {footdrop,
360
~ dl•••ctlon llnlc
~ p. 337). This is the most common nel\18 lesion of the lower extremity!
Muscles _. Topography _. Sections
Vessels and nerves of the popliteal fossa and leg
M. aanocnemh.lt, C8llUt lltlnlt A.; v. tl61118 Rr. muec:ulln8 (N.1!blll8)
Rg. 4.198 Ver.selland ..l'YM of tr. poplltell fossa. Fossa poplit-. and the let. Regio Cfuril post8rior, right IIide; dorsal view; after removal of the Fascia cruris and dissecting the M. gastrocnemius. Joined by two concomitant veins and the N. ii)ialia,. the A. ti)illia posterior courses benealh lhe tendinous arch of the M. soleus (Arcus
tendineus musculi solei) and descends between the superiicial and deep flexor muscles of the leg to the medial malleolus. There, it traverses the m1lleolar canal beneath the Retinaculum musculorum flexorum to reach lhe sole of lhe foot.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The N. tibialis may be compressed in lhe m1leolar canal {medial urul tunnel syndrome, -> p. 336). This causes burning pain sensations at lhe sole of the foot and a loss of function of lhe plantar
muscles of lhe foot. Flexion, adduction, or spreading toes is not possible any more.
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the popliteal fossa and leg
Rg. 4.197 V...-ll•nd ..I'YM of1he poplltell fossa, foall popit-. •nd the lag, Regio Cfuril post8rior, right IIide; dorsal view; after dissecting the Mm. gaS1roa'lernius and soleus.
362
~ dl•••ctlon llnlc
Shortly after passing through 1tle tendinous arch of the M. soleus, the A. 1ibilil posterior gives rise to its most important branch, the A. fibularis, which descends to the lateral malleolus.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the leg
A.lrhrlor medllll8genU8
M. toiiM
M. lle.JU haluelsleflgus
Rr. m•l.._llllillnllee
Fig. 4.198 V..Mis and I'I8I"¥''S of 1he leg. Reglo aurls posterior, right side: dorsal view; after removal of the Fascia cruris and dissec1ing the Mm. gastrocnemius. soleus, and flexor hallucis longus. The A. tibialis posteriDr descends together with the N. 1lblllls between the superficial and deep flexor muscles of the leg to the medial malleolus and oontinues through the malleolar c.nal beneath the Retinaculum musculorum flexorum to the plantar side oi the foot. Rr. maleolar• medillle to the medial malleolus deriv& from this vessel.
The A. ftbularls pierces theM. flexor hallucis longus and descends in the deepest layer directly on the Membrana interossea cruris to the lateral malleolus. Together with the branches oi the AJJ. tibiales anterior and posterior, its Rr. maiiiOIIres llter~la complete the arterial network around the ankle which pf'O'.Iides sufficient collaterals to compensate for an occluded vessel.
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the dorsum of the foot
M. 8ittenKlr halluclll~ ..
A. phmt.t• profunda
M. e-.ar halluclllong... liJnda
Rg. 4.189 V...-llend ..I'YM of1he dorsum of the foot. Dorsum ptMiill,. right IIide; dorsal view onto th& dorsum of th& foot after removal of the tendons of the M. extensor digitorum longus and the short extensors of the toes. Th& A. tibillilenterior continues on th& clo!'sum of th& foot as A. dorsals pedis. After the innervation of the extensors of th& leg and the dorsum of the foot. the concomitant N. ftbu..rll profundus dividss into terminal sensory branchss which supply th& first interdigital space. At the level of the malleoli, the A. tibialis anterior provid&s th& .A.. 1111J.
364
~ dl•••ctlon llnlc
leoler• enterlor• meclals and leterelll for the arterial networks around the malleoli {Rete malleolare mediale and Rete malleolare lat&ralel. The A. dorsalis pedis prOIIidss sevel1!1 smaller Aa. tarsales mediaIss and one A. tarsalis lsteralis to the Tarsus and then ccntinuss as A. arcuata. The latter archss to the lateral margin of the foot and gives rise to the Aa. metatarsales dorsalss which continue as Aa. digitales dorsaIss to supply the toss. The A. plantaris profunda participates in the perfusion of the sole of the foot by supplying the Arcus plantaris profu~ dus.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Arteries of the sole of the foot
Aa. dlgtalilll p111ntate11 camrramea
A. euperf!CIIIII
Rg. 4.200 Arteries of the 101e of 1he foot.. Pllnta pediiJ. rlaht lide; plantar viw.v. The plan1ar asp&e1 of the foo1 is perfused by 1erminal branches of the A. tibialis posterior. The A. plantaris medialis provides a R. tupt~rflcl•
•
b
Rp. 4.201• to d V.rlatlons of the arterl•l RPP'v of 1he toes. right IIide: plan1ar view. The Arcus plan1aris profundus may receive its main input from the A. dorsalis pedis via the A. plantaris profunda {II) or from the A. tibialis
lis to the medial margin of the foot and a R. prafundiiiJ which connects to the Atcu1 plantaris profunduL This arterial arch is a direct continuation of the A. plentarilllteraliL
d
posterior (b). Alternatively, both arteries may contribute to the arterial supply of the1oes (c and d).
365
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Vessels and nerves of the sole of the foot
Ar. cat:anel medlale8 0'1. lblllllt)
N. pl.rt.te rnedlalle A. tlll1lll pwtwtor
N. pl.n.te lltwllll
Fig. 4.202 Superficilllayer of the erteriee end nerves of the .ole of the foot. right llde; plantar view. The N. 11bl1lls all'llady dMdes into its two terminal bnmches {Nn. pllntei'M medillil and llltar•ill at th& m&dial maii&Oius within th& 11'111leollr an1l ben&ath the Retinaculum musculorum flexorum. The terminal branches then dMde further into seve!lll Nn. digitales plantares.
366
~ dl•••ctlon llnlc
Similar to theN. ulnaris at the hand. theN. plantaris lateralis dMdes into a R. superiicialis and a R. profundus. The N. plantaris medialis supplies an additional N. dlgltllls pllntlrls proprius at the medial margin of the foot. The sensory branches surface between the longitudinal fibres of the plantar aponeurosis (Aponeurosis plantaris!. The A. tibialis posterior divides only at the plantar aspect of the foot.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Vessels and nerves of the sole of the foot
M. ftuDr dlgllorum - · lllndk'lea
M. d~Jtalea p - camrramea
Nn.d~ltalilll
pillnlalell comml61ea
R.
N. piEtarte lllltlnlll• { R.11'011UI1Ch•---
M.lllductor dlg111 mtlimt
Fig. 4.203 lntennedilrtltllyer of 1M •mri• •nd 1'118r'Y• of 1M 1011 of 1he foot. right side: plantar view. The M. flexor digitorum brevis and !tie M. abductor hallucis were cut to eJCPC)Se the neurovascular passageway of the malleolar canal. The Nn. plant.res medialis and llrtel'lllll are accompanied by !tie correspond-
ing vassals from the A. tibialis posterior. The blood wssels oontinue beneath !tie M. flexor digitorum blllllis to reach !tie intennediate layer of the neurovascular structures to the toes. On their way, the nerves provide motor fibres to the short musdes of the sole of the foot.
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
-+
Skeleton
-+
Imaging
-+
Vessels and nerves of the sole of the foot
~---N-~--- Olp.rtobl~um
}
M. adcfuctcr hllh.IC18
D JUJ.>-i"*'- - M. tlucf hlllucl81n\118
M. abduda'd~ltlmntmt
N........ rnedllllll R414:fi'IIICllllum mueeulorum tlaoNn A. tlblalle poelblrtcr
N. plll'ltlrfelllt«alle
Fig. 4.204 Deep layer of the •rterias •nd nerves of the .ole of the foot. right side; plamar view. The M. flexor digitorum brevis and the M. abduc1or hallucis were split to expose the neurovascular passageway of the m.1lleoler an.IL In addition, !he Caput obliquum of !he M. adductor hallucis was cut to demonstrate the deep plantar arch (Arcus plltntltrts profundus) and the course of the A. profundua of theN. pllnurilleteraliL The Arcus
368
-+ dl•••ctlon llnlc
plamaris profundus cominues the A. plantaris lateralis und receives blood from the R. profundus of !he A. plamaris medialis and from !he A. plan1aris profunda Yhlich derives from !he A. dorsalis pedis. Together with the R. profundus from the N. plantaris lateralis it arches over the Mm. interossei of the sole of !he foot in !he deep layer of !he neurovascular structures.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Foot, sagittal sections
0s mell:bnlll M. ~ dcnelll pedal Ug.tlll~m
ln'llllr-.m
4.205
M.lblllllt anta'ler, Tenelo M. fleJa' hduclllcngua 11bla
llllua
Ug. tlll~m lnt«o-.n
4.208
Rg. 4.205 and Fig. 4.208 foot. Pes. right side; saglttltl sectiDn through 1he ncond phalanx c~ Fig. 4.205) and C01'1'81p01'1dfng magnetic reaon.~nce imagingCMRI) sagittaleection (... Fig. 4.206); medial view.
Th& s&Ction visualis&S 1tl& articular cavity of 1tl& ankle joint !Articulatio talocru~t~lisl and 1tl& posterior chamber of the talocalcaneonavicular joint (Articulatio subtalaris). The longitudinal arch is stabilised by three Oll&l'lying ligamentous systems (Aponeurosis plantaris. Lig. plantare longum. Lig. calcaneonaviculare plantar&) (... Fig. 4.95).
369
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
~
Skeleton
~
Imaging
~
Hip joint, oblique section
M.gemell ...
M.lldduc;tcr tnvfe
Fig. 4.207 Thigh,. Femur, obliq.. section itlrough 1M hip joint. right 11•; distal view illustrating !he axes of movement of the hip joint. The oblique section through the thigh at the level of the femoral head shows the position of !he diverse groups of muscles relative to the articular head and the axes of movement. The M. gluteus maximus is located dorsal to the hip joint. whereas the smaller gluteal muscles (Mm. glutei medius and minimusl in part course ventral to !he longitudinal and transverse axes of the hip joint. This position explains why the M. gluteus maximus acts as external rotator and extensor of the hip, and !he small gluteal muscles function as strongest medial rotators and also as flexors of the hip. The M. iliopsoas is located anterior to the transverse axis and is the most important flexor of the hip joint. It is supported for this function by the anterior group of femoral muscles
370
{M. sartorius. M. rectus femoris). the M. tensor fasciae latae. and the superficial adductor muscles (Mm. adductores longus and brevis. M. pectineus. main part of !he M. adductor magnusl. However. the dorsal part of the M. adcilctor magnus is positioned posterior to the transverse axis and functions as extensor of the hip joint together with !he hamstring muscles of which it is a part of given its function and innervation.Cross-sections through the extremities are well suited to comprehend the course of the neurovascular structures in the respective compartments at several levels. After exiting the small pelvis. the N. isd'liadicus initially courses beneath the M. gluteus maximus. On the ventral side, the A. profunda femoris is covenad by the M. pectineus. " transverse axis of movement in !he hip joint "" saginal axis of movement in !he hip joint
tahir99-VRG & vip.persianss.ir
Muscles ~ Topography ~ Sections
Thigh, transverse section J),,; ,' ' '
.
~
Rr. muaculln8 (N, femoral a)
M. blceil8 fem0118, cawt r~um
M. adcfuctcr mag nus
Fig. 4.208 Thigh. Femur, right side; ira...,.... section at 1he mld-11gh liMit distal view. This cros&-Section shows the lhree muscle groups of the !high. The ventral group comprises theM. quadriceps femoris and theM. sartorius. Medially located are the adductor muscles and dorsally the hamstring muscles.
The V. saphena magna is found in the epifascial subcutaneous adipose tissue on !he medial aspect of the thigh. The A. and V. femoralis joinUy course with !he N. saphenus through !he adductor canal (Canalis adductorius) of theM. quadriceps. The adductor canal is demarcated dorsally by the Mm. adductonas longus and magnus, medially by the M. vastus medialis. and ventrally by theM. sartorius. TheN. ischiadicus is positioned dorsally beneath the M. biceps femoris.
371
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy
-+
Skeleton
-+
Imaging
-+
Knee, transverse section
V.•pllenalllllll. .
N. llldMdl- { N. flll.llarla CGIIIIIUIIB
M. •mlmem..._., 'llllndD
N.llllalla M. gllllllaci'IIIT'IL8, Caput medlallt
Rg. 4.209 IKoN Joint. Articulatio genus. rtghl-.: traiiSYIIIrse •ctian; distal view. The transverse section through the knee joint shows the articular surfaces of the Articulatio femoropatellaris. On the posterior side, the M. biceps femoris is positioned lllt8llllly. Therefore this muscle is the most important lateral rotator. On the medial side, several muscles contribute to medial rotation. The tendons of the Mm. sartorius, gracilis, and semitendinosus are located superficially. They insert further distally with a common aponeurosis at the medial aspect of the libia, com-
372
monly referred to as "Pes anserinus superficial is". Beneath it. the insertion of theM. semimembranosus tendon is referred to as "Pes anseri nus profundus". The V. saphena magna is found in the epifascial subcutaneous adipose tissue on the medial side of the lmee. Dorsally, the terminal branches of the N. ischiadicus (N. tibialis and N. fibularis communis) are the most superficiaI structures, followed further beneath by the V. poplitea with the confluence of the V. saphena parva, and deepest within the popliteal fossa theA. poplitea {NVAJ.
tahir99-VRG & vip.persianss.ir
Muscles _. Topography _. Sections
Leg, transverse section
8ep1um lntennuiCulln crurllantelfua
'llbla
v. 811lf!- l'!liQna N. 8ll)tl elllS
1 Carnp1111tlnwnlum crurt1t .m..t..: A.; v. ~blllun11N!or N. nbulaiiS prcllmdLIS M. tibialis an1811cr M. Mt&neordlglloriJlllell!LIS
2 ea........OMtum crurtlt lliit8NI.c N.nbullllu~le
M. flbulaiiS [peronei.IS)IC!l!LIS M. flbulaiiS [peronei.IS) b1W18
M.-hllllucllle!llua
M. flbulirl8 [pennlul]leltlua
3 Camt-IIIWIIum crur1l padlrtu .. . . . !Pfdjncllr: A.; v. tibialis poeteller
A.;V.flbulirle N. tibialis
M. ft&xor dlgtarum lengua M.tlbllilll~
M. ft&xor hllllucllle!llua
Fig. 4.210 Leg, Cru1. right side; trii'IISWr'U section et 1he mid-leg level with Illustration of the osteofibrous comp.artments; distal view. The Fascia cruris is attached to the bones of the leg by dense connective tissue septa. They separate osteofibrous compartments in which the neurovascular struotures are embedded between the respective muscle groups 1- Fig. 4.211). The Septum intermuseulare anterius partitions the extensor compartment anteriorly from the latellll fibularis compartment which in tum is separated from the superficial flexors by the Septum int&m~usculare posterius. The superficial flexors are isolated from the deep flexors by a deep layer of the Fascia cruris.
The deep flexors are directly adjacent to the Membrana interossea cruris. The Interior (axtentOr) comp.artment harbours the N. fibularis profundus, the A. tibialis and the Vv. tibiales anteriores. TheN. fibularis superficialis is located in the llrt8r•l lfibuleria) comp.artment. In the deep posterior (flexor) CCIIII'p.lrtment. the N. tibialis, A. tibialis posterior, Vv. tibialis posteriores, and- COIIEII'ed by theM. flexor hallucis lo~ gus- the A. and V. fibularis are embedded in the muscles. The V. saph a. na magna and V. saphena parva on the dorsal side course in the epifasciallay&l' at the medial aspect of the leg. "
deep part of the Fascia cruris
373
tahir99-VRG & vip.persianss.ir
Lower Extremity
Surface anatomy -+ ....... Sections
Leg, transverse section
M. Ublala artslar M. 1111tenac1r l"alluclllclngu•
A. 11111111111 anter1ar
M. utei'I8CI' dlglllnlm loi'GLIS
N.tlldarlll...-flciaiB N. ftdaM prvflln1ll•
V. Mpllene m~~g~~~~
M. Ublala paa.tor
M. llalcllr I'Biucll loogus
A. . .1111111 paat8rlar
Fig. 4.21 1 Lag, Crua, right aide; tran.,.,... section at the mid-leg
embedded between the muscle bellies of the indi\lidual muscle groups.
level. distal view. Together with the connective tissue septa reaching to the bones of the leg, the Fascia cruris confines the ostBDftbrous CDIIIJNirtmllnts. These compartments contain the respective neurovascular structures
Of highest clinical relevance is the anterior {extanson compartmant which harbours the N. fibularis profundus together with the A tibialis anterior.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Comprelllion SJndromes most commonly develop in the anterior compartment !compartment SJndrumel, rarely in the posterior deep compartment. With posnraumatic swelling of the extensor muscles or after a long march the SUpPying ~ood vessels and nerves may be compressed and damaged, causing extensive pain. This may also cause the loss of palpable arterial pulses of the A. dorsalis pedis which arises from the A. tibialis anterior. Most frequently, the
374
compression causes a lesion of the N. fibularis profundus (-+ p. 337) with resulting functional deficits including the inability to dorsiflex the foot in the an ide joint and loss of sansory innervation in the first interdigital space. This condition requires the immediate decompression by surgical incision of the fascia (fasciotomy). Diagnostically, the pressure within the anterior compartment is determined using a pressure sensor which requires immobilisation of the opanleg.
Appendix Picture Credits . . . . . . . . . . . . . . . . . . . . 377 Abbreviations, Terms, etc. . . . . . . . . . 379 Index ............................. 381
Picture Credits The editors sincerely thank all clinical colleagues that made ultrasound, computed tomographic and magnetic resonance images as well as endoscopic and intraoperative pictures available: Prof. Altaras, Center for Radiology, University of Giessen (Figs. 2.1 8; 2.39; 2.40) Prof. Bruckmann and Dr. Linn, Neuroradiology, Institute for Diagnostic Radiology, University of Munich (Fig. 4.148) Prof. Daniel. Department of Cardiology, University of Erlangen (Fig. 10.39) Prof. Galanski and Dr. Schafer. Department of Diagnostic Radiology, Hannover Medical School (Figs. 2.97; 5.3; 5.103; 6.31; 6.129) Prof. Gebel, Department of Gastroenterology and Hepatology, Hannover Medical School (Figs. 6.73; 6.75; 6.76; 6.94; 6.95; 7.25) Dr. Greeven, St. Elisabeth Hospital. Neuwied (Figs. 4.96; 8.96) Prof. Hoffmann and Dr. Bektas. Clinic for Abdominal and Tranplantation Surgery, Hannover Medical School (Fig. 4.41) Prof. Hohlfeld, Clinic for Pneumology, Hannover Medical School (Fig. 5.71) Prof. Jonas. Urology, Hannover Medical School (Fig. 7.33) Prof. Kampik and Prof. Muller, Ophthalmology, University of Munich (Fig. 9.66) Dr. Kirchhoff and Dr. Weidemann, Department of Diagnostic Radiology, Hannover Medical School (Figs. 6.131; 6.133; 7.26) Prof. Kleinsasser. Oinic and Polyclinic of Oto-Rhino-Laryngology, Plastic and Aesthetic Surgery, University Hospital Wuerzburg (Figs. 11 .41; 11 .42; 11.43) PD Dr. Kutta, Clinic and Polyclinic for Oto-Rhino-Laryngology, University Hospital Hamburg-Eppendorf (Figs. 8.101; 10.16; 11.16) Dr. Meyer. Department of Gastroenterology and Hepatology, Hannover Medical School (Figs. 6.22; 6.32; 7.1 04) Prof. Pfeifer, Radiology lnnenstadt. Institute for Diagnostic Radiology, University of Munich (Figs. 2.63-2.65; 2.67-2. 70; 3.52; 3.54; 3.55; 4.97; 4.99; 4.1 00; 4.1 05; 4.1 06) Prof. Possinger and Prof. Bick, Medical Clinic and Polyclinic II, Division of Hematology and Oncology, Charite Campus Mitte, Berlin (Fig. 2.141) Prof. Ravelli t, formerly Institute of Anatomy, University of lnnsbruck (Fig. 2.62) Prof. Reich, Orofacial Surgery, University of Bonn (Figs. 8.60; 8.61) Prof. Reiser and Dr. Wagner. Institute for Diagnostic Radiology, University of Munich (Figs. 2. 71; 12.1 05; 12.1 06; 12.11 0; 12.111 J Dr. Scheibe, Department of Surgery, Rosman Hospital, Breisach (Fig. 4.79) Prof. Scheumann, Clinic for Abdominal and Tranplantation Surgery, Hannover Medical School (Fig. 11.58) Prof. Schillinger, Department of Gynaecology, University of Freiburg (Fig.1.49) Prof. Schliephake, Orofacial Surgery, University of Goettingen (Figs. 8.156; 8.157) Prof. Schloesser, Center for Gynaecology, Hannover Medical School (Fig. 7.79) cand. med. Carsten Schroeder, Kronshagen (Fig. 9.27) Prof. Schumacher, Neuroradiology, Department of Radiology, University of Freiburg (Fig. 12.5) Dr. Sel, University Hospital and Polyclinic for Ophthalmology, University Hospital Halle (Saale) (Fig. 9.64) Dr. Sommer and PD Dr. Bauer, Radiologists, Munich (Figs. 4.101; 4.102) PD Dr. Vogl. Radiology, University of Munich (Figs. 9.69; 9. 70) Prof. VVitt, Department of Neurosurgery, University of Munich (Fig. 3.116) Prof. Zierz and Dr. Jordan, University Hospital and Polyclinic for Neurology, University Hospital Halle (Saale) (Figs. 8.82, 12.151)
Additional illustrations were obtained from the following textbooks: 1 Benninghoff-Drenckhahn: Anatomie, Band 1 (Drenckhahn D .• editor), 17. AufI., Urban & Fischer 2008 2 Benninghoff-Drenckhahn: Anatomie, Band 2 (Drenckhahn D., editor), 16. Aufl., Urban & Fischer 2004 3 Benninghoff-Drenckhahn: Taschenbuch Anatomie (Drenckhahn D., Waschke, J., editors), Urban & Fischer 2007 4 Berchtold, R., Bruch, H.-P., Trentz, 0. (editors): Chirurgie, 6. Aufl., Urban & Fischer 2008 5 Biicker, W., Dank. H.• Heitz. P. U .• Mach, H. (editors): Pathologie, 4. Aufl., Urban & Fischer 2008 6 Classen, M., Diehl. V., Kochsiek, K., Berdel, W. E., Bohm, M .• Schmiegel, W. (editors): lnnere Medizin, 5. Aufl., Urban & Fischer
2003 7 Classen, M., Diehl, V., Kochsiek, K., Hallek, M., Bohm, M. (editors): lnnere Medizin, 6. Aufl., Urban & Fischer 2009 8 Drake, R. L., Vogl, A. W., Mitchell, A., Paulsen, F. (editors): Gray's Anatomie fur Studenten, 1. Aufl., Urban & Fischer 2007 9 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Anatomy for Students, 2"d ed., Churchill Livingstone 2010 10 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Atlas der Anatomie, Urban & Fischer 2009 11 Fleckenstein, P .• Tranum-Jensen, J.: Rontgenanatomie, Urban & Fischer 2004 12 Forbes, A., Misiewicz, J., Compton, C., Ouraishy, M., Rubesin, S., lhuluvath, P.: Atlas of Clinical Gastroenterology, 3r<1 ed., Mosby 2004 13 Franzen, A.: Kurzlehrbuch Hals-Nasen-Ohre!l-Heilkunde, 3. Aufl .• Urban & Fischer 2007 14 Garzorz, N.: BASICS Neuroanatomie, Urban & Fischer 2008 15 Kanski, J. J.: Klinische Ophthalmologie, 5. Aufl., Urban & Fischer
2003 16 Kanski, J. J.: Klinische Ophthalmologie, 6. Aufl., Urban & Fischer 2008 17 Kauffmann, G. W .• Moser, E., Sauer, R. (editors): Radiologie, 3. Aufl., Urban & Fischer 2006 18 Lippert, H.: Lehrbuch Anatomie, 7. Aufl., Urban & Fischer 2006 19 Mettler, F. A. (editor): Klinische Radiologie, Urban & Fischer 2005 20 Moore, K., Persaud, T. V. N.• Viebahn, C. (editors): Embryologie, 5. Aufl., Urban & Fischer 2007 21 Schulze, S.: Kurzlehrbuch Embryologie, Urban & Fischer 2006 22 Speckmann, E.-J.• Hescheler. J., Kohling, R. (editors): Physiologie, 5. Aufl., Urban & Fischer 2008 23 Trepel, M.: Neuroanatomie, 4. Aufl., Urban & Fischer 2008 24 Welsch, U.: Sobotta Lehrbuch Histologie, 2. Aufl., Urban & Fischer 2005 25 Welsch, U., Deller, T.: Sobotta Lehrbuch Histologie, 3. Aufl .• Urban & Fischer 2010 26 Welsch, U.: Atlas Histologie, 7. Aufl.. Urban & Fischer 2005 27 VVicke, L.: Atlas der Rontgenanatomie, 7. Aufl., Urban & Fischer 2005 28 Rangier. F.: BASICS Leitungsbahnen. Urban & Fischer 2009
The following illustrators have developed the new illustrations: Dr. Katja Dalkowski: Figs. 1.22, 1.25, 1.26, 1.30, 1.31, 1.35, 2.94, 2.95, 2.134, 3.10, 3.33, 3.39, 3.48, 3.51, 3.57, 3.58, 3.59, 3.100, 4.4. 4.55, 4.68, 4.70, 4.90, 4.91, 4.107 Jorg Mair: Figs. 1.38, 1.39, 1.40, 1.41, 2.111. 2.112. 2.135, 2.136, 2.137, 2.151, 3.40, 3.1 08, 3.109, 3.110, 3.111, 3.112, 3.113, 3.132, 3.134, 4.114, 4.115, 4.116, 4.117, 4.122, 4.123, 4.124, 4.131' 4.132, 4.133, 4.158, 4.160, 4.164, 4.165, 4.166, 4.170, 4.173, 4.174 Stephan VVinlder: Figs. 1.15, 1.16, 2.1 0, 2.11, 2.1 04, 2.1 05, 2.1 06, 2.107, 3.66, 3.67, 4.57, 4.58
377
1. List of abbreviations Singular: A. Lig. M. N. Proc. R.
v.
Var.
Arteria Ligamentum Musculus Nervus Processus Ramus Vena Variation
Plural: Aa. Ligg. Mm. Nn. Procc. Rr.
Vv.
=
Arteriae Ligamenta Musculi Nervi Processus Rami Venae
female male
Percentages: In the light of the large variation in individual body measurements, the percentages indicating size should only be taken as approximate values.
2. General terms of direction and position The following terms indicate the position of organs and parts of the body in relation to each other, irrespective of the position of the body (e.g. supine or upright) or direction and position of the limbs. These terms are relevant not only for human anatomy but also for clinical medicine and comparative anatomy.
longitudinalis= parallel to the longitudinal axis (e.g. Musculus longitudinalis superior of the tongue)
sagitta/is= located in a sagittal plane transversalis =located in a transverse plane transversus= transverse direction (e.g. Processus transversus of a thoracic vertebra)
General terms
anterior- posterior= in front- behind (e.g. Arteriae tibiales anterior et posterior)
ventralis - dorsalis= towards the belly - towards the back. suparior- inferior= above- beiOIN (e.g. Conchae nasales superior et
Terms of direction and position for the limbs proxima/is- dista/is located tOINards or away from the attached end of a limb or the origin of a structure (e.g. Articulationes radioulnares proximal is et distalis)
=
inferior)
crania/is- cauda/is= towards the head- tOINards the tail dexter- sinister= right -left (e.g. Arteriae iliacae communes dextra et
for the upper limb:
radialis- u/naris = on the radial side- on the ulnar side (e.g. Arteriae radialis et ulnaris)
sinistral
internus- extemus = internal- external suparficialis- profundus= superficial- deep (e.g. Musculi flexores digitorum superficialis et profundus) medius, intermedius= located between two other structures (e.g. the Concha nasalis media is located between the Conchae nasales superior and inferior) medianus located in the midline (Fissura mediana anterior of the spinal cord). The median plane is a sagittal plane which divides the body into right and left halws. medialis -latera/is = located near to the midline- located away from the midline of the body (e.g. Fossae inguinales medialis et lateralis) frontalis= located in a frontal plane, but also towards the front (e.g. Processus frontalis of the maxilla)
=
for the hand:
palmaris- dorsalis= towards the palm of the hand- towards the back of the hand (e.g. Aponeurosis palmaris, Musculus interosseus dorsalis) for the lower limb:
tibialis- fibu/aris = on the tibial side- on the fibular side (e.g. Arteria tibialis anterior) for the foot:
plantaris -dorsalis = towards the sole of the foot- towards the back of the foot (e.g. Arteriae plantares lateralis et medialis, Arteria dorsalis pedis)
3. Use of brackets [ ]: Latin terms in square brackets refer to alternative terms as given in the Terminologia Anatomica (1998), e.g. Ren [Nephros]. To keep the legends short, only those alternative terms have been added that differ in the root of the word and are necessary to understand clinical terms, e.g. nephrology. They are primarily used in figures in which the particular organ or structure plays a central role.
( ): Round brackets are used in different ways: - for terms also listed in round brackets in the Terminologia Anatomies, e.g. (M. psoas minor) - for terms not included in the official nomenclature but which the editors consider important and clinically relevant, e.g. (Crista zygomaticoalveolaris) - to indicate the origin of a given structure, e.g. R. spinalis (A. vertebral is).
379
Index
A A cells, MembraNI synovialis 17 Abdomen 6 - CT angiography 34 Abdominal wall - dermatomes 118 - hernias 44 - muscles 83, 93 - - complete lack 44 - - CT 91 - - deep layer 88 - - middle layer 86-87 - - superficia I layer 82, 86 - oblique muscles, fronts I section 95 - posterior, muscles 94 - posterior aspect of the anterior wall 92, 120 - rectus sheath 90 - segmental sensory innervation 118 - structure 125 - surface relief 43 - ventral of a newborn 120 Abduction 4 - fingers 193 - saddle joint of the thumb 154 - shoulder joint 148 Abductors of the hip 306 Accessory bones 14 Acetabular rim 269 - angle of 269 Acetabulum 252 - retroversion 269 Acetylcholin (Parasympathicus) 30 ACHILLES tendon (Tendo calcaneus) 315-317, 362-363,369 Acquired flatfoot 289 Acromioclavicular joint (AC joint) - classification ofTOSSY 159 Acromion 42, 74, 137, 146-147, 149, 156, 160-163, 168-169, 218 Adduction 4 - fingers 193 - knee joint 275 - saddle joint of the thumb 154 - shoulder joint 148 Adductor canal 351 Adductor hiatus 305 Adolescent kyphosis !SCHEUERMANN's disease! 68 Ala ossis - ilii 252- 253, 290 - sacri 56 Amastia 41, 114 Amnion 13 Amniotic cavity 12 Amphiarthroses 17, 286 Ampulla ductus deferentis 120 Anal region - regional lymph nodes 103 - superficial lymph vessels 103 Anamnesis 7 Anastomoses - cavocaval 41. 99 - portocaval 25 Angulus - acromii (Scapula) 137 - costae 47 - inferior scapulae 42, 74-75 - infrasternalis 43 - lateralis scapulae 137 - mandibulae 68 - sterni ILUDOVICil 43, 46, 58 - -clinical examination 46 - subpubicus 264 - superior scapulae 137 - - conventional radiograph 32 -venosus 26 Ankle joint 283- 284 - arthrosis 282
An/de joint - conventional radiograph 294- 295 - dorsal extension 288 - dorsiflexion 288 - ginglymus 288 - hinge joint 288 - hypersupination trauma 284 - injuries 284 - ligaments 283-284 - plantar flexion 288 - range of movement 288 Ankle joint fractures - conventional radiograph 295 - WEBER's fractures 295 Ankylosis, knee joint 19 Ansa subclavia 31 Antebrachium See Forearm Anterior 5 Anterior drawer test 277 Anterior (tibial) compartment syndrome 337, 374 Anteversion, shoulder joint 148 Anular ligament, elbow 150 Anular rim 53, 63 Anulus - fibrosus 45, 63, 67, 110-111 - - chondrosis/osteochondrosis 73 - inguinalis - - profundus 120-121 , 123 - - superficialis 86-88, 121, 123-125 - umbilicalis 43,82-83, 86,90-91, 119 Aorta 44, 72, 100,338 - abdominalis See Pars abdomina lis aortae - descendens See Pars descendens aortae - thoracica See Pars thoracica aortae Aortic isthmus, stenosis 41, 97 - erosions (usures) of the ribs 47 - horizontal bypass circuit 97 - vert ical bypass circuit 97 Ape hand 205 Apertura - pelvis - - inferior 250 - - superior 250- 251 - thoracis - - inferior 46 - - superior 46 Apex - capitis fibulae 259, 292 - dentis 51 - ossis sacri 56-57 - patellae 272, 292 Apical 5 Aponeurosis - musculi bicipitis brachll 131, 170-172, 176, 226,230 - palmaris 131, 188, 234, 239 - plantaris 289, 322-323, 325, 366-369 Apophysis 16 Appendicitis 11 Appendix vermiformis 10-11 Arachnoidea mater spinalis 108-109, 112-113 Arcus - anterior atlantis 60, 6 4, 68 -aortae 22, 24,31 - - conventional radiograph 32 -costa l ~ 43, 46,83 - ductus thoracici 26 - iliopectineus 120, 265, 302, 345 - palmaris - - profundus 208, 233, 236 - - superficial is 208, 233, 235, 239 - plantaris profundus 339-340, 365, 368 - posterior atlantis 50, 64-65, 68, 80, 107108 - pubicus 264 - tendineus musculi - - levatoris ani 300 - - solei 316, 336, 361
AFcus - venosus - - dorsalis pedis 348-349 --palmaris - - - profundus 209 - - - superficialis 209 - vertebrae 50-51 , 53, 66, 70, 110, 113 Area intercondylaris - anterior 258, 293 - posterior 258, 293 Areola mammae 114 Arm (Brachium) - dorsal muscles 161, 170, 173-174, 181-182 - MRI 240 - rotation axis 13 4 - surface relief 130 - transverse section 240 - ventral muscles 160 Arm bud 132 Arteria(-ae) - arcuate 339-340, 364 - auricularis posterior 106 - axillaris 22, 84, 194-195, 208, 211,218220,222-223 - - branches 219 - brachialis 22, 208, 219, 222- 230, 240 - - superficialis 215 - carotis - -communis 22, 31 , 96 - - externa 22 - - interns 22 - cervicalis - - profunda 107 - - superficialls 119 - circumflexa - - femoris latera lis 271, 338- 340, 351-352 - - - medialis 271, 338-340, 361-352, 355 - - humeri anterior 208, 219, 222 - - - posterior 106, 208, 214, 219, 222, 225 - - ilium profunda 96, 123, 338-339, 350 - - - superficialis 119,338-339, 346 - - scapulae 105, 219, 225 - collateralis - - media 208, 225 - - radialis 208, 224-225, 227, 229-231 - - ulnaris - - - inferior 208, 223 - - - superior 208, 223, 226- 227, 240 - comitans nervi mediani 208, 229 - cremasterica 339 - descendens genus 339-340, 346, 352, 358 - digitales - -dorsales - - - (Manus) 239 - - - (Pes) 339, 364 - - palmares - - - communes 208, 233-235, 239, 242 - - - propriae 208, 233- 236, 239, 242 - - plants res - - - communes 339, 366, 367 - - - propriae 365-367 - dorsalis pedis 22, 339-340, 360, 364 - -pulse 22 - ductus deferentis 121 - epigastrica - -inferior 90, 96, 101, 119-121 , 123-126, 338-339 - - superficialis 119, 338-339, 346 - - superior 90, 96, 100-101, 119 - femora l~ 22, 34, 93, 95, 120, 123, 303, 338,340, 345-346,350-352, 370-371 - - branches 339 --pulse 339 - - superficialis 34, 339 - fibularis 22, 339-340, 358, 360, 362-363, 374 - glutea - - inferior 340, 365- 366, 370 - - superior 355, 370
381
Index
Arteria(-ae) - iliaca - - communis 22, 31, 34, 338 - - externa 22, 34, 101, 120, 123, 338,344, 350,352 - - - branches 339 - - interne 22, 34, 338, 344, 350 - inferior - - lateral is genus 279, 339-340, 358, 360 - - medialis genus 279, 339-340, 352, 358, 361-363 - intercostales posteriores 84, 97, 100 - interossea - -anterior 208, 229,231, 237,239 - - communis 22, 208, 228-229 - - posterior 179, 208, 229, 231-232, 239 - - recurrens 208, 230, 232 - lienalis 34 - ligamenti teretis uteri 339 - malleolaris anterior - - lateral is 339-340, 360, 364 - - medialis 339-340, 364 - mammariae - - laterales 116, 211 - - mediales 116, 211 - media genus 279, 339-340, 358 - mesenteries - - inferior 22, 31 - - superior 22, 31,34 - metacarpales - - dorsales 237-239 - - palma res 233, 236, 239 - metatarsales - - dorsales 339-340, 360, 364 - - plantares 339, 365-366, 368 - musculophrenica 96, 100-101 - nutricia - - fibulae 339 - - tibiae 339 - obturatoria 120, 338-339, 345, 351-352 - occipitalis 105-107 - perforans(-tes) 338-340, 352, 354-355, 358 - pericardiacophrenica 96, 101 - phrenica inferior 94 - plantaris - - lateral is 339-340, 365, 367-368 - - medialis 339-340, 365, 368 - - profunda 339, 364-365 - poplitea 22, 279, 308,315, 340,352-355, 357-358,361-363,372 - - branches 339 - princeps pollicis 208, 233-234, 236 - profunda - - brachii 22, 105, 208, 219, 222-225, 240 - - femoris 22, 34, 271,338-340, 350-352, 370 - pudenda - - externa 119, 338-339, 346 - - interne 355-356 - radialis 22, 208, 216, 226-230, 233, 235238,241 - - course 238 - - indicis 208, 233-234, 236 --pulse 208 - recurrens - - radialis 208, 227-230, 339 - - tibialis - - - anterior 339-340, 360 - - - posterior 339-340, 358 - - ulnaris 208, 228-231 - rena lis 22, 31, 34 - spinalis anterior 113 - subclavia 22, 31, 96, 100, 218-219 - subscapularis 96, 208, 219, 222 - superior - - lateralis genus 339-340, 357-358, 360 - - medialis genus 339-340, 352, 354, 357358,360
382
Arteria(-ae) - suprascapularis 219, 225 - surales 339-340, 357-358, 361 - tarsalis(-es) - - lateralis 339-340, 364 - - mediales 339-340, 364 - testicularis 22, 120, 123 - thoracica - - branches 96 - - interne (A. mammaria internal 94, 96-97, 100-101, 116, 119 - - lateralis 96, 116, 119, 211-212, 219-221 - - superior 96, 100, 219,221 - thoracoacromialis 208, 218-220 - - branches 218 - thoracodorsalis 96, 116,219-220 - tibialis - - anterior 22, 340, 358-360, 363-364, 374 - - - branches 339 - - posterior 22, 340, 358, 361-363, 365368,374 - - - branches 339 - transversa calli 221 - ulnaris 22, 205, 207-208, 226-230, 233236,241 - -pulse 208 - umbilicalis(-es) 24, 120 - - obliterated 92 - vertebralis 67, 81, 96, 105, 107-108 Arterial pulses, examination 22 - A. femoralis 339 - A. radialis 208 - A. ulnaris 208 Arteries 22 - abdominal wall 97 - axilla 223 - dorsum of the hand 238 -elbow 230 - forearm 226-229, 231-232 -hand 233,237-239 - lower extremity 208, 339-340 - palm of the hand 234-236 - pelvis 338 - popliteal fossa 358 - pulses 22 - Regia antebrachii 226-227 - shoulder 219, 225 - sole of the foot 365-368 - systemic circulation 22 - thigh 338 - thoracic wall 100 - upperarm 224-225 - ventral wall of the trunk 96 Arteriosclerosis 208, 339 Arthroscopies, knee joint 281, 293 Arthrosis - ankle joint 282 - finger joints 158 - Genu valgum/Varum 249 - pelvic girdle 290 - pelvis 290 - radiological signs 158 - uncovertebral gap 50 - zygapophysial joint 50 Articulatio(-nes) - acromioclavicularis 134-135, 145, 147, 156, 168-169 - atlantoaxialis - - lateralis 64-66 - - mediana - - - anterior 64 - - - posterior 64 - atlantooccipitalis 64-66 - bicondylaris 276 - calcaneocuboidea 248 - capitis costae 53, 61, 69 - carpi 153 - carpometacarpalis(-es) 134, 153 - - pollicis 153
Articu/stio(-nes) - cartilaginea 17 - conoidea 18 - costochondrales 46 - costotransversaria 53, 61, 69 - costovertebrales 61-62 - cotylica 269-270 -coxae 248,264,269-270,291 - - blood supply 271 - - range of movement 270 - cubiti 128, 134, 150 - - radiograph 157 - cuneocuboidea 248 - cuneonavicularis 248 - cylindrica 18 - digiti (Manus) 155 - ellipsoidea 18 - femoropatellaris 248, 272, 372 - femorotibialis 248, 272 - fibrosa 17 -genus 248,272-281,292-293,310,372 - humeri 128, 134, 146-149, 169 - - radiograph 156 - humeroradialis 134, 150 - humeroulnaris 134, 150 - interchondrales 46 - intercuneiformes 248 - intermetacarpales 153 - intermetatarsales 286 - interphalangea(-ae) - - distales - - - (Manus) 36, 155 - - - (Pes) 286 - - (Manus) 134 - -(Pes) 248 - - proximales - - - (Manus) 134, 155 - - - (Pes) 286 - lumbosacralis 46 - manus 153-154 - mediocarpalis 134, 153 - metacarpophalangeae 134, 154-155 - metatarsophalangeae 248, 286-287 - ossea 17 - ovoidea 18 - pedis 286-287 - plana 18 - radiocarpalis 134, 153, 239 - radioulnaris 153 - - distalis 128, 134, 152-153 - - proximalis 134, 150, 152 - sacrococcygea 46,57 - sacroiliaca 42, 46, 71, 248, 250, 264-265, 267-268,290-291,300 - sellaris 18 - spheroidea 18 - sternoclavicularis 43, 59, 135, 144 - sternocostales 46, 59 - subtalaris 248, 285, 294, 369 - synovialis 17 - talocalcaneonavicularis 248, 285, 294 - - radiograph 294 - talocruralis 248, 283-284, 294, 369 - - radiograph 294-295 - talonavicularis 369 - tarsi transversa (CHOPART's joint) 260, 262 - tarsometatarsales (LIS FRANC's joint) 248, 260,262,286 - tibiofibularis 248, 258, 282, 292-293 - - proximalis 272 - trochoidea 18, 288 - uncovertebralis 52 - zygapophysialis 54, 68, 70-72, 268 Assimilation of atlas 48, 50 Athelia 41, 114 Atlanta! arches, isolated fractures 50 Atlantoaxial joint, intermediate 64 Atlantoaxial subluxation 65
Index
Atlas 46,49-50, 52, 64-66,78, 80-81, 107108 - assimilation 48, 50 Atrium - dextrum 24 - - conventional radiograph 32 - sinistrum 24 Auricula sinistra, conventional radiograph 32 Auscultation 10 Autonome neuropathy 31 Autonomic nervous system 28, 30-31 - disorders 31 - neuropathy 31 Axillary fossa 219-221 - arteries 223 - blood vessels 222 - epifascial vessels 212 - lymph nodes 21 0-211 - nerves 212, 222-223 - superficial lymph vessels 210 Axillary space - quadrangular 169, 174, 225 - - blood vessels and nerves 1 05 - triangular 169, 174, 225 - - blood vessels and nerves 105 Axis 46, 49-52, 64-66, 68, 80-81 Azygos systam 99
B B cells, Membrana synovial is 17 B cell zone, lymph nodes 27 Back (Dorsum) 6 - dermatomes 104 - muscles 78, 80-81 - nerves 105 - orientation lines 42 - regions 42 - segmental cutaneous nerves 104 - surface relief 42 - upper region, vessels and nerves 106 - vessels 105 BAKER's cyst 280 Ball and socket joint 18 - medial clavicular joint 135 - shoulder joint 148 - sternoclavicular joint 59 Basal 5 Basis - ossis - - metacarpi 158 - - metatarsi 260 - - sacri 56-57, 70, 290 - patellae 272, 292 - phalangis - - (Manus) 142 --(Pes) 260 Bayonet injury 129 BEKHTEREV's (BECHTEREW's) disease 63, 268 BENNINGHOFF's arcades 17 Bicondylar joint 272, 276 Bifid ribs 47 Bifurcatio - aortae 22, 34, 338 - tracheae, conventional radiograph 32 Blastocyst 12 Blastocyst cavity 12 Blisters (Bullae) 37 - epidermal 37 Block vertebra 45, 55, 68 BOCHDALEK's triangle (Trigonum lumbocostale) 94 Body regions 8-9 Bone marrow biopsies 58 Bones 14 - air-filled bones 14 - cartilaginous skeleton 133
Bones - flat bones 14 - irregular bones 14 - long bones 14-15 - ossification (bone age) 133 - short bones 14 - structure 15 -subchondral bone 17 Bowleg (Genu varum) 248-249 BOYD's perforating veins 342 Brachialis pulse 22 Brachium 6, 130, 134 - See a/so Arm Brain, MRI 35 Breast 114-115 - amastia 114 - anomalies 41 - contours, radiograph 32 - lymphatic drainage 116 - polymastia 114 - radiograph 117 - sagittal section 115 Breast cancer 117 - frequency in relation to the location 117 - mammography 117 - sentinel lymph node 117 Brittle nails 36 Broken neck 65 Bronchus principalis dexter/sinistar, conventional radiograph 32 Buccopharyngeal membrane 13 Bullous pemphigoid 37 Bursa(-ae) - anserina 305 - (Art. genus) 273 - bicipitoradialis 150, 177 - coccygea 105 - infrapatellaris profunda 273, 280 - ischiadica musculi obturatorii interni 309 -musculi - - coracobrachialis 163 - - semimembranosi 315-317 - subacromialis 146, 149, 163 - subcutanea - - calcanea 322 - - infrapatallaris 302 - - olecrani 131 - - prepatallaris 296,372 - - sacralis 105 - - spinae iliacae posterioris superioris 105 - subdeltoidea 169 - subfascialis prepatellaris 280 - subpoplitea 280 - subtendinea - - iliaca 304-305, 370 --musculi - - - gastrocnemii medialis 315-317 - - - sartorii 305 - - prepatellaris 302 - - subscapularis 147, 163 - suprapatellaris 273, 280-281 - synoviales (Art. genus) 280 - trochanterica musculi glutei - - maximi 307-309 - -medii 309 Bursitis 280
c Calcaneal tandon (Achilles) 315-317, 362-363, 369 Calcaneus 260-263, 283, 285, 289, 369 - ossification centres 16 Callus 15 Calx 9, 247 Canalis - adductorius 303, 340, 351 - arteriae vertebral is 50
Canalis
- carpi 191, 205, 235 - - transverse section 241 - inguinalis 123 - nervi hypoglossi 65 - obturatorius 264, 269-270, 305, 345, 351 - sacralis 56-57, 73 - vertebralis 73, 110, 112-113 Capitulum humeri 138, 150, 157 Capsula - articularis - - (Art. atlantoaxialis lateralis) 64 - - (Art. atlantooccipitalis) 64 - - (Art. coxae) 269-270 - - (Art. cubiti) 150 - - (Art. genus) 273, 293, 310 - - (Art. humeri) 147-148, 163 - - (Art. radioulnaris distalis) 152 - - (Art. sternoclavicularis) 59, 144 - interna 35 Caput 6-7 -breve - - (M. biceps brachii) 21, 84, 131, 163, 168172,222 - - (M. biceps femoris) 299,306, 308-310, 337, 355, 371 - costae 47, 53,69 - epididymidis 123 - femoris 34, 254-256, 269-270, 290-291 - fibulae 246-247, 258-259, 272-274, 282, 292-293,296,299,302,313 - humerale (M. pronator teres) 185 - humeri 138-139, 146, 156 - humeroulnare (M. flexor digitorum superficialis) 177, 179 - latarale - - (M. gastrocnemius) 274,280, 299,308311,314-316,354,357-358,361,372 - - (M. triceps brachii) 21, 83, 131, 162, 169170,173-174,181-182,202-203,224225,240 - longum - - (M. biceps brachii) 21, 146-147, 149, 163, 168-172, 174, 222 - - (M. biceps femoris) 299-300,306-310, 336,354-355,370-371 - - (M. triceps brachii) 21, 83, 105, 131, 146, 162-163,169-174,202-203,222-225, 240 - mediale - - (M. gastrocnemius) 274,297,308-311, 314-317,354,357-358,361,372,374 - - (M. triceps brachii) 21, 131, 170-174, 176178,181-183,202-203,222-224,240 -medusae 25 - obliquum (M. adductor hallucis) 325, 368369 - ossis metatarsi 260 - phalangis - - (Manus) 142 --(Pes) 260 - profundum (M. flexor pollicis brevis) 189, 191,242 - radiale (M. flexor digitorum superficialis) 177, 179, 228 - radii 141, 157 - rectum (M. rectus femoris) 269,304 - reflexum (M. rectus femoris) 269, 304 - superficiale (M. flexor pollicis brevis) 189, 191,236,242 - tali 260-263, 294,369 - transversum - - (M. adductor hallucis) 323-325, 368 - - (M. adductor pollicis) 189-190 - ulnae 131, 140, 152, 184, 186 - ulnare (M. pronator teres) 179, 185, 228 Caput-collum-diaphyseal angle (CCD angle) 256
383
Index
Cardiac pacemaker, implantation access via the V. cephalica 213 Carotid pulse 22 Carpal joints 153 Carpal tunnel 204-205, 235, 241 Carpal tunnel syndrome 205 Carpus 133-134 - fractures 158 - joints 153 - ligaments 154 - transverse section 241 Cartilaginous joint 17 Cartilago(-ines) - articularis (Femur) 15 - costal is 46, 59, 88 - cricoidea 68 - thyroidea 72 Cauda equina 73, 109, 112 Caudal/caudalis (= inferior) 5 Cavea thoracis - anterior wall 85 - posterior wall 85 Cavitas - articularis 17 - glenoidalis 137, 146, 156, 163 - medullaris 15, 255 - serosa scroti 124-125 - symphysialis 268 Cavocavalanastomoses 41,99 Cavum serosum scroti 123 Central 5 Central nervous system (CNSJ 28 Centrum tendineum diaphragmatis 85, 93-95 Cervical lordosis 49 Cervical vertebral column 45, 47, 50-52, 66 - computed tomography 72 - lateral radiograph 68 Cervico-occipital joints 66 - cervico-occipital transitional region 64 - deep ligaments 64-65 - ligaments 64-65 - ventral ligaments 66 Chiasma - cruris 311,316 - plantare 311, 325 Chondrosis, Anulus fibrosus 73 CHOPART's joint (Art. tarsi transversa) 260, 262,286 - luxations 260 Chorda - arteriae umbilicalis 90, 119-120, 124-125 - dorsalis 13, 44-45 - obliqua 150, 152 - urachi (lig. umbilicale medianum) 90, 124125 Cingulum - pectorale 128, 134-135 - pelvicum 46, 248, 264 Circumduction 4 Circumferentia articularis - (Radius) 141, 150, 152 - (Ulna) 140 Cisterna - cerebellomedullaris 108 - chyli 26 Clavicula 14, 43, 59, 83, 131, 134-136, 144, 146,156,160,162,168-169,171-173,218 - conventional radiograph 32 Clavicular joint - lateral joint 145 - medial joint 144 - - range of movement 135 - spheroidal joint or ball and socket joint 135 Claw foot 336 Claw hand, lesions N. ulnaris 129, 207 Claw toe 287 Cleavage of the lateral vertebral arch 54 Clitoris, insufficient filling of the cavernous body 333
384
Clivus 64 Club foot 13, 132, 289 - congenital 289 Coccyx 57 COCKETT's communicating perforating veins 342 Collateral arteries, Rete articulare cubiti 208 Collateral circulations 339 Collateral ligaments, elbow joint 150 Collodiaphyseal angle -femur 256 - humerus 138 Collum 6-7 - anatomicum 138-139 - chirurgicum 138-139 - costae 47, 53 - femoris 254-256, 269, 290-291 - fibulae 259, 272 - radii 141, 150, 152, 157 - scapulae 137, 156 - tali 262-263, 294 Colon 10-11 - conventional radiograph, barium swallow test 32 Columna vertebralis 46,48-49, 111 Compartimentum cruris - anterius 373 - laterale 373 - posterius 373 Compression syndrome - forearm 185 - leg 374 Computed tomography
Corpus
- ossis - - ilii 252-253, 291 - - ischii 252-253 - - metatarsi 260, 318 - - pubis 252-253 - phalangis - - (Manus) 142 - -(Pes) 260 - radii 141, 184 - sterni 46, 58-59, 85 - tali 262-263 - tibiae 258, 282, 292 - ulnae 140, 184 - unguis 36 - vertebrae 50-53, 55, 62,68-73, 113 Cortex, hair 38 Cortical sinus, lymph nodes 27 Cortical sinus cells 27 Costa(-ae) 14, 47, 53, 69-70 - conventional radiograph 32 - fluctuantes 45-46 - spuriae 45-46 - verae 45-46 Costovertebral joints 61-62 Coxa - valga 256 - vara 256 Coxarthrosis 256, 269 Cranial/crania lis (=superior) 5 Cremasteric reflex 121 Crista - capitis costae 47 - calli costae 47 - iliaca 42, 70, 74-75, 93, 95, 105, 252, 290, 296,299-300,307-308,334,356 - intertrochanterica 254, 256, 290 - medialis fibulae 259 - musculi supinatoris 140 - obturatoria 252-253 - occipitalis externa 50 - pubica 252 - sacralis - - lateralis 56 - - medialis 56 - - mediana 56-57, 70 - supraepicondylaris - - lateralis 138, 157 - - medialis 138, 157 - tuberculi - - majoris 138 - - minoris 138 Cruciate ligaments 274, 277 - injury 277 - reconstruction 281 Crumbly nails 36 Crural thrombosis - acute 342 - deep, pulmonary emboli 342 Crus - anterius (Capsula internal 35 - dextrum (Pars lumbalis diaphragmatis) 9394, 126 - laterale (Anulus inguinal is superficial is) 86, 88, 121 - mediale (Anulus inguinal is superficialis) 82, 86,88,121 - sinistrum (Pars lumbalis diaphragmatis) 94 - transverse section 373-374 CT angiography -abdomen 34 - pelvis 34 Cubita 134 Cubital fossa - arteries and nerves 230 - epifascial nerves 213-214, 216 - epifascial veins 213,215-216 - epifascial vessels and nerves 214 Cubital pulse 22
Index
Cupula - dextra, conventional radiograph 32 - sinistra, conventional radiograph 32 Cutaneous innervation (segmental) -back 104 - lower extremity 329 - upper extremity 196-197, 329 Cuticle 38 CNC (central nervous system) 28 eve (central venous catheter), V. cephalica 213 Cytotrophoblast 12
D Deep (autochthonous) muscles of the back 7779 - deep layer 75, 79 - intertransversal system 77 - lateral tract 77 - medial tract 77 - sacrospinal system 77 - spinal system 77 - spinotransversal system 77 - superficial layer 74-76 - transversospinal system 77 Dendritic cells - follicular 27 - interdigitating 27 Dens axis 50-52, 64-65, 68 Dermatomes 44 - abdominalwall 118 - back 104 - disc prolapse 197 - lower extremity 329 - stenosis of the vertebral canal 197 - thoracic wall 118 - upper extremity 133, 197 Dermis 37-38 Descensus testis 124 Dexter (= right) 5 Diabetes mellitus, polyneuropathy 29 Diameter - obliqua 1/11 250 - transversa 250-251 - vera 250-251 Diaphragm (Diaphragma) 10-11,85,92-95, 101 - apertures 94 - axial and para-oesophageal hiatal hernias 95 - conventional radiograph 32 - frontal section 95 Diaphragmatic hernias 95 Diaphysis 15 Diarthrosis 17 Digitus(-i) 246 - anularis 130 -manus 134 - medius 130, 242 - minimus [quintus] - - (Manus) 130 - - (Pes) 260-261 - pedis 248 - primus (Pes) 260-261 - quartus (Pes) 260-261 - secundus (Pes) 260-261 - tertius (Pes) 260-261 DIP joint (distal interphalangeal joint) 155 Direction and positioning of body parts 5 Disc prolapse/disc herniations 73 - dermatomes 197,329 -lumbar 67 - medial, MRI 73 - posterolateral 54 Discus - articularis - -(Art. radioulnaris distalis) 152-153 - - (Art. sternoclavicularis) 59, 144 - interpubicus 264, 267-268
Discus - intervertebral is 49, 62-64, 66-68, 72-73, 110-111 Distal/distalis 5 Dithalamic joint 59 Divisiones - anteriores (Plexus brachialis) 194 - posteriores (Plexus brachialis) 194 DODD's perforating veins 342 Dorsal 5 Dorsal aponeuroses - lateral tracts 192 - medial tracts 186, 192 Dorsal extension - ankle joint 288 - carpal joints 154 - interphalangeal joints - - distal 155 - - proximal 155 - metacarpophalangeal joints 155 Dorsalaponeuroses, lateral tracts 186 Dorsalis 5 Dorsiflexion, ankle joint 288 Dorsum of the foot (Dorsum pedis) 8-9, 246247, 349, 364 - arteries 364 - epifascial veins 349 - fascia 296 - muscles 320-321 - nerves 349, 364 - skeleton 260-262 Dorsum of the hand (Dorsum manus) 8, 130, 186 - arteries 238 - arteries and nerves 237-238 - epifascial vessels 217 - epifascial vessels and nerves 217 - nerves 217, 238 - osseofibrous tunnels 183 - tendons 186 - Vaginae tendinum 187 DUCHENNE's gait, loss of function of the small gluteal muscles 335 Ductus(-us) - arteriosus (BOTALLO's duct) 24 - deferens 120-121, 123-125 - lactiferi 115 - lymphaticus dexter 26, 116 - thoracicus 26, 94, 116 - - confluence 221 - - metastases 221 - venosus (ARANTIUS's duct) 24 Duodenum 10 Dura mater - cranialis 64 - spinalis 64, 108-109, 112-113 Dystonia 178 - M. iliopsoas 303
Elevation 4 - shoulder joint 148 Ellipsoid joint, wrist joints 154 Emboli 208, 339 Embryoblast 12 Embryogenesis 12 Embryonic disc 12 Eminentia - iliopubica 252 - intercondylaris 258, 272, 292 Enarthrosis (Art. cotylica) 269-270 Encephalon 28 Enteric nervous system 30 Entoderm 13 Epiblast 12 Epicondylus - lateralis - - (Femur) 254, 257, 272, 292, 372 - - (Humerus) 138, 150-151, 157, 162, 173, 181-184,214,224,231 -medialis - - (Femur) 254-255, 257, 272, 275, 292, 372 - - (Humerus) 130, 138, 150-151, 157, 171172,176-179,223,226,229-230 Epidermis 37-38 Epididymis 124-125 Epidural anaesthesia 46 Epiglottis 68 Epimer, differentiation from myotomes 44 Epineurium 112 Epiorchium 123-125 Epiphysis - anularis 51, 53, 55, 63, 67 - distalis 15 - proximalis 15 Epithelial root sheath 38 Eponychium 36 ERB's palsy (upper brachial plexus paralysis) 194 Erectile dysfunction 333 Eversion, talocalcaneonavicular joint 288 Extension 4 - elbow joint 151 - knee joint 272, 276 - saddle joint of the thumb 154 - vertebral column 60 Extensors, leg 311 External female genitalia - lymph nodes 103 - superficial lymph vessels 103 External ligaments, knee joint 273, 275 External/externus 5 Extremitas - acromialis (Clavicula) 136 - sternalis (Clavicula) 136
E
F cells, Membrana synovialis 17 Facial defects, grafts of the M. pectoralis major 74 Facialis pulse 22 Facies - anterior - - (Patella) 272-273 - - (Radius) 141, 179 - - (Ulna) 140 - anterolateralis (Humerus) 138, 140 - antaromedialis (Humerus) 138 - articularis - - acromialis 263 - -anterior - - - (Atlas) 50 - - - (Axis) 51 - -calcanea - - - anterior 263 - - - media 263
Ectoderm 13 Ectopia of testis 124 Elbow - anular ligament 150 - arteries 230 - epifascial nerves 214 -nerves 230 Elbow joint 128, 150 - collateral ligaments 150 - extensors 170 - flexion 151 - flexors 170 - hinge joint (trochoginglymus) 151 - pronation 151 - radiograph 157 - range of movement 151 - supination 151
F
385
Index
386
Facies articulllris calcanea
Fascia
Foramen(-ina)
- - - posterior 263 - - carpalis 141, 152 - - claviculae 136 - - clavicularis 146 - - cuboidea 263 - - fibularis 258-259 - -inferior - - - (Atlas) 50 - - - (Tibia) 258-259, 282-283, 293 --malleoli - - - lateralis 259, 282-283 - - - medialis 258-259, 282-283 - - navicularis (Talus) 263 - - (Patella) 272-273, 281,292 - - posterior (Axis) 51 - - sternalis 136 --superior - - - (Atlas) 50 - - - (Axis) 50 - - - (Tibia) 258 - - talaris (Calcaneus) - - - anterior 263, 285 - - - media 263, 285 - - - posterior 263, 285 - - tuberculi costae 47 - auricularis (Os sacrum) 56-57, 252 - costalis (Scapula) 137 - intervertebralis 51, 53, 55,68-71 - lateralis - - (Fibula) 259 - - (Radius) 141 - - (Tibia) 258 - lunata 252-253, 270 - malleolaris - - lateralis 262-263 - - medialis 262-263 - medialis - - (Tibial 258-259, 312, 359 - - (Ulna) 140 - patellaris (Femur) 254, 257, 273, 281 - pelvica 57 - poplitea (Femur) 254-255, 272, 292, 310, 316,358 - posterior - - (Humerus) 139 - - (Radius) 141 - - (Scapula) 137 - - (Tibia) 258-259 - - (Ulna) 140 - sacropelvica 252 - superior (Talus) 263 - symphysialis 252, 267 Fascia - antebrachii 131, 171-172, 234 - axillaris 82, 210 - brachii 82, 131,212, 240 - clavipectoralis 82, 218 - cremasterica 124-125 - cribrosa 296 - cruris 296,314, 348,357, 373-374 - deltoidea 74-75 - dorsalis pedis 296 - endothoracica 84 - extraperitonealis 123 - glutea 83, 296, 307, 354 - infraspinata 74-76, 162, 173 - lata 296, 302-304, 307, 345, 347, 371 - musculi serrati 84 - nuchae 107 - pectoralis 115, 163 - spermatica - - externa 121, 123-125 - - interne 124-125 - thoracica - - externa 84 - - interne 84 - thoracolumbalis 62-63, 72-79, 83, 90, 307
- transversalis 78, 88, 90, 92-93,95, 101, 121, 123-125 Fasciculus(-i) - lateral is (Plexus brachia lis) 194-195, 199, 218,222 - longitudinales - - (Aponeurosis plantaris) 322 - - (Lig. cruciforme atlantis) 64-65 - medialis (Plexus brachial is) 194-195, 199, 218,222 - posterior (Plexus brachialis) 194-195, 199, 218,222 - transversi (Aponeurosis plantaris) 322 Fecal incontinence 333, 335 Females, surface anatomy 6-7 Femoral head - fractures 271 - - Coxa vara 256 - necrosis 271 Femoral pulse 22 Femoral (thigh) hernias 121 Femur 6-7, 14, 35, 248, 254-257, 272-275, 281,290-293,305,310,316,358,371-372 - adductor group 301-302 - distal end 257 - proximal end 256 - spongiosa structure 256 - transverse section 371 - - through the middle of the thigh 370 Fertilisation 12 Fetus, ultrasound image 33 Fibrae intercrurales 82, 86, 121 Fibrous joint 17 Fibrous root sheath 38 Fibula 14, 248,258-259, 272-275,282-284, 294-295,316-317,319,373-374 - ligaments 282 Fibular/fibularis 5 Filum(-a) - radicularia 113 - - posteriors 108 - terminale 112 Finger joints 155 - arthrosis 158 - extensor muscles 187 - flexor muscles 192 - ligaments 155 - range of movement 155 Fingers 132 - examination of cuts 191 Fissura sterni congenita 58 Flatfoot, acquired 289 Flexion 4 - elbow joint 151 - knee joint 272, 276 - saddle joint of the thumb 154 - vertebral column 60 Flexion contracture, limited mobility 19 Follicular dendritic cells 27 Foot drop 337, 360 Foot(Pes) 6-7, 248,260 - dorsiflexion position 336 - epifascial veins 348 - joints 286-287 - muscles 313, 325 - nerves 348 - pronation position, lesion of the N. tibialis 336 - sagittal section 369 - - MRI 369 - synovial sheath (Vaginae tendinum) 318-319 - tensioning of the longitudinal plantar arch 289 Foramen(-ina) 15 - costotransversarium 53, 62 - infrapiriforme 300, 307-309, 332, 334, 355 - intervertebrale 49, 54, 63, 68, 70, 72, 110 - - narrowing 54, 110
- ischiadicum - - majus 265-267, 307, 334 - - minus 265-267, 300, 307, 309, 332 - magnum 50, 108 - nutricium - - (Clavicula) 136 - - (Radius) 141 - - (Tibia) 258-259 - - (Ulna) 140 - obturatum 34, 252, 265, 267, 290-291 - ovale 24 - sacralia - - anteriora 56, 71 - - posteriors 56-57 - suprapiriforme 300, 307-308, 332, 334, 355 - transversarium 50-52, 72 - venae cavae 85, 93-94 - vertebrale 50-51, 53, 55, 72 Forearm (Antebrachium) 6, 130, 134 - arteries and nerves - - deep layer 228-229, 231-232 - - superficial layer 226-227 - compression syndrome 185 - conjunctions of the bones in pronation and supination positions 152 - diagonal axis 134, 185 - dorsal muscles 180-184 - epifascial veins and nerves 216 - fascia 131 - pronation 185 - radial muscles 180 - supination 185 - supinator muscles 170 - transverse section 241 - ventral muscles 175, 177-179 Fossa - acetabuli 252-253, 270, 290-291 - axillaris 130,210-212,219-223 - coronoidea 138, 157 - cubitalis 8 - iliaca 252 - iliopectinea 345 - infraclavicularis 131 - infraspinata 137 - inguinalis - - lateralis 92, 120, 124-125 - - medialis 92, 120, 124-125 - intercondylaris 254-255, 257, 272, 292-293 - malleoli 259 - olecrani 139, 157 - ovalis 24 - paravesicalis 92 - poplitea 9, 247, 296, 309, 347, 353-355, 357-358,361-362 - radialis 138 - subscapularis 137 - supraspinata 137 - supravesicalis 120, 124-125 - trochanterica 254-256 Fovea - articularis 141 - capitis femoris 254-256, 290-291 - costalis - - inferior (Vertebra) 53 - - processus transversi 53-54, 60-62, 113 - - superior 53-54, 60, 62 - dentis 50 - radialis (Tabatiere) 186, 238 Fractures 15 - conventional radiographs 156 - healing of 15 FROHSE's arcade 202-203, 227 FROMENT's sign, lesion of the N. ulnaris 207 Frontal plane 4, 135 Frontal/frontalis 5 Fundus ventriculi 32
Index
Funiculus - spermaticus 82,86-87, 121, 123-126, 296,
344-345 - umbilicalis 24 Funny bone 129, 206 - compression of the N. ulnaris 207, 230
G Galea aponeurotica 38 Gallbladder (Vesica bi liaris) 11 Gangl ion[-ia) - cervicale 31 - - medium 31 - - superius 31 - cervicothoracicu m [stellatum I 31 - ciliare 30 - coeliaca 30-31 - impar 31 - lumbalia 31 - mesentericum - - i nferius 30 - - superius 30 - oticum 30 - pelvica 31 - pterygopalatinum 30 - sacralia 31 - sensorium nervi spinalis 29, 67, 108-113 - stellatum 30 - submandibulare 30 - thoracica 31 - trunci sympathici 29, 110-113 Gaster 10-11 - Pars ca rdiaca 94 Gastrulation 13 Genu 248 - corporis callosi 35 - valgum [knock-knee) 248-249 - varum [bowleg) 248-249 Germ layer 13 Gibbus [hump formation), kyphosis 68 GIMBERNAT's ligament [Lig. lacunare) 122,
345 Ginglymus 18 - talocalcaneonavicula r joint 288 Gla ndula[-ae) - areolares 114 - lacrimalis 30 - suprarenalis 30 - thyroidea 10 Gluteal muscles 306 - loss of function of the small gl utea I muscles 335 - - DUCHENNE's gait 335 - - TRENDELENBURG's sign 335 Glutea I reg ion - cutaneous nerves 328 - epifascial 347 - intramuscular injection 335, 3 55 - nerves 347, 353-356 - vessels 353-356 Gonarthrosis 249, 256-257, 272, 279, 292 - tota I knee replacement rTKR) 257 GRYNFELT's lumbar hernias 75 GRYNFELT's triangle [Trigonum lumbale [fibresum[ superius) 75 Gubernaculum testis 124 GUYON's canal 206-207, 234-235, 241 Gynaecomastia 41, 114
H Hair bulb 38 Hair cuticles 38 Hair follicle, structure 38 Hair infundibulum 38 Hair papilla 38
Hair root 38 Hair shaft 38 Hairless skin 37 Hairs [Pili) 38 Hair-sebaceous gland unit 38 Hairy skin 37 Hallux 246, 260-261, 289 - valgus 287 Hammer toe 287 Hamulus ossis ha mati 142, 153, 158, 205, 207 Hand (Manus) 6, 128, 134, 186 - arteries 233, 23 9 - conventional radiograph 158 - injuries 129 - joints 153-154 - ligaments 153-154 - muscles 188-189 - skeleton 142-143 - Vaginae tendinum 190 Hand of benediction - lesion of theN. medianus 129 - proximal lesions N. medianus 205 Hanged man's fracture 51 HAVERS' canal 15 HAVERS' system 15 HEAD's zone 118 Hemivertebra 68 - KLIPPEL-FEI~s syndrome 72 HENLE's layer 38 Hepar 10-11 Hernia dia ph ragmatica - spuria 95 - vera 95 Hernias, abdominal wall 41,44 Herpes zoster (shingles) 118 HESSELBACH's triangle 121 - direct inguinal hernias 12 5 Hiatal hernia, paraesophageal 95 Hiatus - adductorius 304-305, 31 0, 352, 354 - aorticus 93-94 - basilicus 209 - oesophageus 93-94 - sacra lis 56-57 - saphenus 296,344-345 - venae cephal icae 163 High endothelial venules (HEVs) 27 Hinge joint 18 - ankle joint 288 Hip 248 - medial rotation 306 Hip bone 252-253 Hip dysplasia 245, 269 Hip joint 269-270,291 - blood supply 271 - fractures 290 - LAUENSTEIN's projection 291 - malpositions 290 - range of movement 270 - sagittal axis of movement 370 - transverse axis of movement 370 Hip muscles 299-300 - abductors 306 - adductors 301-302 - deep 309 - dorsal (ischiocrural, hamstring) 298, 306-
308 - dorsolateral group 306 - flexors 301 - lateral rotators 306 - medial rotators 306 - pelvitrochanteric 306-307 - ventral 297, 301-305 HODGKIN's disease 27 HOFFA's fat pad (Corpus adiposum infrapatellare) 35, 273, 293, 310 Hallow bones (long bones) 15 Horizontal bypass circuit, stenosis of the aortic isthmus 97
HUETER's triangle 151 Humeral shaft fracture - conventional radiograph 156 - lesions N. radialis 224 Humerus 14, 21, 133-134, 138-139, 146, 150, 15~
-
163,168-169,174,185,226,240
collodiaphyseal angle 138 distal fracture 139 elevation of the humeral head 163 fracture, conventional radiograph 156 proximal fracture - lesions N. radialis/radial nerve paralysis
139,200 - retrotorsion 138 - shaft axis 134 - shaft fracture, conventional radiograph 156 Hump formation (gibbus), kyphosis 68 Humpback 68 HUXLEY's layer 38 Hydrocele 123 Hyperlordosis 68 Hypersupination trauma, ankle joint 284 Hypoblast 12 Hypomer 44 Hypomochlion, Patella 272 Hyponychium 36 Hypothenar (eminence) 130, 160, 188,241
Ileum 10 Impingement syndrome 149 Implantation 12 lmpressio ligamenti costoclavicularis 136 lncisional hernias, abdominal wall 88 Incisura - acetabuli 252-253 - clavicularis 46, 58 - costalis 58 - fibularis 258 - ischiadica - - major 252-253, 291 - - minor 252-253, 291 - jugularis 43, 46, 58 - radialis 140, 150 - scapulae 137, 147 - trochlearis 140, 150, 152, 157 - ulnaris 141 - vertebralis - - inferior 53-54, 68, 70 - - superior 54, 68, 70 Index 130 Inferior 5 Inguinal canal 124 Inguinal hernias 124-125 - direct hernias, HESSELBACH's triangle 125 - indimct hernias 121, 124-125 Inguinal lymph nodes, palpation 344 Inguinal region - cutaneous nerves 328 - epifascial vessels 346 - lymph nodes 344 - nerves 346 - radiating pains 331 Inguinal ring, superficial 121 Inner (medial) collateral ligament, knee joint 275 Inner organs, projection onto the body surface 10-11 Inner root sheath 38 lntegumentum commune (Cutis) 37 Interarticular portion, vertebral arch 53, 70 Interdigitating dendritic cells 27 Intermediary sinus 27 Intermedius 5 lnternus 5
387
Index
lnterpha langeal joints - distal 155 - - dorsal extension 155 - - extensor muscles 187 - - flexor muscles 192 - - of the thumb, extensor muscles 187 - - palmar flexion 155 - - range of movement 155 - proximal 155 - - dorsal extension 155 - - extensor muscles 187 - - flexor muscles 192 - - of the thumb, extensor muscles 187 - - range of movement 155 lntersectiones tendineae 43, 86-88 lnterseg mental artery 45 lnterseg mental blood vessel 45 Intersegmental vein 45 Interstitia IIa mellae 15 Intervertebral discs 67 lntestinum tenue 11 lntragluteal injection 355 - lesion of the Plexus sacralis 3 33 lntramuscu lar injection, wrong placed i njection 335 Intravenous urogram/intravenous pyelogram 12,32 Inversion, talocalcaneonavicular joint 288 lschialg ia 328 lschiocrural (hamstring} muscles 298, 306308 Ischium 252 Isthmus, vertebral arch 53, 70
J Jejunum 10 Joint capsule 17 Joint movement 4 - documentation of the range 19 Joint space 17 Joints 17-18 - dithalamic joint 59 - plane joint 18 - range of movement 19 - synovial (true) joint 17 - types of joints 18 Juncturae synoviales 18
K KLIPPEL-FEIL's syndrome 72 KLUMPKE's palsy (lower brachial plexus paralysis} 194 Knee - complete stiffening of 19 - epifascia I vessels 346 - MRI 35 - nerves 346 Knee joint 272-281, 292-293 - adduction 275 - ancylosis 19 - arthroscopy 281, 293 - bursae 273, 280 - cruciate ligaments 274 - extension 272, 276 - extensor muscles 301 - external ligaments 273 - in 90"-flexed position 277 - flexion 272, 276 - injuries of the cruciate ligaments 277-279 - injuries of the ligaments 272 - lateral col latera II igament (LCLJ 273-275 - lateral rotation 276 - medial collateral ligament (MCLJ 273-275 - medial rotation 276 - MRI 293
388
Knee joint - muscles 310 - radiograph 292 - range of movement 276 - rotational movement 276 - stabilisation 277 - transverse section 372 Knock-knee (Genu valgum} 248-249 Kyphosis 68 - adolescent [SCHEU ERMAN N's disease] 68 - hump formation (gibbus) 68 - senile 68 - thoracic 49
L Labium - externum (Crista iliaca) 252-253, 299 - internum (Crista iliaca) 252-253 - laterale (Linea aspera} 254 - mediale (Linea aspera} 254,256 Labrum - acetabul i 270 - glenoidale 146, 163 Lacuna - musculorum 120,265,345 - vasorum 93, 120, 126, 265, 345 Lamellae of an osteon 15 Lamellar bone 15 Lamina - anterior (Vagina musculi recti abdominis) 82-83, 86-88, 90 - arcus vertebrae 51, 53, 55, 61-63, 72 - cribrosa 126 - parietalis (Tunica vagina lis testis) 123 - posterior (Vagina musculi recti abdominis) 88, 101 - profunda (Fascia thoracolumbalis) 79 - superficia lis (Fascia thoracolumbalis} 79 LARREY's cleft (Trigonum sternocostale} 94, 96,98 Larynx 72 Lateral collateral ligament (LCL), knee joint 273-275 Latera I rotation - hip joint 306 - knee joint 276 - shoulder joint 148 Latera 1/lateralis 5 LAUENSTEIN's projection, hip joint 291 Left ventricular catheterisation 345 Leg (Crus) 6-7,248 - compression syndrome 374 - dorsal muscles 314-317 - epifascial veins 348 - extensors 311 - fascia 296 - muscles 311, 313 - nerves 348, 359-363 - osteofibrous compartments 373 - plantar flexors 311 - pronation 311 - supinators 311 - syndesmosis 282 - transverse section 373-374 - ventral and lateral muscles 312 - vessels 359-363 Lever and muscle action 21 Ligament injuries, MRI 156 Liga mentum(-a) 123 - acromioclaviculare 145-147, 163 - alaria 65 - a nu Iare radii 150, 152, 184 - a picis dentis 64-65 - arcuatum - - laterale (quadratus arcade} 93-94, 126 - - mediale (psoas an::ade) 93-94 - - medianum 94
Ugamentum(-a} - arteriosum (BOTALLO's ligament) 24 atlantooccipitale laterale 66 bifurcatum 284-286 calcaneocuboideum 284-285 - plantare 286-287 calcaneofibulare 283-285 - calcaneonaviculare 284-285 - - plantare 284-287, 289, 369 - capitis - - costae radiatum 60-62 - - femoris 267, 269-270 - - fibulae 277, 282 - - - anterius 277, 282 - - - posterius 274 - carpi - - palmare 205, 207 - - radiatum 153-154 - carpometacarpalia - - dorsalia 154 - - palmaria 153-154,205, 207 - collaterale(-ia} - - (Art. metacarpophalangeal 154-155 - -carpi 153-154 - - - radiale 153-154 - - - ulnare 153-154 - - fibulare 273-277, 279-280, 293 - - (Manus) 155 - - mediale [deltoideum] 283-285 - - (Pes) 286 - - radiale 150, 184 - - tibiale 273-275, 277, 279-280, 293, 372 - - ulnare 150 - conoideum 145-147, 163, 169 - coracoacromiale 146-147, 149, 163, 168169 - coracoclaviculare 145-147, 169, 171 - coracohumerale 146-149, 163 - costoclaviculare 59, 144 - costotransversarium 60-61, 79 - - laterale 61-62 - - superius 62, 78 - costoxiphoidea 82, 86 - cruciatum - - anterius 35,274,277-279,281, 293 - - posterius 274, 277-280, 293 - cruciforme atlantis 64-65 - cuboideonaviculare - - dorsale 284-285 - - plantare 286-287 - cuneocuboideum dorsale 285 - cuneonavicularia - - dorsalia 284-285 - - plantaria 286 - denticulatum 108, 112-113 - falciforme hepatis 90, 92, 120 - flava 61-63,72,79, 109-110, 112 - fundiforme penis 82, 121 - glenohumerale - - inferius 147 - - medium 147 - - superius 147 - iliofemorale 264, 269-270, 304, 370 - iliolumbale 78, 109, 264-268 - inguinale 87, 93, 121-122, 246, 264-266, 296,300,302,338,344-345,350 - intercarpalia - - dorsalia 154 - - interossea 153 - - palmaria 154 - interclaviculare 59, 144 - intercuneiformia dorsalia 285 - interfoveolare 120 - interossea 154 - interspinalia 63, 72, 78, 109 - intertransversaria 62, 78-79, 109 - ischiofemorale 269-270 - lacunare (GIMBERNAT's ligament} 122,345
Index
Ugamantum (-a) - long itudina le - - anterius 60,62-64, 66-67, 85, 90, 111, 113, 264 - - posterius 60, 63, 67, 111-113 - lumbocostale 94 - manus 153-154 - meniscofemorale - - anterius 274, 278 - - posterius 274, 278, 280 - meniscotibiale - - anterius 278 - - posterius 27a - metacarpale[-ia) - - dorsa lia 154 - - i nterossea 153 - - palmaris 153-154 - - transversum - - - profundum 153 - - - superficialis 188, 234 - metatarsa le[-ia) - - dorsa lia 284 - - planta ria 287 - - transversum - - - profundum 284,286-287 - - - superficia le 322 -nuchae 76,81 - palmaria [Manus) 153, 155 - patellae 35, 273, 275-276, 278, 280, 293, 296,299,301-304,310,312-313,350,360 - pectineum 345 - pisohamatum 153-154 - pisometacarpale 153-154 - plantare longum 284, 286, 289, 325, 369 - popliteum - - arcuatum 274, 280, 315 - - obliquum 274, 280, 315-316 - pubicum - - inferius 264, 266-268 - - superius 264-265, 268 - pubofemorale 269-270 - radiocarpale - - dorsals 154 - - palmare 153-154 - reflexum 82, 86, 121 - sacrococcygeum - - posterius - - - profundum 266 - - - superficia le 266 - sacroiliacum - - anterius 264-265, 267-268 - - interosseum 266-268 - - posterius 266-268 - sacrospinale 251,265-267, 269, 334 - sacrotuberale 78, 251, 265-267, 269,300, 307-309,332,334,356 - sternoclaviculare anterius 59, 144 - sternocostale - - intraarticulare 59 - - radiatum 59 - supraspinale 62-63,78, 80, 266 - suspensorium(-ia) - - mammaria (COOPER's ligaments) 115 - - penis 82 - taloca lcaneum - - interosseum 284-285, 369 - - latsrale 284 - - mediale 283 - - posterius 283 - talofibulare - - anteri us 284-285 - - posterius 283 - tarsi pia ntaria 287 - tarsometatarsal ia - - dorsal ia 284-285 - - plantaris 284, 286-287 - teres - - hepatis 24, 90, 92, 120 - - uteri 103
Ugamentum(-a) - tibiofibula re 295 - - anterius 282-284, 318 - - posterius 283-284 - tra nsversum - - acetabuli 270 - - atlantis 64-65 - - genus 277-278 - - scapulae - - - inferius 225 - - - rupture 65 - - - superius 145, 147-148, 168-169,225 - trapezoideum 145-147, 163, 169 - ulnocarpale palmare 153-154 - umbilicals medianum (Chorda urachi) 90, 123-125 - venosum [ligament of ARANT I US) 24 Limbus acetabuli 252-253 Linea(-ae) - alba 43, 82, 86, 90-91, 121 - arcuata 88, 92, 120, 250, 252, 267, 290 - aspera 255-256, 310 - axillaris - - anterior 5 - - posterior 5, 42 - epiphysialis 15, 292-294, 369 - glutea - - anterior 253 - - inferior 253 - - posterior 2 53 - intercondylaris 254 - intermedia (Crista iliaca) 252-253 - intertrochanterica 254 - mediana - - anterior 5 - - posterior 5, 42 - medioclavicularis 5 - musculi solei 258,282 - parastemalis 5 - paravertebralis 5, 42 - pectinea 254, 256 - scapularis 5, 42 - semilunaris 88 - sternalis 5 - supracondyla ris - - latera lis 254 - - medialis 254 - terminalis 250-251, 267,291 - transversae 56 - trapezoidea 136 Lines of orientation 5 Lingua 68 Liquor cerebrospina lis 73 - lumbar puncture 109 LIS FRANC's joints (Artt. tarsometata rsales) 260, 262, 286 - luxations 260 Lobus(-i) - frontalis 35 - glandulae mammariae 83, 115 - occipitalis 35 Long bones (hollow bones) 15 Longitudinal axis 4 Low pressure system, systemic circulation 23 Lower brachial plexus paralysis (KLUMPKE's palsy) 194 Lower extremity 243-374 - arteries 339-340 - bones 248 - cutaneous nerves 328 - deep veins 342 - dermatomes 329 - development 132 - dorsal muscles 298 - joinlE 248 - mechanical axis 249 - ossification of the skeleton 16 - primordial 132 - segmenta I cutaneous innervation 329
LDwsr extremity - superficial lymph vessels 343 - superficial veins 342 - surface relief 246-247 -veins 341 - venous valves 342 - ventral muscles 297 Lumbalisation 48 Lumbar lordosis 49 Lumbar motion element 63 Lumbar puncture 109 Lumbar ribs 45, 54 Lumbar section of vertebral column 55 Lumbar vertebral column 55 - CT 72 - lateral radiograph 70 - movement restrictions 89 - MRI 73 - radiograph 71 - vessels and nerves 109 Lumbosacral plexus 326-327 Lunule 36 Luxatio subcoracoidea, radiograph 159 Luxation - CHOPART's joint 260 - LISFRANC's joint 260 - patella 272 - shoulder joint 129, 147, 159 Lymph capillaries 26 Lymph collectors - dorsolatsral bundle in the upper arm 210 - medial bundle in the upper arm 210 Lymph nodes 26-27 - artery 27 - enlargement 27 - examination 27 - inguinal region, palpation 344 - palpation 211 - veins 27 Lymph vessels 26 Lymphadenectomy 211 Lymphadenitis 27 Lymphatic organs 26 Lymphocyte 27
M M cells, Membrana synovialis 17 Macrophages 27 Magnetic resonance imaging (MRI) - brain 35 - foot 369 - injuries of ligaments 156 - knee joint 35, 293 Main axes 4 - longitudinal axis 4 - sagittal axis 4 - transverse axis 4 Main planes 4 MAISONNEUVE fractures 282 Maldescensus testis 41, 124 Male surface anatomy 6-7 Malleolar canal 319,336,361-362,366-368 - compression of theN. tibialis 336,361 Malleolar fork 282 Malleolus - lateralis 246-247, 259, 282-284, 294-295, 312-314,318,320-322,349,361-362 - medialis 247, 258-259, 282-283, 294-295, 312,314-316,318,320,322,349,362 Mammary gland - aplasia 41, 114 - blood supply 116 - hypertrophy 41, 114 Mammography 117 - breast cancer 117 Mandibula 14 Manubrium sterni 46, 58-59,85, 101
389
Index
Margo - anterior - - (Fibula) 259 - - (Radius) 141 - - (Tibial 246, 258 - falciformis 296 - Interosseous - - (fibula) 316-317 - - (Radius) 141 - - (Tibial 258-259 - - (Ulna) 140- 141 - lateralis (Scapula) 137- 138, 156 - liber (unguis) 36 - medialis - - (Humerus) 138 - - (Scapula) 137 - - - conventional radiograph 32 - - (Tibial 258 - posterior - - (Fibula) 259 - - (Radius) 141 - - (Ulna) 140 - superior (Scapula) 137 Massa lateralis atlantis 50, 66 Matrix unguis 36 Maxilla 14 Medial collateral ligament (MCL), knee joint 273-275 MediaVmedialis 5 Medlan/medianus 5 Medulla - hair shaft 38 - oblongata 31 - spinalis 28, 108, 110 Medullary sinus 27 Melanocytes 38 Membrana - atlantooccipitalis - - anterior 64, 66 - - posterior 64, 66, 81 - fibrosa (Capsula articularis) 17 - lntercostalis interns 78, 85 - interossea - - antebrachii 152, 184, 232 - - brachii 237, 239, 241 --cruris 274, 282-283,295,358, 373-374 - obturatoria 264, 267, 269-270, 345 - synoviatis (Capsula articularis) 17 - tectoria 64 Membrum - inferius 6-7, 248 - superius 6-7, 134 Meniscal tears, stage in the development 279 Meniscus(-i) 278-279 - arterial supply 279 - injuries 272, 279 - lateralis 274, 277-278,280-281,293 - medialis 276, 277-278, 280, 293 - sliding range of the 278 Meralgia paraesthetica 331 Mesoderm 13 Mesorchium 123 Mesotendineum 242 Metacarpal joints 153 Metacarpalia 133 Metacarpophalangeal joints (MCP) 165 - extensor muscles 187 - palmar flexion 165 - radial abduction 155 - ulnar abduction 155 Metacarpus 134, 242 - joints 153 - transverse section 241-242 Metaphysis 15 - proximalis 16 Metatarsophalangeal joint (MTPl - deformity (hallux valgus) 287 - range of movement 288 Metatarsus 248, 260
390
M ICHAELIS' rhomboid 46 Midsaggittal plane 4 MIKULICZ's line 249 Milk line 114 MOHRENHEIM's fossa (Trigonum clavipectorale, Trigonum clavl-deltoidao-pectorale) 82,
218 MORGAGNI's hernia 95 Morula 12 Multidetector CT sections 34 Muscles - biomechanics 21 - bipennate muscle 20 - double-belly, parallel muscle fibres 20 - double-head, parallel muscle fibres 20 - forces of 21 - lever 21 - multi-belly with tendinous intersections 20 - muscle action 21 - single-head, parallel muscle fibre 20 - types 20 - unipennate muscle 20 Musculoskeletal system, active and passive 20 Muscutus(-i) 76 - abdominis 83, 93 - - CT 91 - - deep layer 88 - - frontal section 95 - - middle layer 86-87 - - superficial layer 8 6 - abductor - - digiti minimi - - - - (Manus) 188-191, 242 - - - - (Pes) 318, 320-321,323-325, 367-
Muscu/us(-i) dorsi - - deep layer 75 - - deepest layer 79 - - superficial layer 74 - epicranius 107 - erector spinae 42, 75- 76, 79, 91 - extensor - - carpi - - - radialis 131,230,241 brevis 131, 161- 162, 173-174, 176,
180-184,186,226,230-232,238, 241 longus 131 , 160-162, 173-174, 176183, 186, 231,238,241 - - - ulnaris 131, 161, 180-184, 186, 231232, 237, 241 - - digiti mlniml (Manus) 131, 180-183, 186, 231, 241- 242 - - d igitorum - - - brevis (Pes) 312- 313, 318-321, 337,
360 - - - longus (Pes) 311- 313, 319-321, 337,
374 - - - (Manus) 131, 161- 162, 180-183, 186-18~
360, 364,369 - - hallucis - - - brevis 312-313, 318-321, 337, 364 - - - longus 296-297, 311-313,318-321,
359-360, 364, 374 - - indicis 180, 183-184, 241 - - pollicis - - brevis 131, 161-162, 177, 180-184, 186,
231-232,237-238,241-242
368 hallucis 319, 322-325, 367-368 pollicis - brevis 181, 188-191, 236,238 - longus 131, 161-162, 176-178, 180-
-
-
-
adductor - brevis 301, 304-305, 330, 352, 370 - hallucls 323-325, 368-369 - longus 297, 300-305, 330, 350-352,
- - - longus 131, 162, 180-181, 183-184,
186, 232, 237- 239, 241-242 - fibularis (peroneus] - - brevis 284- 285, 287, 311-313, 317-321, 33~360-361,363, 374
184,191, 231-232,237- 239,241-242
370-371 - - magnus 274, 280,300-301,304-305,
-
307-310, 330, 361-352,355-356, 370371 - minimus 305, 307- 309 - pollicis 162, 189-191, 235-238, 242 anconeus 131, 161-162, 170, 174, 181-184, 232 arrector pili 38 articularis genus 273
- biceps - - brachii 20- 21 , 83-84, 130-131, 146-147,
- - longus 287, 297, 311- 313, 315-316, 319, 324-325, 33~359-361,363 , 369,374
- - tertius 312- 313, 318- 321 , 360 -flexor - - antebrachii 230 - - carpi - - - radialis 131, 160, 162, 175- 179, 185, 191 , 205,20~226,228,235-236, 241
- - - ulnaris 131, 160, 175-179, 181-184,
-
-
- -
226-22~229-230,240
- - - superficialis 160, 175-179, 189, 191,
313-317,332 , 336-33~353-355,357-
358, 361, 370- 372 - biventer 20 - brachialis 21 , 8 3, 131, 160, 162, 170-174,
-
189-190,206, 226,228-229,235-236, 241 digiti miniml brevis 190-191, 323-325 digitorum 230, 236, 316 - brevis 319, 323-325, 367-369 - longus 311 , 316- 317, 324-325, 336, 362-363, 368-369,374 - profundus 160, 175, 179, 189, 191, 193,
149-150, 152, 160, 162-163, 168, 170174, 176- 179, 181. 185, 201, 222-224,
205,20~229-230,239,241-242
- - femoris 274, 280, 298-300, 306-310,
-
192, 230-232, 238-239,241-242
- - - (Pes) 296--297, 312, 318, 337, 359-
176-179, 181-182, 223-224, 226-228, 230, 240 brachioradialis 21, 130-131, 160-162, 171174, 176-183,1 85, 189,226-227,230,241 coni 81 coracobrachialis 84, 163, 168-172, 201, 222-223, 240 cremaster 82, 86-87, 121, 123-125 deltoideus 42-43, 82-84, 130-131, 160163, 168-169,171-174,200,212,218, 220, 224
- - paralysis and atrophy, lesion of the N. axillaris 200 - digastrlcus 78, 80-81 - dorsi 72, 78, 80-81
193 , 205, 20~226-229,239,241-242
- - hallucis - - - brevis 323-326, 364, 367-368 - - - longus 311, 315-317, 323-325, 336,
362-363, 367-369, 374 -
-
(Manus) 236, 241 pollicis - brevis 188-191 , 235-236, 242 - longus 175-179, 189, 191, 205, 207,
226,229,241-242 - fusiformis 20 - gastrocnemius 247, 274, 280, 293, 296299, 308-31~336, 353-354,357-358,361,
372, 374 -gemellus - - inferior 306-309, 332, 355-356, 370 - - superior 306-309, 332, 355-356, 370 - gluteus - - maximus 42, 83, 247, 298-300, 306-
309,332, 334, 353-356,370
Index
Musculus(-i) gluteus - - medius 90, 298, 303-305,307-309, 332,
334-335,353,355-356,370 - - minim us 306, 308-309, 332,335, 356,
370 - gracilis 297-298, 300-305, 307-310, 314,
Musculus(-i) opponens digiti minimi - - - (Pes) 318, 325
-
- pollicis 189-191, 236, 238,242 palmaris - brevis 188, 234 - longus 131, 160, 175-179, 185, 188,226,
330,350-354,357-358,371-372 - iliacus 90, 93, 120, 297, 300-303, 330, 345,
228, 241 - pectineus 297,301-305, 330,345,350-
350-352 -
iliocostalis - cervicis 76-77, 80-81 - lumborum 76-77, 90 - thoracis 76-77, 105 iliopsoas 95, 120,297,301-305, 309, 345,
370 - - dystonia/spasticity 303 - infraspinatus 74-76, 83, 105, 149, 161, 163,
166, 168-169, 174, 198 -
intercostales - externi 78, 84-85, 87-88, 168 - interni 84-88, 168 interossei - dorsales - - [Manus) 161-162, 186-187, 189, 191-
193,236-239, 242 - - - [Pes) 318, 320-321, 324-325, 369
-
- palma res 189, 191-193, 236, 239,242 - plantares 323-325 intersectus 20 interspinales - cervicis 77-78,80, 108 - lumborum 77-78 - thoracis 77 intertransversarii - laterales lumborum 78-79, 109 - mediales lumborum 78-79, 109 - posteriores cervicis 77-78, 81 - thoracis 78 ischiococcygeus [coccygeus] 300 latissimus dorsi 42, 74-76, 82-84, 87-88,
90,94,105-106,130,161-162,166,168169,173,199,219-220,222 -
levator[-es) - costarum - - breves 78-79 - - longi 78-79 - scapulae 21, 75-76, 81, 105-106, 164,
168-169, 198 -
longissimus - capitis 76-78, 80-81, 105-107 - cervicis 76-77, 80-81 - thoracis 76-77, 90 longus calli 85 lumbricales - [Manus) 188-193, 236, 238-239, 242
- - [Pes) 323-325
-
multifidus[-i) 78-81, 105, 107 - cervicis 77 - lumborum 77 - thoracis 77 obliquus - capitis - - inferior 78,80-81, 107-108 - - superior 78,80-81, 107-108 - externus abdominis 43, 74-76, 78, 82-
84,86-88,90-91,95,105,119,121,123126,162,168,299,356 - - internus abdominis 75-76, 78, 86-88, 90-91, 95, 121, 123-126 - obturatori us - - externus 305-306,309, 330, 356,370 - - internus 300,306-309, 332, 355-356,
370 -
occipitofrontalis 107 omohyoideus 168-169, 171, 221 opponens - digiti minimi - - [Manus) 189-191,242
351, 370 - pectoralis - - major 43,82-84,86-88, 114-115, 131,
-
160, 162, 168, 171, 173-174, 199,212, 218-223 - - facial defects, covering 74 - minor 84, 165, 168-169, 171-172, 199, 220-221 pennatus 20 piriformis 300, 303-309, 332, 334, 355356,370 plantaris 274, 310, 314-317,336, 358,361363 planus 20 popliteus 274, 279-280,293, 311,316-317, 336,358,363
- pronator - - quadratus 175-179, 185, 189, 229, 236,
239 - - teres 160, 162, 175-179, 183-185, 204,
226-230, 241 - psoas - - major 72, 90, 93-94, 126,297,300-301,
303, 330, 345 -
- minor 90, 93-94, 300,302,331,345 pyramidalis 86-87, 90, 123 quadratus - femoris 305-309, 332, 355-356, 370 - lumborum 78,90-91, 93-94, 109, 126 - plantae 324-325, 367-369 quadriceps femoris 35, 246, 273, 275, 280, 296-29~301-303,313
- rectus - - abdominis 43, 86-88, 90-92, 101, 119-
120, 123-125, 168 -
-
capitis - lateralis 81 - posterior - - major 78,80-81, 107-108 - - minor 78, 80-81, 108 femoris 269-270, 297, 299-305, 330,
-
rhomboideus - major 21,74-76, 105-107, 164, 169, 198 - minor 21, 75, 106-107, 164, 169, 198 rotatores - cervicis 77 - lumborum 77 - thoracis 77-79 sartorius 83, 246, 297, 299-305, 310, 330,
350-352, 370-371
350-352,354,370-372 -
scalenus - anterior 85, 168, 221 - medius 81, 85, 108, 168, 221 - posterior 76, 81, 85, 168 semimembranosus 274, 280, 298-300,
306,308-310,314-316,332,336,353355,357-358,361,370-372 - semipennatus 20 -
semispinalis - capitis 76-78, 80-81, 106-108 - cervicis 76-78, 80, 107 - thoracis 78, 80-81 semitendinosus 298, 300, 305-310, 314,
332,336,353-355,357-358,361,370-372 - serratus - - anterior 43, 75-76, 82-84, 86-88, 94,
114,162,165,168-169,198,219 - - posterior - - - inferior 75-76 - - - superior 75-76, 105
Musculus(-i) - soleus 297-298,311-317,336, 358,361-
363,374 -
spinalis - capitis 77-78 - cervicis 77 - thoracis 76-77 splenius - capitis 74-78, 80-81, 106-107 - cervicis 75-77, 80-81 sternalis 84 sternocleidomastoideus 72, 74-76, 82, 84,
106,162,168,221 - sternothyroideus 85 - subclavius 84, 165, 168-169, 171, 198,218,
221 - suboccipitales 78, 80-81 - subscapularis 147, 149, 163, 166, 168-169,
171-172, 199, 222 - supinator 177-180, 183-185,227-228, 230,
232 - supraspinatus 146-147, 149, 163, 167-169,
171, 173, 198 - tensor fasciae latae 83, 246, 296-297, 299,
301-303,306,308,332,350,370 - teres - - major 42,74-76,83, 105, 131, 161-162,
166, 168-169, 171, 173-174, 199, 219, 222,224 - - minor 83, 105, 149, 161-163, 166, 169, 174,200 - thoracis 83-84 - tibialis - - anterior 284,287,296-297,311-313, 318,320-321,33~359-360,364,369,
374 - - posterior 284, 287, 311, 315-317, 325,
336,361-363,374 -
transversospinales 79 transversus - abdominis 78, 88, 90-95, 121, 123-126 - thoracis 85, 101 trapezius 42,74-76,80-81, 83, 106, 131,
161-162, 164, 168-169, 172-173 - triceps - - brachii 21, 83, 105, 130-131, 146, 161-
163,169-175,178,181-183,203,222225,240 - - surae 311, 369 - vastus - - intermedius 301, 304-305, 330, 371 - - latera lis 293, 297, 299, 301-305, 308-
310,313,330,350,352-353,371 - - medialis 297, 301-305, 310, 330, 350-
352,371 Myotomes 44
N Nail(s) 36 - distal finger phalanx 36 - dystrophy 36 - oily spots 36 - onychomycosis 36 - small pits 36 - white spots 36 Neck - deep posterior region, vessels and nerves 108 - muscles 78, 80-81 - nerves 106-108 - short muscles 80 - vessels 106-107 Neck-shaft angle 256 - Coxa valga 256 - - vara 256
391
Index
Nervous system - autonomic and somatic 28 - organisation 28 Nervus(-i) - accessorius [XII 106-107 - anococcygeus 326 - auricularis magnus 104-106 - axillaris 105, 194-196,200, 219,223-225 - - lesions, paralysis and atrophy of the M. deltoideus 200 - cardiacus - - cervicalis - - - inferior 31 - - - medius 31 - - - superior 31 - cervicales 29, 64, 111 - clunium - - inferiores 328, 347, 353-354 - - medii 104, 328, 347, 353-354 - - superiores 104-105, 328,347,354 - coccygeus 29, 111, 326 - cranialis 28 - cutaneus - - antebrachii - - - lateralis 131, 195-196, 201, 213,216,
353-355, 357,360-362, 372 - - - lesions 333, 337, 360 - - profundus 327-328, 337, 349, 360, 364,
374 - - - lesions 337 - - superficialis 327-328, 337, 348-349,
360, 374 - - - lesions 337 - genitofemoralls 119, 121, 123, 126, 326-
328,330-331,346 - lesions 331 glossopharyngeus [lXI 30-31 gluteus - inferior 326- 327, 332-334, 355-356, 370 - - lesions 336 - superior 326- 327, 332-334, 356, 370 - - lesions 335 hypogastricus 31 iliohypogastricus 119, 126, 326-328, 330-
331, 356 - - lesions 331 - ilioinguinal is 119, 121, 123, 126, 326-328,
223-225, 234 - - - medialis 131, 194-196, 206, 213, 216, 222 - - - posterior 104, 131, 195-196, 213-214, 216-217, 224-225, 238
330-331, 346 - - lesions 331 - intercostalis 29, 84, 95, 110- 111, 119, 194 - intercostobrachialis 106, 131, 196, 213,219220
-
-
-
brachii - lateralis - - inferior 104-105, 195-196, 214, 224 - - posterior 195 - - superior 104, 196, 200, 214, 224 - medialis 131 , 194-196, 206,213-214,
216,221-222 - - - posterior 105, 131, 195-196, 214,216,
224 -
-dorsalis - - intermedius 327- 328, 337, 348-349 - - lateralis 327-328, 337, 348-349 - - medialis 327-328, 337, 348-349 - fem oris - - lateralis 95, 104, 120, 126, 326-328,
33D-331, 345-347, 350-351 - - - - lesions 331 - - - posterior 104, 326-328, 332-334, 347,
353-356,370 -
-
- - lesions 335 (N. radialis) 214, 224- 225 perforans 327 surae - lateralis 327-328, 337, 348, 353-355,
357 - - - medialis 327, 336-337, 348-349, 353-
355, 357, 373 -
digitales - dorsales manus 196, 238, 242 - - (N . radialis) 217 - - (N. ulnaris) 196 - - pedis 327-328, 349, 360, 364, 368 - palma res communes (N. medianus) 235 - - - (N. radialis) 195-196, 204 - - - (N. ulnarisl 195-196 - - proprii - - - (N . medianus) 196, 235, 242 - - - (N. radiaHsl 195-196 - - - (N. ulnarisl 195-196, 234-235, 242 - plantares - - communes 366-368 - - proprii 366, 368 dorsalis scapulae 106-107, 194, 198 - lesions 198 facial is [VII I 30-31 femora lis 95, 119-120, 126,326-328,330-
331,345,350-352,370 - - lesions 331
392
NeMJs(-i} - fibularis 328 - - communis 326-328, 332- 333, 336-337,
-
interosseus -antebrachii - anterior 195, 229, 241 - - posterior 202-203, 232, 237, 241 ischiadicus 326-328, 332-334, 336-337,
354- 366, 370- 372 - lesions 333 laryngeus recurrens sinister 31 lumbales 29, 111, 328 medianus 131, 185, 194-196, 204-205, 207,
221-223,226-230, 234-235, 240-241 - - lesions 206 - - - hand of benediction 129, 205 - musculocutaneus 131, 172, 194-196, 201 ,
221-224, 234, 240 - - lesions 201 - obtura torius 120, 126, 326-328, 33D-331, -
-
-
346, 361- 352, 370 - lesions 331 - - phenol injection 351 - spasticity 351 occipitalis - major 106- 108 - minor 104-106 - tertius 106, 108 oculomotorius [II II 30-31 pectoralis(-es) 199 - laterails 194, 199 - medialis 194- 195, 199, 218 phrenicus 94, 194 plantaris - latera lis 327, 336, 366-369 - medialis 327, 336, 366-368 pudendus 326-32~332-334 - lesions 335 radialis 106, 131, 185, 194-196,200, 202-
203,216-217, 222-225.227-232, 237-238, 240-241 - lesions 203 - - humeral fractures 139, 224 - - wrist drop 129, 203 sacrales 29, 111, 328 saphenus 327-328,330-331 , 348-349, 351-352, 371 , 373 scrotales anteriores 328 spinalis 28-29, 45, 67, 72, 108-113 splanchnicus(-1) - lumbales 31 - major 29, 31, 94, 111 - minor 31, 94
NeMJs(-iJ sp/anchnicus(-i) - - pelvici 31, 327 - - sacrales 31 - subclavius 194, 198 - subcostalis 126, 326 - suboccipitalis 105, 107- 108 - subscapularis(-es) 194-195, 199, 222 - supraclaviculares, 119, 196 - - intermedii 212 - - iaterales 104-105, 212- 214 - - mediales 212 - suprascapularis 168, 194, 198, 222, 225 - - compression 137, 198 - sura lis 327- 328, 336- 337, 348, 354 - thoracicus(-1) 29, 106, 111, 119, 196 - - longus 194, 198, 219- 221 - - - lesions 198 - thoracodorsalis 194- 196, 199, 219-220,
222 - tibialis 326- 327, 332- 333, 336, 353-355, 36~361-36 3, 372,374
- - compression 361 - - lesions 336 - - - pronation and dorsiflexed position of the
foot 336 - ulnaris 194-196, 204-207, 217, 221-231,
234-236, 240-241 - - lesions 206-207 - - - claw hand 129, 207 - - - FROMENT's sign 207 - - - funny bone 207, 230 - - - park bench paralysis 139 - vagus [X] 30-31 Neural tube 44-45 Neuropathy, autonomic 31 Neutral-null method 19 Nodus(-i) lymphoideus(-i) - abdominis parietales et viscerales 26 - aortici laterales 103 - axilla res 26, 209-210 - - apicales 116, 211 , 221 - - centrales 116,211, 221 - - humerales 116 - - interpectorales (ROTTER's node) 116 - - laterales 116, 211, 221 - - pectorales 211, 221 - - subscapulsres 116, 211, 221 - - superficiales 212 - brachiales 102 - cavales laterales 103 - cervicales 26 - - anteriores 221 - - - profundi 221 - - - superficiales 221 - - latersles 221 - - - profundi 221 - - - su perficiales 221 - cubitales 209-210 - deltopectora lis 209 - iliaci - - communes 103 - - extern! 103, 344 - - interni 103, 344 - inguinales 26 - - profundi 344-346 - - superficiales 103, 343-344 - - - inferiores 102-103, 344 - - - superolaterales 102, 344 - - - superomediales 102-103, 344 - interpectorales 211 - lumbales 103 - paramammarii 116, 211 - parasternales 116 - pectorales 102, 116 - pelvis parietales et viscerales 26 - poplitei - - profundi 357 - - superficiales 343, 357 - preaortici 103
Index
Nadus(-i) lymphaidaus(-i) - retroaortici 103 - subaortici 103 - supraclavicu lares 221 - tibialis anterior 3 59 Noradrenalin (norepinephrine), sympathetic system 30 Notch of the roof of the acetabulum 291 Notochordal process 13 Nucleus - lentiform is 3 5 - pulposus 45, 63, 67
0 Occipital bone 50 Occipital region, vessels and nerves 106-107 Odontoid fracture 51 Oesophagea I varices, increased portal vein pressure 25 Oesophagus 10,93-94 Olecranon 130-131, 140, 150-152, 157, 162, 173-174,181-184,214,216,224,230-231 - fractures 157 Omphalocele 91 Onychomycosis 36 Orbita 14, 34 Os(-sa) - accessoria 14 - brevia 14 - capitatum 142-143, 153-154, 158,205, 207, 239, 241 - - ossification centres 16 - carpi 14, 134, 142 - coccygis 14, 46, 48, 57, 267, 290 -coxae 14,46, 71,248,252-253 - cuboideum 260-262, 285, 287, 289, 369 - - ossification centres 16 - cuneiforme(-ia) 289 - - intermedium 260-262, 369 - - - ossification centres 16 - - laterale 260-262 - - - ossification centres 16 - - mediale 260-262, 286 - - - ossification centres 16 - digitorum [Phalanges! - - (Manus) 14, 134, 142 - - (Pes) 14, 248, 261-262 - frontale 14 - hamatum 142-143, 153-154, 205, 207, 241 - - ossification centres 16 - hyoideum 68 - ilium 34, 70-71, 120, 250, 252-253, 268, 291 - irreg ularia 14 - ischii 14, 250,252-253 - longa 14-15 - lunatum 142-143, 153, 158, 239 - - ossification centres 16 - manus 142-143 - metacarpi 14, 13 4, 142, 153, 155, 158, 23 9, 242 - - indicis 242 - - pollicis 242 - metatarsi 14, 248, 261-262, 285, 289, 369 - naviculare 260-262, 285-286, 289, 294, 369 - - ossification centres 16 - occipitale 50, 64-66, 68 - pedis 260-262 - pisiforme 142-143, 153, 158, 189, 191, 235 - - ossification centres 16 - plana 14 - pneumatics 14 - pubis 34, 250, 252-253 - sacrum 14, 46, 48, 56-57, 70, 109, 247, 250,267-268,290,300 - - differences in both sex 57
Os(-sa) - scaphoideum 142-143, 153-154 - - ossification centres 16 - sesamoidea 14 - -(Manus) 142, 153, 158 - - (Patella) 272 - - (Pes) 261, 287 - tarsi 14, 248, 262 - temporale 108 - thoracis 46 - trapezium 142-143, 153, 158, 205,207,241 - - ossification centres 16 - trapezoideum 142-143, 153-154, 158, 205, 207, 241 - - ossification centres 16 - triquetrum 142-143, 153-154, 158, 241 - - ossification centres 16 - zygomaticum 14 Osseous joint 17 Ossification - chondral 133 - desmal 133 - diaphyseal 16 - epiphyseal and apophyseal 16 - lower extremity 16 - skeleton 16 - upper extremity 16, 133 Osteochondrosis 73 - intervertebralis 50 Osteofibrous compartments of the leg 373 Osteon 15 - lamellae of 15 Osteophytes 73, 11 0 Osteoporosis 70 - vertebral fractures 70 OTT's sign 89 Outer root sheath 38 Ovarium - regional lymph nodes 103 - superficial and deep lymph vessels 103 Ovary (Ovarium) 344 Ovulation 12
p Palm of the hand (Palma manus) 9, 130 - arteries and nerves - - deep layer 236 - - intermediate layer 235 - - superficial layer 234 - bacterial infections 190 - muscles 242 - - deep layer 191 - - intermediate layer 189 - - superficial layer 188 - phlegmon 190 - tendinous sheaths 190 Palmar aponeurosis (Aponeurosis palmaris) 188, 234 Palmar arterial arch - deep 233, 236 - - variations 233 - superficial 233, 23 5 - - variations 233 Palmar flexion - distal interphalangeal joints 155 - metacarpophalangeal joints 155 - proximal interphalangeal joints 155 - wrist joints 154 Palmar/palmaris 5 Pancreas 10 Panniculus adiposus 82, 90 Papilla mammaria 83, 114, 210 Paracortical zone, lymph nodes 27 Para-oesophageal hiata I hernia 95 Parasympathetic system 30-31 - Acetylcholin 30 Park bench paralysis, lesions N. ulnaris 139
Pars - abdominalis - - aortae (Aorta abdominalis) 22, 24, 26, 31, 34,72,93-94 - - (M. pectoralis major) 82-84, 86, 167 - - (Oesophagus) 93-94 - acromialis (M. deltoideus) 167 - anterior (Lig. collaterale ulnare) 150 - anularis (Vagina tendinis musculi flexoris hallucis longi) 323 - ascendens - - aortae (Aorta ascendens) 22, 31, 34 - - (M. trapezius) 74, 164 - atlantica (A. vertebralis) 81, 108 - basalis (A. pulmonalis sinistral, conventional radiograph 32 - basilaris (Os occipitale) 64-66 - cervicalis (Ductus thoracicus) 26 - clavicularis - - (M. deltoideus) 167,218 - - (M. pectoralis major} 82, 84, 131, 167, 218 - costalis - - diaphragmatis 84, 93-95 - - (Pleura costa lis) 84 - cranialis (Parasympathicus} 31 - cruciformis (Vagina tendinis musculi flexoris hallucis longi) 323 - descendens - - aortae (Aorta descendens} 22,34 - - (Lig. iliofemorale} 269 - - (M. trapezius) 74, 164 - diaphragmatica - - (Pleura costa lis) 84 - - (Pleura parietalis) 94 - infraclavicularis (Plexus brachialis) 71, 84, 194-195,199,219-220 - - lesions 199 - intermedia (A. pulmonalis dextral, conventional radiograph 32 - lateralis - - (Os occipitale) 66 - - (Os sacrum} 56-57,109, 290 - Iibera membri - - - inferioris 248 - - - superioris 128, 134 - lumbalis diaphragmatis 93-94, 126 - parasympathica (Parasympathicus) 31 - parietalis (Vagina synovia lis tendinis) 20 - pelvica - - (Parasympathicus} 31 - - (Ureter) 120 - posterior (Lig. collaterale ulnare) 150 - profunda (Compartimentum cruris posterius) 373 - spinalis (M. deltoideus) 167 - sternalis diaphragmatis 93-94 - sternocostalis (M. pectoralis major) 82-84, 86, 167 - superficialis - - (Compartimentum cruris posterius) 373 - - (Plexus brachialis) 195 - supraclavicularis (Plexus brachialis} 194, 198 - - lesions 198 - sympathica (Sympathicus) 31 - tendinea (Vagina synovialis tendinis} 20 - thoracica - - aortae (Aorta thoracica) 22, 31, 94, 97 - - - branches 97 - - (Ductus thoracicus) 26 - - (Oesophagus) 94 - tibiocalcanea (Lig. collaterale mediale) 283284 - tibionavicularis (Lig. collaterale mediale) 284 - tibiotalaris - - anterior (Lig. collaterale mediale) 284 - - posterior (Lig. collaterale mediale} 283284 - transversa - - (Lig. iliofemorale) 269
393
Index
Pars tnmsvsrsa - - [M. trapezius] 74, 164 - transversa ria [A. vertebralis] 108 Patella 14, 35, 246, 248, 272-273,275,281, 292-293,296,299,303-304,310,312-313, 348,372 - hypomochlion 272 - luxation 272 - sesamoid bone 272 Pecten ossis pubis 93, 250, 252-253, 267, 300,303-304 Pediculus arcus vertebrae 51, 53, 55,60-61, 63,67-72 Pelvic girdle 264 - arthrosis 290 - metastases 290 Pelvic inlet 251 Pelvis 6, 250, 290 - arteries 338 - arthrosis 290 - conventional radiograph 290 - CT angiography 34 - inner diameters 250 - metastases 290 - of a man 250 - - joints 264-265 - - ligaments 264-265 - of a woman 250-251 - - joints 264-267 - - ligaments 264-267 - - pelvic diameters 251 - riclcats [vitam in D deficiency] 46 - transverse diameter 251 Pelvitrochanteric muscles of the hip 306-307 Pemphigus 37 Pericardium 94 Peridura I anaesthesia 46 Peri neal region - regional lymph nodes 103 - superficial lymph vessels 103 Periorchium 123 Periosteum 15, 17 Peripheral 5 Peripheral nervous system ( PN SJ 28 Peritoneum - parietale 84, 92-93, 95, 123-125 - viscerale 84 Perkussion 1o PERTHES' disease 271 Pes - Sae Foot - anserinus - - profundus 310 - - superficial is 304-305, 31 o PETIT's lumbar hernias 7 5 PETIT's triangle (Trigonum lumba le inferius] 75 Phalangeal joints, range of movement 288 Phalanx - distalis - - [Manus] 36, 134, 142-143, 155, 158,239 - - (Pes] 248, 260-262, 289, 369 -media --(Manus] 134,143,155, 158,239 - - [Pes] 248, 260-262, 369 - proximalis --[Manus] 134,142-143, 155,158,239 - - (Pes] 248, 260-262, 289, 369 Phenol injection, lesions N. obturatorius 351 Phlegmon, palmar tendinous sheaths 190 Pia mater spinalis 109, 112 Pili 38 PIP (proxima I interphalangeal joint) 155 Pivot joint 18 - talocalcaneonavicular joint 288 Pivot-hinge joint 272, 276 - elbow joint 151 Placenta 24 Planes 4 Planta pedis Sae Sole of the foot
394
Plantar aponeurosis 322-323 Plantar arch - active bracing of the 323 - bones 289 Plantar/pia ntaris 5 Plantarflexion - ankle joint 288 - talocalcaneonavicular joint 288 Plantarflexors of the leg 311 Planum - frontale 4 - sagittale 4 - transversale 4 Platysma 82 Pleura - parietal is 84, 94 - position of the needle during pleural puncture 84 - visceral is (pulmonalis) 84 Plexus - aorticus abdominal is 31 - brachialis 28, 84, 128, 194-195, 198-199, 219-220 - ca rdiacus 31 - cervical is 28, 108 - coccygeus 326 - coeliacus 31 - hypogastricus - - inferior 30-31 - - superior 30-31 - lumbalis 126, 326, 330 - - branches 327 - - lesions 331 - lumbosacralis 28, 326-327 - mesentericus - - inferior 31 - - superior 31 - oesophageus 31 - pampiniformis 121 - renalis 31 - sacra lis 126, 326, 332-333 - - branches 327 - - lesions 333, 335 - venosus - - areolaris 98, 119 - - pampiniformis 123 - - submucosus 25 - - vertebral is - - - externus anterior 113 - - - internus - - - - anterior 109, 112-113 - - - - posterior 109, 112-113 Plica(-ae) - alares 273 - axillaris - - anterior 130 - - posterior 130 - synovialis 17 - - infrapatella ris 35, 273 - umbilicalis - - lateralis 92, 120, 123 - - medialis 90, 92, 120 - - mediana 90, 92, 120 - vesicalis transversa 120 PNS (peripheral nervous system) 28 Pollex (thumb] 130 Polymastia 41, 114 Polyneuropathy 29 Polythelia 41, 114 Pons 31 Popliteal fossa - arteries 3 58 - epifascial vessels 347 -nerves 347,353-355,357,361-362 - vessels 353-355, 357, 361-362 Popliteal pulse 22 Port systems, access via the V. cephalica 213 Portal vein 23-25 - circulation 25
Portal vain circulation - increased pressure 25 Portocaval anastomoses 25 Posterior 5 Posterior drawer test 277 Prechordal plate 13 Prenatal circulation 24 Primitive node 13 Primitive streak 13 Processus - accessorius (Vertebra lumbalis] 53-55 - articularis - - inferior (Vertebra) 50-51, 53-55, 63, 68, 70-72 - -superior - - - (Os sacrum] 56-57 - - - (Vertebra) 50-51, 53-56, 62-63, 68, 70-72,109 - - (Zygapophysis superior) 53 - axillaris 116 - coracoideus 137, 145-149, 156, 163, 168169, 171 - coronoideus (Ulna] 140, 150, 152, 157 - costalis 54-55, 71-72 - lateralis - - tali 260, 263 - - tuberis calcanei 261, 263 - mamillaris 53-55, 72 - mastoideus 68, 80, 108 - medialis tuberis calcanei 261-263 - posterior tali 262-263, 294 - spinosus 42, 50-55, 63-64, 68, 70-74, 8081, 110 - styloideus - - (Os temporale] 80-81 - - radii 130, 141, 152-154 - - ulnae 130-131, 140, 152-154, 158 - transversus 50-51, 53, 69, 72, 81, 108 - - atlantis 78, 108 - uncinatus (Uncus corporis] 51-52, 67 - vaginalis peritonei 120, 124-125 - - persistens 124-125 - xiphoideus 46, 58, 85 - xiphosternalis 58 Profundus 5 Promontorium 46, 49, 56-57, 70, 93, 250 Pronation - elbow joint 151 - forearm 152 - leg 311 - talocalcaneonavicular joint 288 Protuberantia occipitalis externa 74, 107 Proximal/proximalis 5 Prune-belly syndrome 44 Psoas arcade (Lig. arcuatum mediale] 93-94 Pubic symphysis 268 Pubis 252 Pudendal nerve block 335 Pulmo 10-11,24, 30 Pulmonary emboli, deep venous thrombosis 342 Putamen 35
Q Quadratus arcade (Lig. arcuatum laterals) 9394, 126
R Rachischisis 45 Radial abduction - metacarpophalangeal joints 155 - wrist joints 154 RadiaVradialis 5 Radialis pulse 22 Radialis tunnel 202, 227, 230
Index
Radiograph - Angulus superior scapulae 32 - ankle joint 294-296 - Arcus aortae 32 - Art. humeri 156 - Art. talocalcaneonavicularis 294 - Art. talocruralis 294-295 - Atrium dextrum 32 - Auricula slnistra 32 - Bifurcatio tracheae 32 - breast contours 32 - Bronchus principalis dexter/sinister 32 - cervical vertebral column 68 - Clavicula 32 - colon, barium swallow test 32 - conventional 32 - diaphragm 32 - elbow joint 157 - fractures 156 - - of the anlde joint 296 - - of the humeral head 166 - - of the humeral shaft 166 - - of the humerus 166 - hand 168 - knee joint 292 - lumbar vertebral column 71 - luxatio subc::oracoidea 169 -pelvis 290 - ribs 32 - talocalcaneonavicular joint 294-295 - talocrural joint 294- 295 - WEBER fractures 295 Radiological section planes 4 Radio-ulnar joint 128 - distal 152 - prox ima I 152 Radius 14, 21, 133-134, 141-143, 150, 152154,157-168, 179, 181-186, 189,191,239, 241 - distal fracture 168, 203 Radix - anterior (N. spinalis) 29, 109-112 - lateralis - - (N. medianus) 195 - - (Plexus brachialis) 195 - medialis - - (N. medianus) 195 - - (Plexus brachiatis) 196 - parasympathica (Nn. splanchnici pelvici) 31 - posterior (N . spinalis) 29, 109-112 RamusH) - acetabularis - - (A. circumflexa femoris medialis) 271,338 - - (A. obturatoria) 338, 351 - acromialis (A. thoracoacromialis) 96, 218220 - anterior - - (A. collateral is radialis) 226, 229-230 - - (A. media genus) 279 - - (A. obturatoria) 338 - - (A. recurrens ulnaris) 208 - - (N. cutaneus antebrachii medialis) 196 - - (N. obturatorius) 126 - - (N. spinalis) 108- 113 - artic::ularis - - (A. descendens genus) 350-351 - - (A. femoralis) 340 - ascendens - - (A. circumflexa femoris lataralis) 271, 340, 352 - - (A. circumflexa femoris medialis) 338, 355 - bronc::hiales (A. thoracica intama) 96 - calcanei - - (A . fibularis) 339 - - (A. tibialis posterior) 363 - - mediales (N . tibialis) 366
Ramus(-i) - carpalis - - dorsalis - - - (A. radialis) 237-238 - - - (A. ulnaris) 208, 228, 233, 235 --palmaris - - - (A. radialis) 208, 233 - - - (A. ulnaris) 233 - ciavicularis (A. thoracoacromialis) 96, 218 - collateralis - - (A. intercostalis posterior) 1oo - - (Aorta thoracica) 97 - communicans(-tes) - - (A. fibularis) 339-340 - - albus 111 - - cum nervo ulnari 196,236 - - fibularis (N. cutaneus surae latera lis) 327, 337,348 - - griseus 111 - - (N. spinalis) 29, 110-112 - - (Truncus sympathic::us) 31. 113 - - ulnaris 196 - cutaneus(-i) - - anterior(-es) - - - abdominales - - - (N. femoralis) 119, 126, 328, 346 - - - (N. itiohypogastricus) 119, 328, 330, 346 - - - (Nn. intercostales) 119 - - - (N. obturatorius) 330-331 - - - (N. saphenus) 360 - - - (N . spinalis) 29, 111 - - - pectorales - - - - (Nn . intercostales) 119, 196,212 - - - - (Nn. thoracici) 119 - - cruris mediales - - - (N . femoralis) 328 - - - (N . saphenus) 348 - - latera lis(-es) - - - (Aorta thoracica) 97 - - - (N . iliohypogastricus) 104, 328, 330, 347, 356 - - - (N . subc::ostalis) 326 - - - (Nn. intercostales) 104, 110 - - - (Nn. spinales) 29, 104, 111 - - - pectorales (Nn. intercostales) 106, 119, 196, 212 - - - - (Nn. thoracici) 106, 119 - - - - (Plexus lumbalis) 104 - - medialis(-es) - - - (Aorta thoracica) 97 - - - (Nn. spinales) 104, 110 - - (N. obturatorius) 328, 330, 346-347, 351352 - - posteriores - - - (Nn. cervicales) 106 - - - (Nn. intercostales) 106 - - - (Nn. thoracici) 106, 196 - deltoideus - - (A. profunda brachii) 224 - - (A. thoracoacromialis) 96, 218-219 - descendens - - (A. circumflexa femoris lateralis) 271 , 340, 361-362 - - (A. circumflexa femoris medialis) 338 - dorsalis(-es) - - (A. lumbalis) 109 - - (Aorta thoracica) 97 - - (N. spinalis) 44 - - (N. uinaris) 195, 216-217, 226, 228-229, 231 - - (V. lumbalis) 109 - femoralis (N . genitofemoralis) 119, 123, 126, 326, 328, 330, 345-346 - genitalis (N . genitofemoralis) 121, 123, 126, 326, 328, 330 - inferior ossis pubis 252-253, 268, 290, 300 - infrapatellaris (N . saphenus) 328, 346, 348
Ramus(-i) - intercostales anteriores (A. thoracica intema) 96-97, 101 - interganglionaris (Truncus sympathicus) 113 - lateralis (N. spinalis) 110, 112 - malleolares - - laterales (A. fibularis) 339-340, 363 - - mediales - - - (A. fibularis) 363 - - - (A. tibialis posterior) 339-340 - mammarii - - laterales (A. thoracica lateral is) 97 - - mediales (A. thoracica internal 96-97 - mastoideus (A . occipitalis) 106 - medialis (N. spinalis) 110, 112 - mediastina les (A. thoracica i nterna) 96 - meningeus(-i) (N . spinalis) 29, 110-113 - muscularis(-es] - - (N. femoralis) 350-362, 371 - - (N. fibularis profundus) 364 - - (N. radiatis) 232 - - (N. saphenus] 350 - - (N. tibialis) 354-355, 367, 361 - - (Plexus brachialis) 194 - - (Plexus lumbosacralls] 326 - obturatorius (A. epigastrica inferior) 96, 338 - occipitalis - - (A. auricularis posterior) 106 - - (A. oc::c::ipitalis) 106 - oesophagealis (V. gastrica sinistral 25 - ossis ischii 252-253, 290, 300 - palmaris - - (N. ulnaris) 195-196,216,228,234-235 - - profundus (A. ulnaris] 233, 235 - - superficialis (A. radialis) 208, 228, 233, 235,238 - pectorales (A. thoracoacromialis) 96, 218, 220 - perforans(-tes) - - (A. fibularis] 339, 364 - - (A. thoracica internal 96, 100 - - rv. thoracica internal 100 - - rvv. paraumbilicales) 98 - phrenicoabdominalis (N. phrenicus) 94 - posterior(-es) - - (A. collateralis radialis] 226 - - (A. media genus) 279 - - (A. obturatoria] 338 - - (A. recurrens ulnaris) 208 - - laterales (Nn. thoracic::i) 106 - - mediales (Nn. thoracici) 105 - - (N. auricularis mag nus) 104 - - (N. cutaneus antebrachii medialis] 196 - - (N. spinalis) 107-113 - profundus(-i) - - (A. circumflex& femoris medialis) 338, 355-366 - - (A. gl utea superior] 366 - - (A. plantaris medialis) 366 - - (A. transversa coli i) 106-107 - - (N. plantaris lateralis) 367-368 - - (N. radialis) 185, 195, 202-203, 227-232, 237 - - (N. ulnaris) 195,206, 236-236 - - (V. glutea superior) 356 - pubicus 96 - - (A. epigastrica inferior) 339 - - (A. obturatoria) 338 - radicularis anterior 113 - saphenus (A. descendens genus) 340, 362 - spinalis(-es) - - (A. intercostalis posterior) 113 - - (Aorta thorac::ica) 97 - sternales (A. thoracica internal 96- 97 - superficialis - - (A. circumflexa femoris medialis) 351,355 - - (A. glutea superior] 365 - - (A. plantaris m edialis) 366, 368 - - (A. transversa colli] 107, 221
395
Index
Ramus(-i) superficialis - - [N. medianus] 196 - - [N. plantaris latera lis] 366-368 - - [N. radialis] 131, 195, 202-203, 216-217,
227-232,23a,241 - - [N. ulnaris] 195, 206, 235-236 - superior ossis pubis 252-253, 268, 290,
300 - thymici [A. thoracica internal 96 - trachea las [A. thoracica i nterna] 96 - transversus (A. circu mflexa femoris lateralis] 271, 3 3a - ventrales ( N n. spinales) 44, 126 Recessus - axillaris 146-147 - costodiaphrag maticus a4 - - conventions I radiograph 32 - su bpopliteus 317 Rectum 10-11,30, 93, 344 Rectus sheath 90 Recurrent arteries, Rete a rticulare cubiti 20a Referred pain 11a Regia 214 - abdominalis lateralis 8 - analis 9 - antebrachii - - anterior a-9, 130 - - - arteries 226-229 - - - epifascial nerves 216 - - - epifascia I veins 216 - - - nerves 226-229 - - posterior a-9, 130 - - - arteries 231-232 - - - epifascia I nerves 216 - - - epifascia I veins 216 - - - nerves 231-232 - axillaris a-9, 130 - brachii - - anterior a. 130, 213 - - - arteries 213, 222-223, 225 - - - epifascia I nerves 213 - - - epifascial veins 213-214 - - - nerves 213, 222-223, 225 - - posterior 9, 130 - - - arteries 224 - - - epifascia I vessels 214 - - - nerves 224 - - vessels 222 - calcanea 9 - cervicalis - - anterior a - - latera lis a - - posterior 9, 42, 108 - - - nerves 107-108 - - - vessels 107 - cruris 34a - - anterior 8-9, 246, 3 59-360 - - posterior 8-9, 247, 361-363 - cubitalis - - anterior a - - - epifascia I nerves 213, 216 - - - epifascia I venes 213, 216 - - arteries 230 - - epifascial veins, variations 215 - - nerves 230 - - posterior 9 - - - arteries 230 - - - epifascial nerves 214 - - - epifascial vassals 214 - - - nerves 230 - deltoidea a-9, 42, 130 - - arteries 225 - - epifascial nerves 213-214 - - epifascial vessels 213-214 - - nerves 225 - epigastrica 8 -femoris - - anterior 8, 246, 346, 3 50-3 52 - - posterior 9, 247, 347, 353-356
396
Regio - genus - - anterior a. 246, 346 - - posterior 9, 247 - glutealis 9, 42, 247, 347, 353-356 - hypochondriacs 8 - inframammaria a - i nfrascapularis 9, 42 - inguina lis a. 246,346 - - lymph nodes 344 - lumbalis 9, 42, 109 - mammaria a - nucha lis, vassals and nerves 106 - occipitalis 9 - - vessels and nerves 106-107 - parietalis 9 - pectoralis - pedis 34a - presterna lis a - pubica (Hypogastrium) 8 - sacral is 9, 42 - scapularis 9, 42 - sternocleidomastoidea 8 - surae 9 - thoracica latera lis 220-221 - - epifascial vessels and nerves 212 - - superficial lymph vessels and lymph nodes 210 - - vessels and nerves 221 - umbilicalis a - urogenitalis - vertebra lis 9, 42 Ran 10-11, 34,72 Rete - acromiale 96, 218-219 - articulare cubiti 231 - - collatera I arteries 208 - - recurrent arteries 208 --genus 340,352,360 - calcaneum 363, 367-368 - carpale - - dorsale 237-239 - - palmare 239 - malleolare - - laterals 360, 364 - - mediale 364 - patellare 346, 350 - venosum dorsale - - manus 217 - - pedis 341, 348 Reticular cells, lymph nodes 27 Retinaculum - cutis 37 - musculorum extensorum - - - inferius (Pes) 296, 319, 349, 359-360 - - - (Manus] 131, 162, 176, 181-1a4, 1a6-
a
a
1a7, 237-238 - - - (Pes] 312-313, 318, 320-321 - - - superius (Pes) 296 - - fibularium [peroneorum] 313,315-317,
319-320,361-362 - - flexorum - - - (Manus) 160, 1a8-191, 205,207,239,
241 - - - (Pes] 315-317, 319,336, 361-362,
366-368 - patellae 273 - - laterals 273, 296,372 - - mediale 273, 310, 372 Retroposition, Tibia 258 Retrotorsion, Humerus 13a Retroversion - acetabulum 269 - shoulder joint 148 - tibia 258 Rickets (vita min D deficiency). pelvis deformation 46 Rips 47 - anomalies 45
Rips - depression (by the Mm. intercostales internil 85 - development 45 - elevation (by the Mm. intercostales externi) 85 - false ribs 45-46 - free ribs 45-46 - true ribs 45-46 - two-headed ribs 47 - usures 41, 47 ROMBERG's knee phenomnon 331 Roof of the acetabulum 291 Roof of the shoulder 147 Root sheath 38 ROSEN MULLER's lymph node 345 Rostral 5 Rotation 4 - knee joint 276 Rotator cuff 163 - kinematics 163 - muscles 129, 163 ROTTER's lymph nodes (Nodi lymphoidei axillares interpectorales] 116
s Sacral kyphosis 49 Sacralisation 48 Sacro-iliac joint 268 - pain caused by injuries or degenerative conditions 268 Sacrum 56-57 - differences in both sexes 57 Saddle joint 18 - of the thumb 153-154 - - abduction 154 - - adduction 154 - - extension 154 - - flexion 154 - - range of movement 154 Sagittal axis 4 Sagittal plane 4 Saturday night palsy, lesions N. ulnaris 139 Scaphoid bone, fractures 158 Scapula 14, 21, 42, 74-75, 134-135, 137, 146 - alata 198 Scapular plane 135 SCHEUERMANN's disease [adolescent kyphosis] 68 SCHOBER's sign 89 Scintigraphy, thyroid gland 33 Sclerosis, Anulus fibrosus 73 Sclerotomes 44-45 Scoliosis 49 Sebaceous glands 38 Secundary follicle, lymph nodes 27 Senile kyphosis 68 Sensory deficiences - lesions N. radialis 205 - lesions N. ulnaris 207 Sentinel lymph node, breast cancer 117 Septum - intermusculare - - brachii - - - laterals 131, 162, 173-174, 181-183,
224,240 - - - mediale 131, 171-172, 176-179,204,
206,222,240 -
-cruris - - anterius 312-313,373-374 - - posterius 315, 374 -femoris - - laterals 371 - - mediale 371 - - posterius 371 - vastoadductorium 303, 351 nasi 34
Index
Septum
- scroti 124-125 Sesamoid bones 14 - Patella 272 Sexual function, disturbances 335 Shingles (herpes zoster) 11 8 Shoulder - arteries 219, 225 - dorsal muscles 161, 166, 173-174 - epifascial nerves 214 - epifascial veins 213 - epifascial vessels 213-214 - muscles 163, 166-169 - nerves 225 - ventral muscles 160 Shoulder blade 137 Shoulder girdle 135 - muscles 164-165, 168-169 - range of movement 135 Shoulder joint 128, 146-149, 163 - abduction 148 - adduction 148 - anteversion 148 - conventions I radiograph 156 - elevation 148 - external rotation 148 - internal rotation 148 - luxation 129, 147, 159 - - lesions N. axillaris 200 - - reposition 159 - medial rotation 148 - range of movement 148 - retroversion 148 - spheroida I or ball and socket joint 148 Shoulder separation 159 Sinister (= left) 5 Sinus - frontal is 35 - lactiferi 115 - maxi llaris 34 - sagittalis superior 108 - tarsi 262, 294 - transversus 108 - valvulae 23 Sinuses, computed tomography 34 Skeletal trunk 46 - bones 46 - cartilages 46 Skeleton 14 - ossification 16 - thoracis 46 - upper extremity 134 Skin layers 37 Sliding hernia (axial) 95 Small intestine (lntestinum tenue) 11 Socket joint 18 Sole of the foot (Pianta pedis) 9, 246, 365-368 - arteries 365 - - deep layer 368 - - intermediate layer 367 - - su perfi cia I layer 366 - muscles - - deep and deepest layers 325 - - intermediate layer 324 - - su perfi cia I layer 323 - nerves - - deep layer 368 - - intermediate layer 367 - - su perfi cia I layer 366 Somatic nervous system 28 Semites, organisation 44 Spasticity 178 - M. iliopsoas 303 - N. obturatorius 351 Spatium - epidurals 73, 109, 112 - intercosta le 46 - subarachnoideum 109-110, 112-113 - subdurale 109, 112
Special lamellae 15 Spermatic cord 122-123 - content of 123 - coverings of testis 125 Spermatocele 123 Spermatogenesis 41 Spheroidal joint 18 - medial clavicu Ia r joint 13 5 - shoulder joint 148 - sternoclavicular joints 59 SPIGELIAN hernia 88 Spina - bifida 55, 72 - - KLIPPEL-FEIL's syndrome 72 - - occulta 45 - iliaca - - anterior - - - inferior 252-253 - - - superior 34, 43, 82-83, 86-87, 246, 252-253,265,296,299-300,304, 334,345 - - posterior - - - inferior 252-253, 290 - - - superior 78, 83, 252-253,266, 290 - ischiadica 252-253, 290-291, 307 - scapulae 42, 74, 83, 131, 137, 148, 162, 169 Spinal nerves 29, 110-111 Spinal radicular syndrome 67 Splen (lien) 10-11 Splenium corporis callosi 35 Spondylitis ankylosans 63 Spondylolisthesis 54, 71 Spondylolysis 54-55, 71 Spongiosa trabeculae 256 Squama occipitalis 64 Stenosis of the aortic isthmus 41, 97 - horizontal bypass circuit 97 - usures of the ribs 4 7 - vertical bypass circuit 97 Steppage gait 333, 337 Sternal bands, failure of fusion 45 Sternal bars 45 Sternal puncture 58 Sternoclavivular joints, spheroidal joint or ball and socket joint 59 Sternum 14, 58-59 - development 45 -joints 59 Stratum - fibrosum 20 - papillare 37 - synoviale 20 Subcapsular sinus, lymph nodes 27 Subcapsular sinus cell 27 Subchondral bone 17 Subcutis 37-38 Substantia - compacta 15, 255 - spongiosa 15, 255, 257 Sulcus - analis 247 - arteriae - - subclaviae 47 - - vertebralis 50, 66 - calcanei 263 - gluteal is 247, 296, 347 - intertubercularis 138-139, 156 - malleolaris 258-259, 282 - musculi subclavii 136 - nervi - - radialis 139, 174 - - spina lis 51-52 - - ulnaris 139, 206 - obturatorius 252 - sinus sigmoidei 64-65 - tali 263 - tendinis/tendinum musculi - - fibularis longi 261, 263 - - flexoris hallucis longi 262-263
Sulcus
- venae subclaviae 47 Superficialis 5 Superior 5 Supination - elbow joint 151 - forearm, conjunctions of the bones 152 - talocalcaneonavicular joint 288 Supinator canal 202, 227, 230 Supinator muscles of the leg 311 Sura 247 Surface anatomy -female 6-7 - male 6-7 Sustentaculum tali 261-263, 286, 294 Sweat gland 38 - eccrine 37 - efferent duct 37 Sympathetic system (Sympathicus) 30-31, 113 - Noradrenalin 30 Sympathetic trunk 30, 113 Symphysis - manubriosternalis 46, 58-59 - pubica 46, 95, 250, 264, 267-268, 290, 300,345 - xiphosternalis 46, 58 Synarthrosis 17 Synchondrosis 17 - costae 59 Syncytiotrophoblast 12 Syndesmosis tibiofibularis 248, 282, 294-295 Synovia 20 - Acells 17 - B cells 17 - Fcells 17 - M cells 17 Synovial sheaths 20 - ofthefoot 318-319 - of the palma 190 - palmar, carpal and digital 190 - - variants 190 Synovial (true) joint 17 Synovialocytes type A and type B 17 System a sceletale 14 Systemic circulation 22-23 - arteries 22 - fetal 24 - low pressure system 23 - prenatal circulation 24 -veins 23
T T cell zone, lymph node 27 Tabatiilre (Fovea radialis) 186, 238 Talocalcaneonavicular joint 285, 288 - conventional radiograph 294 - eversion 288 - injuries 284 - inversion 288 - pivotjoint 288 - pronation 288 - range of movement 288 - supination 288 Talocrural joint 283-284 - arthrosis 282 - conventional radiograph 294-295 - dorsal extension 288 dorsiflexion 288 - ginglymus 288 - hinge joint 288 - hypersupination trauma 284 - injuries 284 - ligaments 283-284 - plantarflexion 288 - range of movement 288 Talus 260-263, 283, 285, 289, 294, 369 - ossification centres 16
397
Index
Tarsal tunnel syndrome 336-337, 361 Tarsus 248, 260 Temporalis [artery) pulse 22 Tendo [Musculus) 20 Tendo calcaneus 283-284, 296, 298,311, 313-31~319,361-363,369
Tendons, vector forces 21 Terminal hair [long hair) 38 Testicular torsion 123 Testis 124-125 - coverings 123-125 - maldescensus 41, 124 - retention 124 Thalamus 35 Thenar 130, 160, 188, 241 Thigh 6 - arteries 338 - deep medial muscles 304-305 - dorsal [ischiocrural) muscles 306-309 - epifascia I vessels 346-347 - fascia 296 - medial muscles 301-303 - muscles 299-300 - nerves 346-347, 350-356 - oblique section 370 - transverse section 371 - ventral muscles 301-305 - vessels 350-356 Thoracic cavity 6 - anterior wall 85 - bones 46 - muscles 162 - posterior wall 85 Thoracic ~yphosis 49 Thoracic nerves 29, 111 Thoracic vertebra 53-54 - conventional radiograph 69 -with spinal cord 113 - structure 53 Thoracic wall - arteries 97, 100 - dermatomes 118 - development 44-45 - lateral 220-221 - - epifascial vessels and nerves 212 - - superficial lymph vessels and lymph nodes 210 - M. latissimus dorsi, cover defects of the thorcic wall 74 - muscles 83-84 - - superficial layer 82 - of a woman, vessels and nerves 119 - segmental sensory innervation 11 8 - superficiallym ph vessels of the posterior wall 102 - surface relief 43 - veins 100 Ventral - - arteries 96 - - regional lymph nodes 102 - - superficial lymph vessels 102 --veins 98 - - vessels at the posterior aspect 101 Thumb - interphalangeal joint, distal and proximal, extensor muscles 187 - saddle joint 153-154 - - abduction 154 - - adduction 154 - - extension 154 - - flexion 154 - - range of movement 154 Thyroid gland [Glandula thyroidea) 10 - scintigraphy 33 Tibia 14,248, 258-259, 272-275, 281-284, 292-296,312,315-31~359,364,369,
373-374 - connections 282 - distal end 282-283
398
Tibia - ligaments 282 - retroposition 258 - retroversion 258 Tibial compartment syndrome 337, 374 Tibia 1/ti bialis 5 Tibia lis-posterior pulse 22 Toes 132 - variations of the arteries 365 TOSSY classification of injuries of the acromioclavicular joint 159 Total knee replacement [TKR) 257, 271 - donarthrosis 257 Trabeculae - long bones 15 - lymph nodes 27 Trachea 10 - conventional radiograph 32 Tractus - horizontal is (Nn. lymphoidei inguinales) 102 - iliotibialis 296, 299, 301-302, 306-307,
312-313, 353, 371 - verticalis [Nn. lymphoidei inguinales) 102 Transverse axis 4 Transverse plane 4 TRENDELENBURG's sign 306 - paralysis of the small gluteal 335 Triceps slit 174, 202, 224-225 - vessels and nerves 105 Trigonum - a rteriae vertebralis (vertebralis triangle) 81,
107 - clavipectorale [clavi-deltoideo-pectorale, MOHRENHEIM's fossa) 8, 82, 218 - femorale 350 - femoris 8 - lumbale 74, 83 - - inferius [PETIT's triangle) 75 - - superius [GRYNFELT's triangle) 75 - lumbocostale [BOCHDALEK's triangle) 94 - sternocostale (LARREY's cleft) 94, 96,98 Trochanter - major 246-247, 254-256, 269, 290-291,
307-309,334 - minor 254-256, 269-270,290-291, 305,
309,356 Trochlea - fibularis 262-263 - humeri 138-139, 150, 157 - tali 260, 262-263, 294 Trochoginglymus 276 Trophoblast 12 Truncus(-i) 6-7 - brachiocephalicus 22, 96 - bronchomediastinalis 26, 221 - coeliacus 22, 31, 34, 93 - costocervicalis 100 - inferior [Plexus brachialis) 194 - intestina les 26 - jugularis 26, 221 - lumbales 26 - lumbosacralis 126,326 - medius (Plexus brachia lis) 194 - nervi spinalis 29, 110-113 - pulmonalis 24 - - conventional radiograph 32 - subclavius 26, 116, 221 - superior [Plexus brachialis) 194 - sympathicus 31, 94, 110, 113, 126 - tibiofibularis 3 58, 363 - vagalis - - anterior 31 - - posterior 31 Tru nlc-arm muscles - deep layer 75 - superficial layer 74 Trunk-shoulder girdle muscles - deep layer 75 - superficial layer 74
Tuba uterina 344 - regional lymph nodes 103 - superficial and deep lymph 103 Tuber - calcanei 262-263, 286-287, 294, 313-316,
323-324 - ischiadicum 252-253, 266,290-291,300,
307-308,334 Tuberculum - adductorium 254-255, 272 - anterius 50-52,72,85 - conoideum 136 - costae 47, 53 - dorsale 141 - iliacum 253 - infraglenoidale 137, 156 - intercondylare - - laterale 258, 292 - - mediale 258, 292 - laterale (Talus) 263 - majus 138-139, 147-149, 156, 163 - mediale (Talus) 263 - minus 138-139, 156 - musculi scaleni anterioris 47 - ossis scaphoidei 158 - posterius 50-52, 66, 68, 72, 78, 80 - pubicum 252-253, 345 - supraglenoidale 137 Tuberositas - deltoidea 138 - glutea 254, 256, 307 - iliaca 252 - ossis - - cuboidei 261-262 - - metatarsi 262 - - - primi 261 - - - quinti 260-261, 285, 318 - - navicularis 261 - - sacri 56-57 - phalangis - - distalis - - - (Manus) 142-143 - - - [Pes) 261 - radii 141, 150, 152, 157 - tibiae 35, 246, 258, 272-273, 275, 282, 292,
312-313 - ulnae 140, 150 Tunica vaginal is testis 123
u Ulna 14,21,133-134,140,142-143,150,152-
154,157-158,181-182,185,189,241 Ulnar abduction - metacarpophalangeal joint 155 - wrist joints 154 Ulnar/ulnaris 5 Ulnaris pulse 22 Ultrasound image of a fetus 33 Umbilical hemias 91 Umbilicus 90, 92 Uncovertebral joints, arthrosis 50 Uncus corporis (Proc. uncinatus) 51-52, 67, 72 Upper arm [Brachium) 128 - arteries 223 - - of the lateral side 224-225 - blood vessels 128 - development 132 - dorsal muscles 161, 170, 173-174, 181-182 - epifascial nerves 213-214, 216 - epifascial veins 213, 216 - epifascial vessels 214 - fascia 131 - MRI 240 - muscles 162, 170 - nerves 195, 222-225 - surface relief 130 - ventral muscles 160, 170-173, 176
Index
Upper arm (Brachium)
Veins
Vena(-ae) marginafis
- vessels 222 Upper brachial plexus paralysis (ERB's palsy] 194 Upper extremity 127-242 - arteries 208 - bones 134 - cartilaginous precursors of the bones 133 - dermatomes 133, 197 - development 132 - joints 128, 134 - ossification of the skeleton 16, 133 - segmental cutaneous innervation 197 - veins 209 Upside-down stomach 95 Ureter 34, 120 Urinary incontinence 333, 335 Usures of the ribs 41, 47 - stenosis of the aortic isthmus 47 Uterine epithelium 12 Uterine lumen 12 Uterus 344 - metastatic route of carcinom 103 - regional lymph nodes 103 - superficial and deep lymph vessels 103
- ventral thoracic wall 98 Vellus hair 38 Vena[-ae) - auricularis posterior 106-107 - axillaris 23, 84, 98, 209-211,218-221 -azygos 23,25,94,99-100 - basilica 23, 131, 209-210, 213,215-216, 240-241 - - a ntebrachii 209, 215-217 - basivertebralis 113 - brachialis 23, 209, 219, 240 - brachiocephal ica - - dextra 23, 99-100 - - sinistra 23, 98-100 - cava - - inferior 23-25, 72, 94, 98-99 - - - conventional radiograph 32 - - superior 23-24, 98-99 - - - conventional radiograph 32 - cephalica 23, 82, 98, 119, 131,209-210, 212-216,218,220-221,240-241 - - access route of cardiac pacemakers and port systems 213 - - antebrachii 209, 215-217 - - central venous catheters (CVCJ 213 - cervicalis - - profunda 107 - - superficial is 119 - circumflexa - -femoris - - - lateralis 341 - - - medialis 341 - - humeri posterior 105, 214,219 --ilium - - - profunda 123 - - - superficialis 98-99, 119, 341, 344-346 - - scapulae 105,219 - col ica si nistra 25 - digitales - - dorsales pedis 349 - - palmares 209 - epigastrica(-ae] - - inferior 25, 90, 98-99, 101, 119-121, 123 - - superficialis 25, 98-99, 119, 341, 344346 - - superiores 90, 98, 101, 119 - femoralis 23, 93, 95, 98-99, 120, 123,303, 341,345-346,350-352,370-371 - - thrombosis 342 - fibula res 341 - gastrica sinistra 25 - glutea - - inferior 356, 370 - - superior 370 - hemiazygos 25, 94, 99-100 - - accessoria 99-100 - hepaticae 23, 25, 94 - iliaca - - communis 23, 25 - - externa 23, 98-99, 120, 123, 341, 344, 350,352 - - i nterna 23, 25, 99, 344 - iliolumbalis 99 - intercostalis[-es), 95 - - anteriores 98, 100 - - posteriores 84, 98, 100 - - superior 99-1 00 - - suprema 99 - interossea[-ae] 209 - - posterior 179 - intervertebralis 113 - jugularis - - anterior 23 - - externa 23, 106, 221 - - i nterna 23, 26 - lumbalis ascendens 25, 99, 113 - marginalis - - lateral is 348-349
-
v Vag ina(-ae] - communis tendinum musculorum - - fibularium [peroneorum] 318-319 - - flexorum [Manus] 190,205, 207 - musculi recti abdominis 82-83, 86-88, 90,
101 -
regional lymph nodes 103 superficial and deep lymph vessels 103 synovialis 20 - digitorum manus 190 - tendinis 20 tendi nis/tendinum 20, 160 - digitorum pedis 319, 323-324 - Dorsum manus 187 - intertubercularis 146, 149, 172 - (Manus] 190 -musculi - - abductoris longi 187, 190 - - extensoris - - - carpi ulnaris 187 - - - digiti minimi 187 - - - digitorum 187, 207 - - - digitorum pedis longi 318-319 hallucislongi 318-319 indicis 187 pollicis brevis 187, 190 pollicis longi 187 - - - flexoris - - - - carpi radialis 190, 205, 207, 238 - - - - digitorum longi 319 - - - - hallucis longi 319, 323 - - - - pollicislongi 190, 205, 207 - - - tibialis - - - - anterioris 318-319 - - - - posterioris 319 - - museu Ierum extensorum carpi radiatum 187 - - [Pes] 318-319 Valium unguis 36 Valvulae venosae 23 Varices, increased porta I vein pressure 25 Varicocele 123 Varicosis 342 Vas[-a] lymphaticum[-a] 26 - afferens 27 - efferens 27 Vegetative dysregulation 31 Veins 23 - systemic circulation 23 - thoracic wall 100
- medialis 348-349 mediana - antebrachii 209, 213, 215-216, 241 - basilica 215-216 - cephalica 215 - cubiti 23, 131,209, 213, 215-216 mesenteries - inferior 23, 25 - superior 23, 25 metacarpales palmares 209 obturatoria 120, 345, 351 occipitalis 105-107 ovarica 23 paraumbilicales 25, 90, 98, 119 pectorales 98 perforans 348-349 phrenicae inferiores 25, 94 poplitea 23, 35,315, 341,353-355,357, 361-362,372 - portae hepatis 23-25 - profunda - - brachii 105, 209 - - femoris 23,341,352 - pudenda(-ae) - - externae 98-99, 119,341,344-346 - - interna 355-356 - pulmonalis, conventional radiograph 32 - radiales 209 - rectalis[-es) - - inferiores 25 - - superior 25 - renalis 23, 25 - sacralis - - lateralis 99 - - medians 99 - saphena - - accessoria 98, 341, 344, 346 --magna 23,98, 119,126,296,341,343350,352,357,371-374 - - parva 23,35,341,343,347-349,353, 355,357,361,372-374 - scapularis dorsalis 98 - sigmoidea 25 - spinalis posterior 109 - splenica [lienalis] 23, 25 - subclavia 23, 26, 98, 209 - subcostalis 99 - subcutaneae abdominis 119 - subscapularis 219 - suralis 361 - testicularis 23, 120, 123 - thoracica - - interna (mammaria) 23, 94, 98, 101, 116, 119 - - lateral is 98, 119, 211, 219-221 - thoracoacromialis 98 - thoracodorsalis 98, 219-220 - thoracoepigastrica 98, 119,209-210,212, 219-220 - tibiales - - anteriores 23, 341, 359 - - posteriores 23, 341, 361 - transversa colli 106, 221 - ulnares 209, 241 - umbilicalis 24, 120 - vertebralis 107 Venoles 23 Venous valves 23 - veins of the lower extremity 342 Venter - inferior (M. omohyoideus) 168-169, 171 - [Musculus) 20 - occipitalis (M. occipitofrontalis) 107 - posterior (M. digastricus) 78, 80-81 - superior (M. omohyoideus) 221 Ventral 5 Ventriculus - dexter 24
399
Index
Ventriculus - lateralis 35 - sinister 24 - - conventions I radiograph 32 Ventrogluteal injection according to HOCHSTETlER 334 Vertebra(-ae) - cervicales 14, 48, 51-52, 68, 72, 108 - - radiograph 68 - coccygeae 57 - inferior vertebra I end plate 55 - lumbales 34, 42, 46, 48, 54-55, 70-71,73 - - radiograph 70-71 - prominens 42, 46, 49, 51-52, 74, 81 - structure 53 - superior vertebra I end plate 55 - thoracicae 46, 48, 53-54 - - radiograph 69 Vertebral arch - cleft formations 50, 55 - connections 61 - interarticular portion 53, 70 - isthmus 53, 70 - ligaments 62 Vertebral bodies 45 - development 45 Vertebral canal - content 108, 112 - stenosis, dermatomes 197 - veins 113 - vessels nad nerves 109
400
Vertebral column 48-49 - autonomic nerve fibres 111 - CT 72 - extension 60 - flexion 60 - ligaments 60-62 - MRI 73 - nerves 111 - site of metastases 69 Vertebral end plates - inferior 55 - superior 55 Vertebral fractures, osteoporosis 70 Vertebralis triangle (Trigonum arteriae vertebralis) 81, 107 Vertical axis 4 Vertical bypass circuit, stenosis of the aortic isthmus 97 Vesica - bil iaris 11 - fellea 24 - urinaria 93, 120, 123, 344 Vestigium processus vaginalis 124-125 Vinculum(-a) tendinum - breve 191 - longa 191 VIRCHOW's node 221 Vola (Palma) 9, 130 Volar 5 VOLKMANN's canal 15 Volume-rendering technique (VAT) 34
w Wall of the trunk See Thoracic wall WEBER fractures 282, 295 - conventional radiograph 295 Wedge shaped vertebra (hemivertebra) 45 Whits spots, nail 36 Wrist drop, lesion of theN. radialis 129,203 Wrist joints - arthrosis 158 - dorsal extension 154 - ellipsoid joints 154 - palmar flexion 154 - radial abduction 154 - range of movement 154 - ulnar abduction 154
y Yolksac 13
z Zona orbicularis 269 Zygapophyseal joints - arthrosis 50 - range of movement 89 Zygapophysis superior (Proc. articularis) 53 Zygote 12
At las of Human Ana t omy Internal Organs 15th Ed: ort
Ed1t ·c1 by F I' ul~ -n w:f J WOJSdl n Engh"'ll Vrr.;1on \'\" 1h I o n Norru-nchlfurc
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The Clinical Remarks boxes describe medical contexts to the anatomical structures illustrated on the page. Mostly, these dinical aspects are also of high relevance for the exam.
The following contents can be found in the other two volumes: 1 General Anatomy Orientation on the Body -+ Surface Anatomy -+ Development -+ Muskuloskeletal System -+Vessels and Nerves .... Imaging Techniques .... Integumentary System
2 Trunk Surface Anatomy .... Development .... Skeleton .... Imaging .... Muscles .... Vessels and Nerves .... Topography, Back .... Female Breast .... Topography, Abdomen and Abdominal Wall
3 Upper Extremity Surface Anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles Topography .... Sections
-+
4 Lower Extremity Surface Anatomy -+ Skeleton -+ Imaging -+ Muscles -+ Topography -+ Sections
8 Head Overview -+ Skeleton and Joints -+ Muscles -+ Topography -+ Vessels and Nerves .... Nose .... Mouth and Oral Cavity .... Salivary Glands
9 Eye Development .... Skeleton .... Eyelids .... Lacrimal Apparatus .... Muscles of the Eye - t Topography -+ Eyeball -+ Visual Pathway
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10 Ear
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Overview .... Outer Ear .... Middle Ear .... Auditory Tube .... Inner Ear .... Hearing and Equilibrium
0
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11 Neck Muscles .... Pharynx .... Larynx .... Thyroid Gland .... Topography
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12 Brain and Spinal Cord General .... Meninges and Blood Supply .... Brain .... Sections .... Cranial Nerves -+ Spinal Cord
Paulsen, Waschke
Atlas of Human Anatomy Latin Nomenclature Internal Organs
Translated by T. Klonisch and S. Hombach-Kionisch
Atlas of Human Anatomy Internal Organs
G R V
15th edition Edited by F. Paulsen and J. Waschke
r i 9 . 9 & s r s i n hby T. Klonischiaand Translated a t sWinnipeg, Canada S. Hombach-Kionisch, r e p . with 441 Figures p 363 Coloured Plates i v
ELSEVIER
URBAN & FISCHER
URBAN.tFISCHBR
Munchen
Editors
Prof. Dr. Friedrich Paulsen
Prof. Dr. Jens Waschke
Dissecting Courses for Students
More Clinical Relevance in Teaching
In his teaching, Friedrich Ptlu/sen puts grest emphasis on the filet that studMts can actually dissect on csdsV9fs of body donors. ·The hsnds-on sxperience in dissection is extremely important not only for the thre&-dimensions/ understanding of anatomy end as the basis for virtually eV9fY medics/ prof9ssion, but for meny students also clearly addresses the issue of death and dying for the first time. The members of the dissection tesm not only study anatomy but also 168m to dNI with this special issue. At no other time medical students will have such a close contact to their classmates and teachers again.· ·The dissection links in the atlas lead to online imttges that ttre relevant for the dissection. You cen print them end ts/ce them along. The o~red dissection tips are not instructions, but make sure that you ere oriented exceptionally well and not 'cutting in the dBrlt::·
From Merch 2011 on, Pmfesscr Jens Wesdl/ce is Chsirman of D9(J8ftm&nt I at th9 Institute ofAnatomy and C8/l Biology at th9 Ludwig-MaximHians-Uniwrsitlit (LMUJ Munich. "For me, teaciJing at the
Professor Friedrich Paulsen lborn 1965 in KieD passed the 'Abitur' in Brunswick and trained suCC&Jsfully as a nurse. After studying human medicine in Kiel, he became scientific associate at the Institute of Anatomy, Department of Oral and Maxillofacial Surgery and the Department of Otolaryngology, Head and Neck Surgery of the Ch ristian-Aibrechts-U niversitiit Kiel. In 2002, together with his calleagues, he was awarded the leeching Award for outstanding teaching in the field of anatomy at the Medicel Faculty of the University of Kiel. On several occasions he gained work experience abroed in the acedemic section of the Department of Ophthalmology, University of Bristol, UK, where he did rnearch for several months. From 2004 to 201 0 as a Unillersity Prof8l1Sor, he was head of the Macroscopic Anatomy and Prosector Section at the Department of Anatomy and Cell Biology of the Martin.(.uther.Unillersitiit HalleWittenberg. Starting in April2010, Professor Paulsen became the Chairman at the Institute of Anatomy II of the Friedrich-AiexanderUnillersitiit Erlangen. Since 2006, Professor Paulsen is a board member of the Anatomical Society and 2009 he was elected the general secretary of the International Federation of Associations of Anatomy (I FAA). His main research area cancerns the innate immune system. Topics of special interest are antimicrobial peptides, trefoil factor peptides, surfactant proteins, mucins, carneal wound healing, as well as stem cells of the lacrimal gland and diseasn such as eye infections, dry eye, or osteoarthritis.
department of WJ99tBtive anatomy. which is res{JOfJsible for the dissection coursBS of both Munich's lerge univsrsitiss LMU endTU, emphasizes the importance of tHching anstomy with clear cDnical relevance~, SttyS .lens Wssdlke. ·The clinics/aspects in the Atlas in traduce studBn ts to anatomy in the first S4Nnesters. At the S6m9 tim9, ir indicetes th9 importsnce of this subject for future clinical prectice, ss undBrstsnding human anatomy m98ns more than just memorastion of structures. 6
Professor Jens Waschke (born in 1974) habilitated in 2007 after graduation from Medical School and completing a doctoral thesis at the University of Wuerzburg. From 2003 to 2004 he joined Professor Fitz-Roy Curry at the University of California in Davis for a nine months research visit. Starting in June 2008, he bees me the Chairman at the Institute of Anatomy and Cell Biology Ill at the University of Wuerzburg. In 2005, together with his colleagues, Professor Waschke was awarded the Albert KoellikerTeaching Award of the Faculty of Medicine in Wuerzburg. In 2008, he was awarded the Wolfgang Bargmann Prize of the Anatomical Society. His main research area cancerns cellular mechanisms that control the adhesion between cells and the cellular junctions establishing the outer and inner barriers of the human body. The attention is focused on the regulations of the endothelial barrier in inflammation and the mechanisms, which lead to the formation of fatal dermal blisters in pemphigus, an autoimmune disease. The goal is to gain a better understanding of cell adhesion as a basis for the development of new therapeutic stretegin.
All bu1in•• corre1pondence should be made with:
Elsevier GmbH, Urban & Fischer Verlag, Hackerbri.icke 6, 80335 Munich, Germany, mail to: [email protected] This atlas was founded by Johannes Sobotta t, former Professor of Anatomy and Director of the Anatomical Institute of the University in Bonn, Germany.
Addresses of the editors:
Professor Dr. mad. Friedrich Paulsen lnstitut fur Anatomie II (Vorstand) Un iversitat Erlangen-Ni.i rnberg Un iversitiitsstra l1e 19 91054 Erlangen Germany
Professor Dr. med. Sabine Hombach-Kionisch Professor Dr. med. Thomas Klonisch Faculty of Medicine Department of Human Anatomy and Cell Science University of Manitoba 745 Bannatyne Avenue Winnipeg Manitoba R3E OJ9 Canada
Garman editions: 1"edition: 1904-1907 J. F. Lehmanns Verlag, Munich 2"d-11'h edition: 1913-1944J. F. Lehmanns Verlag, Munich 12'h edition: 1948 and following editions Urban & Schwarzenberg, Munich 13'h edition: 1953, editor H. Becher 14'h edition: 1956, editor H. Becher 15'h edition: 1957, editor H. Becher H!'h edition: 1967, editor H. Becher 17'h edition: 1972, editors H. Ferner and J. Staubesand 18'h edition: 1982, editors H. Ferner and J. Staubesand 19'h edition: 1988, editor J. Staubesand 20'h edition: 1993, editors A. Putz and A. Pabst Urban & Schwarzenberg, Munich 21'' edition: 2000, editors R. Putz and R. Pabst Urban & Fischer, Munich 22"d edition: 2006, editors R. Putz and R. Pabst Urban & Fischer, Munich 23'd edition: 2010, editors F. Paulsen and J. Waschke Elsevier, Munich
Bibliographic information published by the Deutsche Nationalbibliothek
Arabic edition
The Deutsche Nationa lbibl iothe k Iists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://www.d-nb.de.
Chinese edition (complex characters)
Professor Dr. med. Jens Waschke lnstitut fi.ir Anatomie Ludwig-Maximilians-Un iversitiit Patten koferstraBe 11 80333 Mi.inchen Germany Addresses of the translators:
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Table of contents Viscera of the Thorax Heart.......................................................
4
Lungs......................................................
28
Oesophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42
Thymus....................................................
50
Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
Viscera of the Abdomen Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
Stomach . .. .. . . .. .. . . . .. .. . . .. .. . . .. . .. . . .. .. . . .. .. . . .. . .. .
74
Intestines . .. .. .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. . .. .. .. .. ..
86
Liver and Gallbladder....................................... 102 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Spleen ..................................................... 128 Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Pelvis and Retroperitoneal Space Kidney and Adrenal Gland.................................. 160 Efferent Urinary System . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. 174 Genitalia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Rectum and Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Sections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Translators
Prof. Dr. Thomas Klonisch
Prof. Dr. Sabine Hombach-Kionisch
Professor Thomas Klonisch [born 1960] studied human medicine at the Ruhr-Universitiit Bochum and the Justus-Liebig-Universitiit (JLU) Giessen. He successfully completed his doctoral thesis at the Institute of Biochemistry at the Faculty of Medicine of the JLU Giessen and became a scientific associate at the Institute of Medical Microbiology, University of Mainz (1989-1991). As an Alexander von Humboldt Fellow he joined the University of Guelph, Ontario, Canada, from 1991 -1992 and, in 1993 -1994, continued his research at the 0 ntario Veterinary College, Guelph, Ontario. From 1994-1996, he joined the immunoprotein engineering group at the Department of Immunology, University College London, UK, as a senior research fellow. From 1996-2004 he was a scientific associate at the Department of Anatomy and Cell Biology. Martin-Luther-Universitiit Halle-Witten berg, where he received his accreditation as anatomist [1999], completed his habilitation [2000), and held continuous national research funding by the German Research Council (DFG) and German Cancer Research Foundation [Deutsche Krebshilfe]. In 2004, he was appointed Full Professor and Head at the Department of Human Anatomy and Cell Science at the Faculty of Medicine, University of Manitoba, Winnipeg, Canada, where he is currently serving his second term as department chairman.
Teaching clinically relevant anatomy and clinical case-based anatomy learning are the main teaching focus of Sabine Hombach-Kionisch at the Medical Faculty of the University of Manitoba. Since her appointment in 2004, Professor Hom bach has been nominated annually for teaching awards by the Manitoba Medical Student Association.
His research areas concern the mechanisms employed by cancer cells and thai r cancer stem/progenitor cells to enhance tissue invasiveness and survival strategies in response to anticancer treatments. One particular focus is on the role of endocrine factors, such as the relaxin-like ligand-receptor system, in promoting carcinogenesis.
Sabine Hombach (born 1963] graduated from Medical School at the Justus-Liebig-Universitiit Giessen in 1991 and successfully completed her doctoral thesis in 1994. Following a career break to attend to her two children she re-engaged as a sessional lecturer at the Department of Anatomy and Cell Biology of the Martin-Luther-Universitiit Halls-Wittenberg in 1997 and received a post-doctoral fellowship by the province of Saxony-Anhalt from 1998-2000. Thereafter, she joined the Department of Anatomy and Cell Biology as a scientific associate. Professor Hom bach received her accreditation as anatomist in 2003 by the German Society of Anatomists and by the Medical Association of Saxony-Anhalt and completed her habilitation at the Medical Faculty of the Martin-Luther-Universitiit Halls-Wittenberg in 2004. In 2004, Professor Hom bach was appointed Assistant Professor at the Department of Human Anatomy and Cell Science, Faculty of Medicine of the University of Manitoba. She has been the recipient of the Merck European Thyroid von Basedow Research Prize by the German Endocrine Society in 2002 and received the Murray L. Barr Young Investigator Award by the Canadian Association for Anatomy, Neurobiology and Cell Biology in 2009. Her main research interests are in the field of cancer research and environmental toxicants. Her focus in cancer research is to identify the molecular mechanisms that regulate cancer cell migration and metastasis. She employs unique cell and animal models and human primary cells to study epigenetic and transgenerational effects facilitated by environmental chemicals.
Preface In the preface to the first edition of his Atlas, Johannes Sobotta wrote in May 1904: "Many years of experience in anatomical dissection led the author to proceed with the presentation of the peripheral nervous system and the b load vessels such that the illustrations of the book are presented to the student exactly in the same manner as body parts are presented to them in the dissection laboratories, i.e. simultaneous presentation of blood vessels and nerves of the same region. Alternating descriptive and image materials are distinctive features of this atlas. The images are the core piece of the atlas. Apart from table legends, auxiliary and schematic drawings, the descriptive material includes short and concise text parts suitable for use of this book in the gross anatomy laboratory.· As with fashions, reading and study habits of students change periodically. The multimedia presence and availability of information as well as stimuli are certainly the main reasons of ever changing study habits. These developments and changing demands of students to textbooks and atlases, which they uti lise, as well as the availability of digital media of textbook contents, is accounted for by editors and publishers. Apart from interviews and systematic surveys of students, the textbook saotor is occasionally an indicator enabling the evaluation of expectations of students. Detailed textbooks with the absolute cia im of completeness are exchanged in favour of educational books that are tailored to the didactic needs of students and the contents of the study of human medicine, dentistry, and biomedical sciences, as well as the corresponding examinations. Similarly, illustrations in atlases such as the Sobotta, which contain exact naturalistic depiction of real anatomical specimens, fascinate doctors and associated medical professions for many generations throughout the world. However, students sometimes perceive them as too complicated and detailed. This awareness requires the consideration of how the strength of the atlas, which is known for its standards of accuracy and quality during its centennial existence featuring 22 editions, can be adapted to modern educational concepts without compromising the oeuvre's unique characteristics and authenticity. After careful consideration, EIsevier and the editors Professor Rein hard Putz and Professor Reinhard Pabst, who were in charge of the atlas up to its 22"d edition, came to the conclusion that a new editorial team with the same great enthusiasm for anatomy and teaching would meet the new requirements best. Together with the Elsevier publishing house, we are extremely pleased to be charged with the new composition of the 23m edition of Sobotta. In redesigning, a very clear outline of contents and a didactic introduction to the pictures was taken into account. Not every fashion is accompanied with something entirely new. Under didactical aspects we have revisited the old concept of a three-volume atlas, as used in Sobotta's first edition, with: General Anatomy and Musculoskeletal System (val. 1]. Internal Organs (val. 2), and Head, Neck, and Neuroanatomy (val. 3). We have
also adopted, although slightly modified, the approach mentioned already in the preface of the first edition, i.e. combining the figures in the atlas with explanatory text which is an old trend being currently back into fashion once more. Each image is accompanied by a short explanatory text, which serves to introduce students to the image, explaining why the particular preparation and presentation of a region was selected. The individual chapters were systematically organised in terms of current subject matter and prevailing study habits; omitted and incomplete illustrations - particularly the systematics of the neurovascular pathways- were supplemented or replaced. The majority of these new figures are conceptualised to facilitate studying the relevant pathways of blood supply and innervation by didactical aspects. We have also reviewed many existing figures, reduced figure legends, and highlighted keywords by bold print to simplify access to the anatomical contents. Numerous clinical examples are used to enhance the "lifeless anatomy", present the relevance of anatomy for the future career to the student, and provide a taste of what's to come. Introductions to the individual chapters received a new conceptual design, covering in brief a summary of the content, the associated clinical aspects, and relevant dissection steps for the covered topic. It serves as a checklist for the requirements of the Institute of Medical and Pharmaceutical Examination Questions {IMPP) and is based on the German oral part of the preclinical medical examination (Physikum). Also new are brief introductions to each topic in embryology and the online connections of the atlas with the ability to download all images for reports, lectures, and presentations. We want to emphasise two points: 1 . The "new· Sobotta in the 23m edition is not a study atlas, claiming completeness of a comprehensive knowledge and, thus, does not try to convey the intention to replace an accompanying textbook. 2. No matter how good the didactic approach, it cannot relieve the students of studying, but aid in visualisation. Anatomy is not difficult to study, but very time-consuming. Sacrificing this time is worthwhile, since physicians and patients will benefit from it. The goal of the 23m edition of Sobotta is not only to facilitate learning, but also to make learning exciting and attracting, so that the atlas is consulted during the study period as well as in the course of professional practice. Erlangen and Wuerzburg, summer 2010, exactly 106 years after the first edition. Friedrich Paulsen and Jens Waschke
Acknowledgements First, we would like to express that the work on the Sobotta was exciting and challenging. During stages, at which one could see the progress of development of individual chapters and newly developed pictures with a slight detachment, one obtained satisfaction, was elated with pride and identified oneself evermore with the Sobotta. The redesign of Sobotta is obviously not the sole work of two inexperienced editors, but rather requires more than ever a well-attuned team under the coordination of the publisher. Without the long experience of Dr. Andrea Beilmann, who supervised several editions of the Sobotta and exerted the calming influence of the Sobotta team, many things would have been impossible. We thank her for all the help and support. Ms. Alexandra Frntic, who is also part of the four-member Sobotta team, pursued the first major project of her ca rear and tackled it with passion and enthusiasm. Her liveliness and management by motivation have enlivened and cheered the editors. We express our gratitude to Ms. Frntic. We like to reflect back on the Sobotta initialisation week in Parsberg and weekly conference calls, in which Dr. Beilmann and Ms. Frntic supported us in the composition of the Sobotta and presented an admirable way to merge the variety of two personalities to achieve a single layout. Without the assertiveness, the calls for perseverance and the protective hand of Dr. Dorothea Hennessen, who directed the project of the "23'd edition of Sobotta" and always believed in her Sobotta team and the tight schedule, this edition would have not been published. Like a number of previous productions, the routinier Renate Hausdorf led the successfu I reproduction of the atlas. Other people involved in the editing process and the success of the 23n1 edition of the Sobotta and whom we sincerely thank are Ms. Susanne Szczepanek [manuscript editing), Ms. Julia Baier, Mr. Martin Kortenhaus and Ms. Ulrike Kriegel (editing], Ms. Amalie Gutsmiedl (formal text editing], Ms. Sibylle Hartl (internal production), Ms. Claudia Adam and Mr. Michael Wiedorn [formal figure editing and typesetting), Ms. Nicola Neubauer (layout development and refining the typesetting data] and the students Doris Bindl, Derkje Hockertz, Lisa Link, Sophia Poppe, Cornelia Ri ppl and Katherina and Florian Stumpfe. For the compilation of the index, we express our gratitude to Dr. Ursula Osterkamp-Baust. Special thanks are expressed to the illustrators Dr. Katja Dal kowski, Ms. Sonja Klebe, Mr. Jorg Mair and Mr. Stephan Winkler, who in addition to revising existing illustrations have developed a variety of excellent figures. Priv.-Doz. Dr. rer. nat. Helmut Wicht, Senkanbarg Anatomy, GoetheUn iversitiit Frankfurt/Main, has revived the lifelessness of the introductions to the chapters indited by the two editors through his unique style of writing. We express our gratitude to Priv.-Doz. Dr. rar. nat. Wicht. A big help to us was the advisory council, which in addition to the former editors Prof. Dr. med. Dr. h. c. Reinhard Putz, Ludwig-Maximilians-Univarsitiit Munich, and Prof. Dr. med. Reinhard Pabst, Hannover
Medical School, and colleagues Prof. Dr. mad. Peter Kugler, JuliusMaximilians-Universitiit Wuerzburg, and Prof. Dr. rer. nat. Gottfried Bogusch, Charite Bertin, supported us strongly with advice and critical comments. We would like to specifically emphasise the effort of Ms. Renate Putz, who corrected the manuscript very carefully; her comments were of crucial importance for the consistency of the work in itself and with the earlier editions. For support with corrections and revisions, we express our sincere thanks to Ms. Stephanie Beilicke, Dr. rer. nat. Lars Brauer, Ms. Anett Dikar, Mr. Fabian Garreis, Ms. Elisabeth George, Ms. Patricia Maaka, Ms. Susann Moschter, Mr. Jorg Pekarsky and Mr. Martin Schicht. For assistance in creating clinical figures, we express our gratitude to Priv.-Doz. Dr. mad. Hannes Kutta, Clinic and Polyclinic for Oto-RhinoLaryngology at the University Hospital Hamburg-Eppendorf, Prof. Dr. med. Norbert Kleinsasser, University Clinic for Oto-Rhino-Laryngo-Pathology, Julius-Maximilians-Univarsitiit Wuarzburg, Prof. Dr. mad. Andreas Diatz, Haad of Clinic and Polyclinic for Oto-Rhino-Laryngology at the University Leipzig, Dr. med. Dietrich Stoevesandt, Clinic for Diagnostic Radiology at the Martin-Luthar-Univarsitiit Halls-Wittenberg, Prof. Dr. mad. Stephan Zierz, Director of the University Hospital and Polyclinic for Neurology at the Martin-Luther-Universitiit Halle-Wittenbarg, Dr. mad. Barit Jordan, Hospital and Polyclinic for Neurology at the Martin-Luthar-Universitat Halls-Wittenberg, Dr. mad. Saadettin Sal, University Hospital for Ophthalmology at the Martin-Luther-Universitiit Halle-Wittenberg, Mr. cand. med. Christian Schroeder, Eckernforde, and Mr. Danis Hiller, Bad Lauchstiidt. We also would like to express our thanks to our anatomical mentors Prof. Dr. med. Bernhard Tillmann, Christian-Aibrechts-Universitiit Kiel, and Prof. Dr. mad. Datlav Drenckhahn, Julius-Maximilians-Univarsitiit Wuerzburg, whom we not only owe our anatomical training, the motivation for subject matter, and the sense of mission, but also have been great role models in their design of textbooks and atlases, as wall as in their teaching excellence. Our deepest gratitude to our parents, Dr. med. Ursula Paulsen and Prof. Dr. mad. Karsten Paulsen, and also Annalias Waschka and Dr. mad. Dieter Waschke, who intensely supported and sustained the Sobotta project. Karsten Paulsen, who passed away in May 2010, studied anatomy as a medical student from the 4'h edition of Sobotta. Dieter Waschke used the 16'h edition of Sobotta and continues to attain knowledge with medical literature even during retirement. The 23nledition is dedicated to our fathers. Last but not least, we thank our wives Dr. mad. Dana Paulsen and Susanne Waschke, who not only had to share us with the Sobotta in the last year, but also were on hand with help and advice on many issues and have bean strongly supportive.
Viscera of the Thorax Heart........................ . .. . . ..
4
Lungs . . .. . . .. . . ..... . . . ... . .... . . . . 28 Oesophagus . . . . . . . . . . . . . . . . . . . . . . . 42 Thymus ............ . .............. . 50 Topography . . . . . . . . . . . . . . . . . . . . . . . . 52 Sections ...................... . .... 62
The ThoraxPartly Intricate Organs The thoracic cage (Cavea thoracis) contains the heart (Cor) and the lungs {Pulmones). In ancient times, it was believed that life spirits along with the inhaled air reached the lungs, mixed with blood in the heart, which was at that time thought to be the seat of the soul, and distributed throughout the whole body by the blood vessels. Even today, the heart is still considered to be the engine of life and in colloquial terms it is also referred to as the centre of emotions. Scientifically, the heart is defined as a hollow muscle which pumps blood through the lesser circulation of the lungs (pulmonary circulation) and the greater circulation of the body (systemic circulation): The left side of the heart pumps oxygenated blood into the systemic circulation which transports the blood to the organs via arteries (leaving the heart). Blood vessels of the microcirculation branch out to allow the nutrient and gas exchange at the capillary level. The veins return deoxygenated blood to the right side of the heart from where the blood is forwarded to the pulmonary circulation. Pulmonary arteries transport deoxygenated blood to the lungs. In a network of pulmonary capillaries the deoxygenated blood finally reaches the alveoli, is enriched with oxygen and transferred via pulmonary veins to the left atrium. This completes the blood circulation. The function of the heart as a pump is especially fascinating: On average the heart rate is 70 beats per minute and with every systolic contraction the heart forces 70 ml of blood into the circulation. Even without further stimulation of the heart in ·excitement", it beats more than 100,000 times per day and 36 million times per year. The volume of blood {206,000 m3J, which is pumped by the heart in the course of 80 years, would be sufficient to fill 80 Olympic swimming pools. Conversely, no function of the body would be possible without the heart: in most cases cardiac arrest is an immediate cause of death. In the dissection course, the opening of the thoracic cavity is perceived with mixed feelings of awe, excitement and interest by teaching professionals and students. The exposure of heart and lungs as well as the entitlement to touch and obseNe these vital organs is perceived as a great privilege during these training sessions.
The Mediastinum A sagittal massive separation crosses the Thorax from the rear aspect of the Sternum to the ventral aspect of the thoracic vertebrae. It is called the Mediastinum {from Latin "in media stans· ="standing in the middle"). Cranially the Mediastinum is continuous without sharp boundaries with the viscera of the neck through the superior thoracic aperture. Caudally it rests on the diaphragm and is sharply defined. The lungs are located within individual pleural cavities {Cavitates pleurales) to both sides of the Mediastinum. In the Mediastinum, several organs are intertwined. The Thymus is located in the Mediastinum superius just behind the Sternum. It is an organ of the immune system but soon after puberty regresses to become an adipose body. The V. cava superior is displaced to the right from the median plane. Its tributaries - both Vv. brachiocephalicae cover the large arterial trunks to the neck and the arms that emerge from the aortic arch. The cane-like cuNed main artery (Aorta) dominates on the left side of the Mediastinum. Hidden beneath the veins and the arch of the Aorta, the Trachea descends in the Mediastinum superius and branches into right and left main bronchi, Bronchi principales. The Oesophagus descends dorsal of the Trachea and in front of the vertebrae. Between the Oesophagus and the vertebrae
2
there is the delicate thoracic duct, the Ductus thoracicus, which carries milky lymph {containing absorbed fats from meals) from the lower body. The heart dominates in the Mediastinum infarius which is directed towards the diaphragm. It is located in a separate, thin-walled serous cavity, the Cavitas pericardiaca, and extends the Mediastinum towards the left side. The heart is only exposed after incision or removal of the cavity wall, the pericardium. A large area of the heart rests on the diaphragm with its apex (Apex cordis) pointing to the lower left side towards the left fifth intercostal space. Holding the heart by the apex, it can be freely moved in the cavity. Its only attachments are the large vessels that emerge at the upper pole (Aorta, A. pulmonalis) and enter at the its rear surface rvv. pulmonales, Vv. cavae superior et inferior). The base of the heart {Basis cordis) with the origin of the blood vessels is opposite to the apex. Immediately behind the Pericardium -more exactly: behind the left atrium of the heart- the Oesophagus descends to the oesophageal hiatus {Hiatus oesophageus) in the diaphragm. Slightly left side to the Oesophagus, also behind the Pericardium, the Aorta and the Ductus thoracicus descend and pass through the Hiatus aorticus in the diaphragm. The V. cava inferior traverses the diaphragm through a separate orifice (Foramen venae cavae), located slightly to the right and dorsal side of the centre of the diaphragm, and enters the pericardium and the Basis cordis from inferior. Additionally, numerous other structures, such as the Aa. thoracicae internee, Nn. phrenici, Nn. vagi, Vv. azygotes, and ganglia and neNes of the sympathetic trunk (part of the autonomic neNous system) descend in the mediastinum.
The Lungs and their Cavities The larger trilobular right lung and the smaller bilobular left lung are located in separate serous cavities {Cavitates pleurales, pleural cavities) to the right and left side of the Mediastinum, respectively. Both lungs are covered by a thin, transparent, serous membrane {Pleura visceralis), through which a black, net-like pigment pattern is visible. This anthracotic pigment consists mainly of soot, the carbon which emanates from exhaust fumes and cigarette smoke. Numerous lymph nodes near the hilum of the lungs (see below) show an abundance of this pigment. The lungs are supposed to move freely in their pleural cavities. They are attached only at the hilum where the bronchi, the Aa. pulmonales, and the Vv. pulmonales enter the lungs from the Mediastinum. Often, as a result of inflammation, the pleura covering the lungs (Pleura visceralis) adheres to the serous pleura of the ribs (Pleura costa lis), the Mediastinum (Pleura mediastinalis), or the diaphragm (Pleura diaphragmatica), all of which comprise the Pleura pariatalis. In exhaled condition, the parietal pleura is more substantial than the visceral pleura and reaches beyond the margins of the lungs. The virtual spaces in which the lungs may expand during deep inspiration are called the pleural recesses of the Pleura. During respiration, the lungs adapt to the shape of the thoracic walland diaphragm. The lungs expand and retract as they slide in and out of the recesses. Therefore, adhesions of the Pleura parietal is to the Pleura visceralis restrain lung function.
Clinical Remarks---------. The el~rdiogrtlm (ECG) is a ttandard diagnostic tool and provides infonnat ion on the muscular function of the heart and on its size end position. The ECG may be indicative of a stenosit of <:ertain coronary arteries. Conwntlonal rw:llotnphy, comput«< tomography len and matnetic ,_nanoa tomotnphic im• tint (M Rl) of the Thorax are essent ial diagnostic tools to identify diseues of the lung and tha Mediut inum and prOIIida information on the size and function of the heart. Specific diagnostic procedures, tuch as cardiac cathatari...ion, require detailed anatomical knowledge. The cardiac catheter is used to inject a contrast agent into the coronary artariat (coronary angiogram) to visualise end potentially dilate stenoses. The achocardlotraphy enables visualisation of the cardiac valves and their function. These diag. nostic methods ere carried out by specialists in internal medicine or radiologists. Cerdiothorecic surgery is perfonned for lung r§ion lor parts of the lung), treatment of detects of the great vessels, transplantation of the heart or lungs, or other indications.
-+ Dlaaactlan Link The Vue thoracica intema, which are datcending parallel to the Sternum, ere presented by fenestration of the intercostal spaces to avoid damage during opening o f the t horacic cavity. After removal of the Sternum with the anterior portions of t he ribs, the lungs are separated at the hilum and removed. Now, the mediastinum is dissected: First t he pericardium and the adjacent N. phrenicus are exposed. The pericardium is opened ventrally. The heart oan be dissected in situ or after~ ration from the great vessels. The removal of epicardial adipose tissue terves the purpose of tracing tha branches of the coronary arteriat. Using scitsort, t he vent ricles are opened from the direction of the aorta and the pulmonary trunk, ratpectively, and the right at rium is opened from the direction of both Vv. cavae. After removal of the pericardium, the Oesophagus end the course of the Aorta thoracica, the Vv. azygos and hemiazygos, the N. vagus, and the Ductus thoraciOJs are pratented in the posterior mediastinum. The parietal pleura is removed to facilitate the dissection of the aympathetic trunk with the corratponding Nn. splanchnici as welles intercostal neurovascular structures. Finally, the preparation of the superior mediastinum exposes the residual Thymus and the passageways to the neck are traced.
EXAM CHECK LIST • Development cardiac chamber• and aaptation, foetal circulation, malformation• ·heart aitua with projac:tiona in radiology and auacultation oftha velvet. pericardiaI cavity and N. phranicus, organiAtion (inner relief and valvae, conducting ay8tem), Aa. coronaries including importllnt branches and autonomic innerv&tion •lunge: C.Vitaa plauraliawith r-ea, projac:tiona of pulmonary borders, organisation in lobes and segments, Nodi lymphoidai ·organisation and content oftha madia8tinum: brancha1 of the aortll, Oatophagul with part1, constrictions and blood veae la. Trachea with bifUrcation, Ductua thoracicua with dependent lymphatic drainage, organiaation of the autonomic nervoue eyatem including the coureee of the Truncua aymp~thicus and N. vaguaiXJ
3
Thoracic Viscera
Heart
-+
Lungs
-+
Oesophagus
-+
Projection of the heart
-lrul'l:l pulmanalll
Fig. 5.1 Contoun of the hurt. carciac Ylllvas and auscult.tion a,_ proj.ctod onto tho ventral thoracic wall. The right hRrt contour projects from the third to the sixth costal cartilage onto a Iine 2 em lateral of the right sternal border. The contour of thalal hurt projects onto a connecting line between the lower border of rib Ill (2-3 c:m parasternal) and the left middavicular line. On each side, the heart contains an atrioventricular valve between the atrium and the ventricle and a semilunar velva between the ventride and the respective artery. The proJection of the four cardiac valves forms a cross which is slightly deviating to the left side from the median axis. The projection of the cardiac valves is of minor importance in clinical practice since the heart sounds and potential murmurs travel with the blood ftow and are auscultated at the points of maximal intensity (circles).
Surface ProjectiDn of CardiH Valvas
A-btion SitH of C.rdiac V.lvas
Pulmonary valve
left (I) sternal border, 3'" costal cartilage
parasternal left 2"" ICS
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left sternal border, 3.u ICS
parasternal right 2"" ICS
Mitral ,.lve
left 4111 to 5"' costaI cartilages
in the midclavicular line 5"' ICS
Tricuipid ,.lve
retrosternal 5'' costal carti Iage
parasternal right 5111 ICS
ICS ~ intercostal a~ace
Fig. 5.Z ProJection of tho hoart onto ttlo thoru; ventral view (according to [211 We distinguish four au"- of the heart: The ventrally oriented Facies stemocostalis predominantly represents the right ventricle. The Facies diaphragmatica points inferiorly and consists of parts of both ventricles. The Facies pulmonalis is formed by the right atrium on the right side and by the left ventricle on the left side. Thus, the right ventride does not contribute to any of the cardiac borders. The m ajar part of the Facies stemocostalis is covered by the Pleura. These areas represent the cotrtomodi...inales of the pleural cavity. The pleural borders separate from each other inferior to rib IV and form the boundary of the Trigonum poricerdiacum where the Pericardium is directly adjacent to the ventral wall of the Thorax.
R-•
Trtgonum p~~radal:um
Plell'lll fo!S
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , During ausculta1fon of the heart using a stethoscope hurt sounds are detected at several locations. These sounds are the result of the normal heart action: • The first hRrt sound 1811 is generated at the beginning of the systole due to ventricular contraction and closure of the atrioventrieu Iar valves. • The second hurt sound 1821 is generated at the beginning of the diastole due to the closure of the semilunar valves. In contrast, hHrt murmurs are alwavs pathological phenomena and are generated by malfunction of heart valves. Narrowing (stenosis) as wall as insufficient closure (insufficiency) of the valves may cause heart murmurs. The lime point and the location of the murmur provide information about the nature of the dysfunction of the affected valve. The percuuion of the heart is used to assess its aizo.
4
The projection of the heart contours, which are covered by the Recessus costomediastinales, equals the rala11Va cardiac dulln- since the percussion sound is lass absorbed. If this area extends to the left side beyond the midclavicular line, left ventricular hypertrophy is likely. The Trigonum pericardiacum is the area in which the heart is directly adjacent to the ventral thoracic wall. This is referred to as the area of the aohltll cardiac dullness since the percussion sound is maximally absorbed. Although the Trigonum pericerdiacum has only minor diagnostic value, it may be relevant to determine the position of the right ventricle for emergency lntracardlac InfliCtions. Here, the risk of injuring the Pleura and thus inducing a pneumothorax is minimal. lntracardiac injections are performed in the fourth or fifth intercostal space approximately 2 c:m left parasternal. However, this procedure is hazardous and not recommended anymore.
Thymus
-+
Topography
-+
Sections
Projection of the heart
Fig. s.a Thoracic cas•, eav.. ittoracil, wittl thoracic Yitctora; radiogreph in postero-anterior (PA) beam projection.
The radiograph can be used to assess the size of the heart. In eddition to the absolute size, knowledge of the structures contributing to the heart contours is of importance. M
Flg. 5.4 Schematic drawl'ne of itte heart contoun In itt• radiotJ'IIIh. From cranial to caudal, the rfeht border of itt• hNrt is formed by the following structures: • superior vena cava rv. cava superior) • right atrium (Atrium dexter) From crenial to caudal, the 111ft border of itte h..rt is formed by the following structures: • aortic arch (Arcus aortae) • Truncus pulmonalis • left auride (Auricula sinistra) • left ventricle {Ventriculus sinister) Thus, the right ventricle does not oontribute to any of the cardiac borders I M Median axis of the body
=
M
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The conventional radiogreph of the Thorax provides information on the size of the heart. The transverse diameter of the heart shows individual differences. However, if it is larger than half of the diameter of the Thorax, an enlargement of the heart is present which may be cauSI:ld by hypertrophy of the cardiac muscle or by dilation of the cardiae wall. Frequently, the heart i9 enlarged to the left side (Facies pulmonalis sinistra) indicative of left ventricular pathologies. Artlrf· al hyplrten1ion., .tenoti1, or in1ufficiency of the aortic or mitral
valvn, respectively, may be causally involved. In oontrast, an enlargement of the right ventride, as in pulmonary hypertension, chronic obstructive pulmonary diSI:laSI:l {COPDl, or pulmonary emboli are not recognised with a sagittal radiograph of the Thorax. This is ex~ lained by the fact that the right ventride does not oontribute to any of the cardiac contours. In this case, lateral radiographic projections or tomogrephic methods such as oomputed tomography ten or magnetic resonance tomographic imaging (MRI) are required.
5
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Fig. 5.9 Foettlliver; dorsal view. Arrows mark the direction of blood flow. The Ductu1 ven01u1 obliterates postnatally and remains as Ut. ven0111m at the hilum of the liver.
Fig. 5.8 Prent..l circulation tfoml circulation); schematic illustration. This illustration distinguishes the different oxygen contents of the blood by colour eodings: oxygenated blood (red), deoxygenated blood (blue), mixed blood (purple). The arrows mark the direction of blood flow. The following aspects distinguish the foetal circulation from the postnatal circulation: umbilical blood vessels, Ductus venosus, Ductus arteriosus, Foramen ovale (-t Fig. 5.Hl). Deoxygenated blood from the foetus is conveyed to the placenta by the A.a. umbilic.ln whid1 derive from the Aa. iliecae internee. After
8
oxygenation the blood from the placenta read'las the foetus via the V. umbRie4lll•and bypasses the liver through the Ductu1 ven01111 due to the high flow resistance of the foetal liver. A valve at the opening of the inferior vena eave !Valvula venae cevae inferioris) directs the incoming blood predominantly through the Fortmon ow.. to the left atrium. This WfiY, the oxygenated blood tekes the shortest WfiY to read1 the foetal organs. Blood from the superior vena eave enters the right atrium end right ventride. From the right ventricle it reaches the Truncus pulmonali9 and is shunted through the Ductu1 1rterio1u1 directly into the Aorte, thus bypassing the non-funetionellung circulation.
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Lungs
~
Oesophagus
~
The heart in-situ
N. W:gue(lCI
v.-~01'
A. putmonalle daldnl
A. pl.fmonllelllnlltra
v. putmonalte
ar!lltra l'l1'wlor
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Fig. 5.11 Potr.lon of 1h• hMrt.. Cor, wlttlrn 1he1horu.. SMut cord it; ventral view; after opening of the Pericardium. The heart is positioned within the pericardia! c!Mty {CINites pericerdi~ ee) in the inferior middle mediastinum. The broad base of the heart is oriented in an oblique direction towards the superior right side end oorresponds to the valvular plene at the base of the great vessels. The apex of the heart {Apex oordisl points to the inferior left side and ventrally. Base end apex ere oonneeted by the lontitudinll axil 112 em) which shows an oblique course in the Thorex directed from the dorsal right side to the ventral left side. Thus, the longitudinal axis of the heart
10
forms an Ingle of 45" witt! 1ll1hr.. 1n~omtnal pl11111. The heart has four surfaces 1~ Fig. 5.2). The anterior surface (Facies sternocostalisl is predominantly formed by the right ventricles. The inferior surfece ill adjacent to the diaphragm end consists of parts of the right end left ventrides. The inferior surfece clinically represents the *posterior wall" in the diagnostic electrocardiogram {ECG) when referred to as posterior myocardial inferction. The Fecias pulmonalis is determined by the right atrium on the right side end by the left ventricle on the left side.
Thymus
-+
Topography
-+
Sections
Pericardium
V. CIIWIIUP'lf1a'
'l putmonalle daxlnllrlfw!cr
\L pulmonalia •trflltnl •upwlor
\L pumo!lllll9 ar~lml ~cr
Pwicarclillm -· Lamina plrietllill
Flg. 5.12 PttrfC41rdlum. PttrfC41rdlum: ventnJI ~ew; efter remover of the anterior part of the Pericardium and the heart. The Pericerdium surrounds the heert, stllbilises its position end enebles the heart to contract without friction. The outer layer af dense conne<> tive tissue is the Pttrfc.rdlum flbrosum. Adjaoent to the Pericerdium fibrosum on the inner side is the Tunica serosa or Peric.rdium terosum which comprises the parietal layer llemine parietelisl of the Pericerdium serosum. This Lamina parietalis is a continuation af the Lamina ~scerelis of the Pericerdium I= Eplc.rdluml folding becket the ventnJI side of the roots af the great cardiac vessels. At the posterior side of the atria, the reflection between the Epicardium and the parietel Pericerdium forms a vertical fold between the V. cava inferior and superior end e horizontlll fold between the upper pulmonary veins of the right end left side. These folds of the Pericerdium aeete two sinuses of the pericardia! cavity at the posterior side (Sinus pericerdii, arrows):
• Slnu' ~ran!IVtlnu' pttrfc1rdll: above the horizontel fold between the V. cava superior (posterior) and the Aorta and Truncus pulmonalis {anterior) • Sinu' obliquu' peric1rdii: below the horizontal fold between the pulmonary veins on both sides The Pericardium fibrosum is connected to: • the Centrum tendineum of the diaphragm • the posterior aspect of the Sternum lligg. sternopericardiaca) • the trecheal bifurcetion {Membrena bronchopericardieca) At the outer side. the fibrous Pericardium is covered by the Pleur1 parlmll,. Pll'l rnedlatfnalll. The N. phrenicus end the Vese pericercliaoophrenica course between these two layers. The Epicerdium is the ~scerellayer of the Pericerdium serosum.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The pericardia! cavity usually contains 15- 35 ml af serous fluid. The Perieerdium has a total volume of 700- 1100 mi. induding the heert. With diseases accompanied by inflammatory reactions af the pericerdium fpttrfclrdttr'l or with insufficiency of the heart, edditionel fluid may accumulate fperi'C41rdill effution) which may even impede the eardiac function.
Rlllowing rupture of the cardiac wall due to myocardial infarction or injury lstllb wounds), blood may repidly eccumulete in the pericerdial cavity and inhibit the cardiac functions resulting in death (paricttr4'al urr.,onldlll.
11
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Heart
Pa1c:ardum ~um, I.Jimlnaplllfat.lllt
A. COI'Oflllf• 8ll'lllltnl, R.l~--lluf•ant-
Fig. 5.1S HN~ Cor; ventnJI ~ew. The heart weighs 250-300 g and has approximately the size of the fist of the respective pei'S(In. The epex of the heart (Apex cordis) is directed to the inferior left side. The base of the heart represents the position of the Sulcus coron1rlu• which herbours. emong other structures. the A. corona ria dextra. The heart consists of a ventricular chamber (ventricle) and en etriel member latriuml on the right end left side. respectively. At the anterior surface {Facies stemocostalisl. the Sulcu• interventric.,. l•rt• 1ntttrfor is visible. It depicts the position of the interventriQJiar septum !Septum interventriculare) and contains the R. interventriQJlaris anterior of the A. coronerie sinistnJ. At the inferior surfece !Facies di~ phragmatiea). the border between the two ventricles is marked by the
12
Sulcu• lnterventrlcullrl• postttrfor {-> Fig. 5.14). Prior to the trensition into the TrunQJs pulmonalis. the right ventricle is dilated as Conus erteriosus. The origin of the Aorta from the left ventricle is not ~sible from the outer surface due to the spiral course of the Aorta behind the Truncus pulmonelis. Therefore, the Aorte appears at the right side of the Truncus pulmonalis. The aortic arch is connected with the pulmonary trunk through the Ug. arteriosum. e developmental relict of the Ductus arteriosus of the foetal circulation 1-> Fig. 5.8). Both atria have en enteriar pouch which is referred to as euricle (Auriculee dextre end sinistra). The V. cava superior and inferior enter the right atrium. the four pulmonary veins enter the left atrium.
Thymus
-+
Topography
-+
Sections
Heart
W. pl.fmonllae c:lutrH
Atrium di:Jdnlm
Plrlctrdllm -um, Ltmrla'\118Qn1181,Eplell'dllm]
v.eaw..,.....
A. QCI'CIIIIfa dllM, R. IMII'Wmleullll$ PQ114110r
Yllll'llti:\Mdotw
Fig. 5.14 H••~ Cor; dorsal'.liew (explanation~ Fig. 5.13).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Most hearts seen in the gross enetomy dissection course ere enlarged. This clearly shows how frequently diseases oceur that present with either hyptll"trophy !e.g. arterial hypertension) or dll• tion (aloohol abuse. viral infections) of the heart.
The weight of the heart in professional athletes !training, enabolic substences) may reach 500 g. This is considered the criticll h"rt weltht sinoe sufficient blood supply is not werrented above this weight with resulting risk of myocardial infarction. Some pathologic conditions may ceuse the heart to weigh up to 11 00 g, e condition referred to a cor bovinum (bovine heart).
13
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Cardiac wall
MISCI!MIIlm IIP!ell'dlall) I.JimiM Pf"PP11S
Fig. 5.15 Struetur. af ~h• atrdf•e w•ll; microscopic detlJil from the right etrium. (eceording to 12D The wall of the heart is composed of three layers: • Encloellrdium: inner surface consisting of endothelium end eo nne~> live tissue • Myoe.rdium: cardiae muscle with eerdiomyocytes
14
• Ep(C41rdfllm: Tunica serosa end Tela subserosa et the outer surtece of the heart, representing the visceral layer of the Pericardium serosum. In the human, the Tela subserosa contains plenty of white adipose tissue in which the coronary blood vessels and nerves are embedded.
Thymus
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Topography
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Sections
Cardiac muscle
vv. putmona~..s ar!1811u
.Milum dutNn
V. CIMIInfllrlcr
5.11
Flg. 5.1tto Flt. 5.11 C.rdlle mute!•. Myoeardlum; ventrsl view 1... Fig. 5.16}. view from the apex(... Fig. 5.17). end dorsoceudel view 1... Fig. 5.18). The cardiae muscle fibres consist of eardiomyoeytes end have a spiral srrsngement within the cardiac well. In the well of the stria and the right ventricle they form two layers. in the wall of the left ventride they even
form three lsyers. Thus. the Myocerdium and the cardiac well ere much thicker in the region of the left ventricle. In comparison to the right ventricle, this srrsngement reflects the much higher pressure required in the left ventride to pump the blood into the systemic circulation. The right ventrio.rlar well is 3-6 em thick, the left ventrio.rlar well is~12 em thick.
Clinical r e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . If the thickness of the left ventricular wall exetled' 15 mm, the term hypertrq~hy is used. A left ventricular hypertrophy may be ceused for exsmple by stenosis of the sortie valve or srterial hypertension. In the right ventricle, a hypertrophy i9 already diagnosed if
the wall thickness tiXC:Hds 5 mm. This may be caused by a stenosis of the pulmonary velva or by pulmonary hypertension. resulting from chronic obstructive pulmonary diseases ICOPD; e.g. asthma) or recurrent pulmonary emboli.
15
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Heart valves and skeleton of the heart
Yllhll e.tri-*'!Cikril { liinilttll (VIMI milrlie]
-~lin
C.-pllt pollla!CII'
C1,18pl8 al'ltii1Cr C.-pllt ccnmllt8Lnlllt-
Fig. 5.19 HMrt vtlvn, V11¥. . cordis; m~nial view; after removal of the etrie, Aorta end pulmonary trunk. The heart has two lrtrfoventrfcultr vtlves !Valvae cuspidales) between the etrie end the ventrides of each side. The right atrioventricular valve !Valva atrioventriculeris dextra} consists of three cusps HriCuiiPid vltv.). The left etrioventriculer valve (Valve etrioventriculeris sinistre} has two cusps lblcutipld v11¥1, mltr1l Vll¥1). The rusps ere anchored to the papillary muscles by tendinous cords {Chordee tendineeel to prevent a prolapse of the valves during ventricular contraction.
Fig. 5.20 Fi'bN:Iullkeleton of 1tte hMrt; ereniel view, schematic illustration. {according to [2)) The valves ere anchored to the cardiae skeleton. The letter consists of connective tissue forming a ring IAnuli fibrosi dexter and sinister) around the atrioventricular valves (Valvulae etrioventriculares) end e fibrous ring around the semilunar valves !Valvulae semilunaresl. Between the Anuli librosi lies the Trigonum librosum dextrum. Here. the bundle of HIS belonging to the conducting system of the heart passes
In addition, between the ventricles end the greet arteries lie the 101'1fc wive (Valve aortae) on the left side end the pulmon1ry wive (Valve pulmonelisl on the right side, both of which consist of three semilunar C\Jsps (Valvulae semiluneres). When blood ill ejected from the ventrides into the greet arteries during the systole the semllun1r v11¥M •r• open end the atrioventricular valves ere closed. When the ventricles ere filled with blood from the atria during the dlmole the lrtrfoventrfcullr v1lv11 IN open end the semilunar valves ere closed.
over from the right atrium to the interventriCIJiar septum. In addition to the stabilisation of the valves, the fibrous skeleton of the heart serves es en electrical insulator between the stria end the ventricles because ell cardiomyocytes ere attached to the cardiac skeleton. Since there is no connection between etrie and ventricles via cardiomyocytes, the electrical impulse reaches the ventricles elCdusively through the bundle of HIS.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . If the valves ere constricted {stenosis) or do not close properly (insufficiency), h11rt murmurs develop. These ere most noticeable et the euscultetion sites of the respective valves (-t Fig. 5.1). If e murmur is detected during systole (between the first end second heart sounds) in the eree of one of the etrioventricullr tAVJ wlvn, en Insufficiency of the respective valve is likely, since AV valves ere normally closed during systole. If the murmur is detected in this
16
eree during di11tole, 1 1teno1i1 of the respective valve can be suspected since the AV valves ere fully opened during diastole. The oppo1ite is true for the Mmilunlr v1lv81. Valvular stenoses ere either congenital or acquired {rheumatic diseases, bacterial endocarditis). Valvular insufficiencies ere mostly acquired and may also be the result of a myocardial inferction if one or more of the papillary muscles ere affected by the infarction.
tahir99-VRG & vip.persianss.ir
Thymus
-+
Topography
-+
Sections
Chambers of the heart
M.pllpllllllfleHpl:lll..
PaoioM:Iium _...,, 1..8mna vieconl it [Epicardium]
Fia. 5.21 Riaht atrium. Atrium dutrum. and ritht ventricle, Ventriculus daxtar; ventral view. The right atrium consists of a part with a smooth inner surface, the sinus of venae cavae (Sinus venarum CBVarum), and of a muscular part with a rough inner surface consisting of the pectinate muscles (Mm. p&etinatil. Both parts are separated by the Crflta temlnalrs. which serves as important landmark: for the localisation of the sinu~rial node !SA nodal of the cardiac conducting system {-+ pp. 2Q-22l. The SA node is positioned at the outside (subepicardial) of this demarcation line between the entry of the V. cava superior and the right auricle (Auricula dextral. The interatrial septum (Septum interatrial&) shows a remnant of the former Foramen ovale, the F - ovali1 with its rim, the Limbus fossae ovalis. The opening of the Sinus coranarlus (Ostium sinus coronarii), which repre!Kints the largest cardiac vein, has a valve (Valvula sinus coronariil and the opening of the V. cava inferior is also demarcated by a valve (Valvula venae cavae infarioris). Both valves, however,
are not able to close the respective lumen. Smaller cardiac veins enter the right atrium directly (Foramina venarum minimarum). An extension of the Valvula venae cavae inferioris is the TODARO's tendon {Tendo valvulae venae CBVae inferioris). It serves as a landmark: and, together with the opening of the Sinus coronarius and the tricuspid valve (Valva atrioventricularis dextral, it forms the KOCH's triangle which harbours the AV node (-+ Figs. 5.25 to 5.27). In the right ventricle, the three cusps are attached via Chordae tendineae to the three papillary musdM (Mm. papillares anterior, posterior and septal is). Of the interventrirular septum (Septum interventriculare) only the muscular part is visible in this illustration. Starting from the interventricular septum, specific fibres of the cardiac conducting system (moderator band described by LEONARDO DA VINCI, not visible here) course to the anterior papillary muscle (M. pepi111rill 1ntariarl- This conn&etion is referred to as the 'lhlbecula uptomargln~lls (-+Fig. 5.271.
Yarblcuua-
Fig. 5.22 Left 1nd right ventricln, Ventriculus sinister and Ventriculus dattr; cross-s&etion, cranial view. Because of the substantially stronger muscle layer, the wall of the left ventricle is thicker than the wall of the right ventricle.
17
tahir99-VRG & vip.persianss.ir
Thoracic Viscera
Heart
-+
Lungs
-+
Oesophagus
-+
Chambers of the heart
v. cardlaca lcordl81 IIIIQIII
'lllllva IIDtavarUicu-
..,..m. Lamina..-11 [Epicardium]
81'li&U'I, Cuepll p~or
Part::ardlum
M. paplllatll paetwlcr
Septum hllnartrlculanl, Psnl mLIIICIJIIrlll
Fit. 5.!3 Laft .trium, Atrium ainider, •nd left vantric:le, Ventrlc:ulus slnlltllr; lateral view. The auricle
18
during the development of the heart(-+ Fig. 5.7]. The Ostium atrioventricular& sinistrum is the junction to the left ventricle and contains the Valva mitralis. The wall of the left ventricle is not smooth but structured by trabeculae of the wntricular Myocardium rrrabeculae cerneae).
tahir99-VRG & vip.persianss.ir
Thymus
-+
Topography
-+
Sections
Chambers of the heart
LU'Iulll valllulaa oamuu...rta
A. ccranarla alnllltnl. R. lnlllrvantrlcuarta a -
&olplum inlllrwntriculwa, Pan rnamb,...._
Fig. 5.!4 Left ventricle, Vantriculua ainiater; lateral view. The mitral valve !Valva alliovenllicularis sinistral only consists of two cusps. Thus, only two p1pillary mu•IM are required {Mm. pepillares anterior and pOllterior). Beneath the mitral valve, the approximately 1 cm2 1arge area of the Para membr11naCH of the interventricular septum is located. However, the major part of the interventricular septum
consists of cardiac muscle fibres {Pars muscularis). Blood from the left ventricle is pumped through the aortic valve {Valva aortae) into the dilated part of the Aorta (Bulbus aortae). The aartl'c valve consists of three semilunar valves (Valvulae semilunaresl which cover the Sinus aortae from which the right and left coronary arteriH originate (Ae. coronariae dextra and sinistral.
19
tahir99-VRG & vip.persianss.ir
Thoracic Viscera
Hean
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Lungs
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Oesophagus
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Electrical stimulation and conducting system of the heart
Fig. 5.25 Eledr~l stl'mul-'lon •nd conductlnt system [Complbulltimul•l'll conducente cordiI] •lont tiM axil of tiM
«
Hctfoned hNrt. The heart harbours an electrical stimulation and conducting system which consists of modified cardiomyocytes instead of nerve fibres. This system is divided into the following parts: • tln&Htrf•l node (Nodus sinuatrialis, SA-node; node of KEITHFLACKJ • .trioventricul•r node {Nodus atrioventriCIJiaris; AV-t~ode, node of TAWARAl • Mrloventrlcul•r bundle {Fasciculus atrioventricularis, bundle of HIS} • ritht •nd ltft bundle bNnch (Crus daxtrum and sinistrum node of TAWARAl The electrical stimulation is initiated independently within the 1in"' Mrlll node by sponteneous depolarisation in the specialised myocardial calls and has a frequency of approximately 70/min. The SA-node has a size of approximately 3 x 10 mm and is located within the wall of the right atrium in a groove (Sulcus tarminalis cordis) between the entry of the V. cava superior and the right auride. This groove oorresponds to the Crista terminalis at the inner surface of the right atrium. The SA node is oca~Sionally covered by an area of subepicardial adipose tissue making it visible from outside. The SA node is supplied by the sinu-atrial nodal branch !R. nodi sinuatrialisl which derives from the A. corona ria
20
dextra in most cases. The electrical signal spreads from the SA node through the Myocardium of both atria {myogenic oonductionl and read'les the AV node. The latter slows down the frequency of the electrical signal to allow a sufficient filling of the ventrides. The AV node, approximately 5 x 3 mm in size, is embedded within the Myocardium of the atrioventricular septum at KOCH's triangle. The KOCH's triangle is confined by the TODARO's tendon. the entry of the Sinus coronarius, and the septal CIJSP of the triCIJspid valve{-+ Fig. 5.21 ). The AV node is also supplied by a separate branch (R. nodi atriovantricularis) which usually derives from the dominant ooronary artery fin most cases the A. coronaria daxtra) near the branching of the R. intarventriCIJiaris posterior. From the AV node the electrical signal is conveyed by the bundle of HIS lapprox. 4 x 20 mml through the Trigonum fibrosum dextrum to the intervantriCIJiar septum. In the Pars membranacea of the interventriCIJiar septum the bundle of HIS divides into the ritht •nd ltft bundle bNnch. The left bundle branchsplits into the anterior, septel and posterior subendocardial fasciculi to the respective parts of the Myocardium including the papillary muscles and the apex of the heart. The right bundle branch descends subandocardially in the septum to the apex of the heart and reaches the anterior papillary musda via the Trab9C\Jia septomarginalis {-+ Fig. 5.271.
tahir99-VRG & vip.persianss.ir
Thymus
-+
Topography
-+
Sections
Electrical stimulation and conducting system of the heart
Fit. 5.2t ElectrfC411 stlmul~lng ~md eondudl'nt syftlm of ~h• hurt; schematic illustration.
Noelualinue.trlllill Ofatwmt~•l•
Fig. 5.27 Electricll .timut.tion 1ncl concluding ayltem of~" hNrt. The electrical stimulation and conducting system is organised in four p•m {.... Fig. 5.251.
The illustration demonstrates how a part of the right bundle branch {Crus dextruml reaches the right anterior papillary muscle via the Trabecula septomarginalis.
21
tahir99-VRG & vip.persianss.ir
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Electrical stimulation and conducting system of the heart
1 Sin ~a node dapO-n (m ECG ligna!)
2 Depo-n dalay lnAVnoda
(PQI-) p Alllll depcilrl9a11011 Q Depo-nof1hl
Wmi'ICUir 91P'l!m R Depo-n of 1hiiiSCII 111~ ct1M ¥41'1111Culr 91P'l!m
(YIIC1or In ICIIghlldMI ell'dlle UIS)
8
Depo-nofn~m~ll'llnjj~
cC' 1M wn1rlclae
ST Complate d a p e l - of ~emi'ICiae (m pofenllal c111'wrJnca
;-Gdl1c)
T Rllpcl.-lcn dnmi'ICiae
I
ECG
Fig. 5.28 An~om!C411 prlncl'pln of 1he elllctrocardlogr•m IECG). (aceording to [2)) The electricel signel spreeds from the sinu-tnrial node to the AV node which ceuses a delay in electricel conduction before raeching the interventricular septum via the bundle of HIS. The right and left bundle brenchas then divide end stimulate the ventricular Myocardium. This conduction of electricel impulses within the heert can be detected by electrodes on the surface of the body. If the electrical signal travels towards the electrode at the surfece of the body, it results in e positive upward amplitude of the baseline voltage. Baceuse of the small volume of the sinu-Gtrial node, the SA excitation is not detectable in the ECG. The depolarisation of the atria is represented by the P wiYe. The depolarisation delay by the AV node occurs during the PQ segment. The letter depicts the lack of polerisalion changes during the depolarisetion of the entire atrial Myocardium. The rapid retrograde direction of the
0
I
I
I
I
I
I
0.1 0.2 0.3 0.4 0.5 0.8 eec
depolarisetian of the interventriculer septum is illustreted by the Q WIYe. Depolerisetion of the ventricular myocardium towards the apex of the heart is represented by the ascending limb of the R woe. wtreraes the propagation of the depolarisetion away from the apex results in the descending limb of the R weve and in the short S woe. During the ST segment the entire ventricular Myocerdium is depolarized. Since the repolarisation of the ventriculer myocardium occurs in the same direction as the depolerisation. the T wave also shows a positive (upward) amplitude. Usuelly, three limb leads are recorded to determine the electricel axis of the heart aceording to the largest emplit~r de of the R wave. However. this electrical axis is influenced by the thickness of the Myocerdium in both ventricles end by the excitability of the tissue and is therefore not identical with the anatomical axis of the heert.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The ECG is used to detect c.rdiac armytftmin, for example if the heert beets too fest ftlchycardll. > 100/ min). too slaw lbr•clyc.rdil, oe 60/min). or in en irregular way tarrhythmia). In addition. reduced erteriel perfusion due to coronary artery disease !e.g. myocardial infarction). end other diseases sud1 as myocardial inflammation result in alteretians of the electricel conduction. The ECG is of particular importance for the identification of myocerdial infarction.
22
If atrial Iibras bypass the AV node and directly link to the bundle of HIS or the ventricular myocardium (KENT's bundles), cardiac errhythmias ere the result twOLFF-PARKINSON-WHITt: ~~ynclrome). If these arhythmias cause severe symptoms and resist phermecological traetrnent, it may be n&C&Ssary to interrupt the accessory bundles using a cardiac catheter device.
tahir99-VRG & vip.persianss.ir
Thymus
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Topography
-+
Sections
Innervation of the heart
Fig. 5.29 Innervation of the hurt: Piau• c.rdiacUII with sympdlatle tgr..n) 1nd p1ruympdlatfe tpurplel nerve flbr•: schematic illustration. The function of the eleetriclll oondueting system end the Myocerdium cen be modified by autonomic innervation to adjust to the needs of the whole body. This is the purpose of the PleX\Js cerdiecus es part of the autonomic nervous system. The Plexus cerdiacus consists of sympathetic end paresympethf:ltic nerve fibres. The cell bodies {Perikerye) of the postganglionic ~ympathetie nerv• fib,.. reside within the cetvicel ganglie of the sympathetic trunk (Truncus sympethicusl end reech the Plexus cerdiacus via three nerves INn. cerdiaci cervicales superior, medius end inferior). Sympathetic: "lmulatlon increases the heert rate
(positive d'tronotropic effect), the speed of conduction (positive dromotropic effectJ. and the exatebility (positive bethmotropic effectJ of the cardiomyocytes. In addition. sympathetic stimulation enhances the contrectile force (positive inotropic effectJ due to acceleretad relaxetion (positivelusitropic effect). PINIIympdletie "imulation elicits negative d'tronotropic, dromotropic, end bethmotropic effects and, edditionally, has negative inotropic effects on the atrial Myocardium. The p• n~sympathatle n.,. fllres derive as pregenglionic nerve fibres from the N. vagus [)(] and reach the Plexus cerdiacus as Rr. cerdiaci cervicales superior and inferior end es Rr. cerdiaci thorecici. In the PleX\Js cerdiacus, they are synepsed within numerous (up to 500) tiny genglia {Ganglie cardillCil) onto postgenglionic neurons.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Increased sympathetic tonus, es in stress situations, is acoompanied by increased heart rete ttachyeerdie) and elevated arterial blood
pressure C1rterlal hyperttlfltilon). Injury to the peresympethetic fibres may also result in tachycardia. The increased activity of the
heart elso increases the oxygen consumption by the cerdiomyocytes. This may cause an angina pectoris and myocardial infarction in the case of a pre-existing coronary artery stenosis {coronary artery disease).
23
tahir99-VRG & vip.persianss.ir
Thoracic Viscera
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Lungs
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Oesophagus
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Coronary arteries
Fig. 5.30 Coron1ry 1rterin, Aa. coronttrile; ventral view. The rfght coron1ry •rwry {A. coronaria dextral has its origin at the right aortic sinus end courses in the Sulcus coronarius to the inferior margin {Margo dexter). It continues to the Facies diaphragmatice where in most cases the R. interventricul1ri1 pontrior branches off as a temrinal branch. The left coron1ry 1rtery lA. coronaria sinistra) originates et the left aortic sinus and di-vides after 1 em to form the R. lnterventrfcul•rf•
Interior, which courses to the apex of the heart, and the R. circumfl•
xu1. The latter courses in the Sulcus coronarius around the left cardiac margin to reacl1 the posterior aspect of the heart. Conventionally, the coronary dominance is determined by the artery that supplies the R. interventricularis posterior. In most cases the right coronary artery is dominant fin the Mc
lmporant hnch• of1he Ritht Coronttry Artery tA. oaran•rf• cladr•J
R.nodla~lllllfal8
• R. coni erteriosi • R. nodi sinuatrialis {tw~thirds of all cases): to the SA node • R. marginalis dexter • R. posterolateralis dexter • R. nodi atrioventriQJiaris: to the AV node (if right dominantM) • R. interventricularis posterior (if "right dominant") with Rr. interventriQ.tlares septales, supplying the buncle of HIS M
lmporwnt hnch• of1he Left Caran•ry Artery tA. oarvn•rf• •lnlslnl
R. lnttii"Vttlltrleul•rhl •nterfor: • R. coni arteriosi • R. lateralis !dinical term: R. diagonalis) • Rr. interventriculares septales R. circumfleliUI: • R. nodi sinuatrialis {one-third of all cases): to the SA node • R. marginalis sinister • R. posterior ventriculi sinistri
R. muglnelle daxtw
Fig. 5.31
24
Coran1ry 1rterin, Aa. coronlriH; cranial view.
tahir99-VRG & vip.persianss.ir
Thymus
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Topography
-+
Sections
Veins of the heart
Y. _,._ [cordi•] l * f t ----",~ V. rn.s~~n•• cla.a'a _ _ _.......:~!r'ill:;:
Fif. 5.32 Cardiac Mint, Vv. cordia; ventral view. [8) The venous blood from the heart is collected in ~hr.e meJor systems. 75% of the venous blood are collected in the Sinu1 coron1ri111 and
Coranery •lnus "*m: • V. eerdieee magna (greet cardiac vein): corresponds to the supply area of the A. coroneria sinistra - V. interventrieularis anterior - V. merginelis sinistre - Vv. ventriculi sinistri pOllteriora • V. eerdieee media: in the Sulcus interventriculeris p01terior • V. eerdieee perva: in the right Sulcus coronerius, present in 50% • V. oblique etrii sinistri
drain into the right atrium. The remaining 25% of the venous blood drain into the atria and ventricles directly via the trensmu1'411 end the enclomurll tlyltem 1-+ pega 17-19).
v. obllq~ atr118lrtl1ri·--Y. CMI- [eonlie] mljllfiM _ _
Tre•murel~yNm:
• Vv. ventriculi dextri anteriores • Vv. etrieles Enclomurel~yNm:
• Vv. eerdieeee minimee CTHEBESIAN veins)
Fig. 5.33 C1rdiac vein I, Vv. cordi I; dorsoceudal view.
25
tahir99-VRG & vip.persianss.ir
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Coronary artery dominance
R.l.tllllle
Fr.1111'11*' Rr.~llns
A.CCI'ONII1a81NIIInr,
R. poii!GIIcrwrtlfcutlllnlltll
"PUI*' R.~
Vlm!C:UIIalrf9111 Rr. ~ullne eeptlllae
5.34 Fig. 5.34 and Fig. 5.35 "BIIanced• or co-dominant coron1ry clrcul~lon betwetln 1he coronary al1tll'les, AI. eoronarfH; ventre! (-+ Fig. 5.34) end dorsal (-+ Fig. 5.35) views.
5.35 In 55% of ell casas. the R. interventriCIJiaris posterior originetas from the A. corona ria dextre but does not supply the posterior espect of the left ventricle. This is referred to as a Mbalanc&dM or "co-dominantM perfusion type.
A. Ccnlrwla 8tlfltnl,
R. cl'cl.mflaxllt
A. OCIOMI!a alrf91nt, R. poiiiGI!crwrtlfcul ~n191!1
S.H
26
Fig. 5.38 and Fig. 5.37 "Left domrnant" coron1ry clrcul~lon IMt:wMn 1he coron1ry al1erin, Aa. coron1ri1e; ventral (-+ Fig. 5.36) end dorsel (-+ Fig. 5.371 ~ews.
In 25% of ell ceses. the R. interventriCIJiaris posterior originates from the A. coroneria sinistra.
Fig. 5.38 and Fig. 5.39 "Right-dominant" coronary circul~ion Mtwtlln 1he coron1ry 111t11'1es, Aa. coron~rfae: ventre!(-+ Fig. 5.361 and dorsal (-+ Fig. 5.39) ~ews.
In 20% of ell cases. the A. ~ronerie dextra not only branches off the R. interventricularis posterior but also supplies parts of the posterior aspect of the left ventride.
tahir99-VRG & vip.persianss.ir
Thymus
-+
Topography
-+
Sections
Coronary artery dominance
A.ll'tlllrYW1trlcullrle · -
•
2696
b
b R.l111wals
2096
Fit•· 5.441 to c Are111upplied by 1tte A. coron1ri1 chxtr1 tlitht rtldl1nd tlnlstnllcllrk rtldl rn the ertm~-Sectfon: a~udsl view. (aec
Fit•· 5.411 to d lnf1rction p.U.m owint to the occlu1ion of the coronary 1rterfft. • Isolated occlusion of the R. interventriculeris anterior (left anterior descending [lAD) branch) results in an anterior myocardial infarction. b Distal occlusion of the R. interventricularis anterior results in myocardial infarction of the apex of the heart, often referred to as apical infarction. c If only the R. laterelis is occluded the myocardial infarction is restricted to the lateral wall of the ventride. cl Occlusion of the R. intervantrio.tlaris posterior results in a posterior myocardial infarction !PMII of the Facies diaphragml.ltica.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The coron1ry 1rt.ry diiUH {CADI is caused by a stenosis of the coronary arteries resulting from arteriosclerosis. Due to insufficient myocardial parlusion this may causa pain in the chest t•ntin• pee. torltl which may radiate into the arm {mostly the lett arml or into the neck. Total occlusion of en artery results in necrosis of the dependent Myocardium Cmyocardllllnflretron. MU. Functionally, coronary arteries era terminal arteries end a distinct infarction pattern results from the ocdusion of the supplying arteries. These patterns may be detected in various leeds in the ECG. The most definitive evidence is achieved through coronary catheterisation using a radiocontrast agents (coronary angiogram). The pOiterior myocardill
inf1rction (PMII is often accompanied by bradycardiac errtrythmias because the artery supplying the AV node originates near the outlet of the R. intervantrio.tlaris posterior(-> Fig. 5.38). Mostly, the R. interventricularis posterior is the terminal branch of the A. corona ria dextre ~n the balanced end the right-dominant parlusion types). Due to the low pressure system of the right heart, the Myocardium of the right vantride requires lass oxygen when compared to the left ventricle. Thus. even a proximal ocdusion of the A. corona ria dextra may only result in en isolated posterior myocardial infarction. In this case, the bradycardia may be severe due to the insufficient perfusion of the SA node.
27
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Projection of trachea and bronchi
.,_9tlbu~m 11881-t._,.-.,._ ~:::.1-..--:::4-~-- Pin nll8tll8 llfl~ls} .HI.~-+--- Pent cnlllt phlllyngle
Pfl.-,nx
~J;J"T--t----...,.r~aa p~~~~~yngle ---~dl
Fig. 5.42 Upptrr and IIJWer r-.rmory ~ract schemiJtic illustration. The respiratory system i.t devided in upper end lower pert.t. The upper respiriJtory tract comprises: • nasal eflllity (C811ites nB.ti) • parts of the Pharynx
The lower respiretory tract oomprises: • Larynx • wind pipe (Tractrea) • lungs (Pulmone.t) The right lung {Pulmo dexter) has three lobes, the left lung {Pulmo sini$ter) hBll two lobes.
Bnlncllue loblufa madkla daxlllr
Fig. 5.43 Proiection of ~he Trachu and main bronchi onto ~" anterior chest wall. The Trachea is 1~13 em long end elongates up to 5 em during deep inspiration. The origin of the Trachea et the cricoid cartilage projects onto the 1"' eeNicalvertebre; the bifurcation of the Trachea into the two main bronchi projects onto the 4'h and 5'h thoracic vertebrae !rib II
to Ill). The engle between the main bronchi is 55" to 65°. The right main bronchus !Bronchus principalis dexter) is larger, 1-2.5 em in length, end is positioned nurfy vertically. The ltft main bronchu• !Bronchus principal is sinister) is almost twioe as long end located more horizontally.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Because of the almost vertical position of the right main bronchus foreign bodies more frequently enter the rlgh~ luna during inspire-
28
tion (upiration). This knowledge may provide the crucial time ventage when dealing with medical emergencies.
~
Thymus
-+
Topography
-+
Sections
Projection of the lungs
Mklulllllylne
81em1IIA
5.44
Fig. 5.44 •ncl Fit. 5.45 Projection of1f'l• bordlr11 of1f'l•lunp •nd Pleu,.. onto 1tle •ntelfor C-+ Fig. 5.44) •nd posterior C-+ Fig. 5.451 thorecic w•ll•. The right lunt has three lobes which are separated by the Flssu,.. obliqu• end the Fi11ura horizont•lil. On the dorsal side. the Fissure oblique follows rib IV and. thus, separates the superior and the inferior lobl:lS. From the midaxillery line onwards, the Fissure oblique descends more steeply to reach rib VI at the midciiNicular line. Anteriorly. the Fissure oblique separates the middle end inferior lobes 1-+ Figs. 5.53 and 5.54). The Fissura horizontalis projects along rib IV on the anterior chest wall and separates the superior and the middle lobes.
The left luno only has two lobes which ere separated by the FiMura oblique. Because the heart enlarges the Mediastinum to the left side (Incisura cardiace), the volume of the left lung is smaller and the position of the left lung differs in the sternal and midciiNicular lines lsee table). Each pleu1'411 cntty {Cevitas pleuralisl is lined by the fNirletel pleu1'41 (Pleura parietalis). The Pleura parietalis is divided into Pars mediastinalis, Pars costalis, and Pars diaphregmetica 1-+ Fig. 5.65). The pleural CINities hiNe four pleural recesses (Recessus pleurall:lS). The largest rl:lCI:lSsus is the Recnsu1 CNtodil!llhratmaticut which expands laterally up to 5 em in the midel
Bordera of 1tle Ritht Lunt
Bordera of 1tle Left Lunt
c:rosses rib VI
c:rossesrib IV
Mlclclnfcular line
parellel to rib VI
c:rosses rib VI
Midaill•ry line
crosses rib VIII
as right side
Scl!lluler line
c:rossesribX
as right side
P•ravart-.lline
crosses rib >0
as right side
pleural borders: one rib lower each
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Identifying lung and pleural borders is important during physical examination in order to determine the ll'ze •nd mobility of the lunss clurint Ntpiration. In addition, these borders are invaluable for the loceiiMtlon of pdlologlcel chentes such es pulmonary infiltretions in pneumonia or increased fluid in the pleural CINity (pleural effusion). Pleu1'411 effull'ons are drained from the Rec:essus c:ostodiaphragmaticus by thoracocentf:lllis.
Nociceptive innervation and rf:lllulting fN!in Mnlation i9 restricted to the Pleu1'41 fNirletells. Chest pain ec:c:ompanying pneumonias or bronchial carcinomas therefore indicatf:lll an involvement of the Pleura parietalis. If air enters the pleural cavity, the lung collapsf:lS completely or partially (pneumoitlonucJ. This is detected by a loud {hypersonoric:l sound during percussion.
29
Thoracic Viscera
Heart -+ Lungs -+ Oesophagus -+
Development
Day32 Day25
5.46
Fig. 5.48 and Fig. 5.47 Development of the lower respiratory tract on day 25 (-+Fig 5.46) and day 32 (-+Fig 5.47). (according to [3])
In week 4, the epithelial tissues of Larynx, Trachea, and lungs begin to develop from the endoderm of the foregut. Connective tissue, smooth muscles, and blood vessels derive from the surrounding mesoderm.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Incomplete separation of the Oesophagus and the Trachea may result in the formation of pathological connections (tracheo-oesophageal fistuln) which are frequently associated with an oesophageal blind-ending pouch (oesophageal atresia). From week 28 onwards, the alveoli produce and secrete surfactant, a lipoprotein mixture which reduces the surface tension of the alveoli. From week 35 on, surfactant production is usually sufficient to enable spontaneous breathing. Insufficient surfactant production
30
results in a respiratory distress syndrome (RDS) which accounts for the most common cause of death in premature infants. Up to 60% of infants born before week 30 develop RDS. It is only after birth with the first cry of the newborn, that the lungs inflate with air. Thus, in forensic medicine the floating lung test is used to differentiate whether a child was born alive (lung floats) or dead (lung sinks).
__... Re.~M
Da 1 u•~toftM.....,....aptllc•..tllllfa 1201
~w.&Je
"'"',...... ~ lil'a
.... •
--
ftMI""' ~
-...
.....
.
...
..,
-
__
.......... 4 . . . . . . . . . . . II Ill' •lt.tfOI
,..,.. ...... ~"' t.rq . . . .liii'TI!Jnl . . l'tO(QIIilt:ld .tlkfrl
Jlril
• , . . , . , . . . , ......... ~7-17):ott:*"""""Ciht11Ufl~ pwt crt . . ~..... O'llrt
Sl
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Trachea and bronchi
Branchu1 prfnclpallll dexter Brondlua loberia IUptrior <1at:tr 1 ; Broflcl'ala eegmalltalla aplcalle (B ~ 2 ; Broflcl'ala eegmallta111t p-or [B II) 3 ; Broflcl'ala eegmant.111t antafor [B 110 Brondlua loberia mediua
4 ; Broflcl'ala eegmallta111t ll.tln111t (B Ill] 5 ; Broflcl'ala eegmallta111t medlalle (B V'j
Brondlua loMb lnfwfor
7 • Broflchls 84GII'IIn1111b baatlla medial Ia [B VIII Broflchls MGII'IIn1111b baatllaiii'RII'ICr [9 Vl10 S • Broflchls MGII'IIn1111b baatllaiiWIIb [B llQ 10 ; Broflcl'llaeegmatm~11a~a.Jie~(B>CI
a•
Branchu• prfnclpalle elnleter Brondlua loberia IUptrior liniiW
1, 2; 3 ; 4 ; 5 ;
Broflcl'ala eegmallta111t apll:(lpoltafor (B 1+10 Broflcl'ala eegmatm~111t antafor [B 110 Broflcl'alal~~gl.f- •ul*for [B 1V'j Broflcl'alal~~gl.f- hfafor (B V'j
Brondlua loberia inferior linilller 8 ; Broflcl'ala eegmant.111t •ul*for (B VI)
8 ; Broflcl'llaeegmatm~11a~a.Jie-[BVII~ 8 ; Broflcl'ala eegmant.111t ~a.Jie ll.tlnlllt (B IX] 10 ; Broflcl'llaeegmallta11a~a.Jie~(B>CI
a
10
Fig. 5.50 Lower resplr«tary tntct wtth l1rynx. lArynx. trlch"' TriCh. . and bronchi, Bronchi; ventral view. The Trachea is 1o-13 em lang end extends from the cricoid cartilage of the Larynx to its division (Bifureetio tracheae) into the two main (primary) bronchi !Bronchi prfnc_,llesl. The Trachea is organised in a ceNieel pert (Pars ~Nicalis) end a thoracic part (Pars thoracice). Projection and topography ere described in ~ Fig 5.43. The main bronchi further divide in three and two lobar bronchi tBronchi lob1ra) on the right and left sides, respectively. The Iober bronchi give rise to the segmentlJI bronchi tBronchi MJmentlln). The right lung has 10 segments end, thus. 10 segmental bronchi. In the left lung, however, segment 7 end the re9pective Bronchus ere missing.
The more detlJiled systematic description of the bronchial tree is not illustrated here. The bronchi further dillide six- to twelvetimes before oontinuing as bronchioles. lranchloles have a diameter smeller than 1 mm end lack cartilage end glands within their wells. Each bronchiole is associated with a pulmonary lobule (Lobulus pulmonisl and further divides three- to fourtimes before oontinuing es terminal bronchioles !Bronchioli ~ermlnlles). These represent the last segment of the err conducting p1~ of the respiratory system which has a volume of 15o170 mi. Each Bronchiolus terminelis opens into a pulmonary acinus 1Acinu1 pulmonil) which generates 10 edditionel generations of Bro~ chioli respiratorii with Ductus end Seco.~li elveolares. All parts of the acinus contain alveoli end, thus, the ecinus belongs to the gas-exchanging pert of the respiratory system.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The volume of the air oonducting part of the respiratory system 1150-170 ml) is equivalent to the 1natomical dMd-IPICII end has en important practical relevance for resusltdon. During ventilation the volume of oxygenated air needs to ex~ed 170 ml to effectively
32
reach the alveoli end avoid just moving the air column within the conducting part. Thus. artificial ventilation is more effective when performed slower with larger volume then with high frequency and smeller volume.
Thymus
-+
Topography
-+
Sections
Structure of trachea and bronchi
10
Fit. 5.51 Lower rfllliratory tract with llrynx, Larynx, trachea, 'lhlch.., and bronchr, Bronchr: dorSill view. The systematic ~mposition of the bronchial tree is described in -> Figure 5.50. The dorSill view dearly shows that the dorSill walls of the Trachea and the main bronchi do not ~nsist of cartilage (Paries
membranaceus) but predominantly of smooth musdes (M. trachealis). The incomplete trecheal eartileges ere connected by Ugg. enularie. Th&se comprise elastic connective tissue and enable the elongation of the trechea for up to 5 em during deep inspiretion.
Fig. 5.52 Trachea, Trachee; cross-section. microscopic view. The wells of the trechea end the main bronchi comprise e mucous membrane (Tunica mucosa) on the luminal side followed by the Tunica fibromusruloeartilaginea and the Tunice edventitie. The Tunics fibromusculocertilaginee consists of 16 to 20 horseshoe-shaped incomplete trecheal certilages of hyaline certilege, which ere bridged posteriorly by a smooth muscle IM. trachealis).
33
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
Lungs
Fit. 5.53 and Fit. 5.54 Rltht lunt. Pulmo claterl-. Fit. 5.51), and left lung, Pulmo slnr.t.r 1-. Fig. 5.54): lateral view. The right lung has t hree lobu (Lobi superior, medius end inferior) which ere sepanrted by the Fistura oblique and the Fissura horizontalis. The left lung has only two lobes (Lobi superior and inferior) separated by the Fissura oblique. The Ungula pulmonis of the superior lobe is equivalent to the middle lobe of the right lung and forms a tongue-like extension inferior to the Incisura cardiaca. The volume of the right lung encompasses 2-3 I, during miiXimal inspiration even 5-8 I. Thill volume ill equivalent to a gall exchange area of 7G-140 m2 . Due to the left~hifted position of the heart the volume of the left lung illllmaller by 1G-20'11.. The apex of the lung !Apex pulmonisl is cranial pa rt, the broad bue of the lung (Basis pulmonisl is the caudal part of t he Iung. The su rfaee of t he lung it covered by t he Pleura visceral is end haslhree surface alignments. The Facies COitalill is located laterally and continues at the Margo inferior as the Facies diaphregmetica (-.Figs. 5.55 and 5.58). At !he Margo anterior and !he blunt Margo posterior it continues as the Facies mediastinalis towards the Mediastinum.
M111110 1/!Wicr --~:( uowa~--~~~~~~n~
Mqo pooartor
5.54
34
~
Thymus -+Topography -+ Sections -+
Lungs
l..ig. pwh
5.55 Fit. 5.55 •ncl Fit. 5.545 Ritht lunt. Pulmo dexter C... Fit. 5.551. and left lun1. Pulmo tinilter C... Fit. 5.56); medial view. The Hilum pulmonis is the medially positioned entry for the main bronchi and the neurovasQ.IIar structures to the lungs, which together are referred to as the root of the lung (Radix pulmonis). At the hilum, the Pleura "isoeralis is blends into the Pleura pariatalis and both parts line the pleural C~.Nity. This pleural fold extends inferiorly into the Ug. pulmonale. The topographical orientation of the main bronchi in relation to the great blood wssels at the hilum of the lung is different for both lungs. At the rftht l11n1. the Bronchu1 prfn· cip1li1 is the mMt tuperior structure and the Vv. pulmonales are positioned anteriorly. In contrast, the main bronchus of the left lung is positioned below the A. pulmonalis. When dissecting the root of the lung, the hilum frequently shows sewral lymph nodes (Nodi lymphoidei trachaobronchiales). which are normally black due to deposits of carbon dust. The Facies mediastinalis is cone~Nwhaped (more pronounoed IJt the left side) by the heart (lmpressio cardiace). Both lungs show impressions which are caused by adjacent blood vessels or. on the left side. the oesophagus. These impressions nioely demon· strate the topographical relations of the lungs to neighbouring organs but they are, similar to the margins of the lungs, only apparent in the fi>Ced lungs (fixation artefacts).
Hlum pulrnorb
Mll'I)O inflrior
5.56
A . . . . obllqUII
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The apex of the lung extends up to 5 em above the laval of the superior thoracic aperture. Thus. with plaoement of a ctlfltrll venoUI cattt.ter (CVC) via the V. subclllllia, injury to the lung may oceur and acadental injury of the ceNical pleura mey cause a pneumothoro: with resulting collapse of the lung. But in catheterisation of the V. jugularis intema IJt the neck there is also a risk of pneumothorax
since during this procedure the catheter is directed towards the stemocla-,icular joint near the apex of the lung. But this risk is much since the latter directly higher when using the subclavia for a contacts the Pleura ( .... Fig. 5.99) before continuing as V. brachiocephalica.
v.
eve
35
Thoracic Viscera
Heart
-+
Lungs
-+
Oesophagus
-+
Bronchopulmonary segments
5.57
Pulmo dexter
Pulmo sinister
IAbua superior
Lobus superior
-
Sag mentum aplcale [SO
-
Sag mentum poster1us ISII]
-
Sag mentum anterlus [Sill]
:
!Abu• mediu• -
Segmentum latorale (SIV]
-
Sag mentum madlala [SV]
+ II]
-
Sag mentum anterlus [Sill]
-
Segmentum lingulare superius (SIV]
-
Segmentum lingulare inferius (SV]
Lobus inferior -
Sag mentum superlus [SVI]
lAbus inferior
-
Segmentum basale anterius (SVIIO
-
Sag mentum superlus [SVI]
-
Segmentum basale latorale (SIX]
-
Segmentum basale mediale [cardiacum] (S VIO
-
Segmantum baaala poster1usiSX)
-
Segmentum basale anterius (SVIIO
-
Segmantum baaalalatarala [SIX]
-
Sag mentum baaala poster1usiSX]
Fig. 5.57 and Fig. 5.58 Bronchopulmonary segments, Segmenta bronchopulmonalia, of the right lung 1-+ Fig. 5.57) and the left 1-+ Fig. 5.58) lung; lateral view. The lobes of the lung are organised in cone-shaped lung (bronchopulmonary) segments which are incompletely divided by septations of connective tissue. The segmental borders are not visible on the surface of the lung. The lung segments are associated with segmental bronchi and segmental branches of the pulmonary artery. The right lung
36
} Segmentum apicoposterius (SI
has ten segments, three in the superior, two in the middle, and five in the inferior lobe. The 111ft lung only has nina segments since segment VII (Segmentum basale mediale-+ Fig. 6.69) on the left side is missing or drastically reduced and fused with segment VIII due to the larger extension of the Mediastinum. The organisation of the other lung segments is similar on both sides since the segments of the middle lobe of the right lung are equivalent to the two segments of the Lingula pulmonis in the left lung.
Thymus
-+
Topography
-+
Sections
Bronchopulmonary segments
5.51 Fit. 5.59 and Fit. 5.10 Bronchopulmonary sqmarmt, Segment• bronchapulmonalfa. of 1he rfght lung t ... Fig. 5.51) ~md 1helelt t... Fit. 5.60) luno; medial view.
5.60 The right lung hBll ten segment!. The left lung only hat nine tegments; segment VIIISegmentl.lm bas ale medialel is missing.
Fig. 5.61 Bronchi, Bronchi; brond'losoopy showing the segmental bronchi of the left side. It is apparent that the segmental bronchus VII it missing on the left side!... Fig. 5.60).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The knowledge of the lung segments is crucial for orientation during bronchotle'Opy. A bronchoscopy is performed if radiological imaging revealed a suspicious nodule and biopsies are needed to rule out
or diagnose a tumour. Another indication for brond'losoopy is to a<> quire material for pathogen identification in cases of drug resistent pneumonia.
37
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Blood vessels of the Lungs
BRinclllclue tarmlnalllt
r ..1
Fig. 5.12 Acinu• of itt• lung, Acinu• pulmoni1, wittl blood
vftHI,. The lung hBll two blood vBSsel systems whid1 communicate through their terminel brenchBS in the well of the elveoli lelveolar septlJ). The Aa. pulmonaiBS and Vv. pulmonales of the pulmonary circulation constitute the Vu• p~IIC41 which serve for the gas exd1enge of the blood. Brand1es of the Aa. pulmonaiBS course in the peribronchial and su~
pleural connective tissue and transport the deoxygenated blood from the right heert to the elveoli. The Vv. pulmonales are loceted in the i~ tersegmental connective tissue and transport the oxygenated blood to the left atrium. The V•u prMat• of the lung suppy the lung tissue itself. The arterial Rr. bronchieles end the Vv. bronchieles course together with the bro~ d1i.
A.lntGR:OIItalllt-lll
Fig. 5.13 V••• privata of the lung; dorsal '.liew. The erteriel Rr. bronchiales derive directly from the Aorta thoracica on the left side, but usually branch off the third intercostal artery (A. intercostalis dextre Ill) on the right side. The Vv. bronchieles drein into the azygos system (not shown here).
38
Thymus
-+
Topography
-+
Sections
Lymph vessels and lymph nodes of the lung
Flg. 5.84 Lymph VftHI,, Vaa lymph~lc.. ~md lymph nodel, Nodi lymphoiclti, of tiM luna; ventral view; schematic illustration. The lung hes two lymph vessel systems which converge et the hilum. The peri'bronchill ~m follows the bronchi and feeds into several lymph node stetions. The first stetion era the Nodi lymphoidei intrspulmonales at the transition from Iober to segmental bronchi. The second stetion comprises the Nodi lymphoidei bronchopulmonales et the hilum of the lung. The subsequent Nodi lymphoidei trecheobronchieles are loarted elresdy at the root of the lung. Nodi lymphoidei trecheobronchieles superiores and inferiores are distinguished according to their loca-
lion ebove end below the trechesl bifurcetion. From here the lymph passes on to the Nodi lymphoidei paretracheeles or to the Trunci bronchomedisstinales on both sides. Thus, there is no strict separetion of the lymph drainage from the different sides. The tlllbpiiiUI'II and the ,.WI lymph spttlfll drein into the Nodi lymphoidei trecheobronchieles as the first station. Their delicate lymph vessels form a polygonal network at the surfeoe of the lung. This network represents the boundaries of distinct pulmonary lobules. Due to cerbon dust deposits {exhaust fumes end cigerette smoke) these lymph vessels end the boundaries of the pulmonary lobules ere dearly visible.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Clinicians usuelly summerise all lymph nodes of the lung with the term hi11r lymph nocln. However, this disregards the fact that the Nodi lymphoidei intrepulmoneles ere loceted deep within the lung parenchyme. This linguistic blurring may entail the misinterpretation
of parenchymal processes es separate disease entities end neglect
the association with lymph node enlargement which may initiate unnecessery diagnostic procedures.
39
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Lungs and pleural cavities
V'l. t:nc11locllphallcee
\( 1110111Qea IMWIII
AparQnam ntymue
~VI)micum)
Pllunl. pe.rillda, IWII colllalil
tllnht4r, I.Cbus aul*fcr
Pllrnc>4UIW, MII80 ai'UI1cr
ll'llllgo•m-
(1'lfaorNn ~cum)
r
SUJ)II'Icr
Nrno do.tllr IJ:Ibue 11144ue
lnciiLn catdlaca
lnflrlclr
Ungula pjlmCIIII "*no tllnhtw,
Pl-pe.rilld..
P. . cliqflrqmllti<:e
Lobuall'lwfcr
A-
ll'llllgolnf-
C08tocii~Ffnall'll.ticu8
Fig. 5.65 Lung•, Pulmon-. •ncl pleuNI caviti•, Cavitftell pleur•les, of •n •dolesant; ventrlll ~ew; efter remove! of the enterior thorecic well. The pleurel ce~ty IC.VItu pleuNIIs) is covered by the parietel Pleura (Pleura parietelill). The parietal Pleura ill di~ded into Pars mediastinelis. Pers costelis, end Pars diaphregmatice. The ~scerel Pleure IPieure 'VI• ceNiil) C<~¥ers the outer surface of the lungs. The capillary space between both pleurellayers conteins 5 ml of e serous fluid which lubricates the pleural surfaces and reduces friction during breathing. The pleural Q.lpule IC"'ula pleureel extends up to 5 em ebove the superior thorecic aperture. The superior end inferior medial borders of the Pleure form the boundaries of the Trigonum thymicum and the Tri-
gonum pericardiecum, respectively. The pleural cavities possesses four pleurel recesses (Recessus pleuralesl into which the lungs cen expand during deep inspiration:
• lhcnsu1 coltoc5•phr•gmeticus: lateral, in the midexillery line up to 5 em deep
• Recessus coltomeclaltln•lls: ventral. to both sides of the Mediastinum end chest wall
• Recessus phrtlfllcomecllatln•lls: caudal, between diaphragm end Mediastinum
• Recessus vertebromedlaltl'nalls: dorsal. adjacent to the vertebral column 1-> Fig. 5.104)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Increased fluid in the pleural cavity tpleural tffulion) may be ceused by inllemmetory reactions in pneumonia !pleuritis), by congestion in the pulmonary circulation due to a (left) ventricular insufficiency, or by tumours of the lung or the Pleura. In addition, there ere chylous pleural effusions if lymph from the Ductus thorecicus
enters the pleural c~ty. Pleural effusions cause a dull percussion sound. Diagnostic puncture of a pleural eHusion from the Recessus costodiaphregmetiCIJs is performed to sample fluid for diagnosis and to improve bresthing.
Thymus
Topography
-+
-+
Sections
Thoracic viscera, radiography
B~IIO U11C:114oae
An:ue-
Bronclsla pmc\:IIIJia daxtw
1l'lrlcue putmontll8
\Lpumonalllt V.pllrncnal8 Bnlnctlue pfndpela llrfltw
Nodi ~holdal bnlnctlopulmoi'talae*"
All'tcu• alnlltnl
Bnlnctll
V.pllrncnal8 VWI1rlcUal$ 8l'lf81W
Alnlm-&.m \L putmontll8
" Dlap!ngma, tcUPIII atli911'1)
" Dlap!w'qm•. (C&Ipula-J
RacaNue CX>Iti:>
Fig. 5.H Thoracic cqe, Cav• thoracil, with 1ttoracic vitcera; radiograph in postero-anterior !PAJ beam projection. [271
The course of the bronchi is partly '.lisible. On the right side, clusters of lymph nodes in the ares of the hilum of the lung are visible. •
*"
contour of the breast !mamma) clinical term: hiler lymph nodes
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Chest radiographs are frequently taken if pdlolotfcal p~ of the lungs or the pleura are suspected, such as inflammations (pneumonia, pleuritis) or tl.lmours !bronchial carcinoma). Parenchymal alterations are often present as "shadows• because they absorb mora
of the radiation than the intact lung tissue. In the upright position, a pleural affusion blunts the Recessus costodiaphragmaticus and forms a horizontal fluid level.
41
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Projection of the oesophagus
r----------~~~
Fig. 5.67 Overviftv of the cl'anti've tract. The Oesophsgus is s musrular tube connecting the Pharyn)( with the stomach {Gaster). It transports the ingested food.
Fit. 5.61 Projection of itt• Onophqu• onto the vantralitloracic wall.
The Oesophagus is 25 em long and originates at the cric
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The projection of the Oesophagus explains why an inflammation of the oesophageal mucosa by gastric scid reflux Cgatro-Colnopha· teal Nlfl~.~~t di...M, CIERD) causes a retrosternal burning sensation end psin st a similar location ss s myocardial infarction. Afferent nerve fibres from both organs and the ventral chest wall converge
42
at the same spinal cord segments. The brain cennot differentiate whether the pain originates from interns! organs or the body surfsoe. These organ..essociated dermatomes are referred to as HEAD's zones, the phenomenon is celled "referred pain".
Thymus
-+
Topography
-+
Sections
Oesophagus
A. ctr0t1t com!nlnl8
-
F0111menW!"
5.19
Flg. S.et and Flg. 5.70 OesophiQIIS, Onophqu,, tntch... Trachu, and 1ttoracic aorta, Pa11t thoNCic. aortae; ventral view (-o Fig. 5.69) and view from the right side (-o Fig. 5. 70). The Oesophagus is25 em long end is organised in three parts: • Pars oervicelis {!HI cml • Pars thorecice {16 em) • Pars abdominalis 11-4 em)
5.70
The P111t cervlcalls is adjacent to the vertebfl.ll column. The Pa11t1ttoracica crosses the aortic arch which is adjacent on the dorsal left side. This part runs along the left main bronchus end descends ventfl.llly with increasing distance to the vertebral column. The dorsal view shows the close prolCimity of the Pars thoracice to the Pericerdium end to the left atrium {-o Fig. 5.71). After traversing the Hiatus oesophegeus of the diaphragm, the short intreperitoneelly loceted Pan abclomlnlll' begins.
43
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Structure of the oesophagus
A. cti'C$ communis
1hlneue brectllocaphallcu •
Fig. 5.71 Onophqul, Onophagul, perica,..um, Pericardium, and ~horacl'c aorta. Pan 1horacfca aorue: dorsal view.
Fig. 5.72 Strueture af ~h• wall of 1h• onophqu1, O..aphaeu•: microscopic view. Similar to the entire gut, the wall of the Oesophegus consists of a luminal mucous membrane (Tunic. muc01a) which is separated from the muscular layer 0\lnfc. muHUiarftl by e loose connective tissue layer (Tela tubmuco.). The Partes ceNicalis end thorecica ere covered by the 1\lnfc. advtln~Mia. The outer surfeca af the intreperitoneal Pers abdominelis is covered by visceral peritoneum (Peritoneum viscerale) which constitutes the 1\lnfc. HrOSa.
44
The caudal part af the Pars thoracica of the Oesophagus is separated from the left etrium only by the pericardium.
Thymus
-+
Topography
-+
Sections
Constrictions and diverticula of the oesophagus
Fif. 5.73 Conetriction1, AntultiH, of1tt• Oaophatua; ventral view. The Oesophagus has three constrictions: • cervical constriction at the criooid cartilage {Angustia criooidea; pheryngO.()Gsophegeal constriction) • thoracic constriction at the Aorte {Angustia eortica; aortobrondtial constriction) • diaphragmatic constriction {Angustia diephragmatice) The cervical eonltrldlon has the smallest lumen end is located at the level of the upper oesophageal sphincter end the 6th oervicel vertebre. The thoracic conetriction is created by the direct proximity of the aortic er<:h from the left end dorsal side {level of the 4~ thoracic vertebra). The dfi!Phragmdc conltrfctfon lies in the Hietus oesophegeus Oevel
Fig. 5.74 Diverticull of 1f'l• Onoph-.ua; view from the right dorsal side. •
dinical term: ZENKER's diverticulum dinicel term: traction diverticulum •• • dinical term: epiphrenic diverticulum
*"
of the 1()'II thoracic vertebra). There is no true sphincter muscle but en angiomuscular mechanism that acts like e velva under extension (lower oesophageal sphincter, LES). Elastic connective tissue llig. phrenicooesophegealel etteches the outside of the Oesophagus to the Hiatus oesophegeus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Swallowed fo..-ign bodin (e.g. fish bones) may gat stuck at the oesophageal oonstrictions. True diverticula {outpouchingsl of the enlire oesophageal wall may occur at several locations. ZENKER'• divtll1fcuiii70'Yol ere most common. These diverticula bulge through the KILLIAN's triangle of the hypopharyngeal muscles end are wrongly categorised as oesophageal diverticula. Responsible for these diverticula is a defective relaxation of the inferior pharyngeal con-
strictor (Pars cricopharyngea). TNCtion c5verticul• (22%) are Mtrue• diverticula and involve the entire oesophageal well. They ere either caused by incomplete separation between Oesophagus end Trachea during development {.... Fig. 5.481 or thy result from inflammatory reactions involving adjacent structures. Ep.,hr«tic diverticul• (8%) are believed to be evoked by e disturbed function of the engiomusculer lower oesophageal sphincter.
45
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Blood vessels of the oesophagus A. thyraldMinfwtor, Rr.~....
Acommurfa daxtrll
Fig. S.7S Arterln of 1he Onaphqus; ventnJI ~ew. The different parts of the Oesophagus ere supplied by surrounding arteries: • P1rs cenfctlls: A. thyroidea inferior • Ptrs1hor.cfct: Rr. aesaphagaeles of the Aorta • P1111111Ciomintlis: A. gastrica sinistra end A. phrenice inferior The arterial and venous supply of the Trachae is equivalent to the blood vessels of the cervical end thoracic parts of the Oesophagus.
Fig. 5.76 Veint of tiM OHOphqul, Vv. onaphque; ventral view. The complex venous network of the Tunica adventitia drains into different veins: • P1111 cervicllit:: V. thyroidae inferior • P1rs 1hor.cfC41 and P1rs lbdomfntlls:: via V. ezygos and V. hemiazygos into the V. cave superior The inferior parts gain 1cens to the portll venous system via the gastric veins N. gestrice sinistra). These veins may be utilised as portoCOli IRiftomons with increased pressure in the portal vein {portal hypertension) (-t Fig. 5.77).
,,,.,.,..
V.g~l8
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In cantrest to ather organs of the gastrointestinal trect, the Oetophtgul has no cfeclicated 1rterin but is supplied by blood vessels
46
from the surrounding organs. This has implications for surgical procedures end poses challenges to oesophagael surgery.
Thymus
-+
Topography
-+
Sections
Veins of the oesophagus
V.l!em~
... ~Ill}
\L plnnlce lmrtor
\L asva lrlfwfor
Fig. 5.77 Vein• of1tae oe10phagU1, Vv. onophageH, with lllustnatlon of the portocaval a natomOMS between portal vein. V. portae hepatil, and V. cava lllfUrrior; ventral view. The extensive venous network in the Tunica adventitia is connected to the submucosal veins (Plexus venosus submucosus). The blood dreins
via V. azygos {right side) and V. hemiezygos (left side) upwards to the V. cave superior. The lower parts of the Oesophagus also connect to the V. portae hepatis via the veins at the lesser curvature of the stomech IV. gastrice sinistrel.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . If pressure in the portal venous system increases fporal hyperttlfl· lion), e.g. due to increased liver parenchymal resistance {cirrhosis of the liver), the venous blood is redirected to the Vv. cavee superior end inferior vie portocaval anutom01e1. Clinically, the most important portocaval anastomoses are the connections of the Oesophagus to the gastric veins. This may result in dilations of the
oesophageal submucosal veins !onophaaMI varfces _., Fig. 5.81 ). Rupture of these varices is associated with a mortality of approximately 50'Yo and is, thus, the most frequent cause of death in patients with liver cirrtlosis. Rupture into the lumen leads to the accumulation of darkened blood in the stomach, the rere external rupture results in bleeding into the peritoneal cevity.
47
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Lymph vessels of the oesophagus
v.eavu~
Noeli IJmpfloidei ttadleIChiiiM . . . . , . _ \i.IZYIJO$
Fig. 5.78 Lymph nodn. Noclllympholdlll. of ~he pofttlrfor meclilftinum; dorsal view. The lymph of the Oesophagus drains into the lymph nodes directly edja~nt to the Oesophagus !Nodi lymphoidei juxtaoesophageales): • P1n ctnlcllls:: Nodi lymphoidei oervicales profundi
• P1n thortclc. and P1n tbdamlntlls:: lymph nodes of the Media$tinum !Nodi lymphoidei mediastinales posteriores, Nodi lymphoidei trecheobronchiales end peratredleeles) end of the peritoneal ce'Vity (Nodi lymphoidei phrenici inferiores on the abdominal side of the diephragm end Nodi lymphoidei gestrici on the lesser curvature of the stomach)
Oaeophlgue, Pant-w:ale
Fig. 5.79 Lymph dNinqe of ~he Oteophtgus; ventral view. The lymph of the Pers cer'Vicalis reaches the 'lhlncus Jusullrls via the deep ~r'Vicallymph nodes. The Pars thoracica drains in two directions: the upper pert above the tracheal bifurartion drains via the mediestinel lymph nodes into the Tl"'lncu• bronchiomedintinllit; the lower part beneath the trecheal bifurcetion connects to the abdominel lymph nodes which are the regional lymph nodes for the Pars abdominalis. From here the lymph passes the Nodi lymphoidei coelieci to reach the Tl"'lncu• intatin1lis.
Oaeophlgue, Pant lhoraclcol
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The direction of lymphatic dreinage influences the location of metasteses in onophqnl 1ncl glftric ctranam11. Metastases of cercinomes of the lower oesophegus are likely to occur in the abdominal lymph nodes. Similar drainage ways appear to exist for
48
the venous blood since oesophageal carcinomas below the trecheal bifurcetion frequently cause liver metastases, whereas carcinomas ebove the tracheal bifurcation ususelly metestesise into the lungs.
Thymus
-+
Topography
-+
Sections
Oesophagus,oesophagoscopy
Fig. 5.10 Oesaphqut, Oesophagus; oesophagosoopy, nonnal finding. [12)
Fig. 5.11 Oesaphqut, Oesophagus; oesophagosoopy, oesophageal varioos in liver cirrhosis. [12) •
dinieal term: varioose vein
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In portlll hypel1tlfllfon. the dilation of pol1ocaval anaftomOMI involving the veins of the Oesophagus may develop into OHOphllf"l varfen. The rupture of these varices frequently results in lif•th....ttlfling bleeding I. Therefore. prophylactic treatment is per-
formed in oesophageal varices including banding ligation !endosoopic band ligation) or the endosoopic injection of sclerosing agents (sclerotherapy).
49
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Thymus
(ll'lgciflum 11!ymleum)
-fr------:--- Pllrno ar!l81w, LWU!18UI*fCI'
t--~--
Fig. 5.12 Thymut, Thymu1, meclintinum 1ncl pleur1l caviti•, Clvlt«tes pleul'll•. of 1n ldal-.rt; ventre! view; efter remove I of the anterior thoracic well. The Thymus is loceted in the Trigonum thymiQ.Im between the medie9tinal borders of the pleural CEIIIiti9ll. The Thymus is relatively large in a
50
lnciSilra ca'dlac« l)lllmcnla
young adult. In en older individual it is almost completely replaced with edipose tissue. Thus, in the dissection of enetomicel specimens only residual thymic tissue is found which i9 identified only due to smaller erterial branches derived from the A. thorecica interne or venous co~ nections to the Vv. brachiocephelicae.
Thymus
-+
Topography
-+
Sections
Thymus
Flg. 5.83 Thymu1, Thymus. of •n •clolesctlflt; Vf:lntrel "iew. The Thymus is a primary lymphatic orgen. It ser-,es for the proliferetion and selection ofT-lymphocytes which then leevtl the Thymus to settle in secondilry lymphatic organs to function in the adapti-le immune r• sponses. The Thymus dwelops from the endoderm of the third pharyngeal pouch and the ectoderm of the third pharyngeal cleft. It consists of two lobes (Lobi dexter end sinister) which co-,er the great vessels of the superior Mediastinum. Microsoopicelly, these lobes are subdi"Vidad into smeller lobules.
Fig. 5.84 Po1ition of the thymu1, Thymu1, in • "View; efter remove! of the Vf:lntral thorecic wall.
nwt~born;
The composition of the thymic tissue changes continuously during life. Since its volume remains almost the same, its relative size is larger in the newborn than in the edult I... Fig. 5.841. After puberty, the specific thymic parenchyma is gradually substituted by adipose tissue and the residual thymus is hardly "isible in elder persons. Howevtlr, functional thymic tissue remains present at all times to warrant adequate immune reections.
ventral
51
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Mediastinum
Fig. 5.16
Ors•nrs~lon
ot1h• Medlatl'num.
The mediastinum is divided into a Mediastinum inferius which ~nteins the heart, end e Mediestinum superius. The Mediestinum inferius is
fut111er divided into the Mediastinum enterius in front of the heart, the Mediastinum medium, containing the Pericardium, end the Mediastinum posterius behind the PeriQJrdium.
\L tn.chlocephlllca-
N. pln"lcue; A.; \L pGI!canUa.coptnnlal 1i'lr!CII9 tympcllllc119, ---l"!T.III/&
B: CCII'mii!ICI.n188
P'lrlaRklm flbroeu~ Plain pai!Gtllla, Pllra medillllt~a.le
Fig. 5.16 Medi11tinum 1ncl pleur1l cavity, C.vit11 pleur1li1, of 1n
41dol._.nt; view from the right side; efter remove I of the leteral thoracic well end the right lung. The ~ew from the right side demonstretes clearly the V. aygos which ascends next to the vertebral ~lumn in the Mediastinum posterius.
The V. azygos crosses the root of the right lung superiorly end enters the V. QJVS superior from dorsel at the level of the 4U>J5"' thoracic vertebrae. After brenctting off the N. vagus [)(]. the N. leryngeus recurrens winds eround the A. subde~e on the right side.
Thymus
-+
Topography
-+
Sections
Mediastinum
N. wgua [XJ, R. a.Rllllcue thoraclcue
Nodllymphok!Gitrecl1ao!Rrtehllllaa
V. hwnluygoe A:; \L ll'bRDI1alla ~ N.~Oitalla
~~*~~~~~~r,g{
·~minot'
A.pwtc::.rdht~c:.
Fig. 5.87 Mecliutinum and pleural cavity, Clvita pleur1li1, of an •cloletetlflt; view from the left side; efter removal of the leteral thoracic wall and the left lung. The view from the left side demonstretes dearly the Aorta thorecice which descends on the left side of the vertebral column in the Media• tinum posterius. The V. hemiazygos ascends on the laterel espect of the vertebral bodies end drains ino the V. azygos at the level of the thorecic vertebree 10111 to 7"'. Frequently, the V. hemiazygos commun~ estes with the V. hemiazygos eccessorie which collects the blood from the superior intercostal veins.
Further lateral, next to the heeds of the ribs, the ganglia of the Truncus sympathicus ere positioned which brench off the N. splanchnicus major end theN. splanchnicus minor. TheN. vagus (X) descends behind the root of the lung next to the Oesophagus after releasing the N. laryngeus recurrent. On the left side. the N. laryngeus recurrens winds around the sortie arch. The Mediastinum medium herbours the Pericerdium end the adjacent N. phrenicus accompanied by the V6lla pericerdiacophrenica. In the Mediastinum superius the Thymus covers the great vessels ventrally.
Contenb of the Mecli..&num luperiu• • Thymus • Trachea • Oesophagus • Aorte and Truncus pulmonelis • Vv. brachiocephalicae end V. cava superior • Lymph vessels: lymphatic trunks (Ductus thorecicus, Trunci bronchiomediastinalesl and mediastinal lymph nodes • Autonomic nervous system (Truncus sympathicus. N. vagus [XJ with N. laryngeus recurrensl • N. phrenicus
Meclf..,num •nterfut: retrosternallymph drainege of the mammary gland • Mecli..ainum m_.um: pericardium with great vessels, N. phrenicus end Vasa pericerdiacophrenica • Mecli..ainum ~rius: Aorta, Oesophagus with Plexus oesophegeus from theN. vagus, Ductus thoracicus. Truncus sympathicus with Nn. splenchnici, V. azygos end V. hemiazygos end intercostal neur0V81cular structures
•
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
N. phrenicus
A. C8l1ltte comrnmte N. v.gua p(j T-~~-~-iN.IIIIyflgauanac~.m~ne
\1. lnc:IIIOQiphtllea sfniSOll PUtmo dutw, I.Cillls a~r!Cir
- -+- -IJ.:......(oiiA'I
H>tr-~--.-- A. tllonlclce · -
'i'!-;:-;;~-:-"~~!Y.fHjf---- Pllmo alnllltQr,I.Cillla al.plli1Cr N. wgua (X), Rr. ~lacltllor8clcl
N. plntllc:Ua N. Plnfllc:Ua
Pumo 41X!w, Lobuatl'tlrlor
Fig. 5.18 Midcle mMintinum; ventral view; after removal of the ventn~l thoracic well, the lungs were dissected in the frontal plane.
Fig. 5.19 CourM of the N. phrenicul. The N. phrenicus originates from the spinal cord segments C3 to C5 (predominantly C4l of the Plexus ~rvicelis and descends on the neck anterior to the M. scalenus anterior {guiding musdel). Next the phrenic nerve courses anterior to the root of the lung and des~nds together with the Vasa periQJrdiacophrenica between the PeriQJrdium end the Pleura mediestinalis to the diaphragm. The N. phrenicus provides motor innervation to the diaphragm end sensory innervation to the Pericardium {R. pericerdiacus), the Pleura diaphragmatice, end the Peritoneum parietale at the abdominal side of the diaphragm {Rr. phrenicoebdomineles). The Rr. phrenicoabdomineles also convey sensory fibres to the Peritoneum viscerele on liver end gallbladder.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The developmentally based course of the N. phrenicus has important clinical implications in cerviQJispfnal eord lnJurlelltetreplegia). Injuries of the spinel cord below C4 do not compromise breathing, whereas injuries involving segment C4 bear the risk of suffocation end may require assisted ventilation.
54
Sensory innervation of the liver and pllbladcfer by the Rr. phrenicoebdominales may cause rtrferrM pafn In the rftht shoulder !e.g. in liver biopsies. inflammation of the gallbladder). Similarly. ruptures of the spleen may QJUse referred pain in the left shoulder.
Thymus
-+
Topography
-+
Sections
Aortic arch
A. vertabf'IIIU~IIIIa A. eetOtia commlrill linillln.
Fit. 5.90 HMrt. Cor, and aol1fe arch, Arcus aorta, wMh bnlnchlne of 1he treat v.,.,.lt; ventre! view. The Pars ascendens aortae continues as the aortic arch which ill co~ neeted to the Truncus pulmonalis vie the Lig. erteriosum. The aortic arch continues with the descending part {Pars daseandens) of the Aorta thoreeicl.ll .... Fig. 5.921. The sortie ereh has the following branches: • Truncus brachiocephalicus (right side) which divides into the A. subelavia dextre end A. cerotis communis dextra • A. cerotis communis sinistre • A. subd811ia sinistra
Alrklm dutnlm
•13,...
..;,.-.
7Q,.-.
A.CIIIottelntllrM81rfllla
A.
A. •ubclallllllnlltnl
A. aubclallll ~n191!11
Flgs. 5.t1a to • Br.nchtne varf.tlons ot1h•sre.t ,...,, tram the aortic arch.
a "textbook case• b common origin ofTruncus brachioeaphalicus end A. carotis communis sinistra e common stem for Truncus brechiocephelicus and A. cerotis communis sinistra d independent branching of the A. vertebralis sinistra off the Arcus eortae
,.,,...
<1"
• brenching of the A. subclavia dextre as the last brench of the Arcus aortae. This unusual artery mostly courses behind the Oesophagus to the right side end may cause problems with swallowing !dysphagia lusorie). The existence of en independent A. 1hyroldea lma coursing to the thyroid gland is uncommon. When existent, it either derives from the Truncus breehiocephalicus ores a second branch from the sortie arch.
55
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Arteries of the posterior mediastinum
111mcue~lcue, ~lion
N. ~lllChi'KUS miner
Fig. 5.92 Aorta •ncl it. bNnchn; ventral view onto the posterior wall of the trunk. The Pars dascendens of the Aorta descends in the Mediastinum posterius {Pars thoracica) and traverses the diaphragm {Pars abdominalis).
PeriNI brench•
• As. intarcosteles posteriores: 9 pairs (the first two era
to the wall of the trunk
branches of the Truncus costooervicalis from the A. subdavia • A. subcostalis: the last pair below rib XII • A. phrenica superior: to the upper side of the diaphragm
VIHer•l brenches to the thoracic visoera
• Rr. bronchiales: Vasa privata of the lung {on the right side mosdy from the A. intercostelis posterior dextre Ill) • Ar. oasophageales: 3-6 branches to the Oesophagus • Rr. mediastinales: small branches to Mediastinum and Pericardium
Thymus
-+
Topography
-+
Sections
Veins of the posterior mediastinum
Mm.~~l
Nn. U!cnlclcl, Nn.lnta-lae
Yv.i~
polhri-
A.;Y.~•
Fig. 5.93 Vein• of 1tte azy101 ~m; ventral view onto the
hemiazyg01 RC8110ri8. Beneath the diaphragm, the V. lumbalis as-
posterior well of the trunk; after removal of the diaphragm.
cendens on eech side continues the course of the ezygos vein end
The azygos system connects the Vv. cavae superior and inferior and its tributeries ereequivelent to the branches of the Aorte. The V. azysos ascends on the right tide af the vertebral column end drains into the V.
1\'lbutarfes:
cave superior from dorsal on the level of the 4"'J5'1' thorecic vertebrae.
The equivalent blood vessel on the ltft 1ide is the V. hemiazygo1 which merges with the V. ezygos at the level of the thoracic vertebree "ff' to 1Qth. Blood from the upper intercostal veins drains into the V.
connects to the V. cava inferior. • Vv. mediastinales: from the mediastinal organs (Vv. oesophageeles.
Vv. I:Jronchiales, Vv. pericerdieceel • Vv. intercosteles posteriores and V. subcostalis: from the posterior well of the trunk
57
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Nerves of the posterior mediastinum
N.~-
N. \'IIQUSPQ, AI llfellctllll..
1Nic.a8Y'"pe.tllli:ue, Rr. commul'llcant•
o.cptque, Pso1tal:uiomt11la
Dllplwqma
Fig. 5.94 Nlll"'lft of 1he posterior mecllatfn11m; ventre! view onto the posterior wall of the trunk; after removal of the diaphragm. The posterior mediastinum contains the intercostal nerves {Nn. intercostales) of the somatic nervo111 tlyatem and parts of the sympathetic {Truncus sympathiQJS) and parasympathetic systems INn. vagi) as components of the 111tonomic nervo111 t~yatem. The aympatttetic trunk {Truncus sympathicusl forms a paravertebral chain of twelve thoracic ganglia which ere connected vie Rr. interganglioneres. The preganglionic sympathetic neurons are located in the lateral horns !C8 L3) of the spinel cord end exit the vertebral canal with the spinal nerves. The Rr. communicantes albi guide the preganglionic fibres to the ganglia of the TrunQJs sympathicus where they are synapsed to postgang-
58
lionic neurons. A>cons of the postganglionic neurons join the spinal nerves and their branches again via the Ar. communicantes grisei. Some pregan-glionic fibres are not synapsed in the ganglia of the sy~ pathetic trunk but continue as Nn. splanchnici major and minor to the nerve plexus around the Aorta abdominalis where they eventually sy~ apse. The preganglionic fibres of the Nn. viti course behind the root of the lung adjacent to the Oesophagus and form the Plexus oesophageus. The latter is the origin for the two vagal trunks {Trunci vegales anterior and posterior) which traverse the diaphragm together with the Oesophagus to reach the autonomic nerve plexus of the Aorta ebdominalis. However, synapses to the postganglionic parasympathetic neurons mostly OCQ.Ir in doser proximity to the respective target organs.
Thymus
-+
Topography
-+
Sections
Lymph vessels and lymph nodes of the mediastinum
Nodllympl!ol®l ~lglllal
Flg. 5.95 Lymph VftHI1 •nd lymph nodn of 1he meclu"n11m: '1/iew from the right ventrolateral side after removal af the lateral chest wall. {according to [21J The Mediastinum harbours several different groups of lymph nodes which are categorised into parietal lymph nodes {drainage of the wall of the trunk) end visceral lymph nodes (drainage of the thoracic viscera). These drain into the large lymphatic trunks. P•rimllymph nocln: • Nodi lymphoidei paresternales: on both sides af the Sternum. They drain lymph from the anterior chest wall, the mammary glands and the diaphragm into the Truncus subclavius. • Nodi lymphoidei intercostales: bl:ltWI:len the heads of the ribs. They drain lymph from the posterior chest well. Their efferent lymph vessels drain directly into the Ductus thorecicus. VilceNIIymph noda wittl connection to 1he Trunci bronchomodi· •ftln•ln: • Nodi lymphoidei mediastinales anteriores: on both sides of the great vessels, tributaries from lungs and Pleura, diaphragm {Nodi lymphoidei phrenici superiores), heart and Pericardium (Nodi lymphoidei pericardiacil, and Thymus.
Nodllympl!ol®l parlcatdla.cl
• Nodi lymphoidei mediastinales posteriores: at bronchi and Trachea (Nodi lymphoidei tracheobronchiales and paretracheeles) and Oesophagus !Nodi lymphoidei juxtaoesophageales) Lymphatic trunkt:: The Ductus thoracicus traverses the diaphragm anterior to the vertebral column(-> Fig. 5.93) and ascends in the Mediastinum posterius, first behind the Aorte then behind the Oesophagus, to reach the 71' oervical vertebra. Next, the ductus crosses the left pleural cupula and opens into the left jugular-subclavian junction af veins from dorsal {between V. subdavia and V. jugularis interne). Shortly before draining into the jugular-subcla'olian junction, it collects the lymph af the Truncus bronchioMediastinalis sinister. which courses independently in the Mediastinum, the Truncus subcla'olius sinister !from the arm), and the Truncus jugularis sinister (from the neck). On the right side, a short (1 em) Du1> tus lymphaticus dexter connects the respective lymphatic trunks and enters the right jugular-subcla'olian junction of veins.
59
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Superior thoracic aperture
Truneua inferior f"au• brachillia)
~~------nu~·~~nad~
~r----- Conlu-oftlla
Dudua IJft'lpfll:ti- d~
lnnd»-
me~l•llnlllt. dutw
Fig. 5.98 Neurovueul1r structurn of ~he '"'erlor 1hontde IIIUirture, rigM sicle; caudal view; after removal of the cervical pleural cupula. The V.subclevie crosses the pleural cupula anterior to the M. scalenus, whereas the A. subclavia end the Plexus brechialis course posterior to the M. scalenus (Hj~len. g1p). Branches of the A. subdellie ere the A. thorecica inteme descending to the lateral aspect of the Stemum, the A. vertebrelis, end the Truncus thyreoeerllicelis with its branches. The Truncus costocerllicalis branches off dorsel of theM. scalenus anterior
end divides into the A. profunda cerllicis end the A. interoostelis supreme. The N. phrenicus is located ventral to the V. brechioeephaliee. The N. vagus courses dorsel to the V. brechiocephalice end releeses the N. laryngeus recurrens which winds around the A. subdevia to ascend to the neck. Posterior to the A. subdevia, the Truncus syrnpathicus with its Ganglion cervieothorecicum (stellatum) is found. Most difficult to identify is the short Ductus lyrnpheticus dexter which drains into the right venous engle (between V. subdevia end V. juguleris internal after merging the Truncus bronchomedieslinalis and the Truncus subclavius.
Thymus
-+
Topography
-+
Sections
Superior thoracic aperture
N.~l81
A. pnrlunde c-.:111
~~~--------~~ medieatinllia
A.~ communl!lalrfSII'II
Flv. 5.97
Neurovacultr strudurw of 1h• superfor ~hor«clc apertu,., klft tict.; caudal '1/iew; after removal of the pleural cupula. Here, only struetl.lres are desaibed which differ in their course from the neurovascular structures of the right side (-t Fig. 5.96). On the left side, the N. v«gus lXJ desoends further before releesing the N. laryngeus recurrens which then winds around the aortic arch (not '1/isible here) and asoends to the neck. Particular attention must be
paid to the Duetut 1hor«cfcut which is often injured during dissection in this region. The Ductus thorecicus asoends in the Mediastinum posterius and aosses the left pleural cupula before entering the left jugular-subclavian junction of veins ijunction between V. subclavia and V. jugularis internal from dorsal. Just before reaching the jugular-subcla'olian junction. it joins with the Truncus bronchomediastinalis. the Truncus subcla'olius, and the Truncus jugularis (not visible here).
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Thoracic cavity, midsagittal section
A. ccronatlll llnlltnl
~~.~~ -J--~bL~iD~~~
~~~~~~~,~~i~
V. pl.fmofllle llnlltra 81n~alnlniMn~apwlcatdiiV.ham~
Atrium linillnlm
Fig. 5.91 Thoracic cavity, Cavitt11tloraci1; midsagittal section; lateral "iew from the right side.
In this section. the close proximity of the Oesophagus to the left atrium of the heart {Atrium sinistruml in the Mediastinum posterius is otMous. Both structures ere only separated by the pericerdial ce-,ity {Ce-,ites periCI.IrdieCI.I).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The spatial proximity of the Oesophagus to the heart is useful when performing e tnntOeiiJPh. .eal eehocardloaraphy. With the ultr. sound transducer in the Oesophagus. more detailed images of the
62
heart end in particular, the heart "elves, can be acquired than from outside of the chest well.
Thymus
-+
Topography
-+
Sections
Thoracic cavity, transverse sections . 5.8111.r' t l - i\ 511111> _J_{ I
f)'
.
'\
Scapula
PIII.IIB WICINIIII
M.tnpazl18
M. stamchyoklal8
Oeaophaaus
Bpatllm ..~noi!Saum
Medulla •plnals
b N.&UpnuiCIIpUiarla
Figs. 5.H• •nd b Pl•ur.l cupul•. Cupul• pleur..; transverse sections; at the level of the shoulder joint; caudal view.
These sections demonstrate that the pleural cupula extends behind the neurovascular bundle of the arm above the superior thoracic aperture. Thus. the apex of the lung is positioned immediately posterior to the V. and A. subclavia.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , The extension of the pleural cupula needs to be cansidered when placing a oentral venous Ath.tw (central line, CVCJ in the V. subclavii. For this procedure the cannula is placed just below the anterior canvexity of the clavicle in the direction towards the sternoclo-
vicular joint. If the can nuIa is positioned too steep the pleural cavity may be injured which leads to an intrusion of air into the pleural cavity end results in collapsing of the lung (pneumothonud.
63
Thoracic Viscera
Heart
-+
Lungs
-+
Oesophagus
-+
Thoracic cavity, transverse sections
Manubrium ala'nl
l,L ttaaclca ~· N. plnnlcua daxter
\1:-...,.tat
PL.imotlmw, L..obLB suptlior
._,._
---'l!...,..IIIB::,..-- N. lhcraciCLB
N. tllon.:lcualongua
longLB
Plaxuo bractlllllll
A. subscapularis
M.-major
5.100 Vortabnl thDIIICica II, Pnx:. apinaeuo
A. th~lca n... N. plnnlcul-
\1:-...,ariat
Pulmo alnl-. L..obua auperlor
N. vagus dloiCtlrllQ
M.tnsma,lcr M. subseapularts N. vagua ehllllar [X]
\l:uygo. Flat.n. obllqua
Plolmo alnlabr, L..obua lnfartDr Truncua aympaltllcul
5.101
Fit. 5.100 •nd Fig. 5.101 Thoi'Hic uvity, C.Vita1 thaNe•; transverse sections at the level of the aortic arch; ceudal view. In the Mediastinum superius, the aortic arch is loeat&d ventrally end the V. cava superior is locat&d at the right side of the aortic arch. Position&d dorsal to these blood vessels are the Trachea and, to the left side, the
64
Pan thoradca aOitae
M.1nlpiiZILB Yll1llllra thoraclca PI
Oesophagus and the thorecic aorta. Posteriorly, the Aorta borders at the Recessus vertebromedieslinalis of the pleural cavity. Position&d directly on the vertebral column ere the V. azygos on the right side end the Ductus thoracicus on the left side.
Thymus
-+
Topography
-+
Sections
Thoracic cavity, transverse sections
V. piAmonala •~lin al.pGI!Cr
Costa Ill ----1---!
N. Ul
--+----<
FIMI.ft oblqua
M.-•Putmo.s-.
Lobualrlfw!cr Fbsura Cllllqu.
5.102
Plwa pll'll1tllt, Pin I!Md11811MIIt M. pactcntta m•Jor Pin aeca""-- (Aclrta ucendaM)
---+- \L CSYI8UpGI!Cir
r------ Bronctlua
pmc~ttaall'llltw
- - - - - P i n daeca-aaO!Iu (Aoltlldaeca-.)
-Scapula
O.OplltQus \lllflllbra 1heni:IC« lv, CctplS wctltne
5.103 Flg. 5.102 ~md Fig. 5.103 Tbor•clc cotty. Cntta ~hontelt; transverse section et the level af the Aorta descendens 1-> Fig. 5.102) end computed tomogrephic cross-section ICT; _.,Fig. 5.1031; ceudal view. In the Mediastinum superius, the Aorte ascendens is positioned most ventrally followed posteriorly and to the left side by the Truncus pulmo-
nelis which branches into the pulmonery erteries. The V. ceva superior is located at the right side of the Aorta. Behind the pulmonary arteries {Aa. pulmonales) are the main bronchi {Bronchi principalesl and the Oesophagus. The Aorta descendens i9 visible on the left side af the vertebral column. the V. azygos on the right side.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Cross sectional imaging with C01!11utedl tomogr1phy {CT; -> Fig. 5.1 03) or mqn"lc reson1nee ~omogi'I!Phle fm•glng {MRII is of high relevance in medical diagnostics. It is the general convention thet these images ere always displayed with e view from caudel. The advantage in computed tomogr1phy ten is based on the feet thet ell structures with their spatial distribution are imaged in a steck af sections with a thickness af a few millimeters. In contrast, in con-
ventional radiography the structures are projected on top af each other. In tomogrephy, the density of pathological structures elreedy provides information regarding the tissue composition. Using CT· controlled puncturn. biopsies cen be obteined from individuel enlarged lymph nodes which enables microbiological and pethological diagnosis.
65
Thoracic Viscera
Hean
~
Lungs
~
Oesophagus
~
Thoracic cavity, transverse section
V+./
81nl8 lriiiiiMinl18 pwlcetdll
'D'uPICue pulmonelle Cotta Ill
! . (
N. plnfllcue sfnl9tlr
M.-8tmrlcr
M.lnlj:HIZI18
Fig. 5.104 Thoracic cavity, Cavital thoraci•; transverse section at the level of the left etrium; ceudal view.
The left atrium of the heart {Atrium sinistrum) reaches further cranial than the right atrium and is positioned behind the great vessels. The Oesophagus is directly edj&e&nt to the dorsal espeet of the left atrium.
Oet.,m atJicMintrlculete •lrflltnlm
Sepum lnl-ntrtcl.f~n - - - - ''..:
\llltl1rleulus
Fig. 5.105 HMrt.. Cor: ultrssound imege teken from within the Oesophagus (trensoesophegeal eehoeerdiography).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The spatial proximity of the Oesophagus to the heart is useful when performing e tnntOesaphqeal echocardlography ( ... Rg. 5.98). With the ultrasound transducer in the Oesophagus, more detailed
66
images of the heart end particularly the heart valves, can be taken then from outside of the chest well.
Thymus
-+
Topography
-+
Sections
Thoracic cavity, transverse sections
N. plrarlcus dlllllw PUimo - . Labus maclus
Flann ol:lllq.ia
N. plnnlcus slnllbr
V. c:a.lla.ca magra
ltuncus aymplllhlcua Ductus thonclcus
5.111&
M. peetlnlla mll)or
V.: p .-monals slniSUlllrtwlor
N. lmtn:rlStllls
Ncclll,lmphokltl-......-+--:-"'1 tra:hlollrtlnchlaiN lnll!lbu
PUimo - . Labus lnfarlor PUimoalrlllar, L.obulllrlarlcr
M. lniM:olltllllo axlamus
1!11lnchus aegmel'bls basals 1--..11& [B IX]
Ncclus lymll/lcldeus Jwcta-phlaulls N.vag.~a-()(l
5.107 Fig. 5.106 and Fig. 5.107 Thoracic cavity, Cavit111 thONCil; transverse sections at the level of the aortic valve {.... Fig. 5.1 06) and beneath the aortic valve {.... Fig. 5.1 07}; cauda I view. These sections show that the Mediastinum medium, which contains the heart and the pericardium, extends further to the left side than to the right side. This results in a smeller volume of the left lung.
In the Pericardium, a thick: layer of subepicardial adipose tissue is evident in which the coronal'{ arteries are embedded. The lllteral aspect of the heart {Facies pulmonalis of the heart) at this sectional level is confined by the right atrium on the right side and the left ventricle on the left side. The right ventricle does not participate in the borders of the heart but. instead, f orms the anterior aspect of the heart (Fecies stemocostalis).
Thoracic Viscera
Heart -+ ••• -+ Sections
Thoracic cavity, frontal sections
M. lnlpaue
r:,-..1,\l,~iR..IH-&--
M.1- mll)cr
I.QI.~M-HH-io=:-- Plu119 btlH:IIIIIIt,
Faeclcl.fue~
'f.:'"""itt\'IM~J.l--
A.ullub l'fllllld lnchida, Fuc:lcukla madill Ia
\tai'IIII'ICir, Pin ln11'1184Qrn41'1\tllt
Fuc:lcuklaii1W8Ia
Brcnell~~t 9itjlmel'ltllls
M. ccnu:otnclllllllt
ll'ltii1Cr lB 110
5.101
\( )lgullrl8 1n11ma
M. sctiWIUS I!Mdl.ie
f-\"-\
~~
M. bleolps mcl'll, ClapU110~um, T~t~do
Pl-lndlillil Nodi tympl!oklal patlllnlellaalae
COSCia I M. aubacapulllfa A. carotte communllt 81rfllta'
Y.ullub Nodua tympholdaue 1nlcl!eobroncl11111e M.111Wmll)cr
"'-1101118
•"' J)
1>
·~
Pl.fmo•t~letw
5.109
Fig. 5.101 •nd Fig. 5.1ot 'lbontde cntty, Cavltu 1hontd,, aill•ry fosu, Axill., •nd thoulder joi~ Articuhatio humeri; frontal sections at the level of the shoulder joint 1-+ Fig. 5.1 OSland anterior to the shoulder joint 1-+ Fig. 5.109); venttel view.
68
N.111Cilii:II:Uslell;~~t
M.aiii'I'Ctll8al'ltii1Cr
Coatarl
These illustrations show that the neurovascular structures supplying the arm, A. end V. exilleris and the PleXIJS btacl1ialis, course venttel to the shoulder joint in dose topographical relation to the apex of the lung.
Viscera of the Abdomen Development . . . . . . . . . . . . . . . . . . . . . .
72
Stomach . . .. . . . . . . . . . . . . . . . . .. . . . .
74
Intestines. . . . . . . . . . . . . . . . . . . . . . . . . .
86
Liver and Gallbladder .............. 102 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Spleen ............................. 128 Topography ....................... 130 Sections. . . . . . . . . . . . . . . . . . . . . . . . . . . 148
The Abdomen Concealed Organs The origin of the terms abdomen and abdominal for the organs that lie in its cavity {Cavitas abdominalis), are derived from the Latin verb "abdo"- "I hide". In fact, the abdomen does not only hide many organs, but even more causes for diseases.
At a First Glance Once opened, one looks into an abdominal cavity which is tightly filled with soft and solid organs {Viscera). This is called the situs, "the positioning" of the organs in relation to one another. The inside of the abdominal wall as well as the surfaces of the abdominal organs are covered with soft, moist. and shiny linings, known as the Peritoneum. The wall-covering Peritoneum is the parietal layer; the organ-covering Peritoneum is the visceral layer. The smooth peritoneum enables for example the peristaltic movements of stomach and intestines, allowing intestinal loops to slide against each other.
Upper Abdominal Situs The organs of the upper abdomen lie beneath and between the arches of the rib cage, beneath the dome of the diaphragm, in the Regiones hypochondriacae and the Regia epigastrica. This region contains the liver (Hepar) and the Pancreas, the largest glands in the human body. The liver occupies the entire Regia hypochondriaca dextra and parts of the Regio epigastrica, where its surface clings closely to the diaphragm. At its inferior surface it bears the reservoir for its secretion, the gall· bladder {Vesica biliaris). The stomach {Gaster) is just below the ribs of the Regio hypochondriaca sinistra. At the right Regio epigastrica, the stomach transitions into the Duodenum (the first part of the small intestine) at the Pylorus {M. sphincter pyloricus). Between the Duodenum and stomach on one side and the inferior surface of the liver on the other spans a peritoneal duplication, called the Omentum minus. The Pancrus and a greater part of the Duodenum are located dorsal and slightly caudal to the stomach at the dorsal wall of the abdominal cavity. Lateral and posterior to the stomach, in the "outer left corner" of the Regio hypochondriaca sinistra, the spleen (Splen) is located in its "niche". It is also not visible at first, but easily palpable when one glides the hand over the stomach towards the spleen.
Lower Abdominal Situs In the remaining larger part of the abdomen, in the Regiones abdominalas laterales, inguinales, umbilicalis, and pubica, the intestines (lntestinum) are located -hardly visible at first. Hanging down from the lower margin of the stomach, the Omentum majus resembles an apron containing adipose tissue. Lifting it, one observes the convolution of the intestines. The lower segments of the small intestine {lntestinum tenue), Jejunum and Ileum, are strongly wound and several meters long. If the small intestines are slightly moved back and forth, one notices that they are framed by the Colon (lntestinum crassum) like an inverted "u·: the Colon ascendens on the right hand side, the Colon transversum (where the Omentum majus is attached to in a similar way as to the stomach) marks the border to the Epigastrium, and the Colon descendens on the left hand side. Then, with an elegant swing, the Colon sigmoideum disappears in the lower pelvis where it transitions into the Rectum.
70
uMesosu and Peritoneal Relationships Some of the organs of the Situs viscerum (e.g. lntestinum tenue) are attached to planar, adipose-rich duplications of the Peritoneum (•Me· sos·) which project into the lumen of the body cavity. The Mesas carry blood vessels and nerves for the particular Viscera. Depending on the organ associated with the Meso, it is referred to as the Mesocolon (of the Colon transversum), the mesentery (of the small intestine) or the Mesogastrium (of the stomach). The "Mesas· can be pictured as socalled "planar stems· that serve to suspend the respective organs from the abdominal wall. As a result, the entire organs are covered by Peritoneum, except on the "seam-line· to the Meso. They are therefore called intraperitoneal. Other organs {such as the Colon ascendens, the Colon descendens or the Pancreas) are located at the dorsal wall of the abdomen and fixed in place by connective tissue; hence they have no ·stalks". Therefore these organs are less mobile, they are covered by Peritoneum only on their ventral surfaces facing the abdominal cavity, and are referred to as retroperitoneal. In contrast to the organs of the retroperitoneal situs (see below), these organs shifted to the dorsal body wall during development and are, therefore, called secondary retroperitoneal. The position of these two groups of organs is not only of academic interest, but essential for all surgical disciplines: in contrast to the organs of the retroperitoneal situs, intraperitoneal organs can only be reached once the abdominal cavity is opened and this increases the risk of infection and complications.
Retroperitoneal Situs If the space occupied by the gastro-intestinal tract, including its accessory glands, were "cleared", the organs behind the Peritoneum paristale would become visible on the dorsal wall of the Cavitas abdominalis, which resembles the retroperitoneal space{-> p. 158). The kidneys (Ranes) are located ventral to the lowest ribs. The V. cava inferior ascends just to the right side of the vertebral column. It arises at the level of the lowest lumbar vertebra from the confluence of the two Vv. iliacas communes. Nota bene, the V. cava inferior receives no direct venous inflow from the abdominal viscera. Instead their venous blood is collected in the hepatic portal vein, the V. portae hepatis, and flows through the capillary bed of the liver before it enters the V. cava inferior. The Aorta abdominalis descends in the median plane along the vertebral bodies, and divides into the Aa. iliacae communes ventral to the fourth lumbar vertebra. Three large, unpaired arterial trunks, which leave the Aorta ventrally, supply the organs of the upper abdomen (Truncus coeliacus) and the intestines (Aa. mesentericae superior and inferior).
Abdominal Pain Abdominal pain has several causes which range from innocuous situations to imminent disasters. The abdominal wall can be soft and hardly tender to palpation, but also show board-like rigidity and rebound tenderness. It takes a skilled internist or surgeon to accurately diagnose the causal pathology of an "acute abdomen •, which per se is only a symptom, to provide appropriate therapeutic options. This will only be successful, if one has a clear picture of the composition of the abdomen.
Clinical Remarks---------.. Ralevanc• for 1taa Phylician Diseases of sbdominsl organs ere of high importence not only for the general practitioner, but also for the specialist in intemel medicine, smong them gastroenterologists end hepatologists. I~ flemmetory diseases of the stomach tgutritis) or ontric ulc8rl ere common. Peptic ulcers may perforste end erode the blood vessels of the stomach causing potentially life-threatening co~ plications. Bile stones with inflsmmetion of the gsllbllldder tcho18Cyltitis) end Pancreas tpa~ncrotitis) ere in the Western world as common ss liver diseases, from the fatty degeneration to fi~ rous desii'\Jction (liver cin11osis), due to alcohol abuse end excessive nutrition. Liver cin11osis may cause hypertension in the portsl venous system (portal hypertension) potentially resulting in portocaval anastomoses end subsequently in life-threatening bleeding from oesophageal varlcn. Organs such as the stomach or the Colon ere common sites for mslignent tumours. In these cases, the anatomical knowledge of the supplying blood vessels and the lymphatic drainage pathways is of dinical importance for diagnostic staging ss well ss surgical therspy. Other orgsns such as the spleen ere at risk of rupturing due to a blunt abdominal trauma end may be the source of life-threatening internal bleedings.
-t
Di•••ction Linlr
After opening the abdominal cavity, initially the undissected situs with the Bursa omentelis end the Omenta mejus and minus should be demonstrsted, ss dissection significently changes the relative positions of the structures. Altemstively, only the organs of the lower abdomen or ell organs of the peritoneal cevity ss e block should be removed to di9sect the retroperitoneum and pelvic situs. Prior to resection, the three unpsired blood vessels of the sbdominal sorte {Truncus coeliacus, All. mesentericae superior and inferior) must first be identified end cut, if needed. After transection end ligation of the Oesophagus or Duodenum proximally, end of the terminal ileum end the Rectum distally, the intraperitoneal end secondary retroperitoneal organs are mobilised bluntly. In addition, the liver should be separated from the V. cava inferior. Afterwards, neurovascular structures of the organs remaining in situ end the removed orgsns must be traced. At stomach, spleen, end intestines, primarily the blood vessels are to be dissected and displayed. The extrshepatic bile ducts ere dissected in the region of the hilum of the liver end the gallbladder.
EXAM CHECK LIST • Development: abdominal situs, Pancreas with malformations • topography: positions of the organs with ligaments, recessus of the peritoneal cavity with Bursa omentalis, CT sectional diagnostics • organs: all organs including neurovascular structuru and lymphatic drainage pathways (particularly Gaeter and lntertinum crassum), liver segments and structures of the liver hilum • portal venous system • portocaval anastomoses with clinical relevance • Vesica biliaris with CALOT's triangle • course and junctions ofthe extrahepatic bile ducts • secretory ducts of the Pancreas
71
Viscera of the Abdomen
Development ..... Stomach
-+
Intestines
-+
Liver and gallbladder
Development of the upper abdominal situs
Peritoneal cavity
Mesogastrium clorsale
- - - ,____._ Peritoneal cavity
Rec.sus -t-H~U.I ~t----r--Gast• pneumaiDenlllrJcus
Hepar Hepar Septum 1ranawrsum
b
Figs. 6.1a to d Davelopmant of the upper abdominal situs at the end of week 4 Ia), at the beginning of week 5lbl, and at the beginning of week 7 (c); transverse sections (a to c) and paramedian section (d) of the upper abdomen. Peritoneum (green); Peritoneum of the Recessus pneumatoentericus and the Bursa omentalis (dark red), respectively. (according to [111 The primordial gut predominantly derives from the endoderm and parts of the yolk sac. In the surrounding mesoderm, developing gaps fuse to form the body cavity. The mesoderm covering the primordial gut later forms the Peritoneum viscerale and, as Peritoneum parietale, lines the abdominal cavity. The Peritoneum viscerale also forms the mesenteries which contain the supplying neurovascular structures and serve as attachments. The dorsal mesentery connects the primordial gut with the dorsal wall of the trunk. The upper abdomen also contains a ventral mesentery. At the beginning of week 4, an endodermal outgrowth develops ventral to the primordial gut at the level of the later Duodenum and gives rise to the epithelial tissues of liver, gallbladder, bile ducts and Pancreas. Subsequently, the following restructuring occurs: 1. The liver expands into the Mesogastrium ventrale and, thus, creates a division into the Mesohepaticum ventrale (between ventral wall of the trunk and liver) and the Mesohepaticum dorsale (between liver and stomach) (a and b). The Mesohepaticum ventrale later forms
72
2.
3.
4.
5.
the Lig. coronarium cranially and the Lig. falciform& hapatis caudally. The Lig. teres hapatis at the caudal margin is a remnant of the umbilical vein. The Mesohepaticum dorsale becomes the Omentum minus. In the Mesogastrium dorsale a gap appears at the right side (Recessus pneumatoentericus) which later forms the Bursa omentalis (a and b). The stomach rotates 90" in a clockwise direction (cranial view) and thus is located in a frontal position at the left side of the body (c). The Omentum minus connects the liver and lesser curvature of the stomach also in a frontal plane and forms the ventral border of the Bursa omenta lis which has reached a position on the left side behind the stomach. In the Mesogastrium dorsale, the Pancreas and the spleen develop. The Pancreas subsequently acquires a retroperitoneal position, and the spleen remains intraperitoneal. The Mesogastrium dorsale eventually separates into the Lig. gastrosplanicum (from the greater curvature of the stomach to the spleen) and the Lig. splenorenale (from the splenic hilum to the dorsal abdominal wall) and forms the other portions of the Omentum majus (apron-like at the greater curvature of the stomach; d). Therefore, due to its development and the neurovascular supply, the Omentum majus is associated with the upper abdominal situs.
-+
Pancreas
-+
Spleen
-+
Topography
-+
Sections
Development of the lower abdominal situs
PrtrnaJY m.SIIIIIII--T Prtnwy lmesdnal Duclul VllllllriLIB---
loop
c d
Figs. a.z. to d Sch•m.tlc lllustntfanl Gil the fntwtlnal rcrt.tlan. Intestinal segments and their mesenteries are highlighted in different colours: Guter and Mesogastrium (purple). Duodenum and Mesoduodenum {blue!, Jejunum and Ileum with associated mesentelies (orange), Colon and Mesocolon {ochre). (acoording to [1]) 1. Cause
Ductus vitellin us. If the intestines filii to relocate entirely into the embryo, a congenital umbilical hernia lomphalocelel remains which contains portions of the intestinal segments and their mesenteries. Because this congenital hemia traverses through the later umbilical ring, it is covered by amnion only but not by muscles of the abdominal wall. 3. Remnants of the Ductus vitellin us may remain as MECKEL'S dfvw. ticulum located at the small intestine. 4. The elongation of the intestines initiates a Z7D" counter-clockwl• rotation, resulting in the colon to surround the small intestine like a frame. 5. Colon ascendens and Colon descendens are secondalily relocated in a retroperitoneal position.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , MECKEL'I diverticula are common (3% of the population) and are usually located in the part of the small intestine that is located approximately 100 em cranial of the iliocaecal valve. Due to the fact that these diverticuIa frequently contain disseminated gastric mucosa, inflammation and subsequent bleeding thereof may mimic symptoms of an appendicitis. Disturbances of the intestinal rotati-
on can cause a malrobltlon (hypo- and hyperrotation). These may result in intestinal obstruction (ileus) or an abnormal positioning of the respective intestinal segments, a condition that may impede the diagnosis of an appendicitis. A Sftus lnv•rsus describes a condition where all organs are positioned mirror-inverted.
73
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Projection of the stomach
Fig. a.a Projection ofitle stomach, Gaiter, onto 1tle ventNI wall of 1tle trunk. The cardiae orili~ (Cardia) projects onto the level of the 10"' thoracic vertebre, thus, ventrelly below the Proe. l
Fill'· 6.48 and b
ProJ~Ion of 1tle Internal organ' onto 'he body
'urface; ventral (a) end dorsal (b) views. The stomach is positioned lntnperMon8111y in the left Epigastrium between the left lobe of the liver end the spleen. The stomach is most-
74
the level of the 2~><~ to 3'd lumber vertebre. The Pylorus, on the other hand, regularly locates halfway along a virtual line connecting the pubic symphysis (Symphysis pubieel end the jugular fossa (Fosse jugularis), projecting onto the 1" lumbar vertebre.
ly covered by the left costal ereh but e smell eree is directly edjaoent to the ventral abdominal wall. This area is dinicelly relevant since PEGtubes {percuteneous endoscopic sastrostomyl een be placed here for parenteral nutrition.
-+
Pancreas
-+
Spleen
-+
Topography
-+
Sections
Divisions of the stomach
Flg. 8.5and Fig. 8.8 Stomach. Gmw; ventnJI ~ew {... Fig. 6.5) and c:.nta [Pin <=MMicaJ - - - - - schematic illustretion 1... Fig. 8.6). !Fig. 6.8 according to [1)) The stomach has three parts: • P1r11 c1rdi~e~: entrance to the stomach • Corpus gatrfcum: main part with superior Fundus gastricus • P1r11 pytorictt: exit of the stomach which continues as Antrum ~ loricum and Canalis pyloricus, the latter being surrounded by the sphincter musde IM. sphincter pyloricus). The stomach has an anterior and posterior wall {Paries anterior and posterior). The lesser curveture {Curvature minor) is directed to the right side, the greater curvature {Curvetura major) to the left side. The kink in the lesser curvature (Incisure anguleris) marks the beginning of the Pars pylorica. The greater curveture also begins with an indentation !Incisura cerdielis) which marks the engle of HIS between the Oesophagus end the stomach !cardiac notch). At the inside of the stomach, this trans~ tion between both organs is marked by a mucosal fold which, together with the angiomuscular gasti'01lesophageal valve, contributes to the dosure of the stomach.
1.8
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . If the cerdiac notch is stnJightened and the angle of HIS is lost, such as in sliding hiatal hernias, the resulting reflux of gastric juice into the Oesophagus may cause gaftro-to)nophagMI reflux dlsMse tGERD) with inflammation of the oesophageal mucosa. If therepeu-
tic approaches with proton pump inhibitors {antacids) to reduce the gastric acid production ere not successful, surgical procedures, such as fixing the fundus around the Oesophagus {NISSEN fundoplicstionl ere performed, to restore the gestro-oesophegeel valve mechanism.
75
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Muscles of the stomach
Fig. 6.7•ncl Fig.l.8 Outer(-> Fig. 6.7) •nd inner t-> Fig. 6.1) mu• cultr lilY•"' of ~he stomHh, Gaster: ventral view. The well of the stomach comprises three muscular layers (Tunice muscularis) not consistently found in all regions of the stomach. The e)(ter-
76
nallongitudinel layer (Stratum longitudinal&) i9 edjecent to the circular layer !Stratum cirrulare). The innermost layer consists of the oblique muscle fibres (Fibrae obliquae) which are missing at the lesser rurvature.
-+
Pancreas -+ Spleen -+ Topography -+ Sections
Inner relief of the stomach
0419Cjlt!agus, Pin •bdomtntllt -~tli"'t:"" cll'dll [Pin ctldceiiJ, Ost~m e~~"~III!Qolm - ---"'
Pin ll')ictlel, Clntlls p~. Anlrum pyklrlc~~n
M.lflhin<*W p,lori<:ue
Fig. 6.9 Stomach, G11ter, and cluocltnum, Duodenum; ventral view.
The gastric mucosa has a characteristic relief ser~~ing the enlargement of the inner surface. The maaosoopia.~lly recognisable gastric folds !Plicae gestricae) ere longitudinally oriented end form the functional canal
along the lesser C\Jrlleture (gastric canal). The mucosal folds rweel small microscopic areas {Areae gastricae; ~ Fig. 8.10). At the elCit of the stomach (Pylorus), the cirCIJiar muscle layer is thickened to form the pyloric sphincter muscle {M. sphincter pyloricus).
77
Viscera of the Abdomen
Development -+ Stomach -+ Intestines -+ Liver and Gallbladder -+
Structure of the wall of the stomach
Fig. 6.10 W11l of the no mach, Gnter:; microscopic view. Similar to the wtlole intestines, the well of the stomech comprises en inner mucosal layer {Tunice mucose) wtlich is seperat&d from the mu~ euler leyer {Tunice musculeris, ~ Figs. 6.7 end 6.8) by a layer of loose
connective tissue {Tela submucosa). As en intraperitoneal organ the outer surface of the stomech is covered by visoerel peritoneum IPerit~r neum visoerele) which forms the Tunioe serosa.
Fig. 6.11 G11tric ulcer tUicul ventriculi). [5) Gastric ulcers ere peptic defects wtlich effect the entire well of the stomach. Asterisks mark the pyloric ring, arrows mark the rim of the ulcer.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . More than 80% of all g11tric 1nd duodtn1l ulcer1 ere ceused by the bacterium HelicobiJcter pylori. In eddition, an increesed production of gastric acid or a reduced production of mucus. e.g. caused by pain treetment with ecetylsalicylic acid, may promote the form~ tion of peptic ulcers. Thus. therapeutic approaches include antibiotic
78
treatment and antacids. Complications may include a perforation into adjecent organs or the abdominal cavity with resulting lifethreatening peritonitis, or the erosion of a gastric artery I~ p. 80) with subsequent severe bleeding. These complications require surgical intervention.
Pancreas -+ Spleen -+ Topography -+ Sections
Topographical relations of the stomach
6.12
S!ll•n [Lien) -
8.13
Fig. 6.12 and Fig. 6.13 Contact a....., Faciet, of itte anterior wall C-+ Fig. 6.121 •nd itt• pofttll'for w•ll C-+ Fit. 6.131 of itt• stomach wittl adjacent 0f11antc • ventral: liver. diaphragm, abdominal well
The stomach is mobile and, depending on the filling stl.lte, has different contact areas with its adjacent organs.
• dorsal: spleen, kidney, adrenal gland, Pancreas, Mesocolon tran9versum
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The contact areas have clinical relevance since peptic ulcers may result in perforation into edjecent orsan1 resulting in severe
damage to these organs and the formation of ac!hesions which impose difficulties for the surgical removal of tumours.
79
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Arteries of the stomach
v. pcrWI heplllllt
6.14
A. IKiplltlcol prop ria
A.; Y. ~h dutn, Ar. orrMI'I1«
Fig. 6.14and Fig. 6.15 Arterift of theltomech, Gnter:, n schtlrrurtfe lllultr'Mion C... Fre. 8.141and 1helr coui'M •lone1h• curvlturn of thtlltomach C... Fig. 6.15); ventral view.
The three main branches af the Truncus coeliacus {A. gastrice sinistra. A. hepatice oommunis, A. splenicel collectively give rise to si)( gastric arteries I... Table).
Arterin of the Stom•ch • A. gastrice sinistra !direct branch of the Truncus coeliacusl • A. gastrice dextra !derived from the A. hepatica propria) • A. gastroomentelis sinistra (derived from the A. splenice) • A. gastroomentalis demra !derived from the A. gastroduodenalis of the A. hepatica communis) These vessels also supply the Omentum majusl
80
Fundus
• Aa. gastricee breves {derived from the A. splenica in the area of the splenic hilum)
Poeterior ticS.
• A. gastrice posterior !present in 30-60%, derives from the A. splenica behind the stomech)
-+
Pancreas
-+
Spleen
-+
Topography
-+
Sections
Veins of the stomach
Flg. 8.18 Veln1 of the "omach, Gmer:. rn reldon ~o the porul vein, V. portae hepftit; ventral view. The veins ere corresponding to the arteries, but the veins at the lesser
curvature directly enter the portal vein, whereas the veins at the greater curvature drain into the larger branches af the portal vein.
• V. gestrica sinistre • V. gestrica dextra Drainage into the V. portae hepatis: these veins anastomose vie the Vv. oesophageae with the azygos system end thus, with the V. cave superiorI Greeter curvature
• V. gestroomentelis sinistre (to V. splenica} • V. gastroomentelis dextre (to V. mesenterica superior)
• Vv. gestricae breves (to V. splenica} • V. gestrica posterior (present in 30-60'11., to V. splenice)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In cases af increased blood pressure in the portal vein system (portal hypertension), such as in liver cirrhosis, portocoal ana"omo,., may form via the oesophageal veins which may substantially dilate
fonophalJHI varicn) and beer the risk for rupture with subs• quent potentially lif•threatening haemorrhage{... Fig. 5.8111
81
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Lymph vessels of the stomach
Noclual)mflhoidaua
epenic:ua
Nocli IJmpfloidei hep8tiei
- - . ,.__
Nocli ~oidei
tufrici 4atri
Fig. 6.17 Lymph venell1nd lymph nocle1 of tiM .tomach, Gater, 1nd the liver. H.,.r: ventre! ~ew. The lymph vessels and lymph nodes of the stomach are located alongside both cunr.ture:~ and around the Pylorus: the lesser curvature shows the Nodi lymphoidei gastrici, the greater curvature harbours the
Nodi lymphoidei splanici and caudal thereof the Nodi lymphoidei gastroomentlJies. The Nodi lyrnphoidei pyloria in the region of the Pylorus connect to the Nodi lymphoidei hepatici at the hilum of the liver. Three major lymphatic drainage pathways with three subsequent lymph node stations are distinguished (-t Fig. 8.1 8).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The lymphatic drainage stations (-t Fig. 6.19) of the stomach are of clinical relevance in the IUrtf~l ther1py of tatrfe e~ncer. The lymph nodes of the first and second stations are usually removed to-
82
gather with the stomach. If lymph nodes of the third station are also affected by metlJstatic cancer cells, curative therapy is not possible. In these cases, total gastrectomy will not be performed.
-+
Pancreas -+ Spleen -+ Topography -+ Sections
Lymph vessels of the stomach
Fig. 6.11 Lymphatic dr1inage1ncl Nfjionlllyf!11h noda of 1tte stomHh, Gater: ventral view. {acoording to 11 JJ The three principle lymphatic drainage pathways which exist for the stomach are marked by dashed lines in this illustration:
• Clrdilc .,.. 1ncl .....,. curvatur« Nodi lymphoidei gBlltrici • upper left qu1clr1nt: Nodi lymphoidei splenici • low• two-~hlrds of 1tte triMer curvature1nd Pylorus: Nodi lymphoidei gastroomenteles end Nodi lymphoidei pylorici
Fig. 6.19 L:¥mphftic dreinqe .tatiol'll of1tte stomach; ventral view. !acoording to 11 D IMthin the three principle lymphatic drainage pathways there are 1ttr. .
• second station {yellow): lymph nodes along the branches of the Truncus coeliacus • third station (blue): lymph nodes at the origin of the Truncus ooeliacus [Nodi lymphoidei coeliaciJ; from here the lymph is drained ~a the Truncus intestinalis into the Ductus thorecicus.
I~HqUIM ~ons:
• first station (green): lymph nodes along the curvatures {-t Fig. 6.1 8)
83
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Autonomic innervation of the stomach
Fig. 6.20 Autonomic inMrVation of itt• stomach, Oa~ter; st~mischematic
illustration. Sympathetic innervation {green), paresympathetic innervation (purple). (ecC
muso.~lar layers of the stomach. The para~ympatMtic inMrVdon ~mulates the production of gastric acids end promotes the
within the
gastric peristalsis. Preganglionic sympathdc flbrn traverse the diaphragm on both sidu u Nn. splenchnici major end minor end ere synapsed to the postganglionic sympathetic neurons in the Ganglia coeliaca located et the origin of the Truncus coeliecus. These postganglionic sympathetic fibres reach the stomach as peri-erterial nerve plexus. The sympathetic innervation counterbalances the parasympathetic influence by reducing gastric acid production, peristalsis, and perfusion.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A former therapy in patients with peptic ulcers was to sever the entire N. vagus lXI inferior to the diaphragm ttat.l vaaotomyl or its branches to the stomach (Miective vagotomy) to reduce the pro-
84
duction of gastric acid. Nowadays, with the su~ss of oral treatments with antacids and antibiotics to eradicate the causal Helicobacter pylori bacteria. the surgical vegotomy is only rarely performed.
-+
Pancreas -+ Spleen -+ Topography -+ Sections
Stomach, gastroscopy
Fit. 6.21 Technique for OeiOflhatMCOJ'V •ncl tntroiCOJ'V•
.. "* .....
GM!w, PVIae•-
Flgs. 8.2Z. ~mel b Stom•ch. Gmw; sastroKOpy: cranial view. • view onto the Corpus gastrirum showing the longitudinal mucosal folds {Piicee gastriceel
gastroscope gastroscope, tip in the Corpus gastrirum 1-+ Fig. 8.22el gastroscope, tip in the Antrum pyloricum (-t Fig. 8.22b)
.._._ ...
~·a---------------------r-- c.
b view onto the Antrum pyloricum showing predominantly smooth mucosa
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Gastroscopy enables the intpeetion of the gastric mucosal lining. Pathological findings such as erosive gastric lesions or ulcers {-t Fig. 6.11) require tissue bioptin for further pathological diag-
nostics to distinguish between a benign peptic ulcer and a gastric carcinoma.
85
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Projection of the small intestine
Celoni9C4fldlm COlon O.SO.ndlne ln119tlr.lmQ'888um
86
Celonalgmo~m -~f-Jt-~~~~:;S~l)F-\----
Fig. 6.23 Projection of the lbdominll viscera onto 1tte bocly surt.ce; ventnll view. The small intestine {4-6 m) has three parts: • Duodenum, 2~3{1 em • Jejunum. two-fifths of the total length • Ileum. three-fifths of the totlJIIength
The Duodenum starts at the Pylorus of the stomach end ends at the Flexure duodenojejunelis. Except for its first part (Pars superior), the Duodenum is fixed in its retroperitoneal position end well separated from the other parts of the smell intestine. In oontrest, the rntrlparl· tonal convoluted ptlrf:l of the Jejunum and Ileum ere not separeble mea'osoopicelly end reach distally to the Valve iliocaecalis {BAUHIN's valve) at the transition to the large intestine.
Fig. 6.24 Projection of the duodenum, Duoclenum, 1nd p1ncras, P1ncrNt, onto 1tte ventr111bdomln11 Will. The infFI!peritonul P1r11uperior of the Duodenum projects onto the level of the 1" lumbar vertebre. All other ptlrf:l ere loooed second1ry retroperitone~~lly and enoompass the head of the Penaees in a C.
shaped manner. The head of the Pancreas is adjacent to the Pars descendens of the Duodenum. The Pars horizontelis lies at the level of the 3n11umbar vertebra and oontinues as Pars eseendens to the Flexure duodenojejunelis at the level of the 2~~<~ lumbar vertebre. This flexure marks the transition to the intraperitoneal Jejunum.
-+
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the wall of the small intestine
Fig. 6.25 Sm11l intHtine, lntHtinum tenue; cross-section. The layers ere described in ~ Figure 6.28.
Fit. 1.28 Well ltructuN of ihe 1mell inteltine, lntlltinum tenue; microscopic view. Similar to other parts of the intestines, the wall of the small intestine consists of the innermost mucosal layer (Tunice mucou) with intestinal villi (Villi intestinalesl for surface enlargement. Separated bV a loose connective tissue layer (Tell 1ubmucoae), the muscular layer (Tunice mu~euleri•t consists of the inner circular layer (Stratum circulate) and
the outer longitudinal layer {Stratum longitudinal&). The intraperitoneal parts {Pars superior of the Duodenum, Jejunum end Ileum) are covered on their outer surface with peritoneum {Peritoneum visceralel which forms the Tunice •rou. Retroperitoneal parts of the Duodenum ere anchored by a 1\lnlca eclvemftl1 within the connective tissue of the retroperitoneal space.
87
Viscera of the Abdomen
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Divisions of the duodenum
....
/~~~
~~j
DIIOdllnum,
p.,._..pwtor
~~ """'·~-·~]
\
---/---r
8.27
Fig. 8.27 and Fig. 8.28 Divisions of the duocltnum. Duodenum. iloletH C- Fie. 8.27) and toe..her with the «xtNhep..ic .bile dum C- Fie. 8.28); ventral view. The Duodenum has four p1m: • Pars superior • Pars descendens • Pars horizontalis • Pars ascendens The Pars atperlor is the only intraperitoneal part and its wider proximal lumen is referred to as Ampulla {Bulbus} duodeni.
88
The excretory duct of the Pancreas !Ductus pancreaticus. duct of WIRSUNGl enters the Pars clnc«
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the duodenum
Fig. t.2t InnI f relllf of th• clloclllnum, Duoclllnum: frontlll Mction; ventral view. The Duodenum has the following four parts: 1. Pars superior, 2. Pars d&Scendens, 3. Pars horizontalis, and 4. Pars ascendens. To increase the absorptive surface, the inner relief of the Duodenum shows circular muoosal folds (Plicae circulares, KERCKRING's folds) similar to other parts of the small int&Stine. The Pars dascendens contains the Papilla duodani major (ampulla of VATER} at the entrance of the Ductus pan-
creaticus {duct of WIRSUNGl and the common bile duct {Ductus choledochus), both of which usually merge to form the Ampulla hapetopancreatica. The Pars asoendens is attached to the aorta near the origin of theA. mesenterica superior by smooth muscle fibres IM. suspensorius duodeni, muscle of TREITZ) and dense connective tissue (lig. suspensorium duodenil, just bEJfore the Duodenum transitions into the intraperitoneal Jejunum at the Flexure duodenojejunalis.
1\lnlce muacullnl, &ralll!IIOnQk'udlntlt
Fig. 8.30 Wall st:ructur• of th• duod•num. Duod•num. wfth OlanduiM duod•naln; view from outside.
The mucous-producing Glandulae duodenales!BRUNNER's glands) are located in the Tala submucosa and allow the identification of the Duodenum in histological sections.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The muscle of TREilZ dEJfines the border between upper and loww lrrtln11nal tract h..monheg... This classification is of clini-
cal relevance since both forms of haemorrhage have different oommon causes and require different diagnostic steps.
89
Viscera of the Abdomen
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Duodenum, imaging
Fig. 8.31 Duodenum, Duodenum: radiograph in anteroposterior lAP} beam projection after oral application of e contrast material; patient in upright position; ventral view.
Fig. 8.32 Duodenum. Duodenum: endoscopic image. The circular mucosal folds (Plicae circulares. KERCKRING's folds) are clear1v visible.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Similar to the situation in the stomach, duoden•l ulcers are oommon end clinically they cannot clearly be distinguished from gastric ulcers (... p. 781. Malignant tumours. however. are rare in the Duodenum. Several diagnostic approaches can be employed. Conventional ,..
90
dloloty with contrut fm1glng is less frequenUy used because diagnostic endoacopy (duodenosoopy) not only enables the direct inspection of the mucosa but also allows the sampling of tissue biOP'ies.
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the wall of jejunum and ileum
Plcuctrcg-
Fig. 1.33 Deuil of the jejunum, Jejunum. The structure of the Jejunum is very similar to the Duodenum but does not oontain ltle Glandulae duodenales !BRUNNER's glands).
Fia.l.34 o.t.il of the proxim1l ileum, Ileum. The Plicae cirC\.IIares (KERCKRING's folds) ere much less frequent in the Ileum when oompered to the upper smell intestine.
Fig. 1.35 Deull of th• distal Ileum, Ileum. The large assemblies of lymph follicles are charecteristic for ltle terminal Ileum. They are a part of ltle muooS~Hssociated lymphoid tissue IMALn. The lymph nodes ere eiltler located indMdually !Nodi IVfnphoidei solitarii;-> Fig. 8.34) in ltle Tela submucosa or are assembled in groups (Noduli lymphoidei aggregati; PEVER's plaques) underneath the elevated muoosa.
Fia. 1.31 MECKEL's diverticulum, Diverticulum ilei. Up to 3% of people have been diagnosed with e diverticulum. which exists as a remnant of ltle embl)'ological Ductus vitellinus {-+ Fig. 8.21. It is usually located in the Ileum about 1()0 em proximal to the ileocaecal valve at ltle opposite side of the mesentery. MECKEL's diverticula mey contein disseminated gastric mucosa and, when inflamed or bleeding, cen mimic the svmptoms of an appendicitis.
91
Viscera of the Abdomen
Development .... Stomach .... Intestines .... Liver and gallbladder ....
Projection of the large intestine
\" /\ ·r
d
Fig. 8.37 Divi.-an• al the lerge inbl..ine, .,tfttinum c,_um; ventral view. The lerge intestine is about 1.5 m long and consists of four perbl: • CAecum (blind gut) with Appendi~t vermiform is
• Colon with Colon ascendens, Colon transversum, Colon dascendens, and Colon sigmoideum • Rectum • CAnalis analis
- - - - FIIIXIft coll1hlltnl
- - - Colon deacerdens
Colon olgmDidllum
C.Cum Appandbc VII'1T1lfDrmla
RecllJm
- - - - c a..llllanallo
Fig. 8.38 Projection of the lerge intntine, lnblltinum cr•num, onto the ventr•l abdomln•l w•ll. Caecum with Appendi~t vermiformis, Colon transversum, end Colon sigmoideum are positioned intraparitoneally and have individual mesenteries. Caecum end Appendix vermiformis may also be located retroritoneally (CAecum fi~tuml; in this case they do not have a mesentery. Colon ascendens, Colon descendens, and the major part of the
92
Rectum are usually secondarily retroperitoneal organs, the distal Rectum and the anal canal are subperitoneal. The projections and the length of the indi\ridual segments of the large intestine ere highly veriable and the ratroperitonael segments are usually inconsistently fused with the posterior abdominal well. Due to the position of the liver on the right side, the left colic fle~ture (Fie~tUra coli sinistral is positioned farther cranial than the right colic fleltUre (Flexure coli dextra; -+ Fig. 6.53).
Pancreas -+ Spleen -+ Topography -+ Sections
Projection and positional variations of the Appendix vermiformis
• <1"
b
Fig. 8.38 Profactlon of the caecum, Caecum. and Appendix vermlformls onto the ventral abdominal w.ll. The base of the Appendix vermiform is projects onto the McBURNEY'~ point (tha transition between the lateral third and tha medial two-thirds on a line connecting the umbilicus with the Spina iliaca anterior superior). The location of the tip of tfle appendix is more variable and projects onto the LANZ's point (the transition between the right third and the left two-thirds one line connecting both Spinae iliacae anterioras supariores; 30%; .... Figs. 6.40 end 6.41).
c
d
Figs. 8.408 to d Positional variants of the Appendix wrmlformls; ventral view. a descending into the small pelvis b retrocaecal (most common position) c pre-ileal d ratro-ileal
Omentum m.,..•
Cclondeacendefto
.......
Ampulla tuba& ut8t!u
Fig.l.41 view.
Po1itional varienta of the Appendix vermiformi1; ventral
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The diagnosis of appendicitis is often not easy since right lower abdominal pain can also be caused by enteritis or, in women, by inflammatory conditions of the ovary or the fallopian tube. Thus, the
pain induced by pressing end releasing (rebound tenderness) the McBURNEY's or the LANZ's point is an important discriminatory sign.
93
Viscera of the Abdomen
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Structure of the large intestine
PUcee aeml~nns cell
M-en tnii'MM!niLITI
Fig. 8.42 Structural characterfstfa of 1tlelarge lrmmln•. lntestlnum crassum, th1tr1nswrse colon t1k1n as an IXImpl•; ventral caudal view. The large intestine has four characteristic differences to the small intestine: • larger di1m1ter ("thick" rather than "thin") • Taenia: the longitudinal muscle laver is reduced to three bands. Of these. the Taenia Iibera is visible, whereas the Taenia masocolica atmches to the Mesocolon transversum and the Taenia omentalis connects to the greater omentum !Omentum majus).
• Haustra and Plica• Mmllunares: the haustra {Haustra coli) are sa~> c:ulations of the intestinal well which correspond to aescent..shaped mucosal folds {Plicae samiluneres) at the inner surface. • Appendices eplplolca•: fatty projections from the adipose tissue of the Tela subserosa.
'llllll~ - - - - - - - - - - - . . - - Strf.tllm ~lire 1\l.. t:a n~U~~c:Uiub Stratum { longnudr..le
Tela ....lroA.
Fig. 8.43 Structure of 1tle Will of th• larg• Intestine, lntmlnum CNIIUm; microscopic view. Similar to the other parts of the intestines. the wall of the large intestine consists of an inner mucosal laver 11\lnlca mucosaJ which, in contrast to the Duodenum, has no mucosal villi. Separated from the Tunica mucosa bV a connective tissue laver (Tela submucosal is the muscular layer fTUnlca muscularis). It consists of an inner circular layer (Str. tum circullre) and an outer longitudinal layer (Strltum longitucl'ne-
94
T....a
le). However, the longitudinal layer is not continuous but is reduced to three bands (T11ni1). At the outside, the intraperitoneal parts (Ceacum with Appendix vermiformis. Colon transversum. end Colon sigmoideum) are covered bV peritoneum {Peritoneum visceral&) fonming the Tunic. ....... In contrast, the retroperitoneal parts (Colon escendens, Colon dascendens, and upper rectum) are anchored bV the 1\lnlca aclv•rrW• in the connective !issue of the retroperitoneal space.
Pancreas
~
Spleen
~
Topography
~
Sections
Caecum and Appendix vermiformis
Fig. 8.44 C..cum wfttl Appendix nrmlformls, •nd terminal J11um, Pars tlrmln•JJ• Jill; dorsal view. The Caecum is approximately 7 em long. The ~ em long Appendix vermiform is is attached to the Caecum and has its own mesentery (not
shown here) with supplying neurovascular structures. The taenia of the Colon converge at the eppendix to form e continuous longitudinel mu9cular layer.
Fig. 8.45 C..cum wfttl Appendix vermiform Is, •nd terminal ilium, Pal'l t1rmin1li1 ilei; ventral view; after removal of the anterior parts of the wall. The Caecum is separated from the terminal ileum by the IIIOCHCII Vlllve (Velva ileoce9C91is, BAUHIN's valva). Internally, the two lips of the valve form the Papilla ilealis and border the ileal orifice !Ostium ile-
aiel. Laterally, the lips continue in the Frenulum ostii ilealis. The terminal ileum contains aggregations of lymph follicles {Nodi lymphoidei aggregati), referred to as PEVER"s plaqu•, which are part of the mucosHssociated lymphoid tissue {MALT). Similarly, the Appendix vermiformis contains large aggregations of lymph follicles and serves the immune defence.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The appendicitil is a common disease in the 2"d and 3"' d9C8des of life. The appendicitis is an endogenous inflammation caused usually by the obstruction of the lumen of the appendix by faeces or, in rare cases. by foreign bodies with a resulting transmural inflammation due to intestinal micro-organisms. A perforation may cause a potentially lif&-threatening peritonitis. Important tasl:s of the terminal
ileum are the absorption of vitamin 8, 2 and bile acids es wall as its immunological functions. It is frequently affected by CROHN's disease, a chronic inflammatory disease of the intestine with autoimmune component, which. due to a vitamin 812 deficiency, may cause anaemia.
95
Viscera of the Abdomen
Development .... Stomach .... Intestines .... Liver and gallbladder ....
Arteries of the small intestine
Fig. 6.41 Arteri• of the duodenum, Duodenum; ventral view. (according to [1 D The blood supply of the Duodenum is accomplished by a ventral and dorsal double arterial arch. This arch is supplied cranially by the As. pancreaticoduodenales superiores anterior and posterior which branch off the Truncus coeliacus. Caudally, the arches are supplied by the A. pancreaticoduodenalis inferior (R. anterior and R. posterior) of the A. mesenteric& superior.
Fig. 6.47 Arteries of the Munum. Jejunum. and neum. ll•um; ventral view; Colon transvarsum reflected superiorly. (ae<:ording to [1]) The intraperitoneal convolute of the Jejunum end Ileum is supplied by
96
A,;v.......-.... .........
the A. mesenterice superior which dist ribut es its branches {usually four to five Aa. jejunales and twelve Aa. ileeles) within the mesentery of the smell intestine{-+ Fig. 8.115}.
Pancreas
~
Spleen
~
Topography
~
Sections
Arteries of the large intestine
RIOLAN'a . . .~:~c~mo~~a
Fig. 8.48 Arbtrin of 1fl• 111'1• irrtltltine, lrrtastinum c,...um; ventral view; Colon transversum reflacted superiorly. !according to 11)) • C.ecc.tm and .Appendix vermiformil: A. ileocolic. with a A. ilealis to the terminal ileum lanastomosas with the last A. ilealis) and with a R. colicus !anastomoses with the A. colica dextral. The artery then divides into the A. caecal is anterior and the A. caecal is posterior on both sides of the Caecum and into the A. appendicularis which courses in the meso-appendix to supply the Appendix vermiformis. • Colon ..cendene and Colon inntvel'lum: A. colic• dexn end A collca mltdla (from the A. mesenterica superior) anastomose with each other. The A. colica media connects to the A. colica sinistra (AIOLAN'e anastomosilt. An occasionally existing anastomosis
with one of the arcades at the left colic flexure is referred to as DRUMMOND's anastomosis. • Colon ciHcendene and Colon eiamoicleum: A. colica einiltN end Aa. elamolde.. from the A. mesenteries inferior. The A. rectalis superior also derivas from the A. mesenterica inferior and supplias the upper rectum. For developmental reasons, the lett colic flexure is the watershed for the neurovascular supply. With respect to the arteries: the supply by the A. mesenteric& superior for the Colon escendens end Colon trensversum shifts to the supply by the A. mesenteries inferior for the Colon descendens and upper Rectum.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The connactions between the A. colica media and the A. colica sinistre, collectively referred to as RIOLAN's anntomosle, ere clinically important in malperfusions such as in cases of erteriosderosis or following en arterial ocdusion by an embolus. Similar connections exist in the area of the Duodenum and the Rectum,... Fig. 6.111).
Even the complete ooclusion of one of the three unpaired lildominal arteries {Truncus coeliacus. A. mesenterica superior, and A. mesenteries inferior) can largely be compensated for without intestinal infarction. Intestinal malperfusion frequently causes abdominal pain after meals (postprandial pain).
97
Viscera of the Abdomen
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Veins of the small and large intestine
Vv. panocnNI'IIcocjkjoellllnlliiM ,.....-
v. ell! lei •ln191n1
Fig. 8.49 Veins of th• small Intestine. lnw"lnum tenu•. •nd th• larg• intenine, lrrmtinum CNI8Um; ventral view. Name and course of the intestinal veins are similar to those of the arteries. The veins enter one of the three main tributaries of the portal vein (V. portae hepatis}: the V. mesenterica superior merges with the V. splen~ behind the pancreatic head to form the V. portae hepatis. The V. mesenterica inferior drains into the V. splenica {70 % of all cases) or into the V. mesenterica superior (30%). Developmentally, the left colic flexure is the watershed for the neurovascular supply. With respect to the veins: from the Colon ascendens and Colon transversum venous blood drains into the V. mesenteries superior and from the Colon descendens and the upper Rectum the venous blood drains into the V. mesenterice inferior.
Branches of the V. mnenterfc• SUJMrfor: • V. gastroomantalis dextre with Vv. pancraaticoduodanales
• Vv. pancraat~a • Vv. jejunales and ileales • V. ileocolica • V. colica dextre • V. colica media Br1nch" of th• V. mnenteric• inferior: • V. colica sinistra • Vv. sigmoideae • V. rectalis superior: this vain has connections to the V. r&etalis media and the V. rectalis inferior, which are tributaries of the V. cave inferior.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In ceses of high blood pressure in the portal system (portal hypertension}. such as in liver cirrhosis, anastomoses between the venous systems of the V. portae hepatis and the V. C8VIJ (portociiVII •n• .tomot•t may develop (-+ Fig. 8.70). These include connections between the V. rectalis superior and the V. rectalis media, and V. rectalis inferior, respectively, which drain into the V. cava inferior.
98
They are clinically less important and are not, as previously assumed, the causa of haemorrhoids. When applying rectal suppositories, it is helpful to know that the drugs are absorbed by the rectal veins to bypass the liver and to enter the general circulation vie the V. cava inferior, thus, preventing hepatic metabolism and potential degradation of the drugs in the liver.
Pancreas
~
Spleen
~
Topography
~
Sections
Lymph vessels of the intestines
Tnln-llniiiMtllrllllle
Hodii'Jmph014el meeoc:ollel
Nodllympholdel cold •t~lltrl
Nod tpnpholclll col lei daldJI
Nodi ttmpholdalleoc:ollcl Nodi t.wmllfloldellll.d lnternl
NodllymfholdeiU'IIiiMIIII'
Fig. 8.50 Lymph vHMI• end Ngionellymph nod• of the •m•ll lntntlne,lm..trnum tenue. end the l1rge lntmlne. lntmlnum cr~num.
The respective groups of lymph nodes (a total of 100 to 200 lymph nod&S} are coloured differently according to their drainage areas. laocording to [1)) lac8tad directly adjacent to the small intestine are the Nodi lymphoidei juxtaint&Stinales, adjacent to the large intestine the Nodi lymphoidei paracolici. After filtration in several suocessiv& lymph stations along the v&scular arcades (e.g. Nodi lymphoidei colici dex:tri, colici medii, colici sinistri, ileocolici, mesocolicil, the lymph enters into two major drainage systems: • From the entire small lm.stlne as well as Caecum. Colon ~:~C~~n· den1, and Colon trln~Vet~um, the lymph drains into the Nodi lym· phoidei m~~~nterici 111perioN1 at the origin of the A. mesenterica superior and further via the Truncus intestinalis into the Ductus thonacicus (green).
• From the Colon d~:~C~~ndens, Colon 1igmoideum, and proximel rectum, the lymph reaches the Nodllympholdel miHflterlcl rnf• rio... sat the origin of the A. mesenterica inferior {yelloW) and further via the retroperitoneal pare-aortal lymph nodes {Nodi lymphoidei lumbales, grey) into the Trunci lumbales {grey). The diltll rectum and the enel unelalso drain into the Trunci lumbales. The first lymph node stations. however. are the Nodi lymphoidei iliaci intemi, and the Nodi lymphoidei inguinalas (pink, turquoise) for the terminal segment of the anal canal. respectively. Developmentally, the left colic flexure is the watershed for the neurovascular supply. With respect to the lymphatic drainage: the Nodi lynr phoidei mesenterici superiores are the regional lymph nodes for the Colon ascandens and Colon transversum, whereas the Nodi lymphoidei mesenterici inferiores drain the Colon dascendens.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The lymphatic dreinege plays a clinically important role in the diagnosis of colon carcinomas since the therapeutic approach depends on the stBge of the disease !staging). Lymph node metastases of tumours in the area of the Colon ascandens or Colon transvarsum are expected to appear in the Nodi lymphoidei mesenterici superiores.
Carcinomas in the Colon descandens, however, metastasis& into the Nodi lymphoidei mesenterici inferiores along the retroperitoneal A mesentarica inferior and often connect to other retroperitoneal lymph nodes.
99
Viscera of the Abdomen
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Innervation of the intestines
N. spllnellnleUe miner G1~llonaortlc~lll
P11Dw1 uratellcua
N.~•th111Ur
Fig. 8.51 Autonomre rnnervatron of ~h• sm111 rrmmln•. lrrbtltinum ~enu1, 1nd l1rg• in~eltin•, lrrbtltinum CN~~M~m; ventral view. (9C¢0rding to [1)) The autonomic nerves of the svmpalhetic (green) and parasvmpathetic (purple} nervous system generate a plexus at lhe anterior side of the Aorta CPiuus aortleus abdomlnalls). These nerve fibres continue along the major branches of lhe Aorta to reach the target organs. Small and large intestines are innervated by fibres derived from lhe plexus around the three major visceral branches of lhe Aorta (Pinus co.ll• eus, Pluus m.senMI'fcus sup•rlor and Pinus mnen~erfeus rnferf. or).
The perikaryll of the pretangllonle symp8ttllltfc n•urons are located in lhe intermediolateral cell column of lhe spinal cord. Their axons reach lhe sympath&tic trunk. crruncus sympathicus) and course without synapsing in lhe Nn. splanchnici major and minor to the plexus around the Aorta, where th&y finally synapse in lhe respective ganglia (Oan· glion co•liHum, O•nalil m ...m.ric.t euperiua and inferiua) to postganglionic neurons. Axons of the postganglionic neurons tnrvel along the arteries to reach the intestines. PNg•nallonlc plrnymp8ttllltfc n•urons of lhe Nn. vagi (XJ course along the Oesophagus as Trunci vagales anterior and posterior, pass
100
through the diaphragm and reach the visceral nerve plexus of the Aorta abdominelis. They pass lhrough lhe ganglia without synapsing to reach the postganglionic neurons within lhe well or in the vicinity of the target organs. The innervation area of the Nn. vagi lXI ends in the PleXI.Is mesentericus superior end. thus, in lhe area of lhe left colic fleXI.Ire. The Colon descendens is innervated by the siCI'tll dMsfon of ~h• ,.. r~symp~hetlc n•rvous symm. The preganglionic paresympalhetic neurons are localised at the S2-S4 spinel cord level end lhe nerve fibres leave the spinal nerves as Nn. splanchnici pelvici. They ere synapsed in the ganglia of the PleXI.Is hypogestricus inferior in lhe vicinity of lhe Rectum. The postganglionic nerve fibres either ascend to lhe PleXI.IS mesentericus inferior {not shown) or directly reach the Colon descendens. The p1r1tympathatic innervation atimulat.., end lhe trympathatic innervation Inhibits peristalsis end perfusion of the intestines. For developmental reasons, the left colic flexure is the watershed for the neurovascular supply. With respect to lhe autonomic innervation: Colon escendens end Colon transversum ere innervated from the Plexus mesentericus superior, whereas the Colon descendens is innerveted by lhe Plexus mesentericus inferior {creniei/Secrel division of lhe parasympathetic system).
Pancreas
~
Spleen
~
Topography
~
Sections
Large intestine, imaging Flexln. coli llnlltnl
Colonn-ereum Hall!ltraeeol
Fig. 1.52 urv• lrrmtlne,lntestrnum crassum: radiograph in anteroposterior lAP) beam projection after application of contrast
medium and air {double contrast barium enema). Positional variations of the Colon transversum can be detected 1... Fig. 6.531.
Figs. 1.538 to d Pollelonal ..,.rlaelons of eh•transv•,.. colon, Colon tnlnsv•rsum: venlnll \liew.
Fia. 15.54 A-..ndina colon, Colon aiCir'ldens; endoscopy of the colon {coloscopyl. In contrast to the circular mucosal folds of the smell intestine. the mucosal folds of the large intestine ere Cfescent-shaped (Plicae semilunares).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Malignant tumours of the colon lcolon carcl'nomu) are among the most common malignancies in both, men end women, end therefore contribute substantially to the causes of death in the Westem world. With preventive medical check-ups the number of deaths could be reduced. Coloscopv is recommended as diagnostic method of choice for the detection of colon carcinoma and the costs are covered by the public health system. Not only does ooloscopv
enable the inspection of the mucosa but it also allows taking biopsies for definite diagnostics by a pathologist. The importance of the radiological contrast imaging has declined. However, this conventional radiological method allows to obtain a reliable diagnosis based on characteristic alterations of the shape and position of the lumen in cases where endoscopy is not possible {e.g. obstructing tumours or diseases located beneath the mucosal lining).
101
Development~ Stomach ~ Intestines ~ Liver and gallbladder~
Viscera of the Abdomen Projection of liver and gallbladder
.,..,_ _ _ _ _ Gil_
'1'1-- - - - Splen (Uen)----+""1#
+---~----Pen-,~===~~~~5~~~~ -----+....., DuodllnLm '-t-----JejunLm Ren
•
Fig a. S.ss. 1nd .b Proj'ection of 1fl• vite41N onto th• .body
turfMit; ventral Ia) and dorsallb) views. The liver and gallbladder are located fntnrperMonHIIy in the right ep~ gastrium. The fundus of the gallbladder projects onto the right middavicular line at !he level of rib IX. The left lobe of the liver is located in the left Epigastrium (up to the left midclavicular line) anterior to the stomach. The position of the liver varies with respiration (lower with inspiration, higher wilh expiration) because its Area nuda is attached to !he diaphragm. Therefore, its position is also dependent on the size of the
b
lung. Because of the dome-shaped diaphragm, the anterior end posterior side of the liver is covered in part by !he pleural cavity{-+ Fig. 6.124). Up to the midclavicular line, the inferior margin of !he liver usually co-locates wilh the right inferior costal margin and. thus. the liver is not palpable. Wilh an enlarged lung, such as wilh pulmonary emphysema in a smoker, the liver may be palpable without being enlarged. The tcr pogrephy of !he liver is also important for diagnostic procedures such as liver biopsies 1-+ Fig. 6.75).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - , A complete physical examination includes the palpation of !he liver to determine its size. Changes in consistency and size may already suggest certain conditions such as a fatty IMit (diabetes mellitus, alcohol abuse), rnnammatron (hepatitis) due to viral infections or alcoholism. or livar cirrholia es the terminal stage of almost ell liver pathologies. Palpation of !he liver margin alone is not sufficient to detenninelhe size of !he liver, since !he anatomy of the lung and the
102
position of the diaphragm influence !he position of the liver margins. Therefore !he palpation of the inferior liver margin during inhalation is complemented by the percussion of the liver to determine the upper margin of the liver undemealh the rib cage. The craniocaudal diameter of a nonnal liver should not exceed 12 em in the midclevicular line.
PoncrNt ... 8plton .. Topog111fjtry .. 8octlont
DIMIIa!)ment of the Iiiier and gal bladder
__ .. ..--
__
--~..,
•
_..........,.................... ... ~
... ..,.........,. ........................ SiJil Ttw~"W......_.<1f1Mtn!QI...._\f .... frotn t.....,..n, otfltt pt1101dWIIWlft tt.l...,ottM f\llln ~m. In Mile 4 ~0/lfUcti}N~"'fCIINal!ldiWIJ\f~
• t llU
...,..1m ......._lm
.... wNih 4-M .. tno. till~~~trior l);w ·~t.m .-.4'" lr!hrior JQo IT'ICH'dklmb' fit bllitiiiJIQII'I'I 01..-.:1 'f, n.
In 'fllllctl '*tt <1f "'-"'• '.luL,....... Ttllll wrv,1MCGI'I'lldM tM,M«)),....et'lillftttltUIIII~ IIIOCIII't~MiiMtt--ldl)lr!W-
fl..,....,,
1'1'11,. Yltfl fl•ltw Je!'I'I'IOtd'om. ,..,. .... ~'"9'0W'~ ~)MtQ. ~wrnRit c.ttnel.
lmoa.,..~m ~
w • ,.._.,lllfii'IICI.IITI OOtMa.,.. Rf.C.1), 1'l'llt ~ ~ ""''~arm"'
u.. •• •• •••,... ~ CQ'II'JMt ~ fl•
Wl'mlt boctt ..... h M.cf!IIIJir1lc:un . _ ._.,. 1M 0.... tlft . . . . OOMd'le1MII\oW"""'N~N1tl&~lft.
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
Liver, overview
.....,.....-- Llg.1rlllngulllle
alnl!iiii'Um
6.57 M-vo Inferior
V. pcttae hepatltl
DuC1118 eh01e4octlus f.blllllr18) A. lObi c:t.Udl11
6.58 Llg.- hepeUa
Fig. 6.57 and Fig. 8.58 Uv•r. HlfPir; ventral!~ Fig. 6.57land dorsal caudal( ... Fig. 8.58) views. For explanations ... Figure 8.59.
104
Pancreas
~
Spleen
~
Topography
~
Sections
Liver, overview
Fig. 8.59 Uv•r. H1p1r; cranial view. The liver is the largest gland (12~1800 g) and the main metabolic organ of the body. The Facias diaphragmatica is adjacent to the diaphragm and the Facies visceralis with the anterior lower margin {Margo inferior} points towards the abdominal viscera 1... Figs. 6.57 and 6.58). The FecfM dlephregmltlce is partly adherent to the diaphragm and lacks the peritoneal lining in this area (ArM nud1J. The liver is dMded in a larger right and a smaller left lobe (Lobua dexter and Lobue eini• terl which are separated ventrally by the Lig. falciform e. The latter continues as Lig. coronarium which then becomes the right and left Lig. triangular& connecting to the diaphragm. The Lig. triangulara sinistrum continues into the fibrous Appendix fibrosa hepatis. The free margin of the Lig. falciform& contains the Lig. teres hapatis {remnant of the pr~ natal V. umbilicalis}. Both ligaments conn9ct to the ventral abdominal wall. At the FKiH viHen~lie the Fissura ligamenti teretis hepatis continues
to the Porta hepatis which harbours the WSC\.IIar structures to and from the liver N. portae hepatis. A hepatica propria. Ductus hapaticus communis). Cranially, the Lig. venosum {remnant of the prenatal Ductus venosus) is shown. On the right side of the Porta hepatis (hilum of the liver). the V. cava inferior is located in a superior groove and the gellbla~ dar tvMice blllarls) is embedded in the inferior Fossa vesicae biliaris. The Lig. teres hepatis, Lig. venosum, V. cave inferior. and gallbladder delineate two rectangular areas on both sides of the Porte hepatis at the inferior side of the right hepatic lobe, the ventral Lobus quadr.tus end the dorsal Lobus caudltus. The liver is not covered by peritoneum in four larger areas: Area nuda. Porte hepatis, bad of the gallbladder, end groove of the V. cava inferior. In vivo, the liver is deformable and adjusts to the shape of the surroun~ ing organs. In fixed condition. adjacent organs causa impr&Ssions which are fixation artifacts without further relevance, although they pr.r vida positional information about the liver.
105
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
Structure of the liver
Fre. 1.80
Liver, HllfNir; sagittal section through Ute right lobe of Ute liver. The vascular end bile duct structures entering the liver et the hilum N. portae hepatis, A. hepetice propria, Ductus hepeticus communis) are surrounded by connective tissue. They branch within the parenchyme of the liver, end create the GLISSON's triad {portel triad) in the portal trects !portal canelsl 1~ Fig. 6.611. The liver veins rvv. hepaticas) end their tributaries which drain the blood from the liver into the V. cave inferior course separetely from the vessels of Ute GLISSON's tried.
Fig. 1.11 Structul'lt of th•llv•r. H.-p1r; microscopic view. 1241 The structural unit of the liver parenchyma is the hepatic lobule which consists of radially oriented trab9CUiae of h.-pmcytet. The dessical almost hexagonal hlpltlc lobul• is surrounded by portal tntctJ at 1hree to si" corners. Three structures referred to collectively as GLISSON's trild (portlll trild) are always found in the portal tract, embedded in connective tissue (A. and V. interlobularis, Ductus bilifer interlobularis). The centrilobular venule (V. cerrtNiia) is loceted in the
oentre of the hepatic lobule end collects Ute blood from the liver sinusaids which originally derives the arteries end veins at the periphery of the lobule. The oentrilobuler venule then drains into the Vv. sublobuleres, which ere branches of the Vv. hepaticas. The slow radial blood flow in the sinusoids enables hepetocytes to absorb nutrients end metabolites and to secrete synthesised proteins as for example plasma proteins.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The blood flow in Ute hepetic lobules is extremely importent for the liver function. In liver cirrhosis. the structure of the hepatic lobules is altered by nodular connective tissue remodelling of the parenchyma which compromises the blood flow. The high perenchymal resis-
106
tence in Ute liver results in en increesed blood pressure in Ute portal vein ('poml hY)MII'tenllon). This condition may re-cenelise or open portoCIVIIInldltomoses (->Fig. 6.70).
Pancreas
~
Spleen
~
Topography
~
Sections
Segments of the liver
Fig. 8.82 •nd Fig. 1.&3 Setmem. of 1ttelivet, Hlplr; ventral (-+ Fig. 6.621and dorsal (-+ Fig. 6.63) views. Individual liver sagmants are coloured differently. The three almost vertically oriented liver veins (Vv. hepaticae. -+ Fig. 6.64) dMde the liver into four adjacent segments. The Segmen· tum llttlnlle corresponds to the anatomical left lobe of the liver and is bordered by the Lig. felciforma hapatis, which is adjacent to the left
liver vein. The Seementum medilll is located between the Lig. falciforme and the gallbladder at the level of the middle liver vein. To the right side, the Segmentum •ntert'us and the Seamentum ~ert'us follow and are separated by the right liver vain, which is not visible on the liver surface. The structures of the portll triad organise these liver segments into eight funetfon•l and clinically important liver menta(-> Fig. 6.64) which are indicated hera by different colourations.
•1·
107
VIscera of 1tte Abdomen
DMIIopll*'t ~ Slomocfl ~ lnllltl- ~ Uvtr ond gollllo.cldor ~
Segments of thaliv11r
I
0
...............................................
ftlli.U4 t•:aw .. l'k:tAa. . . ...., i!PM*Wid-*
........w~...-..~,.alllt
Ttwltw "~lrm .......... ::tt ... 3iPMiW~iltl«'fflltiWW 11¥ Gnt~
*""'""'It»-..,.
Cllnlc.l Rem•rta~----------------------. ln...._,. ~ tt.lwt """"'"'., d~k:tllv d ~ tW..-.ce. Tht m a1-.. ot..,.. t&f'TI~ •~~~~rH~ N ~~ ot..,_ cH::Mi '"""'*MIW ft v.t' ~"""'"~"*"111M b-lood . . . l.oc:tfiMclk ~ -...ct\ •MhlfJ I.....
ln~.n»
•
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-...c.~M~tllflltlll.l'fa!~d~_.,lll'ltl:
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Segments of 1tle liver
VI
ft
---+•
-+---
y
-
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. t,..... . . ..,.. .___.,.,._.,..
~ ftQ, &ail. OOI'IOGI~(.. F\p. t.ee.N*'l'IIIM*'I'II.IU .. F\p. 1.$1) ........ ~rowl1t a...ot1:hNcftlk:ll **"~· ITIIIMI: Ill'& IN!'bd II WI .... Wlfil R.IW!'IIn tl\1'1'1-*1 .. F\p. f .641 eo'\
fl•ltw ....-.""' ~~·-· ·~ ..,...IMJ . ~lint &ll'tdi:IN., ~" 'N ld 10M (II 'N ......
tot
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
Arteries of the liver and gallbladder
A.m--•upertor
•
•
d
f
Figs. 8.8811 to f Arterf• of th• llv•r. H.-p1r, 1nd th• aallbllclclw,
v..ic.t .bili1ril.
The liver is supplied by the A. h1patic1 propri1 derived from the A. hepatica communis, a direct arterial branch of the Truncus coeliacus. After giving off the A. gestriea dextra. the A. hepatica propria courses within the Lig. heplltoduodenale together with the V. portae hepatis and the common bile duct !Ductus choledochus) to the hilum of the liver. Here, this artery divides into the R. dexter and the R. sinister to the liver lobes. The R. dexter gives rise to the A. cystlcl to the gallbla~ dar. In 10-20% of all cases. the A. mesenterica superior contributes to the blood supply of the right liver lobe, and the A. gastrica sinistta contributes to the supply of the left liver lobe.
110
V1rl1tlons of the blood supply of the liver: textbook case b contribution of the A. mesenteries superior to the blood supply of the right liver lobe c origin of the A. hepatica communis by the A. mesenteries superior d blood supply of the left liver lobe by the A. gastriea sinistra • contribution of a branch of the A. gastrica sinistra to the blood supply of the left liver lobe in addition to the R. sinister of the A. hepatica propria f blood supply of the lesser curvature of the stomach by an accessory branch of the A. hepatica propria 1
Pancreas
~
Spleen
~
Topography
~
Sections
Veins of the liver and gallbladder
Y. galltltc:a dlldnl
V.cylltlce
Y. meeenl:llrke lnfeltor
W. )ejlllllt$; W.IIMIM
V. AICtalla aupll'lct
Fig. 8.69 Vein• of 1tle liver, H.,.r, and 1fl• e•llbllclder, Vatice bR11rlt; ventral view. The liver has an incoming and an outgoing venous system. The pol11l vein (V. portae hepatis) collects the nutrient..fich blood from the unpaired abdominal organs !stomach, intestines. Pana-eas. spleen) and feeds this blood, together with the arterial blood from the A. hepatica communis, into the sinusoids of the liver lobules. Threelivet vain a (Vv. hepatica&, ~ Fig. 6.60) transport the blood from the liver to the V. cave inferior. The portlill vein has three main tributaries: Behind the heed of the Pana-eas, the V. mesenterica superior merges with the V. splenica to form the V. portae hepatis. In most cases (70 %), the V. mesenteries inferior drains into the V. splenica; in the remaining casas (30%) it drains into the V. mesenterica superior. Branch• of the V. aplenice (collecting blood from the spleen and from parts of the stomach and Panaeas): • Vv. gastricae breves • V. gastroomentalis sinistra • Vv. pancreaticae (from the pancreatic tail and body!
Branch• of 1fl• V. m ...m.rica superiOr' (collecting blood from parts of the stomach and Pancreas. from the entire small intestine. the Colon ascendens, and Colon transversum): • V. gastroomantalis dextra with Vv. pancreaticoduodenales • Vv. pancreaticae (from the pana-eatic head and body) • Vv. jejunalas and ilealas • V. ileocolic& • V. colica dextra • V. colica media Br1nch• of 1fl• V. meaenterfc. Inferior !collecting blood from the Colon descendens, and the upper Rectum): • V. colica sinistre • Vv. sigmoideae • V. rectalis superior: the vein anastomoses with the V. rectalis media and the V. rectalis inferior, which drain into the V. cava inferior. In addition. there are veins which drain directly rnto 1tle portlll vein once the main venous branches have merged: • V. cystica (from the gallbladder) • Vv. paraumbilicales Ma veins in the Lig. teres hepatis from the a~ domina! wall around the Umbilicus) • Vv. gastricae dextra and sinistra (from the lesser curvature of the stomach)
111
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
Portocaval anastomoses
Y. portllellepde
lt.~leulnlml
V. algmolclee
Y. reddl eupelkr
Fig. 8.70 Portoca,.l •natomOMt (connHtiona .betwMn itt• portal v•ln and t!Mt V. coa sup•rlornnt.rlort. Tributaries to the V. caw superior/inferior (blue), tributaries to the V. portae hepetis (purple}. There are four possible collateral circulations via portocaval anastomoses (marl:ed by blacl: circles): • Vv. gestricae dextrae end sinistrae via oesophageal veins end veins of the azygos system to the V. cave superior. This may result in the dilation of submucosal veins of the Oesophagus (onophll"l v1riceat.
• Vv. pareumbilicales '.lie veins of the ventrelebdominel wall (deep: Vv. epigestricae superior end inferior; superficial: V. thoracoepigastrica and V. epigestrica superficialisl to the V. caw superior and inferior. Dilation of the superficial veins may appear as Caput meclus... • V. rectalis superior '.lie veins of the distal rectum and anal C8nal end '.lie the V. iliece inteme to the V. cave inferior • retroperitoneal anastomoses '.lie the V. mesenterica inferior to the V. testiculariS/overiC8 with connection to the V. cava inferior
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Increased blood pressure in the portal system (portal hyp•rten· sion; e.g. in liver cirrhosis) may cause the dilation or the opening of the above mentioned venous connections to the systemic venous system (portocaY•I•n..tomOMS). Clinically important ere the connections to the oMOph•s••l v•lns because rupture of oesophageal varices may result in llh-threltenlns ha•morrh•t•· the most com·
112
mon cause of deeth in patients with liver cirrhosis. The connections to superficial veins of the ventral abdominal well ere only of dielr nostic value. Although the C.put m.clu... is rare. the appearance is so charecteristic that a liver cirrhosis cannot be overlooked. The anastomoses to the retroperitoneal veins end to the veins of the inferior rectum end anal C8nal ere dinically not important.
Pancreas
~
Spleen
~
Topography
~
Sections
Lymph vessels of the liver and gallbladder
l)'mpholclel phrenlcl•'4*fDAIII
Fig. 8.71 Lymph v"MI• end lymph nod• of itt• I Mit end bile duct system. The liver has two lymph WSMI systems: • the subperitoneal system at the surface of the liver • the intraparenchymal system alongside the structures in the portal triad to the hilum of the liver With respect to the regional lymph nodes, there are two mejor lymph dnllnaa• routts: • in ceuclll direction to itt• hilum of itt• IMit (most important) via the Nodi lymphoidei hepatici at the hilum of the liver I~ Fig. 6.17) and from there via the Nodi lymphoidei coeliaci to the Truncus intestinalis • in cranial direction passing itte dl1phragm via the Nodi lymphoidei phrenici inferiores and superiores into the Nodi lymphoidei me-
diastinales anteriores and posteriores which drain into the Trunci bronchomediaslinales; using this drainage pathway, atrcinomas of the liver may also metastasis& into thoracic lymph nodes. There are two minor lymph dreinea• route: • to the anterior abdominal wall via the lymph vessels in the Ug. teres hepatis to the inguinal and axillary lymph nodes • to the stomach and Pancreas from the left lobe of the liver The gellblldder usually has its own Nodus lymphoideus cysticus in the area of the neck, which drains into the lymph nodes at the hilum of the liver (in the caudal direction). "The arrows depict the direction of lymph drainage from the parenchyma via the cranial or atudal route.
113
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
Liver, imaging " ·i
rI(...."" "' •• I .-r" I
I . 1,
1
v
I v: hepatica anlatnl
Pulmod_., Lobualnlerlclr
Fig. 6.72 Confluenc. of th•liwr wins. Vv. hepatic.•. with th• V. inf•riDr; ultrasound image; caudal view.
c.v•
• abdominal wall
/ '"
rJ~ -·0/ . I ~ I
Pars abdomln.ls-
Fig. ll.73 Liwtr, Hepa~r, V. portM hepati1; demoni1Ntion of the b,..nching of the porul win; ultrasound image; caudal view. • abdominal wall
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Ultrasonic aamln..lon (sonographyl of the liver is a standard diagnostic tool used by specialists in internal medicine and by r&diologists. Sonography enables a noninvasive investigation of the liver parenchyma and allows the detection of structural changes, for axample by the local or general increased echogenicity in cases of a fat-
114
ty liver degeneration in hepatitis or liver cirrhosis. Focal tumours or
cysts are also detectable. Subsequently, liver biopsies (-o Fig. 8.75) or a laparoscopic investigation of the liver (-o Fig. 6.761 may be perf ormed to raech a diagnosis.
-+
Pancreas
~
Spleen
~
Topography
~
Sections
Liver biopsy
Ffe. 8.74 Prafectlon of 1heltver. Hlp.lr. and 1he e•llblldder. V•ic. .bililria. onto 1he verttNI e.bdomin1l Will in mid-N~Piration posttron.
" position of the needle during liver puncture
Fig. 8.75 Layers of th• ch•st wall 1nd the lfver. Hep1r; frontal section; liver puncture biopsy. The ultrasound-guided puncture is performed in expiration through one of the lower intercostal spaces. Since the liver is partly covered by the pleural cavity this access reduces the risk. of a pneumothorax. To spare the intercostal neurovascular structures, the puncture is always per-
formed at the superior costal margin. The peritoneal lining covering the liver capsule receives sensory innervetion by the N. phrenicus (C3C5) from the Plexus cervicalis. This explains why patients often experience p1ln in the area of the right shoulder.
m41mHi
• position of the needle during liver puncture
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . A liver puncture biopsy is performed to determine the nature of suspicious tumours. or the stage of a hepltMis or lfver cirrhosis,
respectively. Only the biopsy enables the definitive diagnosis by e pathologist.
115
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
Liver and gallbladder, imaging
FUndllll-li:M bllll!a
Fig. 8.78 Liver, H.,.r, 1nd gallbl1clcltr. Vnfc• bfllarls; laparoscopic image; oblique caudal view from the left side.
LobUs hePt11tdu:tw·--
Fig. 8.77 Liver, H.,.r, 1nd e•llbllclcltr, Vnic• bili1ria; laparoscopic imeg&; v&ntral vi9W.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Llparoacopy is the final opportunity to inspect th& liver or to take biopsy materiel prior to th& surgical opening of the abdominal wall. Using a laperoscop& end on& or two additional entrance ports for
116
light sources. camera, or biopsy instruments, the entire abdominal cavity can be inspected and biopsies can be taken under visual control.
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the gallbladder and extrahepatic bile ducts
Duew.hepd--" ltil1---ll'-li-- Dlldllll eyd-
Fig. 8.78 Gallbladder, Velie. biliarie, and extnhe,.tic bile ci.Jcts; ventral view. The gallbladder usually holds approximately 40-70 ml of bile. It consists of a body (Corpus vesicae biliaris} with a fundus and a neck part (Collum vesicae biliaris}. A spiral fold (Plica spiralis HEISTER! at the terminal end of th& neck. closes th& opening of th& excretory cystic duct !Ductus cysticusl. which than fuses with the common hepatic duct (Ductus hepalicus communis! to form the common bile duct {Ductus choledochus).
Fig. 8.79 Gallbladder, Velie. biliarie, fttrahepatic bile ducts and duod1num, Duod1num: ventral view. The common bile duct (Ductus choledochus! is usually 6 em long and 0.4-0.9 em in diameter. It courses within the Lig. hepatoduodenale ventral to the portal vein, then runs behind the Pars superior of the Duodenum to traverse the head of the Pancreas and reach the descending part of the Duodenum. In 60% of all cases. the common bile duct fuses
with the Ductus pancreeticus to form the Ampulla hepatopancreatica, which enters the Duodenum at the Papilla duodeni major (Papilla VATERII. At its distal end, smooth muscles of the common bile duct (Ductus choledochus} create theM. sphincter ductus choledochi. The inferior part thereof, also referred to as M. sphincter ampullae lODDII, encompasses the ampulla and the entrance of the Duodenum.
117
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder ~
CALOT's triangle
A. hllplllca _,munle
A. gutloduodllnalle
Fig. 8.80 CALOrstrlangle. 1\'lgonum chol.eylltoh.,.rtrcum: caudal view.(eocording to [1)) The Ductus cysticus. the Ductus hepaticus communis and the inferior eraa of tha livartogathar form tha Trigonum chol&eyStohapaticum, also
raferred to as CALOT's triangle. In 75% of ell casas. tha A. cystica originates in this triangle from the R. dexter of the A hepatica propria end courses posteriorly through this triangle to reach the Ductus cystiCIJs and the nack of tha gallbladder.
Figs. 8.81a to c Varfdons of 1tle .bile dum reeardlng 1fl• confluenc. of 1fl• Ductu1 hepaticua communi• 1nd Ductu1
cyltil:ul. high junction .b low junction c low junction with crossing
1
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The CALOT's triangle is an important landmark. during the 1urgic11 rwmoval of the gallbladder. Prior to ramoval of tha gallbladder, all structures are identified before the A. cystica and the Ductus cysti-
118
cus are ligated. This way, the risk of an accidentelligation of en the Ductus choladochus with subsaquent stasis of tha bila {cholastasis) is reduced.
Pancreas
~
Spleen
~
Topography
~
Sections
Gallbladder and extrahepatic bile ducts, imaging Ductue lleplltlala communla
Fig. 6.82 OallblacMit, VMica biliaris, axtrahepetic bile ducts; radiograph in anteroposterior IAPl beam projection after application of contrast medium; patient in upright position; ventral view.
Ductu8 cya~Sa~a
Ductu8 chollldachua [blll11rll)
Fig. 1.83 GallblacMtt. VMfca blllarls, a well a lrrtn- and extr1hepatic bil• ducta; radiograph in anteroposterior lAP) beam projection after application of contrast medium; patient in upright position; ventral view.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . R1diDgr1phy after intravenous application of contrast medium allows the visualisation of the gallbladder and bile ducts, induding the detection of noncalcilied bile concrements. Malignant tumours of
the bile ducts (cholangiocarcinomas) or of the Pancreas {pancreatic carcinomas) may cause cholastasis which appears as dilation of the bile ducts.
119
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Projection of the pancreas
Duodenum, Para eupertor
Fig. 8.84 ProJection of th• pancr--. hncrMs. and th• duodenum, Duodenum, on the ventral abdominal wall.
The Pancreas is in a MCondary mroperftonNI p0$ition and projects roughly onto the 1" or 2nd lumbar vertebra. The head (Caput pancreatis)
is adjacent to tile Pars desoendens of the Duodenum and continues es pancreatic body !Corpus pancrealisl which crosses the vertebral column to continua as pancreatic tail {Cauda pancaatisl to tile hilum of the spleen.
a Figt. 8.8511 and .b Projection of the vitcera onto the .boclv surface; ventral Ia) and dorsal lb) views.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The lnflammatl'on of th• Pancreas (pancreatitis) is most commonly caused by an obstruction of the duodenal papilla by a gallstone
120
with resulting stasis of bile or by chronic akxlholabuse. It frequently causes a belt-like radiating abdominal pain.
Dsvela!)ment <7f the panaeas III'JI..._t»f Da II r•lfofU.J ........... llGJ
.. --
--•
-
. _ , _ . - . ...
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hrleta:l
On c111 a.a. • vwnr4 .-.4 • 4:nlf p~~~INII'4o lll.o4 ~ fKm
fl•...,.
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e P 1. ~ ~ "'
,~
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fill* .... Ttlt friiiKIICOr1 ~'IICII'IMtiit d.IMitftltMfll:l byfit Wl'liOrl d N ~~
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121
Viscera of the Abdomen
Development ~ Stomach ~ Intestines ~ Liver and Gallbladder ~
Structure and topographical relationships of the pancreas
A.; V. aplerfca (lanalla)
Duoclllnull\
_,...!..._....~_,
....,.dlecencillne
Fie. 1.87 Retroperiton"l ore1n1 of th1 1Pie11trium: p1nc,..1, PanmMs.. duocllnum. Duodenum. and on .both sides kl*t.y, Ran. and adrenal eland. Glllndulasupn~renalls; ventral view. The Pancreas is in a MCOndlry retroperiton..l position. The head (Caput pancreatis) is adjacent to the Pars descendens of the Duodenum and has a dorsal uncinate process IProc. uncinatus) which embraces the A. and V. mesenterica superior. Caudally, the Pars horizontalis of !he Duodenum is adjacent. To !he left side, !he pancreatic head continues as the panCfeatic body (Corpus pancreatis) which traverses !he vertebral column. The subsequent pancreatic tail !Cauda panCfeatisl passes over the left kidney to reach !he hilum of the spleen.
Corpue pulcredl
The Pancreas has an anterior and a posterior surface {Facies anterior and Facies posterior) which are separated by the dull upper and lower border (Margo superior and Margo inferior!. The anterior espect of the PanCfeas is covered by parietal peritoneum and forms !he posterior wall of !he Bursa omentalis. The posterior aspect of !he Pancreas is fused to the original parietal peritoneum of the posterior abdominal wall because !he Pancreas was repositioned into the retroperitoneal speca during its development. The fused area appears as a fascia during dissection.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The dose topographic411 relationship of !he pancreatic head wilh !he A. and V. mesenterica superior and the portal vein imposes the risl: of injury to lhasa vessels during 1ndoecopic m1nipul1tion of 1tle Papilla duodenr mlljor. Damage to these structures may occur
122
during endoscopic procedures when removing a bile conaement or during application of contrast medium for en endoscopic retrograde cholangiopancreatography {ERCPI to visualise !he bile end pancreatic ducts. In cese of injury emergency surgic411 treatment is required.
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the pancreas
Fig. 8.88 Pane....._ PancrMS,. and duodenum. Duodenum: dorsal view. The figure illustrates the pancreatic heed (Caput pancreatis) located in the Cshapad Pars descendens of the duodenum where it is obliquely
pierced by the common bile duct {Ductus choledochus) in its course to the Papilla duodeni major. Dorsally, the uncinate process {Proc. uncinetus) of the pancreatic head embraces the A. and V. mesenterica superior.
Fig. 8.89 Structur. of 1tle pane rea, Pane....•: microsoopic view.
The endocrine part consists of the islets of LANGERHANS {Insulae pencreaticael and is embedded within the parenchyma of the exocrine gland, particularly in the pancreatic tail. Besides other hormones, the islets produce insulin and glucagon which ere secreted into the blood end serve the regulation of the blood glucose level.
1261 The pancreas is a mixed exocrine and endocrine gland. In the acini, the exocrine part produces digestive enzymes which are delivered as inactive precursors via the duct system to reach the lumen of the intestine.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The function of the Pancreas explains why tissue damage (necrosis} in the pancreatic parenchyma has exocrine end endocrine consequences; inflammatory diseases (plncrHtttfs) for example, will
result in diaeetive problem• and fatty stools end may in cases of severe tissue loss {8o-90o/ol also cause diabetes mellitus due to the insufficient insulin production.
123
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Excretory ducts of the pancreas
Plfllla diiOdllnl
Fig. 8.90 Excretory duet system of",. p1ncrM1. PancrMs: ventral view; Ductus pancreaticus after partial resection of the Duodenum and the ventral Pancreas. The main excretory duct !Ductus pancreaticus (duct of WIRSUNG)) fuses with the terminal segment of the common bile duct (Ductus choledochus! in 60% of all cases to form the Ampulla hepatopancreatica.
The latter enters the Pars descendens of the Duodenum at the Papilla duodeni major (papilla of VATER). Developmentally{-> Fig. 6.88), en accessory duct {Ductus pancreaticus eocessorius ISANTORI Nl's duct)) exists in 65% of all cases which opens into the Duodenum 2 em proximal to the Papilla duodeni minor.
+ ---Ampulla l\ep«1opanc:A«11ea Plplla <*Iodin!
miiJO!'
b
d
•
Figs. 8.911 to f V1rl1tlons of the Junction of the Ductus p1ncretaticu• 1nd Duetu1 choleclothul. 1 long common portion b ampullary dilation of the terminal part 160% of all cases)
c short common portion d separate entrance • common entrance with septated common duct f accessory duct !Ductus pancraaticus aocassorius, 85% of all casas)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The variations in the confluence of the excretory pancreatic ducts and the bile ducts influence the courM of p1ncrMtfc ciSAMS. Besides alcohol abuse. an obstructive bile concrement in the Papilla duodeni major is the most common cause for inflammatory conditions of the Pancreas !pancreatitis). The main risk hera is the
124
autodigestion of the gland by prematurely activated enzymes of the exocrine Pancreas. In the cases of obstruction of the papilla of VATER, a separate Ductus pancreaticus accessorius may allow sufficient secretion and, thus, prevent e pancreatitis.
Arteries of the pancreas
,.. &a Al'llfiiMflltt.c,
- . ,...,,...,.,,..,
• ........... tllliV.P*f«S'gf'fl:ltliiNA. ......... ~~~~
I~Nmtfm, CW>;iQ1frq~ It I
,... ~ "&IIP'llltlod II¥._ .,. ................... fCI'
"-' ........... .,...,..*" ..... d:lwtM..,....,
..,A,J ...I~MdMitif"~fw~l'llftlf~W'I .. ~
tilt
ftl!t,...llll<: ..,.,.."'" ~~ ~AI>. ~:drl:...... 1
~~ltlrM~.-.4~1:fromfltA~ ... WI!I fi'CI!'IIM A.I*'I!CfM~·INtl'lllf ¥1!11\ aft, ~anclt fl. fCIW0'~1MAITI...,.Wk.a~.
-·'""'""....
hfWkl'ft Nlr!fWO'bofe.lt
Ttlllt~~d'N .... Hf~~~d'N Ttlt...,Mdtt.~OOI'IIMifiOiod~N .......... tl"ddl'liti'I-N
\t flWtMiot ·~ - ' dw Y, . , . lr!W fw Pl'f'Qt ....,
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Lymph vessels of the pancreas
Nodi tympholdel c:oelad
Nodllympholdlll8pl&rfcl
il-,___ Nodllympholdlll ma.al'tllrld a~parleree
Fie. 1.93 Lymphltic dr•inaa• plthw.-ye of the pencN.Ie, PanmMs: ventral view. The distinct parts of !he pancreas have separate regional lymph nodes. • hNd: Nodi lymphoidei pane«~aticoduodenales anteriores and posteriores along the identically named arteries !Aa. pancreaticoduodenah» superiores anterior and posteriori. then via Nodi lymphoidei hapatici to the Nodi lymphoidai coeliaci or directly to !he Nodi lymphoidei mesenterici superiores and finally to the Truncus intestinalis
• body: Nodi lymphoidei pancreatici superiores and inferiores along !he A. and V. splenica; from !here to the Nodi lymphoidei ooalieci end to the Nodi lymphoidei masenterici superiores. There are also connections to the retroperitoneal Nodi lymphoidei lumbalas. • teil •ament: Nodi lymphoidei splanici
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The diverse lymphatic drainage pathways explain why in cases of penmMt~ a.rcinom• usually extensive lymph node mltlltllll
126
exist at !he time of diagnosis. Since these metastases cannot be completely removed, curative surgery is not possible.
Pancreas
~
Spleen
~
Topography
~
Sections
Pancreas, imaging
A. me~a~ supQI'Iclr A. aplen~ l"lliii!J]
Fig. 8.94 Pane,..,, PencrMS; ultrasound image; oblique ~udal view in deep inspiration.
The ultrasonic examination of tile Pancreas frequently is unsatisfactory as tile retroperitoneal Pancreas is usually obscured by air-filled bowels "
V.Sic:a blliln
- +-- - - -
abdominal wall
Je)lnum
AmpiAII. he~lltopanaHik:a--
Fig. 8.95 Pane....-. Pencr..,. end .bR• ducts; endoscoprc retrogrwle chollngiop•nere.rtography (ERCPJ; ventral view. To visualise the duct systems in tile radiograph, tile excretory duct of
the Pancreas and the Ductus choledochus were filled with medium from tile Papilla duodeni major '.lie an endoscope.
e<~ntrast
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . For the im•ging of itle P•nerNI ultrasound is performed initially to detect a potential swelling of the organ as an indi~tion for pancreatitis. In ~ses of a non-<:onclusive ultrasound image, computer tomography is performed. With ERCP tile diegnosis of a Pancreas
divisum as potential reason for recurrent pancreatitis is possible. Contrast filling defects of the pancreatic duct may indicate a pancreatic ~rcinoma.
127
tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Projection of the spleen
e.st.
Utb
Fig. 8.98 •nd Fig. 1.91 Projection of itt• vitceN onto th• body turfMII; ventral 1~ FiiJ. 6.96aland dorsal 1~ FiiJ. 6.96bl views, and
view from th& l&ft sid& (~ Fig. 6.97). Th& sple&n is locat&d intr.JMf'iton..ttv in th& left epigastrium. Its longitudinal axis projects onto rib X. A normal-sized spleen is not palpable b&yond th& costal margin. Du& to its larg& contact area with the diaphr&gm, th& position of the spl&en is d&pend&nt on respiration. The spleen lies in the so-called splenic niche which is confined inferiorlv by th& Lig. phrenicocolicum betw&en the l&ft colic flexure and diaphragm c~ Fig. 6.102}.
128
lnteeclnll!l t11111e
tahir99-VRG & vip.persianss.ir
Pancreas
~
Spleen
~
Topography
~
Sections
Structure of the spleen
FlldM'WI_...Ie, Fllcleerenalllt
8.18
Fig. 8.91 and Fig. 1.99 SpiMn, Splen (Lien]; medial ventral 1~ Fig. 6.98land lateral cranial c~ Fig. 6.99} views. The spleen is a NCOndlry lymphatie oraan and plays a role in the immune system as wall as in filtering of the blood. The spleen weighs 150 g, is 11 em long, 7 em wide and 4 em high. Its convex side. Facias diaphragmatica, is adjacent to the diaphragm, its concave side. Facies visceralis, is facing the abdominal viscera, espacially the left kidney, the left colic flexure, and the stomach. The superior border (Margo supari-
or) shows indentations. whereas the inferior border {Margo inferior) is ratllar smootll. The blood vassals enter and exit at the splenic hilum (Hilum splenicum). The branching pattern of tile blood vessels reflects the segmentation of the spleen. altllough the segments can not be identified at tile surface. The spleen is anchored to tile surroundings by two peritonMI duplicatu,.., both of which insert at the splenic hilum. The Lig. gastrosplenicum connects tile spleen to the stomach end co~ tinuss as Lig. splenorenale to tile posterior wall of the trunk.
Fig. 8.100 Spleen, Splen [Lien); croswection through the hilum; medial cranial view. The spleen is covered by a firm capsule which projects trebeculetians of connective tissue towards tile centre of the parenchyma (Pulps splenical. Embedded witllin these trabeculae are the larger branches of the A and V. splenica. The splenic pulp consists of the blood-filled red pulp and disseminated "white" nodules which are collectively referred toes wttlte pulp. The white pulp contains lymphatic tissue.
Hlum tpl-*un
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Following a traumatic injury to tile abdomen, a ruptur• of th• tpleen mey occur. A rupture may result in life-threatening haemorrhage. Because of the segmental structure of the spleen, longitudinal lacerations will affect several splenic segments and cause in-
tense bleeding; transverse lacerations bleed weakly since splenic arteries are terminal arteries. This also explains the wedge-shaped area of inferction between the segmental borders.
129
tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Greater omentum
M. re«uslbdomtnb
Fund.. veetae blllu1a
Colon aacenctene, 'llNnla lbe111
Fig. 8.101 Postt:ron of thlt "'scere, Sttus "'scerum. rn 111• Epigutrium •nd the trMter omerrtum, Omerrtum m•jue; ventral view. The abdominal ~ty is opened and the Umbilicus was cut from the left side to preserve the Lig. teres hepatis between the liver and the ventral abdominal wall. The horizontal Colon transversum dMdas the abdomen in epigastrium and hvpogastrium. The viscera of the lower abdomen are almost completely covsred by the greater omentum which is attached to the greater curvature of the stomach. The Omentum is
associated with the Epigastrium because its blood supply is derived from the vessels of the greater curvature of the stomach (Rr. omentales of the All. gastroomentales;-> Fig. 8.118). The Ome~ tum majus is a peritoneal dupliceture composed of the Ug. gas-trocolicum, the Lig. gastrosplenicum and a free apron-like portion. The greeter omentum plavs a role not only in the mechanical protection and thermal insulation but also in the secretion and absorption of peritoneal fluids. It also contains lymphatic tissue end has immunological functions.
tahir99-VRG & vip.persianss.ir
Pancreas
~
Spleen
~
Topography
~
Sections
Epigastrium
Lob~ hepa.tfa •l'lllter,
Faclea dllpln.grtWtlce
Fig. 8.102 Polition of the Yiet:era, Situ• Yilcerum, in 1tte Epigastrium; ventral view. The liwr was reflected cmniallv to visualise the lesser omentum (Omentum minus). It spans between the liver and the Iasser curvature of the stomach end the Pars superior of the Duodenum. The Omentum minus consists of the Lig. hepatogastrieum and the Lig. hepatoduodenela. The letter guid&S the common bile duct !Ductus choledochus), the portal vain r/. portae hepalisl. end the A. hepatica propria to the Porta hepatis (the hilum of the liver). Behind the Lig. hepatoduodanale is the
entrance to the Bursa omentalis {Foramen omentale, marked here bye probe), a sliding space between stomach end pancreas anteriorly confined by the Omentum minus. The Omerrtum majue is attached to the greater cuM!ture of the stomach and to the Taenia omentalis of the transverse colon. It is su~ divided into the Lig. gastrocolicum {to the Colon transversum) and the Ug. gastrosplanicum {to the spleanl. The spleen resides in the splenic niche and rests on the Ug. phrenioocolicum between the left colic flexure and diaphragm.
~ dia. .t::tion link 131 tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Epigastrium with Bursa omentalis
Omertum mtnue, Lfll.hllplll~m
Meeocclon nnr.era~m
Fig. 8.103 Potition of t!Mt viiCirl, Situs viiCerum, in itt• Epigastrium; ventral view. The lesser omentum {Omentum minus) between the liver and the lesser CUMlture of the stomach was separated to shaw the Bursa omentalis. The Bursa omentalis is a sliding space between stomach and Pancreas and exclusively communicates with the abdominal cavity through the Foramen omental& behind the Lig. hepatoduodenale. Due to its confined position. the Bursa omentalis is also referred to as the wlesser sac of the peritoneal cavity". The Bursa omentalis is subdivided into four parts: • Fon~men omentllle: The entrance to the Bursa omentalis is eonfined anteriorly by the Ug. hepatoduodenale, cranially by the Lobus caudatus. caudally by the Bulbus duodeni, and posteriorly by the V. C8\lll inferior.
• Vlltibulum: The vestibule is confined by the Omentum minus ve~ trally and its Recessus superior extends behind the liver. • '"hmus: The narrowing between vestibule and main space is co~ fined by two peritoneal folds: on the tight side by the Plica hepatopan<:featica which is created by the A hepatica communis. end on the left side by the Plica gastropancreatica which marks the course of the A. gesttice sinistra. • M1ln spH« This space is located between the stomach {anterior) end the Pancreas end the Mesocolon trensversum (posterior). respectively. On the left side. the Recessus splenicus extends to the hilum of the spleen; the Recessus inferior lies behind the Ug. gastrocolicum end extends to the origin of the Mesocolon at the Colon transversum.
tahir99-VRG & vip.persianss.ir
Pancreas
~
Spleen
~
Topography
~
Sections
Epigastrium with Bursa omentalis
M-lt>n 11W!SW'llum
Fig. 8.104 Polition of the vi~eera, Situ• vilcerum, in itt• Epia11trium; ventral view. The Ug. gastrocolicum was sectioned and the stomach reflected cranially to show the main space of the Bursa omentalis. The posterior well
of the bursa is created by the Pancreas end the Mesocolon trensversum. On the left side, it extends to the hilum of the spleen (Recessus splanicus), inferiorly to the origin of the Mesocolon at the Colon transversum (Recessus inferior).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Similar to the other recesses of the peritoneal oavity, the Bursa omentalis is of clinioal relevance. Herniation of small intestinal loops (intemll herniM), dissemination of malignant tumours (peritonlll nrclnosls), or bacteria (perltonttfs) can involve the omental bursa. Therefore. during abdominal surgery, the surgeon usually inspects the Bursa omentalis.
During surslcal trlltment in the epigastrium !e.g. interventions at the PenCfeas). the surgeon can eecess the Burse omentalis in th,.. diff....nt ways: • via the Omentum minus(-+ Fig. 8.1031 • via the Lig. gastrocolicum • via the Mesocolon transversum
~ diaut::tion link 133 tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Hypogastric urn
FISXln. cell llnlln
Jejurun
'-Il--l._-
Colon~ • .,.
,_---:41-- Colan 19Mkfewn
Ileum
Fig. 8.105 Po1ition of ttM. vi~eer•, Situs viiCerum, in 1tte Hypogutrl'um: ventral view. The Omentum majus was reflected cranially to visualise the smell and large intestines in the Hvpogastrium. Thus. the intraperitoneal segments are visible: Jejunum and Ileum of the small intestine. Caecum. Colon ttansversum. and Colon sigmoidaum of the large intestine. This
figure also shows that the retroperitoneal segments of the oolon ere relocated to the posterior wall of the abdomen to a variable extent. In this case, the Colon ascendans is clearly visible. but the Colon desce~ dens is shifted further dorsally and is partially oovered by the small i~ testine. The large intestine frames the convolute of Jejunum and Ileum.
tahir99-VRG & vip.persianss.ir
Pancreas
~
Spleen
~
Topography
~
Sections
Hypogastric urn
~l~n---+~~W.
.uptdor et Inferior
Fig. 8.108 Potition of the vilcer•, Situs viscerum, in 1tte lfvllopst:rl'um; ventral view. The Omentum mejus was reflected Cfanially and the loops of the small intestine were reflected to the left side to visualise tile secondary retroperitoneal Pars horizontalis of the Duodenum. At the transition between the Ileum and the Caecum there are two spaces: tile ReCM-
sus ileoc.eulia superior is covered by the Plica eaecalis vascularis !contains a branch of the A. ileocolical. the Recessus 1'-oc.eulls lnf• rior is covered by the Plica ileoceecelis between the Ileum end the Appendix. vermiformis. Similar to tile Bursa omentalis and other abdominal recessus. small intestinal loops may be trapped here !internal hernias).
~ diaut::tion link 135 tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development
-+
Stomach
-+
Intestines
-+
Liver and gallbladder
-+
Hypogastric urn
Fig. 8.107 Potition of ttM. viiCirl, Situs viiCerum, in 1tte Hypog11trlum: ventral view. The Omentum majus was reflected Ct'8niallv and the loops of the small intestine were reflected to the right side to demonstrate the Flexure duodenojejunalis which marks the transition of the retroperitoneal Duo-
denum into the intraperitoneal Jejunum. This er&a elsa contains two recesses: Recessus duoden1ln superior end Inferior. In the right Hy. pogastrium. the Appendix vermiformis is visible. the tip of which descends into the small pelvis {descending type).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The Recessus duodenales superior and inferior are the most common sites for the herniation of small intestinal loops CllEIT'Z'a h•
nla). This herniation may result in en intestinal ebstruction file us) or intestinal infarction.
tahir99-VRG & vip.persianss.ir
Pancreas
~
Spleen
~
Topography
~
Sections
Mesenteries
Colon tnln111e1'1Um
Duode~m. Pin 81c«!dane
Fig. 8.108 MIMtlteri• of the sm1ll irrtntine, M ...ntlrium, 1nd l1rge fntettl'ne, lntestlnum cr1ssum: ventral view. The Omenwm majus and the Colon transversum were reflected cranially. The intraperitoneal small intestinal convolute of Jejunum and Ileum
was resected at the mesentery. The mesentery consists of a duplicature of the peritoneal membranes. contains the neurovascular structures to supply the smell intestine, end serves as mobile attachment af the small intestine to the posterior abdominal wall.
~ diaut::tion link 137 tahir99-VRG & vip.persianss.ir
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Secondary retroperitoneal organs
Fig. 8.1 ot Postt:ron of ttt. second•rv rftroper(tonHI org1ns; ventral view. The stomach was remowd, Jejunum end Ileum were resected at the mesenteJY, and Colon transversum end Colon sigmoideum were sectioned. Most of th& secondaJY retroperiton&el organs er& now visibl&.
These include the Duodenum !except for the Pars superior), the Pa~ cress, th& Colon asoendens. end th& Colon dascendens. and th& R9<> tum to the Flexure secrelis. Anterior to th& Rectum. the opening of the ExG8Vatio rectovesicelis can be seen. This peritoneal pouch is the most inferior part of the peritoneal cavity in men.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In an upright position !seldom in bedridden patients), in the most inferior ex:tension of th& peritoneal cavity, the ExciYitio rectovati· cali• in men. and th& ExCIYitio Ndouterinl (pouch of DOUGLAS) in women I~ Fig. 6.11 0), may accumulate inflammatoJY exudate or
pus in oases of inflemmatoJY events in the Hypogastrium. By ultra· sound (abdominal. transvaginal) examination. this oan be detected as free fluid in the abdomen.
Pancreas
~
Spleen
~
Topography
~
Sections
Posterior wall of the peritoneal cavity
[Uel11
PUcellllocucella
Ureter
Fig. 8.110 Donal wall oUh• perftonAI cnlty, C.Witas ra-ritonAiil,. with recnMS, RMeaUa, 1nd tpiMn, Spl•n [Li•nh ventral view. Liver, small and large intestines were removed except for tile Duodenum to e)CJ)Ose the dorsal wall of tile peritoneal cavity. The peritoneal lining over tile right l:idney and the Pars descendens of tile Duodenum is clearly visible due to its shiny surface. The attachment areas of the seoondary retroperitoneal Colon ascendens and Colon descandans are lacl:ing this peritoneal lining. The peritoneal duplicatures form the relief of the dorsal wall of the peritoneal cavity as folds (Plicae} and ligaments and create diverse recesses (Recessus). The largest of tllem is tile BurM omentlllls (~Fig. 6.103), the portions and extensions thereof are visible here. At tile area of the Flexura duodenojajunalis, the Plicae duodenalas superior and inferior form two recesses (RICNIUI duoden11M superior and
lnferfor). Further recesses (peritoneal gutters) are located at the e~ trance of the terminal ileum into the Caecum {Recntul iliocaect~lll sup1rior end inf•riorl end occasionally another recess is located inferior to the Mesocolon sigmoideum IRecenus lnterslgmofdeus). Anterior to the rectum. a deep peritoneal space exists which is oo~ fined by the uterus end the broad ligament at the ventral side. This Excavftfo rectouterfn1 (pouch of DOUGLAS) is tile most caudal recess of the peritoneal cavity in woman. The ventrally positioned Exc• mlo vnrcouterfn• between urinary bladder and Uterus does not extend downwards as deeply as tile ExG8V8tio rectouterine. Between the Flexure duodenojejunalis and the right Fosse ilieca. the 12-16 em long root of tile mesentery !Radix mesenterii) is attached. It contains the blood vessels supplving the small intestine fAN. mesenterica superior). The root of the mesentery trevarses the Pars horizontelis of the Duodenum and tile right Ureter.
~ diaut::tion link
139
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Arteries of the abdomen
Pin •~ctomtrwtla 80itH (Acrta llbdomlrwlll) R. oeeophlgellflll
A.eplantca
(lerwtla)
Fig. 8.111 Atteri.. of the llbdomin1l vill*'e; eemiechem.tic lllultrdon; ventral view. The most important anastomoses are marked by black circles. The three unpaired arteries to the abdominal viscera derived from the Aorta abdominalis are the Truncus coeliacus, the A. mesenterica superior. and the A. mesentarica inferior. The A mesenteries superior has its origin directly below the Truncus coeliacus {hera not shown due to semischemalic prasentalionl. Its respective branches are described on the following pages. All three arteries anastomose with each other and with branches of the A ilieca interna. This may prevent ischemic infarction in casas of an occlusion of one of these vessels.
140
The 1n11tomo... are: • connections between the Truncus coeliaws and the A. mesenterica superior via Aa. pancraaticoduodenalas t•). • connections between the Aa. masentericae superior and inferior: RIOI.AN's anastomosis between the A. colica media and A. colica sinistra 1...1. • Plexus of r&Ctal arteries: here the A. rectalis superior from the A. mesenterica inferior connects to the Aa. rectalas media and inferior from the A. ilieca intama ('""').
Pancreas
~
Spleen
~
Topography
~
Sections
Veins of the abdomen
Vv. gutllale b r -
V: •plerfca (len~lll)
V. col lee meda
V.colca-
Vv. rectal• lnfllficnll V: appendlcullrla
Fit. 1.112 Portlll vein. V. portlle hepds, wMh ~rlbuurfes; Mmilchematic illuuration; ventral view. The tributaries of the portal vein are described in detail in -> Figure 8.69.
141
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Truncus coeliacus
Fig. 8.113 Truncu1 coeli1cue; ventral view; after removal of the Omentum minus. The Truncus coeliacus derives as first unpaired branch from the Aorta abdominalis. In the retroperitoneal space behind the Burse omentalis ills short (mostly 2-3 em) trunk divides into the three major arteries which supply the viscera of the Epigastrium (Gaster, Duodenum, Hepar, Vesica biliaris, Pancreas and Splen): • A. gastrlce sfnlstre: branches off to the left and superior side. It anastomoses with the A. gastrica dextra at the lesser curvature of the stomach and is usually the stronger vessel. • A. hlpltlca communis: tums to the right side and dMdes into: - A. hepatica propria: releases the A. gastrica dextra and supplies liver and gallbladder lA. cystical - A. gastroduodenalis: descends behind the Pylorus or Duodenum. dMdes into the A. gastroomentalis dextra to the greeter curvature of the stomach and the Aa. pancreeticoduodenales superiores anterior and posterior which anastomose with the A. pancreaticoduodenalis inferior from the A. mesenteries superior to supply the head of the Pancreas and the Duodenum. • A. eplenica: courses to the inferior left side at the superior border of the Pancreas and releases the following branches during its course to the spleen: - Rr. pancreatici for the Pancreas - A. gastrica posterior to the stomach 13o-60% of all cases) - A. gastroomentalis sinistra: courses from the left side to the greater curvature of the stomach and anastomoses with the A. gastroomentalis dextra - Aa. gastrici breves: short branches to the fundus of the stomach - Rr. splanici: terminal branches to the spleen
blllllfa
A. gullrclduaolnallll' A. ga~troomeralla d -
Fia. 8.114 BNnch• of the Ttuncue coeliecua.
Pancreas
~
Spleen
~
Topography
~
Sections
A. mesenterica superior
RJOI.AN'e uulltomoele
......
Fig. 1.115 A. mMintllrlee superior; ventral view; Colon transvarsum refleetad cranially. (acoording to [1 D The unpaired A. mesenteries superior branches off the Aorta abdominalis directly below the Truncus coeliacus, courses retroperitoneally behind the Pancreas and then enters the mesentery. Its branches can be displayed if the mesentery is opened and the adipose tissue between the vascular artades is removed. It supplies parts of the Pancreas and Duodenum, th& entir& small intestine, and th& large intestine up tx1 the left colic flexure.
BranchM of the A. meHnterlee superior: • A. pa~ncnlticoduoclenllia inferior: branches off to the superior right side; R. anterior and R. posterior anastomose with the AIJ. pa~ creaticoduodenales superiores anterior and posterior{... Fig. 6.116). • All. jejun11H {4-5) and AI. il11lea {12): directed to th& left side • A. colic.~ media: originates on the right side and anastomoses with the A. colica dextra and with the A. colica sinistra !RIOLAN's anastomosis) • A. colic.~ dextN: courses to the Colon ascendens • A. Reocollca: supplies the distal Ileum, Caecum and Appendix vermiformis (A. appendicularis)
143
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
A. mesenterica superior
A.~-
A. heplltta communa
A.; V. apiW!Jea DIW!als)
v.-rnt.nor
Llg. gaatmcollcum
Fig. 8.118 Origins of the A. m...,.teric• superior •nd Truncus CCNIIIHUS: ventral view; after relleclin!il the stomach cranially and dissecting the Pancreas. Following its origin from the Aorta abdominalis inferior to the Truncus coeliacus, the A. mesenterica superior descends behind the Pancreas
and enters the mesentery anterior to the Duodenum. The Pancreas was sectioned to show the A. and V. mesentarice superior ventral to the Pro c. uncinatus of the Pancreas. The A. mesenterica superior su~ plies the A. pancreaticoduodenalis inferior as its first branch to the right side.
Pancreas
~
Spleen
~
Topography
~
Sections
A. mesenterica superior
Fig. 8.117 Courw of 1fl• A. and V. mnenterlea superior; ventral view; after opening of the mesentery with the Colon transversum reflected cranially. Within the mesentery, the A. mesenterica superior gives rise to the following branches: Aa. jejunales and Aa. ileales to the left side. A. colies media, A. colica dextra, end A. ileocolica to the right side. All arteries form arcades at different levels of their dMsions. This allows the mobility of the intestinal loops. At the left colic flexure, the A. colica media forms a functionally impon.rrt •n11tom01i1 (RIOLAN'e
•n..tomoeie) with the A. colica sinistra from the A masanterica inferior. This facilitl!ltes the formation of collateral circulations in the case of occlusion of one of the arteries. The anastomosis between the two arteries in one of the arcades close to the intestines is occasionally referred to as DRUMMOND's anastomosis. In the dinical jargon, all anastomoses in the area of the left colic flexure era summarised as RIOLAN's anastomosis. The venous branches correspond to the arteries.
~ diaut::tion link
145
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
A. mesenterica inferior
Fig. 8.118 A. mMenterlea rnflrlor; ventral view; Colon transversum reflected cranially. (according to [1)) The unpaired A. mesenteries inferior branches off the abdominal aorte approximately 5 em above its bifuroation and turns to !he left side. Wilh the exception of a short terminal section, !he A mesenterice inferior descends into !he retroperitoneal spece to supply !he Colon descendans and the upper Rectum.
BranchM of 11!1 A. miHnterlea Inferior: • A. colic. liniltra: ascends along the Colon descendens end anastomoses via the A. colica sinistra wilh the A. colioa media from !he A. mesenteric& superior IRIOLAN's anastomosis) • Aa. siemoidue: several branches to !he Colon sigmoideum • A. rectalia superior: descends to the upper Rectum end supplies the rectal cavernous bodies in the submucosa !Corpus cevernosum recti) which are a part of !he continence mechanism.
Pancreas ~ Spleen ~ Topography ~ Sections
A. mesenterica inferior
A.; Y. collcalllnlltn.
A. col lee. lllnlltn.
A.;
v.
""*"
.upertw
Colon aiQmOideum
Fig. 8.119 Courw of 1fl• A. and V. mnenwrlea Inferior In ~h• N~roperltonNI tfHICe; ventral view; Colon transversum reflected cranially and small intastinalloops to the right side. Following il:$ origin above the aortic bifurcation, ltle A. mesenterica inferior descends in the retroperitoneal space and releases first ltle A. oolica sinistra to the left side, then several Aa. sigmoidaae and finally the unpaired A. rectalis superior.
The A. eolica sinistra asoands along the Colon deseendans, forms arcades and anastomoses with the A.
~diaut::tion link
147
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Abdomen and pelvis, median section "-.--:
_...J
•
...........
~~··~:;;.·-......•.
!
't~ . .: -~:i
_.....\ , ... ·:i /\ ,)i i
\
.}J
!lir~..4--
Qlllter, Cll'dle.
1+---'H--
Fomblel!lltlf-
YJ.~~+-- PIIIICt'MII, Ductua p1ncree!lcua
lt...,;.,ll--++-..-..:.....l\,----..11--li-r+--
!line. 011111'11111111 Colen
'"'ll8V...Il!l
ooi!H- - Omemum 1111)118 ~.;....-- Pll!toneum \118Qnle
-'ti--Anutua umbltlcall -if"""rl~-
Cnlta perftonMb
M. aphl'u:ter ant exll!mua M. aphlncter anttntemua
Fig. 8.120 AbciDmen. Abdomen. •nd pelvfs. PeMs. of • m•n: median section; view ftom the tight side. This illusl18tion shows chiNltly that the petitonliNll cavity (Cavitas petitonaalisl is not a wide empty space, but rather consists of small recesses
148
between tile intraperitoneal viscera. Also tile Bursa omentalis between the stomach and the Pencteas is only a netrow space with peritoneal lining. A large portion of the abdominal cavity is ocrupied by the mesa~ tery which may accumulate plenty of adipose tissue.
Pancreas -+ Spleen -+ Topography -+ Sections
Abdomen and pelvis, sagittal section "-.
,--<..,~?:'\ ' \. .} \
\. .
~-~-r--
t\ . '\ l;,•
I
V. CIIV8.Infa1ar
!.ti.l---- ~-=~~~Iii~~~~ ~]__jJA~~-J:;f.ir}j Omertl.lm ....,,., Ug. gUnx:ollcum
---&...,_--,!~
A. hepalk:a propria
~-- DUCUJs choledochus [bllllrts]
Bl.- -
v. renals dex1l'l A.IWIOIIII dexlnl
Caput pancnoatla, Proc. ..,clrmue
Colon 11'1!\IMII'SLm Oment1111...,,.
V. mesel'bl1ca sl4*1or A. me""rt.1ca auperlar
A. llaca communis V. lleca comm..,B
M. levator an~ M. pubccoceygeus
Fig. 8.121 AbciDmen.AbciDmen. and pelvis....lvls. af • man; sagittal section; view from the left side. This is a right paramedian section at the level of the V. cava inf erior. Thus, the confluence of the liver veins Wv. hepaticas), which drain the
rv.
venous blood from the liver, is clearly visible. The portal vein portae hepetis), which brings the nutriant~ch blood from the unpaired viscera to th a liver, arises from the canfl uenca of the two main tributaries bahind th a pancreetic heed.
149
Viscera of the Abdomen
Development .... Stomach .... Intestines .... Liver and gallbladder ....
Abdomen and pelvis, frontal section
1L CIMI irlf
A. hepallca propr11 A.; 1L gdl1cl alnlalnl Duodllnum, Plnlauparlar
Colon ascenclens
A. me11nlel1ca superior A.; V. meea- aLperla
Fig. 8.122 Abdam•n. Abdom•n. and ]MIIvls. P•lvls. of • m•n: frontlil HCtion through the anterior p•rt; ventral view.
150
This is e frontal section through the portal vein IV. portae hepatisl which oou rs as above the pencraetic head (Caput pa ncreatis) ta th a hilum of the liver and divides into a right and a Iaft branch.
Pancreas -+ Spleen -+ Topography -+ Sections
Epigastrium, frontal section
Pulmo d - , L..cbus hlwlor
Pulmoshlsi.-
Lobus
•"'*""
{ L..cbus hlwlor
Pumo d_., L..cbus medl.ls
L.Jg. tnlngulanl olnlotrum
DlaplnQma
NodllymphokMI aplenlcl
Nn. aplulchnlcl ma)llr at minor
A.; V. aplenlca Plllnalls]
Fig. 8.123 AbciDmlnal colty. C.vtta abciDmlnalls. and lnt.rlor thoNX. Cavill• thor1ci1; frontal section at thei9VBI of the kidneys; dorsallliew. The section shows the topogrep hical relationships of the epigastric viscera. The right Epigastrium is entirely occupied by the right lobe of the liver (Lobus hepatis dexter) which contacts the right kidney (Ran) and
the right adrenal gland (Glandula suprarenalis) at its caudal aspect. On the left side, the cranial part of the left hepatic lobe covers the stomach (Gaster) which, in turn, contacts the spleen and caudally the left kidney, the left adrenal gland and the Pancreas. The pancreatic tail extends towards the spleen.
151
Viscera of the Abdomen
Development .... Stomach .... Intestines .... Liver and gallbladder ....
Epigastrium, sagittal section '-·<
,/.-.<' :.~:. . . \
Pumo d - , lAbus 1n11111or
Fig. 8.124 Abclam•n. Abdom•n: sagittal section through the right epigastrium at the level of the kidney; view from the right side. The right epigastrium canteins the right lobe of tha liver {Hepar, Labus dexter) which has extensive cantacts with the inferior aspect of the
152
diaphragm. Dorsal and inferior tn the liver, the kidney (Renl is located in th a retroperitan eel space; ventral thereaf the Pass pyloric11 of the stomech {Gaster) is located in the intraperitoneal cavity.
Pancreas -+ Spleen -+ Topography -+ Sections
Epigastrium, sagittal section "-.
,--<..,~?:'\
Pa1carclum
PUimo slnlabr, L.cbus lnlertcr
Omentum IIIIIIILII.---r Ug. gastrwolk:um
Fig. 8.125 AbciDmen.AbciDmen; sagittal section through the left epigastrium at the laval of the spleen; 'View from the left side. The stomach {Gaster1 OCCI.Ipias the major part of the left Epigastrium. It is covered ventrally by the left lobe of the liver {Hepar, Lobus sinister)
and contacts the spleen and the left kidney !Ran) at its dorsal side; the left kidney is located in the retroperitoneal space. Lined by peritoneum, the Bursa omentalis farms a small recess behind tha stomach.
153
Viscera of the Abdomen
Development~ Stomach ~ Intestines~ Liver and gallbladder~
Epigastrium, transverse sections
~~-::~""'. !
't~ ....: -~~i
\
_,1.8
"'' '-- - M. obllqwa
lbdemrlle
Com VIII V: eparfca Oillnaill) A. •planlca (lan~~llll)
.,..Min 1h0nlelca lO, Pro<:.~~~~~~~ e~r
1.121
'Aittbi'I~Xl
Pnlc. Xlpholcilua - - -
- - - M. rectuaabclomlrfa
Hepw, I.Qbutelnlabr - - Co91l V I I - - -
H'l)llr, LobutdiXtw----
---Geltet
- - - Sllltn [lllln)
Pa'lllumlllllllldllptng..-
1.127
Fig. 1.121 •nd Fig. 1.127 Abdomin•l cmty, Cmt.. .tldomin•lie; tranS\Ierse section at the level of the 11 111 thoracic vertebra 1... Fig. 6.126} end corresponding computed tomographic section (CT; ... Fig. 6.127); caudal view.
The liver oceupies the entire right epigastrium end with its left lobe extends to the left anterior side of the stomach {Gaster). Posterior to the stomach end lined by peritoneum is the Burse omentelis. The spleen is cut in the left Epigastrium.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Sectional imaging as shown here for computed tomognrphy {CTI is established routinely in diagnostic procedures. It allows !he imaging of soft tissues without contrast medium end is less prone to disturbances than ultrasound imaging which may suffer from decreased resolution by certain conditions such es air-filled intestinal
154
loops. Therefore, CT imaging is used as additional diagnostic tool end in preoperative planning. According to convention, CT images ere •IW1l'P ehown in auclll yjjM, For didactic end practical purposes, it is advisable to study anetomia~l sections also in caudal view.
Pancreas
~
Spleen
~
Topography
~
Sections
Epigastrium, transverse sections M. ntetua abdomlnla, ~Ina muea~ll ntettllbdomtnta M. U'III'IIMII'SUS llbdomlnl8
Aen, C.paulll adlpoea hemllll':ygoe; N. aplllnc11nlalaiTIIIJOf Df•PinGmt: N. •pllnclrllals mln
Peritoneum Perkrlneum In 11!8.,.. tlf 111• BUJ'$11 Q1!M!111118
1.121
Hepar,I.J)b~~S~ delcter -
--
v. ()QI1U hepa.Ua - - - iii~iiii V. cava t1f~Nfcr - - -
Pant tlmballl dllptn.gme.tta - - -
Co91&X---
M. unamuadOI'III - - -
Ren-
---M.--9PtlM
1.129
Fig. 8.128 •nd Fig. 8.129 Abdomin•l cmty, Cmt.. .tlciDmin•lie; tranS\Ierse section at the level of the 1" lumbar vertebra(~ Fig. 6.1281 and corresponding computed tomographic section (CT; ~ Fig. 8.129); caudal view.
At the level of the pt lumbar vertebra, additional viscera ere visible, such as the superior poles of the kidneys IRani and the Pancreas. The Pancreas is loceted posterior to the stomach, separated by the Bursa omentelis, end extends to the left side until it reaches the hilum of the spleen.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . For the examination of the Pancreas, ultrasound imaging is often not very informative due to the air-filled intestinal loops. The CT is performed to find or confirm the diagnosis of pancreatic conditions
such as inflammatory disease (pancreatitis). when oedematous or cystic swelling of the organ is detected. CT imaging is also used to monitor the progress of pancreatic diseases.
155
Viscera of the Abdomen
Development
~
..•
~
Sections
Epigastrium, transverse sections
Pan eomllt claptnQmaUs\ ru.c-1111 eostodlap!ngmll1k:us
COICII Vlll - --F---.W
Yellca ~llllfelfellllJ -
IX
-F---tiH.I
8.130
JejunLm
V. cwalrlertof
V: renal Ia Co!p!Ja - - tlmballa 1
Hepr, I.Qbua dexter
1.131
Sin LIS 1111111111
Ren Ran
Fig. 1.130 •nd Fig. 1.131 Abdomin•l cmty, Cmt.. .tldomin•lie; trenS\Ierse section at the level of the 1.. 1umbar vertebra (-> Fig. 6.130) end corresponding computed tomographic section (CT; ~ Fig. 6.131 ); caudal view.
156
Typically, the hilum of the kidney (Ran) is located at the level of the first two lumbar vertebrae (recognised by the confluence of the left V. renalis). The gallbladder (Vesica biliaris) is sectioned at the inferior border of the liver (Hepar). In the left Epigastrium, portions of the small intestinal Loops (Jejunum) and portions of the large intestine (Colon transvarsum and Colon descendensl are visible.
Pelvis and Retroperitoneal Space Kidney and Adrenal Gland . . . . . . . . 160 Efferent Urinary System ........... 174 Genitalia.. . . . . . . . . . . . . . . . . . . . . . . . . . 182 Rectum and Anal Canal . . . . . . . . . . . 220 Topography . . . . . . . . . . . . . . . . . . . . . . . 228 Sections .......................... 236
Pelvis and Retroperitoneal Situs The pelvis (Pelvis) is designed to fulfil two purposes: On the one hand, it has to bear the weight of the viscera in humans exhibiting an erected posture. Hence, a solid, weight bearing, possibly bony floor would be reasonable at the caudal aspect of the abdominal cavity (Cavitas abdom inalis]. On the other hand, with regards to the alimi nation of products by the intestines and the kidneys, the act of procreation, and in particular childbirth, a rigid closure is not practical. The ·constructive" compromise is the Diaph ragma pelvis: a funnel-shaped group of muscles at the bottom of the pelvis, which is perforated in the midsagittal plan a by the Urethra, the Rectum, and the Vagina in females. To review the retroperitonHI situs of the abdomen- including the organs, which are not situated in the abdominal cavity, but at the dorsal wall- along with the pelvis, has a good [ontogenetic] reason. The kidneys, the major organs of the retroperitoneal space, initially originate from the pelvis and ascend to a level just i nfa rior to the ribs. Conversely, the gonads, i.e. testicles (Testes) and ovaries (Ovarial, descend from the abdomen into the pelvis and in men evan further down into the Scrotum. Thus, the subperitonaal [sea below] connective tissue spaces of the pelvis and the retroperitoneal space form a continuum. In order to gain insight into the regions addressed in the following, radical dissection steps are n acessa ry to soma extent: The small and large intestines have to be removed or at I east mobilised so that they can be cleared from the posterior abdominal wall. Soma dissectors evan remove a II organs of the epigastric region at once.
The View into the Pelvis The so-<:alled greater pelvis (Pelvis major, between the wings of the ilium) seams to be almost empty after the removal of the intestines. The psoas major muscle (M. psoas major) is accompanied by the Vasa iliaca externa and spans from the lumbar spina down to the inguinal reg ion flanking the entrance to the Iesse r pelvis [Pelvis minor]. In contrast, the caudally narrowing fun n al-s hapad Iasser pelvis is not vacant, especially in women. Ventrally, immediately behind the Symphysis pubica, lies the fundus of the urinary bladder (Vesica urinaria). In women, the Fundus of the Uterus is located immediately posterior to the urinary bladder. Bilaterally, two uterine (FALLOPIAN) tubes (Tubas uterinaa] ascend from the Uterus towards the ovaries [Ovarial, which they embrace with their fimbriated projections. The ovaries are located bilaterally at the pelvic wall, just i nfarior to the boundary between the greater and the lesser pelvis. The rectum (Rectum) is positioned between the urinary bladder, the Uterus, and the dorsal pelvic wall (i.e. the sacrum), respectively. The body of the Uterus as wall as the uterine tubas and the ovaries are located in separate pa ritoneal du pi icaturas/m asenteri as (" M asos ") in the abdominopalvic cavity (Cavitas peritonaalis pelvis! which project at various depths towards the actual pelvic floor. In women, there is a particularly deep recess between th a rear wall of th a Uterus and the frontal wall of the Rectum, the Excavatio rectouterine. The fundus of th a bladder and the upper portion of the Rectum are covered by peritoneum. Incising the peritoneum and dissecting the above-mentioned pelvic organs reveals the su bperitoneal space of th a pelvis (Spatium extraperitoneale pelvis!. The lower parts of urinary bladder, Uterus, and Rectum are located within this connective tissue, as well as the tam ala Vagina and the mala accessory sax glands [in particular the
158
prostate gland (Prostata( and the seminal vesicles (Glandulae vesiculosaall, respectively. Branches of the A. iliaca interne and numerous nerves that supply the pelvic organs, but also the lower extremities, extend into this subparitonaal connective tissue. Mobilisation of the blood vassals and organs exposes a muscular pelvic floor, the Diaphragm• pelvis. which is perforated by the Urethra and Vagina (if present). It is like a deep, laterally compacted funnel. At the deepest point of the cone, the Rectum perforates the funnel. The M. levator ani is the muscle that forms a large part of the pelvic floor, and is able to (voluntarily!) raise and lower the Anus by a few centimetres. Balow the walls of the pelvic diaphragm, virtually in the "basement" of the pelvis, lias the perineal region [Regia perinaalis]: Tracing the urethra (Urethra) one reaches the anterior perineum. the urogenital triangle [Regia uroganitalis]. The roots of the cavernous bodies of the Penis, which bears the male Urethra, originate in and protrude from this region. This region also encompasses the cavernous bodies of the Clitoris enclosing the opening of the short female Urethra. The posterior perineum, the anal triangle (Regia analis), is located below the pelvic diaphragm to the right or left side of the Rectum. It contains large, adipose-filled pits called Fossae ischioanalas. They resemble cranially pointing pyramids with their bases directed caudally with respect to the Rectum. Major nerves and blood vessels are traceable in the Fossae ischioanales, supplying the organs of the perineal region [i.e. Penis, Clitoris, Labia majora and minora, Vestibulum vaginae, and Anus).
View of the Retroperitoneal Situs Removal of the parietal peritoneum and the underlying adipose tissue first reveals the inferior vena cava W. cava inferior, slightly to the right side of the vertebral column) and the abdominal aorta (Aorta abdominalis, immediately to the left side]. Both are reminiscent of an "upsidedownY", bifurcating atthe level of the lower lumbar vertebrae into the Aa. and Vv. iliacaa communes, i.e. the iliac arteries and veins. The V. cava inferior has several tributaries; in the upper third especially the two renal veins (Vv. ranales) and the short hepatic veins (Vv. hepaticas) are remarkable. The Aorta abdominalis has likewise many branches. The large vassals are densely covered with lymph nodes and lymph vassals that rise as paired Trunci lumbales from the pelvis. At the laval of the branching renal vessels, the Trunci lumbales merge in the Cisterna chyli, which also receives the lymph of the intestines, to form the thoracic duct (Ductus thoracicus). The kidneys [Ranes] and the adrenal glands are located bilaterally in a perirenal fat capsule (Capsula adiposa) just below the diaphragmatic dome. Dorsal to the upper pole of each kidney lias rib XII. Medially, the Vasa renalia enter the kidneys at the hilum. The Ureter exits at the hilum descending into the pelvis along with the vessels of the gonads. The vessels of the gonads arise from the Aorta and enter- in a fascinating asymmetrical fashion (and therefore popular as an exam question) -the left renal vain and the V. cava inferior. Above and medial to the upper pole of the kidneys are the adrenal (suprarenal) glands (Glandulae supraranalas] which constitute endocrine glands that produce steroid hormones {e.g. cortisol) and catecholamines (adrenaline (epinephrinall.
Clinical Remarks---------. Two medical specialists, the ~&ecologist and the urologist, ere involved in the treatment of diseases of the urogenital tract. Detailed knowledge of the topographical anatomy is required for the interpretation of radiological and ultrasonic images and during surgery, such es resection of the kidney, the Uterus, or the prostate gland in cases of malignant tumours. Ptoltric ctl'o clnoma• are among the three most common malignancies in men. Beceuse they usually dwelop from the peripheral zone of the prostate gland, the simple digital rectal eX8mination already provides important diagnostic information. Even more common ere the benign tumours of the prostate gland (benian prostatic hypwpllltlla) which occur in almost all male individuals over 70 years of age. Since the hyperplasia occurs in the transitional zone of the gland surrounding the Urethra, problems with micturition are early symptoms. In women, lnfllmmlltory procn!llft of ~he u~erin. (FALLOPIAN) hlbe and ~M ovary need to be considered in addition to en appendicitis as potential causes of pain in the right lower abdomen. These eX8mples demonstrate the clinical relevance of topographical anatomy of the pelvis.
-t Dissection Link It is useful to dissect the pelvis from the outside end from the inside in order to trace pathways that emerge from the pelvis. The Regio glutealis, the Regio perinealis with the Fossa ischioanalis, and the perineal cellities including all pathways ere dissected frGm ~he outlide. From 1tle lntilcle, the parietal peritoneum is removed together with the perirenal fat capsule including the anterior fascia up to the lesser pelvis. Kidneys end adrenal glands are exposed from the Capsule adipose; the Ureter and the retroperitoneal neurovascular strucktures with their branches are traced. For proper dissection of the pelvis, it is useful to perform e midsagittal cut in order to split the pelvis into two equal parts. The urinary bladder and the Rectum are mobilised from the connective tissue of the subperitoneel space but remain attached to the blood vessels. The branches of the A. iliaca interne are to be presented as a whole. Some branches exit the pelvis via the Foramina suprapiriforme end infrapiriforme and enter the Regio glutealis end the Regio perineelis. At last, the pelvic floor with its muscle layers is exposed.
EXAM CHECK LIST
• Development: kidney, internal and external genitalia {major steps) • topography: positional relationships at the organs in the retroperitoneal apace and the pelvis, composition of the pelvic floor, organisation of the Regio perinealis, sectional imaging with CT • organs: all organs with neurovascular pathways including the lymphatic drainage (in particular Testis and Ovarium), Anua (including zones) and continence organ, organisation of the Ureter and Urethra with constrictions, Uterus and ligaments, Corpora eavemoaa penia with erection, male acceaaory aex glands with excretory ducts • vascular pathways: Aorta with branches, V. cava inferior with tributaries, Ductus thoracic us with lymphatic trunks, Plexus lumboaacralis with individual nerves and autonomic nerve plexuses around the Aorta
159
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Organisation of the urinary system Fig. 7.1 1nd Fig.'7.2 Organiution of the m•l• 1~ Flg.7.1) and1hefiHTiale (~Fig. 7.2) urinary system; latiN'III ¥lew from 1he left side. The urinary svmem comprises the p~~ired ki~ nays (Ran [Naphros)), producing the urine, and the efferent urinary tracts. These consist of: • renal pelvis (Pelvis ranalis} • Ureter • urinary bladder IVes~ urinarial • Urethra Except for the Urethra, the urinary system is oonstructed identically in both sexes. The Urethra within the male penis provides the exit of urine as well as semen. Thus, the male Urethra also belongs to the external male genitalia.
Organa !J81'ftalla mMa~llnalntema
Tub~:'!i)
51-- -+rH:--- T - - - - CMII!um
orvan• a•rtta•• f•mtntna tntwna ~u~---~~~
~~n~·--~~~~
+---7'----+--+---Vqtna
7.2
Figt. 7.3al 1nd b M•l• 1nd fem•l• enciDcrlne org1ns; ventral view. The adrenal gland {Glandula suprarenalisl does not belong to the urinary organs but to the endocrine glands. Several vital steroid hormones such as aldosterone (mineralooort~ id) and cortisol (gluoocorticoid}, as well as catecholamines !epinephrine and norepinephrine} are produced in the cortex and medulla, respectiwly, and released into the blood. Since the adrenal glands are adjacent to the kidneys and are. in pllrt, supplied by the same neurovascular structures, the adrenal gland is discussed here, too. b
160
y
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Projection of kidney and adrenal gland
Flas. 7.4a and b ProJection of 1ft• ¥1Kenl onto the body surtac.; ventral Ia} and dorsallbl views. Kidneys and adrenal glands are located in a r.trop•ritonMI poaition. The adrenal glands are adjacent to !he superior pole of the kidneys and
are embedded in !he common adipose capsule {Capsula adipose!, which is furlher enclosed in a sheath of connective tissue {Fascia renalis, GEROTA's fascia).
Fla. 7S ProJHtfon ofttt. lddnifYonto1fl•dorNII body wall. • superior pole: 12th lhoracic vertebra, rib XI • hilum: 2nd lumbar vertebra • inferior pole: 3n~ lumbar vertebra These positions only apply for the left kidney. Due to the size of the livar, !he right kidney is located about half a vertebra furlher down. The superior pole is thus positioned just below rib XI Because of !he proximity of the diaphragm, the position of bolh kidneys changes during respiration and moves about 3 em lower during inspiration. The adrenal glands project onto the heads of ribs XI and XII.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . During physical examination a first step in assessing the pain sensitivity of the kidneys may be a well-dosed punch into the region of the kidneys in !he flanks just below !he inferior margin of the rib cage. However, !he patients must not be warned in advance to prevent tension of the back muscles which would result in a cushioning of
the impact. In !he case of an inflammation of the renal pe"-is {pyel~ nephritis), the patient will wince and report considerable pain in response to the punch. Even if carried out correctly, this examination can challenge the relationship between patient and physician.
161
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Development of the kidney
Meeoneptrlc ~m with meeor>epllrlc UCAitl:lfyU~
~,--.J---wOI.Fl'IAN duct
Fig. 7.8 Development of 1tlelkidney~~ in week 5. (aocording to [1)) The kidneys and the efferent urinary tract derive from the mesodenn which, next to the somites. fonns nephroaenic cell dusters referred to as nephrotomes. These successively give rise to thi"M kidney aen.,.. tlons which are from cranial to caudal: • pronephroi: first generation of e rudimentary kidney which completely regresses.
• mesonephros: temporary excretory tubules ere fonned, but with the exception of the mesonephric duct {WOLFFIAN duct) the mesonephros also regresses. Its distal part contributes to the fonnation of the efferent ductules between Testis and Epididymis. • metenephros:: beginning in week 5, the ureteric bud from the WOLFFIAN duct induces the development of the parenchyma of the permanent kidney lnephronsl in the metanephric mesodenn. The collecting ducts end the proximal parts of the efferent urinary tract !renal pelvis and Ureter) develop from the ureteric bud.
Hcneahoe kklney
Figs. 7.7• to d AK4ntutofthelddn.,laocording to [1)) The metanephros develops at the level of the 1n to 41t1 sacral vertebrae and ascends during weeks 6 to 9 of development. In fact. this is a relative ascensus since the part of the developing body caudal to the inferior pole of the kidney grows faster and b). If the kidneys fail to as-
<•
oend, e pelvic kidney lcl is present. A horseshoe kidney develops if both inferior renal poles position in dose proximity to each other and fuse (d). The horseshoe kidney does not fully escend beceuse the root of the A. mesenterica inferior presents an obstede.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Pelvic kidn4¥t and hoi'MihN kidn4¥t are usually accidental findings and heve no clinical relevance if the Ureter is not compromised. However, displacements of the Ureter may cause an urine
162
stasis with resulting hydronephrosis and potential ascending urinary trect infections. These mey cause damage to the kidney.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Development of the urogenital organs
Fig. 7.8 Development of the urln•rv ortans and ..rty dev1lopm1nt of t!Mt intll'l'lll g1niml org1n1 in bottl ..... during w11k 8. (according to [1)) The kidneys develop from the metanephros and the ureteric bud which arises from the WOLFFIAN duet. The ureteric bud gives rise to the proximal efferent urinary tract !renal pelvis and Ureter) whereas the urinary bladder and the Urethra develop from the Sinus urogenitalis (ventral part of the cloaca of the hindgut). Until week 7, the internal genitalia develop in a similar manner in men and women (sexually indifferent stage). Besides the indifferent gonads.
two parallel duct systems exist: the Ductus mesonephricus or WOLff· IAN cllct and the Ductus paramesonephricus or MOLLERIAN duct. In contrast to the WOLFFIAN duct. the distal ends of the MULLERIAN duct fuse prior to entering the Sinus urogenitalis. At the end of week 7 the indifferent gonad develops into the Testis end into the
163
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Topography of the kidney and adrenal gland
~p-181!14dll;
aup-aesruwa
Fig. 7.9 Po1ition of1tl• kidney, R.n [Nephroa], 1nd 1dren11 gl1ncl. Gl1ndula suprar.n1lls, rn 1tle mroperftonAisp_.; ventral view. Kidney and adrenal gland are located in the retroperitoneal space ventrally of the M. psoas and the M. quadratus lumborum. FatH:i1l t~y~~t•ms: The surface of the kidney is covered by a organ cep. sule of dense connective tissue (Capsula fibrosa). Together with the adrenal gland, the kidney is covered by a capsule of perinephric fat (Capsula ediposa). The perinephritic adipose tissue is surrounded by a connective tissu& sheath (Fascia renalis). Medially and inferiorly, the renal fascia remains open for the passage of the Ureter and the blood vessels. Th& anterior lamina of the renal fascia is referred to by clinicians as GEROTA's fascia.
Proximity to 1fl• nerv• of 1tle Plbu1 lumbllil: Between the renal fascia in the area of the inferior renal pole and the muscles of the dorsal abdominal wall. the N. iliohypogastricus and the N. ilioinguinalis from the Plexus lumbosecralis descend. They provide sensory innervation to the skin of the inguinal region. The N. genitofemoralis courses further caudally and therefore has no contact to the kidney, but to the Ureter. Further crenially, the 11th and 12tll intercostal nerves {1 2tll intercostal nerve= N. subcostalisl course beneath the lower ribs along the posterior side of the kidney.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Th& fascial systems and the topographical relationships of the kidneys ere clinically relevant. In cases of m11lgnant tumours. the kidney is always removed together with the adrenal gland and including th& GEROTA's fascia (nephrectomy).
The close proximity of the kidney to the N. iliohypogestricus and N. ilioinguinalis explains why certain diseases of the kidney such as inflammation of the renal pelvis {pyelonephritis) or concrements in the renal pelvis (nephrolithiasis) may cause r1dilting pein into the rnguln•l region.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Segments and topographical relationships of the kidney
Segmeni~MT~Bntert .. aupert..
• Fit•· 7.10. and .b Renal Mf1Minf.11, Seflmem. Nnllie, ritht lide; ventral (al end dorsal {b) views. The renal artery (A, renalis) divides at the hilum of the kidney into a R. principalis antarior, which supplies the superior, the two anterior and th& inferior r&nal s&gments with several branches, and th& R. principalis
posterior for the posterior segment. In the case of occlusion of one of the branches of the A. renalis, the extent of renallnt.mlon correlates to the area of th& sHeeted renal segments. However, th& branching patterns ere highly variable among individuals.
GIBndull6aupnnnallle
-
Colon,FIUI.ftdU!rw.
-
Spien (Uen)
-
Htpu
-
J4junum
-
PlliCIIMI&
-
Duocs.num, Pn ae_,aens
-
QuUr
-
Colon d-n
Fig. 7.11 Conflict arMI of itleli:idney, Ren [Niphrol], with adjacent organs; ventral view. Th& dorsal side of th& kidney is adjacent to the dorsal abdominal wall. The anterior side has contact to several other organs. Together with the
adrenal glands, the kidneys are separated from the other abdominal organs by th& parietal peritoneum, the renal fascia, and the edipos& capsule. Thus, th& anterior contact areas have no clinical relevance.
165
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Organisation of the kidney
Glll'll:hlla~•
Glllncilla tUpnuellllllt, Hlhm
ll. IUpnnnlla, Rr.
Matgo auperfor
All. aupnuenalea mediae
7.12
7.13
Fig. 7.12 1nd Fig. 7.13 Kidney, Ren [Niphroe], 1nd •dren•lglencl, Gl1ndul• supi'INnlllt. rfght side I~ Fig. 7.1211nd left sfCS. (~Fig. 7.13•; ventral view. The bean-shaped l:idnev has a superior and an inferior pole. Located between !he poles and oriented medially is the hilum of the kidney
166
(Hilum renale) which connects to the inner space of the kidney (Sinus renalisl and contains !he renal blood vessels and !he Ureter. The ~ renal gland is adjacent to the superior pole of the kidney. The entrance of the blood vessels at the medial margin is sometimes also referred to as !he hilum.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Organisation of the kidney
Fig. 7.14 1nd Fig. 7.15 Kidney, Ren [Niphroe], lift eidl; ventral view; attar vertical bisection I~ Fig. 7.141 and opening of the renal peMs 1~ Fig. 7.15). The kidney consists of a cottec(Cortex renalis) and a medulll (Medulla renalisl. The medulla is subdivided into several parts which, according to their shap&, ar& r&ferr&d to as r&nal pyremlcll {Pyramides renalas). Located between these renal pyramids are the renal columns
(Columnae renalas). One pyramid and its adjacent cortical area is called a ren1llobe (Lobus renalisl. Th& border between th& 141obes is not visible at !he surface of an adult human kidney. The tips of lh& pyramids (Papillae renales) enter the ren1l ulyce~ (Calices renales majores end minoresl to release the urine !arrows). Togelher wilh adipose tissu& and !he renal blood vessels, !he ren1l pelvfs (Pelvis renalis) is located in a medial recess of !he parenchyma of the kidney {Sinus renelis).
167
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Organisation of the kidney
Fig. 7.18 Kfdn.y, Ren [l\lephrosl: tnlnsvei'M section 'hroueh 1tle ren11 sinus (Sinue NnllieJ; caudal view.
Tha parenchyma of the kidney is composed of a cortex !Cortex renalisl and a medulla (Medulla renalis).
- -"...,.'-:-:::--:......-t- - Speuof1tte BOWMAN'• etp8Uie
Fig. 7.17 Ren1l cowx (Cortex NnlllsJ; microscopic section, 100-fold. [26) The entire parenchyma of the kidney consists of nephrons and collecting ducts. Nephrons comprise renal corpuscles and a tubular system. Renal corpuscles (Corpuscula renalia) are located in the renal cortex, but not in the renal medulla. In the renal corpuscles, water and low molecular weight constituents from the plasma are filtered into the
168
space of the BOWMAN's capsule {primary urine, 170 Vday). From the urinary pole of the BOWMAN's capsula, the primary urine enters the proximal tubule (Tubulus proximalis). In the tubular system end the collecting ducts the major part of the primary urine is reabsorbed and the urine composition is altered by secretion before the final urine is released into the renal papillae and the renal peMs {1.7 Vday).
Eflei'0/11 u riwy oyllum • Gonloh • Redum end onol..,nel • T-"'f'ITr • Socii oM
Organisation of the kidney ""r.• Ota• ,..... .,..,.,.. ...., a ._..,,~;WI1t
-.Gttt:~CJW~W~e
II 1M ..... 044$ ..... 'fl!~~r~J fl' IIII'ITWY ~ Ia ~ 1M ;a r • W.IIIJIIM w.t~a UII'NQI'Ibcl J*t tJ'ft UII'NQI\Itll N a ~mi$1'n fllll't(,...,_,, 'J'hi.aitfOI'I'tirtl.-.d~Nr........
.__...¥1tlthfiCII'IIIIrw
t.lbllll~
PM fitOIIII'd PM~. h Mt1 II ,.......... ......._ ......... Ia 1M ~ liD " ' . . . . . . . . . -.frllctl thllv ttIMIIS U.lft\11 hiD wit~
'N,..,.,.,.....
I !
..
__ ---
.... 7.11 Cot•I'I'............WIIN..._.a.ct. . . . .....,., . . . . . . . . ~..... ~i~.~tl) ~~ TMA. ... V....... ~IIf:NI'!IIII!\ft_,llte:Aft't ..... ....... fltade*d flt~idll. ~ ... fiiO.ItiiCI tfrltbMad fill ~•AfttY. . . . .nl hom U'ln~- PfltA.fttY. 'N 11'1 OCIIW'M till 1M COI'IWTIIN:il't-
-a
a
-to,.,. "'*'··
for.,...
ir.t ..... tfrlaMIWI• ... ~MIIan:w'JM. ~ ttrr.OMI~Of 10 .,_,, h' • bb:I4M tw!'fxiflwrf. w1 ~~~ • ....
.....Ill!.
d .. W<1hi\Nbe!MOfN~1¥fi11Mf/lii&/Mttt..,.....tdllltf.
18$
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Organisation of the adrenal gland
Fig. 7.20 Adren11 gl1nd, Ollndullsupr.NI'IIIil, right side; ventral view. The adrenal gland consists of cortex and medulla. Both have different diMIIopmantal origins and functions. The cortex develops from the mesoderm of the dorsal abdominal cwity lintnHmbryonic coelome), the medulla, howaver, derives from neural crest cells and is equivalent to a modified sympath9tic ganglion.
Fig. 7.21 Adrenel glend, Ol1ndul1 1upreren1lis, right 1icle; sagittal section; lateral view. The adrenal gland is a vital endocrine gland. The cortex produces st. roid hormon11 {minaralocorticoids. glucoe<~rticoids. androgens), the medull• produces clltechol•mrnn (epinephrine and norepinephrine) for the regulation of metabolism and blood pressure.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . If both adrenal glands have to be removed due to disease. the substitution with mineralocorticoids and glucocorlicoids is essential to prevent lh-thr'Atilntng concltlons such as hypogtvcaemic shock.
170
or severely law blood pressure (arterial hypotension). Adrenocortical insufficiency {ADDISON's disease) may cause the same symptoms.
Efferent Urinary system_. genitalia _. Rectum and anal canal _. Topography _. Sections
Blood vessels of the kidney
A.; v. ptnnlce llnflrtor
V. pfww1lca lnflllfor
A. ..,....,...II medii;
Y.lllpnnnllelllnlltre.
A.;Y.NIIdl
Fig. 7.22 CourM of th• A. and V. r.nalls; ventral view. The paired All. r.nal• arise from the abdominal aorta and course dorsal to the veins to the hilum of the l:idney. The right A rena lis <:fosses the V. ~ inferior posteriorly. At the hilum, they dMde into several branches. The Vv. r.naiM drain into the V. ~ inferior on both sides. The left V. renalis receives blood from three tributaries, whereas on the right side these veins enter the V. cava inferior directly: • V. suprarenalis sinistra • V. testiculariS/ovarica sinistra • V. phrenica inferior sinistta
The r..lonallymph nod• of the kidney are the Nodi lymphoidei lumbales around the aorta and the V. G8V8 inferior. The postganglionic eymplthetic netves to the kidney derive from the Ganglion aorticorenale and form the Plexus rena lis around the A renalis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Renal cell carcinoma frequenUy obstruct the renal veins and may, in case of a tumour on the left side, cause a venous blood stasis in the left testicular vein resulting in the dilation of testicular veins (varf-
eocele) in the left Scrotum. Therefore, a varicocele on the left side always requires the exclusion of a renal cell carcinomel
171
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Blood vessels of kidney and adrenal gland
Figs. 7.2Sa to d Varfdons of 1t11 1rterlal supply Clf 'held*t.y: ventral view. Polar 1raui• do not enter the kidney at the hilum, but reech the renal parenchyma directly. Aec.ssory arterl• independenUy arise from the Aorta.
a A. rena lis with a branch as superior polar artery b two AIJ. renales to the hilum of the kidney e accessory superior polar artery d accessory inferior polar artery
•28W.
A. prnna !rtwlor
A. rtnallf Plra abdominalI a -
b
c V.ranalta-
Fig. 7.2.C. to d Supn~renalarterln. Alt. suprarenal•. •nd tupn1ren11 vein, V. tupn1ren1lil; ventral view. Usually there are thrae arteries to the adrenal gland: • A. suprarenalis superior: derives from the A. phrenica inferior • A. suprarenalis media: arises directly from the Aorta • A. suprarenalis inferior: branch of the A. ranalis This "luxuriousN arterial supply prevents infarctions of the vital adrenal gland. V•rllrtfons of 1ft• arterln ~ 1ft• adrenal gland: • arterial supply via three arteries (textbook. case) b arterial supply without tributary from the A. ranalis c arterial supply without a direct branch of the Aorta
172
v.-rrhl!or
In contrast. only on• supr1renal wl'n exists for eech adrenal gland. The V. suprarenalis collects the blood from the adrenal gland end drains into the V. cava inferior on the right side, end into the V. renal is sinistra on the left side lciJ. The region1llymph nod• of the adrenal gland ere the Nodi lymphoidei lumbales around the aorta and V. cava inferior. The 1utonomic innetvation derives from preganglionic {II sympathetic nerve fibres from the Nn. splanchnici {the adrenal medulla represents a sympathetic paraganglion).
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Kidney, imaging
Ffe. 7.25 Kidney, Ren [Nephi'O!II], rleht !~Ide; ultrasound image;
lateral view; transducer positioned almost vertie~.~lly.
* abdominal wall
Colon
-
..rw.-~~~
~----.-.
st~• renal Ill ---J.!!!!!!!:!:!:!!!:!!!!!!!::!!i!::::!!!!!!!t...--....,.&•
Mm. .womtna!M
*
CoetaXII
Fig. 7.28 Kidney, Ren [Nephi'O!II]; rfght tfde; computed tomographic transverse section (CT); e~.~udal view.
•
direction of the needle for renal biopsy, also named fine needle aspiration biopsy (FNAB).
CT.guided renal biopsies are performed to obtain tissue specimens for diagnostic purposes in cases of obscure dysfunctions of the kidney.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Ultratound (sonography} is a suitable imaging technique to visualise ltle kidneys. It enables the detection of solid or cystic tumours. CT-I'maglng is performed in cases of undefined ultrasound findings,
or to assess lymph node metastases or the invasion of tumours into the renal veins.
173
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Renal pelvis and ureter
Fig. 1.21 Ren1l pelvie, Pelvil ren1lil, left lie»; ventral view.
Urine is released from the renal pyramids to the renal calyces {Celic&S renales; arrows).
b
Fige. 1.2811nd b Rln1l pelvie, Pelvis tenllia,left eic»; mould preparation; ventral viaw.
174
According to the width and the length of the renal calyces. e dendritic {al and an ampullaJY (b) type of renal pelvis are distinguished.
Efferent urinary system
~
Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Ureter
Fig. 7.29 hrm, constriction•, 1nd courM of th• uNter; ventral view.
P1rb: • Pars abdominalis: in th& retrop&ritoneal space • Pars peMca: in the lesser pelvis • Pars intramuralis: trav&rses th& wall of th& urinary bladd&r
Constrictions: • at the exit from the renal peMs • at th& crossing of th& A iliaca communis or A. iliaca axterna • at th& passag& through th& wall of th& urinary bladder (most narrow part) CourM: th& ureter first crosses over the N. genitofemoralis, courses unclet the A and V. testicularis/ovarica, crosses owr the A. and V. iliaca end then crosses unclet and passes beneath the Ductus deferens in men end the A. uterine in women.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . R4tnll concnmem. may dislodge, descend in the ureter and gat stucl: at th& ur&teric constrictions. This causes intense, colic-Iii:& pain (ureteral colic}.
The close proximity of the ureter to the uterine artery has to be considered in hyltet~etomi.. to avoid ligation of the ureter during surgery. The resulting urine stasis would irreversibly damage the effected kidney.
175
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Renal pelvis and ureter, imaging
PBplla rvnallt
M.p-.rr.)or
Fig. 7.30 Ren1l pelvl's. Pelvis ren1lll, 1nd ureter. Ureter:
radiograph in anteroposterior !AP} beam proj9Ction after retrograde injection of contrast medium via both ureters; ventral view.
Figs. 7.311 1nd b
Common Vlrlatrons ofth• ureter. Ureter;
radiographs in anteroposterior (AP} beam projection after retrograde injection of contrast medium via both ureters; ventral view. [18) 1 double ureter !Ureter dupleX} b split ureter (Ureter lissus) In both ~ses two renal pelvises are present.
b
• Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The Ureter fiau• often is an eocidental finding and has no clinical relevance. In contrast, ~ses of an Ureter duplex are frequently~ companied with malformations of the ureteric opening into the urinary bladder. a condition potentially causing reflux of urine or incontinence. Frequently, both ureters cross each other !MEYER-WEIGERT rule}. As a rule, the Ureter from the superior renal pelvis enters the
176
urinary bladder mora inferiorly or even directly enters the Urethra resulting in urinary incontinence. The Ureter from the lower renal pelvis often has a much shorter intramural part within the wall of the urinary bladder. facilitating reflux of urine. Urine reflux promotes ascending urinary tract infections potentially resulting in permanent damage to the kidney parenchyma.
Efferent urinary system
~
Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Structure of the urinary bladder
Llllfcu"• llfOIItatl~a·' Dllet'llll cMI'wtnt.., Ductllll•~lato!11
Fig. 7.32 Urin1ry blldder, V•a urin1ri., 1nd opening into the m•l• u!Wttll'l. Urethl'l; ventral view. Tha urinal'( bladder is located in the subperiton"l sp~ce and is composed of a body (Corpus vesicae), apex !Apex vesicae), and an inferior fundus (Fundus vesicae). At the fundus, the internal urethral orifice !Ostium urethrae internum} and the two ureteric orifices (Ostium ureteris) form tha triaone of the blldder (lrigonum vesicae). The urinal'( bla~ der holds about soo-1500 ml of urine. although the urge to urinate starts when a volume of 250-500 ml is reached. The wall consists of the internal mucosal layer (lunica mucosa} followed by three layers of smooth muscles with parasympathetic innervation (Tunica muscularis
=M. detrusor vesicae), and the external Tunice adventitia or the cranial Tunica serosa {peritoneum), respectively. The urinal'( bladder is surrounded by paravesical adipose tissue and stabilised by several lia•menta. At the apex. the Lig. umbilicale medianum {contains the urachus, a remnant of the embryonic connection of the allantois) connects to the Umbilicus. In women, the bilateral Lig. pubovesicala (... Fig. 7.116) and in men the bilateral Lig. puboprostaticum{... Fig. 7.115) anchor the bladder to the bony peMs. In men, the prostate gland is located directly beneath the fundus of the bladder end is traversed by the Urethra.
Plica lrannta'lca
• Figs. 7.33 1 1nd b Ureterfc orHlce, Oltlum ureterl's; cystoscopy. 1 opanad ureteric orifice, a peristaltic wave has released urine into the bladder b closed ureteric orifice
The valve-like shape of the ureteric orifice contributes substantially to the prevention of urine backflow which may endanger the kidneys via ascending urinal'( tract infections.
177
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Urinary bladder and urethra in men
Fit. 7.34 Urinary bllldcllr, Ve!llce urfnarfa. val dlferene, Ductu1 dlf.,.nta, Mminll W!llcle, Glandula ve.tlcuiO!I., and p!"'fl«te el•nd, Pnm.ta; dorsal view. In man. the following paired anatomical stru<> tures are positioned posterior and adjacent to the bladder, from mlldi1I1D lmr1l: • dilated part of the vas deferens [Ampulla ductus deferentisl • seminal vesicle (Glandula vesiculosa) • Ureter The urinary bladder is positioned directly superior to the prostate gland.
Fie. 7.35 Urfn1ry .blldcllr, Vnlce urfn1rf1, 1nd m111 ur.tttr1, Ur.tttr1 mnculin1; ve~ tral view; urinary bladder and Urethra opened ventrally. P1rt1 of 1tt1 UJ'IthN: • P1rs irrtl'lmur1lil (1 em): within the well of the urinary bladder • P1rs proltaticl {3.5 em): traverses the prostate gland. Here the following ducts enter the Urethra: Ductus ejaculatorii toommon duct of vas deferens end seminal vesicle) on the Colliculus seminal is and the prostatic ducts on both sides. • P1rs m1mbr1R1CII (1-2 em): traverses the pelvic floor. • Pars1PORifOM {15 em): embedded in the Corpus spongiosum of the Penis, runs to the extemel urethral orifice (Ostium urethrae extemuml. COWPER's glands !Glandulae bulbourethrelesl end LITIR~'s glands !Glandulae urethralesl enter here. The terminal part is dilated to form the Fosse naviculeris. The Urethra has the following connldlons: • Ostium urethrae internum • Pars membreneceae • Ostium urethrae extemum
178
Efferent urinary system
~
Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Urethra in men
Fig. 7.38 M•l• ra-lvi•, P1lvi1; median section; view from the left side. The illustration shows the course and the parts of the male Urethra (Urethra masculine): • Pars rntramuralls: within the wall of the urinary bladder • Pars proltdca: traverses the prostate gland • P•rs m.mbran~K~ta: penetrates the pelvic floor • Pars sponalosa: embedded in the Corpus spongiosum of the Penis. exits at the Glans penis
The Urethra has two benda: • at the transition from Pars membranacaa to Pars spongiosa • in the middle part of the Pars spongiosa
~ diaut::tion link
179
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Urethra in women
Fig. 7.37 Female pelvis. Pelvis; median section; view from the left side. The illustration shows the course and the external orifice of the female urethra. The female urethra is 3-6 em lon!J and enters directlv in front of the Vagina in the vestibule (Vestibulum vaginae).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Because of the shatter length of the female Urethra, ascending infections of the urinarv bladder lcystftfs) are more common in women than in men. Positioning of a trantuNthNI c.rttaeter is easier in women due to the straight course of the shorter Urethra. However, it has to be considered that the urethral orifice in the vestibule is located ventral to the Vagina.
In men. the bends of the Urethra have to be straightened prior to insetting a catheter to avoid painful perforations in the area of the Pars membranacee or the Pars prostatic& with consecutive profuse bleedings. First, the Penis is straightened to compensate for the kink. in the Pars spongiosa of the penile Urethra, then the catheter is inserted until the resistance from the second bend in the Pars membranacea is noticed. To straighten it. the Penis is positioned downwards between the thighs before the catheter is carefully a~ vanced further into the bladder.
Efferent urinary system
~
Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Sphincter mechanisms of the urinary bladder
•
b
Figs. 7.388 and b Sphlnmr mechanisms of urinary bladder, V•lca urfnarfa,and urethra, Urethl'l.. In men Cat and In women {b); median section; view from the left side. Contributing to the sphincter mechanisms are not only smooth muscle fibres in the wall of the urinefY bladder but also striated muscles of the perineum: • smoot~~ muscl• of the circular muscle layer of the Urethra ("M. sphincter urethrae intemusw): morphologically, a true sphincter muscle is not identified. • M. sphincter urethrN externus:: in men a separation of the M. transversus perinei profundus which often does not exist in women.
In addition. the shape of the pelvic floor {Diaphragma pelvis) is important in supporting the urinafY bladder, and thus ensuring urinafY continence. During urination (micturition) the smooth muscles of the well of the bladder (M. detrusor vesicae) contract following parasympathetic activation. At the same time, the striated muscles of the pelvic floor relax allowing the bladder to descend, the sphincter muscles to rela)(, and urination to occur. " smooth muscles of the Urethra
Peritoneum pntale
Veelca IIIIWII.
--.lo-~:i!i'o~o:::!~..,...u.:oloi.-:1>'
Gymph)'ala _
__,.,_"""
plblca
• Figt. 7.3911nd b Urin1ry bladder, V•ica urinaril, •mpty (e) end urfn•flllecl (b); schematic median section; view from the left. The urinafY bladder is located in the subperitoneal space and is covered by parietal peritoneum on its upper surface. The empty bladder is positioned behind the pubic symphysis (Symphysis pubica). When filled,
b
the bladder rises above the pubic sumphysis and can be accessed without opening the peritoneal CSI/ity !suprapubic cystostomy) for cy!ftoscopy or insertion of a suprapubic catheter. • puncture needle
181
Pelvis and Retroperitoneal Space
Kidney and adrenal gland -+
External male genitalia
,, '
Fig. 7.40 Extflmal mal• aenitlllia, Oraana genitalia m-ulina 81dama; ventral view. The mala genitalia are categorised as external genitalia (Organa genitalia masculine external and internal genitalia (Organa genitalia masculina interne-+ Fig. 7.41). The utarnal mala genitalia comprise: • Penis • Urethra masculina • Scrotum
182
The external genitalia are the Mxual organ1. The Penis servas intercourse. The Urethra is described with the efferent urin ery system (.... p p. 178 and 1791.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Internal male genitalia
glandulae bulbowat!n1la
Fig. 7.41 Mal• urln•rv and sa org1n1. Orpn1 urogenftlll1 matec.tlinl; view from th& right side. Th& inner m•l• g•niulil compris&: • • • • •
Testis Epididymis Ductus deferens Funiculus spermaticus 9CC&Ssory sex glands: - prostate gland (Prostatal - seminal vesicle (Glandula vesiculosa) - COWPER's glands (Glandula bulbour&thralis). paired
Testis and Epididymis belong to the internal genitalia because during development they were relocated from the intra-abdominal cavity into the Scrotum together with a peritoneal covering {forming the Cavites serosa scroti). The internal genitalia era reproductiv• ora•n• and serve the produ<> tion, maturation, and transport of spermatozoa and the production of seminal fluid. The testes also produce male sex hormones !testosterone).
183
Pelvis and Retroperitonea I Space
Kidney and adrenal gland .....
Development of the external male genitalia
Genillll tubercle ( j f lkogenilal groove (glans area) Urogenital fold
l.abioscrotal fold
Glans penis
Corpora cavemosa penis
Fig. 7.42 Development of tha external mala genitalia, Organa genitalia masculina externa. The external genitalia develop from the caudal part of the Sinus urogen ita Is. Th a Sinus urogenitalis develops from the cloaca of th a hindgut and gives rise to the urinary bladder and parts of the Urethra (-+ Fig. 7.8). Also contributing are the ectoderm and the connective tissue (mesenchyme) beneath. The first part in the development of the externa I genitalia is identical in both sexes (indifferent gonad). The anterior wall of the Sinus urogen itaIis indents to form the urethral groove which is bordered on both sides by the urethral folds. Latera I to tho sa
the labioscrotal folds are located and anterior to the groove lie the genital tubercles. Subsequently, in men the genital tubercle develops into the Pan is (Corpora cavernosa) due to the influence of the male sex hormone testosterone which is produced in the Testes. The genital folds merge above the urethral groove to form the Corpus spongiosum and the Glans penis. This way, simultaneously the Pars spongiosa of the Urethra develops. The Pars prostatica and the Pars membranacea of the Urethra derive further proximally from the Sinus urogenitalis. The labioscrotal folds enlarge and fuse to form the Scrotum.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , If incomplete fusions of the urethral folds occur, the opening of the Urethra is not located at the tip of the Glans penis but further proximally. In hypospadiasis, the Urethra exits at the inferior side of the Penis between the Scrotum and the glans.
184
In epispadias, the Urethra opens into a ridge at the dorsal side of the Penis. In addition to problems with urination, this condition may involve a distortion in the penile body requiring surgical correction within the first years of life.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Development of the internal male genitalia
Fig. 7.43 D.velopment of ttt. lnt.m1l m1J. genftall1, Org1n1 genitlllil m11culin1 intM'tll.(aocording to [1)) Up to week 7, development of the internal genitalia is ident~l in bolh sexes (sexual indifferentstege, ~ Fig. 7.8). In !he male, !he primordium of the primitive gonad then develops into !he Testis. The Testis develops in the lumbar region at !he level of the mssonephros which contributes several canaliculi as a connection between !he Tsstis end the Epididvmis. Due to !he longitudinal growth of !he body the Testis is then relocated caudally co..c.nsus testis) but remains oonnected to its vascular structurss. Along the inferior mssenchymal gubernaculum (Gubernaculum testis) a peritoneal pouch is formed (Proe. vaginalis peritonei} which reachss down to !he future Scrotum and serves in
guiding the descent of !he Testis, a process normally completed at birth. At birth, the Proc. vaginalis peritonei closes and obliterates in !he area of the Funiculus spermaticus. The distal part of the Proc. veginalis remains and forms a part of !he testicular coverings rrunica vaginalis testis). The sex hormones of the Testis {mainly testosterone) induce the final dtH.rentlltlon of tM WOLFFIAN duct to !he internal male genitalia (Epididvmis, Ductus deferens). the seminal vesides. and olher accessory sex glands !prostate gland, COWPER's glands) from the Sinus ur~ genitalis. The anti-MOLLERIAN hormone suppresses the differentiation of the MULLERIAN ducts into female genitalia.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The dsscent of the Testis explains why !he t&Sticular blood vessels arise at the level of the kidneys and why the regional lymph nodes of !he Testis are positioned at !his level in the retroperitoneal space. Thus, lymph node metastases from testicular cancer are to be expected in the lumbar peri-aortal region, not in the inguinal region. Persistent inoomplete t&Sticular descent wilhin !he first years of life Ccryptorchldfsmt may rssult in infertility and increases the risk of
testicular cancer. Recent research indicates !hat a timely hormonal or surgical therapy of ayptorchidism wilhin !he first year of life may prevent infertility. However, this treatment does not influence the risk of testicular cancer. If !he Proc. vaginalis peritonei fails to obliterate, accumulation of fluids may occur {even in adullhood) in the Scrotum (hydn:~ceJ. t.MII, or abdominal organs may prolapse into the Scrotum (congentt.llngulnll hM'llll,,
185
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Penis
GII!Nlula buboure111ralll
Corpore
7.44
Fie. 7.44 •nd Fie. 7.45 Urinary biMI•r, V•ic.t urin1ri1, prcm.te gllnd, Prostlrtll.. 1nd penrs. Penrs. wfth exposMI ciiVernous bodiH; ventral view, urinary bladder and Urethra opened(-+ Fig. 7.441 and dorsal view 1... Fig. 7.45). In a flaccid state, the Penis is usually about 10 em long and divided into the body (Corpus penis). glans (Glans penis). and base or root (Radix penis). It consists of the paired Corpora cavarnosa which are andosed in a dense fibrous covering (Tunica albuginaal and separated by a Septum penis. The other component is the Corpus spongiosum surroun~
-.m- perb
7.45
ing the Urethra. The proximal parts {Crura penis) of the Corpora cavernosa are fixed to the inferior pubic rami. The proximal and distal parts of tha Corpus spongiosum are dilated to form the Bulbus penis and the Glans penis, respectively. All cavernous bodies together era ansheathed by the fascia of the Penis {fascia penis), which was removed in this illustration. For the different parts of the mala Urethra (Urethra masculine) ... Figs. 7.35 and 7.36.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . If the prepuce is very narrow (phlmoslst and cannot be retracted, problems in micturition and infections may occur. In this case, the
186
removal of the prepuce by cirwmcision is required.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Penis and scrotum
F-=la penllt (auperflcllllllt)
Fig. 1 A8 Pettie with gl1n1, Olin• peni1, •nd p,.puce, Preputium penie; view from the right side.
The distal end of the Penis is enlarged to form the Glens penis and shows e ridge {Corona glandis) at its base. In the flaccid state. the glans is covered by the prepuce {Preputium penis). At its underside, the prepuce is connected bye smell ligament {Frenulum preputii).
A.lHIIculatla - - - -
Epldklymlll {C..put IA;Ipenlill)
Fig. 7A7 Scrotum, Sctotum; ventral view; the Scrotum opened end the Penis sectioned in the front. The root of the Penis is attached to the anterior body wall by the superficial Lig. fundiforme penis and the deep Lig. suspensorium penis. The Scrotum is divided internally by a septum which at the outside corresponds to the Raphe scrotum of th& skin. T11til and Funicc.due epermati'CQI hev& th& following covering•: • skin of th& Scrotum • Tunica dartos: subcutaneous layer with smooth muscles
• Fascia spermatica extema: continuation of the superficial body fascia !Fascia abdominalis superlicialisl • M. cremaster with Fascia cremasterice • Fascia spermatice interne: continuation of th& Fascia transversalis In addition, the testis is covered with the Tunica vaginalis testis which consists of an external Lamina parietalis {periorchiuml and an inner Lamina viscarelis (epiorchium). Both ar& connected by the mesorchium and create between them the Cavitas serosa scroti.
~ diauction link
187
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Testis and epididymis
Fig. 7.41 Tatia, Tetrti1 [OrchiiL 1nd epidi~mil, Epididymis; view from the right side. The Testis is egg-shaped and 4 x 3 em in size {2~30 g). It has a tup• rior end en inferior pole (Ex:tremitas superior and inferior). The Epididymil is located adjacent to the superior end dorsal aspect of the Tes-
tis and is attached to it by a superior and an inferior ligament (ligg. epididymidis superius and inferius). The Epididymis has the following parts: head {Caput), body {Corpus), and tail {Caudel which continues as vas deferens.
Funa.tua apennllllcua
Fig.7.49 Tetrtie, Tnti1 [Orchil), 1nd •pididymia, Epididymil;sagittal section; view from the right side. The dense Tunica albuginea surrounding the Testis sends septa into the parenchyma of the Testis and, thus, subdivides the parenchyme into 370 lobuln !Lobuli testis). The umrnlfen~us tubulll within these
188
lobules are the site of sperm production. The interstitial tissue between the seminiferous tubules harbours the testosterone producing testicular LEYDIG's cells. At the Mediastinum testis neurovascular structures enter and exit the testis and here the seminiferous wbules ere oonnected to the head of the Epididymis.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Testis and epididymis
•
Fig. 7.50 Tetrti.. Tetrtie [OrchiiL •nd epididymi.. Epididymi.. with blood v...111; view from the right side. The testis is connected to the head of the Epididymis !Caput epidicfrmis} via tiny wbules (Ductuli efferentes testis). The Epididymis itself consists of a 6 m long convoluted duct which continues as vas def~ rens (DucbJs deferens} at the tail of the Epididymis. With a length of 35-40 em and a thickness of 3 mm, the vas deferens is loceted within
the spermatic cord and courses through the inguinal canal to the dorsal aspect of the urinary bladder. The terminal part of the vas deferens combines with the excretory duct of the seminal veside to form the Ductus ejaculatorius. which enters the Pars prostatica of the male Urethra. Testis and Epididymis are supplied by the A. taticul1ri1and a plexus of veins !Pinus plmplnlfonnls).
Fig. 7.51 Tetrti1, Tetrti1 [OrchiiL •nd epididymi.. Epididymis; tranS\Ierse section; cranial view.
In addition to the testicular coverings (-> Fig. 7.55), the vascular struo. tures and the vas deferens {Ductus deferens! are sectioned.
189
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Accessory sex glands in the male
7.52
Fig. 7.52 and Fig. 7.53 Semrnal Ynlcln. GlanduiH v•lcuiOSH, and pronat. el•nd,. Prostata; cranial view( ... Fig. 7.52) and view from the left side; median section(... Fig. 7.53). The aC»MSSry MK elands consist of: • proltatlt ellncl: unpaired gland beneath the base of the bladder. The prostate gland measures 4 x 3 x 2 em (20 g) and has a superior base and an inferior apex. It consists of a right lobe and a left lobe (Lobus dexter and Lobus sinister). demarcated by a small groove, and a middle lobe {Lobus medius!. The prostate gland discharges its secretions into the centrally traversing Urethra (Pars prostatica).
• seminal H~fcle {Glandula vesiculosa): paired gland at the dorsal aspect of the urinary bladder ,... Fig. 7.34). The seminal vesicles are elongated oval glands {5 x 1 x 1 em). Their excretory ducts combine with the Ductus deferens to form the Ductus ejaculatorius and enter the Pars prostatica of the Urethra. • COWPER"• tllnd {Glandula bulbourethralis): paired gland located within the perineal muscles 1... Fig. 7.351. The excretory ducts of the lentil-sized COWPER's glands enter the Pars spongiosa of the Urethra. Seminal vesicles and prostate gland produce the liquid component of the ejaculate which nurtures the spermatozoa. The secretion of the COWPEA's glands enters the Urethra prior to ejaculation end functions in lubrication.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Proltatic c.rcinom• is one of the three most common malignant tumours in men. It usually develops from the microscopically distinct peripheral zone of the gland. Therefore, symptoms related to micturition are only caused at advanced stages. Due to the fact that the prostate gland is separated from the Rectum only by the thin rectoprostatic fascia {DENONVILLIER's fascia; ... Fig. 7.1151 prostatic carcinomas are usually palpable through the Rectum. The digital rectal examination lORE) is therefore part of a complete physical
190
examination in men over 50 years of age. The benign prowatic hypertrophy {BPH: hyperplasia! is a benign tumour of the prostate gland, causing it to enlarge up to a weight of 1QO g. BPH is a condition usually present in various degrees in all men over 70 years of ega. Since BPH develops from the central zone of the gland. constriction of the Urethra and resulting micturition difficulties are early signs of this condition.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Spermatic cord
Fig. 7.54 Spennde cord, Funiculus spermdcus.ltft slclt; frontal section; ventral view, magnification 2,!Hold. The spermatic cord contains the following structures: • ws deferens (Ductus deferens) with A. ductus deferentis (from the A. umbilicalis) • A. testicularis from the abdominal aorta end the Plexus pampiniformis as accompanying veins
• N. genitofemorelis, R. genitalis (-> Fig. 7.56) • lymph vessels IVasa lymphatical to the lumbar lymph nodes • autonomic narw fibres (Plexus tasticularisl from the aortic plexus Extemallv. the N. ilioinguinalis and the A. and V. cremesterica are adjacent to the spermatic cord{... Figs. 7.55 and 7.56).
A. tel1bllub - - - Epldlclyml•
Caput { (Append I()
Al!l*l(IJ(1..clll
Fig. 7.55 Cov•rina• of thlsptrmltic cord,. Funiculu• ..,mati-
cus, and tht tntrs. T.nt's; ventral view; Scrotum opened. T.nrs and spermatic cord have the following coverings: • scrotal skin !Cutis) • Tunica dartos: Subcutis with smooth muscle cells
• Fascia sparmatica axterna: continuation of the superficial bodv fascia {Fascia abdominalis superlicialisl • M. cremaster with Fascia eremasterice • Fascia spermatiee intema: continuation of the Fascia transversalis
191
Pelvis and Retroperitoneal Space
Kidney and Adrenal Gland _.
Blood vessels and nerves of the penis
Funlcuha •permlllcue
A;M~•
- - - - - - - - Rr.8cnlti!IMIII!terlor811
Y. dorM! Ill~· pent. Y.dorMIIII
tu~perb
Fig. 7.58 Extemal male genitalie. Ol'flana genitalia matculina utema, wMh naurvwascular st:ructur"; ventral view; after remOI/81 of the fascia of the Penis. The Penis receives its arterial blood supply from three paired arteriH arising from the A. pudenda interne: • A. dorsalis penis: subfesciel course, supplies the skin of the Penis and the glans penis • A. profunda penis: located within the Corpora cevernose; regulates the filling of the corpora cavernose • A. bulbi penis: enters the Bulbus penis, supplies the Glandula bulbourethrelis and es A. urethrelis it supplies the Urethra end the Corpus spongiosum
Fig. 7.57 Pani•, Pani•; croswection et the midlevel of the penile body; ventral view. The location of the blood vessels is important for the erection of the Penis. Following parasympathetic innervation, dilation of the A. profunda penis causes the filling of the Corpora cavemosa. These compress the V. dorsalis profunda penis beneath the tough Fascia penis and prevent venous drainage. Supported bv the contraction of the Mm. ischiocevernosi {innervated by the N. pudendusl, this results in penile erection.
The venous blood is collected bv three vanou• syftem•: • V. dorsalis superficialis penis: paired or unpaired, epifescial course, drains blood from the penile skin to the V. pudenda externa • V. dorsalis profunda penis: unpaired. subfascial course. drains blood from the Corpora cavemose to the Plexus venosus prosteticus • V. bulbi penis: paired, drains blood from the Bulbus penis to the V. dorsalis profunda penis lnnarvation: • sensory: N. dorsalis penis (from the N. pudendus) • autonomic: Nn. cavemosi penis (from the Plexus hypogastricus inferior) penetrate the peMc floor end course adjacent to the N. dorsalis penis !sympathetic stimulation causes vasoconstriction; parasympathetic stimulation causes vasodilation and cons9C\Jtive erection).
1\ma
•blllllnM COfPCI'IJm c:8\W"''llOIO u m
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Parasympathetic stimulation induces elaveted levels of nitric monoxide (NO). In turn, this increases the concentration of the second messenger cGMP in the smooth muscle cells of the arterial wells
192
with resulting smooth muscle relaxation. Inhibitor~ of 1tle enzyme photphodi....,... {such as Viagra•. Cialis~ delay the metabolism of cGMP and improve erection.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Blood vessels of testis and epididymis
Plaua pemfllnl'ormla
Fit. 7.58 Cour,.. of the A. 1nd V. tetrticul1ri1; ventral view.
Fig. 7.59 IL!oodl vMMia of itt• irrt.rn1l m1le aenit.lil; '.liew from the right side.
Blood V•MI• ofitle lnt.m•l Genitllill
ArteriH
Vlina
Ora•n
BloociVenel
Testis and Epididvmis
A. testicularis (from the Aorta abdominalisl
vas deferens
A. ductus deferentis (usually from the A. umbilicalisl
spermatic cord (M. cremaster!
A. cremasterice (from the A. epigastrica inferior)
accessory sex glands
A. vesicelis inferior and A. rectalis media (from the A. iliaca interne)
Testis, Epididymis, Ductus deferens, spermatic cord
Plexus pampiniformis: plexus of veins that merge to form the V. testiculeris which drains into the V. cave inferior on the right side and the V. renalis sinistre on the left side
accessory sex glands
Plexus venosi vesicalis and prostaticus with outflow into the V. ilieca interne
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Obltruc1ion of 1tt1 venou1 dNin•a• into the left V. rena lis or ren1l c.ll c1rci'nomas growing into the renal vein may cause a congestion of blood as revealed by a palpable and visible dilation of the
veins in the left Plexus pampiniformis (vlricocele). A left-sided varicocele requires the exclusion of a renal cell carcinoma es e possible cause. A persistent varicocele mey cause infertility.
193
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Innervation of the male genitalia
Fig. 7.80 lnnerntion of 1t11 m•l•g•n~lie; ventral end lateral view; schematic illustration. The Plexus hypogastricus inferior contains sympathetic !green! end parasympathetic (purple! nerve fibres. The preganglionic symplthltle flbrw (T1G-L21 descend from the Plexus aorticus ebdominelis vie the Plexus hypogastricus superior end from the sacral ganglia of the sympathetic trunk (Truncus sympathicus) via the Nn. splanchnici sacreles. They are predominantly synap_,ed to postganglionic sympathetic neurons in the Plexus hypogastricus inferior. These postganglionic fibres reach the pelvic viscera, including the accessory sex glands. Sympathetic fibres to the vas deferens (Plexus deferentialis} activate smooth muscle contractions for the emi11ion of spermatozoa into the Urethra. Some fibres also join the Nn. cavernosi and penetrate the peMc floor to reach the Corpore cavemosa of the Penis. The (mostly) postganglionic sympathetic fibres to the Testis and Epidictymis course in the Plexus testicularis alongside the A. testicularis after being already synapsed in the Ganglia aorticorenalia or the Plexus hypogastricus superior.
Preganglionic peresymplthltic fib,.. derive from the sacral division of the parasympathetic nervous system {S2-$4l vie the Nn. splenchnici peMci end reach the ganglia of the Plexus hypogestricus inferior. They ere synapsed either here or in the '.licinity of the pel'.lic organs (Ganglia peMce) to postganglionic neurons for the accessory glands. The Nn. cavemosi penetrate the peMc floor end course to the Corpora cavernose (partly adjacent to the N. dorsalis penis) to induce «ection upon parasympathetic stimulation. Somatic innervation via the N. pudendua conveys sensory innervation to the Penis via the N. dorsalis penis and aids in ejHUIItion of spermatozoa through the motor innervation to the M. bulbospongiosus end M. ischiocavernosus via the Nn. perinealas in the perineum. P1rasymp1theth: stimulation induces erectfon, while symplthltlc fibres initiate the emlnlon, end the N. pucllndus is involved in e)l· cullrtion.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . During surgical resection of pare-aortal lymph nodes, as required with testicular or colorectal carcinomas, end surgical procedures involl!ing the abdominal aorta or the larger pelvic arteries. sympathetic fibres may be damaged end emission as well as subsequent ejacu-
194
letion may be compromised resulting in Impotence. Surgical procedures on the prostate gland or the rectum as required in prostatic or rectal carcinoma may injure the parasympathetic fibres to the Penis causing erectile clytfunctlon.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Lymph vessels of the male genitalia
Ncdllymplloldel lll.cl communee
Nod lymphotill IIIICIInleml
Nocllymphotill lllllcluteml
Fig. 7.11 Lymph vnNia 1nd lymph nodM of th11Xtem11 1nd lrrtem1l m1.. eentt.lla; ventral view. The regional lymph nodes for the ex:tarnal genitalia are the inguinal nodes (Nodi lymphoidli inguinlln). In contrast, the first regional lymph nodes for the Testes and Epididymis are located in the retroperitoneal space at the level of the kidneys tNodi lymphoidei lumblln).
Ncdllympholdlllaaaalee
Ncdllymplloltlell~ulnaiH auperflclllea
Fig. 7.82 Lymphlltfe draln1g1 pathWIYS of th• memaland irrtltrn1l m1.. genitllli1; ventral view. In men, ex:temal and intamal genitalia have completely different lymphatic drainage pathways. Extem11 geni..lil: • Penis and Scrotum: Nodi lvmphoidai inguinales
lrrt1tm11 g~nftllll1: • Testes end Epididymis: Nodi lymphoidei lumbales at the level of the kidneys • vas deferens. spermatic cord, and accessory sex glands: Nodi ly~ phoidei iliaci intarn~extemi and Nodi lymphoidai sacrales
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The different lymphatic drainage pathways explain why lymphatie mltlstaws of penile carcinoma first appear in the inguinal region. whereas those of testicular carcinoma manifest in the retroperitoneal space. Because the lymphatic drainage pathways of the ex:ternal and internal genitalia do not communicate, no tnlnncrotll tl!rtleu-
l1r .biopev should be performed when suspecting tetticular urcinoml since this may ceuse the dissemination of malignant calls into the inguinal lymph nodes. In these cases, biopsies must be taken from the inguinal canal.
195
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Pelvic floor in men
M.lmator ul, Dllflfnqrna P'llillb
Fig. 7.&3 MUid" of 1tle pelvic floor, Di•phr•am• pelvie, thiah 1nd hlp In men; view from the left side. The pelvic floor closes the pelvic cavity caudally. Org•nieetion: • M. levator ani, comprisin~ M. pubococcygeus. M. iliococcygeus. and M. puborectelis • M. ischiocoe<;ygeus In contrast to the M. pubococcygeus and the M. ischiococcygeus. the M. iliocoe<;ygeus does not originate from the Os coxae but from the Arcus tendineus musculi levatoris ani, a reinforcement of the fascia of theM. obturatorius internus. The muscles of both sides spare the levator hiatus between them (Hie-
196
tus levatoriusl (... Fig. 7.871. This muscular gap is divided by the connective tissue of the Corpus perineal& {Centrum perinei) into the anterior Hletus uroaentt.lls and the posterior Hlllt:Us ~m•lls for the passage of Urethra and Rectum, respectively. The pelvic floor is innervated by direct branches of the Plexus secrelis IS3-S4l. Function: The pelvic floor stabilises the position of the pelvic viscera and, thus, is essential for urinary and fecal continence. Pelvic floor i~ sufficiency with resulting incontinence is rare in men since potential injuries due to repetitive strain during childbirth is lacking.
l-tT20.
I
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Perineal muscles in men
Fig. 7.&4 P•rin"l muKin in m•n; caudal view; after removal of all other muscles. In men, the muscular gap of the levator hiatus (Hiatus l&vatorius) is almost entirely closed by th& perin&al musci&S b&n&ath which leav& only the passage for the Urethra masculine. Th& perin&al muscles in men compris& th& strong M. tNn.,....ue plrin•i profundu• and th& thin M. tr•nll'llltllll perinli euperfteillie located at its posterior margin. These muscles have formerly bean referred to as woiaphragma urogenitel&w analogous to th& Diaphregma p&lvis. Sine& a tru& diaphragm do&s not exist and because a similar muscular plate is missing in women, this term is not used anv more. Th& voluntary sphincter muse!& of th& urinary bladder, th& M. sphincter urethrae extamus, is a part of theM. transversus perinai profundus. The M. transversus perinai profundus is covered by a fascia on both
sid&S. Th& stronger inferior fascia is referred to as perineal membren& IMembr~n• perfnell. The space between both fascias is the deep perfnNI sp~~e~ (Spatium profundum perinai)end is entirely occupied by the M. transversus perinei profundus. This space also contains the Urethra end the COWPER's glands {Glandula& bulbourethralas) and is traversed by deep branches of theN. pudandus as well as th& A. and V. pudenda interne befor& they reach the Radix penis. Th& euperfici•l perinNI epee. {Spatium superficiale perinei)lias caudal to th& perineal membrane and contains amongst others the M. transversus parinai superficialis.
197
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Pelvic floor and perineal muscles in men
M. aphhctlr •nl611temue
M. trwm4n~U• pertnel prW!du•
Fig. 7.85 P•lvlc floor. Dl1phragm1 p•lvls. 1nd perfnMI musclas in m•n; view from the left side. At its anterior and posterior aspect. the pelvic floor consists of the M. levator ani and the M. ischioCCJ
fundus). A partition of the latter, the M. sphincter urethrae extemus, functions as sphincter of the urinary bledder. Embedded within theM. transversus perinei profundus are the COWPER's glands.
I-+T20
I
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Perineal region in men
Fucla obtii'Ca1a
Fit. 7.e8 PerinNI ret ion, Retio perinMiil, in man; caudal view; aftar remowl of all neurovascular structures. The perlnNI regfon extends from !he inferior margin of the pubic svmphysis (Symphysis pubica} to lha tip of the coccyx (Os coccygis). The tarm perineum in men, however, exclusively describes !he small connective tis sua bridge between !he Radix penis and the Anus. The perineal region is subdivided into the ant.rior Regio uroaanit.lil (ur~ genital triangle!, containing the external genitalia and !he Urethra, and the potttlrior Raaio anali1 (anal triangle! around the Anus. The following spaces can be found within these triangles: • The Regia analis contains the Fossa IKhfoanells 1-+ Table). which constitutes a pyramid-shaped space on both sides of the Anus. The cranial border is the M. IIWBtor ani of the pelvic floor. The lateral wall enclos&s the fascial duplicature of the M. obturatorius internus (Fascia obturatoria}. the pudendal canal (ALCOCK's canal). The pudendal canal contains !he A. and V. pudenda interne, and the N. pudendus after their passage from the gluteal region through !he Foramen ischiadicum minus.
The Regia urogenitelis has two perinNI apac•: • The ciHp perinMI apace (Spatium profundum perinei) comprisas the M. transversus perinei profundus and the COWPER's glands !Glandulae bulbourethralesl. • The euperficiel perinMI apace {Spatium superficial& perinei) comprises the M. transversus perinei superficialis, the M. bulbospongiosus. and the M. ischiocavernosus, which stabilis& lh& cavemous bodies of the Radix penis end enable ejaculation. Borders of the Fo. . i•hioanalia Medial and cranial
M. sphincter ani externus and M. ltMitor ani
Lateral
M. obturatorius externus
Dorsal
M. gluteus meximus end Lig. seer~ tuberale
V.ntNI
posterior margin of the superficial and the deep perineal spaces; anterior reoess reaches the pubic symphysis
Caudal
fascia and skin of the perineum
199
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Perineal region in men
N. pll'healle
N. darealle penla
A.;¥. pud.-.Jallntama
A. "'*i•lnf.tor Hn. ekmtum tnlerlen$ (H. W~tneue feln«
Nn. anococeygel
Fig. 7.87 Blood YMMis and nerYes of th•IMI'fnMI r..lon. R..lo parinMiia, in m•n; caudal view. Covered by a fascial duplicature of the M. obturatorius internus, the Canalis pudendalis !ALCOCK's canal), the neurovascular structures enter the F08N iKhiCNJnllit from a dorsolateral direction. The pyramidshaped fossa is filled with adipose tissue. Branches to the Anus and the anal ~nal come off first and cross the ischio-enal fossa to reach the anus. The neurovascular structures then continue ventrally to the Radix penis and the two perineal spaces.
Cont.ntJ of th• FOilI IKhf01n1llt: • A and V. pudenda interne and N. pudendus: in the Canalis pudendalis !ALCOCK's ~naO • A, V., and N. rectalis inferior: to the anal canal
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The Fossa ischioanalis is of great clinical relevance because of its expansion to both sides of the anus. Collection of puslabscessesl. e.g. fistulas from the anal canal, may expand within the entire ischio-
anal fossa. including its anterior racass and even extend to the pubic symphysis. These abscesses not only generate non-specific inflammatory signs but also cause intense pain in the perineal region.
Efferent urinary system-+ Genitalia -+ Rectum and anal canal -+ Topography -+ Sections
Perineal spaces in men
Ampull.dud>adalanlntlll
'--------OIM!kabul:la&nllnlil
Fig. 7.88 Perin•lsp.~- in men; left 1icle; frontal section at the IIMII of the femoral head; dorsal view. The frontal section shows thr• levels of the male peMs: • peritoneal cavity of the pelvis (Cavitas peritonealis peMs), caudally bordered by the perietsl peritoneum • subperitoneal space !Spatium extraperitoneale pelvis}, caudally bordered by the M. levator ani of the pelvic floor • perineal region (Regia perineelis) inferior to the peMc floor. The anterior portion contains the two perineal spaces, and includes the variably expended anterior recess of the ischi
dendus (N. dorsalis penis), end the A. and V. pudenda interne (A. bulbi penis, A. dorsalis penis, A. profunda penis) before reaching the Radix penis. The Nn. cavernosi penis pierce the perineum and enter the Corpora cavemosa of the Penis. The luperfici•l perinHispece (Spatium superficiale perinei) is located between the perineal membrane {Membrane perinei) at the underside of the M. transversus perinei profundus and the body fascia (Fascia perin e ~. It conteins the M . tre nsversus p sri nei superficielis end the proximal ports of the Corpore cavernosa of the Penis. The Bulbus penis is ensheathed by the M. bulbospongiosus, the Crura penis by the M. ischiocavernosus. The superficial branches of theN. pudendus (N. perineal is with Nn. scrota las posteriores) and the A. and V. pudenda interne (A. perineal is with Rr. scrota las posterioresl also tr!Mirse this space to reach the Scrotum.
201
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
External female genitalia
PrepUiklm cUtcrldle
Commlt$Ln lllbiOrllm ponw~or
Fig. 7.19 Extem11 femalegeni..lil, Organagenitllil feminine «!Cttm1; caudal view.
The female genitalia cen be categorised into external genitalia (Organa genitalia feminine external and intamal genitalia (Organa genitalia faminina intema ~Fig. 7.71). The extem1lgenitllil are referred to as Vulv1 and comprise: • Monspubis • Labia majora pudandi
c~•~d~------------+-~~
Lllllum
"*""'
pudnl------~;::,..~
• Labia minora pudandi • Clitoris • vestibula (Vestibulum vaginae) • Glandulae vestibularas majores !BARTHOLIN's glands), and minores The vestibula extends to the hymen at the vaginal orifica(Ostium vaginae). Ventral thereof is the axtamal urethral orifice {Ostium urethrae ex:ternum). The external genitalia era the MX ors•n• end serve for intercourse.
·
------01111urn umhrH ut.nurn ~---------<~1~~~~·~~-------M.~~~~
-:-',........>~hlllk---- M. bubollpan:gbl~
Fig. 7.70 Extem1l femalegenr..na, Organa aenftllll feminine extem1; caudal view; after removal of body fascia and neurovascular structures. The Labia majora pudendi are removed in this illustration. They contain the cavernous body of the veetibule (Bulbus vestibul~. The Labia minora pudendi surround the vestibule !Vestibulum vaginae) and continue anteriorly as Frenulum clitoridis to the glans of the clitoris !Glans ditoridis). The vestibular glands (Glandulae vestibularas majores !BARTHOLIN's glands) and minores) enter the vestibule from lateral. The CUtoffs is the sensory organ for sexual arousal. The Corpora cavernas a clitoridis form a short body (Corpus clitoridis) with the glans at the
202
inferior end. The crura of the clitoris {Crura clitoridis) are attached to the inferior ischiopubic rami end covered by the M. ischiocavernosus on both sides. The M. bulbospongiosus stabilises the bulb of the vestibule. Developmentally, the organisation of the Penis end the Clitoris is similar including the presence of the prepuce {Preputium ditoridisl. The filling mechanisms of the cavernous bodies and the process of erection are also similar in both sexes. • dinical term: BARTHOLIN's gland
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Internal female genitalia
- - - PelvltAIIIIIt
Fig. 7.71 Femal• urln•rv and genltll org1ns. Ortana uroaenltllll femininl; ventral view. The irrtltmll genitlllil comprise: • vagina (Vagina) • uterus (Uterus} • uterine tube (Tube uterine) • ovary (Ovetium} Uterine tube and CNary are paired organs and are collectively referred to as uterine adnaa.
The internal genitalia in women are nrprodudlve and MX organs. Functionally, the ovary serves for the maturation of follicles {and ova) and the production of female sex hormones {oestrogens and progesterone). The uterine tube provides the piece for the fertilisation of ova and transports the zygote to the Uterus where the embryo/fetus develops and grows during pregnancy. The Vagina serves the sexual intercourse and is part of the birth canal.
203
Pelvis and Retroperitonea I Space
Kidney and adrenal gland .....
Development of the external female genitalia
Genital tubercle (glans area)
LkoGenltal groove L.abioscrotal fold
Genital ridge
~
~ Cl~or1s
labium majus
Fig. 7.72 Development of the external female genitalia, Organa genitalia faminina axtarna. The external genitalia develop from the e.g udal part of the Sinus urogenital is. The Sinus uroganitalis develops from the cloac.g of the hindgut and gives rise to the urinary bladder and parts of the Urethra (-+ Fig. 7.6). Contributing to these structures are also the ectoderm and the connective tissue (mesenchyme) located beneath the Sin us urogenitalis. First, the external genitalia dave lop identically in both s axes (indifferent gonad). The anterior wall of the Sinus u rag enitalis indents to farm
the urethral groove, and is bordered on both sides by the urethral folds. LBteral of those ere the labioscrotal folds and anterior the genital tubercle. Subsequently, the genital tubercle develops into the Clitoris (Corpora cavernasa) under the influence of the female sex hormone oestrogen which is produced in the ovary. In contrast to the development in men, the genital folds and the labioscrotal folds do not merge. The genital folds develop into the Labia minora and the labiascrotal folds into the Labia majora. The short female Urethra and the BARTHOLIN's glands develop from the Sinus uroganitalis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The common developmental stages of the external genitalia in both sexes explains the development of penis-like hyperplasias of the Clitoris in casas of excessive production of mala sax hormones such as
204
in adrenogenital syndrome (production of androgens in the cortex of the adrenal glands).
Efferent urinary system~ Genitalia
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Rectum and anal canal
~
Topography
~
Sections
Development of the internal female genitalia
Fig. 7.73 DtWalopmant of t!Mt int.m1l f~mal•g~nit.lie, Oreana ganftlllla t.mlnlna Interne. lacc:ordin~ to 11)) The intemal genitalia develop identically in both sexes up to weak 7 (sexual indifferent stage, - Fig. 7.8). In the female, the primordium of the primitive gonad then develops into the ovary. Similar to the Testis, the ovary also develops in the lumbar region at the level of the mesonephros. Due to the longitudinal growth of the body the ovary is then relocated caudally to the lesser peMs without leaving the peritoneal cavity. Thus, ovary and uterine tube haw en intNperitonlll position.
Without the suppressing effects of the enti-MOLLERIAN hormone from the Testis, the MULLERIAN ducts differentiate into female genitalia. Beginning in week 12, the MULLERIAN ducts form the uterine tube. Their distal portions merge and give rise to the Uterus end the upper Vagina. The lower Vagina develops from the Sinus urogenitalis. If the MULLERIAN ducts fail to fuse. a ••mat• ut~n~a (Uterus septus or subseptus) or a doubla mrut (Uterus duplex, Uterus didelphys) may result.
205
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Uterus, uterine tube and ovary
A.; W. CIYtllell(e)
Ug. c.dlnal& ~. tranw.-..n ceMcteJ Ug. redlaii.IWtnum 1 Plea 18Ctouta't!•
Fig. 7.74 Uteru1, Ubtru1, o,.ry, Ov1rium, 1nd ut.rin1 tub1, Tub1 ut.rln1, wtth pil'(tonNI duplledons; dorsal view. The Ubtrus IMatral is 8 em long, 5 em wide and 2-3 em thick. It consists of th& body (Corpus ut&ri) with a superior fundus (Fundus uteri) and a neck !Cervix uteri). A constriction {Isthmus uteri) marks ltle transition b&twe&n body and neck. of the Uterus. The uterin& tube (Tuba ut&rina) &xtends on both sides from th& uterine body to connect to the ovari&S. Th& ut.rine tube (Tuba uterine) is 10- 14 em long and has several parts: • Infundibulum tubae uterinaa: 1 - 2 em long, contains ltle opening to th& peritoneal cavity (Ostium abdominale tubae uterinae) and th& fimbria& (Fimbriae tubae uterinee) for the collection of ovulated ova. • Ampulla tubae uterinae: 7- 8 em long, crescent-shaped around the ovary • Isthmus tuba& ut&rinae: 3- 8 em long, constriction at the transition to ltle Uterus • intramural part (Pars uterine tubas), enters the Uterus (Ostium uterinum)
206
The o,.ry (Ovarium) is 3 x 1 .5 x 1 em in size and oval. A tubal extremity (Extremitas tuba ria) and an uterine extremity {Extremitas uterine) ere distinguished. The mesovarium is attached to the anterior margin !Margo mesovari<:os). but the posterior margin is loose (Margo liber). Uterus. uterine tube, and ovary have an inttlperitone•l position end thus, have indMdual perftonNI duplle~turn covered by a Tunica serosa. The following lia•mentland attachments ere relevant for gynaecological surgical procedures: • Ug. letum uteri: broad ligament as frontal peritoneal fold • Mesaver and Mesosalpinx: peritoneal duplicatures of ovary and uterine tube, respectively, connected to ltle Ug. latum • Ug. cardinale lUg. transversum cervicis): connective tissue co~ necting the Cervix to the lateral pelvic wall • Ug. rectouterinum !clinical term: Lig. sacrouterinuml: connective tissue attaching the Cervix dorsally • Ug. teres uteri (clinical term: Lig. rotundum): the round ligament coursing from ltle uterotubal junction ltlrough the inguinal canal to the Labia majora • Ug. ovarii proprium: the ovarian ligament connects ovary end Uterus • Ug. suspensorium averii {clinical term: Lig. infundibulopelvicuml: connects ovary and lateral pelvic well, carries the A. end V. ova rica
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Uterus and vagina
lnfUfldlbUIIITI tub MIMI'!~ Fmbr!U tubN uwrnu
Fimbria 0\III'IC«
Fig. 7.15 Uteru1, Ubtru1, vagina, Vaaina, ovary, Ovarium, and uwrlne tube, 1\.tba uwrlna; frontal s9Ction; dorsal view. The space inside the Uterus is dMded into !he Cavitas uteri in the body and the Canalis cervicis uteri in the uterine cervix. The lawsr portion of the Cervix entel"$ the Vagina and is referred to as Portio vaginalis cervieis. The upper portion is th& Portio suprevaginalis cervicis. The Vagi· na is a hollow muscular organ of about 10 em l&nglh in a eubpariton.. al l~lion. The Fornix vaginae surrounds the Portio vaginalis cervicis. At th& inner surface, bolh th& anterior and posterior wells (Paries anterior end Paries posterior) of th& Vagina reveal transverse mucosal folds !Rugae vaginalesl.
The frontal section also shows !he strucblr• of 11'1• uterine wall: !he intemal mucosal layer CTunica mucosa; endometrium), then the strong muscular layer CTunica muscularis; myometrium) of smooth muscles, end the outermost peritoneal lining (Tunica serosa; perimetrium). Embedded in !he stroma of the owry are the ovarian follicles !Folliculi ovarieil which contain the ova end develop into the Corpus luteum following ovulation. Follicles end Corpore lutea produce !he female sax hormones {oastrogens and progesterone) which regulate !he cycle-dependent differentiation of the endometrium.
207
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Position of the uterus and adnexa
lnfundlbUIIM!l tube WlrfnH
Ampule. tubu uteme
Ug. ovarl proptfwn
Plea ~Mnblllclllla medii Ia
Fig. 7.71 Uterut, Uauu1, o,.ry, Ov1rium, 1nd ut.rinetube, Tub• ut.rlna, with perftonNI duplleatures; ventral view. Uterus, uterine tubes, and ovary have an intrlperitonNI position. Their perftonNI duplleatur" (Lig. latum uteri, Mesosalpinx. Mesovarium} form a transverse fold in the lesser pelvis. The Ug. teres uteri reaches ventral from the uterotubal junction to the lateral wall of the lt»ser pelvis and traverses the inguinal canal to merge with the conn~ tive tissue of the Labia majora. The Lig. ovarii proprium connects Uterus and ovary. The Ug. suspensorium ovarii connects ovary end lateral pelvic: wall and contains the A. and V. ova rica.
The dose topographical relationship between the adnexa {ovary end uterine tube) end the Appendix vermiformis of the Colon eJCplain why inflammations of the appendix (appendicitis) as well es those of the uterine tube {salpingitis) may cause similar pain in the right lower a~ domina! quadrant. The peritoneal pouch between the Uterus end the urinary bladder is called ExCIVItio vllicouterin1. The ExCIVItio NCtoutll'fna {pouch of DOUGLAS) behind the Uterus is the most ceudal extension of the peritoneal cavity in women end may rollect fluids end pus in ceses of inflammatory processes in the lower abdomen.
Fles. 7.771 to d Posltfon of uterus, Uterus, and v•elna, Vaelna; view from the right side. • Normally, the Uterus is angled in its ventral aspect in relation to the Vagina {anteversion) end the body is tilted anteriorly in relation to the neck (anteflexion). This position prevents e prolapse of the Uterus through the Vagina during increased intraabdominal pressure {coughing, sneezing). b anteversion, anteflexion =normal position c anteversion, lack of anteflexion d retroversion. retroflexion
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Position of the uterus and connective tissue spaces
Ug.~um
~mph)W piDic:& -~====~---'
Olllum &ntlne lrtlrnum
Fig. 7.78 Ligament11and connective tiaue spiCa of the ut.ru1, Uterus; transverse section at the level of the Cervix. uteri; caudal view; semischematic illustration. The connective tissue in the lesser pelvis is categorised according to th& relation to adjacent organs. Some of the connective tissue strands are ref&rred to as ligaments in clinical terms although an anatomical demarcation is not possible.
• parametrium: connective tissue from the cervix to the pelvic well llig. cardinale) • paraproctium: conneclive tissue around the Rectum • parac,.tium: connective tissue around the urinary bladder • paracolpium: connective tissue around the Vagina The Lig. rectouterinum between the Cervix. uteri end the dorsal pelvic well is the only separable ligament end is preserved during gynaecological surgery to protect the autonomic nerves of the Ple)(IJS hypogastricus inferior.
Flp. 7.79 a and b Uterfne neck. Po111o vagtnalls CII"VIcls; caudal view. 1 uterine neck. of a young woman who has not yet delivered a child (nullipara} b uterine neck. of a young woman who has delivered two children
For the inspection of the Portio vaginalis cervicis the Vagina is distended by two specula. • speculum
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Inspection and cervical swabs !PAPANICOLAOU smear! are routinely performed for gyni!Kologlcal scrMnlng examlndons and the costs are covered by the public health system for women above the age of 20 years. This examination should be performed annually to detect precancerous lesions indicative of the development of cervil:ll a.rcinoma and to enable early curative surgery. Cervical carcinoma is among the most common malignancies in
women below the age of 40 years. It is caused by infections with viruses of the human papilloma virus IHPVl group. A vaccine was developed and vaccination is recommended for girls during puberty to prevent infections. However, due to the low ex.perience with this vaccine and the lack of evidence that vaccination can prevent cervical carcinoma. the benefit of this veccine is currently disputed.
209
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Uterus in pregnancy
l.hlln famlnl'le
~ltJ!IIIt publce,
Dlacua lnterpublcta
Fig. 7.80 Utlrus. Uterus wlth placentll. Pl~~e~ntll. 1nd f•us.: median section of the pelvis except for the fetus; view from the left side.
The developing child in the Uterus is nourished vie the Piacente which develops from metemel end fetal tissues after implantation. The Cervix uteri is closed during pregnancy by the KRISTELLER's muoous plug(*).
Fig. 7.81 L4MII of ~h• Fundus uteri dulfng pregn1ncy; ventral view. The numbers represent the end of the respective month of pregnancy. In the 6th month {Weak. 24) the Fundus uteri is at the level of the umbilical region. in the !fh month {Week. 36) at the oostel margin. Up to parturition. the uterine volume increases SQO -1200 times end the uterine weight increases from 3Q -120 g to 1000-1500 g.
210
Efferent urinary system-+ Genitalia -+ Rectum and anal canal -+ Topography -+ Sections
Arteries of the internal female genitalia
LICI. ovanl 111\)p~um
Llg. 8U11pen1011um ~I
Fig. 7.82 Arteries af thaln..rnal femalaganltall~ dorsal view. The internal female genitalia are supplied bythNe paiNCI arteriM: • Ut.n.~s: A uterine (from the A. iliace internal with Rr. helicini • Ovarrum: A ovarica (from the abdominal aortal and A. uterine with R. ovaricus • Tuba ut.rina: A. uterine with R. rubarius and A. ovaries • Vagin•: A. vaginal is {from the A. iliace internal and A uterina with Rr. vaginales
The venous drainage occurs via two vanous systems: • venous plexus in the lesser pelvis IPieKUs venosi uterinus and veginalis) with drainage into the V. iliaca interns • V. ovaries; drains into the V. cava inferior on the right side and the V. renalis sinistra on the left side. " dinical term: Lig. rotundum
-~
>80'Mi
A.ovll'lca
•40'Mi
c
b
•4'Mi
d
r
Rr. hellclnl
• • Figs. 7.83 • to f Variations oftha arterial supply of tha int.rnal famalaganttalla; dorsal view.
f
• arterial supply of the Uterus (textbook case) c and d arterial supply of the ovary lb textbooK. easel • and f arterial supply of the Fundus uteri I• textbook easel
211
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Innervation of the female genitalia
N. aa'll.. [61]
o.,...
N.wgh•l• pelvlce, Radlxpa~ (Nn. tplandlnld pelvldJ
Fig. 7.84 lnn11'11'Mion of th1 f~mal• sen Mall~~; ventral view; schematic illustration. Plexus hypogastricus inferior end Plexus uteroll&ginalis conlllin sympathetic (greenland paresympathetic (purple) nerve fibres. Preganglionic 1ympattaric nerw. fibNS (rl 0 - L21 descend from the Plexus aorticus abdominalis via the Plexus hypogastricus superior and from the sacral ganglia of the sympathetic trunk (Truncus sympathicus) via the Nn. splanchnici secrales to be synapsed to postganglionic neurons in the ganglia of the Plexus hVPQgastricus inferior. Axons of the postganglionic neurons continue to the peMc target organs and reach the Plexus uteroveginalis (FRANKENHAUSER's plexus) for the inneMtion of Uterus. Tuba uterina. and Vagina. The (predominantly) postganglionic sympathetic nerve fibres to the overv have already been syn-
212
~~~+--
Gangl& pellotce. Raclx p&l'lUiyll'lpdllce. [Nn. •pllndlnlcl petwtel]
ap_,ed in the Ganglia aorticorenalia or in the Plexus hypogastricus superior and descend within the Plexus Oll&ricus alongside the A. ovarica. Preganglionic fNII'Uympfthde nerw. flbNS derive from the seaal parasympathetic division {S2-S41 and reach the ganglia of the Plexus hypogastricus inferior via the Nn. splenchnici peMci. They ere synapsed to postganglionic neurons either here or in close vicinity to the pelvic viscera (Ganglia pelllica) to inner\19te the Uterus. Tuba uterine end Vagina. Somatic innervation by the N. pudendus conveys sensory innervation to the lower part of the Vagina and the Labia minora end majora vie the Rr. labiales posteriores and to the Clitoris via the N. dorsalis clitoridis.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Lymph vessels of the female genitalia
Fig. 7.85 Lymph vnNis 1nd lymph nodes of itt• atem11 1nd lrrtem1l f~~m•l• e.nltllll~t.: ventre! view. The regionel Jvmph nodes for the external female genitalia are the i~ guinel nodes (Nodi lymphoidei inguinlles). In C
Nodllympholciiiii~IAnalee prcfundl Nodllympholl:lell~ulnaiH auperftclllea
Fig. 7.88 Lymphatic draln•g• plitlways of itt• extem111nd irrtltrn1l fem•l•g.nitlilill; ventral view. Unlike the situation in men, the lymphatic drainage pathways of the external and intemal female genitalia are not completely separate, and parts of the lymph of the internal genitalia also drain into the inguinal lymph nodes.
External g•nrtana: • Nodi Jvmphoidai inguinales: Vulva
lrrt1tm11 . .nltllll1: • Nodi lvmphoidai lumbales at the level of the kidneys: Overium, Tube uterine. Uterus !uterotubal junction), Jvmphatic vessels within the Ug. suspensorium ovarii • Nodi lymphoidai iliaci interni/externi end Nodi Jvmphoidai sacreles: Uterus. Vagina. Tuba uterine • Nodi lymphoidei inguinales: lower Vagina. Uterus {uterotubal junotionl. Jvmph vessels within the Lig. teres uteri
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Due to the different lymphatic drainage pathways, the primary lymph node m.tlntiMI are: with carcinoma of the Vulva the inguinal lymph nod&S, with carcinoma of the Endometrium and the Cervix
the lymph nodes in the lesser pelvis, and with ovarian carcinoma the retroperitoneal lymph nodes.
213
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Pelvic floor in women
Symph)'lle publca
~~~~~~"} Hr.tu.~
Hllltllaanllll
.,:.+.,-lr/-.r'--M.~
[coccy;-J
Fig. 7.lJ'I Pelvic floor. Dl1phragm1 pelvis. rn women; cranial viaw. The organisation of the pelvic floor in women is similar to men. The pelvic floor closes the pelvic cavity caudally. Org1nfs1tlon:
• M. levator ani, comprising theM. pubococcygeus, M. iliococcygeus, and M. puborectalis • M. ischiococcygeus In contrast to theM. pubococcygeus end M. ischiococcygeus, theM. iliococcygeus does not originate from the bone of the hip but from the Arcus tendineus musculi levatoris ani, a reinforcement of the fascia of theM. obturatorius internus.
The muscles of both sides spare the levator hiatus between them {Hiatus levatoriusl This muscular gap is subdivided by the connective tissue of the perineum {Centrum perinai) into the anterior Hiltul urogenitalil for the passage of Urethra and Vagina and the posterior HfltUI 1nalls for the passage of the Rectum. The pelvic floor is innervated by direct brenchas of the Plexus secrelis IS3-S4l. Function: The pelvic floor stebilisas the position of the pelvic viscera end. thus, is assentiel for urinary end faecal continence.
l-tT20.1
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Women more frequently suffer from pelvle floor rnsuffldeney due to the extensive dilation of the levator hiatus during vaginal deliveries. As a consequence, a lowering {d..cen1u1) or prolepu of Uterus and Vagina may occur. This condition is often combined with
214
a prolapse of the bladder !cystocele) and the Rectum {rectocele) resulting in urinary and feecel incontinence because the Uterus is firmly connected to the posterior wall of the urinary bladder end the Vagina adheres to the anterior wall of the Rectum.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Pelvic floor in women
M.lnarwul
Fig. 7.88 Pelvic floor. Df1phraem• pelvfs.ln women: view from the left side. The pelvic floor consists of the M. lwator 1ni and the M. iechiococcyI'UI. TheM. iliococc;ygeus of theM. levator ani originates from the Arcus tandineus musculi levatoris ani. The latter is a reinforcement of the fascia of the M. obturatorius intemus. One of the origins of the M. obturatorius internus is the superior pubic ramus where it is pierced
by the Canalis obturatorius with the A. and V. obturatoria and the N. ob-
turatorius. The M. obturatorius intamus than exits the pelvis laterally through the Foramen ischiadicum minus. The M.levator ani extends to the sacrum and the coccyx and closes the peMc cavity caudally.
I~T20.
I
~ diaut::tion link
215
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Perineal muscles in women
0. publa, Ramua
M. •phlnctet 1n1m1e _ ,. . ~~=;~~~~~------U~Mfem~
216
Fig. 7.19 Perin"l mu1cln in women; caudal view; after removal of all oltlar muscles. In women, !he muscular gap of !he levator hiatus {Hiatus levatorius) is almost entirely dosed by connective tissue which leaves only the passaga for the Vagina and !he Ureltlra feminine. Unlike in men, the perineal muscles in woman are weak(-> Fig. 7.64). The waak M. tnnl'ftl'o 11.11 perinei profunli.l1, which onlv consists of single muscle Iibras embedded within connective tissue{-> Fig. 7.90), and theM. tnnSYeflo 11.11 perinei 1upel'ficillil do not form a muiCullr plltl. Therefore, the term woiaphragma uroganitalaw is not used anymore. While in men the ciMp perlnMI sp.c. {Spatium profundum perinei) is filled with the M. transversus parinai profundus, the separation of the
perineal spaces is more difficult in woman. Howavar. similar to man the female dMp perfnMI 'pace is confined inferiorly by the perineal membrane !Membrana perfnllf). In addition, it contains the Vagina and the Urethra and is traversed by daap branches of the N. pudandus and A. and V. pudenda intema before they reach the Vulva. The superficill perin..lspace (Spatium suparficiale parineij is located caudal to the parinaal membrane and. amongst oltlars, contains the M. transversus perinei superlicialis.
Fig. 7.90 Volun..ry sphincter mu1el11 of th1 urin1ry blldcllr. The M. transversus perinei profundus in women does not form a continuous muscular plate. Instead, indMdual striated muscle fibres around the Uraltlra form !he M.tphinct.r uretfti'M ftblrnul which constitutes the voluntary sphincter muscle of !he urinary bladder {~ Fig. 7.89).
Some distal fibres continua to surround the distal Vagina and era referred to as M. sphincter ur~hrovaglnalls.
I-+T20b
I
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Perineal region in women
.... ~lo
Fig. 7.91 PerlnMI rwglon, Reglo perfnealls.ln wom411'1: caudal view; attar ramowl of all naurowscular structures.
The ,a.rin"l ret ion reaches from the inferior margin of the pubic symphysis !Symphysis pubical to the tip of the CO
woman, contains the weak M. transversus perinai profundus and theM. sphincter urethrae externus. - The MJperficiel perinMI apece (Spatium suparficiele perinei) between the Membrane perinai end the body fascia {Fascia perineil contains the M. transversus perinei superficialis, the M. bulbospongiosus. the M. ischiocavernosus. These three muscles stabilise the cavamous bodies of vestibule end Clitoris.
Borderl of 1he F. . . illhi08nalia
Medial und cranl•l
M. sphincter ani extemus end M. 18119tor ani
lAteral
M. obturetorius extemus
Dorwel
M. gluteus meximus end Ug. sacrotuberale
V411'1tral
posterior margin of the superficial and the deep perineal spaces; anterior recesses reach the pubic symphysis fascia and skin of the Perineum
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . During wginal delivery tears of the perineal skin and the perineal muscles, including the anal sphincter musdes, may occur (perfnMI tMrst. Selective incisions extending from the Vagina medially or Ia-
tarelly (episiotomy) are performed to prevent uncontrolled perineal tears.
217
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Perineal region in women
Rr.pertullllee (N. c:utanel.ll fllmol1a POtanol1
Nn. cklntum t n f (N. c:utane1.11 femot1a pOIUrtal) Nn.•noc~el
Fig. 7.92 Blood YMMis and nerYn of th•IMI'fnMI r..lon. R..lo perinMiit, in women; caudal view. Tha FoiN ildtioanalit has a vary similar anatomy in men and women. The pyramid-shaped fossa is filled with adipose tissue. Covered by a fascial duplicature of th& M. obturatorius intamus, th& Canalis pudendalis (ALCOCK's canal}, th& n&urovascular structures antar the Fossa ischioanalis from dorsolateral. At first branches to the Anus and the anal
canal exit and cross the ischio-enal fossa to reach the Anus. The neurtr vascular structures than continue ventrally to the Vulva and the twa perineal spaces. ContentJ of th• Fossa lschfoanlllt: • A and V. pudenda intama, and N. pudandus: in the Canalis puda~ delis !ALCOCK's oanall • A, V. and N. ractalis inferior: to the anal canal
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Similar to man, the Fossa ischioanalis is of great clinical relevance becaus& of its &xpansion to both sides of th& Anus. Collection• of put (abscesses), &.g. fistulas from the anal canal, mav expand within the entire ischio-enal fossa. including its anterior recesses and evan
extend to the pubic symphysis. These abscesses not only cause noMpecific inflammatory signs but also result in intense pain in the perineal region.
Efferent urinary system-+ Genitalia -+ Rectum and anal canal -+ Topography -+ Sections
Perineal spaces in women
--
N. pudand,. -----1,..-+-~~
A. pudenda lntema --T~~If!~~=~
!lpdum profirldum ,.m.i Reglo parhHI..
{
lpallum .....,..... pamal-------{ M.lllchlocavamDIIUII
Octum uretlne lllCiarnum
Fig. 7.93 Parin•lsp.~- in woman; median section, and frontal section on the right side; ventral view. The frontal section shows thr•lavals of the female pelvis: • peritoneal cavity of the pelvis (Cevitas peritanealis pelvis) bordered caudally by the parietal peritoneum • subperitoneel space (Spatium extraperitoneale pelvis}, caudally bordered by the M. levator ani of the pelvic floor • perineal region (Regia perineelis) inferior to the pelvic floor. The anterior portion contains the two perineal spaces, end includes the variltlly expended anterior recesses of the ischi0-6nal fossa 611ustrated here in two different Wfi11S for the right and left sides}. The deep perin•l•pace {Spatium prafundum perinei) consists of connective tissue and single muscle fibres of the M. transversus perinei profundus. It also contains the passage of the Vagina end t he Urethra. The deep perineal space is traversed by the deep branches of the N.
pudendus {N. dorsalis clitoridis), end the A. end V. pudenda interne {A. bulbi vestibuli, A dorsalis clitoridis, A profunda clitoridis) before they reach the Vulva. The Nn. cavemosi clitoridis pierce the Perineum and enter the Corpora cavernosa of the Clitoris. The suparfici•l parinHispaca {Spatium superficiels perinei) is located between the perineal membrane {Membrane perine~ and the body fascia (Fascia perineD. It contains the M. transversus perinei superficial is, the proximal parts of the Corpora cevemasa clitoridis, the Glandulae vestibulares majores (BARTHOLIN's glands), and the vestibular bulb {Bulbus vestibuli). The bulb of the vestibule is embraced by theM. bulbospongiosus, the Crura clitoridis by the M. ischiocavernosus on both sides. The superficial branches of the N. pudendus {N. perineal is with Nn. Iabiaias posterioresl, and of the A. and V. pudenda intema lA perineal is with Rr. lebioles post eriores) also traverse this space to reach the labia.
219
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Projection of the rectum and anal canal
7.9-M
lnleatf~mta~e
~'"6"~~_....-+---- Appendlx¥ermfama r-JIJ}-....,.......,....-+,,e----J~----R--.J
..
-J~-~~-,_7-------~m------~r+~~~-~~~. ~:,.::;;,.'---;L--+-----
Ruin pemella
~~~-L--~--------c.-
.. ~.------~+--~~~J¥ 7.95.b
Fig. 7.94 and Fig. 7.95 ProJection of th• r41dum. R41dum. •nd of the •1'1.11 c.~n•l, C.n•li• an•li-. onto the .body •urface; ventral 1... Fig. 7.94&), dorsal(... Fig. 7.94b), end lateral(... Figs. 7.95a and b) views. The Rectum begins at the level of the 2nd or 3"' sacral vertebrae and ends on !he pelvic floor which is trevers8d by the anal canal. In the sa-
220
gittal plane, !he Rectum has 1:\NO bends: !he dorsally e<~nvex Flexure sacralis and !he ventrally e<~nvex Flexure perineelis. The upper portion of the Rectum above the Flexure sa<:f91is is a Mcondarily retroperiton..l ore•n. the distal portion and !he anal canal have a subperltonul
poeition.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Position of the rectum
Fig. 7.98 RKtum, R.ctum, rn 1:h1 mal• p1Ms: view from the left side. The illustration shows the two bends of the Rectum in the sagittal plane. In the upper secondary retroperitoneal portion, the Rectum ~ justs to the curvature of the sacrum end displays the dorMIIy convex F1«11ura Mcralls. Inferior to this part, the Rectum is not covered by parietal peritoneum. but has a subperitoneal position. The Vlnt:nllly convex Flexura ra-rin..lil is at the level of the pelvic diaphragm. lnf~ rior to the pelvic diaphragm, the Rectum continues as the anal canal in an inferior and dorsal direction. In men. the anterior aspect of the Reo-
tum is adjacent to the posterior wall of the urinary bladder {Vesica urineria) end the seminal vesicles (Glandulae vesiculosae) end further caudally to the prostate gland. Here, the Rectum is separated from the prostate gland only by the thin Facf• r.ctoproftftfc. IDENONVILLIER's fascia). In women. the Rectum is closely adjacent to the posterior aspect of the Vagina and only separated from the Vagina by the Fascia rectovaginalis {-+Fig. 7.116). • clinical term: COWPER's glands
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Because the prostata gland is separated from the Rectum onlv bv the thin Fascia rectoprostatica IDENONVILLIER's fascia), the prostate gland can be assessed by dlgllal rectal ••minlitton lORE). Due
to the hilt! incidence of benign prostatic hyperplasia {BPH) end prostatic carcinoma, the digital rectal examination is part of a complete physical examination in men over 50 years of age.
221
Pelvis and Retroperitoneal Space
Kidney and adrenal gland -+
Structure of the rectum
l.n
Fig. Rectum, Rectum; view from the left side. Cranially, the Recrum forms the dorsally convex Flexure sacralis and caudally, at the laval of the passege through the pelvic floor, the ventrally convex Flexure perineal is. Unlike the Colon, the muscular layer {Tunics muscularis) of the Rectum not only contains the circular layer !Strarum circulars) but also a continuous longitudinal layer !Stratum longitudinale).
1\mlca mll8ciJII1s,
Slralum lo~lllldlnale
M. sphlnctM ani extlm118
Anlll./
Plc•baww. . . recti
Fig. 7.98 Rectum, Rectum, and anal e~~nal, C.n.li• anali•; ventral view. The inner relief of the Rac\um shows transverse folds, so-called Plicae transversae recti. One of the three folds is palpable regularly at about 8-7 em above the Anus {KOHLRAUSCH's fold). Below this fold, the Rectum is dilated to form the Ampulla recti. The Linea anorectelis marks the transition to the anal canal. This area is characlerised by the change from the transverse folds of the Rectum to the longitudinal folds of the anal canal end represents a transitional zone between Reotum end anal canal I.Junctio anorectal is). The anal anal is divided into thi'M Hgmenb: • Zo1111 columnarls: contains longirudinal folds (Columnae analesl formed by the underlying Corpus C8V9rnosum recti • Pecten analls: the stratified non-lceretin is ad squamous epithelium creatss a white zone in the mucosa !Zona alba!: the superior border of this zone is referred to as UnN pectlnata (clinical term: Lin•• dentatlil; here, the Valvulae r,meles end the white squamous epithelium meet. • Zone cutenH: external skin, inconsistently limited by the Lineaanocutanea "
222
heemorrhoidel knots
Efferent urinary system~ Genitalia ~ Rectum and anal canal ~ Topography ~ Sections
Structure of the anal canal
~~~~------~------Pua
pRifundl
:-----:-- -,____ _ Ptrs supedlclllle
....-----+-----Pua
..
M. ~ ~
..tx:w.nee
Fig. 7.99 Rectum. Rectum. and anal canaL Canalis analls, rn men; median section; viaw from the left side. (according to [1)) This illustration demonstrates the segments of the anal canal and the organisation of the continence organ. The anal canal is dMded into Fig. 7.98}: 1tu..ueemem. The pectinate line !LinN pectfnatal is the d&Wiopmental border between the hindgut and the proctodeum and marks the border between the Zone columnatis end the Pecten anelis in the adult. Similar to the left colic flexure, the pectinllte line represents the watershed for several neurovascular structures and sef\18S as clinically important landmark: in the anal canal. The anal canal possesses a continence organ controlled by the CNS which is composed of th& anus. sphincter muscles. and the Corpus cavernosum recti. Apart from defecation, th& Anus is dosed by th& permanent contractions of the internal anal sphincter muscles. The Corpus cavernosum recti is supplied by the A rectal is superior end this wauants a gas-tight dosur& of th& anal canal.
<-
The tphfnctll" musciiS comprise: • M. tphinc111" ani int.rnu1 {smooth muscles, involuntary sympathetic innervation): continulltion of the cirC\.IIar musC\.IIar layer • M. corrugator ani (smooth muscles): continuation of th& longitudinal musC\.IIar layer • M. 1phlncter ani atemus lstrillted muscles, voluntary control vie the N. pudendus): has different segments (Partes subcutenee, superficialis, profunda) • M. pubol'lc181ls !striated muscles, voluntary control via the N. ptr dendus end direct branches of th& sacral plexus): pert of the M. lavator ani; forms a loop behind th& Rectum to pull it ventrally and create the Flexure perinealis. The resulting kink. of the Rectum enables the storage of faeces in the rectal ampulla. For lymphatic drainage _. page 99. " proctodea! gland
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Sine& th& Rectum has transvers& folds (Plicae trensv&rse& recti) and the anal canal has longitudinal folds !Columnae anales). inspection of the mucosa of a prolapse allows the visual discrimination between a rectlll versus an anal prolap18. Both result in faecal incontinence. Due to the different neurovascular supply of the Anus. the Linea pectinate serves as clinically relevant landmark: during 1urgery of anal cencer. Proximal tumours metestesise to the pelvic lymph nodes. distal cartinomas spread first to the inguinal lymph nodes. Nevertheless. th& tumours ar& staged according to their proximity to th& Linea anocutanea.
Dilations of the Corpus cavernosum recti ere referred to as haemorrhoids 1- Figs. 7.104 and 7.105). Behind the Valwlae anales, the Sinus anales are located es depressions in which proctodea! glands (Glandulae enales) enter th& anal canal. These glands may travers& the sphincter muscles and cause frstula when inflamed and, thus, potentially facilitating th& spre&d of the inflammation into the ischi~ anal fossa.
~ diaut::tion link
223
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Arteries of the rectum and anal canal
M.ephl'u:tar anlutemua A. Ndalelnftltor
Fig. 7.100 ReciiJI•rteriet, M. reculet; dorsal view. Rectum and anal C41nal are supplied by tllree arteries: • A rectlllls superior (unpaired): from the A. mesenterica inferior • A .-uli• medi• (paired): from the A. iliaca interne above the pelvic floor (M.Ievator ani) • A rectali• inferior (paired): from the A pudenda intema beneath tile pelvic floor The border between the correspondin~ arterial supplv from the A mesenterica inferior and the A. iliaca interne is located at the Linea pecti-
224
nata where numerous anastomoses between these arteries exist. The A. rectalis superior is tile last branch of tile A. mesenterica inferior and provides a branch for the anastomosis with the Ae. sigmoideae. From this point onwards (clinical term: SUDECK's point I"D. the A reetalis superior is considered a terminal artery. The Corpus cavernosum recti is primarily supplied by the A. rectalis superior. Therefore, bleedings of haemorrhoids, which represent dilated rectal cavernous bodies, are arterial bleedings as shown by the bright red colour.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Veins of the rectum and anal canal ll.llllce commu~a
Y.redda...,_. Colon lllgmolcleum
V.llllce
exuma
Fit. 7.101 Rectlll wrns. Vv. reculn; dorsal view. Corresponding to the rectal arteries. the venous blood from the Rectum and the anal canal drains 'Ilia three veins: • V. rect.lie euperior {unpaired): acoass to the portal vain N. portae hepalisl via the V. mesenterica inferior • V. rectlllls medl• !paired): access to the V. cave inferior vie the V. iliaca interne • V. r'HUiia inferior {paired): access to the V. cave inferior via the V. pudenda interne end the V. iliace interne The watershed between the venous drainage to the V. portae hepatis and the V. cave inferior is in the area of the Linea pectinate. There era numerous anastomoses.
Hl.•~,,..--ll.llllce
nwr-.
Fit. 7.102 Venoue dr1inaa• of rectum, Rectum, end enel un1l, C•n•ll• •n•lls; ventral view. Tributaries to the V. portae hepetis !purple) and to the V. C8V8 inferior {blue). vv. NCtalla This illusii"Qtion demonsii"Qtes that the venous drainage pathways to meciM the portal vein and to the inferior vena cava have numerous anastomoses. With increased blood pressure in the portal system fport1l hYJMf" tension), e.g. in liver cirrhosis. these anastomoses are utilised for the drainage of blood to the V. cava inferior fportocnal an~ttomoaa). Since they do not result in haemorrhoids. the anastomoses have no dinical relevance.
225
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Innervation of the rectum and anal canal
Pwe abclomlnalll a01tae Ganglia lnlncl ~lei
mt Plllxua •Oittcua abclomlnalle
M. •phlncter ani externua
Fig. 7.103 lnnerw.rtion of the rectum, Rectum, 1nd enel anel, C.n1111 1n1lls; ventral view; schematic illustration. The Plexus rectalis contains sympethetic !green! and parasympathetic (purple) nerve fibres. The Plexus rectalis is a continuetion of !he Plexus hypogastricus inferior. The preganglionic ~ym,.th.rtic fibNS (T1 Q....U) descend from the Plexus aorticus abdominalis via !he Plexus hypogastricus superior and from the sacral ganglia of the sympathetic trunk. (Truncus sympathicus) vie the Nn. splanchnici sacrales. They ere predominantly synapsed to postganglionic sympathetic neurons in the Plexus hypogastricus inferior. These postganglionic fibres reach the Rectum and anal canal vie the Plexus rectalis. Sympathetic fibres activate the sphincter muscles (M. sphincter ani intemus).
226
Preganglionic peruympethetic fibNS derive from the sact'el division of !he parasympethetic nervous system {S2-S41 via !he Nn. splanchnici peMci to the ganglia of the Plexus hypogastricus inferior. They are s~ epsed to postganglionic fibres either here or in the vicinity of the intestines for the stimulation of the peristalsis and the inhibition of !he internal anal sphincter muscles IM. sphincter ani intemusl to facilitate defaecation. The autonomic innervation ends approximately in the area of !he Unea pectinate. The inferior portion of the anal canal is innervated by the somatic N. puclendu1 to convey sensory innervation to the skin inferior to the pectinete line. Thus. anal carcinomas inferior to !he pectinate line ere extremely painful. whereas anal carcinomas located above this demarcation line are not. In addition, the N. pudendus conveys motor fibres to theM. sphincter ani externus and to theM. puborectalis and, thus, facilitates voluntary closure of the Anus.
Efferent urinary system-+ Genitalia -+ Rectum and anal canal -+ Topography -+ Sections
Haemorrhoids
*
C.nollll anoia
•
Fla. 7.104 Anal nnal. Canalis analls; rec:toscopy; cranial view. Oear1y, six substantially enlarged knots of the Corpus cavernosum rec-
coloscope •• three haemorrfloidal knots
ti are visible (haemorrhoids).
1 MaJor node { : : : : : - -+--------::'--lr
....
lo'ciDc:k ---..-------..:.:!~
Fia. 7.105 Hllamorrfloids arade IV; caudal view with the patient in supine position and the examiner facing the Perineum. 141 The position of haemorrhoidal knots is documented according to the clock-face. Due to the major branching pattern of the A. rectlllis superi-
or in the Corpus cavemosum recti, major haemorrhoidal knots typically appear at 3, 7 and 1 1 o'clock. Minor knots may derive from the smaller arterial branches. A smaller knot is visible here at 1 o'clock.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , HMmorrhoids are frequently occuring pathological dilations of the Corpus cavernosum recti. The causes are not fully understood but the nut rit ion in industrialised countries (rich in fat, poor in f ibres) may be a contributing factor. Haemorrhoids are categorised in different aradee: • grade 1: only visible endoscopically • grade II: protrude during bearing down for bowel movements; afterwards retrect into the anal canal
• grade Ill: protrude sponteneously, can be reposited manually • grade IV: cannot be reposited Beginning at grede II, therapeutic intervention is recomm ended either by sclerotherapy, rubber band ligation, or surgical excision (heemorrhoidectomy; grade Ill and IV).
227
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Blood vessels of the retroperitoneal space A.; V. ptnnlca lrlerlof
A. •ulll'll'lntlle I!Mda; 1t. •u~~~V~ntllt slnlml
A.; V. MCnllle mecllllna
Fig. 7.108 Blood v...111 in 1111 retroperiton..l epece; ventral view. After its passage through the diaphragm, the Aorta continues as Pars abdominalis and is located in the retroperitoneal space at the left side of the V. caw inferior and anterior to the vertebral column. The branches of the hl'lilbdDminelie eon. are listed in the table. The V. cav• inferior originates from the merging of the two Vv. iliecae communes and is located at the right side of the Aorta.
Tribu..ri• of 1111 V• ...,. inferior
• Vv. iliacae communes
INnchee of the Pll'lilbclominllil eon. P1riltll
• A. phrenica inferior: at the inferior side of the
bn~nch•
diaphragm, gives rise to the A. suprarenalis superior to the adrenal gland • Aa. lumbales: four pairs directly branching off the Aorta, the fifth pair derives from the A. sacralis mediane
tothl boclyw11l
Viecer•l branch• to111e VfiCifll
• V. sacralis medians • Vv. lumbeles • V. phrenica inferior dextra. enters the V. renalis on the left side • V. testiculari!lovarica dextra, enters the V. renalis on the lett side • V. suprarenalis dextra. enters the V. renalis on the left side • Vv. renales dextra and sinistra • three Vv. hepaticee Wv. hepaticee dextra, intermedia and sinistral
Tenninel branch•
228
• Truncus coeliacus: unpaired, originates directly beneath the Hiatus eorticus end supplies the viscera of the Epigastrium 1~ Fig. 6.113) • A. suprarenelis media: supplies the adrenal gland • A. renalis: to the kidney, also gives rise to the A. suprarenelis inferior to the adrenal gland • A. mesenteric& superior: unpaired, supplies parts of the Pancreas, the entire small intestines and the Colon up to the left colic flexure 1~ Fig. 6.115) • A. testiculeriS/Ovarica: supplies Testis end Epididymis in men and the ovary in women • A. mesenteric& inferior: unpaired, supplies the Colon desoendens end upper Rectum 1~ Fig. 6.118) • A. iliaca communis: to the pelvis end the lower
extremity • A. sacralis mediane: descends on the sacrum
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Lymph vessels of the retroperitoneal space
H.....,.r-JirfllW..~---
Nod lymphotillllllcl
---i:---~1\W
commurwa
1.1n1tet
\t I I - comflljnlf Nodll)lmllhaldel lkdllnll:llmll
Nodllyml)llO!d•llll!UinM$ 8U~IIet, Nodi IUperolallniiMI
Fig. 7.107 Lymph YMMII and lymph nodes of th• ret:ro,.lfton•
alipac.; ventral view. The lymph from the pelvis drains via !he Nodi lymphoidei iliaci communes into !he parietal lymph nodes of the retroperitoneal space which are collectively referred to as Nodi lymphoidei lumbalea. These are positioned in lhree chains as Nodi lymphoidei lumbales sinistri around !he Aorta. as Nodi lvmphoidei lumbales dextri to both sides of the V. cava inferior, and as Nodi lymphoidei lumbales intermedii in between boltl blood vessels. The lumbar lymph nodes not only collect !he lvmph
from !he lower extremities, pelvic viscera, and the Colon descendens, but they also serve as regional lymph node stations for the kidney, the adrenal gland. and !he testis/ovary. The efferent lymph vessels from the lumbar lvmph nodes form the bilateral Trunci lumbalet. Both Trunci lumbales merge with the Truncu1 lntentlnalls {collects lymph from the viscerallvmph nodes of the abdominal cavity) in !he Cisterna chyli and continue as Ductusthoracfcus. Thus. the Ductus thorecicus below the diaphragm drains the lymph from the entire lower half of the body.
~ diaut::tion link
229
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Somatic nerves of the retroperitoneal space
M. qllll:t'a1118lumbel\lm
lllollypog-•
Rr. musculln6
N.llkllngulnllll
Fig. 7.108 Somatfe n•rv• of th1 ret:roplfltonNI'fNICI; ventral view. In addition to the blood end lymph vessels, the nerves of the Plexue lumballs for the innervation of the inguinal region and the anterior aspect of the thigh are also located in the retroperitoneal space,... p. 330, Vol. 1}. The Truncus lumbosacrelis is the connection to the Plexus sacralis in the lesser pelvis. Thus, the Plexus lumbosacralis constitutes a continuous nerve plexus.
Branchn of the PIIXUs lumb1lls tT12-UI: motor branches to theM. iliopsoas and M. quadratus lumborum (T12-L4) • N. iliohypogastricus CT12, L11 • N. ilioinguinalis (1'1 2, L1) • N. genitofemoralis IL1, 1.2) • N. cutaneus femoris leteralis {L2, L31 • N. femorelis {l2, L41 • N. obturatorius IL2, L41
1-+r~l
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Autonomic nerves of the retroperitoneal space
N.thcnclcua [T11], N.lnten:cletalla Costa)QI
M. ~-· klmbcnJm
N. lloi~IAnalla
N. cutane,. femOifalltenllla
N. eenllofemon~rra
N.femcnllla
M. llacll$ 1hJnc,.I~Mnbo-=nlla
Ganglion lmpr
Fig. 7.109 AutDnomlc ner¥es of the mrofMI'(tonAisp-.; ventral view; after removal of the viscera. The autonomic nerves of the sympathetic end the parasympathetic system form a plexus of nel\le fibres on the anterior aspect of the AIJrta (Plexus 110rticu1 llbdominllis). It contributes to additional nerve plexuses at the origins of the branches of the Aorta. The nel\le fibres thereof accompany the arteries to their target organs. These plexuses include those at the three unpaired branches of the Aorta: the Plexus coelllcus.. the Pl•us m~tMnterlcl superior and lnt.rlor and the Pl.. xus rntennesenterlcusl~ Fig. 6.51). Farther caudal, the plexuses continue via the Plexus hypogastricus superior to the Plexus hypogastricus inferior in the lesser pelvis for the innervation of the peMc viscera. The preganglionic ltymplthltil: neurons are located in the lateral column of the thoracic and upper lumbar spinal cord. They pass through the sympathetic trunk (Truncus sympathicusl without being synapsed and continue es Nn. splanchnici major and minor to the eortic plexuses. Here they synapse in different ganglia (Ganglia coalieca, Ganglia mesenteries superius and inferius, Ganglia eorticorenalia} onto postganglion-
ic neurons. Their axons reach the target organs alongside arterial brenchas. The preganglionic ,_raympethetic neuron• of the Nn. 'VIti [X] {~ p. 316, Vol. 31 descend along the Oesophagus as Trunci vagales anterior and posterior, traverse the diaJ)hragm and travel within the autonomic nerve plexuses around the Aorta without synapsing to reach their target organs. The postganglionic parasympathetic neurons are located in the vicinity or within the wall of the target organs. The visceral innervation of the Nn. vagi lXI ends in the Plexus mesentericus superior and thus, in the area of the left colic flexure {CANNONBOEHM'S point). The Colon clncendens is innervated by the sacr•l division of ~he fNirayJnplthltlc nll'¥0us system. The preganglionic neurons are located in the sacral spinal cord (82-84), exit the vertebral column together with the spinal nel\les and travel as Nn. splanchnici peMci to the Plexus hypogastricus inferior in the vicinity of the Rectum. After baing synapsed, the postganglionic nerve fibres escend to the Colon descen~ ens and Colon sigmoideum.
231
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
A. iliaca interna
A.. epJgutrfce. nf\Nfor
A. pudendalnWna
Fig. 7.110 A. iliec. interne; view from the left side. In most cases {60%1. the A. iliaca interne dMdes into an anterior and a posterior main branch. The sequence for the oonsecutive branching is
Fig. 7.111 Parietlll branch• of itt• A. iliec.~ int.rna. • A. iliolumbalis: supplies the Fosse iliaca end the lumbar region • Aa. sacrales laterales: to the seCt'al canal • A. obturatoria: traverses the Canalis obturetorius • A. glutea superior: exits through the Foramen suprepiriforme to the gluteal region • A. glutea inferior: exits through the Foramen infrapiriforme to the gluteal region For the visceral branches {different in men and women) -> Figs. 7.1 12 and 7.113.
232
highly variable. Thus, the arterial branches are categorised aooording to their perfusion area in palfml branches for the pelvic wall and the external genitalia and vrseen~l branches for the pelvic viscera.
ptfomla
A. aiii'IR lnf.tor
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Blood vessels of the male pelvis
A.; Y. 'Mik:tllll111pelfor
A.; V. - • • eupertor
PUce umbllcellalllteralla; A.; V. epfVUII!Ce lnfertar
A.; V. pl.dendlllntem•. ""-8C10181•~
Fig. 7.112 Blood supply of the pelvic Yi.c.ra in men; view from the lett side. The peMc viscera are supplied by the "'•cera! branchH of the A. iliaca interne. The pari.UI branchn for the pelvic well are identical in men and women 1~ Fig. 7.111). VIK«~~I branchH of the A. Rlace rntema In men: • A. umbilicalis: gives rise to the A. vesicalis superior to the urinary bladder and often (here not shown) the A. ductus deferentis to the vas deferens before its obliterated part {Lig. umbilicale mediale) creates the Plica umbilicalis medialis. • A. vesicalis inferior: to the urinary bladder, prostate gland, and seminal vesicle, occasionally (as shown here) gives rise to the A. ductus deferentis • A. rectalis media: above the peMc floor to the Rectum • A. pudenda interne: passes through the Foramen infrapiriforme and successively the Foramen ischiadicum minus to the lateral well of the Fossa ischioanalis {Canalis pudendalis, ALCOCK's canal). Here the A. rectalis inferior branches off to the inferior anal canal. The A. pudenda interne then divides into the superficial and deep terminal branches to supply the ex:ternal genitalia. The superficial A perinealis supplies the Perineum and provides Rr. scrotales posteriores to the Scrotum. The deep branches provide arterial blood to the cavernous bodies of the Penis (A. bulbi penis, A. dorsalis penis, A. profunda penis).
The venous blood drains into the V. iliac• irrterna. Its tributaries form communicating venous plexuses (Plexus venosi) around the peMc viscera. These have to be removed during dissection to display the arteries and nerves of the pelvis: • Plexus 'Venosus ractalls:: connected via the V. rectalis superior to the portal venous system and via the Vv. rectalas media and inferior to the drainage system of the V. cava inferior !portocaval anastom~ sis) • Plexue venoeue Y81ialie: at the base of the urinary bladder, also collects the venous blood from the acoessory sex glands • Plexus venosus prostMicus: drains not only the venous blood from the prostate gland, but also the blood from the Corpore cavernosapenisN.dorsalisprofundapanis). Connactionstothavenous plexuses around the vertebral column explain the trevenUy occurring vertebral metastases in patients with prostatic carcinoma.
~ diaut::tion link
233
Pelvis and Retroperitoneal Space
Kidney and adrenal gland ~
Blood vessels of the female pelvis
,.• • • lnf. . .
Pluu• venot~~• ut.fn1.111
Fig. 7.113 Blood IUPPiv of t!Mt pelvic viKera in women; view from the left side. The pelvic viscera are supplied by the "'•cen~l bnlnchn of the A. iliaca interne. The p•rilul branch" for the pelvic wall ere identical in men and women(-> Fig. 7.1111. VIsceral br~nchn of the A. lilac. Interne rn women: • A. umbilicalis: gives rise to the A. vesicalis superior for the urinary bladder and the A. uterine before its obliterated part (Lig. umbilicala medialel creates the Plica umbilicalis medialis. • A. vesicalis inferior: to the urinary bladder end Vagina, may not be present and is then substituted by the A. vaginalis • A. uterine: supplies the Uterus end has branches to the Tube uterine. Owrium, and Vagina • A. wginalis: occasionally substitutes the A. vesical is inferior • A. rectalis media: above the pelvic floor to the Rectum • A. pudenda interne: passes through the Foramen infrepiriforme end successively the Foramen ischiadicum minus to the lateral wall of the Fossa ischioanalis (Canalis pudendalis, ALCOCK's canal). Here. the A. rectalis inferior branches off to the inferior anal canal. The A
pudenda interne then divides into the superficial and deep terminal branches to supply the external genitalia. The superficial A. perinealis supplies the perineum and provides Rr. labiales posteriores to the labia. The deep branches supply to the cavamous bodies of the Clitoris and vestibule (A. bulbi vestibuli, A. dorsalis ditoridis, A. profunda clitoridis). The venous blood drains into the V. lilac• Intern•. Its tributaries form communicating venous plexuses {Plexus vanosi) around the pelvic viscera. These haw to be removed during dissection to display the arteries and nerves of the pelvis: • Plexus venosus Netllls: connected via the V. rectalis superior to the portal venous system end via the Vv. rectales media and inferior to the drainage system of the V. cava inferior (portocaval anastomosis) • Plexua veno1u1 v81iali1: at the base of the urinary bladder, also collects the venous blood from the Corpora cavemosa clitoridis r/. dorsalis profunda clitoridis) • Plexua venOii uterinus •nd vaain1li1: drains the blood from Uterus and Vagina
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Lymph vessels of the pelvis
Fig. 7.114 Lymph nod• end lymph veaela of 1tte pelvis (shown heN in e women); view from the left side. The peMs contains the Nodi lymphoidei iliaci intemi and extemi along the respective blood vessels and the Nodi lymphoidei saCfales at the ventral side of the sacrum. Due to their dose proximity a strict separation between parietal lymph nodes at the pelvic wall and visceral lymph nodes around the peMc viscera is not possible. Thus. the pelvic viseere (Rectum, urinary bladder. internal genitalia) drain into all groups of lymph nodes. The fvmph from the upper Rectum flows via the Nodi lymphoidei raetales superiores to the Nodi tvmphoidei mesenterici inferiores in the retroperitoneal space and to the Nodi lymphoidei iliaci intemi in the pelvis. However, the lymphatic drainage from the lower Rectum is di-
rected into the Nodi lymphoidei inguinales superficieles. This eXJ)Iains why fvmph node metesteses from proximal rectal carcinomas ere found in the retroperitoneal space and in the peMs, but those from distal rectal carcinomas are found in the inguinal region. The regional lymph nodes of the urinery blecldet are predominantly the Nodi lymphoidei iliaci intemi. The fvmphatic dreinage pathways for the femele tenitelil (-> p. 213) and the mel• genit.lie (-> p.195) are described in detail with the respective organs. At last, the lymph passes through the Nodi lymphoidei iliaci communes and reaches the parietal lymph nodes of the retroperitoneal space which are collectively referred to as Nodi lymphoidei lumbales on both sides of the Aorta and the V. cava inferior.
~ diaut::tion link
235
Pelvis and Retroperitoneal Space
Kidney and adrenal gland _.
Male pelvis, median section
0t1~m II'IIUvu ln'*'lum
Pili: a umbUicela mild lana (Ug. umbllo:alt mlldllnurn}
s.,.1Un mropubblm"
~~~~~rq--- AmpullaAC11 'a,~jp,'IEJ:.--- Fuel I red!Cipottdce."*
rl~~~ff,fT___
=•Ms\118Qn118
U.-4: . - - - - IJG. I/!OQOCcygaum
M. eptl~•nl~"'
M. U'llllMII'SUSI*frMI pro1'Un411$ Mentnna pil'fnel
Fig. 7.115 P11vi1, P1lvi1, of • m1n; mldiln MC1ion; view from the left side. The most inferior pouch of the male peritoneal cavity is the Excavatio rectovnic.lil. It is laterally conlin9d by the Plic.t NCtovllic.tlil containing the Plexus hypogastricus inferior. Caudal to this pouch, the FIIICi1 rectoproltatic. (*clinical term: DENONVILLIER's fascia) in the subperitoneal space separates the Rectum from the prostate gland.
The connective tissue space behind the pubic symphysis, the Spatium r.t:ropubleum {...dinical term: RETZIUS' space), contains the Ug. ptr boprostaticum wl'lid'l attaches the prostate gland and urinary bladder to the pelvic bona. In the inferior part of the Spatium ratropubicum, the V. cloi'SIIII profuncll penis drains the blood from the Corpora cavernosa penis into the PIIXUI v1no1u1 prostatic:u1 and further into the V. iliaca intama.
Efferent urinary system~ Genitalia
~
Rectum and anal canal
~
Topography
~
Sections
Female pelvis, median section
lrlundlbuklm tubu Wlrl'IM
FuncilaWri
L". t:na
A.; v. eplg..trlce
P4N!toneurn
Glornue coccygaum
Ostklm II'IIUVU Intern urn
1L dora~ Ia ~ndla c:Utcrldla
Ulblum majue pudllndl
Fig. 7.118 Palvil, Pelvi1, of • woman; median section; view from the lett side. Because the Uterus is positioned b9tW9en the Rectum end the urinary bladder the female peritoneal cavity has two caudal pouches. The most caudal pouch is the Excamlo rectouterfna I"" clinical term: pouch of DOUGLAS}. This spece is adjacent to the posterior Fornix vaginae and is confined laterally by the Plica Netout.rina and the associated Plexus hvpogastricus inferior. Caudally, the subperitoneal Fascra NCtova· oinalil separates the Rectum and the Vagina. The Excav.tio v•ico· ut.rfna between urinary bladder and Uterus is not as deep and covers
the subperitoneal Septum vesicovaginal&. The connective tissue space behind the pubic symphysis. the Sp.tfum mropubfcum. contains the thin Lig. pubovasicale which attaches the urinary bladder to the pelvic bone. In the inferior part of the Spatium retropubicum. the V. dorulil profunda clltorlcls drains the blood from the Corpora cavemosa clit~ ridis into the Plaxua vano1u1 veticalil and further into the V. iliaca interne. " clinical term: Septum vesicoll8ginale
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . With rnflamm.tlons In th• lowar abdoman, pus and fluids may accumulate in the pouch of DOUBLAS. The close vicinity to the pos-
terior to mix of the Vagina enables the sampling of exudates through the Vagina.
~ diaut::tion link
237
Pelvis and Retroperitoneal Space
Kidney and adrenal gland -+
Male pelvis, transverse sections
Funlcuua operrnodk:l.a M. p~teti'I8L18
Noct.ls i'Jmpholdlll8 II'GUI'Ials 814leriiCIIIIII
M.allrlatla M.lloplll>llll M. r8CUI8 hlmorls ~V.ollllnklrll.
Llg. capilli fllmorll -f:-·~~
au... aubtendl.11.,.
M. IBnaor lucile leiBe
Femur,
--r-
M. Clbllntlllllua Haft~~~
11'ccha!Ur n1ljor
BlftBIR>chB-.:a
M. gluteue mulrr&Ja
rr&J9CUII gllbl medl
au... aublendl.- mueoull ob!Lnklrlllnl
Oacaccygla
Reelum
G......_HIIIcul_
7.117
08 pubis
M. ai!Ualllrlua htemu•
FunlcL.ius spwmllllcll8
M. reccus fllmorlll
FoBBB-.obul
v..lca ...narla Mm. gl.ltel medlue Ill mlnmue
M. gluteu8 rnaxlmus
N. lschlldlcus
7.118
Fig. 7.117 and Fig. 7.118 P•lvls. P•lvls. of a man; transverse section ot the laval of the Iasser pelvis (-+ Fig. 7.117) and corresponding computed tomographic section (CT;-+ Fig. 7.1 18); caudal view. According to general convention, CT imagas are •rw.p viewad from aucllll. The following pelvic viscera ere recognizable: urinary bladder (Vesica urineria), Rectum, end parts of the intemal genitalia !vas deferens [Ductus deferens) end seminal vesicle [Glandula vesiculose)). The transverse section is best suitad to trace distinet muscles. Hera, the M.
238
puborectalis of theM. IIMitor ani is shown, which forms a loop behind the Recrum end supports the perineal flexure. This mechanism cantributes to the dosura of the Rectum and is i m portent for faecal continence. In addition, the complicated coursa of theM. obturotorius internus is visible: the muscle originates anteriorly from the inner aspect of the bony pelvis and courses dorsally until it bends around the ischium which serves as hypamochlion far the muscle. Finally theM. abturetorius internus inserts at the inner aspect of the Trochanter major.
tahir99-VRG & vip.persianss.ir
Efferent urinary system-+ Genitalia -+ Rectum and anal canal -+ Topography -+ Sections
Female pelvis, transverse sections
Ug. publcum aup•ll•
Spatlum ....,pubk:um
Symph)tlla publca
Iamora!III A.o~; N. obtLn\l:lrlus
A fllmcrala A. profunda femat1o
~~--t--t-1-o:_ ~ '"';:::=o,-...,b.J:-k,{:._,...._.,_, N. fllmcrallo
M.-.. lldlnllll
e..... albtendln"" mLaC:LII obllniDrlllntamt 1\lb.-lllchlllcicum M. aklteus maxmus
7.119
M.llbUIIIDIU
A glulelllniart
N. alutaus lnl'el1or v.; A pudenda huma; N. pudenclus
i·
l M.a.torl,.
M. 111ctua famorlll
v.r..-.ls
M.llop1101111
M. tensor la&clae latM
Vqlna
Fema.r,
Aeclum, Ampulla recti
Coll.lm farnorill
M. a1111niD!tln ....,_
-
lachlcanallll
Ramus osals lschll; lli!Mr le~:hllldll:um N.lachllldlc,.
7.120
Fig. 7.119and Fig. 7.12D hlvls.P-.!vls,Dhwoman:transverse section at the level ofthe lesser pelvis{... Fig. 7.119) and corresponding computed tomographic section {CT; ... Fig. 7.120); caudal view. The following pelvic viscera ere visible: urinary bladder {Vesica urineria}, Rectum, and the Vagina in between the Rectum and bladder. The seo-
tion also shows the ExaM~tio rectouterine (pouch of DOUGLAS) as the most ceudel pert of the peritoneal cavity. Compared to the section of the mele pelvis {... Fig. 7.117), the transverse section hare is further caudal. Therefore, in addition to the M. obturatorius internus, the M. obturetorius extemus at the opposite side of the pelvic bone is shown.
239
tahir99-VRG & vip.persianss.ir
Pelvis and Retroperitoneal Space
Kidney .-.•...-. Sections
Male pelvis, frontal section
Oellklm
Colon llgmoldllum
M. levt11lr af'j
-'r-'r-lr--- M. bleolp& f•mOI!s;
M. Mmllllndlnoell9; M. Mmlrntmbl'llnotll9
Fig. 7.121 ,.Ms. P•lvls. of • man: oblique frontal section lhrough the lesser pelvis.
240
The A. and V. pudenda intema course together with the N. pudendus within e dupliceture of the M. obturetorius intemus fascia {dinicel term: ALCOCK's canal) to the Fosse ischioenelis.
tahir99-VRG & vip.persianss.ir
Appendix Picture Credits .................... 243 Abbreviations, Terms, etc. . . . . . . . . . 245 Index ............................. 247
tahir99-VRG & vip.persianss.ir
tahir99-VRG & vip.persianss.ir
Picture Credits The editors sincerely thank all clinical colleagues that made ultrasound, computed tomographic and magnetic resonance images as wall as andoscopic and intraoperative picturas available: Prof. Altaras, Canter for Radiology, University of Giassan (Figs. 2.18; 2.39; 2.40) Prof. Briickmann and Dr. Linn, Nauroradiology, Institute for Diagnostic Radiology, University of Munich (Fig. 4.148) Prof. Daniel, Department of Cardiology, University of Erlangen (Fig. 10.39) Prof. Galanski and Dr. Schafer. Department of Diagnostic Radiology, Hannovar Medical School (Figs. 2.97; 5.3; 5.1 03; 6.31; 6.129) Prof. Gebel, Department of Gastroenterology and Hepatology, Hannovar Medical School (Figs. 6.73; 6.75; 6.76; 6.94; 6.95; 7.25) Dr. Greeven, St. Elisabeth Hospital, Neuwied (Figs. 4.96; 8.96) Prof. Hoffmann and Dr. Bektas. Clinic for Abdominal and Tranplantation Surgery, Hannover Medical School (Fig. 4.41) Prof. Hohlfeld, Clinic for Pneumology, Hannover Medical School (Fig. 5.71) Prof. Jonas, Urology, Hannover Medical School (Fig. 7.33) Prof. Kampik and Prof. Miillar, Ophthalmology, University of Munich (Fig. 9.66) Dr. Kirchhoff and Dr. Weidemann. Department of Diagnostic Radiology, Hannover Medical School (Figs. 6.131; 6.133; 7.26) Prof. Kleinsasser. Clinic and Polyclinic of Oto-Rhino-Laryngology, Plastic and Aasthatic Surgery, University Hospital Wuarzburg (Figs. 11 .41 ; 11 .42; 11.43) PD Dr. Kuna, Clinic and Polyclinic for Oto-Rhino-Laryngology, University Hospital Hamburg-Eppendorf (Figs. 8.101; 10.16; 11.16) Dr. Meyer. Department of Gastroenterology and Hepatology, Hannover Medical School (Figs. 6.22; 6.32; 7.1 04) Prof. Pfeifer, Radiology lnnenstadt, Institute for Diagnostic Radiology, University of Munich (Figs. 2.63-2.65; 2.67-2.70; 3.52; 3.54; 3.55; 4.97; 4.99; 4.1 00; 4.1 05; 4.1 06) Prof. Possingar and Prof. Bid:, Medical Clinic and Polyclinic II, Division of Hematology and Oncology, Charite Campus Mine, Berlin (Fig. 2.141) Prof. Ravalli t, formerly Institute of Anatomy, University of lnnsbruck (Fig. 2.62) Prof. Reich, Orofacial Surgery, University of Bonn (Figs. 8.60; 8.61) Prof. Reiser and Dr. Wagner, Institute for Diagnostic Radiology, University of Munich (Figs. 2.71; 12.1 05; 12.1 06; 12.11 0; 12.111) Dr. Scheibe, Department of Surgery, Rosman Hospital, Breisach (Fig. 4.79) Prof. Scheumann, Clinic for Abdominal and Tranplantation Surgery, Hannover Medical School (Fig. 11.58) Prof. Schillinger, Department of Gynaacology, University of Freiburg (Fig. 1.49) Prof. Schliaphake, Orofacial Surgery, University of Goaningan (Figs. 8.156; 8.157) Prof. Schloesser, Canter for Gynaacology, Hannover Medical School (Fig. 7.79) cand. mad. Carsten Schroeder, Kronshagen (Fig. 9.27) Prof. Schumacher, Neuroradiology, Department of Radiology, University of Freiburg (Fig. 12.5) Dr. Sal, University Hospital and Polyclinic for Ophthalmology, University Hospital Halle (Seale) (Fig. 9.64) Dr. Sommer and PD Dr. Bauer, Radiologists, Munich (Figs. 4.101; 4.102) PD Dr. Vogl, Radiology, University of Munich (Figs. 9.69; 9.70) Prof. Win, Department of Neurosurgery, University of Munich (Fig. 3.116) Prof. Zierz and Dr. Jordan, University Hospital and Polyclinic for Neurology, University Hospital Halle (Seale) (Figs. 8.82, 12.151)
Additional illustrations were obtained from the following textbooks:
1 Benninghoff-Drenckhahn: Anatomie, Band 1 (Drenckhahn D., editor). 17. Aufl., Urban & Fischer 2008 2 Banninghoff-Dranckhahn: Anatomia, Band 2 {Dranckhahn D., editor). 16. Aufl., Urban & Fischer 2004 3 Banninghoff-Dranckhahn: Taschanbuch Anatomia (Dranck:hahn D., Waschke, J., editors). Urban & Fischer 2007 4 Berchtold, R.• Bruch, H.-P., Trentz, 0. (editors): Chirurgie, 6. Aufl., Urban & Fischer 2008 5 Boeker. W., Dank, H .• Heitz, P. U., Mach, H. (editors): Pathologie, 4. Aufl., Urban & Fischer 2008 6 Classen, M.. Diehl, V.. Kochsiek, K., Berdel, W. E.. Bohm, M .• Schmiagal, W. {editors): lnnara Madizin, 5. Aufl., Urban & Fischer 2003 7 Classen, M., Diehl, V., Kochsiak:, K., Hallak:, M., Bohm, M. (editors): lnnere Medizin, 6. Aufl., Urban & Fischer 2009 8 Drake, R. L., Vogl, A. W., Mitchell, A., Paulsen, F. (editors): Gray's Anatomia fur Studantan, 1. Aufl., Urban & Fischer 2007 9 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Anatomy for Students, 2"d ad., Churchill Livingstone 2010 10 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Atlas der Anatomie, Urban & Fischer 2009 11 Fleckenstein, P., Tranum-Jensen, J.: Rontgenanatomie, Urban & Fischer 2004 12 Forbes, A., Misiewicz, J ., Compton, C., Ouraishy, M ., Rubasin, S., Thuluvath, P.: Atlas of Clinical Gastroenterology, 3'd ad., Mosby 2004 13 Franzen, A.: Kurzlehrbuch Hals-Nasen-Ohren-Heilkunde, 3. Aufl., Urban & Fischer 2007 14 Garzorz, N.: BASICS Neuroanatomie, Urban & Fischer 2008 15 Kanski, J. J.: Klinische Ophthalmologie, 5. Aufl., Urban & Fischer 2003 16 Kanski, J. J.: Klinische Ophthalmologie, 6. Aufl., Urban & Fischer 2008 17 Kauffmann, G. W., Moser, E., Sauer, R. (editors): Radiologie, 3. Aufl., Urban & Fischer 2006 18 Lippert, H.: Lehrbuch Anatomie, 7. Aufl., Urban & Fischer 2006 19 Mettler, F. A. (editor): Klinische Radiologie, Urban & Fischer 2005 20 Moore, K., Persaud, T. V. N., Viebahn, C. (editors): Embryologie, 5. Aufl., Urban & Fischer 2007 21 Schulze, S.: Kurzlahrbuch Embryologia, Urban & Fischer 2006 22 Speckmann, E.-J., Hescheler. J., Kohling, R. (editors): Physiologie, 5. Aufl., Urban & Fischer 2008 23 Trepel, M.: Neuroanatomie, 4. Aufl., Urban & Fischer 2008 24 Welsch, U.: Sobotta Lehrbuch Histologie, 2. Aufl., Urban & Fischer 2005 25 Welsch, U., Deller, T.: Sobona Lehrbuch Histologie, 3. Aufl., Urban & Fischer 201 0 26 Welsch, U.: Atlas Histologie, 7. Aufl., Urban & Fischer 2005 27 Wicke, L.: Atlas dar Rontgananatomia, 7. Aufl., Urban & Fischer 2005 28 Rangier, F.: BASICS Leitungsbahnen, Urban & Fischer 2009 The following illustrators have developed then- illustrations: Dr. Katja Dalk:owski: Figs. 5.2, 5.5, 5.6, 5.7, 5.10, 5.20, 5.26, 5.28, 5.40, 5.41' 6.1' 6.2, 6.6, 6.64, 6.65, 6.66, 6.67, 6.92, 6.114, 7.6, 7.7, 7.8, 7.18, 7.19, 7.42, 7.43, 7.53, 7.72, 7.73
Sonja Klebe: Figs. 5.62, 5.64, 5.79, 5.95, 5.96, 5.97, 6.12, 6.13, 6.18, 6.19, 6.20, 6.28, 6.46, 6.47, 6.48, 6.50, 6.51, 6.71' 6.79, 6.80, 6.93, 6.115, 6.118, 7.61, 7.62, 7.85, 7.86, 7.90, 7.99
243
tahir99-VRG & vip.persianss.ir
tahir99-VRG & vip.persianss.ir
1. List of abbreviations Singular:
A. Lig. M. N. Proc. R.
v.
Var.
Arteria Ligamentum Musculus Nervus Processus Ramus Vena Variation
Plural: Aa. Ligg. Mm. Nn. Procc. Rr. Vv.
Arteriae Ligamenta Musculi Nervi Processus Rami Venae
female male
Percentages: In the light of the large variation in individual body measurements, the percentages indicating size should only be taken as approximate values.
2. General terms of direction and position The following terms indicate the position of organs and parts of the body in relation to each other, irrespective of the position of the body (e.g. supine or upright) or direction and position of the limbs. These terms are relevant not only for human anatomy but also for clinical medicine and comparative anatomy.
longitudinalis= parallel to the longitudinal axis (e.g. Musculus longitudinalis superior of the tongue)
sagitta/is = located in a sagittal plane transversalis =located in a transverse plane transversus= transverse direction (e.g. Processus transversus of a thoracic vertebra)
General terms
anterior- posterior= in front- behind {e.g. Artariae tibiales anterior at posterior)
ventralis- dorsalis= towards the belly- towards the back. superior- inferior= above -below (e.g. Conchas nasal as superior at
Terms of direction and position for the limbs proxima/is- distalis located towards or away from the attached and of a limb or the origin of a structure (e.g. Articulationes radioulnares proximal is at distalis)
=
inferior)
crania/is -cauda/is= towards the head- towards the tail dexter-sinister= right -left (e.g. Arteriae iliacae communes dextra et sinistral
internus- extemus = internal- external superficialis -profundus= superficial- deep (e.g. Musculi flexores digitorum superficialis et profundus) medius, intermedius= located between two other structures (e.g. the Concha nasalis media is located between the Conchas nasalas superior and inferior) median us= located in the midline (Fissura madiana anterior of the spinal cord). The median plane is a sagittal plane which divides the body into right and left halves. medialis -latera/is = located near to the midline- located avmy from the midline of the body (e.g. Fossae inguinales medialis at lateralis) frontalis= located in a frontal plana, but also towards the front (e.g. Processus frontalis of the maxilla)
for the upper limb:
radialis - ulnaris =on the radial side- on the ulnar side (e.g. Artariaa radialis at ulnaris)
for the hand:
palmaris -dorsalis= towards the palm of the hand- towards the back of the hand {e.g. Aponeurosis palmaris, Musculus interosseus dorsalis) for the lower limb:
tibialis- fibularis = on the tibial side- on the fibular side {e.g. Arteria tibialis anterior)
for the foot
plantaris -dorsalis= towards the sole of the foot- towards the back of the foot (e.g. Artariaa plantares lateralis at medialis, Arteria dorsalis pedis)
3. Use of brackets [ ]: Latin terms in square brackets refer to alternative terms as given in the Terminologia Anatomies {1998), e.g. Ren [Nephros]. To keep the legends short, only those alternative terms have bean added that differ in the root of the word and are necessary to understand clinical terms, e.g. nephrology. They are primarily used in figures in which the particular organ or structure plays a central role.
( ): Round brackets are used in different ways: - for terms also listed in round brackets in the Terminologia Anatomies, e.g. (M. psoas minor) - for terms not included in the official nomenclature but which the editors consider important and clinically relevant, e.g. (Crista zygomaticoalveolaris) - to indicate the origin of a given structure, e.g. R. spinalis {A. vertebral is).
245
tahir99-VRG & vip.persianss.ir
tahir99-VRG & vip.persianss.ir
Index
A Abdomen 148-163 Abdominal cavity 70, 151 - t ransverse section 154-158 - - computed tomography 154-156 Abdominal viscera 69-156 - anastomoses of arteries 140 - arteries 140 - development 70 - projection onto the body surface 86 - topography 70 Abscess, Fossa lschioanalis 200 Absolute cardiac dullness 4 Accessorysexglands 1S3, 190 Acetabulum 238 Acinus{-1} - pancreatic! 123 - pulmonalis 3S - pulmonis 32 Acromion 6S ADDISON's disease 170 Adrenal gland 122, 166, 170 - in the retroperitoneal space 164 Adrenocortical Insufficiency 170 - hypoglycaemic shock 170 Air conducting part, lower respiratory tract 32 ALCOCK's canal (Canalis pudendalis) 199-200,
217-218, 234,240 Ampulla - ductus deferentis 178, 186, 190, 201 - duodeni 7~S8-90 - hepatopancreatica 127 - recti 148, 1SO, 222, 226, 236-237, 239-240 - tubae uterinae 93, 206-20S, 237 Anal canal 92, 222- 223 - innervation 226 - projection onto the body surface 220 - rectoscopy 227 - sphincter muscles 223 - veins 225 Anal cancer 223 Anal fistula 223 Anal prolapse 223 Anastomoses, arteries of the abdominal viscera 47, 81, 106, 112, 140, 225 Anatomical dead-space, resuscitation 32 Androgens, adrenal glands 170 Angina pectoris 27 - coronary artery stenosis 23 Angle of HIS 76 Angustia {Oesophagus} 45 - aortica 46 - cricoidea 46 - diaphragmatica 45 Annular pancreas 121 Ansa subclavia 58, 61 Anteflexion, uterus 20S Anteversion, uterus 208 Anti-MULLER IAN hormone 163,205 - differentiation of the MOLLER IAN ducts 185 Antrum pyioricum 42, 75, 77, 85, 89, 153 Anulus - fibrosus - - dexter 16 - - sinister 16, 18 - inguinalls - - profundus 232 - - superficlalis 187, 191-192 - umbiticalls 93, 148 Anus 163,199, 202,217,222, 224-226 - projection onto the body surface 86 Aorta 4, 16,20,24,66,68, 72, 103,148,155,
162 - abdomlnalis/thoracica See Pars abdomina lis/ thoracica aortae - ascendens/descendens See Pars ascendens/descendens aortae - branches 56 - overriding aorta 7 Aortic arch 6, 55 - branching variations of the great vessels 55 Aortic coarctation 7, 9
Aortic ring 16 Aorticvalve 16, 19 - insufficiency 5 - projection onto the ventral thoracic wall4 Aortic valve stenosis 5, 7, 9 - hypertrophy of t he cardiac muscle 15 Apex - cordis 4-5, 10, 12- 13, 16, 17-1S - pulmonis 34-36, 40, 63 - vesicae 177-17S Appendicitis 73, 93, 95 - perforation, peritonitis 95 - pouch of DOUGLAS 237 Appendix{-ces) - epididymidis 18S, 191 - epiploicae (omentales) 94, 134, 240 - fibrosa hepatis 104- 105 - projection - - onto the body surface 86 - - onto the ventral thoracic wall 93 - testis 1S3, 188, 191 - vermiformis 74, 86, 92-93, 95-97, 101-102,
120, 12S, 135-138. 143, 145-146, 161, 187, 208, 220 - vesiculosa 203 Arcus -aortae 5-6,8-9, 11 -1 3, 24-25, 3S,41,43-
44,48,54-66,62,64,68 - costalis 210 - tendineus musculllevatoris ani 196, 214-
215 Area(-ae} - cri brosa 167 - gastricae 77-78 - nuda 104-106, 148 Arrhythmia, ECG 22 Arteria{-ae) - appendicularis 96-98, 140, 143, 146 - arcuata {Ren) 167, 169 - axillaris 60-61 , 64, 68 -bulbi - - penis 197, 200 - - vestibuli 216 - caecal is anterior 96-97, 146 - carotis - - communis 6, 12- 13, 38, 43-44, 46, 48,
Artsria(-as} - gastrica(-ae} - - breves SO, 140, 142, 144 - - dextra 80, S3, 110, 140, 142 - - posterior SO, 142 - - sinistra 46, SO, 83, 96, 110, 125, 140, 142,
144, 150, 155 - - - branches 142 - gastroduodenalls SO, 83, 96, 110, 11S, 122,
125, 140, 142, 144, 150 -
140, 142, 144, 166 - - - branches 142 - - propria SO, 83, 96, 104, 108, 110, 118,
122, 126, 140, 142, 149- 160, 156 -
ileales 96, 140, 143, 146 ileocolica 96-97, 140, 143, 146-146 iliaca - communis 8, 148-149, 176, 216, 226,
-
- externa 8, 224, 232-234, 237 - interns 8, 224, 232-234 - - parietal branches 232 - - visceral branches 232 - - - in man 233 - - - in woman 23 4 iliolumbalis 232 intercostalis 3 67 - posterior 62-53, 56-57 - suprema 56, 60-61 interlobaris (Ran) 167- 169 interlobularis 106 jejunales 96. 140, 143, 145, 147, 150 ligamenti teretis uteri 234 lobaris superior 65 lobi caudati 104 lumbales 228 mesenteries - inferior 97, 140, 146- 147, 156, 162, 224,
228,232
-
- externa 55 - interna 55 caudae pancreatis 140 cervicalis - ascendens 60-61 - profunda 56 circumflexa - femoris medialis 238 - humeri posterior 6S - scapulae SS colica - dextra 96-97, 140, 143, 145-146 - media 96-97, 140, 143, 146-147 - sinistra 97, 140, 146- 147 coronaria{-ae), 24 - balanced or codominant perfusion type 26-27 - dextra 12-13, 17, 19, 24- 27, 62, 67 - - branches 24 - infarction pattern in the case of occlusion 27 - left-dominant perfusion type 26-27 - perfusion areas 27 - right-dominant perfusion type 26-27 - sinistra 13, 19.24-27, 62, 67 - - branch&s 24 cortical is radiata 169 cremasterica 191-193, 232 cystica SO, 104, 110, 116, 118, 140, 142 dorsalis - clitoridis 216, 218 - penis 192, 197, 200, 233 ductus defe rentis 191 , 193, 233 epigastrica inferior 232-23 3, 237 femoralis 238-239
a.
226, 228, 232
61,53-55,58,60- 61 , 63-64,68 -
gastroomentalis - dextra SO, S3, 110, 125, 140, 142, 144 - sinistra SO, 83, 110, 140, 142, 144 glutea - inferior 224, 232, 23S-239 - superior 224, 232 helicinae 186 hepatica - communis 80, 96, 110, 11S, 122, 126,
- - - branch&s 146 - - - course 147 - - superior SO, 96-97, 110, 122-123, 125, 12~
-
140, 142-150, 156, 166,22S
- - branches 9S, 143 - - course 146 - - origin 144 obturatoria 196, 215, 224, 232-233, 23S-
239 - ovarica 176, 206-20S, 211-212, 22S, 234,
237 -
pancreatica - dorsalis 125, 140 - inferior 125 - magna 140 pancreaticoduodenalls - inferior 96, 125, 140, 143-144, 147 - superior 126 - - anterior 96, 126, 144 - - posterior 96, 126, 140 pericardiacophrenica 11, 62-54 perinealis 197, 200, 218 phrenica inferior 171-172, 228 profunda - cervicis 60-61 - femoris 23S-239 - penis 186, 192, 198, 233 pudenda - externa profunda 192 - interns 197, 200-201, 218- 219, 224- 226,
232-234, 238-240 - pulmonalis(-es} 8-9, 38, 62 - - dextra 10-13, 15, 26, 36, 44, 62,66 - - sinistra 6, 10- 13, 26, 35, 44, 53
247
tahir99-VRG & vip.persianss.ir
Index
Arteria(-ae) - rectalis - inferior 140, 200,218, 224, 233-234 - media 193, 224, 232-234 - superior 97, 140, 146-147, 224-225,234 renalis 148-149, 156, 162, 164-167, 171-
172, 175, 193, 228 - accessoria 164, 171 - course 171
-
- polaris - - inferior 172 - - superior 172 - sinistra 165 sacralis - lateralis 232 - mediana 228, 232-234 sigmoideae 97, 140, 146-147,224,240 splenica [lienalisl 80, 83, 96, 110, 122, 125,
127, 129, 140, 142, 144, 150-151, 154-155 - - branches 142 - subclavia 6, 12-13, 38, 43-44, 46, 48, 51,
54-56,58,60-61,63-64 - subcostalis 57 - subscapularis 64 - supraduodenalis 140 - suprarenalis(-es) 172 - - inferior 164, 166, 171-172, 228 - - media 166, 171-172, 228 - - superiores 166, 172 - suprascapularis 60-61 - testicularis 171, 187, 189, 191-194,228,238 - - course 193 - thoracica interns 52, 54, 56,60-61, 64, 66 - thoracodorsalis 64 - thyroidea - - ima 55 - - inferior 46, 60-61 - transversa cervicis 60-61 - umbilicalis(-es) 8, 210, 232-234 - urethralis 192 - uterina 211, 232, 234 - vagina lis 211, 234 - vertebralis 46, 55, 60-61 - vesicalis - - inferior 193, 232-234 - - superior 232-233 Articulatio(-nes) - acromioclavicularis 68 - coxae 239 - humeri 68 - sacrococcygea 198 Ascending colon 101 ASCHOFF-TAWARA node {AV node, Nodus atrioventricularis) 20-21 Aspiration 28 - foreign bodies 28 Asthma bronchiale, left ventricular hypertrophy 15 Atrioventricular bundle (Fasciculus atrioventricularis, bundle of HIS) 16, 20-21,24 Atrioventricular valves 16 - stenosis 16 Atrium cordis 6 - dextrum 4-10, 12-13, 15, 17, 21,24-25,41, 55,62,6~
149-150
- sinistrum 6-9, 13, 15, 18,24-25,55, 62,
66-67 Auricula - dextra 12, 17, 19 - sinistra 5, 12-13, 15, 18,24-25,41, 55, 66 Auscultation, cardiac sounds 4 AV node (Nodus atrioventricularis, node of TAWARAJ 20-21 Axilla 68 Axillary fossa 68 Azygos system, veins 57
B BARTHOLIN's glands {Gil. vestibulares majores) 202, 204, 217, 219
248
Basis - prostatae 190 - pulmonis 34-35 BAUHIN's valve {Valva ileocaecalis) 86, 95 Benign prostatic hypertrophy (BPHJ 159, 190 - digital rectal examination (DREJ 221 Bifurcatio - aortae 147 - tracheae 32-33, 41, 43-44, 62 - trunci pulmonalis 11 Bile concrement, pancreatitis 124 Bile ducts - ERCP 127 - extrahepatic ducts 117 - - radiography 119 - intrahepatic ducts, radiography 119 - lymph vessels and lymph nodes 113 - malignant tumors 119 - variations 118 Biopsies, CT-controlled punctures 65 Borders of the right and left lungs - midaxillary line 29 - midclavicular line 29 - paravertebral line 29 - projection - - onto the anterior thoracic wall 29 - - onto the back 29 - - onto the posterior thoracic wall 29 - scapular line 29 - sternal line 29 BPH (benign prostatic hypertrophy), digital rectal examination (DREJ 221 Bradycardia, ECG 22 Bronchial buds 31 Bronchial carcinoma 41 Bronchial trunk 31 Bronchioli 32 - respiratorii 38 - terminales 32, 38 Bronchopulmonary segments 36-37 Bronchoscopy 37 Bronchus(-i) 32-33,41 - bronchoscopy 37 - lingularis - - inferior 32, 37 - - superior 32, 37 - lobaris - - inferior 66 - - - dexter 28, 32-33, 35 - - - sinister 28, 32-33 - - medius 28, 32-33, 35, 66 - - superior - - - dexter 28, 32-33, 35, 43, 65 - - - sinister 28, 32-33, 37 - principalis - - dexter 28, 32-33,35,38, 41,43-45, 52,
56,58,65 - - sinister 28, 32-33, 35, 38, 41, 43-44, 53,
56,58,65 - segmentalis - - anterior 32, 37, 68 - - apicalis 32 - - apicoposterior 32, 37 - - basalis - - - anterior 32, 37 - - - lateralis 32, 37, 67 - - - medialis 32 - - - posterior 32, 37 - - lateralis 32 - - medialis 32 - - posterior 32 - - superior 32 BRUNNER's glands (Gil. duodenales) 89 Bulbus - aortae 19 - penis 186, 201, 236 - vestibuli 202, 218-219, 234 Bundle of HIS (atrioventricular bundle, Fasciculus atrioventricularis) 16, 20-21, 24 Bursa - omentalis 72, 132-133, 139, 148, 153-155 - - development 72
Bursa - subtendinea iliaca 238 - - musculi obturatorii interni 238-239 - trochanterica musculi glutei medii 238
c Caecum 92-93, 95-97, 101, 130, 134-138,
143, 145-146,208 - projection onto the ventral abdominal wall 86 Calices renales 169 - majores 167, 174, 176 - minores 156, 167-168, 174, 176 CALOT's triangle (Trigonum cholecystohepaticum) 118 Canalis - analis 92, 220, 222-223, 225-227 - - projection onto the body surface 86 - atrioventricularis 6 - cervicis uteri 207, 237 - inguinalis 187 - obturatorius 196, 214, 224-225 - pudendalis (ALCOCK's canal) 199-200,
217-218,234,240 - pyloricus 75, 77, 89, 124 Capsula - adiposa {Ren) 151, 155, 164, 166, 171, 173 - fibrosa {Ren) 164, 166-168 Caput 187 - epididymidis 188-189, 191, 193,236 - femoris 238 - humeri 63, 68 - longum (M. biceps brachii) 68 - medusae 112 - pancreatis 93, 120-124, 127, 144, 149-150 - - projection onto the ventral abdominal wall 86 Cardia (Pars cardiaca) 74-75,77, 80, 131, 148,
153 Cardiac arrhythmias, ECG 22 Cardiac muscle 15 - dilation 13 - hypertrophy 5, 13, 15 Cardiac veins 25 Cardiac wall, structure 14 Carina tracheae 62 Cartilago(-ines) - bronchiales 32 - costal is 65, 67 - cricoidea 32-33 - thyroidea 32-33 - tracheales 32-33, 62 Carunculae hymenales 202 Catecholamines, adrenal gland 170 Cauda - epididymidis 183, 188-189, 193,236 - equina 148, 156 - pancreatis 120-122, 124, 127, 138-139, 150,
155 - - projection onto the ventral abdominal wall 86 Cavernae corporum cavernosorum 186 Cavitas - abdominalis 70, 151, 164-156 - extraperitonealis pelvis 201. 219 - glenoidalis 68 - nasi 28 - oris propria 42 - pericardiaca 62, 65 - peritonealis 70, 139, 148-160, 163-156 - - abdominis 158 - - pelvis 158,201, 219 - pleuralis 40, 50, 52-63, 66, 154-156 - serosa scroti 189 - thoracis 62, 64-68. 151 - uteri 207-208,219, 237 Central venous catheter {CVC) 35, 63 - pneumothorax 35 Centrum - perinei 215 - tendineum (Diaphragms) 43, 52, 148, 152
tahir99-VRG & vip.persianss.ir
Index
Cervical carcinoma 209 - lymph node metastases 213 Cervical constriction, oesophagus 45 Cervix uteri 206, 208-209, 211, 219 Cholecystitis 71 - referred pain in the right shoulder 54 Cholestasis 118-119 Chordae tendineae 17-19 Chronic obstructive pulmonary disease {CO PD), hypertrophy of the right ventricle 15 Cisterna chyli 57, 99, 229 Clavicula 5, 54, 63, 68 Clitoris 202, 204, 212 Cloaca 162 Collecting duct 169 Colliculus seminalis 177-178 Collum - femoris 239 - vesicae biliaris 88, 116-117, 119 Colon 74, 102, 120, 128, 161, 173,220 - ascendens 81,92-93,95-98,101,111,130,
134, 137-138, 146, 150, 176 - - projection onto the body surface 86 - descendens 81,92-93,97-98,101,111,
134, 137-138, 146-147, 150, 155-156, 176 - - projection onto the body surface 86 - sigmoideum 92-93, 97, 101, 130, 134, 136-
139,145-148,150,221,224-225,228, 236-237,240 - - projection onto the body surface 86 - transversum 72,92-93,97, 101, 116, 130131, 133-134, 136-138, 145-146, 148-150, 162-163, 165-156 - - positional variations 101 - - projection onto the body surface 86 Colonic carcinomas 101 - lymphatic drainage 99 Columnae - anales 222-223, 225, 227, 240 - renales 167, 174 Commissura - labiorum anterior 202 - - posterior 202 Complexus stimulans et conducente cordis 20-21 Computed tomography (CTJ 65, 154 - abdominal cavity, transverse section 154-156 - kidney 173 - pelvis - - of a man, transverse section 238 - - of a woman, transverse section 239 - thoracic cavity, transverse section 65 - thorax 3 Conducting system of the heart 20-21 Congenital cardial defects 7 Congenital inguinal hernia 185 Continence organ 223 Conus arteriosus 6, 12, 24 Cor 2, 12-13,55, 66, 74, 102, 120, 128, 160-
161 - bovinum 13 - position within the thorax 10 Corona glandis 186-187, 236 Coronary arteries 19 - SBB also Arteria corona ria dextra/sinistra Coronary artery disease (CAD) 27 Coronary artery stenosis 23 Corpus{-ora) - adiposum pararenale 173 - anococcygeum 198,221 - cavernosum - - clitoridis 202, 237 - - penis 178-179, 184, 186, 191-192, 194,
204,236 -
- recti 223-224 clitoridis 237 epididymidis 188-189 gastricum 74-75, 77, 86, 130-132, 151 luteum 207 ossis pubis 149, 214 pancreatis 120-124, 127, 133, 138, 144 - projection onto the ventral abdominal wall 86
Corpus(-ora) - penis 182 - pineale 160 - spongiosum penis 178-179, 184, 186, 191-
192,194,199,223,236 - sterni 64-66 - uteri 206-208, 211, 219 - vertebrae 65, 155, 173 - vesicae 177-178 - - biliaris 88, 116-117, 119 Corpusculum renale 168 Cortex 170 - {GI. suprarenalis) 170 - renal is 156, 167-168, 173-174 Costa 64-68 COWPER's glands (Gil. bulbourethrales) 160,
178,183,186,190,194,197-199,201,221 Crista - iliaca 29, 161, 231 - terminalis 17, 21 - urethralis 177-178 CROHN's disease 95 Crus - clitoridis 202, 219 - dextrum - - (Diaphragma) 155 - - (Fasciculus atrioventricularis) 20-21 - - (Pars lumbalis diaphragmatis) 57 - penis 186, 198, 201 - sinistrum - - (Fasciculus atrioventricularis) 20-21 - - (Pars lumbalis diaphragmatis) 57, 154 Cryptorchidism 185 Cupula pleurae 29, 40-41, 63, 68 Curvatura - major 75, 77, 130-132 - minor 75-77,90, 131-132 Curvatures of the stomach, arteries 80 Cuspis - anterior - - {Valva atrioventricularis dextral 16-17 - - {Valva atrioventricularis sinistral 16, 19, 66 - commissuralis - - dextra 16 - - sinistra 16 - posterior - - {Valva atrioventricularis dextral 16-17 - - {Valva atrioventricularis sinistral 16, 18, 66 - septalis {Valva atrioventricularis dextral 16-
17 Cutis 187, 191 eve (central venous catheter) 35, 63 - pneumothorax 36 Cystitis 180 Cystocele 214 Cystoscopy, ureteric orifice 177
D DENONVILLIER's fascia (Fascia rectoprostatica) 190, 221,236 Descensus - testis 185 - Uterus/Vagina 214 Diabetes mellitus 123 - fatty liver 102 Diaphragma 6, 41, 43-46,48,52, 54, 58, 74,
79, 102, 104, 116-116, 120, 122, 128, 131, 148, 151, 165, 161, 173 - pelvis 158, 196, 198,214-215 - urogenitale 158 Diaphragmatic constriction, oesophagus 45 Diastole 16 Digestive tract, overview 42 Digital rectal examination (DRE), prostata 221 Discus interpubicus 210 Diverticulum(-a) - ampullae 178 - ilei 91 - of the oesophagus 45 Dorsal pancreatic bud 103, 121 Dorsum penis 182
DRUMMOND's anastomosis 97, 145-147 Ductuli - efferentes testis 185, 189 - prostatici 177-178 Ductus - arteriosus 6, 8 - - persisting 7, 9 - bilifer interlobularis 106 - choledochus (biliaris) 88, 103-104, 108, 110,
117-119, 121, 123-124,
12~
142, 149, 155
- - variation of the junction 124 - cysticus 88, 108, 110, 117-119, 122-123,
127, 155 - deferens 149, 160, 178, 183, 185, 187, 189-
192,194,198,233,236,238,240 -
ejaculatorius 177-178, 183 excretorius {pancreas) 123 glandulae bulbourethralis 178, 183, 197 hepaticus - communis 88, 108, 110, 117-119, 122-
-
- dexter 117, 119 - sinister 117, 119 lymphaticus 39, 60 mesonephricus (WOLFF IAN duct) 162-163,
123, 127
186,205 - pancreaticus accessorius (SANTORINI's duct) 88, 117, 121, 124 - pancreaticus (duct of WIRSUNG) 88-89, 11~
121, 123-124, 127, 148-149
- - variations of the junction 124 - paramesonephricus {MULLERIAN duct) 163, 186 - thoracicus 2, 39, 53, 56-67, 59, 61,64-67,
99,161,154-156,229 - - junction 39 - venosus 8 - vitellinus 73 Duodenal ulcers 78 - duodenoscopy 90 Duodenoscopy 90 Duodenum 42, 58, 72,
74-7~80-81,85,88-
90, 93,98,102-103,110-111,116-124,127128,135,137-139,142,149-150,161 arteries 96 divisions 88 endoscopy 90 inner relief 89
- projection onto the ventral abdominal wall 86,120 - radiograph 90 - wall structure 89 Dysphagia lusoria 55
E Echocardiography 3 - transoesophageal 62 Ejaculation, N. pudendus 194 Electrocardiogram {ECG) 3 - anatomical principles 22 - Pwave 22 - 0 wave 22 - R wave 22 - Swave 22 - Twave 22 Emission 194 - Sympathicus 194 Endocardium 14 Endocrine organs 160 Endometrial carcinoma 207 - lymph nodes metastasis 213 Endometrium 207 Endoscopy - duodenum 90 - duodenal ulcers 78, 90 - gastric ulcers 78 Epicardium 11-12, 14, 17-18, 62 Epididymis 160, 183, 187-189, 191, 194 - blood vessels 189 Epigastrium - abdominal surgery 133
249
Index
Epigastrium
Fascia
Frenulum
- position of the viscera 130-132 - retroperitoneal organs 122 Epiorchium 187 Epiphrenic diverticula 45 Episiotomy 217 Epispadias 184 Epithelium - (Gaster) 78 - (lntestinum tenue) 87,94 ERCP {endoscopic retrograde Cholangiopancreaticography) 122 - bile ducts 127 - pancreas 127 Erection 194 - inhibitors of the enzyme phosphodiesterase 192 - parasympathetic system 194 Excavatio - rectouterine {pouch of DOUGLAS) 138-139, 208-210,237,239 - - appendicitis 237 - - salpingitis 237 - rectovesicalis 138, 149, 181, 221-222,236 - vesicouterina 139,208-210, 219,237 External female genitalia 202 - development 204 - lymph vessels and lymph nodes 213 - lymphatic drainage pathway 213 External male genitalia 182-183 - development 184 - lymph vessels and lymph nodes 195 - neurovascular structures 192 Extremitas - acromialis (Clavicula) 68 - anterior - - (Splen) 129 - inferior - - (Ren) 173, 176 - - (Testis) 188 - posterior (Splen) 129 - superior - - (Ran) 173 - - (Testis) 188 - tubaria {Ovarium) 206 - uterina 206
-
- labiorum pudendi 202 - ostii ilealis 95 - preputii 187 Fundus - gastricus 75-77, 116, 131 - uteri 139,206-208,210-211,237 - - position during pregnancy 210 - vesicae 139, 177 - - biliaris 88, 116-117, 130, 135, 138 Funiculus - spermaticus 183, 188, 191-192, 198,221, 238 - - coverings of the spermatic cord 187, 191
F Facies - anterior - - (GI. suprarenalis) 170 - - (Ran) 173 - colica (Splen) 129 - costalis - - (Pulmo dexter) 34 - - (Pulmo sinister) 34-35 - diaphragmatica - - (Cor) 10 - - (Hepar) 104-106, 131-132 - - (Pulmo) 35 - - (Splen) 129 - gastrica (Splen) 129 - medialis (Ovarium) 206, 208 - mediastina lis (Pulmo sinister) 35 - posterior - - (Prostata) 178 - - (Ren) 173 - pulmonalis (Cor) 10 - rena lis (Splen) 129 - sternocostal is (Cor) 10 - vesicalis 208 - visceralis - - (Hepar) 105-106, 131 - - (Splen) 129 FALLOT's tetralogy 7 Fascia - cremasterica 187-189, 191, 236 - obturatoria 199, 217 - pelvis - - parietalis 237 - - visceralis 219, 236
250
penis 192 - profunda 187, 191 - superficialis 187, 192 rectoprostatica (DENONVILLIER's fascia) 190, 221, 236 - rectovaginalis 237 - renalis (GEROTA's fascia) 152-153, 161, 164, 173 - spermatica - - externa 187, 189, 191 - - interna 187-189, 191 Fasciculus - atrioventricularis (atrioventricular bundle, bundle of HIS) 20-21, 24 - latera lis (Plexus brachia lis) 68 - medialis (Plexus brachia lis) 68 - posterior (Plexus brachial is) 68 Fatty liver - alcohol abuse/diabetes mellitus 102 Fecal incontinence 214 Female genital system 203 Female genitalia, innervation 212 Female pelvis 180 Female urinary organs 203 Female urinary system 160 Femur 238-239 Fetal circulation 8 Fibrae obliquae (Tunica musularis, Gaster) 76 Fimbria(-ae) - ovarica 206-207 - tubae uterinae 206-208 Fine needle aspiration biopsy {FNAB) 173 Fissura - horizontalis (Pulmo dexter) 29, 34-35 - ligamenti teretis hepatis 104-105 - obliqua (Pulmo) 29, 34-35, 64-67 - umbilicalis 107 Flexura - anorectalis 198 - coli - - dextra 92, 101, 116, 134 - - sinistra 92, 101, 134 - duodenojejunalis 89-90, 120, 124, 136, 139, 150 - - projection onto the ventral abdominal wall 86 - perinealis 220-222 - sacralis 220-222 Floating lung test 30 Folliculi ovarici 207 Foramen{-ina) - infrapiriforme 196 - ischiadicum - - majus 214 - - minus 196 - omentale 131-132 - ovals 6-9 - papillaria 167 - suprapiriforme 196 - venae cavae 43 - venarum minimarum 17 - vertebrale 65 Foregut 30 Foreign bodies in the oesophagus 45 Fornix - gastricus 77, 148, 153 - vaginae 207, 209, 237 Fossa - acetabuli 238 - ischioanalis 199-201,217-219,238-240 --abscesses 200,218 - - borders 199, 217 - - contents 200, 218 - jugularis 74 - navicularis urethrae 178-179,236 - ovalis 17 Foveolae gastrica(-ae) 78 FRANKEN HAUSER's plexus (Plexus uterovaginalis) 212 Frenulum - clitoridis 202
G Gallbladder 117 - arteries 110 - developmental stages 103 - laparoscopic image 116 - projection onto the ventral abdominal wall 115 - radiograph 119 - - after intravenous application of contrast medium 119 - surgical removal, CALOT's triangle 118 - veins 111 Ganglion(-ia) - aorticorenale 1 00 - cardiacum 23 - cervicale - - medium 23, 58 - - superius 23 - cervicothoracicum {stellatum) 23, 58, 60-61 - coeliaca 84, 100, 155, 226, 231 - impar 231 - mesentericum - - inferius 100, 226, 231 - - superius 100,231 - pelvica 194, 212, 226 - stellatum See Ganglion cervicothoracicum - thoracica 52-53, 58 - trunci sympathici 56-57, 194,212, 226 Gaster 42-43, 46, 58, 72, 74-78, 80-85, 88, 90,93,98,102-103,110-111,120,128, 130-132, 138, 142, 148-150, 152-156, 160161 - See also Stomach Gastric canal 77 Gastric carcinomas 71 - lymph vessels and lymph nodes 82 - lymphatic drainage 48, 82 - perforation into adjacent organs 79 Gastric ulcer 78 - endoscopy 78 - perforation 79 - selective vagotomy 84 - total vagotomy 84 Gastritis 71 Gastro-(o)esophageal reflux disease (GERD) 42, 75 Gastroscopy 85 - biopsies 85 Genital tubercles 161, 163-164, 184,204 - nephrectomy 164 GEROTA's fascia (Fascia renalis) 152-153, 161, 164, 173 - nephrectomy 164 Glandula{-ae) - analis {proktodeal gland) 223 - bulbourethrales (COWPER's glands) 160, 178,183,186,190,194,197-199,201,221 - duodenales {BRUNNER's glands) 89 - gastricae 78 - intestinales 87, 94 - mammaria 65-66 - oesophageae 44 - parathyroideae 160 - pinealis 160 - pituita ria 160
Index
Glandula (-ae) - suprarenalis 79, 122, 139, 151, 155, 160-
161,164,166,170-171,228 - - contact area on the posterior wall of the stomach 79 - thyroidea 48, 51, 54, 62, 160-161 - tracheales 33 - vesiculosa 148-149, 160, 178, 183, 185-
186,190,194,198,201,221,233,238,240 - vestibulares - - majores (BARTHOLIN's glands) 202, 204,
217,219 - - minores 202 Glans - clitoridis 202 - penis 178, 182, 184, 186-187, 194, 236 GLISSON's triad 106 Glomus coccygeum 237 Glucocorticoids, adrenal gland 170 Greater omentum 130 Gubernaculum testis 185
H Haemorrhoidal knots 222, 227 Haemorrhoids 223, 227 Haustra coli 94-95, 101 HEAD's zones 42 Heart 2, 12-13, 55 - auscultation 4 - conducting system 20-21 - congenital cardial defects 7 - critical weight 13 - development stages 6 - fibrous skeleton 16 - innervation 23 - percussion 4 - position within the thorax 10 - projection onto the thorax 4 - radiograph of the right and left border 5 - stages of development 6 - ultrasound image 66 Heart contours - postero-anterior radiograph 5 - projection onto the ventral thoracic wall 4 Heart murmurs 4, 16 Heart sounds 4, 16 - auscultation 4 Heart valves 16 - auscultation areas 4 - projection onto the ventral thoracic wall 4 Helicobacter pylori bacteria, production of gastric acid 84 Hepar 8-9,42, 62, 72, 74, 81, 98, 102-107,
109-111, 114-116, 120-121, 127-128, 148150, 152-156, 161, 173 arteries 110 contact areas 79 development 72, 103 laparoscopy 116 lymph vessels and lymph nodes 82, 113
- of a fetus a - projection - - onto the body surface 86 - - onto the ventral abdominal wall 86, 115 - sagittal section 106 - segments 107-109 - size, measurement 102 - sonography 114 - structure 106 - variations of the blood supply 110 - veins 111 Hepatic diverticulum 103 Hepatic lobules 106 Hepatitis 102 - sonography 114 - suspicious tumours 115 Hepatocytes 106 Hiatus - analis 196, 214 - aorticus 43 - levatorius 214
Hiatus - oesophageus 43-44,48 - urogenitalis 196, 214 Hilar lymph nodes 39, 41 Hilum 166 - pulmonis 35 - renale 156, 166 - splenicum 129, 155 Hindgut 30 Hip, muscles 196 HIS, bundle of (atrioventricular bundle, Fasciculus atrioventricularis) 16,20-21, 24 Horseshoe kidneys 162 Humerus 64 Hydrocele testis 185 Hymen 202 Hypertension - increased sympathetic tonus 23 - insufficiency or stenosis of the mitral valve 5 - pulmonary hypertension 5, 15 - stenosis of the aortic valve 5 Hypogastrium - inflammations 237 - positions of the viscera 134-136 Hypophysis 160 Hypospadias 184 Hypothalamus 160 Hysterectomies, ligation of the ureter during surgery 175
lleocaecal valve {Valva ileocaecalis, BAUHIN's valve) 95 Ileum 74, 91-93,95-96, 102, 120, 128, 130,
134-135,138,143,145,148-150,161,220 - arteries 96 - projection onto the body surface 86 Ileus, malrotation 73 1m potentia - coeundi 194 - generandi 194 lmpressio - cardiaca - - (Pulmo dexter) 35 - - (Pulmo sinister) 35 - colica (Hepar) 104 - duodenalis 104 - gastrica {Hepar) 104 - oesophagea 35, 104 - renalis 104 - suprarenal is 104 Incisura - angularis 75, 77, 90 - cardiaca (Pulmo sinister) 29, 34-35, 40, 50 - cardialis 75, 77 - ligamenti teretis 104 Infundibulum tubae uterinae 203, 206-208,
237 Inguinal hernia 185 Inner female genitalia 203 - arterial supply 211 - development 205 - lymphatic drainage pathways 213 - lymph vessels and lymph nodes 213 Inner male genitalia 183 - blood vessels 193 - development 185 - lymph vessels and lymph nodes 195 Insulae pancreaticae 123, 160 Intermediate tubulus 169 Internal hernias 133 Internal organs, projection onto the body surface 74, 102, 120, 128, 161 Intestinal rotation 73 - malrotations 73 lntestinum 160 - crassum 42, 92, 94,97-101, 137 - - See also Colon - tenue 42, 72, 87,98-100, 128, 136, 220,
236 - - See also Small intestine
lntracardiac injection 4 Intraperitoneal organs 70 Islets of LANGER HANS 123 Isthmus - bursae omentalis 132 - tubae uterinae 206-208, 237 - uteri 206-207
J Jejunum 74, 88-91, 96, 102, 120, 122, 127-
128, 134-135, 137, 143, 145, 148, 150, 153, 155-156, 161 - arteries 96 - projection onto the body surface 86 Junctio {Linea) anorectalis 222
K KEITH-FLACK, node of (sinu-atrial node, Nodus sinuatrialis) 20-21 KERCKRING's folds {Plicae circulares) 77, 89-
91, 124 Kidney 122, 164, 166-167 - See also Ren - arterial supply, variations 172 - ascensus 162 - computed tomography 173 - contact areas 165 - - on the posterior wall of the stomach 79 - course of renal arteries 169 - development 162 - physical examination, pain sensitivity 161 - position in the retroperitoneal space 164 - projection onto the dorsal body wall 161 - transverse section 168 - ultrasound image 173 Kidney lobes 167 KILLIAN's triangle 45 KOCH's triangle 17, 20 KRISTELLER's mucous plug 210
L Labioscrotal folds 184, 202, 204 Labium - anterius (Ostium uteri) 209 - majus pudendi 202, 204, 237 - minus pudendi 202, 204,212,217-219, 237 - posterius (Ostium uteri) 209 Lacunae urethrales 178 Lamina - muscularis mucosae (lntestinum tenus) 78,
87,94 - parietalis - - (Pericardium serosum) 12-13, 62 - - (Tunica vagina lis testis) 187, 189, 191 - propria mucosae 78, 87, 94 - visceralis 18 - - (Pericardium serosum) 12-13, 17, 62 - - (Tunica vagina lis testis) 187, 189, 191 LANGERHANS, iselets of 123 LANZ's point 93 Laparoscopic image 116 - gallbladder 116 - liver 116 Large intestine 137 - See also lntestinum crassum - arteries 97 - autonomic innervation 100 - conventional radiograph 101 - divisions 92 - lymph vessels and regionallym ph nodes 99 - projection - - onto the body surface 86 - - onto the ventral abdominal wall 86, 92 - regional lymph nodes and lymph vessels 99 - structure of the wall 94 - veins 98 Laryngotracheal primordium 31
251
Index
Larynx 28, 32-33, 45 Left ventricle 17-19 Left ventricular hypertrophy 15 Left-to-right shunt 7 Ligamentum(-a) - anococcygeum 198-200, 217-218,221, 236,239 - anularia 32-33 - arteriosum 9-10, 12-13, 53,55 - capitis femoris 238 - cardinale (Lig. transversum cervicis) 206 - coronarium 72, 104-106, 131, 139 - - development 72 - epididymidis - - inferius 188 - - superius 188 - falciforme hepatis 103-105, 107-108, 118, 130-131, 138, 149, 154-155 - - development 72 - fundiforme penis 192, 236 - gastrocolicum 130-133, 144, 149, 153 - gastrophrenicum 139 - gastrosplenicum 72, 129, 131, 133, 139, 151, 153 - - development 72 - hepatoduodenale 108, 118, 131-132, 138139, 155 - hepatogastricum 80, 131-132, 155 - inguinale 182 - latum uteri 206-208 - longitudinale anterius 57, 64 - ovarii proprium 203,205-208,211 - phrenicocolicum 131 - phrenicosplenicum 153 - pubicum - - inferius 197, 216 - - superius 238-239 - puboprostaticum 177, 179, 198, 221, 236 - pubovesicale 237 - pulmonale 35 - rectouterinum (Lig. sacrouterinum) 206, 209 - sacrospinale 200, 232, 235 - sacrotuberale 199-200, 214, 217, 232 - splenorenale 72, 129, 151 - - development 72 - suspensorium - - clitoridis 202 - - duodeni 89 - - ovarii (Lig. infundibulopelvicum) 205-206, 208, 211' 237 - - penis 187, 192 - teres - - hepatis 9, 104, 107-108, 110, 115, 127, 130-132, 138, 142, 155-156 - - - development 72 - - uteri (Lig. rotundum) 203, 205-206, 208, 211, 234,237 - transversum perinei 197,216 - triangulare - - dextrum 104 - - sinistrum 104, 139, 150-151 - umbilicals medianum 9, 177-178, 236-237 - venae cavae 104-105 - venosum 8-9, 104, 107 Limbus - acetabuli 238 - fossae ovalis 17 Linea - alba 154-155, 236 - anocutanea 222-223 - dentata (Linea pectinate, Canalis analis) 222-223 - terminalis 214 Lingula pulmonis (Pulmo sinister) 34-35, 40, 50 Liver See Hepar Liver cirrhosis 102, 106, 112 - portal hypertension 98 - sonography 114 - suspicious tumours 115 Liver puncture - position of the needle 115 - referred pain in the right shoulder 54
252
Lobuli testis 179, 188-189 Lobus - anterior (Pulmo sinister) 64 - caudatus 104-105, 108-109, 132, 150, 155 - dexter - - (GI. thyroidea) 48 - - (Thymus) 51 - hepatis - - dexter 82, 93, 104-105, 109, 115-116, 118, 130-132, 135, 138, 142, 160-152, 154-166, 173 - - sinister 80, 82, 104-105, 109-110, 115116,118,127,130-132,138,142,148149,161,153-156 - inferior - - (Pulmo dexter) 28-29, 34-36, 40, 50, 54, 65-6~ 149, 151-152 - - (Pulmo sinister) 28-29, 34-36, 40, 50, 67, 151, 153 - medius (Pulmo dexter) 28-29, 34-36, 40, 50,66-67, 151 - prostatae - - dexter 190 - - medius 190 - - sinister 190 - quadratus 104, 109, 155 - renalis 167 - sinister (Thymus) 51 - superior - - (Pulmo dexter) 28-29, 34-36, 40, 50-51, 54,64-65 - - (Pulmo sinister) 28-29, 34, 36, 40, 50, 54, 64, 66-67, 151 Lower intestinal tract - haemorrhage 89 Lower respiratory tract - air conducting part 32 Lung bud 30 Lung development - alveolar period 31 - canalicular period 31 - pseudoglandular period 31 - stages 31 Lungs 2,28,40, 74,102,115,120,128,161 - See also Pulmo - acinus 38 - alveoles 38 - floating lung test 30 - lymph nodes 39 - lymph vessels 39 - mobility during respiration 29 - size 29 -Vasa - - privata 38 - - publica 38 Lunula valvulae semilunaris 19 Lymph node metastasis - cervical carcinoma 213 - endometrial carcinoma 213 - pancreatic carcinoma 126 - penile carcinoma 195,213 - vulvar carcinoma 213 Lymph vessels - bile system 113 -colon 99 - external and internal female genitalia 213 - external and internal male genitalia 195 - lungs 39 - peribronchial system 39 - rectum 235 - retroperitoneal space 229 - septal lymph system 39 - small intestine 99 - subpleural lymph system 39 Lymphatic drainage, carcinomas in the colon 99
M Magnetic resonance imaging (MRI) 65 - thorax 3
Main bronchi, projection onto the anterior chest wall 28 Male genital system, innervation 194 Male pelvis 179 Male urinary organs 183 Male urinary system 160 Malrotation 73 - ileus 73 Mamma 67 Manubrium sterni 64 Margo - anterior - - (Pulmo dexter) 34-35, 40 - - (Pulmo sinister) 34-35, 40 - - (Testis) 188 - inferior - - (Hepar) 104, 106 - - (Pulmo dexter) 34-35 - - (Pulmo sinister) 34-35, 40 - - (Splen) 129 - lateralis (Ren) 166 - liber 206 - medialis - - (GI. suprarenal is) 170 - - (Ren) 166 - mesovaricus 206, 208 - posterior - - (Pulmo dexter) 34 - - (Pulmo sinister) 34 - - (Testis) 188 - superior - - (GI. suprarenalis) 170 - - (Ren) 166 - - (Splen) 129, 132-133 McBURNEY's point 93 MECKEL's diverticulum 73,91 Mediastinum 2, 50, 52-53 - anterius 52-53 - inferius 52-53 - lymph nodes 59 - lymph vessels 59 - medium 52-54 - posterius 52-53 - - lymph nodes 48 - - nerves 58 - superius 52-53 - testis 188-189,236 Medulla - (GI. suprarenalis) 170 - renal is 29, 152, 156, 167-168, 173-174 - spinalis 62-63, 154-155, 194,212 Membrana perinei 197, 199, 202, 216-217, 236 Mesenteries 137 Mesenterium 70, 87, 91, 136-138, 236 - diverticuli 91 - dorsals 103, 121 - ventrale 103 Mesoappendix 135-139 Mesocolon - sigmoideum 139 - transversum 94, 132-133, 135, 137, 139, 144-145, 147 - - contact areas on the posterior wall of the stomach 79 Mesogastrium dorsals 72, 103 Mesonephros 162-163 Mesosalpinx 206-208 Mesothelium epicardiale 14 Mesovarium 206, 208 Metanephros 162 MEYER-WEIGERT's rule, crossing of both ureters 176 Midaxillary line 29 - borders of the lungs 29 Midclavicular line 29 - borders of the lungs 29 Mineralocorticoids, adrenal gland 170 Mitral valve (Valva atrioventricularis sinistral 4, 6, 16,18-19,66-67 - projection onto the ventral thoracic wall 4 - stenosis or insufficiency 5 Moderator band 17
Index
Mons pubis 202 MULLERIAN duct (Ductus paramesonephricus) 163, 185 - differentiation, anti-M OLLER IAN hormone 185 Musculus(-i) - biceps - - brachii 68 - - femoris 240 - bulbospongiosus 198-202, 217-219, 223 - coracobrachialis 68 - corrugator ani 223 - cremaster 187-189, 191, 198, 236 - dartos 187, 191 - deltoideus 63, 68 - erector spinae 65, 68, 149, 152-156, 173 - gluteus - - maximus 149, 196, 199-200,217-218, 238-239 - - medius 238 - - minimus 238 - gracilis 199, 217 - iliacus 196, 231, 239 - iliococcygeus 149, 196, 214 - iliocostalis thoracis 155 - iliopsoas 238-239 - infraspinatus 63-65 - intercostales - - externi 56, 64,66-67, 115, 154-155 - - interni 56-57, 68, 115, 154-155 - ischiocavernosus 198-202, 217-219 - ischiococcygeus (coccygeus) 196,214-215, 232-233,238 - latissimusdorsi 66-67, 154-156 - levator ani 148-149, 196, 198-201, 214215,217-219,221-226,233-235,238-240 - longissimus thoracis 155 - multifidi 155 - obliquus externus abdominis 154 - obturatorius - - externus 238-239 - - internus 201,214-215,219, 224-225, 232, 238-240 - omohyoideus 63 - papillaris - - anterior 17-19, 21 - - posterior 17-19 - - septalis 17 - pectinati 17 - pectineus 238-239 - pectoralis - - major 63-67 - -minor 64 - pharyngis 45 - piriformis 149, 196, 215, 232-233 - psoas major 153, 164, 173, 176, 196, 230, 239 - pubococcygeus 148-149,196,214,223 - puborectalis 223, 238, 240 - quadratus lumborum 152-153, 164, 230231 - rectus - - abdominis 130, 153-156, 238 - - femoris 238-239 - sartorius 238-239 - scalenus - - anterior 54, 60-61,63 - -medius 68 - semimembranosus 240 - semitendinosus 240 - serratus - - anterior 63-68 - - posterior inferior 155 - sphincter - - ampullae (ODDI) 117 - -ani - - - externus 148, 198-200, 202, 217-218, 221-226,236,240 - - - internus 148, 222-223, 225, 236, 240 - - pyloricus 77, 89, 124 - - urethrae 221 - - - externus 181, 197-198,216 - - urethrovaginalis 216
Musculus(-i) - splenius capitis 68 - sternocleidomastoideus 63 - sternohyoideus 63 - sternothyroideus 64 - subclavius 63, 68 - subscapularis 64, 68 - supraspinatus 63, 68 - suspensorius duodeni (muscle of TREITZ) 89 - tensor fasciae latae 238-239 - teres major 64-65, 68 - trachealis 33 - transversus - - abdominis 155,230 - - perinei - - - profundus 148, 181, 190, 197-199,201, 216,221,223,236 - - - superficialis 197, 199-200, 217-218 - - thoracis 67 - trapezius 63-66, 68 - vastus lateralis 239 Myocardial infarction 27 - coronary artery stenosis 23 Myocardium 14-15, 17-19 Myometrium 207
N Nephrectomy, GEROTA's fascia 164 Nephrolithiasis, radiating pain 164 Nephron 169 Nervus(-i) - anales 226 - anococcygei 200, 218 - axillaris 68 - cardiacus cervical is - - inferior 23, 60-61 - -medius 23 - - superior 23 - cavernosi 194 - clunium inferiores 200, 218 - cutaneus femoris - - lateralis 230-231 - - posterior 200, 218, 239 - dorsalis - - clitoridis 218 - - penis 192, 197, 200 - femoralis 230-231, 238-239 - genitofemoralis 164, 191-192,230-232,238 - gluteus inferior 239 - hypogastricus 100, 194, 212, 226 - iliohypogastricus 164, 230-231 - ilioinguinalis 164, 191-192,230-231 - intercostalis 52-53, 56-58,60-61, 64, 67, 154,231 - ischiadicus 238-239 - labiales posteriores 212, 218 - laryngeus recurrens 10-11,23, 51-54, 56, 58,60-61 - obturatorius 196, 215, 230-232, 238-239 - pelvici 100 - perineales 200,218 - phrenicus 2, 11, 51-54, 56,60-61, 64-67 - - course 54 - pudendus 197,200-201,212,218-219,226, 232,239 - - ejaculation 194 - rectales inferiores 200, 218 - sacralis 212 - scrotales posteriores 200 - splanchnicus(-i) 84, 239 - - lumbales 226 - - major 52-53, 56-58, 100, 151, 155,230231 - - minor 53, 56, 58, 100, 151, 155 - - pelvici 194, 212, 226 - subcostalis 164, 230-231 - suprascapularis 63 - thoracicus(-i) 52, 56-58, 155, 231 - - longus 64-66, 68
Nervus(-i) - thoracodorsalis 68 - vaginalis 212 - vagus [X] 2, 10-11, 23, 51-54, 56, 58, 6061, 63-67,231 - - preganglionic parasympathetic neurons 100 NISSEN's fundoplication 75 Nodulus(-i) - lymphoidei - - aggregati (PEYER's plaques) 91, 95 - - solitarii 78, 87, 91, 94, 222 - valvulae semilunaris 19 Nodus(-i) - atrioventricularis (AV node, node of TAWARAJ 20-21 - lymphoideus(-i) - - aortici 21 - - - laterales 235 - - axillaris, 64, 68 - - - apicalis 64 - - bronchopulmonales 39, 41, 65-67 - - cervicales profundi 48 - - coeliaci 83, 113, 126 - - colici - - - dextri 99 - - -medii 99 - - - sinistri 99 - - cystici 113 - - gastrici 82-83 - - - dextri 82 - - - sinistri 82 - - gastroomentales 83, 155 - - - dextri 82 - - - sinistri 82 - - hepatici 82, 113, 126 - - ileocolici 99 - -iliaci - - - communes 195,213, 229, 235 - - - externi 195,213,229, 235 - - - interni 99, 195, 213, 235 - - inguinales 99, 113, 213 - - - inferiores 229 - - - profundi 195, 213, 229 - - - superficiales 195, 213, 238 - - - - superomediales 229 - - intercostales 59 - - intrapulmonales 39 - - juxtaintestinales 99 - - juxtaoesophageales 48, 59, 67 - - lumbales 59, 99, 195,213, 235 - - - intermedii 229 - - mediastinales 67 - - - anteriores 10, 51, 59, 61 - - - posteriores 48, 151 - - mesenterici - - - inferiores 99 - - - superiores 99, 126 - - mesocolici 99 - - pancreatici 156 - - - inferiores 126 - - - superiores 126 - - pancreaticoduodenales 126 - - paracolici 99 - - pararectales 235 - - parasternales 59 - - paratracheales 39, 59-60, 64, 68 - - pericardiaci 59 - - phrenici - - - inferiores 59, 113, 229 - - - superiores 10, 59, 113 - - preaortici 235 - - precavalis 235 - - pylorici 82-83 - - rectalis 83 - - - superior 235 - - retroaortici 235 - - sacrales 195, 213 - - splenici 82-83, 126, 151, 155 - - supraclaviculares 59 - - tracheobronchiales 35, 53, 59, 68 - - - inferiores 35, 39, 48, 62, 67 - - - superiores 39, 48, 62
253
Index
Nodus(-i) - sinuatrialis (sinu-atrial node, node of KEITHFLACK) 20-21
254
Oval}' (Ovarium) - inflammatory process 159 - peritoneal duplicatures 206, 208
0
p
Oesophageal atresia 30 Oesophageal carcinoma, lymph drainage 48 Oesophageal varices 47, 81, 112 - bleeding 49, 71 - - liver cirrhosis 112 - portocaval anastomosis 112 - portal hypertension 49 Oesophagoscopy 49,85 - oesophageal varices 49 Oesophagus 2, 30, 42-46, 48, 52-53, 56-58, 62-67,74-77,81,85,98, 111, 148, 151, 161, 231 - arteries 46 - cervical constriction 45 - diaphragmatic constriction 45 - diverticula 45 - foreign bodies 45 - lymph drainage 48 - oesophagoscopy 49 - projection - - onto the body surface 86 - - onto the ventral thoracic wall 42 - structure of the wall 44 - thoracic constriction 45 - veins 46-47 Omentum - majus 72, 80, 82, 93-94, 116, 130-138, 142,148-149,152-153,155,236 - - development 72 - - peritoneal duplicatures 130 - minus 72, 80, 103, 121, 131-132, 138, 155 Omphalocele 73 Orchis See Testis Organa - genitalia feminine - - externa 202, 204 - - interne 160 - genitalia masculine - - externa 182, 184, 192 - - interne 160, 183, 185 - urinaria 160 - urogenitalia - - feminina 203 - - masculina 183 Oris 42 Os - coccygis 148, 199, 217, 238-239 - ilium 150,214,240 - ischii 201, 238 - pubis 148, 150, 186, 198, 216, 221, 238239 - sacrum 148-149, 214 Ostium - abdomina Ia tubas uterinae 206 - appendicis vermiform is 95 - atrioventriculare - - dextrum 17 - - sinistrum 18-19, 66 - cardiacum 77, 138-139, 150-151, 153 - ileale 95 - primum 7 - pyloricum 89 - secundum 7 - sinus coronarii 17, 24 - ureteris 177, 179-180, 236-237 - urethrae 205 - - externum 178-180, 186-187,202-203, 217-219, 236-237 - - internum 177-180, 186, 209, 236-237 - uteri 207, 209-210, 237 - uterinum tubae uterinae 207 - vaginae 202-203,219 - venae cavae inferioris 21 Ovary (Ovarium) 93, 139, 160, 203, 205-208, 211-212,234, 237
Pancreas 42, 72, 74,82, 102,120-124,126128, 132, 135-136, 142, 147-148, 151, 155156, 161 - anulare 121 - arteries 125 - contact area onto the posterior wall of stomach 79 - development 121 - divisum 121 - ERCP 127 - excretory duct system 124 - histology 123 - inflammation 120 - lymphatic drainage 126 - projection - - onto the surface of the body 86 - - onto the ventral abdominal wall 86, 120 - ultrasound image 127, 155 Pancreatic buds 103, 121 - fusion 121 Pancreatic carcinoma 119 - lymph node metastases 126 Pancreatic diseases 124 Pancreatitis 71, 120, 123 - bile concrements 124 - ultrasound image 1 55 Papilla - duodeni - - major (ampulla of VATER) 88-89, 117118, 124 - - - endoscopy 122 - - minor 88, 117, 124 - mammaria 67 - renal is 167-168, 174, 176 Papillary muscles 17, 19 Paracystium 209 Paradidymis 1 83 Parametrium 209 Paraproctium 209 Parasympathetic nervous system - effect on the heart 23 - erection 194 - perfusion of the intestines 100 - sacral division 100, 231 Paravertebral line 29 - borders of the lungs 29 Paries - anterior (Gaster) 85, 131-132 - membranaceus (Trachea) 33, 62 - posterior (Gaster) 85 Pars - abdominalis - - aortae (Aorta abdomina lis) 9, 43, 56, 58, 114, 12~ 140, 147-148, 151, 156, 165, 172-173,193,226,228,230,232-233, 235 - - - branches 228 - - oesophageae 45-46, 58, 75, 77 - - - arteries 46 - - (Oesophagus) 43 - anterior - - (Facies diaphragmatica, Hepar) 106 - - (Fornix vaginae) 209 - ascendens - - aortae (Aorta ascendens) 10, 13, 17, 21, 24-25,55-56,58,62,65-66 - - duodeni 88-90, 93, 117, 120, 124, 137 - - - projection 86 - - - - onto the body surface 86 - - - - onto the ventral abdominal wall 86 - cardiaca 43, 75 - cervicalis (Oesophagus) 43-44, 46, 48, 62 - - arteries 46 - -veins 46
Pa/5 - convolute - - (Tubulus distalis) 169 - - (Tubulus proximalis) 169 - costalis - - diaphragmatis 114, 152-156 - - (Pleura parietalis) 40, 52-53,64, 152-156 - descendens - - aortae (Aorta descendens) 13, 45, 48, 55, 65-67 - - duodeni 75, 7~88-90,93,11~ 120,122124, 127 - - - projection - - - - onto the body surface 86 - - - - onto the ventral abdominal wall 86 - diaphragmatica (Pleura parietalis) 11, 40, 54, 151, 154-156 - horizontalis (Duodenum) 88-90, 117, 120, 122-124, 135, 137, 139 - - projection - - - onto the body surface 86 - - - onto the ventral abdominal wall 86 - intramuralis (Urethra masculine) 178-179 - intrasegmentalis 68 - laryngea pharyngis 28, 42 - lumbalisdiaphragmatis 43, 56-57,62, 114, 142, 148-149, 151, 154-156 - mediastinal is (Pleura parietal is) 11, 35, 5152,65 - membranacea - - (Septum interventriculare) 6-7, 19 - - (Urethra) 178-179, 186, 236 - muscularis (Septum interventriculare) 6-7, 17-18 - nasalis pharyngis 28 - oralis pharyngis 28, 42 - posterior (Fornix vaginae) 209, 237 - profunda (M. sphincter ani extern us) 223 - prostatica (Urethra) 177-179, 190 - pylorica (Pylorus) 58, 74-77, 80, 85, 88-90, 130, 133, 138, 153 - recta - - (Tubulus distalis) 169 - - (Tubulus proximalis) 169 - spongiosa (Urethra) 178-179, 192, 236 - sternalis diaphragmatis 62 - subcutanea (M. sphincter ani externus) 202, 223 - superficial is (M. sphincter ani extern us) 223 - superior (Duodenum) 75, 77, 88-90, 116117, 120, 123, 138-139, 150 - - projection - - - onto the body surface 86 - - - onto the ventral abdominal wall 86 - terminalis ilei 95, 135 - thoracica - - aortae (Aorta thoracica) 7, 38, 43-46, 53, 55-56,58,64,122,154 - - - branches 56 - - (Ductus thoracicus) 53, 56-57 - - (Oesophagus) 43-46,48, 53, 56-58, 62, 151 - uterina 207 Pecten anal is (Canalis analis) 222-223 Pelvic floor - function 196 - in man 198 - muscles 196 - inwoman 214-215 Pelvic floor insufficiency 214 Pelvic kidneys 162 Pelvic viscera - in man, blood supply 233 - in woman, blood supply 234 Pelvis 148-150, 179-180,235-239 - female 180, 237 - - lymph nodes and lymph vessels 235 - - transverse section 239 - - - computed tomography 239 - male 148-150, 179, 236 - - oblique frontal section 240 - - transverse section 238
Index
Pelvis male - - computed tomography 238 - renalis 160, 166-168, 173-174, 176, 183, 203 Penis 182-183, 185-187, 192 - cavernous bodies 186 Perfusion of the intestines - parasympathetic influence 100 - sympathetic influence 100 Pericardia! cavity 30, 72 Pericardia! effusion 11 Pericardia! tamponade 11 Pericarditis 11 Pericardium 2, 11, 13, 40, 44, 50, 54, 153 - fibrosum 11, 48, 51-53 - serosum 2, 11-13, 17-18,62 Perimetrium 207 Perineal muscles - in man 197-198 - in woman 216 Perineal region - in man 199 - - vessels and nerves 200 - in woman 217 - - vessels and nerves 218 Perineal space -deep 19~ 199,201, 21~219 - in man 201 - superficial 197, 199, 217, 219 - in woman 219 Perineal tears 217 Perineum 199, 202, 217 Periorchium 187 Peritoneal carcinosis 133 Peritoneal cavity 70, 72, 148, 158 - dorsal wall 139 - recesses 139 Peritoneum 105 - parietale 70, 116, 130, 148, 154-156, 181, 201,219,221-222,23~240
- viscerale 70, 87, 148, 152, 154-155 Peritonitis 133 - appendicitis, perforation 95 PEYER's plaques (Noduli lymphoidei aggregati) 91,95 Pharynx 28, 42, 85 Phimosis 186 - circumcision 186 Phosphodiesterase, enzyme inhibitors, erection 192 Physiological umbilical hernia 73 Placenta 8, 210 Pleura - parietalis 11, 35, 40, 51-54, 63-65, 151-156 - visceralis (pulmonalis) 40,63-64, 68, 152153 Pleura borders, projection - onto the anterior thoracic wall 29 - onto the posterior thoracic wall 29 Pleural cavitaty 2, 40, 50, 52-53 Pleural cupula, transverse sections at the level of the shoulder joint 63 Pleural effusions 29, 40 Plexus - aorticus - - abdomina lis 226, 231 - - thoracicus 11, 53, 58 - brachialis 51,60-61, 63-64,68 - cardiacus 23, 53-54, 58 - coeliac us 100, 226, 231 - deferentialis 191, 194 - hepaticus 100 - hypogastricus - - inferior 100, 194, 212, 226 - - superior 100, 194, 212, 226, 231 - intermesentericus 100, 231 - lumbalis 164, 230 - - branches 230 - mesentericus - - inferior 100, 231 - - superior 100, 231
Plexus - oesophageus 52,58,231 - ovaricus 212 - pampiniformis 187, 189, 191-193 - prostaticus 194 - pulmonalis 52-53 - rectalis 226 - renalis 100 - sacralis 212, 226, 231-232 - splenicus 100 - testicularis 191, 194 - uretericus 100 - uterovaginalis (FRANKENHAUSER's plexus) 212 - venosus - - prostaticus 193, 201, 233, 236 - - recta lis 225, 233-234 - - submucosus 47, 112 - - uterinus 234 - - vaginalis 234 - - vertebralis internus {posterior) 62-63 - - vesicalis 201, 219, 233-234, 237-238 Plica(-ae) - caecal is vascularis 135 - circulares {KERCKRING's folds) 77,89-91, 124 - duodenalis inferior 137, 139 - gastricae 77, 85 - gastropancreatica 132-133, 139 - hepatopancreatica 132-133, 139 - ileocaecalis 135, 139 - interureterica 177 - longitudinalis duodeni 124 - mucosae (Vesica biliaris) 117 - rectouterine 206, 237 - rectovesicalis 236 - semilunares coli 94-95, 101 - spiralis (HEISTER) 88, 117, 119 - transversa recti 148, 180, 222-223, 236 - umbilicalis - - lateralis 233 - - medialis 208, 233, 237 - - mediana 236-237 Pneumothorax 29 - central venous catheter (CVC) 35, 63 Porta hepatis 104 Portal hypertension 47, 81, 106, 225 - liver cirrhosis 98 - oesophageal varices 49 - portocavale anastomoses 49 Portal system, hypertension 98 Portal tracts 106 Portal vein 81, 141 - increased blood pressure 81 - tributaries 141 - ultrasound image 114 Portio - supravaginalis cervicis 207 - vaginalis cervicis 207, 209-210, 237 Portocaval anastomoses 46-47,81,98, 106, 112,225 - bleedings of esophageal varices 112 - portal hypertension 49 Posterior myocardial infarction (PM I) 10, 27 Postnatal circulation 9 Pouch of DOUG LAS (Excavatio rectouterina) 138-139,208-210,237, 239 - appendicitis 237 - salpingitis 237 Preganglionic parasympathetic neurons 100 Preganglionic sympathetic neurons 100 Prenatal circulation 8 Preputium - clitoridis 202 - penis 182, 186-187, 236 Primary intestinal loop 73 Primitive laryngeal inlet 31 Primordial gut, development 72 Primordial ovary 163 Primordial testis 163 Processus - articularis superior 154 - coracoideus 68
Processus - papillaris 155 - spinosus 63-64, 67, 173 - transversus 65 - uncinatus 123-124, 144, 149 - xiphoideus 62, 67, 74, 154, 210 Proctodea! glands {Gil. anales) 223 Promontorium 148 Pronephros 1 62 Prostate (Prostata) 148-149, 160, 177-178, 181,183,185-186,190,194,198,201,221, 223,233,236 - digital rectal examination (DRE) 221 - zones 190 Prostatic carcinoma 159, 190 - digital rectal examination (DREJ 221 Pubes 182 Pulmo 2, 40, 74, 102, 115, 120, 128, 161 - dexter 11, 28,34-36, 40, 50-51, 54,63-67, 149, 151-152 - sinister 11, 28,34-36,40,51, 54, 63-64, 66-68, 151, 153 Pulmonary circulation 2 Pulmonary emboli, right ventricular hypertrophy 15 Pulmonary hypertension 5 - right ventricular hypertrophy 15 Pulmonary ring 16 Pulmonary valve 16 - projection onto the ventral thoracic wall 4 Pulmonary valve stenosis 7 - right ventricular hypertrophy 15 Pulmonary veins 18 Pulpa splenica 129 Pyelonephritis, referred pain 164 Pylorus (Pars pylorica) 58, 74-77, 80, 85, 8890,130,133,138,153 Pyramides renales 167-168, 173-174
R Radiograph(s) - after intravenous application of contrast medium 119 - colon 101 - duodenal ulcers 90 - duodenum 90 - extrahepatic bile ducts 119 - gallbladder 119 - heart contours 5 - intrahepatic bile ducts 119 - left border of the heart 5 - renal pelvis 176 - right border of the heart 5 - thoracic cage 5, 41 - thoracic viscera 5, 41 - thorax 3, 5 - ureter 176 - - variations 176 Radix - mesenterii 139 - parasympathica 194, 212, 226 Ramus{-i) - anterior - - (A. pancreaticoduodenalis inferior) 96, 125 - - (A. renalis) 166 - - (V. portae hepatis) 114 - atriales - - (A. coronaria dextral 26 - - (A. coronaria sinistral 26 - atrioventriculares - - (A. coronaria dextral 26 - - (A. coronaria sinistral 26 - bronchiales - - (Aorta) 38, 52, 56 - - (N. vagus) 56, 58 - cardiacus(-i) - - cervicalis inferior (N. vagus) 23 - - thoracici - - - (N. vagus) 23, 52-54 - - - {Truncus sympathicus) 53
255
Index
Ramus(-i) - circumflexus (A. coronaria sinistral 13, 24-
26 - coeliacus (Truncus vagalis) 84 - colicus (A. ileocolica) 96-97, 143, 146 - communicantes (Truncus sympathicus) 52,
58, 194, 212 -
coni arteriosi - - (A. coronaria dextral 24, 26 - - (A. coronaria sinistral 24 dexter - (A. hepatica propria) 155 - (V. portae hepatis) 114, 141, 150, 154-155 femoralis (N. genitofemoralis) 230 gastrici anteriores (Truncus vagalis anterior) 58, 84 - genitalis (N. genitofemoralis) 191-192, 230,
232,238 -
helicini (A. uterina) 211 hepatici (Truncus vagalis) 84 ileal is (A. ileocolica) 96, 143 inferior ossis pubis 186, 216 interganglionaris (Truncus sympathicus) 212 interventricularis(-es) - anterior (A. coronaria sinistral 12, 19, 24-
27, 67 - - posterior (A. coronaria dextral 13, 24, 26-
27 -
-
- septales - - (A. coronaria dextral 26 - - (A. coronaria sinistral 24, 26 labiales posteriores (A. pudenda internal 218 latera lis (R. diagonalis, A. coronaria sinistral 24, 26-27 marginalis - dexter (A. coronaria dextral 24, 26 - sinister (A. corona ria sinistral 24, 26 nodi - atrioventricularis (A. coronaria dextral 20,
24,26 -
- sinuatrialis - - (A. coronaria dextral 20, 24, 26 - - (A. coronaria sinistral 24 obturatorius (A. epigastrica inferior) 232 oesophageales - {A. gastrica sinistral 46, 140 - {A. thyroidea inferior) 46 - {N. laryngeus recurrens) 56, 80 - {Pars thoracica aortae) 46, 56 - {V. cava inferior) 47 - {V. portae hepatis) 47 omentales - {A. gastroomentalis dextral 80 - {A. gastroomentalis sinistral 80, 142 ossis ischii 197,216, 239 ovaricus (A. uterina) 211 pancreatici (A. splenical 125 pericardiacus {N. phrenicus) 54 perineales (N. cutaneus femoris posterior) 200,218 - phrenicoabdominales (N. phrenicus) 54 - posterior - - {A. pancreaticoduodenal is inferior) 96,
125 - - (A. renalis) 166 - - {V. portae hepatis) 114, 154 - - ventriculi sinistri (A. corona ria sinistral 24,
26 - posterolateralis dexter (A. coronaria dextral 24, 26 - pubicus - - (A. epigastrica inferior) 232 - - (A. obturatoria) 232 - scrotales - - anteriores (V. dorsalis profunda penis) 192 - - posteriores - - - (A. perinea lis) 200 - - - (A. pudenda internal 233 - - - (V. pudenda internal 233 - sinister (V. portae hepatis) 114, 127 - splenici {A. splenical 144 - subendocardiales 20 - superior ossis pubis 196, 216
256
Ramus(-i) - tubarius (A. uterina) 211 - vaginales (A. uterine) 211 Raphe - perinei 199, 202, 217 - scroti 187, 189, 191 Recessus - axillaris 68 - costodiaphragmaticus 5, 29, 40-41, 50, 54,
Right and left branches of the artioventricular bundle (Crus dextrum and sinistrum, bundle of TAWARA) 17, 20 Right ventricle 17 Right ventricular hypertrophy 7, 15 Right-to-left shunt 7 Rima oris 42 RIOLAN's anastomosis 97, 140, 143, 145-147 Rugae vaginales 207, 209
152-154, 156 - costomediastinalis 4, 40, 50, 64, 67 - duodenalis - - inferior 136, 139 - - superior 136, 139 - ileocaecalis - - inferior 135-137, 139 - - superior 135, 137, 139 - inferior (Bursa omentalis) 132-133 - intersigmoideus 136, 139 - phrenicomediastinalis 40 - pneumatoentericus 72 - sigmoideus 139 - splenicus (Bursa omentalis) 132-133, 139, 155 - superior {Bursa omentalis) 132, 139, 155 - vertebromediastinalis 40, 64, 66 Rectal prolapse 223 Rectocele 214 Rectoscopy, anal canal 227 Rectum 74,81,92,97-98,101,111,120,137-
138, 146-14~ 149,161,181,196,198,208209,215,219-226,230,235,238-239 - arteries 224 - innervation 226 - lymph nodes and lymph vessels in a woman 235 - in the male pelvis 221 - projection onto the body surface 86, 220 - veins 225 Red pulp, spleen 129 Referred pain 115 - in the right shoulder - - cholecystitis 54 - - liver biopsies 54 Regia - analis 158, 199, 217 - perinealis 158, 199,201,217-219 - - in man 199-200 - urogenitalis 158, 199, 217 Relative cardiac dullness 4 Ren (Nephros) 74, 102-103, 120, 122, 127-
128, 131, 136, 138-139, 147, 161-153, 156156, 160-168, 171, 173, 176-176, 183, 185, 193,203,206,228 - See also Kidney Renal biopsy 173 Renal calices 167 Renal cell carcinoma 171 Renal concrements 176 Renal corpuscle 169 Renal cortex 167 - microscopy 168 Renal infarction 165 Renal medulla 167 Renal pelvis 167, 174 - radiograph 176 Renal pyramids 167 Renal segments 165 Renal tumours, obstruction of the venous drainage 193 Renal veins 169 Respiratory distress syndrome (RDS) 30 Resuscitation, anatomical dead-space 32 Rete testis 163 Retroflexion of the uterus 208 Retroperitoneal organs 70, 138 Retroperitoneal space 70, 158, 228 - autonomic nervous system 231 - lymph nodes 229 - lymph vessels 229 - somatic nerves 230 Retroversion of the uterus 208 RETZIUS' space (Spatium retropubicum) 209-
210, 236-237, 239
s Saccus aorticus 6 Salpingitis, pouch of DOUGLAS 237 Salpinx (Tuba uterina) 139, 160, 203, 205-208,
211-212, 234 SANTORINI's duct {Ductus pancreaticus accessorius) 88, 117, 121, 124 Scalene gap 60 Scapula 5, 63-65, 68 Scapular 29 - borders of the lungs 29 Scrotum 182, 184, 187, 236 Segmental bronchi 36 - bronchoscopy 37 Segmentum(-a) - anterius - - (Hepar) 107 - - inferius - - - {Hepar) 108 - - - {Ren) 166 - - (Pulmo dexter) 36 - - (Pulmo sinister) 36 - - superius - - - {Hepar) 108 - - - {Ren) 166 - apicale (Pulmo dexter) 36 - apicoposterius (Pulmo sinister) 36 - basale - - anterius - - - {Pulmo dexter) 36 - - - {Pulmo sinister) 36 - - laterale - - - (Pulmo dexter) 36 - - - (Pulmo sinister) 36 - - mediale (cardiacum) (Pulmo dexter) 36 - - posterius - - - (Pulmo dexter) 36 - - - (Pulmo sinister) 36 - bronchopulmonalia 36-37 - inferius (Ren) 165 - laterale - - inferius {Hepar) 107-108 - - {Pulmo dexter) 36 - - superius {Hepar) 107-108 - lingulare - - inferius {Pulmo sinister) 36 - - superius {Pulmo sinister) 36 - mediale - - inferius {Hepar) 107-108 - - {Pulmo dexter) 36 - - superius {Hepar) 107-108 - posterius - - inferius {Hepar) 107-108 - - {Pulmo dexter) 36 - - {Ren) 165 - - superius {Hepar) 107-108 - renalia 165 - superius - - {Pulmo dexter) 36 - - {Pulmo sinister) 36 - - {Ren) 166 Seminal vesicle (GI. vesiculosa) 178, 183, 190 Seminiferous tubules 188 Septula testis 188-189 Septum - atrioventriculare (Pars membranacea) 7 - interatriale 17-18 - interventriculare 6-8, 17-20, 66 - - {Pars membranacea) 7 - - {Pars muscularis) 7
Index
SeptJJm - oesophagotracheale 31 - - development 31 - penis 192 - primum 7 - scroti 187, 189, 191 - secundum 7 - spurium 7 - transversum 72 - vesicovaginale 237 Septum formation, developmental steps 7 Shoulder joint 68 Sinu-atrial node (Nodus sinuatrialis, node of KEITH-FLACK) 20-21 Sinus - anales (anal crypts) 222-223, 227 - aortae 19, 67 - coronarius 13, 15, 25 - epididymidis 188 - obliquus pericardii 11, 13 - paranasales 28 - prostaticus 177 - renalis(-es) 156, 167-168, 173-174 - transversus pericardii 11, 13, 62, 66 - trunci pulmonalis 15 - urogenitalis 163 - vena rum cava rum 25 Sinus septum 7 Sinus valves 7 Situs - cordis 10 - inversus 73 - viscerum 130-136 Small intestine - See also lntestinum tenue - autonomic innervation 100 - cross-section 87 - mesenteries 137 - projection onto the ventral abdominal wall 86 - regional lymph nodes and lymph vessels 99 - tumors 71 - veins 98 - wall structure 87 Sonography See ultrasound image{s) Spatium - epidurale 154 - extraperitoneale 70, 158 - - pelvis 70, 158 - profundum perinei 197, 199, 201, 217, 219 - retroperitoneale 70, 158 - retropubicum {space of RETZIUS) 209-210, 236-237, 239 - retrorectale 209 - subarachnoideum 63 - superficiale perinei 197, 199,201,217,219 Spermatic cord See Funiculus spermaticus Spina - iliaca - - anterior superior 74, 93, 182, 210 - - posterior superior 161 - ischiadica 238 - scapulae 29, 63 Spinal cord injuries 54 Spleen (Splen, Lien) 72, 74,80-81, 93, 98, 102-103, 110-111, 120-121, 128-129, 131133, 139, 142, 151, 153-155, 161 - contact area on the posterior wall of the stomach 79 - infarction 129 - peritoneal duplicatures 129 - rupture 71, 129 Spontaneous breathing 30 Sternal line, borders of the lungs 29 Sternum 51, 62, 65, 67, 74, 21 0 Steroid hormones, adrenal gland 170 Stomach 30, 75, 77, 85 - See also Gaster - arteries SO - autonomic innervation 84 - contact areas 79 - - of the anterior wall 79 - - of the posterior wall 79
StDmach - development 72 - exit 77 - inner muscle layers 76 - lymph nodes and lymph vessels 82 - lymphatic drainage stations 83 - parasympathetic fibres 84 - projection - - onto the body surface 86 - - onto the ventral abdominal wall 74 - regional lymph nodes 83 - sympathetic fibres 84 - veins 81 -wall 78 Stratum - circulars - - recti 223 - - (Tunica muscularis, Duodenum) 89 - - (Tunica muscularis, Gaster) 76, 78 - - (Tunica muscularis, lntestinum erassum) 87,94 - - (Tunica muscularis, lntestinum tenue) 87 - - (Tunica muscularis, Oesophagus) 44 - longitudinale - - recti 222-223 - - (Tunica muscularis, Duodenum) 89 - - (Tunica muscularis, Gaster) 78 - - (Tunica muscularis, lntestinum erassum) 87,94 - - (Tunica muscularis, lntestinum tenue) 87 - - (Tunica muscularis, Oesophagus) 44 SUDECK's point 224 Sulcus - aorticus 35 - arteriae subclaviae 35 coronarius 12-13, 15, 25 - interventricularis - - anterior 12, 15 - - posterior 12-13, 15,25 - terminalis 13 - venae brachiocephalicae 35 Superior thoracic aperture, neurovascular structures 60-61 Suprarenal arteries 172 - variations 172 Suprarenal glands 122, 166, 170 - in the retroperitoneal space 164 Suprarenal veins 172 - variations 172 Surfactant 30 Sympathetic innervation - emission 194 - perfusions of the intestines 100 Sympathetic tonus, increased - heart rate 23 - hypertension 23 - tachycardia 23 Sympathetic trunk 2, 58 Symphysis pubica 74, 150, 181, 196-197, 202, 209-210,214,216,232,236,238-239 Systemic circulation 2 Systole 16
T Tachycardia - ECG 22 - increased sympathetic tonus 23 Taenia - Iibera 94-95, 130, 134 - mesocolica 94-95 - omentalis 94-95, 130 TAWARA, node of (Nodus atrioventricularis) 20-21 Tela - submucosa - - (Duodenum) 89 - - (Gaster) 78 - - (lntestinum crassum) 94 - - (lntestinum tenue) 87 - - (Oesophagus) 44 - - (Peritoneum viscerale) 87
Tela - subserosa - - (Gaster) 78 - - (Ileum) 91 - - (lntestinum crassum) 94 - - (lntestinum tenue) 87 - - (Jejunum) 91 - - (Peritoneum viscerale) 87 Terminal ileum 95 Testicular cancer 185, 194 - lymph node metastases 195 - transscrotal testicular biopsy 195 Testis (Orchis) 160, 183, 185, 188-189, 191, 194 - coverings 187, 191 - lobules {Lobuli testis) 188 - primordial 163 Testosteron 183 - WOLFFIAN ducts, differentiation 185 Thigh, muscles 196 Thoracic aorta 43-44 Thoracic cage - inferior 151 - postero-anterior radiograph 5 - radiograph 41 Thoracic cavity 62, 68 - radiograph 5, 41 - transverse section 64-67 - - computed tomography 65 Thoracic constriction, oesophagus 45 Thoracic viscera 1-68 - radiograph 5, 41 Thoracic wall,layers 115 Thorax - computed tomography 3 - conventional radiograph 5 - MRI 3 Thymus 40,50-53, 160 - of an adolescent 51 - in a neworn 51 TODARO's tendon 16-17, 20 Trabecula(-ae) - carneae 18 - septomarginalis 17, 21 - splenicae 129 Trachea 2, 5, 28, 30-33, 38, 43, 45-46, 48, 51,54, 56-58,60,62-64,161 - projection onto the ventral thoracic wall 28 Trachea-oesophageal fistula 30 Traction diverticula 45 Transoesophageal echocardiography 66 Transposition of the great vessels 7 Transscrotal testicular biopsy 195 Transurethral catheter, positioning 180 Transverse colon See Colon transversum TREITZ hernias 136 TREITZ, muscle of (M. suspensorius) 89 Tricuspid valve (Valva atrioventricularis dextral 4, 6, 16-17,62, 67 - projection onto the ventral thoracic wall 4 Trigone of the bladder {Trigonum vesicae) 177 Trigonum - cholecystohepaticum (CALOT's triangle) 118 - fibrosum - - dextrum 16 - - sinistrum 16 - pericardiacum 4, 40 - thymicum 40, 50 - vesicae 177 Truncus{-i) - arteriosus 6 - brachiocephalicus 12-13, 43-45,48, 51, 54-56,62,64 - bronchomediastinalis 39, 48, 60-61 - coeliacus 46, 80, 96, 103, 110, 122, 125, 140,142,144,165,226,228,231 - - branches 142 - - origins 144 - costocervicalis 56, 60-61 - inferior 60-61 - intestinalis 48, 99, 229 - jugularis 48, 60
257
Index
Truncus(-i)
-
lumbalis{-es) 99, 229 - dexter 229 lumbosacralis 230-232 pulmonalis 5-6, 8-10, 12-13, 15, 19,24-25, 41,55,65-66 - subclavius sinister 61 - sympathicus 2, 52-53, 56-58, 60-61,6465,67,100,151,154,156,194,230-231 - thyrocervicalis 60-61 - vagalis - - anterior 58, 84, 100, 231 - - posterior 84, 100, 231 Tuba uterina {Salpinx) 139, 160,203, 205-208, 211-212, 234 - peritoneal duplicatures 206, 208 Tuber ischiadicum 199, 202, 217, 239-240 Tuberculum pubicum 202 Tubulus - distalis 168-169 - proximalis 168-169 Tunica - adventitia - - {lntestinum crassum) 94 - - {Oesophagus) 44 - - (Trachea) 33 - albuginea - - corporum cavernosorum 186, 191-192, 236 - - (Testis) 188-189 - dartos 187, 189, 191, 236 - fibrosa {Splen) 129 - mucosa - - (Gaster) 78 - - (lntestinum crassum) 94 - - (lntestinum tenue) 87 - - (Oesophagus) 44 - - (Trachea) 33 - - (Uterus) 207 - - (Vesica biliaris) 117 - - (Vesica urinaria) 177 - muscularis - - (Duodenum) 89 - - (Gaster) 76, 78 - - (lntestinum crassum) 94 - - (lntestinum tenue) 87 - - (Jejunum) 91 - - {Oesophagus) 44, 76 - - {Rectum) 222 - - {Uterus) 207 - - {Vesica urinaria) 177-178 - serosa - - {Gaster) 78 - - {Ileum) 91 - - {lntestinum crassum) 94 - - {lntestinum tenue) 87 - - {Jejunum) 91 - - {Lobus hepatis dexter) 105 - - {Lobus hepatis sinister) 105 - - {Oesophagus) 44 - - {Perimetrium) 206 - - {Splen) 129 - - {Uterus) 207 - - {Vesica biliaris) 117 - vaginalistestis 187-189, 191
u Ulcus - duodeni 90 - - endoscopy {duodenoscopy) 90 - - radiograph with contrast imaging 90 - ventriculi 71, 78 Ultrasound image(s) - kidney 173 - liver 114 - liver veins 114 - pancreas 127 - pancreatitis 155 - portal vein 114 - Vv. hepaticas 114 Umbilical cord 9
258
Umbilical hernia 73 Umbilicus 182 Upper abdominal situs - abdominal surgery 133 - development 72 - position of the viscera 130-132 - retroperitoneal organs 122 Upper intestinal tract, haemorrhage 89 Upper respiratory tract 28, 32-33 - development 30 Ureter 139, 160, 162-167, 171, 174-176, 178, 180,183,185,194,198,203,205-206, 208-209,221,228,233-235,237,240 - common variations, radiographs 176 - constrictions 175 - course 175 - crossing, MEYER-WEIGERT's rule 176 - duplex 176 - fissus 176 - irreversible damage, hysterectomy 175 - parts 175 - radiograph 176 Ureteric bud 162 Ureteric colic, renal concrements 175 Ureteric orifice 163 - cystoscopy 177 Urethra 179, 186, 190, 204, 216, 236 - bends 179 - feminina 160, 180-181,203,210, 216,219 - masculina 160, 177-178, 181, 190, 192, 194, 197 Urethral folds 184, 204 - incomplete fusion 184 Urethral groove 184 Urinary bladder See Vesica urinaria Urinary incontinence 214 Urinary organs - development 163 - in man 183 - in woman 183 Urinary pole 168 Urinary system 160 Urogenital folds 184 Uterine neck 209 Uterus 93,160,203,205-210,216,234-235, 237 - anteflexion 208 - anteversion 208 - connective tissue spaces 209 - descensus 214 - duplex 205 - with foetus 21 0 - ligaments 209 - peritoneal duplicatures 206, 208 - position 208 - prolapse 214 - retroflexion 208 - retroversion 208 - septus 205 - subseptus 205 Utriculus prostaticus 177 Uvula vesicae 177
v Vagina 160, 180, 203-205, 207-208, 210-211, 215-216,219,234,239 - descensus 214 - musculi recti abdominis 155 - position 208 - prolapse 214 Vagotomy, selective proximal or total, gastric ulcer 84 Valva{-ae) -aortae 4,6, 16,19,62,66-67 - atrioventricularis - - dextra {Valva tricuspidalis) 4, 6, 16-17, 62, 67 - - sinistra (Valva mitralis) 4, 6, 16, 18-19, 66-67 - cordis 16
Valva(-as)
- ileocaecalis {ileocaecalvalve, BAUHIN's valve) 86,95 - trunci pulmonalis 4, 6, 16 Valvula{-ae) - anales 222-223 - foraminis ovalis 7, 18 - semilunaris - - anterior 16 - - dextra - - - {Valva aortae) 16, 66 - - - {Valva trunci pulmonalis) 16, 19 - - posterior{Valva aortae) 16, 19, 62,66 - - sinistra - - - {Valva aortae) 16, 19, 66 - - - {Valva trunci pulmonalis) 16 - sinus coronarii 7, 17, 21 - venae cavae inferioris 7, 17, 21 Varicocele 171, 193 Vas(-sa) - lymphatica 87, 191 - privata (Pulmo) 38 - publica (Pulmo) 38 - recta 169 Vena(-ae) - appendicularis 111, 141 - arcuata (Ren) 169 - atriales 25 - axillaris 60-61, 64, 68 -azygos 46-48,52,56-57,64-6~ 112,155 - brachiocephalica 40, 50, 52-53, 60 - - dextra 13, 51, 54, 57 - - sinistra 13, 46, 51, 54, 57, 61-62 - bronchiales 52, 57 - bulbi - - penis 197 - - vestibuli 218 - cardiaca(-ae) (cordis) - - magna 12-13, 18, 25, 67 - - media {V. interventricularis posterior) 13, 25,62 - - minimae (Vasa THEBES II) 25 - - parva 12, 25 - cava - - inferior 5-6, 8-9, 11, 13, 15, 17, 20, 25, 46-4~55,5~ 72,81,98,104-105,107108, 111-112, 114, 122, 127, 141, 144, 149-150, 154-156, 164-165, 171-173, 193,225,228-230 - - - tributaries 228 - - superior 4-6, 8-13, 15, 17, 21, 25, 44, 46, 48,51-52,54-55,5~64-66
-
centralis - (GI. suprarenalis) 170 - (Hepar) 106 cephalica 68 circumflexa femoris medialis 238 colica - dextra 98, 111, 141, 145 - media 98, 111, 141, 145, 147 - sinistra 98, 111-112, 141, 145, 147 cordis 25 corticales radiatae 169 cremasterica 191-192 cystica 98, 111, 116, 141-142 dorsalis - profunda - - clitoridis 216, 237 - - penis 192, 197, 233, 236 - superficialis penis 192, 236 epigastrica - inferior 112, 233, 237 - superficialis 112 femoralis 238-239 gastrica{-ae) - breves 80-81, 98, 111, 141 - dextra 80-81,98, 111, 141 - sinistra 46-47,80-81, 98, 111-112, 141142, 150, 155 - gastroomentalis 80 - - dextra 80-81,98, 111, 141-142, 144 - - sinistra 46,80-81, 98, 111, 141-142, 144
Index
Vena(-ae)
Vena(-ae)
-
- pericardiacophrenica 11, 51-54 perinealis 197 phrenica inferior 46-47, 112, 171, 228 portae hepatis 8-9,47, 80-81,98, 104, 108, 110-112, 114, 118, 122-123, 127, 141-142, 144,149-150,154-156 pudenda{-ae) - externa 191 - - profunda 192 - interna 197,200-201,218, 225,233-234, 238-240 pulmonalis{-es) 38, 41, 52 - dextra{-ae) 10, 13, 15, 18, 25, 35, 44 - - inferior 11, 66 - - superior 11, 66 - sinistra{-ae) 9, 13, 15, 25, 44, 53, 62 - - inferior 10-11, 18, 35, 62,66-67 - - superior 10-11, 18, 35, 62, 65 rectalis(-es) - inferiores 112, 141,225, 233-234 - mediae 141,225,233-234 - superior 98, 111-112, 141, 147,225,234 renalis(-es) 156, 164-168, 171, 175, 193, 228 - - course 171 - - dextra 148-149, 165, 172-173 - - sinistra 112, 127, 165, 172 - sacralis mediana 225, 228 - saphena magna 239 - sigmoideae 98, 111-112, 141, 147,225 - splenica (lienalis) 81, 98, 111-112, 122-123, 12~ 129, 141, 144, 147, 151, 154-156 - - branches 111 - stellata (Ran) 169 - subclavia 44, 51, 54, 57, 63 - - dextra 39, 46, 54, 60 - - sinistra 39, 61 - subcostalis 57 - suprarenalis(-es) 166, 172 - - dextra 164, 171-172, 228 - -media 164 - - sinistra 164-165, 171-172,228 - testicularis 112, 165-166, 171, 192-193,228 - - course 193 - thoracica interne 40, 50-51, 64 - thyroidea inferior 46, 51 - umbilicalis 8, 103, 210 - uterina 234 - ventriculi - - dextri anteriores 25 - - sinistri posteriores 25 - vertebralis 46 - vesicalis inferior 233 Ventral pancreatic bud 103, 121 Ventricular septal defect 7
-
glutea - inferior 225, 238 - superior 225 hemiazygos 46-47, 53, 57, 62, 112, 155 - accessoria 46, 53, 57 hepatica{-ae) 8-9,98, 105-106, 111-112, 141, 228 - dextra 108, 149, 154 - intermedia 108 - sinistra 108, 149-150 - ultrasound image 114 ileales 98, 111, 141, 145 ileocolica 98, 111, 141 iliaca - communis 112, 148-149, 175,215, 225, 228,232 - externa 225, 233-234, 237 - interna 112, 225, 234, 240 intercostales posteriores 46, 52-53, 56-57, 66-67 interlobaris {Ren) 169 interlobularis 106 interventricularis - anterior 12, 25 - posterior (V. cardiaca (cordis( media) 13, 25 jejunales 98, 111, 141, 145, 147 jugularis interna 39, 44, 46, 54,60-61, 68 lumbalis(-es) 228 - ascendens 57 marginalis - dextra 25 - sinistra 25 mediastinales 57 mesenterica - inferior 81, 98, 111-112, 141, 147,225 - - branches 98, 111 - - course in the retroperitoneal space 147 - superior 81, 96, 98, 111-112, 122-123, 141, 144-145, 147-150 - - branches 111 - - course 145 obliqua atrii sinistri 25 obturatoria 196,215,225, 233,238-239 oesophageae/oesophageales 46-47, 57, 81, 98, 111-112, 141 ovarica(-ae) 112, 175, 206-208, 228, 234, 237 - dextra 165 - sinistra 165-166, 171 pancreaticae 98, 111, 141 pancreaticoduodenalis{-es) 98, 111 - superior posterior 141 paraumbilicales 111-112 pericardiacae 57
Ventriculus - dexter 4, 6, 8-10, 12-13, 16, 17, 25, 55,6667,150 - sinister 4-10, 12-13, 15, 17-19,25,41,44, 55,66-67 Vertebra - lumbalis 165-156 - thoracica 63-68, 164 Vesica - biliaris {fellea) 8, 42,80-81, 93, 98, 102104, 107-108, 110-111, 116-119, 121, 127, 131-132, 142, 156 - - projection onto the body surface 86 - urinaria 8, 93, 137-139, 148-149, 160, 162, 177-178,181,183,186-186,190,194,203, 206,208-210,216,219,221,223,233-235, 238-239 - - lymph nodes 235 - - in man 181 - - inwoman 181 Vestibule {Vestibulum vaginae) 202 Vestibulum - bursae omenta lis 132-133 - nasi 28 - oris 42 - vaginae 180, 202 Villi intestinales 87 Visceral surgery, liver segments 108 Vortex cordis 15 Vulvar carcinoma, lymph node metastases 213
w White pulp, spleen 129 WIRSUNG's duct (Ductus pancreaticus) 8889, 117, 121, 123-124, 12~ 148-149 - variations of the junction 124 WOLFFIAN duct (Ductus mesonephricus) 162-163, 205 - differentiation, testosteron 185 WOLFF-PARKINSON-WHITE syndrome, ECG 22
z ZENKER's diverticula 45 Zona - alba (Canalis ana lis) 222 - columnaris (Canalis analis) 222-223 - cutanea (Canalis analis) 222-223 - orbicularis 238
259
Atlas of Human Anatomy Head, Neck and Neuroanatomy 1;.~t
l::dtuon
r rl1tt rl by F. Paul~ n nrl J f\1 ch o na :.h Vt:rtton" 1th I .t•m Nom ncl tur
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User's Guide to the Book Introductory p1gn: • The introductory pages provide all relevant anatomical informations concerning- the subject of the chapter. lmponant details and connections are explained easily to understand. • The Dissection Link for each chapter comprises brief and concise tips essential for the dissection of the respective body r&gion. • Exam Check Lists provide all keywords for possible exam questions. Atlnp~gn:
• The menu bar on top indicates the topics of each chapter, the bold print shows the subject of the respective pages. • Important anatomical str\lctures in the figures are highlighted in bold print. • Small supplement sketches located next to complex views show visual angles and intersecting planes and, thus. facilitate orientation. • Detailed figure captions explain the relationships of anatomical structurN.
• Bullated lists in figure captions as well as in tables help structuring complex facts and provide a better overview. • Figures, tables, and text boxes are interconnected by crossreferences. • Cross-references link the figures to the separate Table Booklet with tables of muscles, joints, and nerves, thus providing a sufficient anatomicell:nowledge for the exam. • Clinical Remarks boxes provide clinical background knowledge concerning the anatomical structures illustrated on 1t1e page. • The dissection link on the page indicates if a tip for dissecting the illustreted anatomical region is available on www.e-sobotta. com.
ApJMift(lix: • List of abbreviations, general terms of direction and position can be found at the end of the book.
Perfect Orientation -the New Navigation System
-
Neck
The subject of this page
-+--i
....' .
The menu bar with the terms printed in bold indicates the subject of the current page.
Sketches facilitate orientation in complex figures by showing visual angles end intersecting planes. Important anatomical structures are printed in bold.
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For pages with this dissection link detailed dissection tips can be found on www.e-sobotta. com.
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Figure ceptions explain anatomical connections concerning the illustrated structures.
...
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The Clinical Remarks boxes describe medical contexts to the anatomical structures illustrated on the page. Mostly, these clinical aspects are also of high relevance for the exam.
The following contents can be found in the other two volumes:
1 General Anatomy Orientation on the Body -+ Surface Anatomy -+ Development -+ Muskuloskeletal System -+ Vessels and Nerves -+ Imaging Techniques -+ Integumentary System
2 Trunk
iiiiiiiiiiiiiil
Surface Anatomy -+ Development -+ Skeleton -+ Imaging -+ Muscles -+ Vessels and Nerves -+ Topography, Back -+ Female Breast -+ Topography, Abdomen and Abdominal Wall
3 Upper Extremity Surface Anatomy -+ Development -+ Skeleton -+ Imaging Topography -+ Sections
-+
Muscles -+
4 Lower Extremity Surface Anatomy -+ Skeleton -+ Imaging -+ Muscles -+ Topography -+ Sections
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Cll
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Cll
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5 Viscera of the Thorax
IS!J
6 Viscera of the Abdomen
w
7 Pelvis and Retroperitoneal Space
Heart
-+
Lungs
-+
Oesophagus -+ Thymus -+ Topography -+ Sections
Development -+ Stomach -+ Intestines -+ Liver and Gallbladder -+ Pancreas -+ Spleen -+ Topography -+ Sections
Kidney and Adrenal Gland -+ Efferent Urinary System -+ Genitalia -+ Rectum and Anal Canal -+ Topography -+ Sections
Paulsen, Waschke
Atlas of Human Anatomy Latin Nomenclature Head, Neck, and Neuroanatomy
Translated by T. Klonisch and S. Hombach-Kionisch
Atlas of Human Anatomy Head, Neck, and Neuroanatomy
15th edition
G R V
r i 9 . 9 & s r s i n hby T. Klonischiaand Translated a t sWinnipeg, Canada S. Hombach-Kionisch, r e p . with 627 Figures p 569 Coloured Plates i v Edited by F. Paulsen and J. Waschke
ELSEVIER
URBAN & FISCHER
URBAN&FISCHER
Munchen
Editors
Prof. Dr. Friedrich Paulsen
Prof. Dr. Jens Waschke
Dissecting Courses for Students
More Clinical Relevance in Teaching
In his teaching, Friedrich Paulsen puts great emphasis on the fact that students can actually dissect on cadavers of body donors. NThe hands-on experience in dissection is extremely important not only for the thretHJimensional understanding of anatomy and as the basis for virtually every medical profession, but for many students also clearly addresses the issue of death and dying for the first time. The members of the dissection team not only study anatomy but also leam to deal with this special issue. At no other time medical students will have such a close C(Jf)fact to their classmates and teachers again.N MThe dissection links in the atlas lead to online images that are relevant for the dissection. You can print them and take them along. The offered dissection tips are not instructions, but make sure that you are oriented exceptionally well and not 'cutting in the darlc~
From March 2011 on, Professor Jens Waschke is Chairman of Department I at tfle Institute ofAnatomy and Cell Biology at the L~aximilians-UniversitBt (LMU) Munich. "For me, teaching at the department of vegetative anatomy. which is responsible for the dissection courses of both Munich's large universities LMU and TU, emphasizes the importance of teaching anatomy with clear clinical re/evancew, sa~ Jens L-\tlschke. •The clinical aspects in the Atlas introduce students to anatomy in the first semesters. At the same time, it indicates the importance of this subject frJr future clinical practice, as understanding human anatomy means more than just memorizJJtion of stJuctlJres.N
8
Professor Friedrich Paulsen (born 1966 in Kiel) passed the 'Abitur' in Brunswick and trained successfully as a nurse. After studying human medicine in Kiel. he became scientific associate at the Institute of Anatomy, Department of Oral and Maxillofacial Surgery and the Department of Otolaryngology, Head and Neck. Surgery of the Christian-Aibrechts-Universitiit Kiel. In 2002, togetner with his colleagues, he was awarded the Teaching Award for outstanding teaching in the field of anatomy at the Medical Faculty of the University of Kiel. On several occasions he gained work: experience abroad in the academic section of the Department of Ophthalmology, University of Bristol, UK. where he did research for several months. From 2004 to 2010 as a University Professor, he was head of the Macroscopic Anatomy and Prosector Section at the Department of Anatomy and Cell Biology of the Martin-Luther-lJniversitiit HalleWittenberg. Starting in April2010, Professor Paulsen became the Chairman at the Institute of Anatomy II of the Friedrich-AiexanderUniversitiit Erlangen. Since 2006, Professor Paulsen is a board member of the Anatomical Society and 2009 he was elected the general secretary of the International Federation of Associations of Anatomy (I FAA). His main research area concerns the innate immune system. Topics of special interest are antimicrobial peptides, trefoil factor peptides, surfactant proteins, mucins, corneal wound healing, as well as stem cells of the lacrimal gland and diseases such as eye infections, dry eye, or osteoarthritis.
Professor Jans Waschk:a (born in 1974) habilitated in 2007 after graduation from Medical School and completing a doctoral thesis at the University of Wuerzburg. From 2003 to 2004 he joined Professor Fitz-Roy Cuny at the University of California in Davis for a nine months research visit. Starting in June 2008, he became the Chairman at the Institute of Anatomy and Cell Biology Ill at the University of Wuerzburg. In 2005, together with his colleagues, Professor Waschke was awarded the Albert Koelliker Teaching Award of the Faculty of Medicine in Wuerzl:lurg. In 2006, he was awarded the Wolfgang Bargmann Prize of the Anatomical Society. His main research area concerns cellular mechanisms that control the adhesion between cells and the cellular junctions establishing the outer and inner barriers of the human body. The attention is focused on the regulations of the endothelial barrier in inflammation and the mechanisms, which lead to the formation of fatal dermal blisters in pemphigus, an autoimmune disease. The goal is to gain a better understanding of cell adhesion as a basis for the development of new therapeutic strategies.
All business correspondence should be made with: Elsevier GmbH, Urban & Fischer Verlag, Hack.erbrOck.e 6, 80335 Munich, Germany, mail to: [email protected] This atlas was founded by Johannes Sobotta t, former Professor of Anatomy and Director of the Anatomical Institute of the University in Bonn. Germany.
AddreiHs of the editors: Professor Dr. mad. Friedrich Paulsen lnstitut fur Anatomie II (Vorstand) Universitiit Erlangen-NOrnberg Universitiitsstra~e 19 91054 Erlangen Germany Professor Dr. med. Jens Waschke lnstitut fur Anatomie Ludwig-Maximilians-Universitiit Pettenk.oferstra13e 1 1 80333 MOnchen Germany
AddreiHs of the translators: Professor Dr. mad. Sabine Hombach-Kionisch Professor Dr. mad. Thomas Klonisch Faculty of Medicine Department of Human Anatomy and Cell Science University of Manitoba 745 Bannatyne Avenue Winnipeg Manitoba R3E OJ9 Canada Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationa lbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://WWW.d-nb.de. All rights reserved 15'h Edition 2011 © Elsevier GmbH, Munich Urban & Fischer Verlag is an imprint of Elsevier GmbH. 11
12 13 14 15
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For copyright concerning the pictorial material see picture credits. All rights, including translation. are reserved. No part of this publication may be reproduced, stored in a retrieva I system, or transmitted in any other form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior written permission of the publisher. Acquisition editor: Alexandra Frntic, Munich Development editor: Dr. Andrea Beilmann, Munich Editing: Ulrike Kriegel, buchundmehr, Munich Production manager: Sibylle Hartl, Munich; Renate Hausdorf. buchundmehr, Griifelfing Composed by: Mitterweger & Partner. Plankstadt Printed and bound by: Firmengruppe appl, Wemding Illustrators: Dr. Katja Dalk.owski, Buckanhof; Sonja Klebe, AyingGroBhelfendorf; Jorg Mair, Munich; Stephan Winkler, Munich Cover illustration: Nicola Neubauer. Puchheim Cover design: SpieszDesign, Neu-Uim Printed on 115 g Cuadra Silk ISBN 978{)-7234-3733-8
Current information by www.elsevier.de and www.elsevier.com
German editions: 1., edition: 1904-1907 J. F. Lehmanns Verlag, Munich 2"
Table of contents Head Overview . . . ......... ......... ......... .......... ........ .. Skeleton and Joints . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . ..
4 5
Muscles.................................................... Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40 46
Vessels and Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
52
Nose....................................................... Mouth and Oral Cavity .. .. . . . . .. .. .. . . . .. .. .. . . . . .. .. .. . . ..
58 68
Salivary Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
90
Eye Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1DO Skeleton . . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. 102 Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Lacrimal Apparatus......................................... 108 Muscles ofthe Eye . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. 112 Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Eyeball . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Visual Pathway............................................. 131
Ear Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Outer Eer . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . . .. .. .. . . .. 138 Middle Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Auditory Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inner Ear . . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. Hearing and Equilibrium....................................
142 148 151 157
Neck Muscles .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . . .. .. .. . . .. 164 Pharynx.................................................... 176 Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Thyroid Gland.............................................. 192 Topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Brain and Spinal Cord General .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . . .. .. .. . . .. 214 Meninges and Blood Supply . . . .. .. .. . . . .. .. .. . . . .. .. .. . . . .. 216 Brain....................................................... 228 Sections.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Cranial Nerves. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Spinel Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Translators
Prof. Dr. Thomas Klonisch
Prof. Dr. Sabine Hombach-Kionisch
Professor Thomas Klonisch (born 19601 studied human medicine at the Ruhr-Universitiit Bochum and the Justus-Liebig-Universitiit (JLUJ Giessen. He successfully completed his doctoral thesis at the Institute of Biochemistry at the Faculty of Medicine of the JLU Giessen and became a scientific associate at the Institute of Medical Microbiology, University of Mainz (1989-19911. As an Alexander von Humboldt Fellow he joined the University of Guelph, Ontario, Canada, from 1991-1992 and, in 1993-1994, continued his research at the Ontario Veterinary College, Guelph, Ontario. From 1994-1996, he joined the immunoprotein engineering group at the Department of Immunology, University College London, UK, as a senior research fellow. From 1996-2004 he was a scientific associate at the Department of Anatomy and Cell Biology, Martin-Luther-Universitiit Halle-Wittenberg, where he received his accreditation as anatomist (1999), completed his habilitation (20001, and held continuous national research funding by the German Research Council (DFGI and German Cancer Research Foundation (Deutsche Krebshilfel. In 2004, he was appointed Full Professor and Head at the Department of Human Anatomy and Cell Science at the Faculty of Medicine, University of Manitoba, Winnipeg, Canada, where he is currently serving his second term as department chairman.
Teaching clinically relevant anatomy and clinical case-based anatomy learning are the main teaching focus of Sabine Hombach-Kionisch at the Medical Faculty of the University of Manitoba. Since her appointment in 2004, Professor Hom bach has been nominated annually for teaching awards by the Manitoba Medical Student Association.
His research areas concern the mechanisms employed by cancer cells and their cancer stem/progenitor cells to enhance tissue invasiveness and survival strategies in response to anticancer treatments. One particular focus is on the role of endocrine factors, such as the relaxin-like ligand-receptor system, in promoting carcinogenesis.
Sabine Hom bach (born 1963) graduated from Medical School at the Justus-Liebig-Universitat Giessen in 1991 and successfully completed her doctoral thesis in 1994. Following a ca rear break to attend to her two children she re-engaged as a sessional lecturer at the Department of Anatomy and Cell Biology of the Martin-Luther-Universitiit Halle-Wittenberg in 1997 and received a post-
Preface In the preface to the first edition of his Atlas. Johannes Sobotta wrote in May 1904: "Many years of experience in anatomical dissection led the author to proceed with the presentation of the peripheral nervous system and the blood vessels such that the illustrations of the book are presented to the student exactly in the same manner as body parts are presented to them in the dissection laboratories, i.e. simultaneous presentation of blood vessels and nerves of the same region. Alternating descriptive and image materials are distinctive features of this atlas. The images are the core piece of the atlas. Apart from table legends, auxiliary and schematic drawings, the descriptive material includes short and concise text parts suitable for use of this book in the gross anatomy laboratory." As with fashions, reading and study habits of students change periodically. The multimedia presence and availability of information as well as stimuli are certainly the main reasons of ever changing study habits. These developments and changing demands of students to textbooks and atlases, which they utilise, as well as the availability of digital media of textbook contents, is accounted for by editors and publishers. Apart from interviews and systematic surveys of students, the textbook sector is occasionally an indicator enabling the evaluation of expectations of students. Detailed textbooks with the absolute claim of completeness are exchanged in favour of educational books that are tailored to the didactic needs of students and the contents of the study of human medicine, dentistry, and biomedical sciences, as well as the corresponding examinations. Similarly, illustrations in atlases such as the Sobotta, which contain exact naturalistic depiction of real anatomical specimens. fascinate doctors and associated medical professions for many generations throughout the world. However, students sometimes perceive them as too complicated and detailed. This awareness requires the consideration of how the strength of the atlas, which is known for its standards of accuracy and quality during its centennial existence featuring 22 editions. can be adapted to modern educational concepts without compromising the oeuvre's unique characteristics and authenticity. After careful consideration, Elsevier and the editors Professor Reinhard Putz and Professor Reinhard Pabst, who were in charge of the atlas up to its 22"d edition, came to the conclusion that a new editorial team with the same great enthusiasm for anatomy and teaching would meet the new requirements best. Together with the Elsevier publishing house, we are extremely pleased to be charged with the new composition of the 23n1 edition of Sobotta. In redesigning, a very clear outline of contents and a didactic introduction to the pictures was taken into account. Not every fashion is accompanied with something entirely new. Under didactical aspects we have revisited the old concept of a three-volume atlas. as used in Sobotta's first edition. with: General Anatomy and Musculoskeletal System (vol. 1), Internal Organs (vol. 2), and Head, Neck, and Neuroanatomy (vol. 31. We have
also adopted, although slightly modified, the approach mentioned already in the preface of the first edition, i.e. combining the figures in the atlas with explanatory text which is an old trend being currently back into fashion once more. Each image is accompanied by a short explanatory text, which selVes to introduce students to the image, explaining why the particular preparation and presentation of a region was selected. The individual chapters were systematically organised in terms of current subject matter and prevailing study habits; omitted and incomplete illustrations - particularly the systematics of the neurovascular pathways -were supplemented or replaced. The majority of these new figures are conceptualised to facilitate studying the relevant pathways of blood supply and innervation by didactical aspects. We have also reviewed many existing figures, reduced figure legends, and highlighted keywords by bold print to simplify access to the anatomical contents. Numerous clinical examples are used to enhance the "lifeless anatomy". present the relevance of anatomy for the future career to the student, and provide a taste of what's to come. Introductions to the individual chapters received a new conceptual design, covering in brief a summary of the content, the associated clinical aspects, and relevant dissection steps for the covered topic. It serves as a checklist for the requirements of the Institute of Medical and Pharmaceutical Examination Questions (IMPP) and is based on the German oral part of the preclinical medical examination (Physikum). Also new are brief introductions to each topic in embryology and the online connections of the atlas with the ability to download all images for reports, lectures, and presentations. We want to emphasise two points: 1. The "new" Sobotta in the 23rd edition is not a study atlas. claiming completeness of a comprehensive knowledge and, thus, does not try to convey the intention to replace an accompanying textbook. 2. No matter how good the didactic approach, it cannot relieve the students of studying, but aid in visualisation. Anatomy is not difficu It to study, but very time-<:onsuming. Sacrificing this time is worthwhile, since physicians and patients will benefit from it. The goal of the 23rd edition of Sobotta is not only to facilitate learning, but also to make learning exciting and attracting, so that the atlas is consulted during the study period as well as in the course of professional practice. Erlangen and Wuerzburg, summer 2010, exactly 106 years after the first edition. Friedrich Paulsen and Jens Waschke
Acknowledgements First, we would like to express that the work on the Sobotta was exciting and challenging. During stages, at which one could see the progress of development of individual chapters and newly developed pictures with a slight detachment, one obtained satisfaction, was elated with pride and identified oneself evermore with the Sobotta. The redesign of Sobotta is obviously not the sole work of two inexperienced editors, but rather requires more than ever a well-attuned team under the coordination of the publisher. Without the long experience of Dr. Andrea Beilmann, who supervised several editions of the Sobotta and exerted the calming influence of the Sobotta team, many things would have been impossible. We thank her for all the help and support. Ms. Alexandra Frntic, who is also part of the four-member Sobotta team, pursued the first major project of her career and tackled it with passion and enthusiasm. Her liveliness and management by motivation have enlivened and cheered the editors. We express our gratitude to Ms. Frntic. We like to reflect back on the Sobotta initialisation week in Parsberg and weekly conference calls, in which Dr. Beilmann and Ms. Frntic supported us in the composition of the Sobotta and presented an admirable way to merge the variety of two personalities to achieve a single layout. Without the assertiveness, the calls for perseverance and the protective hand of Dr. Dorothea Hennessen, who directed the project of the "23'd edition of Sobotta" and always believed in her Sobotta team and the tight schedule, this edition would have not been published. Like a number of previous productions, the routinier Renate Hausdorf led the successfu I reproduction of the atlas. Other people involved in the editing process and the success of the 23nt edition of the Sobotta and whom we sincerely thank are Ms. Susanne Szczepanek (manuscript editing). Ms. Julia Baier, Mr. Martin Kortenhaus and Ms. Ulrike Kriegel (editing), Ms. Amelie Gutsmiedl (formal text editing), Ms. Sibylle Hartl (internal production), Ms. Claudia Adam and Mr. Michael Wiedorn (formal figure editing and typesetting), Ms. Nicola Neubauer U<~yout development Clnd refining the typesetting delta) Clnd the students Doris Bindl, Derkje Hockertz, Lisa Link, Sophia Poppe, Cornelia Rippl and KCltherinCl and Florian Stumpfe. For the compilation of the index, we express our gratitude to Dr. Ursula Osterkamp-Baust. Special thanks are expressed to the illustrators Dr. Katja Dalkowski, Ms. Sonja Klebe, Mr. Ji;irg Mair and Mr. Stephan Winkler, who in addition to revising existing illustrations have developed a variety of excellent figures. Priv.-Doz. Dr. rer. nat. Helmut Wicht, Senkenberg Anatomy, GoetheUniversitiit Frankfurt/Main, has revived the lifelessness of the introductions to the chapters indited by the two editors through his unique style of writing. We express our gratitude to Priv.-Doz. Dr. rer. nat. Wicht. A big help to us was the advisory council, which in addition to the former editors Prof. Dr. mad. Dr. h. c. Reinhard Putz, Ludwig-Maximilians-Universitiit Munich, and Prof. Dr. mad. Reinhard Pabst, Hannover
Medical School, and colleagues Prof. Dr. mad. Peter Kugler, JuliusMaximilians-Universitiit Wuerzburg, and Prof. Dr. rer. nat. Gottfried Be>gusch, Charit6 Berlin, supported us strongly with advice and critical comments. We would like to specifically emphasise the effort of Ms. Renate Putz, who corrected the manuscript very carefully; her comments ware of crucial importa nee for the consistency of the work. in itself and with the earlier editions. For support with corrections and revisions, we express our sincere thanks to Ms. Stephanie Beilicke, Dr. rer. nat. Lars Brauer, Ms. Anett Diker, Mr. Fabian Garreis, Ms. Elisabeth George, Ms. Patricia Maake, Ms. Susann Moschtar. Mr. Jorg Pek.arsk.y and Mr. Martin Schicht. For assistance in creating clinical figures, we express our gratitude to Priv.-Doz. Dr. med. Hannes Kutta, Clinic and Polyclinic for Oto-Rhine>Laryngology at the University Hospital Hamburg-Eppandorf, Prof. Dr. med. Norbert Kleinsasser, University Clinic for Ote>-Rhino-Laryngo-Pathology, Julius-Maximilians-Universitiit Wuerzburg, Prof. Dr. med. Andreas Dietz, Head of Clinic and Polyclinic for Oto-Rhino-Laryngology at the University Leipzig, Dr. med. Dietrich Stoevesandt, Clinic for Diagnostic Radiology at the Martin-Luther-Universitiit Halle-Wittenberg, Prof. Dr. med. Stephan Zierz, Director of the University Hospital and Polyclinic for Neurology at the Martin-Luther-Universitiit Halle-Wittenbarg, Dr. mad. Barit Jordan, Hospital and Polyclinic for Neurology at the Martin-Luther-Universitiit Halle-Wittenberg, Dr. med. Saadettin Sel, University Hospital for Ophthalmology at the Martin-Luther-Universitiit Halls-Wittenberg, Mr. cand. mad. Christian Schroeder, Eckernforde, and Mr. Denis Hiller, Bad Lauchstiidt. We also would like to express our thanks to our anatomical mentors Prof. Dr. med. Bernhard Tillmann, Christian-Aibrechts-Universitiit Kiel, and Prof. Dr. med. Detlev Drenck.hahn, Julius-Maximilians-Universitiit Wuerzburg, whom we not only owe our anatomical training, the motivation for subject matter, and the sense of mission, but also have been great role models in their design of textbooks and atlases, as well as in their teaching excellence. Our deepest gratitude to our parents, Dr. med. Ursula Paulsen and Prof. Dr. mad. KClrsten Paulsen, and also Annalies Waschke and Dr. med. Dieter Waschke, who intensely supported and sustained the Se>botta project. Karsten Paulsen, who passed away in May 2010, studied anatomy as a medical student from the 4'h edition of Sobotta. Dieter Wasch ka used the 16!11 edition of Sobotta and con tin uas to attain knowledge with medical literature even during retirement. The 23n1 edition is dedicated to our fathers. Last but not least, we thank our wives Dr. mad. Dana Paulsen and Susanne Waschke, who not only had to share us with the Sobotta in the last year, but also were on hand with help and advice on many issues and have been strongly supportive.
Head Overview . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Skeleton and Joints. . . . . . . . . . . . . . . . .
5
Muscles .................. . ......... 40 Topography ....... .. .. . .... . ...... . 46 Vessels and Nerves ........ .. ...... 52 Nose ...................... . .. ... . .. 58 Mouth and Oral Cavity ......... ..... 68 Salivary Glands ..................... 90
The Head the Top
Leading from
The skeleton of the head (Caput/Cephalon), i.e. the skull (Cranium), consists of two parts: the facial bones (Viscerocranium) and the skull (Neurocranium). The border between the two -the roof of one and the floor of the other - is the base of the skull (Basis cranii), which lies roughly in an oblique plane defined by the eyebrows, the external opening of the outer ear can aI and the base of the occiput.
Skull Cap (Calvaria) and Scalp The highly arched Calv.ria (skull cap, cranial cap) forms a longitudinal oval dome over the cranial base and protects the cranial cavity !Cavitas cranii), in which the brain [Cerebrum) surrounded by hard and soft meninges (Meninges) floats in the cerebrospinal fluid !CSF). The Calvaria is divided in frontal, parietal. temporal, and occipital regions formed by identically named bones (Os frontale, Os parietale, Os temporale and Os occipitale). The skin of the Calvaria is tough (•scalp•) and firmly adherent to a flat tendon, which spans from the forehead to the occiput. This tendon (Galea aponeurotica) is part of the M. occipitofrontalis, a mimic muscle that raises eyebrows and wrinkles the skin of the forehead horizontally. Skin and tendon are movable on the skull cap and can be relatively easily lifted off and removed as the scalp. Vascular injuries of the scalp can lead to a severe but usually not-life threatening bleeding.
Skull Base The base of the skull forms the roof of the two orbits [Orbitae) and the nasal cavity (Cavitas nasi), but also the roof of the throat [Pharynx, reaching up to the base of the skull) and the base of the occiput which articulates at the occipital foramen (Foramen magnum) with the first cervical vertebra. Numerous foramina, canals, and fissures cover the cranial base and serve as passageways for rna ny nerves and blood vessels. At the bottom side of the sku II base, pointing towards the Visceracranium, numerous processes, spines, and notches (Processus/Spinae/Incisurae) are present, to which muscles and ligaments are attached. The upper side of the skull base, the floor of the Neurocranium, is less irregular and resembles terraces on three floors: the top floor, the anterior cranial fossa {Fossa cranii anterior), is positioned above the Orbitae. One step down, the middle cranial fossa (Fossa cranii media) is located at the level of the tern poral bones. The last step leads down into the posterior era nial fossa (Fossa cranii posterior) with the Foramen magnum.
Facial Bones and Cavities The largest facial bone, the maxillary bone (Maxilla), is placed in the centre of the Viscerocranium. The Maxilla forms the floor of the Orbitae, most of the sidewalls of the nasal cavity, the anterior part of the palate, and carries the maxillary row of teeth. Like many other bones of the skull, the maxilla is "pneumatised", i.e. it is hollow and filled with air which is drawn from the nasal cavity (Sinus maxillaris, paranasal sinuses). Besides the Maxilla, half a dozen other smaller bones are involved in the construction of the Viscerocran iu m.
2
Breathing, smelling, tasting, chewing, swallowing, speaking, seeing, and being seen - these are the tasks of the organs that are supported and protected by the Viscerocra ni urn. The eyes and their auxiliary apparatus (Organum visus, -+ p. 98) are responsible for vision. Being seen is the responsibility of the facial muscles. The permanent activity of these muscles, which do not control bones but the facial skin, is responsible for the formation of wrinkles. The olfactory sense is up to the nose (Nasus), even though it only performs it with its smallest part, the olfactory epithelium at the roof of the nasal cavity under the base of the skull. The outer cartilage-framed nasal vestibule [Vestibulum nasi) and the far more spacious, bony inner nasal cavity !Cavitas nasal is osseal serve for breathing: Through the inner nostrils [Choanae), the nasal cavity opens behind the throat (Pharynx) which in turn communicates much more caudally with the Larynx and the windpipe [Trachea). Biting, chewing, talking, tasting, and swallowing are the functions of the oral cavity [Cavitas oris) and the accompanying organs. Similar to the nose, the oral cavity also has a vestibule [Vestibulum oris), the space between lips (Labiae) and cheeks [Buccae) on one side and the teeth (Dentes) on the other side. Behind the teeth lies the larger oral cavity proper (Cavitas oris propria) which is almost completely filled by the tongue (Lingua) at a closed bite. At its posterior aspect, the oral cavity opens towards the Pharynx and, at the price of choking, the respiratory tract and ingestive tract cross here. The roof of the mouth, the palate (Palatum), also forms the floor of the nasal cavity. In the front, the palate is rigid and bony, while dorsally towards the Pharynx it becomes soft, flexible, and muscular. The Uvula dangles from the soft part of the palate. The floor of the mouth, which is surrounded by the movable mandible (Mandibula) and which carries the tongue, is made of muscle plates. During speech almost all of these structures act together (along with many other structures), whereby the nose is used as an additional resonator. Two pits of the facial skeleton are important: If one removes (first imaginary, later on in reality during the dissection sessions) the ascending bony branch of the Mandibula (Ramus mandibulae), which leads to the temporomandibular joint (Articulatio temporomandibularis), one enters the soft tissues of the lateral aspect of the head from "behind the cheek" and enters a space that is referred to as the infratemporal fossa (Fossa i nfratem poralis). Positioned in this region are masticatory m uscles [Mm. pterygoidei medialis and lateralis) and several branches of nerves. In addition, the terminal branches of the large external carotid artery lead towards the centre of the Viscerocranium. In the direction of the Orbita, the Fossa infratemporal is extends further inwards and cranially into a wider space, the pterygopalatine fossa (Fossa pterygopalatine). It is essential to locate this cavity during dissection and its contents and multiple pathways are important to remember. This cavity is a "key distributor" for vessels and nerves of the Visceracranium. Since it is hidden and its anatomy is extremely complex, all anatomists adore it and like to exam ina students on it.
Clinical Remarks---------. Ailments and injuries of the head ere freQuent events; however. diseases affecting the skull base are rare. Common 10 all is the fact that they are often life-threatening. Since the head is en anatomically complex system. consultation by e 119riety of medical experts is required to ensure optimal care of the patient. This team of experts includes medical disciplines like otolaryngology, heed end neck surgery. neurosurgery. oral. dental, facial end ple&tic surgery, ophthalmology. radiation therapy, and diagnostic ~ diology and neuroradiology. Some patients with a severe head-related ailment (e.g. unclear hENJdache or impaired blood perfusion in a region of the brain stem resulting in vertigo and nausea) have experienced an odyssey of referrals from one doctor to the next before encountering the one physician or, even better, a team of medical experts who identify the problem and are able to help this patient. As a response to this, some university medical centres now offer a co-ordinated, multidisciplinary team approach to provide quality treetment and follow-up for such patients. Thus. therapeutic strategies are discussed and ccrordinated among the members of the different medical disciplines involved in each particuler case in order to provide the most optimal patient care and allow for a speedy recovery of the patient.
~ Dl•••ctlon Link The dissection of the tuparficial facial region at the lateral sagittal plane of the head (head in a lateral position) is showing the facial arteries and veins, muscles of facial expression. all branches of the N. facial is, and the peripheral branches of the N. trigeminus. The dissection of the deep facial r-s.ion includes the removal of the Glandula parotidea. the presentation of the Plexus parotideus {N. facialis lVII)). the dissection of the Fossa retromandibularis, tha representation of all four masticatory muscles. and the demonstration of 1he course of the A. maxillaris up to its terminal branches, as well as the preparation of the temporomandibular joint with presentation of the Discus erticularis and identification of the Chorda tympani. Dissection of the mldugltttll planes of the head (head in medial position}: The dissection of the nasal septum with its cartilaginous and bony parts as well as the Fila olfactoria and the N. nasopalatinus is followed by the removal of the nasal septum and the presentation of the lateral nasal wall with openings of the paranasal sinuses and the Ductus nasolacrimalis. The Fossa pterygopalatine is opened and its contents are displayed. Finally, the A. sphenopalatine et the Foramen sphenopaletinum is located. followed by the full dissection of the oral cavity with representation of the Glandulae submandibularis and sublingualis, Nn. lingualis. hypoglossus. and glossopheryngeus. as well as the dissection of the palatal muscles beneath the auditory tube cartilage. and of the tonsillar fossa.
EXAM CHECK LIST
· Development: Neurocranium, Viscerocranium, Nn. cranieles, sensory organs, Facies, Cranium with Calvaria, Basis cranii, exit points with penetrating etructures, Articulatio temporomandibularis and Fosee infratemporalis • head and neck muscles, Faecie end facial muscles, masticatory muecles, fascia of the head, Os hyoideum and suprahyal muaclea • components of the head: Cavum nasi (with orifices). Sinus parenaealee, topographic relationships, Cavum oris, Dentes, Lingua, Glandulae oris, Palatum and function of the Palarum molle {cleft formation), lethmua faucium. WALDEVER's tonsillar ring, Tonsillae, Pharynx.. Foua pterygopalatlna, Innervation and supply of all structures, facial paralysis and course of the Nn. craniales IV, VI~XIIJ
3
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Regions of head and neck
lll;onum tul>n'lentale} tubmandlbulllre RegloatMalllt
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....-----"nlgcn,lm ewotk:Um
antfllfar
mLIIQillr& [cm-aale) lltemaclltkla-ld~~a
F - aupntellrkulluill m~ar
- - - - ~g~um amacla"'c!Aant
Ag. 8.1 Region• of 1fte hNd and neck. Region• capHia et col II; frontal view. The heltd is divided into the following topographic regions: • Regio frontalis • Ragio temporelis • Regio erbit:llis • Regio nasalis • Regio infraerbitalis • Regio zygematica • Regio oralis • Regio buccalis • Regio mentalis
Fig. 8.2 R1aion1 of the h11d end neck. Region11 capiti• .t eolli;
lateral view.
4
R11Qic. ceMcels I~•
• Regie parietalis • Regio occipitalis • Regie parotideemasseterica The neck is divided into the following topographic regions: • Regio cervicelis anterior. composed of Trigonum submentale. Trigonum submandibular&, Trigonum caroticum, and Trigonum muscular& lomotracheale) • Regia stemocleidomastoidea with Fossa supraclavicularis minor • Regio cervicalis lateralis with Trigonum omoclaviculare • Regia cervicalis posterior
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Skull
Fon~rnen•~
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MaJgO .upniQitlltala
0. Z)'90mllbJm, PIOC. fnlntallt
FOI'IIJ'Mn zygomaticofliCial& _
..,._........ :
O..znorndcum, F-*'11tt1111..
Fig. 8.3 Skul, Cranium; frontal view. From bottom to top one tan see the lower jew or mandible (Mendibula), the two upper jaws or maxillary bones (Maxillae). the nasal bones (Ossa nasalis} located between the maxillary bone and the orbit !Orbital as well as 1he frontal bone (Qs frontalelabove the orbit. The frontal bone (01 fronhllel consists of four parts (... Fig. 8.23). Above the upper margin of the orbit (Margo supraorbitalis! the bilateral Arcus superciliaris bulges out. A part of the Os frontale protrudes mtr
I:EFORTI
I:EFORTII
I:Ef()RTIII
dially downwards and forms a portion of the medial margin of the orbit. At the lateral aspect. the Prot. zygomaticus has contett with the Prot. frontalis of the Os zygomaticum. Both form the lateral margin of the orbit. The zygomatic bone (0• zvtomaticum) constitutes the major part of the lateral and lower margins of the orbit. The pair of nasal bones (Os naall) is connected to the Os frontale by the Suture frontonasalis and to each other by the Suture intemasalis.
Fig. 8A I.E FORT's fracturet.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . car accidents are among the most frequent causes of midfaeial fractures. which are classified according to LE FORT{... Fig. 8.41: • LE FORT 1: horizontal fracture line with isolated detachment of the maxillary alveolar rim (»floating palate»l
• LEFORT II: pyramidal fracture line involving the Maxilla in the r-. gion of the floor of the orbit; involvement of the ethmoidal bones, anterior skull base, end nasal bones is also possible • LE FORT Ill: transversa fracture line with craniofacial dissociation
5
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Skull bones
Forunn m•nt.l•
Fig. 8.6 Skul bonn, Osu ennil; frontal view; colour chart see inside of the back cover of this volume. The upper jew or maxillary bone (MaxiIll) is located between the orbit and the oral cavity. The maxilla participates in the formation of the lower and medial margins of the orbit and has a lateral border with the Os zygomaticum. The Proc. frontalis of the maxilla connects with the Os frontale. The Foramen infraorbitale is located below the lower margin of the orbit in the Corpus maxillae. The Spina nasalis anterior protrudes in the midline. The Pro c. alveolaris creates the lower margin of the Maxi~
Ia and supports the teeth. In the orbit, the Maxilla creates the lower margin of the Fissura orbitalis inferior and, together with the Os zygomaticum, iorms the lateral margin of the orbit. The lower jaw or mandible (M1ndlbul1) consists of a Corpus and Rami mandibulae, which merge in the Angulus mandibulae. The Corpus mandibulse is composed of the Pars elveolsris with teeth and the Basis mandibulae beneath. The latter protrudes in the midline as Protuberantia mentalis. In addition, the Foramen mentale is shown.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . FFICturn of th• nn~l bon• 1nd 1hl supporting urtrlqlnaus n111l frlm.work are among the most frequent fractures of the facial region. One can distinguish closed and open nasal fractures. Open fractures involve bony parts piercing through the skin and soft
6
tissue. The nasal septum and Conchae nasales can also be affected. Fractures of the nasal framework. are typically a result of violent physical disputes. car accidents. martial arts like karate. boxing, and of a variety of team sports.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Skull bones
Sutura acdllltamutaldea
Sutura zygomaticcmaxilatia
fig. 8.6 Skull bon.., o... cnnii; lateral view; colour chart SEIS inside of the back: cover of this volume. The lateral view displays parts of the Ossa frontal&, parietal&, occipital&, sphenoidale, and temporale. parts of the viscerocranium (Os nasale. Os lacrimale. Maxilla. and Os zygomaticum) as well as the lateral side of the lower jaw IMandibula). In the viscerocranium, ttle Oa niiNie has its cranial and posterior borders with the Os frontale end the Maxilla, respectively. The upper part of the lacrimal bone (Os leafmele) forms the Fossa sacci lacrimalis betwEien the Maxilla and the Os ettlmoidale. The Pro c. alveolaris of ttle Maxilla contains the upper tE~eth. The mooial aspect of the Maxilla connects with the Os frontale, its lateral aspect contacts the Os zygomaticum. The Spina nasalis anterior protrudes in the anterior midline. The 0. zygomllticum is responsible for the contour of the region of the cheek:. The head of the mandible (Caput mandibulae) articulates with the Os temp orale in the temporomandibular joint (Articulatio temporomandibularis). In its upper frontal aspect, the Os frorrblll is connected with the parietal bone 10. perimle) and the sphenoidal bone lOa tphenoidale) via the Suture coronelis. The Os perietale connects with the occipital bone lOs occipitalel in the Suture lambdoidea and with the Os sphenoidale in the Suture shenoparietalis. The Os sphenoidal& and the temporal bone 10• temporlle) form the Suture sphenosquemosa. Os temporele and Os occipitale connect in the posterior Sutura occipitomastoidea. The
major part of the lateral wall of the skull is formed by the Pars squamosa of the Os temporale. Os temporale and Os zygomaticum form the zygomatic arch (Arcus zygomaticus!, which bridges the Fossa temporalis. The Pars tympanies of the Os temporele is located below the base of the Pro c. zygomaticus and directly adjacent to the Pars squamosa. At its surface lies the Porus acusticus extemus.
'll'ag~~& oc:Yiar
anglaplana
Fig. 8.7 Rlf1trence nnu tor the tHth.
7
Head
Overview
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Skeleton and joints
-+
Muscles
-+
Topography
-+
Skull bones
LtlMitmporalt t~or
Ag. 1.8 Skul bonn, 0... ennil; superior view; colour chart sae inside of the beck: cover of this volume. A view on ltle upper part of the sk:ull (skull cap. Calvarial reveals the Os frontale, 1he Ossa parietalia, and the Os occipitale. Os frontale and Osse parietalie are sepere1ed by the coronal 111ture!Surure c:oronalis). Both Ossa parietalia meet at the saglttalsutur. (Sutura sagittalis). The Os oocipitale connects with the two Ossa parietalia by the lambdoid
ellture (Suture lambdoidea}. The contact point between 1he Suturae coronelis end sagittalis is called Bregma, the contact point of the Suturae sagittalis and lambdoidea is named a..mbda. In the dorsal part of the Ossa parie1alia and bilaterally in close proximity to the Su1Ura sagittalis are the paired Foramina perietalia for the passage of the Vv. emissariae.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Extensive external physical force can lead to skull fractures. Skull fr1cturM are further differentiated into: • linNr fractures presenting with clear fracture linea • eplit skull fractures with multiple bony fragments (impression fracture with inward pointing bony parts which can cause a compression or 1ear of 1he Dura mater as well as an injury to brain 1issuel
8
• dintatic fractures (with fracture lines including sutures and result in a widening of the suture)
• biNIIkul fntdur.e. All fractures associated with an open wound of the skin of the head and fractures involving the paranasal sinuses or the middle ear are considered to be open fractures with a risk of infection. They require a surgical intervention.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Skull bones
Prolllberultla occlpllll.. a:dama
IJMe rnu:hlll1 ~r Inlen
Rg. 8.t Skull bonN. OIM ennil; posterior view; colour chart see inside of the back: cover of this volume. This view from the posterior side shows the Ossa temporalia, parietalia, and the Os occipital e. To both sides of the Os temporale the Proc. mastoideus is visiblE~. At thEI lower medial margin of the Proc. mastoideus lias the Incisura mastoidea; this notch serves as attachment point for the Venter posterior of the M. digastricus. Shown from posterior. both 0... parilrblli• m~;~et in the midline in the Sutura sagittalis. connect posteriorly with the Os occipital& in the Suture lambdoidea, and are separated laterally from the Ossa temporalia by the Suture parietomastoidea.
The 01 occfpltlll• occupies most of the posterior part of the skull. The central structure is the SQuame oocipitelis. Frequently, sutural bones {Ossa suturalia) are found along the Sutura lambdoidea. The Protuberantia occipitalis externa is an easily palpable bony reference point on the Os oocipital~;~. Its most protruding point is th~;~lnion. The Protuberanlia extends bilaterally in an arch-shaped line as Linea nuchalis superior, a bony crest which serves for the attachment of the autochthonous {intrinsic) muscles of the back:. At approximately 2-2.5 em below the Protuberantia occipitalis extern a, the Lineae nuchales inferioras run in a similar arch-shaped fashion, serving as additional attachment sites for muscles.
9
Head
Overview
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Skeleton and joints
-+
Muscles
-+
Topography
-+
Skull bones
0& etflmoldlll, .......:=!!1;!!1!11;.~---
._..,,,. perpendblllrtt
Sulcu• ... U.h/wMI1111 Sulcu. elnu. elgmoklel Fot11rrMn rn.toldlum
Fie. 1.10
Skulllbon.., 0... er11nii, right •ide; medial view; colour chart see inside of the back cover of this volume. The cranial cavity includes the skull cap !Calvarial and the base of the skull which is composed of the anterior. middle. end posterior cranial fossae. The cranial cavity surrounds the brain with its meninges and encloses the proximal portion of the cranial nerves. including the blood
10
vessels end the venous sinuses. On the inside of the cranial cavity. the pulsations of the A. meningea media have carved out Sulci arteriosi. The Lamina perpendicularis of the Os ethmoidale and the Vomer, the bony part of the nasal septum. ere located at the transition region from Neurocranium to Viscerocranium. The Pro c. pali!ltinus of the Maxilla and the Os palatinum fonn the hard palate.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Skull bones
Sutura-1111
Fig. 1.11 Roof of th• •kull. C.lnri•; inner aspect; (:()lour chart see inside of the back: cover of this volume. The inside of the skull cap reveals the Suture coronalis between Os frontale end O~a parietalie and the Suture lambcloidee between Ossa parietalia and Os occipital&. Also visible at the inside of the Os frontal& is the Crista frontalis which serves as an attachment for the Falx cerebri (duplication of the Dura mater (:(lmposed of tough fibrous tissue; separates both cerebral h&mispheres). The Crista frontalis transitions into the Sulcus sinus sagittalis superioris (location of ttle Sinus sagittalis superior) which b9(:(lmes wider and deeper in it8 posterior part. It ex-
tends across ttle Suture lambcloidea onto the Os cx:cipitele. Bilaterally and alongside the entire length of the Sulcus sinus sagittalis superioris, irregularly grouped small depre~ions (Foveolae granulares, location of ttle cauliflower-lik:e Grsnulstiones arschnoideae [PACCHIONIAN granulations) are identified. The lateral part of th& Calvaria contains multiple grooves (Sulci arteriosi et venosil. The bon• of th• C.IYuia possess a special .trudure. They (:(lnsist of a thick out&r and thin inner (:(lmpacta, nam&d Lamina ext&rna and Lamina intema (Lamina vitreal, and a ttlin layer of spongiosa, known as Diploe.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . The Lamina interne of the calvarian bones is thin end can be easily damaged by ~rn•l r-orc.t ttlat result in a bending fracture of
course in the Sulcus arteriae meningeae mediae of the Lamina interne} ere injured. an •pidur•l h•~~m•tom• may occur(-> Fig. 12.11).
the Lamina. If thereby branches of the A. meninges media (Which
11
Head
Overview
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Skeleton and joints
-+
Muscles
-+
Topography
-+
Inner aspect of the base of the skull Fo~WM~~-um
a11taaglllll
Crtltllfdl
Lamina et FoPWY!Ina ortllrHa
Fcn.m.nJ.....
Fol!lrnenrnutoldllum
Foramen megnum (Criabl occil~Miis intemll)
8ulc:UI "fi'UIIIIIIblll e..mrt.
Fig. 8.12 Inner upect of the bue of the skull, Ball crenll lntema: superior view; colour chart see inside of the back cover of 1his volume. The anterior (Fossa cranii anterior). middle (Fossa cranii media), and posterior cranial fossae !Fossa cranii posteriori form 1he inner base of 1he skull. Ossa frontale, ethmoidalia. and sphenoidale participate in the structure of the entlrfor cnnfel foue. The latter is located above the nasal cavity and orbit and contains the Foramen caecum, 1he Crista galli (attachment point for the Falx cerebri}, and 1he bilateral Lamina crib rosa. Posterior to the Os frontela end Ossa ethmoidelia, the Corpus and the Alae minores of the Os sphenoidale form the base of the anterior cranial fossa. The Corpus also forms the border to the middle era· niel fossa.
12
The mlddll ctenllll fossa is composed of the Ossa sphenoidale and temporalia. Its floor is elevated in the midline, and at this point it becomes part of the Corpus of the Os sphenoidale. The pit~neped leteral portions are parts of the Ala major of the Os sphenoidal& and the Pars squamosa of the Os tamporale. Located in the middle cranial fossa are the saddiHhaped Sella turcica with the Fossa hypophysialiB. and on both sidas the Cenelis opticus, 1ha Fissure otbitelis superior. end the Foramina rotundum, ovale, spinosum, and lacerum. The Facies anterior partis petrosae demarcates the posterior aspect of the middle cranial f0$$8.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Inner aspect of the base of the skull
1'-.cranll media
Rg. 8.13 Inner aspect of the INIM of the skull, Bnh cranll Interne: superior view. Of the three cranial fossae. the polterior e111nilll fveta is the biggest. It is composed of the Ossa temporalia, the Os occipital&, and, to a smaller extent, of the Os sphenoidal& and the Ossa parietalia. In the midline. its anterior margin is formed by the Dorsum sellae and the Clivus. The Clivus is an oblique bony rim. which creates a slope from the Dorsum sellae to the Foramen magnum. The Clivus is composed of parts of the Corpus of the Os sphenoidal& and the Pars basi-
laris of the Os occipitale. The posterior aspect of the posterior cranial fossa consists mainly of the Sulcus sinus transversi. The Foramen m.r gnum is the largest opening of the posterior cranial fossa. Additional structures of the posterior cranial fossa include the Canalis nervi hypoglossi, the Porus acusticus internus, and the Foramen jugula· re. The Sulcus sinus sigmoidei approaches the Foramen jugulare from lateral. The central depression in the posterior cranial fossa is the Fosse cerebelleris.
13
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Outer aspect of the base of the skull
0. Pllllltlnum, Lamlnal1ort!ontalle Foramen palahm nw,Jua
Fon~men juaulln~
F~ mutoldeum
Fig. 8.14 Outeuepect oftheba.. of the ekull. B111iecranii externe; inferior view. The cranial base extends to the middle incisors in the front, bilaterally to the Proc. mastoidei and 1he Arcus zvgomatici. and to the Lineae nuchales superiores in the back. The cranial base divides into three compartments: • anterior compartment with upper teeth and hard palate • middle compartment posterior to the palate up to the anterior margin of the Foramen magnum • posterior companment from the anterior margin of the Foramen magnum to the Lineae nuchalas superiores Anterior cnnlal base: encompasses lt1e palate {... Fig. 8.26). Middle cranial base: the anterior part of this middle compartment is
14
composed of the Vomer and 111e Os sphenoidale; the Ossa temporalia and the Os occipital& form the posterior part. The Vomer is located in the frontal part of the midline, rides on the Os sphenoidale, and constitutes the posterior part of the nasal septum. The Os sphenoidale is composed of a central Corpus and the paired Alae majores and Alae minores (not visible from below). Following directly behind the Corpus of the Os sphenoidale is 111e Pars basilaris of the Os occipitale, which represents th& beginning of the posterior cranial .base. The Pars basilaris extends up to the Foramen magnum. Here, ttle Tuberculum pharyngeum protrudes. It constitutes the bony attachment point for parts of the Pharynx. {continuation- Fig. 8.15)
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Outer aspect of the base of the skull
F~an~;--~~~~~~~~~~~
Fl-ra lflMnopeiRlM
IMIIUra rnaeteldea
Fi1. 8.15 Outer aapect of 1he b8ee of the akull. a..i, cflnii extern-.: inferior view. Middle cr~~nlll base !continuation of-+ Fig. 8.141: The Sulcus tubae auciitivae is positioned at the border between The Ala major of the Os sphenoidal& and the Pars petrosa of the Os temporal& and represents the entrance into the bony part of the Tuba auditiva 1-+ p. 1451. The bony canal continues through the Pars petrosa of the Os temporals to the tympanic cavity. Located laterally is tha Pars squamose of the Os temp orale which is involved in the formation of the temporomandibular joint {Articulatio temporomandibularis). The Fossa mandibularis is part of the articular surface of the temporomandibular joint 1-+ pp. 3~9).
The Tuberculum erticulare is located at the anterior margin of the Fossa mandibularis. Posterior cranial baM: The posterior compartment extends from the anterior margin of 1he Foramen magnum to the Lineae nuchalas supe· riores and consists of parts of 1he Os occipital& and Ossa temporelie. Each of the paired Pars lateralis possesses a Condylus occipitalis for the articulation with the Atlas. Located behind the condyle is the Fossa c:ondylaris. which contains the canalis condylaris; anterior to the condyle the Canalis nervi hypoglossi is situated. Immediately lateral thereof lies the Foremen jugulars.
15
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Foramina of the outer base of the skull Foaaa inci&MI; FC~n~J"Mn inciaivum
Foramina af tha Outar Blu af tha Slwll and 111* Content F0111man pelatfnum mal..
Foramina
Contlnt
Foramen lnclllwm
• N. nasopelatinus (N. maxillaris IV/211
Foramen palatinum
• N. peletinus major (N. maxillerisiV/211 • A. palatine major (A. palatine desoendensl
mafUs Foramina palatina minora
• Nn. pelatini minores (N. maxillaris IV/211 • Aa. pelatinae minores lA. palatine descendens)
Fissura orbltalls inferior
• A. infraorbitalis lA. maxillaris) • V. ophthalmice inferior • N. infraorbitalis IN. maxillaris IVJ21l • N. zygomaticus IN. maxillaris IV/211
~~~--~~~~
Foramen rotundum (•p.12)
• N. maxillaris [V/21
Foramen ovale
• N. mandibularis IV/31 • Plexus venosus foraminis ovalis
Foramen apinoaum
• R. meningeus (N. manciibularis IV/311 • A. meningea media (A. maxillaris)
Fillura tphenopMrosa. Foramen llceNm
• N. petrosus minor IN. glossopharyngeus [IXJ) • N. petrosus major IN. facialis lVII)) • N. petrosus profundus (Plexus caroticus internus)
Apertura extlt'na canalis carotlcl and C.nal• c.rotk:u.
• A. carotis intema, Pars petrosa • Plexus venosus caroticus intemus • Plexus caroticus internus [Truncus sympe1hicus. Ganglion cervicele superiusl
Foramen .tylomastoideum
• N. facialis lVIII
Foramen jueulera
anterior pert: • Sinus petrosus inferior • N. glossopharyngeus [IXJ posterior pan: • A. meningee posterior (A. pharyngea ascendens) • Sinus sigmoideus (Bulbus superior venae jugularis) • N. vagus lXI • R. meningeus (N. vagus lXII • N. accessorius lXII
C.nallculua maatoldeua
• R. auricularis nervi vagi (N. vagus [XJ)
C.nal• nervi hypogloll1
• N. hypoglossus lXIII • Plexus venosus canalis nervi hypoglossi
C.nal• conQieria
• V. emissaria condylaris
Foramen magnum
• Meninges • Plexus venosus vertebralis internus (Sinus marginalis) • Aa. vertebrales IAa. subclaviael • A. spinalis anterior (Aa. vertebrales) • Medulla oblongata/Medulla spinalis • Radices spinales (N. accessorius [XI))
eatemus
Fcrlmtn ~-__,t:.~;....=-::n-::i ·~omutoldlll!l
Fig. 8.18 Out• aspect of 1fle bau of tha lkull, B11l1 cranll externL with Fora min~; inferior view; colour chart see inside of the beck cover of this volume.
Clinical Remarks-----------, In bulllr skull fracturas the fracture lines traverse the openings at the base of 1he skull. Thus. blood vessels and nerves passing through these openinl}S cen be injured with resulting nerve palsies and bleedings as frequent complications. In addition, basilar skull fractures can involve the frontal, sphenoidal, and ethmoidal sinuses (cerebrospinal fluid [CSFI encl/or blood exiting through the nose). Lateral basilar skull fractures often involve the petrous bone {CSF exiting from the outer ear canal).
16
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Foramina of the inner base of the skull
Foramina of 'Ill• Inn• Alp.at of th• a... of til• Skull and th•lr Content Foramina
Com.nt
Lllmina cribroM
• Nn. olfactorii [II • A. ethmoidalis anterior (A. ophthalmica)
Canalia opticua
• N. opticus 1111
• A. ophthalmica lA. car01is internal • Meninges; Vaginae nervi optici F"~~eura orbblil sup•rlor
middle pert: • N. nasociliaris IN. ophthalmicus IV/111 • N. oculomotorius [Ill) • N. abducens lVII lateral pert: • N. trochlearis IIVJ mutual origin of: - N. frontalis (N. ophlttalmicus IV/1)) - N. lacrimalia IN. ophthalmicusiV/111 • R. orbitalis lA. meningea medial • V. ophthalmica superior
Foramlft rotundum
• N. maxillaris IV/21
Foram• oval•
• N. mandibularis IV/31 • Plexus venosus foreminis ovelis
Foram• splnosum
• R. meningeus IN. mandibularis IV/311 • A. meninges media lA. maxillarisl
Fllaura tphanopetroaa. Foram•n lacarum
• N. petrosus minor (N. glossopharyngeus (IXJ) • N. petrosus major(N. facialis (VII)) • N. petrosus profundus (Plexus caroticus intemusl
Apartura lnt.rna cenalil cerotic:i and Canalis carotlcus
• A. carotis interne. Pars petrosa • Plexus venosus cer01icus internus • Plexus caroticus intemus (Truncus sympethicus. Ganglion cervicale superius)
Porua and Maatua acudcua int.mua
• • • •
Foram• Jugulare
anterior part: • Sinus petrosus inferior • N. glossopharyngeus IIXJ posterior part: • A. meningea posterior lA. pharyngea ascendensl • Sinus sigmoideus (Bulbus superior venae jugularisl • N. vagus lXI • N. accessorius lXII • R. meningeus (N. vagus [X))
Canallsnarvl
N. facialis lVIII N. vestibulocochlearis (VIII) A. labyrinthi (A. basilarisl Vv. labyrinthi
hypogiOMi
• N. hypoglossus lXIII • Plexus venosus canalis nervi nypoglossi
Canalis condylarls
• V. emissaria condylaris
Foram• magnum
• Meninges • Plexus venosus vertebralis intemus (Sinus marvinalisl • Aa. vertebrales IAe. subclaviae) • A. spinalis anterior IAe. vertebralesl • Medulla oblongate/Medulla spinalis • Radices spinales IN. accessorius lXIII
Fig. 8.17 Inner upect of1he bin of the skull, Ball cranll externe. with Foramina; superior view; colour chart see inside of the beck cover of this volume.
17
Head
Overview
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Skeleton and joints
-+
Muscles
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Topography
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Development of the skull
Fig. 8.18 •nd Fig. 8.11 Skull, Cnnlum, of • newborn; frontal (• Fig. 8.18) and lateral (• Fig. 8.19) views; colour chart see inside of the back cover of this volume. At bir1tl, the newborn has six fontanelles, two unpaired !Fonticuli ant~ rior and pom!rior) and two paired (Fonticuli sphenoidales and masto· idei). During delivery, sutures and fontanelles serve as reference sti'\ICtures to assess the location and position of the foetal head. Shortly
18
before birth, the Fontirulus posterior becomes the leading part of the head in the case of a normal C4!Phalic presentation. In concert with the sutures (Suturae). the fontanelles allow a limited deformation of the foetal skull during delivery. The remarlcable postnatal growth results in the fontanelles becoming rapidly smaller. and complete closure will occur by the end of the third year of life.
Vessels and nerves
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Nose
-+
Mouth and oral cavity
-+
Salivary glands
Development of the skull
Rg. 8.20 Skull, Cnlnlum, of a new.born; superior view; colour chert see inside of 1he back cover of 1his volume. At birth, 1he bony plates of the skull cap (Calvaria) are still separated by the interstitial tissue located in the cranial sutures. The sutures are widened to fon1anelles (Fomiculij in regions where more 1han two bones meat. During life, most sutures. fontanelles (Fonticuli). and
synchondroses ossify. Important sutures include 1he Suturae lembdoi· dee (lambdoicl.uture), frontalis (frontal auture), sagittalis l•eittal suture), and coronalis (coronll suture) which gradually fuse up to about 50 years of age (the frontal suture already between the first and second year of life).
Fontanel!• Fontanelle
Number
Closure (month of life]
Fonticulus anterior (large fontanelle)
approx. 36
Fonticulus posterior Ismail fontanelle!
approx.3
Fonticulus sphenoidelis !anterior lateral fontanelle)
paired
epprox. 6
Fonticulus mastoideus lpo81erior lateral fontanelle)
paired
approx. 18
19
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Development of the skull
Fig. 8.2t Skull, Cnnlum, of • newborn; posterior inferior view; colour chart see inside of the back cover of this volume. The development of the skull involves a desmal and an enchondral ossification mode (-> tabla). The mesenchyme of the head is the pri-
mordial building material that derives from the prechordal mesoderm, the occipital somitas. and the neural crest. At the time of birth. some cranial bonEIIJ are linked by cartilaginous joints !Articulationes c:artilsgineae; Synchondroses cranii).
Oulflcatlon Mode of the Skull laMS
V'11eer0crenium
Neurocrenium
Desmel
Mandibula except for Proc. condylaris, Maxilla, Os zygomaticum. Oa palatinum, Os nasale, Vomer, Os lecrimale
Lamina medialis of the Proc. pterygoideus of the Os sphenoidale, Pars squamosa of the Os temporale, Squama occipitalis. Os frontale. Os parietale
Chondral
Proc. condylaris of the Mandibula, Os ethmoidale, Concha nasalis inferior
Os sphenoidale except for Lamina medialis of the Proc. pterygoideus. Pars petrosa and Pars tympenica of the Os temporele, Pars lateralis and Pars besilaris of the Os occipitale
MECKEL.. t~~~rllage REICHERrl cutllege
20
Malleus. Incus Proc. styloideus of the Os temporale
Stapes
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Craniostenoses
Figs. 8.221 and b Cranlostenosu; dtlld with SCiphoaphllua.
1201 This clinical picture is the result of a premature closure of the sagittal suture. The skull cap is disproportionally long. a superior view b view from the right side
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A dvsostosis is a deviation from nonnal bony growth. The prem~ ture closure of one or more sutures results in cranio.ynotto.... Premature closure of the Suture sagittalis results in the extension of the skull in the frontal and occipital region. The skull becomes longer and narrower (ec.pllocaphaly). The premature closure of the coronal sutures results in acroc.phaly (also named turrice-
phaly). Asymmetric craniosynostosis fplaglocaphaly) results from unilateral premature occlusion of the Suturae coronalis and lambdoidENI. Microcephaly results from impaired growth of the brain b~ cause the growth of the skull bones adjusts to the size of the brain. Thus, small brain size causes an underdeveloped Neurocranium and mental retardation in children with microcephaly.
21
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Frontal and ethmoidal bones
Mlrgo pftDI•
Facile temporals
Fig. 8.23 Frontal bone, 0. front.le; frontal view; colour chart see inside of the back cover of this volume. Located most anterior in the skull cap, the frontal bone participates in the formation of the walls of the orbital and nasal cavity. The unpaired Os frontale has four part.: • the unpaired Squama frontalis • the paired Partes orbitales and • the unpaired Pars nasalis
Above the upper margin of the orbit (Margo supreorbitelis) the prominent Arcus superciliaris protrudes, a phenotype commonlv more devefoped in men than in women. In the midline between the two Arcus, the bone is flat and creates the Glabella (area between the eyebrows). Frequently, a Foramen supraorbitale, more rarely an Incisura frontalis, is present at the medial margin of the orbit.
La~ua elllmaldalla
Fig. 8.24 Frontal bone, 0. front.l•, .thmoldlll bone, Os llthmDid•l•, and n . .l bonn, Oua nasalla; inferior view; colour chart see inside of the bac~ cover of tnis volume. The Os ethmoidal& and Ossa naselia connect with the Os frontala in a medial anterior and caudal position and form pert of the nasal skeleton. The Sinus frontalis is located within the frontal bone.
22
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Upper jaw and palatine bone
Rg. 8.26 Upper Jaw, Mllldlla, right side; lateral view. The upper jaw c:an be divided into 1he body of maxilla (Corpus maxillae). frontal process (Proc. frontalis, connects with the Os frontale}. zygomatic proc:ess (Proc. zygomaticus. connects with the zygomatic bone), palatine process (Pro c. palatinus, anterior part of the pallrte, ~ Fig. 8.26!, and alveolar prooess (Proc. alveolaris). The latter creates the lower mar-
Foramen lnoii!Wm
Fig. 8.28 Upper jaw, MaxiIlL and pellltine bone. Os pelatinum, right tide; medial view into the Sinus maxillaris; colour chart see inside of the back: cover of this volume. Posterior to the Maxilla lies the palatine bone which is composed of
gin of the Maxilla and is composed of the dental alveoli (Alveoli denta· lesl which contain the roots of the teeth. The protrudinGJ anterior rim of these dental sock:ets ere named Juga elveolaria. The Foremen infreorbitale is located in the Corpus maxillae, immediately below the lower orbital margin.
0. JN!IItlnwn, umlna tlortzantalll
two plates: The Lamina horizorrtalis c:reatea the posterior part of the palate (Palatum ossaum). the Lamina perpendicularis extends vertically upright !perpendicular to the horizontal lamina) and is the posterior medial margin of the Sinus maxillaris.
23
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Nasal cavity
Lamina et Foramina all1'088 SqUM'Ia fnlnlallll, FaciM lnlllma
O.naula
Prvc. p141rygolr.ltut, Lamina mldlllll
Fig. 8.2'7 Bony HPtum of the no. ., Septum naei OMeum; lateral view; colour chart see inside of the back cover of this volume. The Lamina perpendicularis of the ethmoidal bone (Os ethmoidale) and the Vomer create the bony septum of the nose. The Os .thmolda.. is located between the Os frontale and Maxilla and is also connected with tl1e Ossa nasalia, lacrimalia, sphenoidale, and palatine. At its top. the ethmoidal bone forms the Crista galli. Perforated with multiple holes. tl1 e Lam ina cri brosa is the roof of tl1 e nasal cavity and part of the floor of the anterior cranial fossa. The Lamina perpendicularis of the Os eth·
moidale is located below the Crista gelli, divides the bony labyrinth of the ethmoidal bone into a right and left part, and constitutes the upper part of the bony nasal septum. The Vomer forms the largest part of the bony nasal septal skeleton. This flat and trapezoid bone connects cranially with the Lamina perpendicularis of the Os eth moidale and at its posterior aspect via 1t1e Ala vomeris with the Os sphenoidal&. Caudally, its Pars cuneiformis vomeris borders at the Proc. palatinus of the Maxilla and at the Lamina horizonta lis of the 0 s pa latinu m.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Traumatic events (punched nose or falls onto the nose) or abnormal growth of the Maxilla can cause a . .ptum devl.tlon. More than 60% of the population has at least a mild septum deviation. Septum deviations mainly impair breathiniJ through the nose. This can effect the ability of the nose to warm up, clean, and moisturise the air passing through the nose. In turn, patients with impaired nasal
24
breathing are forced to breathe tl1rough their mouth, which results in snoring and an increased susceptibility for infections. Insufficient ventilation of the para nasal sinuses may cause sinusitis with postnasal drip and potential inflammation of the Larynx and the bronchial tree. At an advanced age, this can lead to hypoxia end subsequently results in cardiovascular diseases.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Nasal cavity
Lamina et Fo111mlna
cri~ ~/
Conall•n•III81UI*for
..
-.N:
'
0. Pllllltlnum, Llunlllll hodlonta..
Fig. 8.28 Lat.l'lll wall of tM nasal cav1ty, Ca'VItas natll; right side; view from the left side; colour chart see inside of the back cover of this voluma. The view onto the lateral wall of the nasal cavity reveals the roof created by the Lamina cribrosa of the ethmoidal bone !Os ethmoidalel
which also fonns the upper !Concha nasalis superior) and middle nasal conchae !Concha nasalis media). The upper nasal passage (Meatus nasalis superior) is located betwean the two nasal conchae. Below sits the inferior nasal concha (Concha nasalis inferior) as a separate bone.
Fig. 8.29 bterlll w•ll of 1fle n...l cavity, Ca'VitM nllti; right side; medial view after the middle nasal concha was removed; colour chart see inside of the back cover of this volume. Baneeth th& middle nasal concha. &thin bony lamella. tha Proe. unci· n8tus, is part of the ethmoidal bone. It provides only an incomplete closure of the medial wall of the maxillary sinus. Many openings remain above and below the Proc. uncinarus and one of them is 1he Hiatus maxillaris.
The Mtxil.. end the O• p•l.tinum creeta tha floor and parts of tha lateral wall (floor: Lamina horizontalis; lateral wall: Lamina perpendicula· ris}. The Ot lacrimale is also part of the lateral wall and contributes to tha anterior margin of the maxillary sinus. The Concha nasalis inferior is anchored to all of these three bones and divides the nasal wall in a middle (Meatus nasalis medius) and an inferior nasal passage !Meatus nasalis inferior) which era located above end below this nasal concha. respectively.
25
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Hard palate
t~·
~
Fig. 8.30 Hard pal.te, Pal.tum durum; Mail..ry einu.. Sin.maxlllula, and Inferior n~~ul concha, Concha n...lls lnt.lar; superior view; colour chart see inside of the back cover of this volume.
The hard palate represents a horizontal bony plate created by the Maxilla and the Os palatinum. It separates 111e oral front from 111e nasal cavity. The Foramen incisivum is a connection between both cavities. The present image shows the floor of the nasal cavity. Located laterally are the Sinus maxillares.
L.amlllll mod. . PIIX- pWryggicleu8
{
Lamina lldelllla
Fig. 1.31 Hard pal.te, Palmlm durum; inferior view; colour chart see inside of the back cover of this volume. The hard palate is pert of the anterior cranial to.... The teeth ere at· teched to the two maxillary alveolar arches. These arches are the anterior and lateral margins of the hard palate. Its rostral part consists of the Procc. palatini of the two Maxillae and the Laminae horizontales of the Ossa palatine in its posterior aspect. In the midline. the Pracc. palatlnl are connected by the Suture pelatina mediana and dorsally they con· nect vie the Sut1.1ra palatine transversa with the Ossa palatine. The Lamin~e horizom.l• of the Ossa palatine are connected in 111e mid-
26
line by the Sl.ltura interpalatina (a contin1.1ation of the Suture palatine medianaJ. Located bahind the incisures in tha frontal pert of the midline is the Foaa incieiva which becomes the Foremen incisivum end the Canales incisivi. Near the posterior margin to both sides of the hard palate are the Fon~mlna palatine maJora, which become Canales palatini majores, and the For11mlna palatine mlnDn. The latter are located in the Proc. pyramidalis of the Os pelatinum and open into the Canai&S palatini minores. In the posterior aspect of the midline, the Spina neulie poetarior protrudes as a pointed process of the herd palate.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Orbit and pterygopalatine fossa
r ~' ~LQ tJ· Q
0& paJatinum, PIOC. Ottlilala
~ ·1
,,,
,·· .'
SU!In. zygcml1fcamaxllllll18
0. Q11Dmll1k:um
Fi1. 8.32 Floor of the orbital cavity, Pari" inferior Olrbitae, left slda; superior view; colour chart see inside of the .bacl: cover of this volume. The floor of the orbit is the roof of the maxillary sinus. In it lies the Sulcus infraorbitalis, which beoomas a bony canal .below the floor of the orbit and ends in the Foramen infraorbital&. It contains the N. infraorbi-
talis and the corresponding blood vessels. The Os zygomaticum forms the lateral part of the floor of the orbit and the medial part is composed of the Lamina orbitalis of the Os ethmoidal& and the Os lacrimale. Together with the Maxilla, the latter creates the Fosse sacci lacrimalis containing the Glandula lacrimalis. For the orbital cavity ~ Figs. 9.9 to 9.13.
Rg. 8.33 PtWfiOpalltlne tOSM, Foua pterygopalatlna,lllft tide; lateral view; colour chart see inside of the back. cover of this volume. The Fossa pterygopalatine is the medial continuation of the Fossa infratemporalis. Its bony margins are the Maxilla, the Os palatinum, and the Os sphenoidale. This fossa is an important telals stdon connecting the middle cranial fossa, the orbit. and the nasal cavity. It
serves as a conduit for many nerves and blood vessels locatad in these structures c~ pp. 78 and 79). The latenll acceA routa to tha pf;aryfOpallrtina fotM is a common surgical strategy for the rasection of tumours in this region, such as nasopharyngeal fibroma.
27
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Orbit
For.mlnelllhmaldella .nt.rtu• 81 pc~Wt.r1u•
Alamnor} Ala major, FKI•arblldo
Fig. 8.34 Orbit, Orbit~~, left lide; frontal view; probe in the the Cana lis infraorbitalis; colour chart see inside of the back cover of this volume. The Ossa ethmoidale, lacrimale, palatinum, sphenoidal&, zygomaticum, and the Maxilie create the margins of 1t1e orbital cavity. Passages to and from the orbit are the Fissurae orbitales superior and inferior, the Canalis opticus, and the Foramina athmoidalia anterius and postarius. Lo-
08 8JihiOOidall
cated in the posterior pert of the orbital floor, the Sulcus infruorbitalis becomes the Canalis infraorbitalis which projects towards the front of the orbit and ends as Foramen infraorbitale located below the inferior margin of the orbit. Positioned laterally, the Os zygomaticum regularly contains a Foramen zygomaticofeciale. For the orbital cavity -+ Figs. 9.9 to 9.13.
Cristagali
Oa lllllmalclelll, Lamina oltlll81a
Oa~alhum
Fig. 1.35 Vl-ranlum. Vlac~m~cranlum: frontal HCtlon at the level of the two Orbittle; frontal view; colour chart see inside of the back cover of this volume. The unpaired ethmoidal bona (Os ethmoidale) contains the anterior and posterior ethmoidal cells (Cellulae ethmolclaln). The Lamina perpendicularis of the Os ethmoidale lies immediately beneath the Crista galli, separates the bony labyrinth of the ethmoidal bone into a right and a left half, and participates in the upper part of the bony nasal septum. At
its posterior aspect it is followed by the Vomer. The lateral walls of the Cellulae ethmoidales consist of a thin Lamina orbitali.. known as Lamina papyrec.a, constituting the major part of the medial wall of the orbit. The Sinus maxillaris is located directly below the orbit. The Canalis infraorbitalis is located in its roof, which also constitutes the floor of the orbit. The Lamina cribrosa positions clearly below the roof of the orbit. For the orbital cavity -+ Figs. 9.9 to 9.13.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , The paper-thin Lamina orbitalis (papyracea) of the Os ethmoidale between the orbit and the ethmoidal sinuses represents no barrier to the spreading of an Inflammation from tha Mllmoldal cells into the orbit which can escalate into an orbital phlegmon. Figure 8.35
28
demonstrates the close proximity between a roots of a molar tooth and the Sinus maxillaris. Inflammations of the second premolars and/or the first molars can lead to an odontogenic inflammation of the Sinus maxillaris (maxillary sinusitis).
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Orbit Squama frantalt, Faci118lntema
Rg. 8.38 The hrteral wall of 1he orbit, Parfu le1eralls orblta•, right side; medial view; colour chart see inside of the back oover of this volum~;~. The Ossa zygomaticum, frontal e. sphenoidal&. and the Maxilla form the lateral wall of the orbit. The Canalis infraorbitalis is depicted clearly in the anterior third of the orbital floor, as is the very thin bony layer sepa-
rating the orbit from the Sinus maxillaris. The Fossa pterygopalatina is located posteriorly to the Sinus maxillaris and connects laterally to the Fossa infratemporalis, cranially to tha orbit, end in its inferior aspect connects to the oral cavity via the Canalis palatinus major. From a posterior cranial position, the Canalis pterygoideus exits into the Fossa pte· rygopalatina.
FotM ptefygopalaUna .,.,.....'-- - -
O.~klllle,Co!JM
Maxi Ia, Proe. zygoma1fcu.
Fig. 8.37 The medial wall of Ute orbit. Pariee medialiiJ orbiUe, left 1ide; lateral view; colour chert see inside of the back cover of this volume. ThEI Os lacrimate, the Maxilla, and the Os frontale form the anterior part of the medial wall of the orbit. whereas in the posterior pert the Lamina orbitalis of the Os ethmoidale (lamina papyracea). the Proc. orbitalis of the Os palatinum, and the Os sphenoidal& are placed between the Os
frontale and thEI Maxilla. Both. the Crista lacrimelis anterior of the Me· xilla and the Crista lac:rimalis posterior of the Os lacrimate provide the margins for a depression !Fossa sacci lacrimalisl of the lacrimal sac. Located in the medial wall of the orbit are the Foramina ethmoidalia anterius and posterius and the Canalis ol)ticus. The Foramen sphenope· latinum is located at the top of the Fossa pterygopalatina.
29
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Sphenoidal bone
FoNIMII nrtwldum
Fig. 8.38 Sphenoidal bona, Os sphanoldala; frontal view. The unpaired Os sphenoidale connects the visrerocranium with the neurocranium. Two pairs of wing-shaped bones !Aiael extend from the body (Corpus) of the sphenoidal bone. The Alae minor• sit on the top,
Suk:uo caratlcua
the Alae mlljDrH at the bottom, and below the Procc. ptlrvtoldal project. The oantre of the sphenoidal bone contains the Sinus spha· noidaiN. The Crista sphenoidalis subdivides the anterior part of the Corpus into two halves.
Dan~~~mNIIM
Farwnen ratundum
Fig. 8.31 Sphenoidal bona, Os sphanoldala; posterior view. Ala minor and Ala major of the Os sphenoidale participate in the forma· tion of the F"IMUra orbitalis superior. On both sides, the Proc. pterygoideus divides into a smaller Lamina medialis and a larger Lamina late·
30
ralis, which create the lnclsui'II(Fissul'lll pterygoldH and enclose the Fossa pterygoidea. The Hamulu• pterygoideu• is the caudal extension of the Lamina medialis. At its base, the Canalis pterygoideus perforates the Os spheno idaIa and enters into the Fossa pterygopelati na.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Sphenoidal bone and occipital bone
{PI1)C. clnak!Ma mad f..)
lndeul'll)ug!AIIIIe Ploc';, '-'11U111118 - - -
S!Mua 11nua 1lgmofdll
Fig. 8.~ Sphenoidal bone, Os sphenoldtle, 1nd ocdpltll bone,
0. occipitale; superior view; colour chart see inside of the back oover of this volume. The centre of the Os sphenofdd• is composed of the 81111 turcica with the Fossa hypophysialis. The Tuberculum sellae creates the anterior rim of the Fossa hypophysialis and extends laterally into the Proc. clinoideus medius. The Sulcus prechiasmaticus and the Jugum sphenoidale ere located in front of the Tuberculum sellae. The Clivus forms the posterior part of the saddiHhaped Sella turcica and the Proc. clin~ ideus posterior represents the lateral elevated end of its upper rim. In the region of the Sella turcica and at its anterior rim, the Canalis opticus petforetes the Ala minor. The Foramina rotundum. ovale. end spinosum
pierce the Ala major bilaterally in an anterior cranial to posterior caudal direction. The unpaired Oe ~ltll• is composed of the Squama occipitalis, two Partes laterales. and one Pars basilaris. These four parts delimit the Fon1m1n m1gnum. At the inner surface of the Squama occipitalis. the Sulcus sinus sagittalis superioris end the Sulci of the Sinus transversi meet at the Protuberantia occipitalis interns. Further, the Sulcus sinus sigmoidei and the Sulcus sinus occipitalis are visible at the inner sur· face. Above and below the Protuberantia occipitalis. the inner surface of the Squama occipitalis forms the Fossa cerebralis and the Fossa cerebellaris, respec1ively. Together with the Corpus of the Os sphenoid&Ia, the Pars basilaris of the Os occipitele generates the Cliws.
31
Head
Overview
-+
Skeleton and joints
-+
Muskles
-+
Topography -+
Temporal bone
Pllra aqua,_., Facie. temparalla
Fig. 1.41 Temporal bone, 0. temparale, right .;de: latel"lll view. The paired Os temporals is part of the viscerocranium and neurocranium. It participates in the formation of the lateral side and t/1 e base of the cranium. The Pars squamosa, the Pars tympanica, and the Pars petrosa {petrous bone) can be distinguished. Through its Margo parietalis, the squama-shaped Pars squam- connects with the Os pariatale. The Proc. zygomaticus protrudes anterior and s~o~perior of the Meat~o~s and extends in en anterior direction. The Para patroea borders at the Ossa parietal a and occipitale. The central outer opening is the Meatus acusticus exte rnus. Located at its pos-
terior caudal aspect is the Proc. mastoideus. Middle and inner Bflr are located within the Pars petrosa (not visible). Access routes are the internal acoustic meatus (Meatus acusticus internus.... p. 17), the Foramen stylomastoideum (-+ p. 161 and the Canalis musculotubarius 1- Figs. 10.30 and 10.37). The Pars tympanlca forms the bony wall of the external acoustic meatus. As a ring-shaped structure, it is associated with the Partes squamosa and petrosa. The Pars tympanica delimits ti'le Meatus ecusticus extern us at its frontal, caudal, and posterior side and extends to th a tympanic membrane (-o Figs. 10.16 and 10.26).
Para
Fig. 1.42 Temporal bane, Os temparale, af a nawbam, light side; lateral view; schematic drawing; colour chart see inside of the back cover of this volume.
32
The image displays different parts of the temporal bone: Pars squamosa, Pars petrosa, and Pars tympanica.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Temporal bone
Sulcuo artert.....
Foram1n msstoldeum
MaJogo sphenoidalill
Fig. 11.43 Temporal bone. 0. tllmponle. right lide; inner aspect. The Pars petrosa is shaped like a pyramid with its tip {Apex partis petrosae) directed anterior medial and its base pointing towards the Proc. mastoideus. The Facies anterior is part of the middle cranial fossa and contains the protruding Eminentia arcuata; contained within the Facies posterior is the Porus acustlcus lmrnus which constitutes the en-
trance to the Meatus acusticus internus. The posterior surface of the Pars petrosa shows the indentation by the Sulcus sinus sigmoidei. The Fo,..men mmoideum is located here as well. On the inner surface (Facies cerebral is) of the Pars squamosa the Sulcus arteriosi of the A. meningea media are visible.
Calllllle muacul~ua Margo .,:>h011>01dah
Fig. 11.44 Temporal bone, Os t.mporale, right side; inferior view. The Facies inferior of the Os temporale depresses to become the Fos.. jugularil and, together with the Os occipitale, delineates the Foremen jugulare. The notch attha border between the Pars squamosa and Pars petrosa indicates the starting point of tne Canalis musculotubari-
us. In addition, the Aperture extema canalis carotici and the Proc. styloideus are visible. The Foramen .tyloma.toideum opens to the lateral posterior side. Just in front of the external acoustic meatus, the Pars squamosa contains the Foaa m•ndibul•ri• which, at its rostral aspect, is demarcated by the Tuberculum articulare.
33
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Lower jaw
Fig. 8.45 Lower jaw, Mancfibula; frontal view. The unpaired Mandibula consists of a body of the mandible {Corpus mandibulael and two rami {Rami mandibulae). Each ramus divides into a Proe. coronoideua and a Proc. condylaria. The body of the mandible is compos !XI of the b&se and the Pars alveolaris separated by the Linea
oblique which descends from the Proc. coronoideus in an oblique anterior trajectory. The frontal part of the Pars alveolaris consists of the chin {Mentum} wi!tt the Protuberantia mentalis. the bilateral mental tubercles {Tubercula mentalis) and ltle Foramina mentelia.
Proo.~
Fig. 8.48 Lower Jaw, Mendlbula; lateral view. Corpus mandibulae and Ramus mandibulae merge at ltle Angulus.
Fcllllll-lngualla -
The Caput m1ndlbula• sits on top of the Proc. condylaris.
--J!;,a;..
Spina manta!It
{Tana mandlbullull}
Fig. 8A7 Lower Jaw, Mandlbula; inner aspect of the mandibular arch. The Foremen m•nd•u••• is located at the inside of the Ramus men-
34
dibulae. In front thereof, the UnN mylohyaldN creates a stepwise crest, which serves as an attachment for the M. mvtohyoideus and demarcates the level of the floor of the mouth.
Vessels and nerves -+ Nose -+ Mouth and oral cavity -+ Salivary glands
Lower jaw ----Pnlc. condylub
- -t--c.put muJdii!Ua
(Syn't)hy&la mandb"Ml -------::!~~
Spina mentalis -----~~~~'J......:~~'------ F-dlgulrtca
Fig. 8.48 Lower jlw. Mendlnala: inferior view. The Spina mentalis is located at the inside of the Mandibule close to the midline. Bony depressions represent the Fossa digastrica below and
lateral to the Spina mentalis and the Fovee sublingualis and Fovea submendibuleris above the Spine mentalis. On the inside of the Angulus mandibulae the T~o~berot"- ,WrygoidN is found.
Dena deciduua
Fig. 8.48 Lower J-w, Mandllul-. of an old piiTSOn. l.Dss of teeth- particularly at an advanced age- results in a regrHSion of the Pal'8 alvaalarl8 of the Mandibula. This can progress until the Foramen mentale becomes located at the upper rim of the toothless lower jew. The Anguilla mandibulae has a much widar engle than in a
Fig. 8.&0 Low.r Jaw, Mandlbula, Df a nawborn. In a newborn, the Symphysis mandlbulae connects the two mandibular segments. The angle between the Corpus and Ramus mandibulae is stiII very Iarge.
mandible with dentition.
Clinical Ram a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Apart from nasal fractures, fractures of the Mandibula are common due to its exposed location in 1tle head region. The U-shaped structure explains the various types of mandibular fractures, in particular at the IeveI of the C6 nines and the third molar teeth. Extravasated blood from the Mandibula collects in the loose tissue of the floor of the mouth, results in small spotted bleeding under the
skin {ek.chymoses). and is a typical sign of a mandibular fracture. Without proper prosthetic reconstruction, a lass af ttl.th results in the regression of the Pars alveolaris mandibulae in the aree of the lost teeth. The fitting of a dental prosthesis onto a largely regressed Pars alveolaris is exceedingly difficuIt and often requires bone reconstruction.
35
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Temporomandibular joint
Artlcui.UO tem.,_nendlbulerle,
---=--...-;i!~fo:
Llg.lmn~l•
Proc. condylarla
Arq.iua mandlbulu; {Tuboraaltu m-.tcaj
Fig. 8.51 T•mparom•ndlbular Joint. Artlculnlo temporom•nclbul•rls, right sld•; lateral view. A wide cone-shaped joint capsule (Capsula articularis) stretching from tt1e temporal bone to the Proc. condylaris surrounds the mandibular joint. In its frontal and lateral parts, the Lig. laterale reinforces the joint capsule and extends from the zygomatic arch in an oblique posterior caudlal direction to the Collum mandibulae. At tt1e inside of the joint (not shown), connective tissue generates the variable Lig. mediale. The
Ugg. laterals and mediale (if present) assist in guiding the joint movements and foremost inhibit posterior movements of the mandibular head. When bite force is applied, the Lig. laterale also stabilises the Condylus. The Ug. ftylom•ndibulue projects from the Proc. styloidaus to the posterior rim of the Ramus mandibulae. It is usually weak and, together with the Lig. ephenomendibul.lre, resists further lower jaw movements at a position close to maximal opening of the mouth 1- Fig. B.52).
Shuaaphai'IOidalla
~~-
pterygll8plnele
.-::tr-- C:.Wila I'IIIM hypogloal
Fig. 8.&2 Llg.stylam•ndlbul•r. •nd Llg.sph•nom•ndlbul.lr., right lid•; medial view. Bott1 Iigaments affect the kinematics of the tern porom andibular joint but are not associated with the joint capsule. The strong Lig. ephenamandibu..,. has its origin at the Spina ossis sphenoidalis and passes between the Mm. pterygoidal lateralis and medialis and inserts in a fan-shaped pattern at the Lingula mandibulae. The
36
Ug.stylam•ndlbuler• originates from the Proc. styloideus and projects to the Angulus mandibulae. Together, bath ligaments inhibit lower jaw movements at a position close to the maximal opening af the mouth. The Ug. pterygospinale has no relationship to the temporomandibular joint nor does it affect the joint kinematics. It has its origin at the Spina ossis sphenoidal is and inserts at the Lamina lateralis of the Proc. pterygoideus. This ligament has a l'lllbnlslng function.
Vessels and nerves -+ Nose -+ Mouth and oral cavity -+ Salivary glands
Temporomandibular joint
-
Fig. 8.&3 T•mporom•ndlbul•r )oint. Artlcul..lo umporom•ndlbularls, WI: sld•; sagittal section; lateral view; mouth almost closed. In the temporomandibular joint, 111e Caput mandibulae, Fossa mandibularis, and Tuberculum articulare of the temporal bone articulate with each other. Both joint components are separated by a disc (Discus artiCI.IIaris). The temporomandibular joint is positioned in front of the bony part of the external acoustic meatus (Porus acusticus extern us).
Fig. 8.&4 Temporom•ndlbul•r Joint. Artlcula1lo temporom•ndlbul•rls,l.n sla; sagittal section; lateral view; mouth opened. 181 A Discus articularis completely divides 111e temporomandibular joint intc two separate chambers ld'"lth•l•mic joint): • The lower chamber permits hinge-like opening end closure movements of 111e Mandibula. • The upper chamber allows for the Caput mandibulae to slide forward on the T1.1berculum articulare (protrusion). This particularly requires the action of theM. pterygoideus lateralis. The movement back into the Fossa mandibularis is called retraction (r.tnRion).
Fig. 8.55 Monm...ts ol th• temporom•ndlbul•r )oint. Artlcula1lo temporom•ndlbularls, l.tt sld•; lateral view. 181 Independent movements in one temporomandibular joint are not possible because both temporomandibular joints are joined in the bony mandibular arch. The temporomandibular joints permit two main functions during chewing: elevation l•dductionl and depression (ebduction) of
111e lower jaw as well as grinding movements. Apart from abduction and adduction, the forward (protrusion! and backward movement lr• truslonl as well as grinding (sideways sliding -lmrotrullon and m• diotrueion) constitute the movement patterns of the temporomandibular joint. The masticatory muscles contribute in different ways to the mobility of the joint.
37
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Temporomandibular joint
1\arculum ltllcu....
~~~~F7·
- .;...,._.- Fildes altlcul.... R~~~p~~ R~~ pe1rolqllllll088
F:~lf::i- Fluura potrulyn"fllrolca*
Fluura tympwooequamoea
Fig. 8.&6 foSSil and tubercle of th• temporomandlbul•r Joint, Artlcul.tlo temparamanllbularls, right lid•; inferior view. View onto the Facies articularis of the Fossa mandibularis, which is normally covered with hyaline articular cartilage. Also covered by hyaline cartilage, the Tuberculum articular& is located anterior to the Fossa mandibularis. In the posterior third of the Fossa mandibularis. the Pars squamosa connects with the Pars petrosa of the Os temporale, and medially the Os temporale borders at the Os sphenoidale. As a result. this region contains 111r• fleeu.-..: • In a lateral position the Fissura tympanosquamoae is visible. • In the middle lies the Fissura petrotympanica (" GLASEAIAN fissure). • Medially runs the Fissura sphenopetrosa through which the Chorda tympani leaves the cranial basis.
Fig. 8.&7 Articular PfOCHI, Proc. candylarls, of the lower Jaw, right sld•; frontal view. The Proc. condy1aris is composed of a Caput and Collum mandibulae. At the frontal side, it contains the Fovea pterygoidea. Here, the M. pterygoideua lateralia attaches with its Caput inferius.
Madia!
Fossil mlnllbu..rt. I.Jdallll
Tuberculum
Top
art!~ D~a
ardculutl
Figs. 8.ila and b Articular disc, Discus ar11cularls, of th• temparomandlbular Joint, Artlcullltlo temporom•ndlbularfs. • superior view b lateral view From front to back:, the Discus articularis consists of an anterior ligament (connective tissue), an intermediate zone (fibrous cartilage(, a posterior ligament (connective tissue), and a bilaminar zone (connective tissue). In its lateral part. the intermediate zone is particularly thin.
Fig. 8.&1 Temporomandibular Joint. Articulatio temporom•n· dlbulalls; sagittal section at the level of the temporomandibular joint region with injected veins (coloured); lateral view. 111 The bilaminar zone between the Tuberculum articulare and Caput mandibulae is visible. The bony sept um between the middle cranial fossa and the Fossa mandibularis is thin. Among the connective tissue of the bilaminar zone lies an extensive ratro--artlcular venous plaxus. Close proximity exists to the external acoustic meatus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Significant external force can result in the fracture of the Collum mandibulae (condylar fractur•l- An involvement of the joint capsule and the occurence of dislocated bone fragments is possible in such fractures. In addition. bleeding from the retro-erticuler venous plexus (-> Fig. 8.59) and/or painful sensations from the external acoustic meatus may occur.
38
-+ di,.ection link
The temporomandibular joint is a diathrosis. Thus, this joint can be afflected by the same diseases that also affect the large joints of the limbs. e.g. arthrosis or rheumatoid arthritis. In case of an arthr-oeh of the temporomandibular joint. the lateral part of the Discus articularis is mostly affected.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Temporomandibular joint, radiography
POSUII'Ior
t~cllura mandltuJIIa
Fi1. 8.60 T1mporom1ndibuler joint, Articuhrtio temporom•ndiibullril; computed tomorgaphic image in lateral beam projection; mouth closed.
With thEI mouth closEid end masticatory muscles r~;~laxed. the Proc. condylaris resides in the Fossa mandibularis.
Proc. coroncldlu&
Fig. 8.81 T•mporom1ndibul1r joint. Articulatio temporom•ncliibullril; computed tcmorgephic image in lateral baam projection; mouth open.
With the moU1h op~;~n, thEI Discus erocularis and thEI Proc. condylaris move forward onto the Tuberculum articulare.
39
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Facial muscles
M. eplc111111 ... M. ~ntala, v.nllerfronlelit
M. ortllcul.ta ONI, M. zygomatM mm
PalaOitlllalll
M. zygomldM mtCor
M. · p - . . p t l nul
M.dlpn-II'ICIWiorta
Fig. 8.&2 Faclll mlllldH, Mm. faclel, and mu11catory muscles, Mm. mutlcatorll: frontal view. Mimic muscles determine the facial expre~Ssion end create 1he individual appearance of a facial physiognomy of a person. The muscles around the eye have important protective functions, while the muscles in the region of the mou1h serve in food uptake and articulation. Visible on both sides of the face are the Venter frontalis of the M. occipitofrontalis (M. epicraniusl, the Partes orbitalis and palpebralis of the M. orbicularis oculi (Para lacrimalis • Fig. 9.19}. theM. corruga1or supercilii, the M. procerus. the Mm. nasalis, depressor septi nasi, levator labii superioris alae que nasi, the M. orbicularis oris with Pars labialis and Pars marginalia, 1he M. buccinator, the Mm. zygoma1ici major and mi· nor. the Mm. risorius, levator labii superioris, levator anguli oris, depres-
40
-+ dl..tu:tlon link
M. dlprriNof lllblllnfrlr!of11
sor anguli oris, depressor labii inferioris and mentalis as well as the Platysma projecting onto the neck. Of 1he mastice1ory muscles. only the M. masseter on 1he left side of the face is shown. The Ductus parotideus (STENSON's duct) of the Glandula parotidea passes across the M. masseter and bends around its frontal edge in an almoS1 righ1angle to pene1ra1e 1he M. buccinator. A fat pad (Corpus adiposum buccae. BICHAT's fat pad} is located between the M. masseter and the M. buccinator and contributes to the contour of the region of the cheek. With the exception of the M. bucci· nator, the facial muscles do n01 contain a fascia. The fasciae of the M. buccinator, the M. masseter. and the Glandula parotidea have been removed.
I-+T1e,c-f,41
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Facial muscles
M. aplcranh•. M. temporoplldetllll
M.IIMIIIs M.llntor Iaiii--_,..:;.-_..:,. .upertarll a!Mqu.llllll
Fig. 8.83 Facial mUICIH, Mm. fecleL lift aide; lateral view. In addition to the muscles displayed in -tFigure 8.62, thislaterel view also shows the Venter occipitalis of the M. occipitofrontalis {M. epicraniusl with ttle Galea aponeurotica extending .between the Venter fronUIIis end the Venter oocipitelis. Loceted above the ear end also projecting into the Galu 1pon1urotlce is the M. tamporoparietalis (also a part of the M. epicraniusl which originates from the Fascia temporalis. Additi-
onal mimetic muscles are also shown and include the Mm. auriculares anterior, superior. and posterior. In the necl: region, parts of the M. sternocleidomastoideus, the M. trapezius, and some autochthonous muscles of the back are visible. 1-+T 1
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . P1r1lpi1 of th• M. orbicullrit oculi as pert of a paresis of the N. facia lis lVIII (facial palsy) results in the inability to voluntarily close ttle eyelid. causing it to stay open even during sleep (paralytic lagophthllm~. ~Fig. 12.151). Due to lacl: of tension. the lower eyelid becomes flaccid and hangs down (JNII'IIIytlc ectropion). The Canaliculus inferior fails to drain the lacrimal fluid from the eye. Instead, the fluid passes over the everted lower eyelid onto the cheel: (drooping eye, epiphora). The inability to blinl: the eye causes ttle
cornea to dry out end result$ in corneal lesions (•erritil) and an opaque cornea. The decrease in tension in the lower eyelid at an advanced age can lead to the s~>Called "nile .cuopion. Pll'lllytls of 111• M. orbicularis 01111 (also in the context of a facial palsy) results in speech disabilities. The comer of the mouth on the paralysed side hangs down and saliva involuntarily droops from the mouth.
-+ dl..eetlon link
41
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Facial and masticatory muscles
M. tl)lcranl~~t. M. oee_,nofl'ontallt, Vlnter ocdpltlllr.
Glen dull puatldea
M. dlgaall!cus, V.nter anttllor
Fig. 8.84 Faclll mUICIH, Mm. flcl1l, and masticatory muscl11, Mm. muticctorii; lateral view from an oblique angle. The fascia of the M . .buccinator, the M. masseter. the Glandula parotidea as well as part of the superficial fascia of the neck: were removed. A:s a result, the correspondinq muscles, the Glandula parotidea extending to the neck. and the Glandula su.bmandibularis .become visible. The major excretory duct of the Glandula parotidea, the Ductus perotideus !STENSEN's duct), exits the gland at its anterior pole, crosses the M. ma...tlr in a horizontal line from posterior to anterior and, at the anterior margin of theM. massetar, bends inwards in an almost perfect right angle to penetrate theM. buccinator. Between theM. buccinator and M. masseter lies the Corpus adiposum bucc:ae
{BICHAT's fat. pad}. Associated with the Ductus parotideus is acoessory glandular tissue !Glandula parotidee accessoria). In the temporal region. the M. parietoparietalis of the M. epicrenius was removed. This allows a clear view onto the super1icial lamina !Lamina superficialisl of the Fascia temporalis. Above the zygomatic arch !Arcus zygomaticus} parts of the Lamina superficialis and the temporal fat pad underneath (Corpus adiposum temporalisl were removed to permit a clear view onto the deep lamina {lamina profunda) of the Fascia temp ora lis with the M. temporalis shining through.
I-+T1,41
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Swilling af Ute Gllndula paratldea (e.g. in the case of an epidemic parotitis [mumps]. ~ p. 90} can cause severe pain sens9tions because of the close proximity of the parotid gland to the masticatory muscles and the fact that the parotid gland and M. masseter share a mutual fascia (Fascia parotideomasseterical. Often. the pain also involves the external acoustic meatus and is aggravated by palpating
42
~ dl..tu:tlon link
the tragus or the auricle !tragus pain). Patients with a malignant tumour disease (tumour Cflehexi•) or suffering from advanced stages of HIV infection are often emaciated. The BICHAT's fat pad which models the typical contour of the cheeks is westing end gives way to the emaciated cheek$ in these patients.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Facial and masticatory muscles perliltllle, Facllla-.,a, Ulaa tempcralalr11afar
Cialeupone110Uca
Atl~latio temJ)OtOt'llllndibullria,
Clip!IAa attlcuiiM, Ug. llllenll&
M. eplcrwllue, M. occ~ltofrant.alle,
Vsnter oedpltab M.IIMitot' anguli Crill
M.dell- -~~~~IJ~~:j llabii infeticria
M. dep'ee,80f anguli crll
M. dlgaltrtllua, v.ntllr 11111rfor M. ~llr. Partt~ala
v. Jugullula ln1ema
N ....hyokf0. hyoldNn
A. auotla ~munla
Fig. 8.65 FMill mUICIH, Mm. f1ci1i, 1nd m1atitatory muecl•, Mm. mntlcatorll, lift side; lateral view. Upon removal of the superficial and the deep laminae of the temporal fascia and the partial removal of the zygomatic arch and parts of the M. masseter, the M. tlll'lporalls becomes visible. The origin of theM. temporalis alon" the Unea temporalis inferior of the Facies extema of the Os parietale and the Unea temporelis of the Os frontale are shown. The muscle fibres converge into a flat tendon that disppears in the Fossa infratemporalis behind the zygomatic arch and inserts at the Pro c. coronoideus.
Origins of the M. umpor~lit: • Linea temporalis inferior of the Facies externa of the Os parietale • Facies temporelis of the Os frontal& • Facies temporalis, Pars squamosa of the Os temporal& • Facies temporalis of the Os zygomaticum • Facies temporelis of the Os sphenoidal& up to the Crista infratem· poralis The image also displays a few suprahyal muscles IM. digastricus with Venter anterior and Venter posterior, M. stylohyoideus!.
I-.T 1,41 -+ dl..eetlon link
43
Head
Overview -+ Skeleton and Joints -+ Muscles -+ Topography -+
Masticatory muscles
M.ITIUM1er, Pn P!Ofllncla
Fig. 8.18 M. man Iter and M. temporallt, lift side; lateral view. The M. m....ter consists of a Pars supetfieialis and e Pars profunda.
1-+T 41
Ala mlljcr, Crilta lnfndempa111la
Fig. 8.87 Temporomandibular Joint, Articulatio temporoman· dibuluil, M. pterygoideu:• medialie and M. pterygoideua lmraia, lift tict.; late rei view. TheM. pterygoideus medialis consists of a Pars medialis and a Pars lateralis.
44
-+ dl..tu:tlon link
Fig. 8.88 Tamporomandlbular Joint Articulatio temparoman· dlbularla, and relatlo111hlp to the M. pterygoldeu:• laterall1. left aict.; laterel view. The M. pterygoideus lateralis consists of a Caput superius and a Caput inferius {-+ Fig. 8.671.
Vessels and nerves -+ Nose -+ Mouth and oral cavity -+ Salivary glands
Masticatory muscles
N. Dc:Uomoto~ua PIQ N. 1119an*lua M
N. abducens [VI]
A. tlmparalil, R. fmntalil
A.carotls~a M.~rala
HamuiLB~a
08 hyalde1111, Comu majua
F'.g. 8.19 Matie~~tory mu~~ela, Mm. muticatDrii; frontal section at the level of the temporomandibular joint and horizontal section af the skull cap; posterior view. The bilateral insertion sites of the Mm. masseter and pterygoideus medialis at the Angulus mandibulae are shown. The Mandibula is sus-
pandad by these muscles lika a swing. On the right side, tha Lig. sphenomandibulare between the M. pterygoideus lateralis and the M. pteiYgoideus medialis as well as the N. lingualis are visible.
I-+T41
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Triemus can make it impossible to open or close the mouth. Abscesses in the facial compartments of the masticatory muscles can result in the mouth being locked in a close position. Excessive
yawning movements, extreme mouth opening, or accidents can cause a lockjaw with the movth being locked in the open position.
-+ di•••ttion linll
45
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Vessels and nerves of head and neck
N. euriculotemporetit (V/8)
R. II.-.Ill (VII)
Fig. 8.70 v....la and nervH of hHd and neck. lllrteraleuperflclal rqion1, right 1icll; lateral view. Superficial arteries in the area of the face are the A. taclllla and its branches and the R. psrietalis and R. frontalis of the A. temporallt •uperficilr.., which originates from the A. cerotis extema in the lateral head region. The blood drains from here through identically named veins into the V. Jugularia ntema. The terminal branches of the N. facial it Mil are the superficial nerves radiating from th& Plexus intraparotideus located within the Glandula psrotidea IRr. temporales, Rr. zygomatici, Rr. buceales, R. marginalis
46
-+ dl..tu:tlon link
mandibulae, R. colli mandibulael. In front of 1tle auricle the N. aurlcu· 1otemporali1, a branch of 1he N. trigeminus IVJ. ascends. The N. eu· praolllftellll, also a branch of theN. trigeminus M. leaves the orbit and pierces the M. orbicularis oculi. Neck and occiput receive sensory innervation from branches of the Plexua cwvtcalla which largely derive from th& Punctum nervosum {ERB's point} at the posterior margin of 1tle M. stemocleidomastoideus: N. transversus calli. N. auricularis magnus. N. occipitalis minor. and Nn. supraclavicularas.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Vessels and nerves of head and neck
M. allmocleidomaatoideua
V.~calll
Fig. 8.71 VMAia •nd nervea of the hMd •nd neclr.llterel deep region a, right eict.; lateral view. Upon removal of the facial muscles and the superficial parts of the Glandula parotidea, the course of the A. faclallt and the origin of the terminal branches of the N. facia lis derived from the Pltxue infrlplro1fdllus become visible. Also shown are the termfMI HMOry bren· chn of the N. trigeminus M which originate from its ttlree parts: • Nn. supraorbitalis and supratrochlesris (from N. ophtnalmicus IV/1)) • N. infraorbitalis (from N. maxillaris IVI21l • N. mentalis !from N. mandibularis IV/31l In ttle lateral triangle of the neck at the posterior side of the M. stemocleidomastoideus, the four arvic.~l bnndiH exit at the ERB's point:
• N. transversus colli • N. auricularis magnus • N. occipitalis minor • Nn. supraclaviculares The N. transversus colli receives motor fibres via the R. colli of the N. facialis [VII) for the innervation of more distal parts of the Platysma. Further, in the lateral triangle of the neck the N. ICCHIOrlutiXII runs from the posterior border of ttle M. aternocleidomastoideus to the an· terior border of the M. trapezius. The occiput receives sensory innerva· tion through ttle N. occtplt•llt m•Jor (branch of the Plexus cervicalisl and blood supply through the A. and V. occipitalie.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . Extirpation of lymph nod&S in the l9teral triangle of the neck. can result in IIIiane of the N. ICCHIOriut [XI] and partial palsy of 1he M. trapezius (almost always the M. trapezius is also innervated by the
Plexus cervicalis- in 6.4% of cases exclusively by this plexus! which results in shoulder dysfunctions.
-+ dl..eetlon link
47
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Vessels and nerves of the lateral facial region
lllemPGI'IIIa media
A. tempar11Ua~la
A. zygomatlco ortlltalla
N. zygomat!cua,
R..zygomlllcof'aclrlllt
N. aurtctllotemporan.
~~;.---
N• .uvnokSallt .mellor, R. ,....iuxtemua
N.~lt.allt
Fig. 8.72 V.nel• and nM'VM of 111• hud, literII dHp regions, right lfde; lateral view. Upon removal of large parts of the Glandula parotidee, the structures of the Foeu Ntrom1ndibuluil in the deep lateral head region become visible. Below the auricle. the undivided stem of the N. t.cialit (VIII is visible. Shortly after exiting the Foremen stylomestoideum, the facial nerve Mil provides .branches to theM. digastricus, Venter posterior (R. digastricusl, to theM. stylohyoideus (R. stylohyoideus), and to the auricular muscles IN. auricularis posterior). Beneath the Mm. digastricus and stylohyoideus, the AIJ. carotides interne and extema ascend. Together with the V. retromandibularis and 1he N. auriculotemporelis.1he A. c.rotit ~m• runs in the Fossa r&tromandibularis and branches into the Aa. occipitalis, auricularis post&rior, maxillaris, and temporalis superficialis as well as multiple small
48
-+ dl..tu:tlon link
branches. The M. masseter was cut and folded backwards to demonstrate its supplying structures located on the back of this muscle (N. massetericus - branch of the N. mandibularis IV/31: A. masseterica branch of the A. maxillaris). These supplying structures reach this muscle through the Incisura mandibulae. In the lower facial region. all mimic muscles were removed from the Mandibula; the Canalis mandibularis, which runs within the .bone from tha Foramen menclibulae to the Foramen mentale, was opened up to display the N. alnolarlslnt.rlor and the corresponding artery. At the Foramen mentale, tit is nerve becomes theN. m1nt.lie. Below the orbit, the A. facia lis was partly removed. This artery continues as A. angularis below tile eye and in the orbit it anastomoses with branches of the A. ophthalmica. On top of theM. buccinator. the sensory N. buccallt, a branch of the N. mandibularis IV/31. is visible.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
A maxillaris
Nn. ai'I6CIIar8& ·~
Rr. alveDIIrlts superiores post.-iores
A. mertlgu media
N. lllvec*rl& lnlertor
Fig. 8.73 Art•l• and narv• of tha halld, l.t•al da.., r-s~lons, right llda; lateral view. In most cases, the A maxlllarls courses behind the Ramus mandibulae. Only rarely does the artery run laterally to the ramus. The A. maxillaris continues through the masticatory muscles, supplies these muscles with blood, and provides branches to the M. buccinator and the
Mandibula. Its terminal branches reach the orbit, nose, maxilla, and pa· late. The A carotll ntema and its branches course through the Fossa retromandibularis. The A. facia lis was removed at the level of the Cor· pus mandibulae. Normally, the pulse of the A. facial is is palpable where it bends around the edge of the Mandibula.
• A. auricularis profunda • A. tympanica anterior
• A. alveolaris inferior -
Rr. dentales Rr. peridentales R. mentalis R. mylohyoideus • A. meningea media • A. pterygomeningea
Par. lnurmuscularls
•
b
c
d
• A. masseteric& • A. temporal is profunda anterior • A. temporal is profunda posterior •
Rr. pterygoidei
• A. buccalis
Pars
• A. alveolaris superior posterior
aphenopal.tina
•
• • •
- Rr. dentales - Rr. peridentales A. infraorbitalis - Aa. alveolares superiores anteriores - Rr. dentales - Rr. peridentales A. canalis pterygoidei A. palatina descendens A. sphenopalatina
Flp. 8.748 to d Variations of tha couru of tha A mulllulli. a course of the A. maxillaris medial of the M. pterygoideus lateralis and medial to theN. lingualis and N. alveolaris inferior b course of the A. maxillaris between theN. lingualis and N. alveolaris inferior c course of the A. maxillaris through a loop of theN. alveolaris inferior d branching of the A. meningea media distal of the bifurcation of the A. alveolaris inferior -+
di•••ction linll
49
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Plexus pterygoideus
N. aupiiiOI'tlltella, Fl. 111.-.Jia
N. e.ur1c:ul0ttlm~H'llls,
N. aupraodlitala, R. meatal a
v. tem~la media
N.flll:lala[\llq
Y.facielie
Fig. 8.7& v.....l, and nMYM of 111• hud, lmrd dup reglaM, right side; lateral view. The Plexu• IJteJYtoid..,. drains the venous .blood in the region of the
Fig. 8.78 Branching of 1fte N. mandlbularls (V/3L right slde; frontal view. 191 The branching of theN. mandibuleris IV/31 (-+Fig. 12.1441 into theN. llngudls and N. alvaolarls lnt.rlor nonnally occurs between the Ug. sphanomandibulare and the M. pterygoideus medialis, Pars medialis. Than the N. alvaoleris inferior tums lateral and enters the Canalis mandibulae lateral of the Lig. sphenomandibulare.
50
-+ dl..tu:tlon link
masticatory muscles and releases it mainly into the V. maxillaris. The Plexus pterygoideus also connects with the V. facialis via the V. profun· da faciei and whh the Sinus cavernosus via the V. ophthalmica inferior.
Vessels and nerves
-+
Nose
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Mouth and oral cavity
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Salivary glands
N. mandibularis [V/3]
A. ttmpordt PI01\IlCIII potttl1or: N. ttm)>OIIIIa pra1\lndua
mlndlbullrt8J:VIliJ
A.; N. ~lari& paettl1ar
A. ttmpol'llll
•Lf*'llcl•l• N. faoiiiiii,Vll]
R.dl;~
N. aNealn lnlartar
N. Y111J1M1 00 11\11&8 t11Mtall8 profUnda) A. cero!l8 ccm~TU~I& A. faelall8
Fig. 8.77 ArtertH •nd n•rv• of111• hNd, lmr•l deepest l"'glons, right sldl; l81eral view. Upon exiting the Foramen ovale. the N. mandibularis IV/31 divides into
the N.llngu1111, N. •lnol•rls lnflftor, N. buccalis, and theN. auriculotemporalis and sends branches to the masticatory muscles.
N. lllgamtn~.a M
.-10..:....-
l"""<:rr--
N. faclalls[VlQ
Chorda tyml*ll
Fig. 8.78 Branching of theN. mandl.bular'll lV/3L right side; frontal view from tl1e left side. [9) Branching off the N. mandibularis [V/3), th& N. lingu1f11 enters th& tongue from the lateral side. Shortly after leaving the N. mandibularis [V/3), the lingual nerve is accompanied by the Chorda tympani. which branches off th& N. facialis [VIII within the Canalis fec:ialis. The Chorcle tympani contains parasympathetic fibres for the Ganglion submandibular& as well as gustatory fibres for the anterior two-thirds of the tongue.
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51
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Arteries of the head
occlplt.alle, Rr. occlpllalee
A. alllculall8 I)Oit811or, A.occ.,it.ala
A.pllldl•
.._,dene
A. JlhiiYI'Ifl!ll -.-dene
- .• • .__A. caroti• extem• A. CIIII'Citlllntlml
F1g. 8.79 A. urotls emma ~~ p. 53).
1. A. tllyrel••• •p•lor - R. infrahyoideus - A. lar;ngaa superior - R. cricothyroidaus - A. st8moclei~ mastoideus - Ar. glenduleres
52
c. A.faclellt A. palatine ascandans R. tonsillaris A. submarrtalis Rr. glandulares A. labialis inferior A. 18bielii superior - R. septi nasi - R. leturelis nasi - A. angularis -
Z. A. P.lfYIIIN IHII.... - Rr. pharyngeales - A. tympanica inferior - A. maningea postBrior
5. A. occipitalis
3. A.llneullt - Rr. domlas linguae - A. sublingualis - A. profunda linguae
I. A. aurtculartspOitlrtor - A. stylomastoidea - A. tympanica postsrior - R. auricularis - H. occipitalis - R. parotidaus
- R. mastoideus - H. auricularis - Rr. Wlmoclaidomastoidai - Rr. occipital• - A. meningeus (Var.l - R. descendens
1. A. t111porellt •plllclellt
-
R. parotideus A. transversa faciai Rr. auriculares anteriores A. zygometicoorbitalis A. temporalis media - R. frontelis - R. parietelis
I. A.•uilleril - A. alveolaris inferior } - H. mentalis - A. maningaa media Pars - A. t,mpanica superior mandibularis - A. auricularis profunda - A. t,mpanica antarior - A. messeturica } - Aa. temporeles profundae posterior et entarior d P rygo• aa - Rr. pterygoidei - A. bucx:alis
r:: .
I. A.llullltrtl {~} - A. alvllolaris superior posterior - Rr. dantales - Rr. paridentalas - A. infraorbitalis - Aa. alvaoleres supariores antariores - A. pe18tine descandeM - A. palatina major - Aa. palatinaa minores - R. phar;ngeus - A. sllhanopaiBiina - Aa. nasales posteriores latareles - Rr. saptales postBrioras - A. nasopalatine
Pars pterygo· palatina
Terminal branches of the A. maxillaris are the A. infraorbitalis. A. sphenopalatine, A. alvealaris ~perior post8rior and A. pallltina dascandens.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Veins of the head
v. diploiea fl'clllllla "'v. diP101!:4l wmporaJis W~blrlcr
/ "'-
Rg. 8.79 Elmlm1l arotld 1rt11ry, A. carotls ext11rn1,11ft tide; laterel view (... p. 52). The .branches of the A. carotis externe are listed in tha table 1... p. 521 in their consecutive branching order.
Y. eml-rta plltetlllle
v. temporelie euperficielit
Fig. 8.80 lrrternel Jugullr ntn, V. Jugulerlslnteml, left side; lateral view. The V. jugularis interna statts as a dilated extension of the Sinus sigmoideus at the cranial .base. This vein drains the blood from the regions of the skull, brain, face, and parts of the neck. The Vv. facialis, lingualis, pharyngaa, oc:cipitalis. thyroidee superior. thyroidea media. and Vv. emissariae drain blood from the superficial heed region into the V. jugu· laris interne.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . The pulse of the V. jugularis (Jugullr pulu) provides useful information on the venous .blood pressure and the wave-like characteristic of the jugular pulse reflects the function of the right haatt.
In rare cases, lnfl1mmetlons In h faclel 1ree can spread via the valve-free V. engularis to intra-orbital veins f.\1. ophthalmice superior) and eventually from there to the Sinus cavemosus. This results in a life-threatening phlebitis or even a venous sinus thrombosis.
53
Head
Overview
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Topography
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N. facialis [VII]
Rr.IH.!c:aMe
Fig. 8.81 Terminal b111nchn of thaN. tiu:lalll [VIII In 1tte face, lift side; lateral view. 181 Within the Glandula parotidee, theN. iecislis (VII) (-t Fig. 12.149) creates the Plexus intraparotideus which, for clinical purposes, is divided into a R. temporofacialis !Pars temporofacialis! and a R. cervicofacialis
• Figs. 8.82a and b Parlpha1111 palsy of 1tta N. facial II [VIIL lift slda. a Upon the request to raise the eyebrows, only the left half of the forehead displays wrinkles (loss of function of the M. oc:cipitoironr. lis, sign of peripheral facial nerve palsy).
(Pars cervicofacialis). These two pans generate the tenninal branches of the N. facialis (VII): Rr. temporales, zygomatici, buocales. marginales mandibulse, and colli. Projecting dorsally behind the auricle is the N. auricularis posterior, another terminal branch of the N. facia lis (VII).
b b Upon the request to tightly shut .both eyes, the eve on the injured side fails to close properly (lagophthalmos!. When closing the eyes, the eyeball automatically turns upwards. Bec:euse the eyelid on the affected side fails to close property, the whit& sclera becomes visible !BELL's phenomenon}.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A per\'lharal fKIII narve pahay (-+ Fig. 12.1511 involves damag& to the 2nd motor neuron; this damage can be located anywhere between the Nucleus nervi iacislis and its peripheral branches. Causes are most frequently viral infections or nerve injuries during surgery on the parotid gland. The so-called central (supranuclear! lesion of the N. facialis (VIII lcantral facial nerve palty) is the result of a damage to the 1>~ motor neuron. mainly caused by bleedings or infarctions in the area of the Tractus corticonuclearis of the inner
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capsule on the contralateral side. As the Rr. temporeles of the N. facialis (VII] contain fibres derived from the nuclei located on the contra- and ipsilateral side, the muscles of the fora head and the M. orbicularis oculi in the upper eyelid region can stll contract on both sides. However, on the contralateral side the muscles innervated by the Rr. zygomatici, buccalas, marginales mandibulaa, and colli are paralysed (s~H:BIIed lower facial nerve palsy).
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Skin innervation
N. au~culotamparala
N. aphlhllmlcua 1.\'111 N. mulllluta 1.\'/2] N. mandllul..ts I.VIS.I
N. .,gusla
Fig. 8.83 Branch. . of tile N. trigeminut lVL left eicle; lateral view. [8[ Upon exit from the cranium, the three major branches of the N. trigeminus lVI, N. ophthalmicus IVI11. N. maxillaris IVI21. and N. mandibularis IV/31, subdivide into smaller branches in a specific topographic order. Visible bre.nch&a of the N. opbthelmicueiV/1] are the Nn. supraorbitalis, supratrochlearis, lacrimalis, infratrochleeris, and R. nasalis extern us.
TheN. mexillerie [V/21 provides the Nn. infraorbitalis and zygomaticus with its Rr. zygomaticotemporalis and zygomaticofacialis as shown in the image. Branches of theN. mandlbularls IV/31 are the Nn. bucca· lis, lingualis, alveolaris inferior, and auriculotemporalis. When leaving the Canalis mandibulae, theN. mentalis represents the terminal branch of theN. elveolaris inferior.
Fig. 8.84 Skin innerYation of the h. .d and nect. right eide; lateral view. The view from ventral is depicted in -+ Figure 12.146.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , As part of the physical examination of a patient. the N. trigeminus M is tested by applying pressure on the three exit points (trigeminal preaure point.[. Patients should not show signs of increased sensitivity or pain at the Foramen supreorbiteleJincisura supreorbitalis, Foramen infraorbitale, or Foramen mentale.
Trtgemlnal neuralgia {tic douloureuX) is a complex and painful dysfunction of the sensory trigeminal root. Typically located in the innervation areas of the N. mandibularis IV/31 and N. maxillaris IV/21. the facial pain can be intense end occur Quite suddenly. Touch of the skin in the corresponding facial areas often triggers an attack..
55
Head
Overview
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Skeleton and joints
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Muscles
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Topography
Lymph vessels and lymph nodes of the head
M. omah)'lllcSaua, V&nlaf lnfllllar
Fig. 8.85 Superficial lymph VMAII, VIM lymphatiA 1uperficiari1, and lymph nodM, Nodi lymphoidei, of the hNd and nack of • dtlld, lift side; lateral view. The regional Nodi lymphoidei submentales, submandibuleres, parotdei, mastoidei, and oc:cipitales collect the lymphatic fluid of the faoe. scalp, and occiput. From here, the lymph is drained into superficial INodllympholdll cervfcales lllt~nlu supllflclales) end deep cervical lymph nodes (Nodi lymphoidti cervical" ~raiN profundi •u· perlor• and rnt.riONt, ~ Fig. 11. 75). An important deep cervical lymph node is the Nodus lymphoideus jugulodigesvicus, located between the anterior margin of the M. stemocleidomastoideus and the mandibular angle at the lower border of the Glandula parotidea. The Nodi lymphoidei parotidei are divided into superficial (Nodi lym· phoidei ptrotidei auperficialet) and deep INocli lymphoidei paro1fdtll profundl) nodes. The latter include the Nodi lymphoidei preauriculares, infraeuriculares, and intraglandulares. In addition, there are isolated fac:iellyrnph nodes (Nodi lymphoidei feciales: Nodi lyrnphoidei buc:c:inatorius, nasolabialis, mandibularis, malaris) and lymph nodes of 1he tongue {Nodi lymphoidei linguales).
Lymph Nod• Df the H11d (Nodllympholdal caplt..t • Nodi lymphoidei oocipitales • Nodi lymphoidei mastoidei • Nodi lymphoidei parotidei superficiales • Nodi lymphoidei parotidei profundi - Nodi lymphoidei preauriculares - Nodi lymphoidei infraauriculares - Nodi lymphoidei intraglandulares • Nodi lymphoidei faciales - Nodus lymphoideus buccinatorius - Nodus lymphoideus nasolabialis - Nodus lymphoideus malaris - Nodus lymphoideus mandibularis • Nodi lymphoidei submentales • Nodi lymphoidei submandibulares • Nodi lymphoidei linguales
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Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Deep lymph vessels of the neck
Nodi~Jmpho~de! ctrlflct* ...........
Noel ~pholdel profuncll euperf-
A. carotle eommunle
M. acalenua mediua
V. )lgularia hblma
ll bradllocephdca daxtra
Fig. 8.88 Deep lymph nociH of the neck. Nodi lymphoidei cervical" profundi, right eia; lateral view. Cervical lymph nodes of both the anterior (Nodi lymphoidei cervicales anteriores) and lateral (Nodi lymphoidei cerviceles lateralesl aspects of 1he necl: are divided into a superficial and deep lymph node compartment. The Nodi lymphoidei infrahyoidei with the Nodi lymphoidei prelaryngei. the Nodi lymphoidai thyroidei. Nodi lymphoidei pretracheales. Nodi lymphoidei paratracheales. and Nodi lymphoidei rwopharyng~ res constitute the ant.lar deep cervical lymph nodas (Nodi lymphoidei carviceles anteriores profundo.
The laterel deep cervical lymph nodes (Nodi lymphoidei cervicales late· rales profundi) are divided into an upper group (Nodi lymphoidei pr~ fundi superioresl. composed of the Nodus lymphoideus jugulodigastri· cus, Nodus lymphoidaus lateralis and Nodus lymphoideus anterior, and a lower group (Nodi lymphoidai profundi inferiores} with the Nodus lymphoideus juguloomohyoideus, Nodus lymphoideus lateralis, and Nodi lymphoidai anteriores. In addition, there are the Nodi lymphoidei supraclaviculares and the Nodi lymphoidei aocessorii (in association with the N. accessorius [XI)) with the Nodi lymphoidei retropharyngaales.
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Head
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Muscles
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Topography
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Nasal skeleton
·. ~-- Certllqo a1e.rt. m•Jor, CN•IIIIeralt
Fig. 8.87 N111ltbl1tton; frontal view. The nasal skeleton consists of a bony and a cartilaginous part. Connective tissue fixes the cartilaginous part to the Aperture piriformis which is composed ofthe Os nesale end Maxilla. The individual elements consist of hyaline cartilage and are linked by connective tissue. The upper lmral or triangular cartilage {Cartilage nasi leteralis, Cartilage trian-
gularis) forms the roof; the n...l 1ip or m1jor 1llr cartilage {Cartilage alaris major) with a Crus laterale and a Crus mediale creates the nasal wings. In addition, two smaller alar cartllagM !Cartilagines alares mi· nores) exist bilaterally. At its bottom end central part, the cartilaginous part of the nasal septum (Cartilage septi nasi) supports the nasal skeleton.
Sutlft frontct~M~~il
Mallie. Proc. f!Qntalll
ca.rttlqne --:.........~"---"'-c;...:.. ai&IMmi-
Fig. 8.88 N11al cartllqM, C.rtllagln.. nael; inferior view. The view from below shows the nasal orifices (Nares) which ere delineated by the two crura of the major alar cartilage (Crus mediale and Crus lateral& of the Cartilage alaris major}. In the central lower region, the cartilaginous part of the nasal septum is visible !Cartilago septi nasi).
Fig. 8.19 N11alekeleton; frontal view from the right side. The cartilaginous nasal skeleton attaches to the Aperture piriformis .by connective tissue. The Cartilagines nasi laterales. alares majores, alares minores and the Cartilago septi nasi are visible. There is connective tissue within 1he non-cartilaginous nasal areas.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Specific clinical terms are often used: columella {anterior part of the nasal septum between the nasal tip and the Philtrum). the 'key.tone ,,... {where the Os nesale overlaps the lateral cartilages). a soft triangle !skin area at the upper rim of the nostril, close to the point where the Crus mediale bends to become the Crus laterale; this certil1g..free .,.. is composed exclusively of a skin duplication), the •supretlp UH' !on the bridge of the nose just above the tip!, and the weak triangle !similar to the "supretip area* since here
58
the bridge of the nose is exclusively formed by the septum). These designated areas are important landmarks that reQuire special attention by the rhinoplastic surgeon . A h1em11toma of the nual uptum !e.g., as a result of a fnlctured nose) requires an immediate decompression or relieve by puncture or an incision end nasal t~~mponede as otherwise the cartilage will become necrotic.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Nasal septum
(Sut\n vomaranllldlarla)
Fie. 8.90 N•••IMPtum, Septum n..i; view from the right side. The Cartilago septj nasi forms the frontal part of the nasal septum and extends as a long cartilaginous Proc. posterior between the bony parts
of the nasal septum (top), composed of the Lamina perpenciiculeris of the Os ethmoidale, and the Vomer (bottom).
Fig. 8.91 lnfllrlor n ..al concha, Conch• nasallslnfllrlor, lift siCS.; frontal section st the level of 1he initial pert of the Pro c. posterior of the Cartilage saptj nasi: frontal view. This section demonslT8tes the thin bony skeleton of the inferior nasal
concha (Concha nasalis inferior! which is covered by a vascular plexus (Plexus cavemosusl composed of a network of specialised arteries and veins. Ciliated epithelium and interspersed serous glands (Glandulae nasalesl cover the surface of 1tle nasal concha.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A characteri~c feature of the nasal mucosa is a dense subepithelial plexus of venous sinusoids. Depending on the particular state of swelling, approximately 36% of the nasal mucosa is composed of vascular plexuses. The highest density of subepithelial venous plexuses is found at the lower end middle nasal conchae end the KIESSELBACH's area of the nasal septum.
Some 80% of all humans display a niiNI eycle: this refers to spontaneous alternating changes in 1tle swelling of the nasal mucosa in the two nasal passages lasting 2-7 hours. This alternating swelling results in a 3-fold increase of the airway resistance in 1tle particular nasal passage during nasal breathing while the total nesal airway resistance remains unchanged.
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Head
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Topography
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Nasal cavity Nn. olfactor11 [1). Rll alfaotorta
c.m.
Fie. 8.92 Ltt.,.l w111 of th1 n ...l uvity, n•i.. kilt 1id1; lateral view. The lateral wall of 1he nasal cavity is mainly occupied by 1he inferior (Conch• n1Niit inflrior) end middle nasal conchae (Conch• n ...lit medlllJ. The superior nasal concha (Concha nasalis superior) is small and located in close vicinity to 1he oHactory region at the nasal roof. Hare, the Fila olfactoria of the Bulbus olfactorius penetrate 1he Lamina cribrosa and reach 1ha neighbouring mucosa, including the mucosa of 1he upper nasal concha.
Keratinised stratified squamous epithelium covers 1he VNtibulum
n111. At the Limen nasi, ltle epithelial layer transforms into non·keratinised stratified squamous epithelium and than into ciliated psaudostratified columnar epithelium. An imaginary line from the inferior nasal concha projects to Ostium pharyngaum of the Tuba auditiva. Above the Ostium at the pharyngeal roof lies Tonsilla pharynges.
~!'OWls to:
1 Slnua trcntala
2 Ductua neaoii.Cr1mlls 3 Celulul 1111'1nalcal111 entallaree 4 Sfn~~tmaldlllulll
6 Ctlulu 1111molcalea poeteriorea 8 Slnue aphald:lallll
Slnut tphenoldllh n.MI
Fie. 8.93 NINI c.vity, Cevittt n ..i, •nd 1ntrtnce into the pen~n...lllnuus, Sinus peren~uln, lift siCS.; view from 1he right side. Beneath the anterior third ohhe inferior nasal concha, the Ductus na$0lacrimalis opens into the lower nasal meatus (purple probe). Beneath the middle nasal concha, 1he openings of the Sinus frontalis !green
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probe), Sinue m1Xill1ri1 (red probe!. and c.llulee .thmoiclll" am. rlon~a (blue probe) are located. Beneath and behind the superior nasal concha, 1he Clllulae nhmoldeln posterlorn (yellow probe} and the Sinulll)henoiclalit !dark blue probe) open into 1he nasal cavity.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Paranasal sinuses
Fie. 8.94 Projection of th• p1r1n1..1tinu... onto tile •ull; frontal view. 181 The projections of 1tle Sinus frontales and maxillares as well as the Cellulae ethmoidales era shown.
Fla. 8.95 Loca11on ofh Slnu• frontalfe •nd Slnue aph•noldllll In th• stun, rtaht sld•; view from the left side. 181 The Sinus sphenoidalis is in close topographic relationship to the pitui· tary gland (Glandula pituitaria).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . The Slnu• eplttftoldalle can extend into large areas of the sphenoidal bone. During surgical interventions. this extensive pneumetisation can endanger the A. carotis interna {Tuberculum carotidis
intemael and the N. opticus 1111 {Tuberculum nervi opticil because of their closa proximity to the lateral wall of the sinus.
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Head
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Skeleton and joints
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Muscles
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Topography
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Paranasal sinuses, radiography
0. zygamlllcum, Prac. fnlntalla
Slnua llflhGnaltllllla
Fig. 8.98 Paren11alslnUHS, Sinus parennalu; radiograph of the skull with opened mouth in posterior-enterior (PA} beam projection.
Clinical Remarks-----------------------------. Conventional radiographs provide a quick overview of the state of the parana881 sinuses. However. computed tomography and magnetic resonance imaging have largely replaced X-t8V imaging as the diegnostictoolofchoiceindeterminingindicationsforsurgicalintervention. Stnuett11 is a frequent disease. In children, the ethmoidal sinuses ere most frequently affected. whereas in adults en inflammation
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of the maxillary sinuses is most often observed. Inflammations of
the ethmoidal sinuses can break through the 1hin Lamina orbitalis (papyracea) of the Os ethmoidale and spread into the orbit or can reach the Canalis opticus from the posterior ethmoidal sinuses or the sphenoidal sinus and damage the optic nerve.
Vessels and neiVes
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Nose
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Mouth and oral cavity
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Salivary glands
Paranasal sinuses
D.ora mater ctanialil M. obllquue supellor
M. levalllr palpebra aupe!torls; M. -.s superior
rectus medialis
M. dlgaalrlcus, Venblr anter1or
M. ganlahyold.Ja
flg. 8.117 Fronbll ACtion 1hraugh 1he head at the level of 1he eecond upper molar; frontal view. This section emphasises the individual bilateral differences in the formation of the sectioned paranasal sinuses. On both sides, 1he differently shaped Sinus maxillares display variable degrees of compartmentali-
sation. The nasal septum deviates to the left side {septum deviation). A$ a rasult. the lower and middle nasal conchae on the right side are
markedly more developed than on the left side. The ethmoidal cells show differences in shape between the right and left side. In the left supraorbital region, part of the Sinus frontalis is visible.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Due to a severe Mptum devl'a11on, nasal breathing can be markedly restricted and as a consequence headache, hyposmia, or even anosmia may occur. The shape and size of the peranasal sinuses is extremely variable. This acc:ou nts for interindividuaI as well as side differences within the same individual and can include the complete lack of individual sinuses IIPI••Ia).
However, individual sinuses can reach extreme sizes. If the Sinus frontalis extends in an oooipital direction well beyond the orbital roof !Recessus supr~~Dibttallsl, the clinician refers to it as a dangerous frontal sinus. An inflammatory process of the frontal sinus can overcome the thin bony barrier and can spread into the anterior cranial fossa and lead to meningitis, epidural abscesses, or even brain abscesses.
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Topography
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Development and clinics of the para nasal sinuses
----20.Y
-----&.Y
------12.¥
81nUII'rontdl ~
4.Y
~~~~~m~~----~~~r-~------~ Meetu& nMIInfe~
Coi'Cilai\Millelnfi~--------.JC~ 8llnl.a mlldllllda - - - - - -
------12.Y
------20.Y ~----->80.Y
Fig. 8.11 Denlopment of the mmdllery and front1lsln11M1. Y: year of life. At about 5 years of age, the developing frontal sinus reaches the upper margin of the orbit.
O.tium
Slnue maxi Iaiit
Fig. 8.tt Chronic sinusitis; coronal computed tomography !CTI of the paranasal sinuses; white arrows indicate a swelling of the inflamed mucOila in the right maxillary sinus and the ostium, while white arrow heads point to a swelling of the ethmoidal cells. [17)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The middle nasal meatus is the endonasal access route in paranasal surgery for the treatment of a chronic inflammation of the fromal, maxillary, and anterior ethmoidal sinuses. An unilateral lnDamm•·
64
Uon of th• maxillary 1tnu1 often has an odontogenic origin (odontogenic maxillary sinusitis). Commonly, the cause is an inflammation of the second premolar or the first molar(-+ Fig. 8.36}.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Paranasal sinuses
lnfllnclbulum fihmoldaht ......._
Hllt:ul 18mllunartl
Pliee lacrimal a•
Fig. 8.100 Lateral naul wall, right slcll; view from the left side; nasal conchae separated from the wall at the base. 181 The Ductus nasolacrimalis opens into the lower nasal passage via the Plica lacrimalis (HASNER's valve). Beneath the middle nasal concha, the Hiatus semilunaris is shown. The Bulla ethmoidalis and the Proc. uncinatus are located above and below the Hiatus semilunaris, respeo-
tively. Posterior to the superior nasal concha the Recessus sphenoethmoidalis with the opening of the Sinus sphenoidalis !Aperture sinus sphenoidalis, blue arrow) is located. • HASNER's valve
Plll'ananl Slnutel- Common Clln'lcal Ttlfllll Ag..,nali
an anterior ethmoidal cell in front of and superior to the base of the middle nasal concha
Hiatus semllunarls
a crescent-shaped and up to 3 em wide cleft between the Bulla ethmoidalis and the upper free margin of the Proc. uncinatus: the Hiatus semiluneris provides access to the Infundibulum ethmoidale
Infundibulum Mllmoldale
space delineated by the Proc. uncinatus, the Lamina papyracea and the Bulla ethmoid&lis
Bulla athmoicler•
an anterior ethmoidal cell above the Hiatus semilunaris: regularly present but may not be found in ell cases
Proc. uncinatue
a thin lamellar bone of the Os ethmoidale participating in the formation of the medial wall of the Sinus maxillaris and confining 1tle Hiatus semilunaris at its anteroposterior aspect
....I lamella
embryonic residual lamellae present in the Os ethmoidale There are four basal lamellae IBLI: • 1. BL: Proc. uncinatus • 2. BL: Bulla ethmoidalis • 3. BL: Concha nasalis medie • 4. BL: Concha nasalis superior
Fontanelle
accessory opening in the medial wall of the Sinus maxillaris
o.t.omutal complex
general term to describe the complex anatomy in the area around the Hiatus semilunaris
Recasu frontalis
a cleft providing a connection between the Sinus frontalis and the main nasal cavity (Ductus nasofrontalis, Canalis nasofrontalisl
HALLER's clll
an ethmoidal cell assuring the pneumatisation of the lower orbital wall (infraorbital cell)
()NODI-. cell l•h•n• Mllmoldal air cell,
a posterior ethmoidal cell protruding beyond the Sinus sphenoidalis
~ dl..eetlon link
65
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Arteries of the nasal cavity
Fig. I.101 NaAI c:ntty. Cavttu naal. left dele; transnasal endoscopy with 30° optics.
The examiner views the head of the middle nasal concha {Concha nasalis media). • spatula
A. 81hnoidds an18rior, R. Hplllllll anterior
A. lllhmaldllh pcg~Mtar
A. elhmoldala patllllllar, (R. "PPIllel
A. lllblllllll .,parlor, R. Hptl nul
•
b
A. plllllllna mlljar
Flgs.I.10Za and b Armrln of the n-1 cavity. 181 a lateral wall of the right nasal cavity b nasal septum of the right nasal cavity The A. carotis extarna provides tha arterial supply to tha nose. The All. ethmoldaln antarlar and pasurlor from the A. ophthalmica reach the lateral wall of the nose and the nasal septum by traversing through the anterior and posterior part of the Os ethmoidale. As a terminal branch of the A. maxillaris, the A.IIPhenopala1ina gains acce88 to the
nasal cavity through the Foramen sphenopalatinum. There are anastomoses via arterial vessels of the lip to the A. facie lis. At the nasal septum, the A. sphenopelatina becomes the A. naeopaletina which passes through tha Canalis incisivus to reach the oral cavity whera it anastomoses with the A. palatina major. The KIESSELBACH's area, an arteriovenous plexus, is supplied by the A. nasopalatina and the Aa. ethmoidales anterior and posterior.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - , The most frequent location for a nasal blaadlng (epistaxis} is the KIESSELBACH's area at the nasal septum. Basilar sk:ull fractures involving the Lamina cribrosa can lead to the rupture of the Aa. ethmoidales anterior and/or posterior with consecutive nasal bleeding.
66
-+ di•••ction link
In those cases of nasal bleeding where a nasal balloon tamponade is unsuccessful, the A. sphenopelatina has to be ligated.
Vessels and nerves
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Nose
-+
Mouth and oral cavity
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Salivary glands
Veins and nerves of the nasal cavity
v. lthmoldall8 poel«
Fig. II.103 Veina of 'the nual cavity. right ade; view onto the lateral nasal wall. [8[ The blood is drained via the Vv. ethmoidll. . Interior 1nd po.terior to the Sinus cavernosus at the base of the skull, via the V. •phenoINIIatln• to tt1 e Plexus pte rygoide us in the Fossa i nfratemporalis, and via the connection to the Vv.labl1lnto the V. facia lis. • connecting vein to the Sinus sagitt91is superior via the Foremen caecum (only present during childhood)
N. palalh.ls major, Rr.niiiiSIIIea~
lnfarto....
•
N. alvealarla 11Uparlor
N. nuop~~lllln•
flp.ll.104a 1nd b Innervation of the n1aal cavity. 181 1 lateral well of the right nasal cavity b nasal septum of the right nasal cavity Sensory innervation of the nasal mucosa is provided by branches of the N. trigeminus M: N. ophthalmicus IV/1[ .... N. ethmoidalis anterior and
N. maxillaris IV/21 .... Rr. nasales, N. nasopalatinus. Tha N. olfactort... Ill innervetes the olfactory area. The N. na.o!NIIatinua runs alongside the nasal septum through the Canalis incisivus, and innervates the mucosal area of the hard palate that stretches from the backside of the incisors to the canine teeth.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . As the nasal mucosa receives rich sensory innervation, each manipulation in the nose can cause extreme pain sensations. Brain injuriea wittl damage to the Fila olfactoria can reault in •n. .mia (the patient is unable to small). Rupture of the Dura mater can cause a cerebrospln•l fluid rhlnar-
rhH. A clear transparent fluid drops from tha nose of the patient. The diagnosis of cerebrospinal fluid is confirmed by the detection of glucose using glucose t~N~t strips. A surgical intervention is mandatory to prevent an infection.
Head
Overview
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Skeleton and joints
-+
Muscles
-+
Topography
-+
Oral cavity M. ptery;oldeua Ill....
LQ. l!lhlnOmatldibuu
'*ill-'r"'"!JJi.+--f~- Raphe ptllfygOmandlbulluls
11¥:~1-:ffi~iBf:~- Llg. •~m
M.langus Cllf)llla M.d~
Cotpua 01 h:!toldrlum
{ <:emu mlnua
Fig. 8.105 01'111 cavity, C.W..e orll, light aide; view from the left side. The margins of the oral cavity are the lips !anterior}. the cheeks !lateran.
the muscular floor of the mouth (bottom. caudal), and the palat& (top, cranial).
P.tlatum mole (Veklm pdl.tlnum]
Fig. 1.101 01'111 cavity; Cavltas Oils; frontal view: mouth open. The oral opening (Rima oris! represents the entrance to the digestive tract end the oral cavity. The letter is divided into a vestibule !Vestibulum oris) and the cavity proper {Cavitas oris propria). The borders of lt1e v.-ulum orts are the lips and cheeks at the outside and the alveolar processes and teeth at the inside. With the occlusion of teeth. e space behind the last molar tooth on each side (Spatium retromolare} allows
68
-+ dl..tu:tlon link
access to the oral cavity. In the region of the oropharyngeal isthmus (IIJtllmu. t.uclumllt1e oral cavity becomes the Pars oralis of the Phe· rynx !Oropharynx). The excretory ducts of numerous smeller salivary glands and those of the three paired large salivary glands all drain into the Vestibulum oris and the Cavitas oris propria. The body of the tongue (Corpus linguae) fills large pel't$ of the inside of the oral cavity.
Vessels and nerves
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Nose
-+
Mouth and oral cavity
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Salivary glands
Dental arches
Den•molnll
Dlif1• moln Ill
(M101hus)
Fig. 8.107 Upper dental1rch, Arcut dtntelit mPilllrie [superior).
The teeth !Dentes! are arranged in two dental arches, the upper (Arcus dantelis maxillaris or superior) and the lower dental arch (Arcus dentalis mandibularis or inferior). and are anchored in the upper and lower jaw.
Rg. 8.108 Lower d1ntlll1rch, Arcus dentalll m•ndlbulerls !inferior]. With one exception, tha arrengament of teath in the lower dental arch is similar to that in the upper dental arch. For a precise indication of the "oral* topographic relationships, the terms "palatinal* is used in the upper jaw and "lingual* in the lowar jaw. Tha Oingivl or gums are tha part of the mucosal lining of the mouth which covers the alveolar bony
Dentition in the human is hmroclont; the teeth come in characteristc shapes as incisors (lncisivi), canines {Canini). premolars (Premolares), and molars !Molares}. Incisors and canine teeth are also named front teeth. whereas premolars and molars are lsteral teeth.
processes and the interdental bony septa, known as gingival embrasure. In addition. it covers the cervical part of the tooth and transitions into the oral mucosal laver at the Margo gingivalis. Tha Gingiva supports the anchorage of the teeth and stabilises their position in the alveolar bone !Pars fixa gingivae!; as part of the oral mucosa, the marginal Gingiva forms the junctional epithelium which is attached to the dental surfaces.
69
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Teeth, structure Fia. 8.109 lncitor, Den• incitivu.. Typical features of each tooth are the crown (Corona dentisl. the ceJVic81 part !Cervix dentis). and the root of the tooth (Radix dentis). The crown of • tooth is the visible part of a tooth, rising above the Gingiva, and is covered with enamel (Enamelum}. The root of • tooth sits in the alveolar tooth socket {Alveolus dentalisl. a cavity in the Proc. alveolaris of the Maxilla and Mandibula, and is covered with Cementum. Periodontal fibres (Periodontium, Desmodontium) anchor the root of a tooth in the alveolar bone. The oementHnemel junction (frequently abbreviated as CEJ} locates at the C8f'VIc11 p1rt of • ~h. Here, gingival fibres connect the Gingiva with the cementum of the tooth. The deepest point in a tooth is the root IPIX (Apex radicis dentisl. At the Foramen apicis dentis. the dental papilla (Papilla dentis} is perforated by the root canal (Canalis radicis dentis! which provides an access route for blood vessels and nerves to the pulp cavity (Cavitas dentis). The pulp cevity divides into the Cavitas pulparis !radicular pulp} and the Cavitas coronae !coronal pulp). The pulp (Pulpa dentisl consiSls of connective tissue. conteiing blood vessels, lymph vessels, and nerves, and thus nourishes tile tooth. Similar to the pulp cavity, one can distinguish between rediculer (Pulpa radicularis) and a coronal pulp (Pulpa coronalis). Collectively, the cementum, desmodontium, alveolar bone, end parts of the Gingiva are referred to as tile Parodontium.
Corona clnlea
Cervix{ lllntll
Radix
del1til
T~uklm dentia
\ Feclee lh9UIII
Fla. 8.110 Perm•Mnt low• Clnlne, Dens canlnua permanen•; an example of a tooth with one root.
Fla. 8.111 Second deciduous (milk) mol1r tooth, Dens mollrll declduua; an example of a tooth with two roots.
Fla. 8.112 Flm ,.,manent upPif' mollr tooth, Dens mollrll prfmus; ooclusal surface of a molar tooth with e de· tail9d description of the individual parts.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Form. 1opography, rul• for orienttrtion The midline is the reference line when dMC:ribing the turfac. of a tooth. Dental structures dosest to the midline are named mesial, those located away from the midline are named diSlal. Contact areas to neighbouring teeth are defined as Facies. Number, dimension,
70
and form of the roots !Radices} ere functionally adapted to the dental crown. The morphology of the roots of individual teeth in deciduous end permanent dentition is different and variable. Teeth with a single root are the lncisivi, Cenini, end premolars. The upper premolars I end the lower molars have two roots, and the upper molars have three roots.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Deciduous teeth Dene
Den•
molalla I
molalla II
Dena
Den&
lnf'ellor
Dena
canlnu.
Rg. 8.113 Milk or declduou• teeth, Dent:M decidu!. of 11tu.. year old child; vestibular view.
molluie I
nlelltia II
A complete set of milk !deciduous) teeth is usually present at 30 months of age.
Dens mallulal
lnfellor
081'111
Dll'lll
lntleMiarattralla cerinua
Rg. 8.114 Milk or deciduous teeth, Dentn diCidul, of • two ye1r old cflild; upper row. vestibular view. lower row. inferior view in an obliQue engle.
Dana malalfal
Dena
mcrm.rr
The medial incisors are not shown. In a two year old child, the development of the roots of the teeth is not completed in numerous teeth. This process is only complete after dental eruption.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Dental formull There is an internationally aocepted dental formula which is applied by all disciplines of dental medicine. Each half of a jaw (quldrent) is numbered. Starting from the midline, ..eth of the permanent and deciduous dentition are numbered consecutively from one to eight (permanent dentition) and from one to five (deciduous dentition). r~ spectively. The digit of the quadrant is followed by the digit of the tooth; e.g.• the description 11 !pronounced: one one) means the first incisor in the right upper jew of the permanent dentition; the digits 62 {pronounced: five two) means the second incisor in the right upper jaw of the deciduous dentition.
Dental Fonnule of the Adult upper jaw
right
18 17 16 16 14 13 12 11 2.1 22 23 24 2.6 26 27 28 lift 48 47 48 46 44 43 42 41 31 32 33 34 36 36 37 38
1-.vfaw Dental Formula of Decid..oua Dentition upperjrw right
66 54 63 62 61 61 62 63 64 66 left 85 64 83 82 81 71 72 73 74 75 lOWer jeW
71
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Permanent teeth
B
1
8
5
Fig. 8.115 P•rm•nent ullth, D•ntM perm•n•ntM; oral view.
B
7
1 Dellllnclllvusl 2 Dtlllllnclllvus II 3 Dens caninus
5
Fig. B.11& P•rm•nent t.llth, DentM permenentM; distal view.
Clinical Remarks-----------, Taetl'l ere the most resistant structures in the body end serve as important evidence in foremic medicine for the identification of a victim.
72
4
4
1 Dt1111 lnclllvus I 2 Dens lnclllvus II 3 Da111 canlnus
3
2
4Delllp~~l
6 Dllna PNIIIO~ II
II Denamolarisl
3
een. molarle II e een. molalls Ill
1
(8eroti1uB)
2
4 Dllna PNITHI~ I 5 Den& PNITHIIII1B II II Danamolart•l
7 een. molalls II B Den& molarle Ill (oarothullj
Vessels and neiVes
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Nose
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Mouth and oral cavity
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Salivary glands
Permanent teeth
4
3
Fig. 8.117 Permanent t..th, Dentes p•m•nent.s; vestibular view.
2
3
4
Fig. 8.111 Permanent t..th, Dente. p•m•nentft; mesial view.
7
6
1 Dem h~·lvu8 I 2 een. hciBMIB II 3 Demcanilus
1 Dtn• h~·lvu8 I 2 Dtne hciBMIB II 3 Dtnscanilus
70..mo~n
4 Dtn• premolarla I 6 Dtns premolarts II & Dtns mallllisl
7
6
8
4 Dtn• premolarla I 6 Dtns premalarts II & Dtns mallllisl
a
Dlnsmo~lll
(Hratinus)
8
7 8
Dlnsmo~n
Dlnsmo~lll
(Hratinus)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , • Environmental and genetic factors can influence the dentlll denlopment. Resulting dental anomalies affect the size, form, and number of teeth. • The administration of tft"llcycllna Ia member of the family of antibiotics) during the phase of dental development can result in discolouration of teeth and enamel defects.
• Also important era discolourations of teeth and enamel defects caused by high doses of fluorides in form of tablets ldentllllluol'oslsl. • Enamel defects can point towards hypovitaminosis D lrlcketsl. • Residual elements of the odontogenic epithelium can remain as SERRE's bodiBS, remnants of the epithelial root shEIEith as epithelial cell rests of MALASSEZ, and both can generate cysts.
73
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Times of tooth eruption
Fie. 8.119
Upper jaw, Mexille. wittl deciduou teeth, Derrta declclul, end the ftrst perm1n1nt tocnh; left side: average time of tooth eruption in months (MJ; right side: sequence of tooth eruption. The Development of permanent teeth (replacement teeth) and deci-
duous {milk) teeth is similar but happens at different times. The time of eruption and the sequence at which mill: teeth appear in the oral cavity is subject to significant interindividual differences. However, at 30 months of age the set of deciduous teeth usually will be completed.
Fig. 8.120 Upper Jaw, Maxilie. wlttl perm1n1nt tNth, Derrta penn1nentes; left side: average time of tooth eruption in years (Y}; right side: sequence of tooth eruption. With the exception of the molar teeth, deciduous dentition {first dentition with 20 teeth! is similar to 1tle permanent dentition (second denti-
tion with 32 teeth). The sequence of eruption of the permanent molars is always the same: first molars with six years of age (&.year mollnt), second molars with twelve years of age, end third molars with 18 years of age or later.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Perloclontopathln are diseases affecting the supporting structures of 1he teeth. ParodontoUJ is e chronic degenerative form of periodontal disease and results in an increased tooth mobility and tooth loss with subsequent atrophy of 1he alveolar process caused by 1tle decline of the periodontal support system.
74
Systemic administration of fluoride ions during 1he time of enamel formation of the permanent teeth increases the deposition of tluo· riPitite, instead of hydroxyapatite. resulting in a more durable enamel capable of better resisting dental caries.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Development of teeth
Rg. 8.121 Uppll' Jaw, Maxilla, and lower Jaw, MandlbuiL of 1 fiya ytU old child; deciduous teeth and primordium of the later permanent teeth. Human dentition is diphyodont; there are two consecutive dentitions. known as deciduous and permanent dentition. First, the 20 milk teeth
(Dentes deciduil form in children. Development and eruption of tile first end second dentitions and the body growth are synchronised in a timely manner. Resorption of the noot of the milk teeth occurs at different time points.
Fcn.men mentele
Fig. 8.122 Uppll' jaw, Maxilla. and lower jaw, MancfibuiL of 1 20
yaar old pertOn. Completion of the permanent dentition results in up to 32 permanent teeth !Dentes permanentesl. The third molar {Dens molaris tertius, wisdom tooth. Dens serotinusl has not yet erupted in tile lower jaw. It can regress or may not have developed at all (aplasia). Usually, the molar
teeth erupt approximately seven months ear1ier in girls than in boys. In both sexes. the molar teeth in the lower jaw erupt ear1ier then molar teeth in the Maxilla. The roots of the deciduous teeth require another 16 to 26 months to develop; the roots of the permanent teeth are fully developed only after another 1.7 to 3.5 years.
75
tahir99-VRG & vip.persianss.ir
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Upper jaw, radiography and blood supply to the teeth
\
--------l~..;.....-sti'IJsmllldtfall8
canaismlllndltu.,.
O&hyoldeum
Fig. 8.123 Upp• Jaw, Maxlll.. •nd low.r Jaw, Mandlbul-. without wisdom tH'Ift; panoramic radiograph.
Vv. emfiiiiii!M
v. Jugufall8 extama v. Jugufall81ntema
Fig. 8.124 Blood ~pply of th• t..th. 181 The arterial blood supply to the upper lateral teeth comes from the A. •lveolarll .uparlor po"llfor and to the upper front teeth from 1he A. infr•orbit.l•, both branches of the A. maxillaris. Teeth and Gin-
76
giva of the lower jaw ere supplied by the A. elveolaril inftrior, which runs in the Canalis mandibulae. Concomitant veins drain the blood into the Pluu• pterygolcleul.
tahir99-VRG & vip.persianss.ir
Vessels and nerves
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Nose
-+
Mouth and oral cavity
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Salivary glands
Innervation of the teeth and Ganglion pterygopalatinum
N.lnglllllla
Fig. 8.125 lnnervlltfon of the 1Mth,left tide; lateral view. The N. mexillaris IV/21 and N. mandibularis IV/31 of 1he N. trigeminus M supply the sensory innervation for the teeth. The teeth of 111• upper Jaw are innervated by the Plexus dentalis superior which is composed of the Rr. elveolares superiores posteriores. medii. and anteriores of the Nn. alveolares superiores derived from the N. infraolbitalis. The teeth of 1he lower Jaw are innervated by the Plexus dentalis inferior which is created by 1he Rr. dentales inferiores of the N. alveolaris inf• rior. In addition, the front teeth in tha lower jaw are innervated by tha N. mentalis. The innervation of the Gingiva is even more complex than the sensory innervation of the teath. Here, the upper jaw also receives sensory fibres from tha N. ophthalmicus IV/1 ). N. trtgemtnue M
N. al!ltOiallt tUPti!Of mid lilt
Fig. 8.12& Qanalion pterygopalatinum. Sensory nerve fibres run wi!t1in the Rr. ganglionares of theN. maxillaris IV/21 via the Ganglion pterygopalatinum to reach the soft and hard palate. Preganglionic parasympathetic fibres from th& Nucleus salivatorius superior reach tha Ganglion pterygopalatinum via theN. facialis [VII) (N. intermedius), the N. petrosus major, and the N. canalis pterygoidaL In
the Ganglion pterygopalatinum. these preganglionic parasympathetic fibres are synapsed 10 postganglionic parasympathetic fibres which in· nervate the lacrimal glands and glands of the nose and Oropharynx. These glands receive postganglionic sympathetic fibres from the N. pe· trosus profundus which runs through 1he Ganglion pterygopalatinum and derives from theN. carotirus internus !Plexus caroticus intemusl.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Local infiltr•• an...tha•i• is reQuired for teeth in the upper jew since teeth and Gingiva in the upper jaw receive their innervation from different nerve branches. A unilateral branch block anaesth• tis as the teeth on the ipsilataral half of the Mandibula by blocking tha sensory impulses of the N. alveolaris inferior shortly before it enters
tha canalis mandibulae. Because 1ha N. linguelis is also enaesth• tised in the process, the sensory block extends to the ipsilateral haH of the tongue with the exception of the tip of the tongue. Further, tha chin and pans of the lower lip era numb since all the terminal branches of the N. alveolaris inferior are also anaesthetised.
~ dl..eetlon link 77 tahir99-VRG & vip.persianss.ir
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Fossa pterygopalatina and Ganglion pterygopalatinum
. . /Oeapha'IO!dalt,.
../
All.mii}Or
08 paJaUn~m, Lamine Pt!J)tllaic~Mris
b
• At•· 8.127a and b foMa pterygopalatine. lift eldl; lateral view; colour c:hart see inside of the back cover of this volume. (8) a overview b magnification The Fosse pterygopalatine represents a c:onnec:ting point for the stru~ tures of the nervous system of the middle cranial fossa. the orbit. and the nose. Maxilla, Os palatinum, and Os sphenoidale participate in dtr fining the margins of this fos~~&. The borders of the Fossa pterygopalatine are formed by the Tuber maxillae in its anterior pert. posterior by
the Proc. pterygoideus. medial by the Lamina perpendicularis of the Os palatinum, end c:ranial by the Ale major of the Os sphenoidal&. A cranial passage leads to the Fissura orbitalis inferior providing access to the orbit. The posterior part of the Fossa pterygopalatina opens into the retropharyngeal space; its lateral opening leeds into 1he Fosse infretemporalis. • VIDIAN canal
N.lnfntortlltalll
N. mnll'*'IIIV/31
•
Age. 8.1281 and b N. mlldllari•IV/21. lift 1ldl; lateral view. (8) a terminal branc:hes b spacial relationship to the Ganglion pterygopalatinum The N. maxillaris IV/21 exits the base of the skull through the Fo,.man rotundum to enter the Fossa pterygopalatine and exits this fossa
78
Rr. ganglon.wua ad ganglion pterygopalatl!llm
mol It
through the Fluu,. lnf111orb1tall•. In the Fossa pterygopalatina. the N. maxillaris IV/21 provides Rr. orbitales. the N. zygomaticus. the N. alveolaris superior posterior as well as Rr. ganglionares to 1he Ganglion pterygopalatinum.
tahir99-VRG & vip.persianss.ir
Vessels and nerves -+ Nose -+ Mouth and oral cavity -+ Salivary glands
Fossa pterygopalatina N. CP..Ie PfeiYIOidel F""'ura arbltlola hfalar F~p..dna
Plaxua carutlcua lnllmla
Dluldula
...
~acnn
b
OQion plelygcpalathum
Fip. 8.12S• •nd b N. can•lis pterygoidei, left side; lateral view. JBJ • overview b nerves in the Fossa pterygopalatina Parasympllth.tl~ fibres of the N. facialis lVIII, which form the N. petros us major, reach the Ganglion pterygopalatinum, synapse here from preganglionic to postganglionic neurons, and run to the lacrimal, naael.
and oropharyngeal glands. Poetpnglionic .,.n1)41thetic fibres originating from the Plexus caroticus internus, assemble as theN. petros us profundus, and run through the Ganglion pterygopalatinum without synapsing in this parasympathetic ganglion. They also reach the lacrimal, nasal, and oropharyngeal glands.
Fig. 8.130 A. maxlllarls In 1lte Fosse p1arygapalatlna, laft slda; lateral view. [8] Within the Fossa pterygopalatine, the A. maxillaria divides into its t . . minal brencbM: h. infraorbitalis, sphenopalatine, alveolaris superior posterior, palatine descendens, and R. pharyngeus.
Fig. I.131 Veins of the foSSil ptarygapalatlna, lafl: slda; lateral view.[BJ The Vv. infraorbitalia, sphenopalatine, alveoleris superior posterior, and palatine descendens drain into the PIPua ptth'YitOidaue. which is located in the Fossa infratemporalis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , A lesion of the parasympathetic fibres exiting the brain in association with theN. fecielis [VII] and then reaching the lacrimal gland via branches of theN. ophthalmicus [Vf1] can result in a reduced pro-
duction of lacrimal fluid by the lacrimal gland, leading to a dry syn*oma [sicca syndrome).
-ve
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tahir99-VRG & vip.persianss.ir
Head
Overview
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Skeleton and joints
-+
Muscles
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Topography
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Palate and palatine muscles
Fig. 8.13.2 Hard palat., Palltum durum. and soft pal1t1, Palltum mol._; inferior view. The palate (Palatum) forms the roof of the oral cavity and the floor of the nasal cavity. It separates the oral and nasal cavities. The hard palate (Paletum durum) end the soft palate (Palatum mollel form en anterior and posterior part. respectively. The hard pilltl contributes to the phonation of consonants and serves as an abutment for the tongue when crushing food. A number of flat palatine mucosal folds (Plica& palatines transverses. Rugae pelatinae} to both sides of the midline help grind and pin down pieces of food against the hard palate. Tha .ott Pllltl is flaxibla end, during swallowing, blocks off the Nasopharynx by folding back onto the posterior pharyngeal wall.
Dtlla m0111r1t Ill
[IIIWI~u•J
N. pell.tlnua me,!Or
Raphe PIIIY!Iamandlbullllla
111t11rn1a feu alum M.paiiiOP~
Fig. 8.133 Or11l cavity, Cl'llflas orll, and l)llltln. muscl11, Mm. pilltl; frontal view. Tha palate is covered by a thick mucosal layer firmly anecheci to the periosteum. In its subepithelial layer. the palatine mucosa contains packages of small mucosal glands (Glandulae palatinaa}. The flexible soft palate extends posterior of the hard palate and ends in the Uvula. The latter consists of a muscle IM. uvulae) and mucosal glands. From both sides, the palatine archei (Arcus palatoglossus and Arcus
palatopharyngeus), formed by the identically named muscles, project into the soft palate and the Uvule. On each side, a paletine arch frames a palatine tonsil (Tonsilla palatine). The palatine arches create the ph.. ryngHII11hmus (Isthmus faucium). the entrance to the Pharynx. The passage through the Isthmus faucium is controlled by muscles.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Varying degrees of cleft fonmltlans of the palat., upp1r Jaw, and face result from an insufficient mesenchymal tissue proliferation and the subsequent failure of fusion of tha maxillary and medial nasal processes. Uni· or bilateral clefting is possible and, in severe cases, a gap extends from the upper lip through the hard and soft palate (dlailognlthop•lltoechilil). It occurs at a frequency of 1 : 2500 births with a preference in females. lsolmd cllft l)llltls
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occur if the fusion of the maxillary processes of the secondary palate or the fusion between the primary and secondary palate fails. The mildest form is tha split Uvula (Uvul• bificla). These clefts are not hereditary but the result of a deficiency in folic acid in the maternal nutrition during pregnancy 1~ Clinical Remarks on p. 841.
tahir99-VRG & vip.persianss.ir
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Development of the palate and palatine muscles W8ek7
Week tO
W&ekl
.M Flga. 8.13-M to c Development of 1IHI ~lm, uparatlon of 'lila n-1 and anll cnltlas. [201 The merger of the two medial nasal prominences creates the median palatine process (intermaxillary segment) which is the structural basis for the future philtrum of the upper lip, part of the maxilla (with the four incisors). and the future primary palate. The primary palate extends into the anterior part of the oronasal cavity. The two opposing palatine pro-
c
cessas of the maxilla form the major part of the definitive bony palate. By week 7, the tongue moves into a caudal position, the opposing pa· latina processes assume a horizontal position, start closing the gap bet· ween nose and mouth, and finally merge in the midline as secondary palate. In the anterior part these palatine proc&Sses fuse with the primary palate.
Lamina medial•}
Proc. pterygllkleua
Lan*la lat8rals
M. tenaar vel palatili, Oligo Lamhalateralll} cartllaiiO tubllll ~..arm. medlalll auditival Fcma mandlbuln
Fig. 8.135 M. levator vall palatlnl, M. t.nsar veil palatlnl. and cartila. . of the pharyngotympanic tuba. C.rtilago tubaa auditivaa; inferior view. In addition to the M. palatoglossus and M. palatopharyngeus (-+ Fig. 8.137) which facilitate the depressionjpulk:lown of the soft palate, and theM. uvulae which helps empty the mucous glands of the Uvula, both the M. tensor veli palatini and the M. levator veli palatini project into the Aponaurni• palatine. Both muscles attach at the
base of the skull. The Hamulus pterygoideus serves as a hypomochlion (centre of rotation of a joint) for the M. tensor veli palatini. Upon contraction. this paired muscle pulls the soft palate backwards and upwards and occl"d" the N•eophlrynx 1111intt the Oroph1rynx during swallowing. In addition, this muscle participates in the opening of the Tuba auditiva [auditorial(..... pp. 14S and 150).
1-+nl
I.Jibklm IIIJperiU&--~1-11iF.t,. tmrt•/''~"1."111
~um~----~~~~~~~~~
Palmum moll& [Velum pllatlnuml Fo88a IIIJpmgnaillarls
._.~---An:u• pti!Mogi-
'./L._,N-_ _ _ Plea aalptlgoptoaryniiH Paplllu valldaa--F-z..r.i'r'
I.Jibklm lnferiU&----~'Ni
~:UJI....!---IJfj-----lbn8111a ptllllllllll
Paplafallllll
lb1111lhllngusl.. Fig. 8.136 Tongue. Ungua. in 1ha oral cnity; posterior lateral view. Posterior to the Sulcus terminalis lies the root of the tongue with the lingual tonsil {Tonsilla lingualis).
The Tonsil Ia lingualis is part of the WALDEYER's tonsillar ring. as is the Tonsilla palatine, which is located between the two palatine arches (Arcus palatoglossus and palatopharyngeus).
tahir99-VRG & vip.persianss.ir
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Tongue
Sulcus mecllanue linguae
Fig. 8.137 Tong..., Lingua; superior view. On the donum of the1ongu• (Dorsum linguae), the Sulcus medianus linguae divides the tongue into a right and left half. The Sulcus terminelis linguae (a V-shepEid groove) delineates the Corpus linguae from the Radix linguae and separates the tongue into a Pars anterior and Pars posterior. At the tip of the Sulcus terminalis linguae, the surface epithelium forms a depression, the For.men ~ecum linau... This foramen is the place where the thyroid gland started its descent from the ectoderm of the floor of the mouth to its final destination in front of the lerynx (origin of th& Ductus thyroglos.salis).
The mucosa of the Pars anterior is rough since it contains multiple small, partially macroscopically visible papillae (Papillae linguales, filiformes, foliatae, fungiformes. and vallate&) which play a role in the perception of touch end convey the sensory perception of taste. The root of the tongue (Radix linguae) is covered by the Tonsilla lingualis, framed bilaterally by the two palatine arches, Arcus palatoglossus end palatopharyngeus. end posteriorly by the epiglottis. The singular Plica glossoepiglottica mediana and the paired Plicae glossoepiglotticae laterales project from the root of the tongue towards the epiglottis and delineate th& Veii&CUia& epiglotticae.
~ - aour - aalty Taste sensations by the posterior 1ttlrd of the tongue are projected to Fig. 8.138 lnnerva1fon and tut• quaiHin of the donum of the the lower part of the Tractus solitarius in the brain stem by sensory tongue. The N. lingualis. a branch of the N. mandibularis [Vf3), supplies th& s&nfibres of the N. glossopharvngeus (I)(] and N. vagus lXI. The perikarya sory innervation of the anterior part of th& tongu&, Rr. linguales of the of these nerve fibres reside in the Ganglion inferius of the N. glossoN. glossopharyngeus (IX] supply the region of the Sulcus terminalis lin· pharyngeus (I)(] or the N. vagus lXI. guae, and the N. laryng&us superior. a branch of the N. vagus lXI. inner- All regions within in the anterior two-thirds of the tongue are capable of vates th& root of the tongue. perceiving ell five basic qualities of taste, albeit with different intensity. Taste sensations by the antlllfor two·1tt1rds of the tongue is conveyed For example, the perception of Msweet« is more intense at the tip of by branches of the N. facialis lVIII !Chorda tympani, N. intermedius) to the tongue, whereas the posterior root of the tongue contains recepthe upper pert of the Trectus soliterius in th& .brain stem; the perikarya tors thet are particularly sensitive to a Mbitter« teste. of these sensory fibres are located in the Ganglion geniculi. -
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bitter
umami
tahir99-VRG & vip.persianss.ir
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Muscles of the tongue
M. tran1M1'8118II~M
MIUldlbula
Fig. 8.139 Tongue, Lingue, and muecln of the tongu•, Mm. linguae; median section. The tongue is 8 highly flexible muscular body. It is essential for chewing and swallowing, facilitates sucking, and provides the ability to speak. In addition, the tongue has an acute sense of touch and is the organ of taste sensations. The tongue is composed of intrinsic muscles, making up the body of the tongue, and extrinsic muscles, which have their
origin at the slceleton and project into the tongue. The extrinsic muscles of the tongue alter the position of the tongue, whereas the intrinsic muscles change the shape of the tongue. The majority of the tongue muscles insert at the Aponeurotil linguae, a tough plate of connective tissue beneath the mucosa of the dorsum of the tongue.
1-+TZal
Fig. 8.140 Tongue, Lintue, and intriMic muldn of the tongue, Mm. llnguaelnternl; cross-section at the level of the tip of the tongue. Like 8 wickerwork. the intrinsic muscles of the tongue are interlaced in all three dimensions. In the median plane, the Septum linguae intersects the tongue incompletely into two halves. Agonistic and antagoni· stic muscle facilitate the flexibility of the tongue. To both sides at the tip of the tongue e mucous gland is present {Glandula lingualis, BLANDIN's gland}.
1-+TZal Facie~ inferior lir9U
M.longltudlllllllt IIUJ*Ior
Fig. 8.141 Tongue, Lingue, and intrintic ml.lllek• of itle tongue, Mm. linguae lntKnl; cross-section at the level of the middle part. The origin and insertion sites of all intrinsic muscles of the tongue are within the tongue itself. There ere Mm.longitudinalis superior, longitudinalis inferior, transversus linguae, and verticalis linguae. These muscles are interlaced and positioned perpendicular to each other in all 1hree dimensions. The ability of the tongue to change its shape helps during chewing, sucking, singing, speaking, and whistling. The M. genioglossus is a member of the extrinsic muscles of the tongue.
-+ dl..eetlon link 83 tahir99-VRG & vip.persianss.ir
Head
Overview -+ Skeleton and joints -+ Muscles -+ Topography -+
Hyoid bone and hyoid muscles
Fig. 8.14Z Hyoid bone, 0. hyoideum; anterior superior view. The horseshoe-shaped hyoid bona consists of a body (Corpus) which holds the paired greater and lesser horns (Cornua majora and minora).
Fi1. 8.143 Hyoid bone, 0. hyoideum; lateral view.
Carpuo ITIIIIII~IbuhiHI-...,
Fig. 8.144 Mouth region; lateral inferior view. The muscular Diaphragm• oris consists of the two Mm. mylohyoidei and forms the floor of the oral cavity. In addition, the Mm. geniohyoidei (not shown) and digastrici participate in the formation of the floor of t11e mouth. Directly or indirectly, all these muscles are attached to the hyoid bone and, together with the Mm. stylohyoidei, are collectively
referred to as Mm. 1uprahyoidei (suprahyoid muscles). From a functional standpoint, the floor of the moutl1 represents an adjustable abutment for the tongue.
1-+TZb,tl
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Touching the floor of the mouth. the palatine arches or the back of the throat initiates either the ewallowing or the gag rellax. Muscles of the tongue, Pharynx. Larynx. and Oesophagus participate in these reflexes. Al..,glc .-..c:tlons can result in a life-threatening swelling of the mucosal lining of the soft palate. Inflammation• of the palatine mucosa, here particularly the mucosa of the soft palate, typically evoke severe discomfort during swallowing.
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-+ di•aaction link
Impaired blood perfullon of Ute brain mm frequently coincides with palatine muscle palsy. This causes difficulties in swallowing and an impaired tubal ventilation of the middle ear. These patients can display a velopalatine palsy (nuclear lesions of theN. glossopharyngeus !lXI and N. vagus lXII resulting in the Velum palatinum hanging down on the side of the paralysed M. levator veli palatini. The Uvula deviates to the other (healthyl side. Often, the tongue is the first to be injured by chemical bumtand acaldlng. At t11e margins of the tongue, potential precancerous 11llons can show as hyperlceratosis or leukoplakia.
tahir99-VRG & vip.persianss.ir
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Floor of the mouth and muscles of the floor of the mouth
M. dig~ .. Tendo rrtermedlu.
Fig. 8.145 Lower jaw, Mandi'bull, and muldu of the floor of the mouth, Mm. suprahyolchl; frontal view. The floor of the mouth (Diaphragms oris) is a muscular layer created by the suprahyoid group of muscles. The central muscle at the floor of the mouth is the M. mylohyolchus which extends between the two Rami mandibulae to both sides and joins in the midline at the Raphe mylohyoidee. Beneath this muscle lies tha paired Venter anterior of the M.
digutricue which connects with the Venter posterior by an intramuscular tendon. This intramuscular tendon passas through a tendinous pulley and attaches the M. digastricus to the hyoid bone. A third su· prahyoid muscle coming from the hyoid bone is theM. nylohyoichue.
Fig. 8.146 Lower jaw, Mandi'bull, mutdte of the floor of the mouth, Mm. suprahyolclel, and hyoid bone, Os hyoldaum; superior view. The Diaphragms oris. formed by the two Mm. mylohyoidei and tha paired M. genlohyofdiUI, is shown. The M. genlohyoldeus a member of the suprahyoid muscle group, stretches from the inside of the
Manclibula to the hyoid bone. As a member of the extrinsic muscles of the tongue. the overlying M. genioglossus has been cut at its origin at the Spina mentalis superior of the Mandibula.
-+ dl..eetlon link 85 tahir99-VRG & vip.persianss.ir
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Muscles of the tongue
M. COI'IItllctaf ph.wyngllt medlue
Fia. 8.147 Tonau., Lingu-. •nd extrin1ic muecl• of the tongue, Mm. llngu.. externl; view from the left side. The extrinsic muscles of the tongue project into the tongue. They consist of the Mm. genioglcm~u1, hyoaiOAUt, end etyloglonu1. In a~ dilion, the M. palatoglossus is an extrinsic muscle of the tongue. The
M. hyoglossus can receive functional support bye M. chondroglossus. which originates from the lesser horn of the hyoid bone 1- Figs. 8.148 and8.14SI.
1-+nb I
M. hyo8lo&&u&
Oe llyOidQUII, Cornu mlnue
Fig. 8.148 Tongue, Lingu., end extrin1ic mu•cl• of the tongue, Mm. lingu.. externi; view from the left side. Beneath 1tle dissected M. hyoglossus, the small M. choncfroglonus is shown originating from the lesser hom of the hyoid bone and functionally assisting the M. hyoglossus. In addition to the extrinsic muscles
of the tongue. the M. palatoglossus and the Pars glossopharvngea of the M. constrictor pharyngis superior project into the posterior aspect
of the tongue.
1-+nb I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The protrusion of 1tle tongue requires a functionally intec:t M. genioglossus. In a deep com-. the M. genioglossus becomes flaccid. In a supine position, the tongue slides back into the Pharynx and
86
-+ dl..tu:tlon
link
can block the airways. Thus, as a precaution unconscious patients should always be plaoec! in the lateral recovery position.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Muscles of the tongue and pharynx
TUnlcamucceacrll
M.~gloNINJ
Fia. 8.141 Muecl• of 1tie tonaue, Mm. lintuae; inferior view. TheM. genioglossus was removed at its mandibular origin. Also. the Mm. styloglossus and peletoglossus were removed. At the lateral side. the M. hyoglossus (cut at the right side of the tongue) and M. chondroglossus are shown. which are extrinsic muscles of the tongue. As part
of the intrinsic muscles of the tongue, the M. longitudinalis inferior stretches out within the inferior aspect of the tongue.
l-tT2b
I
A.; v. illlyngN eupelfor;
N. 1.-yngeus supelfor
Fla. 8.160 Extrinsic muscles of the tongue, Mm. llnguee emml, and pharyngHI muscles, Mm. constrfctores pharyngh; lateral view; mandibular arch removed. The Lig. stylohyoideum extends between theM. styloglossus and M. stylopharyngeus. Located below are the pharyngeal muscles: the M. constrictor pharyngis superior with the Pars glossopharyngea and the
M. constrictor pharvngis medius with the Pars chondropharvngea and Pars ceratopharvngea. The M. constrictor pharvngis inferior with the Pars thvropharyngea is located below the hyoid bone.
l-tT2b,5
I
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Vessels and nerves of the tongue
V. IUblnglllllla N. aubll~ualla
M. 'lly!OgloNu•
A. I~
N.l~ IUPIIIfor, R.IMWnUI
F'~t. 8.151 V...111and MI'VN of 1fl1 tongUI, Lingua; inferior view. The A. lingualis from the A. carotis extema provides the arterial blood supply of the tongue. Branches of the A. lingualis are 1he A. profunda linguae. mainly supplying the muscles of the middle and anterior part of the tongue, and !he A. sublingualis. passing to 1he sublingual gland (Glandula sublingualis) and to 1he floor of the mouth. Projecting backwards. 1he Rr. dorsales linguae can communicate with each other. whereas all other branches from each side are separated by the Se~ tum linguae and only provide arterial blood to one half of the tongue. The VIIIOUI drainage is achieved by the V. lingualis. The V. lingualis runs adjacent to the M. hyoglossus end drains into the V. jugularis interne. The V. lingualis collects blood from the Vv. sublingualis. profunda linguae. and dorsales linguae as well as from the V. comitans nervi hypoglossi.
With the exe4'lption of the innervation of the M. palatoglossus by the Plexus pharyngeus, the motor innervation of the tongue derives from the N. hypoglossus (XII). Sensory innervation in the anterior two-thirds of the tongue is provided by the N. lingualis. a branch of the N. manclibularis (V/3), in the region of the Sulcus terminal is by the N. glossopharyngeus (IX), and at the base of the tongue by the N. laryngeus superior {a branch of the N. vagus (X]). Branchu ofh A. llngualls: • IR. hyoideus) • Rr. dorsales linguae • R. suprahyoideus • A. sublingualis • A. profunda linguae
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A subeplttllllal venous plexus is located in the mucosal lining at the underside of the tongue. This facilitates quick resorption of medication placed undemeath the tongue.
88
-+ dluactlon llnlc
InJuries to th1 N. hypoglossus lXIII on one side cause the protruding tongue to deviate to the affected side; muscular atrophy occurs on the ipsilateral side of the hypoglossal nerve palsy.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Vessels and nerves of the tongue, tonsils
M. atylctglaaiUa,
N.llngu•l'- (N. m111dlbullrte lV/311 QIIDIICip~l [IX] M.atylo~
N. flvpoglollulllCJI] N. Q8MCIII&[C1)
M. genl~llcleYe •
Fig. 8.152 v....l• end nei'Ve* of the tonaue, Linaue; lateral view; mandibular arch removed. [1 0]
Ph•ryng•l Lymphoid Ring twALDEYER'a Ton8111•r Ring)
Rr. tonei.._
Dellnltlon
A cluster of lympho-epithelial tissues located at the transitional zone between oral and nasal cavity and the Pharynx form the pharyngeal lymphoid ring. The pharyngeal lymphoid ring selVes in immune responses and is part of the muCOS811SSOCiated lymphoid tissue IMALT).
Componats
• pharyngeal tonsil (Tonsille pharyngeal • tubal tonsil (Tonsillae tubariael • palatine tonsil (Tonsillae palatinael • lingual tonsil (Tonsillalingualis) • lateral assortment of
M. pclatogloeeue
(Nn. P«
~ pp.
60, 68
~ pp.
80. 82
~ pp.
81. 82
MALT
Fig. 8.1&3 Blood 1nd ~MrV~tupply of 1M fHIIatlne tonsil, Ton IIIII plllltlna, right sic»; medial view. The Rr. tonslll1rn of the A. palatine ascendens, the R. pharyngeus of the A. palatine ascendens and the Rr. pharyngeales of the A. pharynges ascendens as well as the Rr. dorsales linguae of the A. lingualis supply blood to the Tonsilla palatine. The innervation of the tonsillar bed comes from Rr. toneillll"8* of the Nn. palatini minores end N. glossopharyngeus (IXJ.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Frequent recurrent infection of the palatine tonsils is an indication for their surgical removal Honslllectomy), one of 1tle most frequently ronducted surgical ENT procedures. Postoperative bleedings can
occur up to three weeks after the operation lin rare cases even longer) and can be a serious romplication.
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Parotid gland
M.~er
M. ~angui cria
V.;A. fldda
F'tg. 8.154 Parotid tland, Glandula parotidN, right eicle; lateral view. The exclusively serous Glandula parotidea is the largest salivary gland. Size and dimensions are quite variable. The superficial layer of the gland is positioned directly in front of the outer ear and covered by a tough fascia (Fascia parotidea; cut margins shown). The Fascia parotidea is a continuation of the Lamina superficialis of the
Fascia <:4lrvicelis. At the anterior margin of the gland, the Ductus perotideus exits end runs horizontally across the upper half of theM. masseter to the M. bucx:inator. pierces this muscle, and. in the Papilla ductus parotidei, opens into 1he Vestibulum oris opposite to the se«~nd upper molar tooth. Frequently, accessory glandular tissue {Glandula parotidea accessorial is associated with the excretory duct.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Surgical removal of tumours the parotid gland can result in guiJtatory
.weating (FREY'• eyndrome). During 1tle surgery, damage occurs to the sympathetic end parasympathetic nerve fibres innervating the glandular parenchyme. Postoperative recovery includes the rage~ eration of parasympathetic fibres and the accidental synapsing of these regenerated fibres with sweat glands of the sldn, formerly i~ nerve ted by sympathetic fibres. Acetylcholine is the neurotransmitter for the sympa1hetic innervation of sweat glands (as it is in parasympa1hetic nerve endings}. Thus, 1he formerly sympathetic innervation of sweat glands has now turned into a parasympathetic innerva-
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tion of the same glands. Activation of the parasympathetic system (e.g. in a hunQry person seeing delicious food) results in sweating of 1tle cheek: area adjacent to the ear (thus. gustatory sweating}. P1rotitie epidemic. or mumps is very painful because the pa~ tid fascia restricts the expansion of the swollen glandular tissue. Malignant tumours of the parotid gland can result in a lesion of theN. facialis [VII); by contrast, benign parotid gland tumours are the most common tumours of the parotid gland and rarely damage the N. facialis lVIII.
Vessels and nerves
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Nose
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Mouth and oral cavity
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Salivary glands
Parotid gland, horizontal section
Slnuamalllllllll
Proc. ccndylallt
Fig. 8.155 P1rotid ea.nct Oa.ndull p1rotide~t, 1nd m..ticatory muecl•, Mm. m..tic:atorii; horizontal section; inferior view. The Glandula parotiaea consists of two parts. The superficial part (PII'$ su.,.,Oclalll) is located immediately in front of the outer ear. Projecting
deep into the Fosse retromandibuleris is the larger pert of the glend (Pirt profundel which is devoid of a fascia. This section shows the Mm. temporalis and pterygoideus lateralis positioned between the Glandula parotidea and the Sinus maxillaris.
l•linry Gl•nda (GI•ndua.e 18li'VIIri•• oria) Three bilateral large salivary glands (Glandulae salivariae majores) and multiple small salivary glands !Glandulae selivariee minoresl supply saliva to the ore! cavity.
Small Rl1vary glenda
• parotid gland IGiendule perotidee} • submandibular gland !Glandula submandibularisl • sublingual gland (Glandula sublingualisl
~pp.40,42,46,54,90.96
• • • • •
~p.68
lip (Glandulae labialesl cheek (Glandulae buccalesl tongue (Glandulae lingualesl palate (Glandulae pal81inael around molars (Glandulae molaresl
~ ~
pp. 42, 92-96 pp. 83, 88, 93-96
~pp.83,95,96 ~
pp. 80,96
91
Head
Overview
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Skeleton and joints
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Muscles
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Topography
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Openings of the salivary glands
Flg. 8.158 Opening of 1fleexcretorv duct of the p1rotld gland; Papi111 ductu. parotidei. right tide; inferior view from en oblique angle. The opening of the excretory duct of the Glendule peroticlea (Ductus parotideus, STENSEN's duct) is located opposite to the second molar tooth on the Papilla ductus parotidei in the Vestibulum oris.
--~':"ff#<---+-- Dena pwmolallall
P-- --f--
Dens pniiTIOiallll
...-:=:-::--:-...-Dena cainua
:::...._--'::.ir--.,_+--
Dena lnciiMiall
~::..111'='--::::•~-+- Denalncii!Mial
Flg. 8.157 Opening of 1fle excretorv duct of the .ubmendlbulu glend, C.runcule tubllnguelll; frontal superior view. The excretory duct of the Glandula submandibularis {Ductus submandibularis. WHARTON's duct} runs at the floor of the mouth 1.... Figs. 8.160
and 8.161). merges with the main excretory duct of the Glandula sublingualis (Ductus sublingualis major}, and opens at the Caruncula sublingualis on both sides af the Frenulum linguae and behind the incisors into the Cavitas oris propria.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . AnomeiiM of the exc:rmry duct IYftlm, in particular the Ductus submandibularis, can result in the formation of a renule (retention cyst filled with saliva}. In lddnev disease, increased levels of renallv cleared substances can be detected in the saliva. Salt !calcium phosphate as main comp~ nent} deposition from the saliva can cause calculus or tartar, perticularly at the lingual side of the lower incisors, or can lead to salivary
92
-+ dissection llnlc
glandular stones (tlelollthl) within the excretory ducts of salivary glands. This can cause the obstruction of the duct with episodes of salivary* colics« and swelling of the gland (so-called} salivary tumour). Radiation therapy of head and neck tumours can lead to the dry mouth syndrome with difficulties in swallowing and speaking. lnflammltlons of the salivary glands can be acute or show a chronic progression.
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Submandibular gland
N. facllllla [VIQ, R. cell
Faecla C«''lfc:alll, Lamii'IIIIUperftdllla
Glandula l~lmendiiiUIII.Ita I
Fig. 8.158 Subm1ndlbul1r gllnd, Gl1ndul1 eubm•ndlbullrfe, left side; inferior view from an oblique lateral angle. The Glandula submandibularis is located in the Trigonum submandibulare. The gland has its own fascia enclosed within the superficial cervi-
cal compartment as delinaated by the Lamina superficialis of the Fascia cervicalis (~ p. 169). This gland has a direct topographic relationship to the A. and V. facialis.
M. II)IOGIOaaUa
Fig. 8.159 Subm1ndlbul1r gllnd, Gl1ndul1 eubm•ndlbullrfe, 1nd eubllngu•ltl•nd, Gl•ndula eubllngu•ll•, lift e1de; lateral inferior view. The superficial glandular portion of the Glandula submandibularis is bent backward, theM. mylohyoideus is separated from the Mandibula and folded medially. Beneath the removed muscle, the deep glandular portion of the Glandula submandibularis end the Glandula lingualis,
positioned parallel to the Corpus mandibulae. become visible. Amrl•l supply to the glands comes from the Aa. facia lis. submentalis. and lingualis. The venous blood is drained by the V. sublingualis and V. submentalis into the V. facialis or directly into the V. jugularis intema. Regional lymph nodes are ttle Nodi lymphoidei submentales and submandibulares.
-+ d,.uetlon link
93
Head
Overview
-+
Skeleton and joints
-+
Muscles
-+
Topography
-+
Submandibular and sublingual glands
Ploa aublntllllllll Duc!Ut ....lnSJUIIK mlnorM
F".g. 8.160 Submenclibuler glend, Olendule •ubmendiibul•ri•, encl eubllngu•l gl•nd.. Gl•ndu.. tubllngu•ll•, right tide; medial view. The Glandula sublingualis is located above the M. mylohyoideus and lateral from the M. genioglossus. The gland sometimes perforates the floor of the mouth. The glandular body bulges out the mucosa at the floor of the mouth creating 1he Plica sublingualis which contains multiple openings of smaller excretory ducts !Ductus sublinguales minoresl
derived from the posterior glandular part. The lower pert of the Glandula submandibularis embraces the posterior margin of 1he M. mylohyoideus in a hook-shaped manner and extends as Ductus submandibularis above 1his muscle. The N. lingualis courses between the Glandula submandibularis and the Glandula sublingualis and below the Ductus submandibularis to the tongue.
A. lll..eollria inferior
N. hrPolll- DCIIJ
Flg. 8.111 Subllnguel , ..nd, Glendul•subllngu•llt, •nd eubm•ndibu..r , ..nd.. G..ndul• .ullm•ndibu..rit; superior view. The anterior portion of the Glandula sublingualis contains a single larger excretory duct (Duetu• •ublinau•lit mejor) which merges with the
Ductus submandibularis superior to the M. hyoglossus. The merged excretory ducts open at the Caruncula sublingualis. The N. hypoglossus [XII) reaches the tongue between the M. hyoglossus and M. genioglossus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Sl•lollths are most frequently observed in the excretory duct of the Glandula submandibularis. In a concentrated saliva, salts form crystals that create a sialolith which can block the excretory duct.
94
-+ dluactlon llnlc
During meals. the gland quickly increases in size and becomes painful (-> p. 92).
Vessels and nerves
-+
Nose
-+
Mouth and oral cavity
-+
Salivary glands
Submandibular and sublingual glands
N.; A.; v. 1111blneua11a
Fig. 8.182 VIII:Mis and n1rves of th1 tongu1, Ltngua, l1rg1 ullvuy gl1nds, Gl1ndul11 ullvarll1 mljores; frontal inferior view. A frontal view onto the elevated tongue displays a subepithelial venous plexus on the underside of the tongue. On the right side, the Glandula sublingualis was reflected upwards to allow en unperturbed view of the
N. lingualis and the Ductus submandibularis !WHARTON's duct) beneath. The N. hypoglossus lXIII enters 1he tongue slightly deeper. As a frequent remnant of the thyroid development, a Lobus pyramidalis, located in front of the larynx, can extend up to the hyoid bone.
Head
Overview
-+ ••• -+
Salivary glands
Parasympathetic innervation of the glands of the head
R. communlean&* ~. cUIM18 bNYea
N. oculomotan.a 01~
RadiX pnsympatlllca
(OC\IIomotorll)
~ Nucleus oculamolollua -rtue
{eutcllomieuar
N. oph1hllrric.. 1)111) N.mmlllfsi.Vf.21 N. pel10e1a m•Jcr
Ganglion Pll!tnopeiatinum------------.=:::
F1r. pii'Otidtll til F1r. communleantll8 cum nervofeeilli N. feeillia IVlO
Flg. 8.183 P•r•sympllth.tk lnn1rvatlon ofth1 glands of th• h11d by autonomic ganali• of 1ftl h11td: schematic drawing. Parasympathetic fibres originate from the upper and lower salivatory nuclei (Nucleus salivatorius superior and Nucleus salivatorius inferior}. Pregangllonlro pu...ympathdtr fibres associate with various nerves to reach the parasympathetic ganglia of the haad (Ganglia oticum, su~ mandibulare, sublinguale, pterygopalatinum. ciliare). Here. these fibres svnapse and. as short postganglionic fibres, reach their target structures (glands). Prlgangllonlc: sympatllatk: fibres for the head derive from 1t1e lateral hom of the spinal cord. For the most part, these fibres svnapse in the Ganglion cervicele superius (upper ganglion of the sym-
96
pathetic chain). Postganglionic fibres create sympathetic plexus around arteries (e.g. A. cerotis internal and reach their destinations via blood vessels or by associatin~ with local nerves.
•
.......••••
lacrimal gland anastomosis of parasympathetic secretory fibres from theN. intermedius of theN. facialis [VII) with the R.lacrimalis of theN. ophthalmicus IV/11 to the lacrimal gland EDINGER-wESTPHAL nucleus JACOBSON's nerve BLANDIN's gland
Eye Development . . . . . . . . . . . . . . . . . . . . . . 100 Skeleton .. . .... .. .. .......... . . . ... 102 Eyelids .................. .... . . . . . . 104 Lacrimal Apparatus ......... . . ... .. 108 Muscles of the Eye ...... . .. . ....... 112 Topography ...................... . 116 Eyeball ....................... ..... 125 Visual Pathway .......... ......... . 131
The Eye a Window to the World When anatomists discuss the visual organ (Organum visusl. firstly they mean the eyeball (Bulbus oculil and, secondly, the auxiliary structures in its immediate surroundings (Structurae oculi accessoriael. Exceptfor the eyelids (Palpebrael. all auxiliary structures- including the eyeballare enclosed within the orbit (Orbital.
Orbit "Orbita" is certainly one of the least appropriate anatomical terms. The word is derived from the word "orbis" (circle), but a quick look at the skull confirms immediately that the outer opening of the orbit (Aditus orbitalisl is not completely circular but its contour is rather oval to round. At the nasal margin of the Aditus orbitalis, the bony structures of the nasolacrimal canal (Canalis nasolacrimalisl open towards the orbit. The walls of the orbit form a steep pyramid towards the inside of the orbit, with its upper and lower wall perforated by two large fissures (Fissurae orbitales superior ;md inferior) to ;~llow m;~ny nerves and vessels to pass through. The canal for the optic nerve (Canalis nervi optici) is located at the tip of this pyramid.
Eyeball The Bulbus oculi (lat. "bulbus": the onionl actually resembles an onion more than a ball. One can imagine a multilayered onion sprouting at one pole and rooting at the opposite pole. Similarly, the ocular bulbus is made up of multiple layers. The eyeball contains a watchglass-curved transparent cornea (Corneal and the optic nerve (N. opticus [IIIJ at its anterior and posterior pole, respectively.
The outer (fibrous) layer of the eyeball (Tunica fibrosa bulbil is composed of the selena (Sclera) and cornea (Corneal and consists of firm collagenous connective tissue. The extra-ocular muscles (see below) are anchored in what one perceives as "the white of the eye", which is the Selena. The Sclera turns into the avascular and transparent cornea (Corneal which consists also m;~inly of coll;~gen. The middle (vascular) layer of the eyeball (Tunica vasculosa bulbi) consists of choroid (Choroideal. ciliary body (Corpus ciliare) and iris (Iris). It is very rich in vasculature (bnanches of Aa. ciliares) and strongly pigmented. This v;~scular l;~yer of the eye ;~lso cont;~ins the intraocul;~r muscles which are not subject to voluntary control. From the outside, the iris, the anterior portion of the Tunica vasculosa, along with the pupil (Pupillal is visible. Muscles located within the iris can constrict or dilate the pupil (adaption). Along and behind the root (outer margin) of the iris, the Tunica vasculos;~ forms <1 circul;~r bulge known ;~s the ciliary body (Corpus ciliare). TheM. ciliaris is anchored within the Corpus ciliare. The ciliary body received its name because of the radial zonular fibres (Fibrae zonulares) which radiate towards the middle to secure the lens (Lens) in its position immediately behind the pupil. Normally, the lens is transparent and elastic. The effect of the zonular fibres and the ciliary body on the shape of the lens changes the refractive power of the lens and leads to focussing of the eye (accommodation). The actual vascular layer sepanates the Sclera and Retina and covers the posterior half of the eyeball. The inner layer of the eyeball (Tunica interne bulbi, syn. Retina) consists of a photoreceptor-free (i.e. nonvisual) (Pars caeca retinae) and a photoreceptor (i.e. visuall part (Pars optica retinae). The Pars caeca is a thin, heavily pigmented epithelium that covers the posterior part of the
98
iris and the Corpus ciliare. Along t he serrated edge (Ora serrata), just behind the ciliary body, it transforms into the much thicker Pars opt ica. However, this "seeing " Pars optica has a blind spot (Discus nervi opticil. where the optic nerve leaves the Retina and the branches of the A. centnalis retinae penetrate into the Ret ina. All layers of the eyeball and their different iat ions su rround the gelatinous, totally transparent interior of the eye, the vitreous body !Corpus vitreuml. It stabilizes the ent ire membranous structure of the eye by its swelling pressure (intra-ocular pressure) -similar to the air bubble inside a soccer ball stabilizing its leathery coat.
Auxiliary Structures The auxiliary struct ures of the eye consist of the eyelids (Pa lpebrael. the conjunctiva (Tunica conj unct iva), the lacrimal apparatus (Apparatus l;~crim;~lis), the six extT<~-ocular muscles ;~nd their three motor (cT<~ni;~l) nerves, numerous blood vessels, and a considerable orbital fa t body (Corpus adiposum orbitae). The ayalids (Palpebrae) are not only responsible for the protect ion of the eyeb;~ll but distribute the te;~ r film ;~cross the surface of the eye while constantly blinking. This prevents the surface of the eye from drying out. Located in the eyelids, numerous specialized sebaceous glands (MEIBOMIAN glands; Glandulae tarsales) contribute a fatty secretion to the tear film. The conjunctiva (Tunica conjunctiva) is a th in , t nansparent epithelial layer and covers the inner side of the Palpebfcular muscles form a muscle cone behind the eyeball with its t ip pointing towards the Canalis nervi optici. Located in the centre of the Canalis nervi optici, the A. ophthalmica and theN. opticus [Ill reach the posterior pole of the eyeball. The three nerves innervating the extra-ocular muscles, various branches of the N. ophthalmicus JV/11, as well as the branches of the V. ophthalmica are posit ioned within or adjacent to the cone. The remaining gaps between t he structures are filled by adipose tissue, the Corpus adlposum orbltae.
Clinical Remarks---------. The dry eye syndrome (keratoconjunctivitis sicca complex) is one of the most frequent chronic diseases affecting the surface of the eye. EveJY second patient consulting an ophthalmologist in Western industrial countries suffers from this disease. The a11Je-dependent macular cfeteneration (AMO} is the most freQuent cause of blindness in the industrialised world. followed bv diabetic retinopathy and glaucoma. While AMD mostly affects elderly people, dldurtlc rettno~ mostly affects individuals during the prime of their life {approx. 2000 new cases of blindness per year). Similar incidence rates as reported for diabetic retinopathy apply to glaucoma. Despite the fact that cmract is a common disease, it is not a frequent cause of blindness in Western industrial countries since prompt surgical intervention is an effective remedy in symptomatic cataract patients. However. cataract is the main cause of blindness worldwide. According to the World Health Organizetion (WHO), cataract is responsible for 48% of ell cases of blindness (approx. 17 million patients) worldwide. The main reason is a poor healthcare system in large parts of the world. In Africa, Southeast Asia, Central and Latin (South) America, and in the Middle East, approximately 84 million patients suffer from trachome lnfHtlon and 1.3 million of those infected cannot be cured !costs for treatment approx. 15 €/person). Trachoma infection is a classical disEHJse of developing countries with poor sanitation and contaminsted drinking water. Another cause of blindness during childhood in developing countries is vittmin A dtftclency (costs of treatment approx. 1 €/ child).
-+ Dl•••ctlon Llnlc For the d'laectfon of the orbit. the Pars orbitalis of the M. orbicularis oculi toge!her with the Partes palpebrales of the upper and the lower lid are removed from the underlying connective tissue and turned over medially. The structures should not be detached at the nasal canthus. Septum orbitals, Tarsus superior and inferior, and the Ligg. palpebralie mediale and laterals are presented. For cranial MaN to the orbit, skin and muscles covering the frontal bone and the Dura mater in the anterior cranial fossa ere removed. The opening the ortlibll roof should be carried out carefully to avoid damage to the Periorbita and other structures passing through the Fissura orbitalis superior. Upon opening ofth• P•todlltl, the M.levator palpebrae superioris with attached eyelid is dissected towards the Anulus tendineus !do not detach the N. trochlearis and R. superior of the N. oculomotoriusl. Next all the structures of the orbit are dissected from top to bottom by removing the orbital fat body. Careful blunt removal of the orbital fat body should be performed to preserve the Ganglion ciliere.
EXAM-CHECK LIST • Orbita: bony margins, openings, structure, topographic relationships • clinical remarks (e.g. blow-out fracture, orbital phlegmon) • blood vessels (cavernous sinus thrombosis) • Nn. crenialeaiiiVIl (including nuclei of the Truncus cerebri, Ganglion trigeminal&) • Glandula lacrimalis • Ganglion ciliare • retro-orbital fat body (GRAVES' disease, MERSEBURG triad, endocrine orbitopathy) • ext,..-ocular muaclee: location, Innervation, function, pt,..lyele • Bulbus oculi: blood supply and Innervation • Intra-ocular muscles: innervation, function, paralysis, HORNER's syndrome • supportive structures and eye surface: eyelids, tear film, conjunctiva, cornea, draining lacrimal ducts
99
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Development
Will ol 01111c stalk (c:on!lnLIOue with wdot'forelnln)
Week4
C.Vityofaptlclltalk Lena placadlt
Lane pit
fc;on11nuOI.It wi1h Cl1rity of fol1llnln}
Outwlllyerof 1heop1fccup
(prtmO!dlll ol nll~lllflVT!ent ~fum)
Fig. 1.1 Development of1fle eye, wHk4. [21) At week 4, the optic vesicle bulges out of 1tle diencephalic area of the prosencephalon. As the optic vesicle grows, its distal part gets in contact with the surrounding surface ectoderm and induces the formation of the lens placode.
Fig. 9.Z Development of 1fle eye, week 6; photomicrograph of a sagittal section. 1201 This image displays an invaginated double-walled optic vesicle with optic cup formation in close connection with the lens placode. Located between the two layers of the optic cup (primordium of the Retina) and in the optic stalk (primordium of 1he N. opticus [II)), the intraretinal space is still relatively wida.
W'Mk5
Optic stalk
c.vttyol !he aptle stalk
Fig. 9.3 Development of1fle eye, week 5.1211 The spherical lens vesicle separates from the surface ectoderm and the rim of the optic cup infolds on 1tle lens vesicle. The optic cup remains connected with the diencephalon by a small optic stalk. the former Sulcus opticus.
Fig. 1.4 Development of 1fle ..,., week I. 1211 At the deepest point in the optic cup, a longitudinal groove, 1tle optic fissure, becomes visible. This optic fissure contains blood vessels and the first nerve fibres of 1he later N. opticus [II). The blood vessels supply as A. end V. hyaloidea 1he inside of the optic cup. At 7 months, distal parts of the hyaloid blood vessels degenerate. whereas the proximal parts persist as A. and V. centralis retinae in close connection with the N. opticus [II).
Development of the E y e - - - - - - - - - - - - - - - - - - - - - - . . Eye development starts at 1tle beginning of week 4 with the formation of the optic vesicle in the prosencephalic area that gives rise to the dienei!phalon. Early on, the anterior pole folds inwards to form a primitive optic cup. The retinal pigment epithelium derives from the posterior section of the outer layer of the optic cup, whereas its anterior section gives rise to the ciliary body and Iris. The inner layer of the optic cup develops to become 1he Retina. At the contact zone between 1he optic cup and 1he surface epithelium. the lens vesicle
100
forms as part of the epithelial laver overlying the optic cup. The lens vesicle translocates beneath this epithelial layer. The ectoderm is also the origin for the Come<~ and Conjunctiva. Most of the other components of the middle and outer eye are of mesenchymal origin. A web of blood vessels (with contribution by the A. hyaloidea) initially surrounds 1tle primordium of the lens which disappears later on. The proximal stump of the A. hyaloidea becomes the A. centralis retinae.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Development
.:~!~~~~~~~~---Pigment epithelium
W..k8
or the reUn •
~--'-~::=:::--
Neurll eplthtilum of the nrtina
N. opUc118
lntllll'etinal ---!-7.'"--.:.,.:..;e:-•pem
Fig. 9.6 O.V.Iopment of the ~. wMk 8; photomicrograph of a sagittal section. [201 At week 7, lens fibres form as an elongation of epithelial cells at the posterior wall of 1he lens vesicle.
Fig. 9.8 Dn411opment of1fle eye, weeki. [21) Mesenchymal cells migrate into the optic cup and form the vitreous body !Corpus vitreum) 1hat is composed of vitreous humour. a gelatinous substance wi1h tiny fibres embedded. The vitreous body gives the eye bulbus its firm shape.
Fig. 9.7 Mele newbom with cyclopia. 1201 Cyclopia is an anomaly of the face and eye associated with a proboscisshaped nasal appendage above a single medially located eye.
Fig. 9.8 Male newbom with anophthalmia. f201 Congenital absence of all components of the eye and a single right nostril, with left nostril not formed. Although eyelids ere formed, the upper and lower eyelids remain largely fused.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Dnelopmenul detiM:ts of the eye are relatively rare. Inherited blindness has an incidence of 20 per 100 000 live births and in most cases coincides wi1h other {mental} disabilities. In some cases. remnants of the A. hyaloidea can persist and project from the papilla af the optic nerve into the vitreous body and even into the lens. As e
result, opacity af the lens can occur; however, often a persistent A. hyaloldea is of no clinical significance. Cyclopia refers to the partial or complete merger af both eyes in the middle of the face (-+ Fig. 9.71. Complete lack af eye development is referred to as anophthalmia (• Fig. 9.8).
101
Eye
Development
-+
Skeleton
-+
Eyelids
-+
Lacrimal apparatus
-+
Bony orbit lncisune frontllia*
0. ophonaldala, Ala minor
oa fmntlle, Pa.a olililala, Faciaa Oltlitalis ~ tr'GChllari&
Fa...rMn MhmDIIWtl polltllriua 0. fmntala, Pmc. zygamdcuo
Os ophenaldall, Ala major, Facl• crbltalla
oa lacrtrnal• Sulc!Ja lacrlmallll Oa zygomaUcum, Proc. fmntllla
08 zygomalicum, Faciaa Dltlitalis MIDdlla, PrDc. fmnllll•
FOI1UTltll zygorrudlcollldllkl 11\Ciaura lac~malls
Fluura orbital• lnfertDr
oa elhmoidlle, Lamina artlitalill 0. palllllnum, PrDc. Dftlltallll
Fig. 9.9 Orbit,. Orblbi, right side; frontal view from an oblique angle; colour ct1art see inside of the back cover of this volume. Seven bones form the walls of the orbit (Os frontale, Os ethmoidale, Os lacrimale, Os palatinum, Maxilla, Os sphenoidale, and Os zygomaticum). The Paries lateralis borders on the Fossa temporal is, the Paries
Fa...mha dvnaldala aniiHM • pa.tllrtu.
oa 81hmoldlla, Llrnlna Dftlllall8 FIMU1I orbltdl tupill'lor
medialis is located close to the ethmoidal cells and the nasal cavity. At its posterior aspect. the Orbita is in topographic proximity to the middle cranial fossa, the Canalis opticus, and the Fossa pterygopalatina. • These structures can be present as Foramina or Incisurae.
Squama f1'ontllle} Pin crbltalls 0. fmntlla Facl18 crbltalls
Cand8 opiiCUIJ
oa sphenoidlle,
Ala mnor
Fllltlu,. Dftlltalllllnfwiar A881ft pterygomaxlllal1a
0. poddnum
Proc. pyramldah { Prac. crbltalla
Rg. 9.10 Medial wall of the orbit. Perin medialia orbitae. right side; lateral view; colour chart see inside of the back cover of this volume.
102
F'lliJ. 9.11 Lateral wall of the orbit, Pariealatwar.. orbit... right aide; medial view; colour chart see inside of the back cover of this volume.
Muscles of the eye
-+
Topography
-+
Eyeball
--+
Visual pathway
Bony orbit
Prac. .zygamallcua
Fig. 9.12 Roof of the orbit. Paries superior orbltH; inferior view; colour chart see inside of the back. cover of this volume. The roof of the orbit is also the floor of the anterior era niaI fossa and
of parts of the Sinus frontalis. All bones of the Labyrinth us ethmoidalis are extremely thin and are easily fractured during surgical procedures.
08 sphii!Gidale, Ala ITIIIjor
Calulae 411hmoldale8
F"~g. 9.13 Floor of the orbit, Pari" inf11rior Olbitae, left aide; superior view; colour chart see inside of the back. cover of "It!is volume. The floor of the orbit is also the roof of the Sinus maxillaris. The Sulcus infraorbitalis is located in the posterior aspect of the orbit and turns
into a bony canal midway through the orbit. This Canalis infraorbitalis penetrates the Maxilla and terminates at the Foramen infraorbitale (not visiblellocated below 1tie orbit.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Despite the fact that the medial wall of the orbit is pa~M~r-1tiin (thus, the name Lamina papyracea), blunt force to the eyeball (e.g. centre blow to the orbit by a tennis ball) usually results in a fracture of the base of the orbit (so-called blow-eut fracrtura). As a result, intraorbital structures (Mm. rectus inferior and obliquus inferior) can be trapped in the fracture gap or be translocated into the Sinus maxil-
laris entirely (orbital h~~rnia). Reduced mobility of the eyeball cen cause double vision, enophthalmos, and/or the inability of this eye to look upwards. Involvement of the N. infraorbitalis, which runs in the floor of the orbit, is likely if, MMOIY dy.tunction in the dermal region of the upper jaw occurs.
103
Eye
Development
-+
Skeleton
-+
Eyelids
-+
Lacrimal apparatus
-+
Eyelids (Sulcu& ~I'll& auptl1~
Anuuru. oc:UIIIIIilnlr.
Arlgulul oculi lllenllle; CGmmiaalft
llrtsral• palptbrarum
Rma palpebrarum
Cllae
...lpeln lnf~utor (Sulcua pq.abn!n...la) Angulus oculi medilla; cammiaaul'l medillli& palpebl'lrUm
Ilis Puplla PalpabN.Infllrlar
l.inbua poslllrlor palpabras l.inbua ll'lltriDr palpebrae
Fig. 9.14 Eye, Oculus, right side, with ~lids dosed. On average, e human eye blinks 20 to 30 times per minute. Each eyelid movement distributes a tear film across the surface of 1he eye. Blinking involves a consecutive contraction of the M. orbicularis oculi from temporal to nasal and results in a wiping motion in 1he direction of the nasal canthus. Mechanical irritations (e.g. sudden draft, dust particle, fly) activate the blink reflex (also known as corneal reflex) to protect the surface of the eye.
Fig. 9.15 Ey., Oculus, right side, with .yellds open. In an adult with eyelids open, the width between the upper and lower eyelid ranges between 6-10 mm, and the distance between the temporal and nasal canthus is 28-30 mm.
TWIIca 110njlnc:tlva buill f(lmbl: ccrjunctllllle
l'llerlor
pelpeb,.l\lm
1\RCII conJunclln Umbus pon,rtor palpebrae
~~======~~~;;;
Umb~~r _J~~~----~~~~~/~--~~--•
Plica Mmllunn can;..,Ciivle
palpebnle
Plica Mmllunn con)roellva
l'ln:tum l•cnn•r. Papilla lacrlmalla l"!fllrior)
C.UIII:UII '-!m11r.
Fig. 9.18 Eye, Oculus, right side, with upper end lower eyelid
everted. With the exception of the cornea, the Conjunctiva, a translucent thin layer of mucosa with blood vessels, covers the pert of the eyeball creating the eye surface, end the side of the eyelids in contact with the eye surface.
Fig. 9.11 Eye, Oculus, right side, with eulsted Ktroplonlsed upper eyelid. The Conjunctiva palpebrae end the Conjunctive bulbi cover the rear side of the eyelid and the eyeball, respectively. Bo1h conjunctival parts merge at the upper end lower Conjunctive fornicis. The letter being the socelled conjunctival sac. Eyedrop medication is administered into the lower conjunctival sac.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , A number of diseases involve the narrowing or widening of the p•lpeilnll fiAun. Lesions of sympathetic fibres can result in palsy of the M. tarsalis superior in the upper eyelid, resulting in the palpebral fissure becoming narrower. Paralysis of the oculomotor nerve causes ptosis of the upper eyelid (wich hangs down) due to the paralysis of 1he M. levator palpebrae superioris. By contrast, a facial nerve palsy results in impaired function of the M. orbicularis oculi and a widening of the palpebral fissure.
104
lnfl•mmation of the conjunctiva (conjunctivitis) is encountered frequently in individuals wearing contact lenses. Anemic pB1ients display a whitish pale conjunctiva because the low erythrocyte count in these patients prevents a normal filling of conjunctival blood vessels with red blood cells. Eversion of the lower eyelid and inspection of the conjunctival sac is a simple diagnostic test to identify this condition.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Facial Muscles 081118111 M. cl'tllallarla OCCJI,
P-Pl!lpebrslle
M. orblcl.flllla oculi, P-o~lit
M. llw8!or labll.upelfalla IIUql/8111181
M . ._rle
M.IIMIOI"Iatli auperioris
M. lllllldor labll.upti!Oift
M.~nwjor
M. zygamallc:ut mlnar
M. Z)'IIOml1lcUII mtlor
Fig. 9.18 Fecill mueclet, Mm. feciei. in the orbitel reaion; frontal view. The Pars orbitalis of the M. orbicularis oculi encircles the anterior
opening of the orbit. The Pars palpebralis of this muscle continues into the eyelids. T 18, c, d, •
1-
I
M. Oltllelll111111 oc:ul. Para llerimalis
..40....--- Ceii!Aa etllmeldalls anttltor U ,._+---+--SMcuall<:llmalla
Fig. 9.19 M. orbiculeril owli.l.tt •icle; posterior view. At the nasal c:enthus the Pars lacrimalis of 1he muscle (HORNER's mu&cle). which assists in draining the tear fluid, is visible. The M. orbicularis oculi consists of three parts. The Per• orbiblli• is responsible for the voluntary firm occlusion of the eyelids. Contraction of the Pars ptlpebrells results in blinldng of the eye, which can occur voluntarily but usually happens involuntarily. Placed around the lacrimal c:enaliculi, the Pers lacrlmalls !HORNER's muscle} is essential for the drainage of the tear fluid. Ouring blinldng, the two lecrfmal punetll (Puncta lacrimalia: Punctum lacrimale suparius end Punctum
lacrimale inferius) in the nasal third of 1he medial canthus dip into the lacrimal lake (Lscus lacrimalisl. It is assumed is that the contraction of the Pars lacrimelis results in a suction effect (pressure-suction pump mechanism). Channeled vie the lacrimal puncta. the tear fluid is sucked through the upper and lower lacrimal canaliculi (Canaliculus superior and inferior) into the lacrimal sac (Saccus lacrimalis). The lower lacrimal canaliculus transports most of the tear fluid. • muscle of RIOLAN
I-tT 1c I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . lnJur1n to 1fle N. &clalla can result in the paralysis of the M. orbicularis oculi with the inability to close the eye llegophthalmos). When the patient is asked to close hisJher eyes, the eyeball rolls upwards as usual !the outer extra-ocular muscles are intact} and the white scr lara becomes the only visible part of the eye IBELI.'a phenomenon; ... Fig. 12.151). The inability to close the eyes prevents the even
distribution of the tear film across the eye surface. As the tear film becomes discontinuous, the Cornea starts to become dry and loses transparency shortly thereafter. The patient is unable to see with this eye. The missing eyelid closure represents the greatest challenge in the treatment of patients with facial nerve palsy.
- dl•••ctlon llnlc
105
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Eyelids, structure
Rg. 1.20 Upper eyelid, Pllpebrltupedor; photograph of a histological specimen; azan stain; sagittal section, magnified. [28] The eyelid can be divided into an outer and inner lamina. The outer lamina is composed of the striated M. orbicularis oculi with its Pars palpebralis. The inner lamina consists of 1he conjunctiva (Tunica conjunctiva palpebrarum). the tarsus (Tarsus) with integrated MEIBOMIAN glands IGiendulae 1arsales, modified sebaceous glands) and, close to 1he rim of tha eyalid, muscle fibres (muscle of RIOLAN, Fasciculi ciliares) derived from the Pars orbitalis of the M. orbitals oculi projacting into the tarsus.
Tunica CC!ljunctiva pelpebnuum
* MEIBOMIAN glands ** muscle of RIOLAN Facleunlellor palpel:ne
.1\nguh• oc:ul mediiIt
Fit. 9.21 Eyelldl, P1-.ebr1e, right aide; posterior view; translucent specimen illustrating the excretory ductules of the tarsal glands. Each eyelid contains approximately 25 to 30 individual glands with their excretory ductules opening into the rim of the eyelid !Rima palpebralisl. • MEIBOMIAN glands
Ltlcffmlllgland and ------!... W.tety ccmponent - t y laclt!1alglllnd8
Strd1ltd 8(1UimOUII
nonkln.ti!lizecl epilheium
\
ofComllandCon)une111111------!.,. MUCO\Iti;OI!lponent
Upd component
Rg. 1.22 Stnlctu,.. of the ev- surfac.. involved in the formation of the three components of the tear film; schematic drawing.
106
Muscles of the eye - Topography -
Eyeball - Visual pathway
Blood supply and innervation of the lacrimal gland and eyelids
MIIXIIa. Proe. fro!MIIt
Fig. 9.23 Orb~el opening, Aditul orbital•, right eide, with Septum orbittle, tlrNI pllt.., 1nd !MIIJiebrtllig•mentl; frontal view. Dissection of the Septum orbital& and of the inserting tendon of the M.
levator palpebrae superioris displays the lacrimal gland. The tendon of the M. levator palpebtlle superioris divides the lacrimal gland located in the temporal upper quadrant of the bulbus into a Pars orbitalis and a Pars palpebralis.
Fig. 9.24 Arterf.., veiM, •nd nerve• ~the omrtal opening, Adltue olbltllle, end In the perJOIIIItll region, right elde; frontal view. [10) The superior and inferior Arcus palpebralis create an arterial circle located above the Septum orbitele end surrounding the orbit. This emr rial circle is supplied by numerous arteries derived from the A. carotls interne {A. supreorbitelis, As.. pelpebtllles laterei9S of the A. lacrimelis, As.. pelpebrales mediales) end the A. cerotie extern• {A. facialis. A.
angularis. A. infraorbitalis. A. temporelis superficialis. A. zygomatic:oorbitalis). The Nn. supraorbitalis and infraorbitalis are branches of the N. ophthalmicus [V/1) and N. maxillaris IV/21. respectively, and exit the orbit through the identically named Foramina (the N. supraorbitalis may exit the orbit through the Incisure supraorbitelisl. The sensory perception of the N. ophthalmicus [Vf1Jend N. maxillaris [V/21 can be tested at both nerve exit points.
- dl•••ctlon llnlc
107
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Clinics Clinical Remarks---------. A ch1lulon is a granulomatous inflammation of a MEIBOMIAN gland, usually as a result of an occluded opening of the excretory duct. Located just below the rim of 1tte eyelid. a chalazion can be palpated as painless, non·movable mass with the size of a gn~pe seed up to a hazelnut. A stye (honlllolum) is a frequently putrid inflammation of individual glands of the eyelids !usually caused by bacteria and painful). Inflammations of the rim of the eyelid often result in bii!Phlriti• 1~ Fig. 9.25) with typical signs of dry eye. including burning. Sensation of foreign objeet in the eye, mild photophobia. and reddening of tha eyelid rim.
Fig. 9.15 lnft1mm.Uon It the rim of the ~lld1, Mbonfloek bleph.rltll. [15)
Fig. 9.26 T"r film of the eye, right •ide; frontal view; slit lamp examination with fluorescent dye in blue light. [15) The spot represents a dry corneal area resulting from the disrupted tear film.
Fit. 9.27 SCHIRMER'1 tett performed on 1 h"Hhy pe,_,n, The two paper strips display a clear purple colouration of 1he yellow SCHIRMER's paper strip. Within 5 minutes, tha paper strips are completely purple.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . If an impaired function of the lacrimal gland is suspected, e.g. as part of a facial narve palsy. the SCHIRMER'$ t..t is performed. A filter paper strip of standardized length, bent at one end, is hooked into the conjunctival sac. Absorped tear fluid causes a change in colour 1~ Fig. 9.271. At a normal rate of tear production, more 1han two thirds of the peper strip should be coloured within 5 minutes. A shorter length of the moisturised (coloured} paper strip suggests a reduced tear production.
Another test of the tear film examinas its ability to maintain a continuous film across the entire eye surface by measuring the time it takes for the tear film to break up (telr br. .k·up time). A normal tear break-up time is approximately 2~0 seconds but break-up times below 10 seconds can cause the dry eye syndrome.
Clinical Remarks---------. The V. angularis located in the medial (nasal} canthus transitions into 1tte intraorbital V. ophthalmic& and connects a part of the facial venous dn~inage system facialisl with the Sinus cavern~ sus. Infections in the outer facial area (e.g. improper squeezing of pimples on the cheel:} can lead to a spread of bacteria reaching tha Sinus cavernosus and causing a c1vemou1 1lnu1 thrombo· •I• (-+ p. 223). At tha first signs of ascending infection. the V. angularis should be ligated at the medial can1ttus to prevent a potentially life-threatening thrombosis of the sinus. lnflllmmatl· on of the laCffmal gland !dacryoadenitis; ~ Fig. 9.28) causes protrusion of 1tte Septum orbitale and reduced eyelid opening.
rv.
Fig. 9.28 Reducld eyelid openine, right tide; in the cue of an acute dacryoadenitie (inflammlltion of thelacrim•lalandl. [15)
108
Muscles of the eye --+ Topography --+ Eyeball --+ Visual pathway
Lacrimal apparatus, innervation
Olan..U a-tmalls, Pats Oltlitali&
R. commun~ct~n• cum nwwo zrgOI'I'IIdlco
M. 19Ctw lallllllll N. opticus pq
oa sphenoidlllll, All. mljor R. comm.ncane cum nervo zrgomltico
Foramen zygamaUcoorbltale
Fig. IZI lnn..v.tion crf 1helacrimalgland. Glandula IIICJimalie, right side; medial view onto the lateral wall of the orbit.
N. ZftCIIIWIIcU•
nection between the N. zygomaticus and N. lacrimalis via the R. communicans cum nerve zygomatico.
Presentation of the lacrimal gland, the A and N. lacrimalis and the con-
N. faclllla IVIO
- - - Prega~gllcnlc parasyrnptdhstlc ftb,_ - - - - - - Paetgangllonlc pareaympalhaUc ftbree - - - - - • Postganglionic IIYJ11lldlleiiC ftbree
Fig. 9.30 Sympllth.tlc and parasympathdc lnnerv.tlon crf 1h• lacrlmalgl•ncl. Glandula lacrlmalls; schematic drawing. [10[ Preganglionic sympathetic nerve fibres synapse in the Ganglion cervical& superius and postganglionic sympathetic fibres leave this ganglion to reach the lacrimal glands either by accompanying the As. carotis interne, ophthalmica, and lacrimalis, or by parting already from the A. carotis intema at the Foramen lacerum and joining the parasympathetic
fibres on their way to the lacrimal gland. Preganglionic parasympathetic nerve fibres run with the intermedius portion of the N. facialis [VII], pass through the Ganglion geniculi without synapsing and reach the Ganglion pterygopalatinum via theN. petrosus major. Upon synapsing, postganglionic parasympathetic fibres associate with the N. zygomaticus and reach the N. lacrimalis and the lacrimal gland via the R. communicans cum nervo zygomatico.
109
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Lacrimal apparatus PliCa eemlunll'l8 con~nC11Vae
CendNut recttmelt •UI*'for
Slcc:ut llecdmllll Cl.n•lcululllcrtm..lelnfertor PolpllelecrirneJjjl;
Punctum lacrinwle tcarpua CIIWIM-.r!)
Fe mix conjunctivM
Candw. IWMlla media
Concha n.allalnflllfor
110
Fig. 9.31 UU:flmll lppil'lltUI, Applr'lltUI llclfmllll, fight llde; frontal view; the eyelids have been pulled away from the eyeball providing a view into the upper and lower conjunctival sac; the nasolacrimal duct has been opened up to the Meatus nasi inferior. The draining nasolacrimal duct is composed of the upper and lower
lacrimal canaliculi (Canaliculi superior and inferior), the lacrimal sac (Saccus lacrimalis), and the nasolacrimal duct (Ductus nasolacrimalis). The Ductus nasolacrimalis exits into the inferior nasal meatus (Meatus nasi inferior) benea1h the inferior nasal concha !Concha nasalis inferior).
Fig. 9.32 1Actfm11 IPPII'IItUI, Applr'lltUI llclfmllll, fight llde; frontolateral view; after removal of skin, muscles, and Septum orbitale in the nasal canthus. The lacrimal sac (Saccus lacrimalisl is located in the Fossa sacci lacrim~ lis and continues caudally as Ductus nasolacrimalis in a bony enclosure formed by the Maxilla and the Os lacrimale in its anterior and posterior section, respectively. Each canaliculus originates as a 0.25 mm (upper)
to 0.3 mm (lower) wide. round, oval or slit-shaped Punctum lacrimal& which oontinues as an approximately 2 mm long vertical tube. Then, each canaliculus bends in an almost right angle and proceeds as an approximately 8 mm long horizontal segment. In the majority of cases (65-70%), both canaliculi merge to form a common tube approximately 1-2 mm long that opens into the lacrimal sac about 2-3 mm below the Fornix sacci lacrimalis.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Lacrimal apparatus
Ampulla ClniiCUI1acR!lll8
M. odllcut.ll acul
Fig. 9.33 U.crfm1l app1r1tut, App1r1tu1 IICifmllll, light tide; horizontal section at the level of the lacrimal sac. A cavernous body of tissue functionally supporting the transport of the tear fluid surrounds the lumen of the lacrimal sac. Swelling of this
cavernous tissue reduces or blocks the transport of fluid and tears run down the cheek (crying). The blood vessels of the cavernous tissue dilate when a foreign particle enters the conjunctival sac or during strong emotions !e.g. intense happiness or sadness).
Fig. 9.34 U.crfm•lapplrltus, App1ratus IICifmalls, light side; horizontal section at the level of the lacrimal sac. Saccus lacrimalis. 181 The vertical diameter of the lacrimal sac measures approximately 12 mm, the sagittal diameter !Hi mm, and the transverse diameter 4-5 mm. The
nasolacrimal duct of an adult is about 12.4 mm long. The surrounding bony canal is approximately 10 mm long and has a diameter of 4.6 mm. Notice the close topographic proximity to the Sinus maxillaris.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Inflammation (dlcryocystltll), stenosis (dacryostenosis). and concrement formation (dlcryollthlasls) are the most frequent ailments aHiicting the nasolacrimal drainage system, causing 18ars to overflow and drip out onto the face (epiphora). There is an inherited form
of dacryostenosis. In most cases, this is the result of a persistent HASNER's valve, a thin membrane of connective tissue at the entrance of the inferior nasal meatus. This valve usually ruptures shortly after birth but needs to be perforated by a physician if it persists.
111
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Extra-ocular muscles
M. oblquua aupM'tar
M. ntetua ~Ia
Fig. 9.35 Extra-owlu mWICIH, Mm. bulbi; superior view; upon removal of the roof of the orbit on both sides, and removal of the major
f'4ltaltllla
M.IIMitorJ)I---8Uper10tta
M. recbl8 auperlor
Anu~a tandl-..
communis
part of the M. levator palpebrae superioris and of the orbital fat body on the right side.
Fig. 9.36 Extra-owlar muldu, Mm• .bulbi, right aide; lateral view: upon removal of the lateral wall of the orbit. The movement of the eyeball is controlled by six extra-ocular muscles in the orbit (four rectus muscles: Mm. recti superior, inferior, medialis, end laterelis; two oblique muscles: Mm. obliqui superior and inferior). With the exe4'.1ption of the M. obliquus inferior {origin at the Facies orbitalis of the Maxilla lateral of the Incisura lacrimalis maxillae in the anteri· or medial region of the orbit) end the M. obliquus superior (origin at the Corpus ossis sphenoidalis medial of the Anulus tenclineus communis and the dural sheath of the N. opticus). all other extra«ular muscles originate from the Anulua tendlneua communi• (tendlnolll anulua ofZINN). All six muscles insert at the Sclera. All four extra-ocular rectus muscles insert anterior to the equator of the eyeball. whereas the oblique muscles of the orbit insert posterior to the equator. A tendinous pulley-like structure !Trochlea), which attaches to the anterior upper area of the Os frontale and acts as a hypomochlion for the M. obliquus superior. redirects this muscle baclc:werds to its insertion area at the top of the eyeball posterior to its equator. The tendinous anulus of ZINN is also the origin of the M. levator palpebrae superioris which projects into the upper eyelid (Palpebra superior}.
M. obllqiAIIIInfllrtor
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Paralysfa of the M. levator palpebrM superlorla (resulting from damage to theN. oculomotorius [1111) causes ptosis {drooping upper eyelid). The patient does not experience double vision !diplopia) becaus& the affected eye is closed. However. upon lifting the eyelid
112
-+ dl. .uctlon link
manually, double vision occurs since the Mm. recti superior, inferior. and medialis are paralysed as well. Palsy of the Nn. abducens and trochlearis am also cause paralytic strebism with diplopia.
Muscles of the eye
-+
Topography
-+
Eyeball
--+
Visual pathway
Extra-ocular muscles
Abductlan
Adduction
Medial
Fig. 9.37 M.lnction CJf the extni-Gc:ular mu.cln, Mm. bulbi. [8] Testing the ability of the eyeball to move into the four main direction• of the vi.ual axia is part of a proper physical exam. Shown are the activated muscles during the movement of each eyeball into the four directions of the visual axis. The coordination of the synchronous movement of botl1 eyeballs is very CXImplex since the various extra-ocular muscles are innervated by different cranial nerves INn. oculomotorius, trochlearis, and abducens). The extra-ocular muscles receive very rich innervation and are distinct in fine structure from the normal striated muscles.
Function Right Eye Lateral
Medial
M. rectus superior
Elevation of the visua I axis Adduction and medial rotation of the eyeball
N. oculomotorius [Ill], R. superior
M. rectus inferior
Depression of the visual axis Adduction and lateral rotation of the eyeball
N. oculomotorius IIIII, R. inferior
M . rectus lateralis
Abduction of the eyeball
N.abducens lVII
M. rectus medialis
Adduction of the eyeball
N. oculomotorius [Ill], R. inferior
M. obliquus inferior
Elevation of the visual axis Abduction and lateral rotation of the eyeball
N. oculomotorius [Ill). R. inferior
M. obliquus superior
Depression of the visual axis Abduction and medial rotation of the eyeball
N. trochlearis !lVI
Fig, 9.38 M.lnction and innervation of the extra-ocular muacl81 inMrting at the Bulin• ocun. [10] The respective muscle is CXIIoured in dark red.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Pall'f CJf the oculomotor nerve results in the paralysis of all extraocular muscles, except for the M. rectus lateralis (N. abducens) and theM. obliquus superior IN. trochlearis). The non-paralysed muscles pull the eye downward and outward (down-and-out). At the same
time, paralysis of the M.levator palpebrae superioris results in ptosis and the inability of the patient to see with this eye. Only when the drooping eyelid is pulled up manually, the patient complains about double vision (diplopia).
113
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Extra-ocular muscles
1~~~§i~i~,E~f/-::::~:::::j;~=M. .' M. ~,_-....,.....--'=""'-M.
:AIF---------.. . ;:. . .,. . _M.
mec~ran•
NCtll& obllquuiiUpedar
obllquulllrl1Wfor
NCtll& 111141rda
_ o----';.,t<-"- - - - - - - - - - - - - - A n W • w n d l n e u l CCIITII7IIritJ
F".g. 9.39 Exh·ocul•r mu--.. Mm. bulbi; superior view. Shown are the Anulus tendineus communis (tendinous anulus of ZINNI and the insertion sites of 1he muscles a1 the eyeball. The visual axis (imaginary line from the midpoint of 1he visual field to
the Fovea centralisl and the axis of the orbit (imaginary line through the centre of the lens} differ bv an angle of 23•. This is the reason why the Fovea centralis (re1inallocation of focused central vision) is located lateral to the Papilla nervi optici (blind spot).
M.IKM ..t.lllll
F".g. 9.40 Exh·ocul•r muldn. Mm. bulbi, right •ide; frontal view onto the posterior Wllll of the orbit. The periorbital space near the
Fissura orbitalis superior contains muscle fibres with sympathetic nerve innaMtion; collectively, 1hase form the M. orbitalis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Damage to the N. trochlearis [IV) can cause p•lsy of 1he trochiNr n•rv.. Paralysis of the M. obliquus superior causes 1he visual axis to point medially (nasal) and upward because 1he normal abduction and downward movement of the eyeball bv 1he superior oblique muscle is absent. Abducen• nllrVe paiiiK are 1he most frequent palsies of the extra-ocular muscles (in part. .because the N. abducens lVII
114
-+ dluactlon llnlc
[->Fig. 9.41) runs through the centre of the Sinus cavernosus and can be damaged more easily here than in the peripheral zone of the sinus where the N. oculomotorius IIIII and N. 1rochlearis [IVJ are located). Paralysis of 1he M. rectus lateralis shifts 1he visual axis medially {nasally}.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Extra-ocular muscles
M. IIIY«ttt Pti_,.,IW eupelfalla
N. optloua 01], P. . lnb'acnlnlllla
H)'I)Oilhyais
M. -lll4)tlriar
CHumaoptlr:Um
N. optiCU8 [10, Pal$ ortllllllt
llw:1us opUe1111
A. ophhlmlr:a A. ophttMIImlce Corpus edipoeum Ol1litu A. Clll'atla lntama,
Pn ctrebrllla
M. rectuall!nla
Si'tus-us N. abducena LVII
M. reclua lnfafar
Fig. 9A1 Optic nerve, N. opticu• (II]; right 1ide; lateral view upon opening of the Canalis opticus. Both, the N. opticus [II) and the A. ophthalmica (brGnch of the A. carotis
internal course through the Canalis opricus and the Anulus tendineus communis !tendinous anulus of ZINNI into the orbit.
N. Oflhthlllmlcua [Vtt), N. fnlnlalla N. optlc~~t [11]
A. ophttMIImlce M.niCtua eupettor R881ftOrt!ltlla MJperiQf
M.niCtu. ll.'lllnrla Anuh• tllndlneua eommunla"
V. ophth.llmlce eupelfar
- - +- N. oblquu. lllll*for
~-~- N. rec:t»>l
--:r-----"-
mediiII 0. ethmaldale
IOIIIIIIPf- - - .E-- - 0. pellllilum
N, oculomo1orfu. Pill. A.aupartor
N. Oflhthlllmle:UII [VII), N. IIMOdllllta
N. abdi.Jcel'lll [Ill] An!Aus tancineua communi~~
- - O.IIIIC:tfrnMa
Ag. 9.42 Mu~eular origins at 111• Anurus tendtn•u• communis (tendinou. anulu• of ZINNI. right •ide; frontal view. [10] The Anulus tendineus communis is the origin for the Mm. rectus superior, rectus medialis, rectus inferior, and rectus lateralis. A neurovascular bundle not depicted in this image passes through the Anulus (->Fig. 9.43). Also shown is theM. levator palpebrGe superioris which originates at the tip of the orbit from the Ala minor ossis sphenoidalis. The M. obliquus superior has its origin at 1tte Corpus ossis sphenoid&lis medial to the Anulus tendineus communis at the dural shea1tt. " tendinous anulus of ZINN
Ag. 9.43 Neurovacular structur.. passing through 111• Canalis opticua and the FiMura orbitali•auJMirior, right •id•; frontal view. [10)
TheN. oculomotorius [Ill), N. nasociliaris, N. abducens, and Radix sympa1ttic:e ganglii c:iliaris pass through the Fissure orbi1elis superior and the Anulus tendineus communis (tendinous anulus of ZINNI. The V. ophthalmica superior, N. lacrimalis, N. frontalis, and N. trochlearis [IV) also pass through the Fissura orbitalis superior into the orbit. However, these neurovascular structures run outside of the Anulus tendineus communis. Not shown are the V. ophthalmic& inferior, A. infraorbitalis, N. infreorbitalis, and N. zygomaticus which enter the orbit through the Fissura orbitalis inferior. Centrally within the N. opticus [II) courses the A. central is retinae as the first branch of the A. oph1halmic:a.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Incomplete or complete oph1tlalmoplegla {ophthalmoparesisl refers to the paralysis of one or more extre·ocular muscles due to different neurological illnesses or caused by chronic inflammations
end tumours at the tip of the orbit. Embolic occlulllon of 111• A. centrar.. retinae is a frequent vascular cause of acute blindness.
115
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Blood vessels of the orbit M. obUQUIIt tuper!Clr
A. e1hmoldllt poettrtor 01111dula lfocrtTlala
A. clln poetertor b,...
A. aphtt!almlca
Fig. 9.44 ArteriH of the eye, Oculus, and of th1 orbit, Orb11a; superior view onto the openend Orbitae; left side: content of the orbit with extra-ocular muscles, right side: without extra-ocular muscles.[10) The A. ophthalmica is the main artery of the orbit and branches off the Pars oerebralis of the A. carotis interne. The A. ophthelmice normally courses below the N. opticus 1111 through the canalis opticus into the orbit. Here. the artery divides into many branches which supply the
eyeball and the structures of the orbit wi1h blood. Anastomoses exist via a R. orbitalis to the A. meninges media, via the Aa. ethmoidales anterior end posterior to blood vessels in the nose, and via blood vessels penetrating the Septum orbitals or the bone to the facial arteries (Aa. supraorbitalis, supretrochl&aris. palpebrelis medialis and lateralis, dorsalis nasi).
M. ree1ut auJ)tl!or M. obllquua euperior
Fit. 9.45 Vein• of till eye, Oculul, and of th1 orbit, Orbita; right eld1; lateral view into the Orbita; after removal of the lateral wall of the orbit. [10] The Vv. ophthalmicae superior and inferior drain the venous blood. The latter is usually smeller than the A. oph1halmice superior. Venous anastomoses exist to the veins of the superficial and deep facial regions {Plexus pterygoideus)and the Sinus cavemosus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . An ascending transmission of genns from the facl1l rwglon via the V. facialis, the V. angularis in the nasal part of the orbit. and the V. oph1halmice inferior can cause a cavernous sinus thrombosis 1~ p. 223). In turn, this can result in the damage of the N. abducens lVII (often the first cranial nerve sHeeted because of its centralloce-
tion within the sinus}, N. oculomotorius IIIII. N. trochlearis IIVJ. and the first and second trigeminal branch {Nn. ophthelmicus IV/11 and maxillaris IVflll with corresponding deficiencies (paralysis of extraocular muscles. sensory deficits etc.l.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Arteries and nerves of the orbit
N•....-tllbllle, A. medld•
M.I'IICIU8
...,_,Of
R. menlngaua entlllfor A. tlhmoidlllis anterior M. obllquua euperior
N. n-clllrf• M. I'IICIU8II!eralla N.~lt
N. ebducene Ml N. tnldJIMrte [IV] N. opflttlalmlcua (V/1]
N.ITIIXIIn [V12J
Carualla apticU8 N. op11cus pq A. opl!thalmlce manr.g..medle.
N. ouomotor11111 ~IQ
N. mlndibullrill [V/31, R. menlngaua
t.l. mandlbulalla[VJ3J
N. lrigerrinua M
Fig. 9.48 Arterfu 1nd nMW• of 111• odllt, Ollllta, right s1de; superior view onto the open end orbit (upper level of th• orbit); Demonstration of the Ganglion trigeminale (Ganglion semilunare, Ganglion GASSER!); bony roof of the Orbita, Periorbit&, and Corpus adiposum orbitae were partially removed.
Shown is the courM of 111• N. ophthllmlcu•IV/1 I through the opened Fissura orbitalis superior and its branching into Nn. lacrimalis and frontalis (incl. consecutive branching) and, running more deeply, the N. nasociliaris. In addition, the gracile N. trochlearis [IVJ for the motor innervation of 1he M. obliquus superior and the more deeply located N. abducens lVII for the innervation of the M. rectus lateralis ere depicted.
- dl•••ctlon llnlc
117
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Arteries and nerves of the orbit
A. eupn1altlltalls
Brench• of 1he A. ophtllelmlce
N. muiln IV/21
Gqllan lr\)emlnale
N. oculomotorillt [Ill]
N. trlgemlnue M
Fig. 9A7 Arterln •nd nerves of the orbit. Orblttt, rfght side; superior view; after removal of the roof of the orbit; presentation of the Ganglion ciliare; the M. levator palpebrae superioris and M. rectus superior were folded back. Shown are nerve branches of the N. oculomotorius IIIII entering beneath the muscl~». Upon removal of the orbital fat body beneath the muscles. the 01nglion cili1re. approximately 2 mm in size, becomes visible. Positioned approximately 2 em lateral to theN. optic:us 1111 behind the Bulbus oculi, the Ganglion ciliare is embedded in the Corpus
118
-+ dluactlon llnlc
• A. centralis retinae • A. lecrimelis - R. anastomoticus cum a. meningea media - Aa. palpebrales laterales • R. meningeus recurrens • Aa. ciliares posteriores longae • Aa. musculares - Aa. cilier~» enteriores - Aa. oonjunctivales anteriores - Aa. episclerales • A. supraorbitalis - R. diploicus • A. ethmoidalis anterior - R. meningeus anterior - Rr. septales anteriores - Rr. neseles anteriores laterales • A. ethmoidalis posterior • Aa. palpebrales mediales - Aa. oonjunctivales posterioras - Arcus palpe.bralis superior - Arcus palpe.bralis inferior • A. supratrochlearis • A. dorsalis nasi
adiposum or.bitae. The G•ngllon cllllnt contains perikarya of postganglionic parasympathetic neurons which synapse wilh the axons of preganglionic parasympathetic neurons located in the Nucleus oculomotorius accessorius (autonomicus, EDINGER-WESTPHAL nucleus). These parasympathetic iibres innervate the inner muscles of the eye (M. ciliaris und M. sphincter pupillae.~ Fig. 8.163}. Having switched earlier from preganglionic to postganglionic: fibres in the Ganglion cervic:ale superius. postganglionic sympathetic fibres for theM. dilatator pupillae simply pass through the Ganglion ciliare.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Arteries and nerves of the orbit
M. rectut eupellor
!PA<-.:i...,r.-- - M. ractualllteralla ~:-fil:""'ilzi!.--..- Nn. cllua brwN
N. OCiliOmotCilla DIQ, R.lnfii!Or
N. ophlllonk:Ue (V/1)
H. tllgamln~~t M Rldb!. M118011a N.~ne(VI]
Fig. 9.48 AlteriK and nerves of the orbit, Orblta, right sic»; superior view; upon partial remOYlll of the Mm. levator palpebrae superioris, ree1us superior, and obliquus superior. The middle level of the orllit is depicted. Shown are theN. opticus
[II) with supplying networlc: of arteries (Aa. ciliares) branching off the A. ophthalmica, which is running through the orbit, as well as the Nn. emares longi and breves, the Ganglion ciliare, and the terminal branching of the N. nasociliaris.
- dl•••ctlon llnlc
119
Auge
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Arteries and nerves of the orbit
M. abllquuuuperlcr, Troclllta M. obllciWa aupei!Or, Teneio M. oblkl~M Slll*!or
N. lnfratruchl.-11
A. ethmOidlllit •nterior
A..i~i&
N. oculcmCI!Oriua 0111. R. inferior
N.lbduc~m•I.VIl
N. mlllCIIIIuls LVfl.l
N. OflhthUnlcut LV11J N. mandlbullula LVISI N. 111gemlnua M
Fig. 1.48 ArblriH 1nd n1rve1 of th1 Olllft, Orlllta, right s1CS.; superior view; the N. opticus [Ill has been cut. After dissecting additional structures and upon removal of the entire orbital fat body, theM. rectus inferior and the lower level of the orbit become visible. The bulbus is roteted in such a way that the insertion site of the M. obliquus inferior close to the entry site of the cut N. opticus [Ill can be seen. The ethmoidal cells (Cellulae ethmoidales) at
the medial side have been opened up to demonstrate the course of the Nn. ethmoiaales anterior and posterior as well as the A:a. ethmoidales anterior and posterior from the orbit into the ethmoid bone. The A. and N. infraorbitalis are located in the lower level of the orbit. In addition to sensory fibres, the N. zygomaticus, a branch of the N. infraorbitalis, also contains postganglionic parasympathetic fibr&$ for the autonomic innervation of the lacrimal gland.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . TheN. opticus !Ill has a close topographic relationship to the sphenoidal sinus (Sinus sphenoidalis). DIIH11 proc..... lnvolvfng the Sinua •ph1noiclalia (sinusitis, tumours) can affect the N. opticus [II)
120
-+ dlsuctlon llnlc
separated from the sphenoidal sinus by only a thin bony wall that may sometimes not be present During surgery of the sphenoidal sinus, great care is required not to damage the optic nerve.
Muscles of the eye
-+
Topography
-+
Eyeball
-+
Visual pathway
Nerves of the orbit
Fig. 1.&0 N•rvn of th• orbit. Orbna, and th• eyt~, Oculus, lnn•rvatlon of th• lacrimal gland, Glandula lacrlmalls, and damonstratlon of the Ganglion clllare, right side; lateral view; after removal of the temporal walland orbital fat body. Sympathetic, parasympathetic, and sensory fibres innervate the lacrimal gland. Postganglionic paruympath.tlc tlbras derive from the Ganglion pterygopalatinum to stimulate excretion by this gland. The fibres leave the Ganglion pterygopalatinum, associate with theN. zygomaticus {a branch of theN. maxillaris [V/211, and separate as R. commu-
Slnua sphtnoklllls
nicans cum nervo zygomatico {.... Figs. 8.163 and 9.30) to anastomose witt1 theN. lacrimalis and reach the lacrimal gland. TheN. lacrimalis (a branch of the N. ophthalmicus [V/111 provides 1t1e sensory innervation of the lacrimal gland. The sympathetic fibres inhibit glandular secretion. Postganglionic sympath.tlc llbrH derive from the Ganglion cervicale superius. Without synapsing, these fibres pass through the Ganglion pterygopalatinum and taking the same route as the parasympathetic fibres 1t1ey reach the lacrimal gland (-+ Fig. 9.30).
p.e.l!ll--
OS sphanoldale, Ala majar
C..alll optlcus
A. oplrlhPrllca
A. CMitlo lnterna
Fig. 1.51 Olllit. Orbita, right aide; horizontal section; superior view. Notice the close relationship between the N. opticus (II], the A. carotis intema, and the Sinus sphenoidalis.
-+ dlsuctlon link
121
Eye
Development
-+
Skeleton
-+
Eyelids
-+
Lacrimal apparatus
-+
Orbit. topography
I Fo.- CI'WIII ant8rlor, antartor cranllll ~ II SFI.Is frontalis, frontal &IIUI Ill Cellulae lllhmaldaiM, lllhmaldll Clllll
IV Clwllas nasi, naaaJ cavity
v sn. mallout., maxlary an.
VI Fossa tempcnlls, tlllnporal fossa
Fig. 9.52 Topogrephlc.l relationshiP* of the orbit. Orbtt., •nd neighbouring regions. right eide; frontal view. The Orbits has a close topographical relationship with neighbouring regions. This includes the anterior cranial fossa (Fossa cranii anterior), the
frontal sinus (Sinus frontalis), the ethmoidal cells (Cellulae ethmoidales), the nasal cavity {Cavites nasi), the maxillary sinus (Sinus maxilleris), and the temporal fossa (Fosse temporal is).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The treatment of diseases, particularly those affecting facia I structures, requires an interdisciplinary approach including specialists from ophthalmology, otolaryngology, radiology, neurology, head! neck/cosmetic surgery, neurosurgery, and potentially other disci-
122
plines (e.g. pediatrics, anesthesia, nuclear medicine, and others). An inflammation or tumour in the orbit can spread to neighbouring areas (and partially vice versa) end may require an interdisciplinary therapeutic intervention.
Muscles of the eye
-+
Topography
-+
Eyeball
--+
Visual pathway
Orbit, topography
Clinical Remarks--------..., Endocrine orbitopathy is an inflammation of the orbit as part of GRAVES' disease. The latter is an autoimmune disease which is believed to result from autoantibodies directed against the thyroid gland and some tissues in the orbit (e.g. extra-ocular muscles and orbital fat body). However, the details of this disease mechanism are not entirely clear. The disease phenotype involves hyperfunction of the thyroid gland (hyperthyroidism) and exophthalmos {bulging out of the eyes, -+ Fig. 9.53). Exophthalmos coincides with widening of the palpebral fissure, retraction of the eyelid, and distorted eye movements.
Ag. 9.53 Patient sufhrtng from endocrine olllltapathy. 1181 Shown is the pronounced exophthalmos as well as a scar in the neck region (condition after thyroidectomy).
Supen:ila
->"'!:=:=~/ M. ~ •uperlor
A. ophlhunlca Vagl1111 IIXIIIma nenll optlcl
N. apllllw [IQ
M. IIIC!u. lnf'wlar ...;::..::::::::-~~- Corpu• lllllpDHm 01t11t111t
~~~~~i~~~~~~~~-
""""6~~~
Rg. 9.54 Ollllt Olblte, right tide; medial view; vertical midline section. The Periorbita {periosteum) covers the inside of the orbit. All structures of the orbit are embedded in adipose tissue (Corpus adiposum orbitae). The Septum orbitale delineates 1he entrance to the orbit; a 1hin layer
M. obllquua
.,.......,"ff~~IJ---- N.lnfnlorbltal•
~lerlor
of connective tissue (Vagina bulbi, Fascia bulbi, or TENON's capsule) surrounds the eyeball. A narrow gap {Spatium episclerale) separates the Vagina bulbi and the sclera of the eyeball.
• TENON's capsule
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , To describe the optimal surgical access route, 1he orbit is divided into parts according to different eliniceI criteria: • Bulbar part- retrobulbar part • Central or intraconal (delineated by the cone-shaped arrangement of the extra-ocular rectus muscles) part- peripheral or extr&«Jnal part • Upper level -middle level- lower level of the orbit: - The upper level of the orbit is the space between the orbitaI roof and the M. levator palpebrae superioris. It contllins: N. frontlllis, N. trochlearis, N. lacrimalis, A. supraoibitalis, A. supratrochlearis, A. and V. lacrimalis, and V. ophthalmica superior (-o Fig. 9.46).
- The middle level of the orbit extends between the extraocular rectus muscles and, thus, includes the intraconal space (... Fig. 9.48). It contllins: N. oculomotorius, N. nasociliaris, N. abducens, N. zygomaticus, Ganglion ciliare, A. ophthalmica, V. ophthalmica superior, Aa. ciliares posteriores breves and iongee. - The lower level of the orbit extends from the M. rectus inferior and M. obliquus inferior to the orbital floor(-+ Fig. 9.49). It contains: N. infraorbitalis, A. infraorbitalis and V. ophthalmica inferior.
123
Eye
Development
-+
Skeleton
-+
Eyelids
-+
Lacrimal apparatus
-+
Orbit. frontal sections
hlt\
~
M. IIMIIor palpebrae auperlorl&
M.~.~~~---~~~~~~~~~~~
Fig. 9.55 Orbit. OrbHa. right slda; frontal section through the orbit at the level of the postarior aspect of the Bulbus oculi; frontal view.
The orbital fat body {Corpus adiposum orbitael surrounds and buffers all structures within the orbit.
Os z:ygGimaDI:/.ITI ,,.N. aculaiTIDIIIrtla ~lq, R.
Fig. 9.58 Orbit. OrbHa. right lkla; frontal section through the retrobulbar region of the orbit; frontal view. The bulbus and the structures of the retrobulbar space connect to the Periorbita and among each other through thin ligaments. Stronger ligaments ara the Retinaculum mediale (between theM. rectus medialis
and the Periorbital. the Retinaculum laterale (between M. rectus lateralis and the Periorbital. and the Lig. suspensorium bulbi {LOCKWOOD's ligament, between the M. rectus medialis, M. rectus inferior and the Periorbital.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Thrombosis of the V. cantralis retinae lcentnl wnou• thromboU.I is a relatively frequent retinal disease associated with significant reduction in vision. Diabetic patients often develop microvascular changes also involving the retinal blood vessels which can rupture resulting in bleeding into the vitreous body and impairment of vision. If remnants of such bleeding into the vitreous body fail to resolve after 2-3 months and impairment in vision continues, removal of the vitreous body (vitrectomy) is often performed.
124
Various conditions (e.g. lceratitis = corneal inflammation, degenerative keratoconus or chemical irritation} may require the surgical replacement of the cornea to restore proper vision h:ornHI tranaplantation). Due to the lacl: of vascularisation of the cornea, the rish of an immunological rejection is much lower than with vascularised organs. Therefore, corneal transplantation is the most frequently performed tissue transplantation procedure worldwide.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Eyeball extemua bUbl eom- Polus amtllor bUlbi Mtellor le!rtb
Llmlna lmttana antll1or'" LAmina I milan& poaterlorlri8 Llmbuac-
CMieta poabW!l. [viWI] bulbi; Corp~.a~um
.,...,Pllnl .... n•. {Stnltum pJgmtntosum optlea
1'1111Me
S!Ntum nei\IOMim
Fig. 9.67 Eyeball, Bulbus oculi, right side; sd1ematic horizontal part at the level of the exit of the optic nerve. In the anterior part of the eye, the Cornn forms the outer cover of the eyeball !Tunica iibrosa bulbi). Shaped like a convex disc, the Cornea bulges out from the rest of the bulbus. At the Limbus comeae, the Cornea merges into the less curved Sclera which forms 1he Tunica fibrosa bulbi in the posterior part of the eye. The extra-ocular muscles insert from outside et the Sclera. The Tunica vasculose bulbi (vascular layer, Uvea) lies beneath the Sclera. Its anterior part consists of the Irk and the ciliary body {Corpus ciliare}, while the choroid {Choroidea) forms the posterior part. At the Ora serrata, the ciliary body and the Choroidea meet. The Choroidea represents the most highly vascularized structure
in the body. Its blood supply provides nutrients and oxygen to the a~ jacent retinal layer and is involved in thermoregulation of the eyeball. The Rdna is the innermost layer of the eyeball ITunica intema bulbi). It contains the neural layer !Stratum nervosum; photoreceptive cells) and the pigmented layer {Stratum pigmentosum; pigment cells), and in the anterior part the pigmented layer of the ciliary body and the epithelium of the Iris. The inner space of the eyeball consists of the vitreous body !Corpus vitreum}. • clinical term: BOWMAN's membrane •• clinical term: DESCEMET's membrane ••*clinical term: canal of SCHLEMM
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Retlnalabletfon describes the detachment of the inner parts of the retina {Stratum nervosum, Neuroretinal from its supplying retinal pigment epithelial layer !Pars pigmentosa, RPE). Symptoms include the sensation of flashes or coloured spots. This may not occur if the Macula (point of central vision} is unaffected. However, if the Macula is detached from its supplying pigment epithelium for more than 48
hours, a permanent the loss of function of the corresponding retinal part will occur. After a successful reattachment of the Retina to the pigment epithelium, the Retina may partially recover, depending on the duration of the retinal ablation. In the case of a continued complete retinal ablation, blindness is inevitable.
125
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Blood vessels of the eyeball
81nu.-ec~~ru•
Acanjunc1MIIIIantallof
Clrcukla artlllloeua
lricla mlnllf
eplacltral" A. ei~• ~nor oiiiNI poetlrtaNI . . , _
rona•
Flg. 9.58 Blood vutelt of the eyeb1ll, Bulbus or:4.111, right slcle; horizontal section at 1he level of 1he N. opticus (Ill; superior view. Arterial blood supply I• Fig. 9.44). Venous drainage is 1hrough 1he V. centralis retinae and four to eigh1 Vv. vof1icosae (vorticose veins; -> Fig. 9.45}. The latter pierce the sclera posterior to the equator of the
eyeball and join the Vv. ophthalmicae superior and inferior. • clinical term: canal of SCHLEMM "" clinical term: Uvea
Dlm•slons of the Eyebllll (average values according to the anatomic and ophthalmologic literature) External bulbar axis (Axis extemus bulbi}
24.0mm
Radius of curvature of the sclera
13.0mm
Internal bulbar axis (Axis internus bulbi)
22.6mm
Radius of curvature of the cornea
7.8mm
Thickness of the Cornea
O.Smm
Refractive index of the entire eye (distance visionI
59dioptres
Depth of the anterior chamber
3.6mm
Refractive index of the cornea
43dioptres
Thickness of the lens
3.6mm
Refractive index of the lens !distance vision)
19 dioptres
Interpupillary distance
6t-69mm
Distance between lens end Retina Thickness of the Retina
126
15.6mm 0.3mm
Muscles of the eye - Topography -
Eyeball - Visual pathway
Iris and ciliary body
c.nara paeterillf bulbi
co~{Prvc:. ci~Ma
c.nara anlallof l:lutll
cl._ M. ellllrta
Fig. 9.61 lrfdocorne~langle, Anguluslrldacornealls. and adJacent stl\lcturM. 181 The Cornea, Iris, end Sclera provide the borders for the iridocorneal engle. The epithelial layer of the ciliary body produces the aqueous humour that flows from the posterior to the anterior chamber of the eye. When it reaches the trabecular meshwork at the iriclocomeal angle.
the fluid is collected in the canal of SCHLEMM l"l and drained into episcleral veins. The M. ciliaris is the major component of the ciliary body and important for accommodation. It consists of meridional (longitudinal, BROCKE's muscle}, radial, and circular !MOLLER's muscle) muscle cells.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Insufficient drainage of the aqueous humour from the iridocorneal angle leads to an increased intra-ocular pressure {normal15 mmHgl end results in glaucoma. Damage occurs primarily to the papilla of the optic nerve with the risk of blindne88. Causes include blockage of the iriclocomeal angle, for example by adhesion of the Iris to the Cornea lclosecklngle glaucoma; rare). or the impaired drain-
age through 1t1e trabecular meshwork of the canal of SCHLEMM in open-angle glaucoma (frequent). The inherited genetic deficiency in 1t1e syn1t1esis of the connecting protein tibrillin-1 IMARFAN'• .-yndrome) results in the insufficiency of the zonula fibres with luxetion of the lens and permanent ballshapecllens (impaired lens accommodation).
...
~~=---Com Fad• polltarlar
Corpwclllare Corona clliltla (lP. . pllcct8lJ
Fig. 9.60 ln., lrie, and lene, a..tl1; frontal view.
Fig. 9.61 lri1, ln., •nd cililry body, Corpu• cili1ra; posterior view; after removal of the lens. The ciliary body is divided into a plane (Pars plana) and a raised part (Pars plicata). The latter serves as origin for approximately 70 ciliary processes (Procc. ciliaras). The ciliary body is covered with ciliary epithelium, which, in the area of the Pars plicate, secretes the aqueous humour for 1t1e iridocomeal angle. Zonula fibres !suspensory ligaments of the lens, Zonulae ciliaresltraverse the distance between the ciliary epithelium end the lens capsule.
127
Eye
Development
-+
Skeleton
-+
Eyelids
-+
Lacrimal apparatus
-+
Lens
Radl
AeQuldor
b
Flga. 9.62a and b unt, Lant.
Depending on its particular level of accommodation, the refractive index of the lens varies between 1~20 dioptres (for comparison, the refractive index of the cornea is 43 dioptres but cannot be modified).
frontal view b viewed from the equator
1
•
&at.!tlalentla
F'tgt. 9.63a and b Lant, Lant. •
enterior oblique view; after meridional cut end partial detachment of the anterior lens capsule, Capsula Iantis.
b
b Lens fibres of e neonate; schematic drawing; view from the equator. The centres of the planes are the enterior (Polus anterior) end posterior pole (Polus posterior}.
Clinical Remarks---------.. The continuous apposition of lens fibres reduces the elasticity of the lens !starting at about 40 years of agel which results in a diminished accommodation of the lens, i.e. the inability to properly focussing on objects et various distances lpl'ltbyopia). Reduction in intracellular water content causes alterations in proteins (crystallinas) important for maintaining transparency of the lens. The resulting increase in opacity of the lens (senile cataract Catllracta unlllsl represents the most common eye disease and can be diagnosed early by slit lamp examination (-> Fig. 9.641. Cataract surgery is one of the most frequently performed surgical procedures in Western industrialised countries lapprox. 10% of all 8(} year old patients suffer from advanced cataract).
Fig. 9.84 Senile c.taract (Cataracta unllls), right siCS.; slit lamp examination. Shown is a condition of progressive cetaract with milky white opacity of the lens. The white curved bar on the right side of the image constitutes the reflection of the cornea.
128
Muscles of the eye -
Topography -
Eyeball -
Visual pathway
Retina
DlecclaiMI"'It opllol"*
MIH!ola temporal II
mrusa inferior
Fig. 9.6!5 Ocular funclut, Fundul oculi, right 1icle; frontal view; ophthalmoscopic image of the central region. The examination of the ocular fundus by direct ophthalmoscopy (funduscopy or fundoscopy) allows the clinical assessment of the condition of the Retina, its blood vessels lin particular the A. and V. centralis retinae), the optic disc !Discus nervi optici}, as well as the Macule lutea and Fovea centralis (point of central vision). The blood vessels of the Retina (A. and V. centralis retinae and their branches) cen be examined end distinguished according to their diameter (arteries- smaller diam&ter). Normally, the optic disc has e sharply delineated margin, e yellow to orange colour. and contains a central depression (Excavatio disci). At 3-4 mm to the temporal side of the optic disc lies the Macula lutea (contains the highest concentration af cone cells for colour vision). Numerous branches of the Vasa centralia retinae converge in a radial fashion onto the Macula, but fail to reach the centre {fovea centralis). The latter is supplied by the Choroidea. • clinical term: Macula lutea .. clinical term: ol)1ic disc or blind spot (discus
=Papilla nervi ol)1ici)
~nude
NUn" euPtr!Or
(\lllnutamedllllll retinae}
(Mftlle. medilli& retinae}
Valda nuala NlfnM hferlar Vtnuta tempo111lle relt~ae InferiOr
Fig. 9.18 Ocular fundu•. F\lndu• oculi. and blood v...... of 1he retin1, VaM nnguinea retin1e, ri1ht tide; frontal view; schematic drawing of the course of the blood vessels. "
Fig. 9.87 Ocular funclut, Fundu• oculi. right •icle; frontal view; fluorescence angiography durinQ the arteriovenous phase with anatomic landmarks: Macule (blue circle); Fovea (yellow circle). [15)
Papilla nervi optici
Clinical Remarks---------. After retinal ablation the retina takes on a whitish-yellow colour. Alterations of the retinal blood vessels, as commonly observed with diab81ic retinopathy or hypertension, are visualised early by fundoscopy. Advanced diagnostic procedures include fluorescence angiography (-+ Fig. 9.67). Increased intracranial pressure makes th& optic disc protrude into the eyeball and its margins appear less well defined (optic disc oedema). Glaucoma also causes characteristic alterations to the optic disc {-+ Fig. 9.68). Pathological alterations to the Macula lutee are often ag&-dependent. The most frequent cause of blindness in Western industrialised nations is age-dependent macular de· fllleration (AMD). Fil. 9.68 Conc.ntric •nl•tement of till optic ditc due to 11aucoma. [15)
129
Eye
Development -+ Skeleton -+ Eyelids -+ Lacrimal apparatus -+
Orbit, MRI M.IIVIItcr palpeb!U eupe!!OIIa M. ntetua eupe!!tlf M. ol:lllqwt~tupe!!at'
N. QP!icua 00
M. rectua llltelllla M. NCtlla mid lila M. ractua lnf'elftlf
Flg. 1.89 Ext,..ocular muscln, Mm. bulbi; magnetic resonance tomographic image (MRU, frontal section of a healthy individual at the level of the orbital centre; frontal view.
The close topographical relationships of the orbit with the Sinus maxillaris, Lobus frontalis, Cellulae ethmoidales, and M. tamporalis (not indicated) are clearly visible.
Ulna
Bulbus ~li, Ccrpua ~ilnlum
Celulae e1hmok1111R
M. rectualalenlla
M. tectua mediaia
Flg. 1.70 Eylllall, Bulbus ocun, and ext,..ocular musclu, Mm. bulbi; magnetic resonance tomographic image IMRil, transverse section of a heahtly individual at Ute level of the N. opticus [II); superior
view. This sectional plane displays the slightly contorted course of the N. opticus [II). The eX1ra len!Jth of the nerve serves as reserve during the movements of Ute eyeball.
M. IIMI!or palpebnut ...,a!OIIa
Shlall)henOidala
Pa~ra lnflllor
Bl.llbue cx:ul, Ctrnera pcetrema (llltJWl
Siluamlleilleria
F'.g. 9.71 Eylball, Bulbul ocuri, and m,..ocul1r mutel.., Mm. bulb1; magnetic resonance tomographic image IMRI}, sagit1al section of a healthy individual at the level of the N. opticus [II); lateral view.
MRI is an imaging technique ideally suited for the visualisetion of the bulbar and retrobulbar space because the tissues of both regions provide distinctly different contrast ratios.
Examination Procedures-----------------------.. Most visible structures of the eye can be examined in vivo with special optic instruments (e.g. magnifying glass, ophthalmoscope, slit lamp), such as Cornea, aqueous humour. iridooorneal angle, Iris, vitreous body, Retina with optic disc and Macula. Imaging techniques assist in the diagnosis of chronic processes and tumours located in parts of the orbit not accessible by visual inspection (outside of the eyeball, retrobulbar space!. Among the most frequently used imaging techniques for the examination of intra-orbital structures and their topographic relationships are com·
130
putel$d tomofl'ephy
end magnric rMOnance im1ging
(MRI). In combination with the intravenous administration of contrast enhancing agents. these imaging techniQues can reveal additional clinically relevant information. In cases where fundoscopy is impossible (e.g. due to pathological alterations of optic media of the eye, like corneal opacity, cataract, bleeding into the vitreous body), ultrnound examination lsonography) of the eye can be performed.
Muscles of the eye - Topography -
Eyeball - Visual pathway
Visual pathway and blood vessels
A. CIIDtl8 lntema A. choroaea antaicr
~~~~.--~+-~~~~~~~
Pecluneutu. c:erelll'l
Tectum -~~1. Collcuu. !IIUI*!or
Rg. 9.72 Bnlln, Cerllln.nn, 1nd bload supply of the vf1u11 pith· w1y; inferior view. The pituitary gland has been removed at its infundibulum 1•1. The pituitary gland lies in close proximity to the Chiasma opticum. The visual pathway originates within the retina and contains the first three neurons end interneurons (horizontal cells. amacrine cells). The different cell layers are (from outside to inside): 1• Neuron: photoreceptor cells of th& retina {con& and rod c&lls) Neuron: bipolar ganglion cells of the retina (perikarya in the Ganglion retinae) which receive signals from the photoreceptor cells and transmit these signals to a multipolar ganglion cell (3rd N&uron) 3"' Neuron: multipolar ganglion cells of the retina (perikarya in the Ganglion opticum). This principle network structure of three neurons forming an intraretinal chain only applies to the cone cells. Up to 40 rod cells converge their
z-
signals onto one bipolar cell and this cell will then transmit these sig· nels indirectly, with the help of amacrine cells 12D-50 different types of these cells are described in the literature), to one multipolar ganglion cell. The axons of the Ganglion opticum extend primarily to the Corpus geni· culatum 19terale !Radix lateralis) although several fibres also extend into the Area pretectalis and into the Colliculus superior (Radix medialis) as well as to the Hypothalamus. The fibres run within the N. opticus [II) to the Chiasma opticum. where the fibres from the nasal part of the Retina cross to the opposite side. The fibres from the temporal part of the Retina do not cross. Each Tractus opticus contains fibres which transmit information from the contralateral half of the visual field. 4111 Neuron: Its axons travel primarily from the Corpus geniculatum Ia· terale to the areas 17 and 18 of the cerebral cortex !Area striatal in the region surrounding 1he Sulcus c:alc:arinus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Prior to activating the light-sensitive parts of the photoreceptors. light must penetrate through all the other layers of the retina (3. neuron, 2. neuron); this is celled the inversion of the retina. The outer segments of the photoreceptors {1. neuron) are in close contact with
the pigment epithelial cell layer. without developing actual adhesion structures between pigment epithelium and photoreceptors. It is in this region that r.ttnlllblltlon can occur, which, if left untreated, can result in blindness.
131
Eye
Development -+ ....... Visual pathway
Visual pathway
1a
3b
1 1• 1b 211 2b
Cmmon vllllllll ftllld Vlallll field af thll left • Vlalal field af the rtght • PraJacllcn an thll Iooft notlna ProJecUon on the rtght rvtlna
Rg. 9.73 Vi1ual pathway; schematic overview; superior view. The central vision field has a disproportionately large projection field. The deer and the fir tree demonstrate how images are transmitted from one part of the visual pathway to the next. It is only at the level of the visual association cortices, that the image is perceived as it presents in front of our eyes. The different colouration of the visual quadrants
38 Pro!K11Dn on 1he IIIII calcart1e cor18ll 3b Pn>jectlan an 1he rlght calcarine carlllx 4 Conscloll8 vllual ftllld u • NBUft ot the lni"'JB!Ive 11Chlowanent D1 1he tJr-.
4
serves to illustrate the way in which the informations of these visual areas are tranBmittad and presented in the visual pathway and on the visual cortex. • pia ne of refraction of light
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Due to their close topographical relationship to the Chiasma opticum (optic chiasm), growing pituitary tumours can cause a bitemporal hemllno~. Postchiasmatic and intracerebral lesions along the visual pathway result in homonymou• hemianop8ia. For example, a lesion in the right Tractus opticus causes left-sided homonymous hemianopsia. Injury to the left Radiatio optica (GRATIOLET's optic radiation) results in a homonymous hemianopsia on the right
132
side. Additional symptoms include a hemianoptic pupillary immobility a pale appearance of the affected pupil after months, or optic papilla oedema. Underlying causes can be tumours. basal meningitis, aneurysm, ischemia and bleedings. Loss of function in both visual cortices causes a cortic.l amauroW. (cortical blindness; -+Fig. 12.1401.
Ear Overview
136
Outer Ear
138
Middle Ear ............... ... . . . . . . . 142 Auditory Tube ............. .. . ... .. 148 Inner Ear .................. . ....... 151 Hearing and Equilibrium .... .. . . . . 157
The Ear Tiny Yet Complex Like a Maze The ear (Auris) contains the sensory apparatus and nerve cells of two sensory systems that arise from a common embryonic system (the otic placode), but serve very different purposes: hearing and equilibrium or balance. The small, delicate, membranous, convoluted organs, which carry the sensory cells of both modalities, are located in the membranous Ia byrinth (see below). In turn, the labyrinth is positioned inside the petrous part of the temporal bone (Pars petrosa ossis temporalis), the bony pyramid that separates the posterior and medial cranial fossa. The sensory nerve, theN. vestibulocochlearis [VIlli. emerges from the inner ear. In humans (as in terrestrial vertebrates) a former (the first) pharyngeal groove (also named bronchial groove, pharyngeal cleft, or bronchial cleft) plus surrounding bones and muscles are part of the construction of the acoustic part of the ear- this includes the sound-conducting apparatus, the middle ear and the outer ear. In fish, a pharyngeal groove is a typical "breathing hole"; water "inhaled" through the mouth is expelled from the pharynx via the branchial hole. The "ear-branchial cleft" of terrestrial animals does not longer open, since a very thin membrane, the tympanic membrane (Membrana tympanica), closes it off. If the tympanic membrane had a hole, one could theoretically breathe "through the ears", since a continuous opening would exist that connects the external acoustic (auditory) meatus to the pharynx. Practic;;llly, this is not possible because the ducts are too narrow. However, divers with ruptured tympanic membranes can experience difficulties due to influx of water into the pharynx.
Outer Ear (Auris externa) The outer ear extends from the auricle (Auricula) to the external acoustic (auditory) meatus (Meatus acusticus externus) up to the tympanic membrane. In other words, it is the "outer part" of the former branchial cleft. Auricles of rabbits or horses are flexible, foldable, and are used for directional hearing. In humans, only some flexibility is conserved, whereas folding and motility of the outer ear are lost. Despite the presence of remnants of these ear muscles, they are usually too weak to support significant movement of the auricle. Nevertheless, the Concha, made of elastic cartilage, assists in directional hearing in humans. The external acoustic (auditory) meatus is 3--4 em in length and Sshaped. It consists of a distal cartilaginous component, which continues as an osseous can aI in the petrous part of the temporal bone. The osseous canal ends at the tympanic membrane. Immediately above and below to the external acoustic meatus is the temporomandibular joint. One can feel the deformation of the cartilaginous component when chewing, especially if one inserts the fifth finger into the externe~l acoustic meatus.
Middle Ear (Auris media) The tympanic membrane marks the lateral margin of the middle ear, which is located inside the petrous part of the temporal bone. The middle ear is a contorted mucosal space connected to other cavities. Various nerve pathways run within the walls and the cavity of the middle ear, where the three auditory ossicles are attached. The "inner part" of the above-mentioned former branchial cleft is connected through the auditory (EUSTACHIAN) tube (Tuba auditive) with the Pharynx. The auditory tuba is lined by a mucous membrane, descending inferiorly e~nd e~nteriorly of the tympanic cavity. The Tube~ auditiva is located in
134
an osseous meatus in the petrous part of the temporal bone and is supported by elastic cartilage tow ards the pharynx, w here its pharyngeal orifice is shaped like a t rumpet bell. The Tuba audit iva serves to equalise the air pressure between the middle ear and the surroundings, which is particularly evident during flying and mountain climbing. The actual tympanic cavity (Cavitas tympani) in the petrous part of the temporal bone contai ns the three auditory ossicles (Ossicula auditus), Malleus, Incus, and Stapes. These ossicles are connected by flexible joints and are mounted t o the wa ll of the tympanic cavity by ligaments to form a V-shaped lever that transmit s t he vibrat ions of the tympanic membrane (to w hich the Malleus is attached) to the oval w indow (which holds the be~se of the Ste~ pes, see below ). In e~ddition , two muscles (M. tensor tympani, M. stapedius) are attached t o the Malleus and the Stapes. They reg u le~te the "tension level " of the bony chain e~nd, thus. the efficiency of sound transmission. The branches of the two cranial nerves, theN. facialis [VIII and theN. glossopharyngeus [lXI. run within the mucose~lle~ye r of the we~ lls of the tympe~nic ce~vity; the Ch orde~ tympani, a branch of the N. facialis [VIII. descends through the tympanic cavity. These nerve bre~nches e~re not directly associe~ted with hearing and balance - they supply other regions by passing through the tympanic cavity and petrous pa rt of the temporal bone. A branch of the N. fe~cie~lis [VIII innerve~tes theM. stapedius (see e~bove); the branches of the N. glossopharyngeus [IX) (Plexus tympanicus) supply the m ucous membranes of the tympanic cavity. The air-filled tympanic cavity extends in an inte rior and posterior direction into the mult i-<:hambered, also air-fi lled Cellulae mastoidaaa in the mastoid process of the occipital bone (w hich is palpable just behind and below the auricle).
Inner Ear (Auris interna) The inner ear is referred to as the labyrinth and is also located in the petrous part of the temporal bone. just superior (vestibular apparatus) and medial (cochlea) of the tympanic cavity. A membra nous and bony labyrinth can be disti nguished. The membranous labyrinth is a closed tube system. It is fi lled wit h a liquid, the endolymph, and contains the sensory organs. Its complex structure consists of three semicircu lar canals (Canales semicircu lares) which contain sensory modalit ies regist ering accelerated rotation. Sensory modalities (Sacculus and Utriculus) of linear accelerat ion and stat ic position are located in the region of the vestibule (Vestibulum). The bony labyrinth is a cavity in t he petrous part of the t empera I bone. It surrounds the membre~ nous le~byrin th e~nd its she~ pe is iden t i ce~l, but bigger in size. Thus. t he result ing space between the two labyrinths is filled with a liquid called perilymph . This perilymphatic space opens via two membranous windows t owards the middle ear: the Fenestra vestibuli (ovalis) and t he Fenestra cochleae (rotunda). The Stapes is secured in the oval w indow and the vibrations of the stapedial foot cause the perilymph to oscillate. The Cochlea records the vibrations of the lym ph, w hich are conferred by the sound-<:onduct ing apparatus of the ear. The Cochlea is the actual auditory organ. The action potentials arising from t he sensory modalities of the equilibrium and the auditory organ are conduct ed via the N. vestibulocochlea ris [VIII) w hich enters the labyrinth from the posterior cranial fossa via the internal acoust ic meatus (Meatus acusticus internus).
Clinical Remarks---------. The most common acute ear diseases affect the inner ear. Permanent tinnitua, the percep1ion of sound without real external sound, is experienced by approximately 1o-20% of the population. Sudden ..ntorintu1111 hl.,ing lott ISSHLI is an idi~ pathic disease usually affecting one ear only with variable degree of hearing impairment. In most cases, recovery from SSHL is spontaneous. A frequent disease is presby1culll which occurs after many years of exposure to higher noise levels. Hurfnglm· p1lrm1nt (hypacusisl generally describes a reduction in hearing ability. Worldwide, the population over 14 years old frequently have a reduced hearing threshold. There is a wide range of heariniiJ impairment from li11Jht redue1ion in hearing to complete deafness. Conductive he~ring imJ)Iirment and ..ntorineural c.u..• of h11ring imJNiirmlnt can be distinguished. Common causes of conductive hearing impairment are cerumen (earwax plugging the external acoustic meatus ~ p. 141), foreign bodies in the external acoustic meatus, inflammation of the external acoustic meatus 1~ p. 138), occlusion of the auditory tube (-+ p. 143), inflammation of the auditory tube(-+ p. 149), middle ear infections (-+ p. 1441, cholesteatoma (-+ p. 1471, or otosclerosis (-+ p. 142}. Sensorineural hearing impairment is frequently caused by aging !see above), genetic syndromes(-+ p. 137). infectious disease3, trauma to the head, tumours (-+ p. 152), and sucklen sensorineural hearing loss. Vett1ao is the sensation of perceived motion when one is stationary. Vertigo most frequently results from contradictory positional information generated during dysfunction of the vestibular system of the inner ear. There are vestibular causes (inner ear, N. vestibulocochlearis, brain} and non-'llestibular causes (e.g. low blood pressure).
-+ Di•••ttion Linlr Auricle (pinna, Auricula), external acoustic meatus. and tympanic membrane are usually not dissected. The anterior and posterior semicircular canals are displayed by chipping open the bone with a chisel. Both semicircular canals are, in part, deeply embedded in the petrous bone. Usually, the horizontal semicircular canal is only demonstrated. The Meatus acusticus externus is exposed along the course of the Nn. facialis lVII and vestibulocochlaris IVIIII up to the Ganglion geniculi, to the Cochlea and vestibular sy8tem, respectively. Next the branching of the N. petrosus major from the Ganglion geniculi is visualised. For illustration of the Cochlea. the anterior surface of the petrous bone. located medially to the internal acoustic meatus, is removed with a chisel approximately 1-2 mm parallel to the bone surface. The roof af tympanic cavity is now opened. The Malleus and Incus become visible. For visualisation of the Stapes, special preparations are required land therefore this is usually only demonstrated). Starting at the Ganglion geniculi, theN. facialis lVIII is traced with care and attention must be paid to the Chorda tympani which runs in the opposite direction in between Malleus and Incus.
EXAM-CHECK LIST • Ear development • Auricula aurie • Meatus ecusticue extemue • Glandulae cerumlnosae • blood supply •lymph drainage • innervation • Zoster oticus • Auris media with Membrana tympani and Ossicula auditus • walls of the Cavum tympani • topographi· cal relationships • clinical relevance • cholesteatoma • Os temporal& • musclea: function and innervation • Plexus tympanic::us • Chorda tympani • N. facialia lVIII and N. veatibulococ::hlearis lVIII] with nuclei • function of the auditory (EUSTACHIAN) tube • Cochlea • Labyrinthus v88tibularia • Ductus 88micirculem with anatomical position • topography: Auris Interna In relation to N. faclalls [VII] and N. vestlbulocochlearls [VIII]• Meatus ecustlcua internus • acoustic neurinoma • Pars petrosa • longitudinal and horizontal fractures of the Pars petrosa • course of the Nn. petrosi major and minor • Ganglion geniculi • vascularisation • A. labyrinthi
135
Ear
Overview
--+
Outer ear
--+
Middle ear
-+
Auditory tube -+
Development
Week4D
Week12
c
• Figs. 10.1a to d DIIValopmant of the aurlcla from tba six aurtcular hillocks, rtght slda. (21 ( The merger of the auricular hillocks (1-6) is a complex process and, thus, developmental abnormalities are not infrequent. The primordial auricles start to develop at the base o11he neck. As the mandible develops, the auricles move cnmially to reach their normal position on both sides o1 the head at the level of the eyes. Ears positioned deeper in the head frequently are associated with (o1ten chromosomal)
developmental abnormalities. The external acoustic canal derives from the posterior part o11he first pharyngeal groove which extends inwards as a cone-shaped tube to reach the entodermal epithelial lining of the tympanic cavity (Recessus tubotympanicus). At the beginning of week 9, epithelial cells located at the floor o11he external acoustic meatus proliferate to generate a cellular plate, the meatal plug, which normally degenerates by 7 months of fetal development. A persistent plate in the external acoustic meatus is a cause of congenital deafness.
Beginni'.g of week 5
a Figs.10.2a and b Differentiation of the auditory o.iciM, o..icula audm.. (21 I At the beginning of week 5. mesenchymal tissue o1the first and second branchial {pharyngeal) arches initiates the formation of auditory ossiclea. The first branchial arch (also named manchibular arch) generatea the Malleus and Incus as derivatives of MECKEL's cartilage as well
End of Wllllk 5
b as the M. tensor tympani which is inner.tated by the first branchial nerve, theN. mandibularis [VfJJ. The second branchial arch generates the Stapes, a derivative of REICHERT's cartilage. The Stapes can be moved by the M. stapedius which is innervated by the second branchial nervas nerve, the N. facial is lVIII.
Ear Development------------------------------------------------~ At approximately day 22, a thickening of the aurface ectoderm occurs on each side of the rhombencephalon. These cellular conde~ sations, the o1ic plac:odea, invaginate to form the otic or auditory pit which gives rise to the otic YfliciM (otocyst). Each otic vesicle divides into a ventral (rvfirall part that gives rise to the saccule and the Ductus cochlearis and a dorNI(occipitall part giving rise to the utricle, semicircular canals, and the Ductus endolymphaticus. Rostral and occipital parts remain connected through a small duct. The epithelial structures formed in this way are collectively named as the membranous labyrinth. The first pharyngeal groove and the first pharyngeal pouch grow and come in close contact with each other. The external acoustic meatus develops from the ectoderm of the first pharyngeal groove; the middle aar derives from the entoderm of the distal part of the first
136
pharyngeal pouch. The proximal part of the first pharyngeal pouch remains narrow and gradually forms the auditory tuba !EUSTACHIAN tube). The latter has a very narrow connection with the part of the foregut which later becomes the nasopharynx. The distal part of the first pharyngeal pouch develops into the tympanic cavity. In the lateral wall of the tympanic cavity the Recessus tubotympanicus forms and gradually extends towards the invaginating pharyngeal groove. At the site of contact, a thin membrane persists- the tympanic membrane (ear drum). At the beginning of week 5, the chain of auditory o.iclaa develops from mesenchyme derived from the first and second branchial arch. At week 6, six auricular hillocka develop at the dorsal end of the first pharyngeal groove and, in a complex progressive process, form the adult auricle.
Inner ear -+ Hearing and equilibrium
Development
~ua--------------~~
Sf.ceulu& ---------+""7"':~'t-f
Coc111aa --------H~
Membrana 1Yn'4*llca
Fig. 10.3 Structur• of the Inner, middle, and outer ear et1he time of birth. [21 I Up to 8 months of pregnancy, 1tte initially cartilaginous auditory ossicles
are embedded in mesenchyme. Gradually. this mesenchvme is replaced by an entoderm-derived mucosal lining which covers the complete tympanic cavity.
Fig. 10A Child w11h a ,._.urlcullr skin tag. 1201 A iirst degree auricular dysplasia.
Fig. 10.5 Child with a small n1dlmentary aurlcfe (microtia). [201 Second degree auricular dysplasia. The auricle is small and severely disfigured. This oiten includes the external acoustic meatus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . Contw~ltal dNfnen oocurs in 2 of 1000 newborns. One third of these cases have underlying genetic defects. Other causes are infections during pregnancy. chronic diseases of the mother, medic.r tion. alcohol, and nicotine. The inability to hear significantly impairs the ability to speak and to develop structured thought processes and communication skills. Thus, early diagnosis and treatment are
essential. External Mr defem are common. These abnormalities are dMded into grades 1 to 3 1~ Figs. 10.4 and 10.5). Dominantly inherited FRANCESCHETTI's syndrome (mandibulofacial dysostosis! is an example of a grade3 dysplasia. Here. a dysplastic first branchial arch and iirst pharyngeal groove result in defects of the external ear end zygomatic bone, recessed chin, and cleft palate.
137
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Ear, overview Ossicula audi1u&
Aurieula
Ptoc. mastadeus
Fig. 10.8 Parts of th• •ar, Auris, right slct.; longitudinal section through the acoustic meatus, middle ~r. and auditory tube; frontal view. Presentation of the auricle (Auricula), external acoustic meatus (M~tus acusticus extemus), tympanic membrane (Membrana tympanies, ear drum), tympanic cavity (Cavitas tympani), auditory ossicles (Ossicula auditus), cochlear labyrinth (Labyrinthus cochlearis), and vestibular labyrinth (Labyrinthus vestibularis). Sound waves initiate oscillation of the tympanic membrane l••rcrtympanal conduction). The auditory ossicles transmit the vibrations to the oval window of the inner ear (-o Fig. 10.27) and match the low air impe-
dance (-o Fig. 10.17) with the high fluid impedance of the liquid-filled inner ear (impedance matching). In addition, the inner ear can also sense vibrations of sk.ull bones (bon• conduclton). Within the inner ear, the sound energy propels as a wave (migrating wave). Sensory cells of the inner ear convert the sound energy into •l.ctrlc lmpulsH which are transmitted via the N. cochlearis to specific regions of the brain. The vestibular organ serves the perception of rotational and linear accelerations. Motion of the endolymph contained within the vestibular organ results in the deflection of cilia on the surface of sensory cells which are in contact with afferent fibres of the N . vestibu Iaris.
- - - - - - - - - - - N. v.tlbUiacochlaarl& [VIIO
Fie. 10.7 Middl• and inn•r •ar. Aun. madi• •nd inblrn•. right Ud•; enlarged section of Figure ... 10.6; frontal view. Depicted are the tympanic membrane, the three auditory ossicles in the tympanic cavity (Cavitas tympani): hammer-shaped Malleus, anvilshaped Incus, and stirrup-like Stapes as well as parts of the membranous labyrinth (Lebyrinthus membraneceus, blue).
138
Clinical Remarks-----------, Mechanical manipulations (e.g., cleaning of the external acoustic meatus using a 0-tip) or injury often result in inflammations in the region of the auricle and the external acoustic meatus lut.m~~l otlllsl.
Inner ear -+ Hearing and equilibrium
Auricle
Hab: cru.. antluollc:la
Cruahallc:lo
lnciMn anlllriar
ee.ttu cone'-
Helbc Concha Mltculae
Helbc
Lobuklt auricuiM
Fig. 10.8 Aurfcle, Auricula, rfght side; lateral view. The basic framework of the auricle consists of elastic cartilage. The skin on the lateral surface of the auricle is fixed to the perichondrium and
A. a~rlcul.ta pol1~a"~Dr,-~ Rr. au~c'*'-
cannot be moved; on the rear side of the auricle, the skin is movable. Subcutaneous fat tissue is lacking. The earlobe (Lobulus auriculae) is free of cartilage.
A. -..icullris posteolor, Rr. perforantlaa
N. occipit.lk minor (C2)
A. carotl9 IIXIama
Fig. 10.9 Art•i• of the auricle, Auricula. right tide; lateral view. [8]
Due to its exposed l~tion, the auricle is highly vascularized (protection against freezing, suitable for heat convection). The supplying arteries are branchR of the A. carer& externa (A. auricularis posterior, A. temporal is superficialis).
A N. vagua (X] e N. faclalls [VII]
N. aurkiUart& maanus (C2,C3)
Fig. 10.10 Sen.ory innervation of the auride, Auricula. right tide; lateral view. [8] The sensory innervation of the auricle is supplied by the N. auricukrtemporali8 (from the N. mandibularis IVfJ]) in front of the ear, the Plexua cervicalia (N. auricularis magnus, N. occipitalis minor! for the region behind and below the ear, the N. t.c:iali8 lVIII for the auricle itself (what pert of the N. facial is lVIII exactly is involved is not entinaly clear), and the N. vagua 00 for the entrance (aditus) to the external acoustic meatus.
-+ dlsuctlon link
139
Ear
Overview
--+
Outer ear
--+
Middle ear
-+
Auditory tube
-+
Auricle and external acoustic meatus
M. obllquu. &rleullle
M. IWrlcularla
M. ...tcu'-11 poslarlor
111111!1or
~--M.t.......,.,,....
1Wrlcullla
cauda
b
Figs. 10.11a and b Muscles, Mm. aurlcularn, and cartilage of the auricle, Auricula, right side. a lateral view b dorsal view Rudimentary muscles can sometimes be found attached to the auricle (some people manage to wag their ears). These are facial muscles (innervation by the N. auricularis posterior of the N. facial is [VII)) which are
Figs. 10.12a and b Externalacou.tlc mNtut, Meatus acuttlcus extemue, right aide; schematic drawing. • frontal section b horizontal section The external acoustic meatus is 5-shaped and is formed by the Pars tympenice of the Os temporals. The auricle has to be pulled up and backwards in order to inspect the tympanic membrane with a reflecting otoscopic mirror or a microscope (otoscopy). This will straighten the cartilaginous part of the extemalacoustic meatus end allow the (at least partial) view at the tympanic membrane. Innervation of the external
part of a rudimentary sphincter system still found in many animals. Horses, for example, move the auricle such that the external acoustic meatus faces the sound waves. During hibernation, hedgehogs and bears use this sphincter function to occlude the external acoustic meatus and bloc!( out unwanted noise.
1-+nbl
acoustic meatus (not shown) is through the N. meatus acustici extemi of the N. auriculotemporal is (anterior and superior wall), the R. auricularis of theN. vagus lXI (posterior end partially inferior wall), and vie the Rr. auriculares of the N. facialis [VII) and theN. glossopheryngeus [IX] (posterior wall and tympanic membrane). Arrows: direction of p~o~ll on the auricle by the examiner to straighten the external acoustic meatus end allow a view at the tympanic membrane.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , • Inflammation of the elastic cartilage of the auricle (auricular perichondriti81 can occur as a result of injuries and insect stings. The treatment includes topical application of disinfecting agents as well as local and systemic application of glucocorticoids and antibiotics. • The earlobes are rich in vascularisation, do not contain elastic cartilage, and are easily accessible and,tnerefore, are often chosen to draw small amounts of blood, e.g. for measuring the blood glucose levels of diabetic patients.
140
• Abnormalities of tne outer ear often require plastic-reconstructive surgery. • The N. vagus [)([ supplies sensory innervation to the external acoustic meatus. Manipulation in the external acoustic meatus (e.g, removal of cerumen or foreign objects) regularly initiates a cough reflex with the respective person !ARNOLD's reflex). In severe cases, the person can show signs of nausea or collapses.
Inner ear
-+
Hearing and equilibrium
Tympanic membrane
Sb1a
mllllaarta
1 ll'ltllrior uflPII' qulllhnt 2 antar1or ' - quadrent 3 po81811ar lower quadrant
4 po81811ar uppar ........,,
Fig. 10.13 Tympanic membrane, Membrana tympanlca, right side; lateral view; otosoopic image. In its anterior, inferior, and posterior aspects, the Meatus acusticus extern us is demarcated by the Pars tympanica of 1t1e Os temporals. In its superior aspect. the bony ring is interrupted by the Incisura tympanies (attachment point for the Pars flaccida of the tympanic membrane). With the exception of the Incisura tympanies, the otherwise circular Sulcus tympenicus is located within the Pars tympanies (the Pars tense of the tympanic membrane is attached here through the fibrous cartilaginous Anulus fibrocarlilagineus) .
Fig. 10.14 Tympanic membrane, Membrana tympanlca, right side, quadrant scheme. Lateral view. Illumination of the peark:oloured tympanic membrane usually results in a triangular light reflex in the anterior lower quadrant, which allows conclusions on the tension of the tympanic membrane.
•
clinical term: SHRAPNELL's membrane •• typically positioned light reflex Plica mdM!Ia po.ter1or
Pice mollearl• ...pertar
Recaaua membranM tympanlcu aupertor Plica mdearllo .m.1gr RlmiJI-+-~u
lyn'flrolc n'MITibrane
Fig. 10.15 Tympanic membrane, Membrana tympanica, and recaHua of the tympanic cavity, Cavitn tympani, right aide, quad,.nt tehama; lateral view; schematic drawing. The quadrant scheme is of practical clinical relevance. The auditory ossicles are located in the upper quadrants. In addition, the Chorda tympani and the attaching tendon of the M. tensor tympani are localized here(-+ Fig. 12.1~1.
*
Fig. 10.11 Tympanoatomytube (grommet) in the anterior lower quad,.nt. To avoid injury of structures of the middle ear, a paracentesis (myringotomy; small surgical incision of the tympanic membrane) is performed in the anterior or posterior lower quadrant. respectively. Longer-term ventilation of the tympanic cavity is ensured by inserting a grommet into the incision.
*
grommet
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , As the Pars fleccida is thinner than the Pars tense, spontaneous perforation of the tympanic membrane during putrid middle ear infection (otitis media) tends to occur in this pert of the tympanic membrane. Serous effusion collecting in the middle ear is visible through the tympanic membrane. This effusion can be drained by myringotomy. Grommets inserted into the opening of the tympanic mem-
brans ensure longer-term drainage and aeration of the middle ear (... Fig. 10.16). Excessive production of cerumen (earwax) can cause blockage of the extemalacoustic meatus (Cerumen abturanalend conductive hearing loss. Cerumen contains bitter substances that provide some protection against insects and micro-organisms.
141
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Auditory ossicles
Prac.
F".g. 10.17 Auditory cmidH, O•icua. 1uditu1, right 1icle; superomedial view. The auditory bones of 1he anditory ossicular chain are connected in series. They are linked by true joints (Articulatio incudomallearis - a saddle joint- and Art. incudostapedialis- a spheroidal joint!. The chain of auditory ossicles transmits the energy of the sound waves from the tympanic membrane to the perilymph of the inner ear. This involves the
transformation from lower air impedance to the much higher fluid impe
Proo.la1ilnllla
F'.g. 10.18 M•lleut, M•ll•u•. right eicle; frontal view.
Flg. 10.19 Mllleut, MIIIIKII, right llcle; posterior view.
CrusbnMt
PI!)C.I8ntiCIJIIris
Flg. 10.20 Incus, Incus, right slrt.; lateral view.
Proc. lllntlcurarta
Fig. 10.21 Incus, Incus,. right side; medial view.
Fig. 1022 Stapn.. StiJMK,. right s1de; superior view.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Defects in the conductive chain (tympanic membrane. auditory ossicles) result in conductive hurtng loss. Complete loss of transformation of sound pressure results in a reduction of hearing by approximately 20 dB. A typical disease causing such hearing loss is otoeclero.il, a disease localized to the petrous part of the temporal bone. The base of the stapes progressively fixes to the oval window
142
through ossification of the Lig. anulare stape
Inner ear -+ Hearing and equilibrium
Tympanic cavity
Fig. 10.23 Different lwell of1fte tympanie cavity, Cavita• tympani, right •ide; frontal view. From a clinical standpoint, the tympanic: cavity divides into three sections named according to their topographic relationship to the tympanic membrane: • The epltympenum (red; Recessus epitympanic:us, epitympanic: recess, attic}, contains the suspension apparatus and the majority of
the ossicles and, through 1he Antrum mastoideum, connee1s with the mastoid cells. • The m••otvmJMinum (blue} contains the Manubrium mallei, the Proc. lenticularis of the incus. and the tendon of theM. tensor tympani. • The hypotympanum (green; Recessus hypotympanicus} leads into the Tuba auditive [auditorial.
Ug. mellelaupll'klll -"-l'l~r-...:..L Receeliu8 ~cua ---TrH~~
Ug. malei anteriua
Manubrium mel lei
Ag. 10.24 Joints 1nd Ogements of1fle 1udltory osslclls,. Articullrtion11 •nd Ligg. OMiculorum •ud"l'lu•. right •ide; superomedial view. Ligaments fasten the Malleus and Incus in the epitympanum. The Art. inc:udomallearis (saddle joint} connects both auditory ossic:les. The Art.
M. Wll>ldkle. Teooo
incudostepedialis (spheroidal joint) connects the Stap&S with the Incus. The base of 1he Stapes !Basis stapedis) is secured to the oval window by the Lig. anulare stapedial& {syndesmosis). All strue1ures in the tympanic: cavity, including the Chorda tympani, are lined with mucosa of the middle ear.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . In children, one of the most common causes of conductive hearing loss is the occlusion of 1fl1 1udltory tube caused by an inflammation of the tube or restricted nasal breathing due to enlarged pharyngeal tonsils {adenoids). With continued functional impairment of
the auditory tube, the mucosa of the middle ear starts to secret a seromucous fluid that collects in the tympanic: cavity (11romucous otifil medii).
143
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Tympanic cavity Chardlo tympani; Plica mlllleart• •nt.b
Mea1118acu811cua axlemua
Cllllllia CII'Oiicua MIIITbrana tympenica
Fig. 10.2& Tympanic c.vlty, Cavttas tympani, rfght side; frontal section: frontal view. The tympanic cavity is an air-filled hollow space within the middle ear and contains the auditory ossicles. The tympanic cavity is located directly behind the tympanic membrane and is aerated and drained by
the Tuba auditiva [auditorial (EUSTACHIAN tube) which also serves in pressure equalization. The spatial distance between the epitympanum and hypotympanum is 12-15 mm and the depth is 3-7 mm, with an inner volume of approximately 1 cm3.
Tympanic C.vity IC.vit• tympanil
Rg. 10.26 Topographical relation~hipa between the tympanic cavity, CIIVitu tympani. and adjacent atructurw, righteide; lateral view; schematic drawing. A thin bony plate {Tegmen tympani, Parln tegmantalls) separates the epitympanum cranially from the middle cranial fossa. The anterior wall of the mesotympanum IPariu c:.roticusl is in close proximity to the A. carotis interne. The tympanic membrane makes up the entire lateral waiiiPari• membranaceu.J. The Tuba auditive [auditorial enters the tympanic cavity in the inferior wall section. The posterior wall (Paries
... ...
mastoid process (Paries mastoideus)
posterior wall (Proc. mastoideus)
V. j ugularis (Paries jugularis)
inferior wall (Fossa jugularis)
A. carotis intema {Paries ca roticusl
anterior wall {carotid canal!
middle cranial fossa (Paries tag mentalis)
superior wall (middle cranial fossa)
t
oval window (Paries labyrinthicu sl
medial wall (labyrinth)
0
tympanic membrane (Paries membranaceus)
lateral wall (tympanic membrane)
~
@
mastoideus) borders the mastoid process (Proc. ma.toideual. In its posterior upper section, a direct connection exists to the pneumatic spaces of the mastoid !Aditus ad antrum). The medial waii(Parfas labyrlnthlcus;-< Figs. 10.27 and 10.28) separates the Cochlea from the tympanic cavity. The inferior wall of the tympanic cavity (Parln jungularisl belongs to the hypotympanum and separates the tympanic cavity from the V. jugularis interne. Here, the bone is very thin and partially air-filled.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The acute infection of the middle ear (otitis medial is one of the most common diseases during childhood. The most frequent cause are bacteria and viruses which reach the middle ear through the auditory tube ITuba auditive [auditorial) during or after an infection of the nasopharynx. This inflammation involves increased vascularisation (red colour), edema, granulocyte infiltration, and pus production. Because the inflammation blocks drainage of pus through the auditory tube, the inflammation can spread to adjacent structures and result in severe complic:.tion•. such as:
144
• rupture of the tympanic membrane (most frequent case, via Paries membranacausl • mastoiditis !via Paries mastoideus, Antrum mastoideum, .... p.134J • thrombophlebitis and thrombosis of the V. jugularis (via Paries jugularis) • septicaemia (distribution of pathogenic organisms from the otitis media site through the blood via Paries caroticus) • brain abscesses and/or meningitis (via Paries tegmenta lis) • labyrinthitis (with vertigo and hearing impairment via Paries labyrinthicusl
Inner ear -+ Hearing and equilibrium
Tympanic cavity Eninentla pyramidalis PromlrMnlla c:~~niiiiii'IIII'Wf fllcJds
lmlltMiiO lrigeminaia
P.tllamllllaldaU8
Fig. 10.27 Mediel well, P•ri.. lebyrinthicue, of the tymJMinic c.vity, Cevit.. tympeni, right eict.; vertical section in the longitudinal axis of the petrous part of the temporal bone: frontolateral view. Above the oval window, the lateral semicircular canal bulges out the wall of the tympanic cavity to form the Prominentia canalis semicircularis laterelis. The N. facielis lVIII passes through the Canalis nervi facialis which is located within the medial wall. This canal creates the horizo~
tel Prominentie canalis nervi fecialis in the medial well. The Tuba auditive (auditorial initiates at the Ostium tympenicum tubae auditivee. L~ catad along the superior aspect of the Tuba auditiva (auditorial. the Sap. tum canalis musculotubarii separates the auditory tube from the Semicanalis musculi tensoris tympani. Typically pneumatised !Cellulae mastoideael. the mastoid process {Proc. mastoideus! connects with the tympanic cavity through the Antrum mastoideum.
Suk:llt promonto~l
Foa"• fll1!811tru ooctl~Me
,_..n coc:hiM.e Rg. 10.28 Medlll w•ll, Pert" hbyrlnthlcus, of th• tympenlc cavity, C.VItas tympenl, right side; anterolateral view; after removal of the lateral wall and the adjacent parts of the anterior and superior walls: facial canal and carotid canal opened. The medial walls separates the tympanic cavity from the inner ear (labyrinth) and has two openings:
• the ovel window (Fenestra vestibuli} with the base of the Stapes affixed to it by the Lig. anulare stapediale • located more inferiorly, the round window !Fenestra cochleae) occluded by the Membrana tympanies secundaria. In the space between oval and round window, the basal cochlear tum creates a prominent bulge in the medial wall of the tympanic cavity, named the Promontorium.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Inflammation of the Cellulae mastoideae (m..toldltll) caused by an inflammatory process in the tympanic cavity is a frequent complication of otitis media. The inflammation can spread from the mastoid
and affect the soft tissue behind and in front of the outer ear, the M. stemocleidomastoideus, the inner ear, the Sinus sigmoideus, the meninges. and the N. facialis lVIII.
145
Ear
Overview
--+
Outer ear
--+
Middle ear
-+
Auditory tube
-+
Tympanic cavity, topography
M.lltllpedlus, 'nlnlkl
N.m.... (VIq
Fig. 10.21 N...cl•lls (VII], tymp.wnlc Cft'lty, C.Vtt.s tymp.wnl, end •udltary tube, Tub• eudltlv• [eudttorf•l. right side; vertical section in the longitudinal axis of tne petrous part of the temporal bone: frontal view; facial canal opened. TheN. facial is [VIII is composed of two branches, tne actual N. facia lis and the N. intermedius. Both branches combine deep in the facial canal (Canalis nervi facialis) to form the N. intermediofacialis (hencefortn referred to as N. facialis [VII J). It arches around tl1 e tympanic cavity and generates the Prominentia nervi facial is in the medial wall of the tym-
panic cavity. Beneath tnereof, the Eminentia pyramidalis protrudes into the cavity. It houses the M. stapedius innervated by the N. facialis (..... Fig. 12.152). The tendon of the M. stapedius exits the Eminentia pyramidalis and inserts at the inferior lateral aspect of the stapedial head. Function of the M. stepedlue: It attenuates vibrations at the oval window by slightly tilting tne stapes, thus, decreasing the transmission of sound waves and protecting the sensory cells of the inner ear from excessive noise.
l..ig.ineudis~
Carpus h:udl•
Ug.lncudle~
. . 8!1.
~,.,
.
~-~~.~Jr-
Proc. lllrtlcularll
F"..,. 10.30 Laterel well, Peri• membreneceus, of the tympenic cavity, C.Yitae tympeni, right side; medial view. The Canalis musculotubarius enters the tympanic cavity from the front. It is composed of two bony semicanals (Semicanalesl, separated by a bony septum, and contains theM. tensor tympani and the Tuba auditiva !auditorial. At the Proc. cochlaariformis, the tendon of the M. tensor tympani makes a right angle turn and inserts at the Manubrium mallei. Func:tion of theM. teneor tymp•ni: It increases the tension of the tympanic membrane by pulling at the Manubrium mallei. This results in
F0881lneudl8
hcus, CNalangum
N. faclalls IVIQ
the chain of auditory ossicles to become more rigid and this improvas their ability to transmit high-frequency sound waves. Shortly before the end of the Canalis nervi facialis, the Chorda tympani leaves the N. facialis lVIII, runs backwards through its own bony canal into the tympanic cavity and, embedded in mucosa, courses through the centre of the tympanic cavity between Malleus and Crus longum of the Incus. The Chorda tympani exits the cranial base through the Fissura sphenopetrosa (or Fissura petrotympanica).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Paralysis of the N. stapedius in the case of facial nerva palsy alters the auditory sensation. Normal sounds are perceived as unpleasantly loud (hypera.:uslsl due to the insufficient dampening action of
146
the stapedius muscle (no tilting of the base of the Stapes in the oval window).
Inner ear
-+
Hearing and equilibrium
N. facialis [VII], topography
PliCa mlllllllrll antwtor. ChOrda tympani
Stapea
Fig. 10.31 Tympanic cnlty, C.VIbls tympani, rfght llda; lateral view after removal of the tympanic membrane and the mucosal layer around the Chorda tympani.
The structures of the tympanic cavity covered by mucosa ara shown.
N. miDCillltia [V/2] N.~IM!Iar
N. mandlbuln [V/3]
N. "r.ckllll [VII]
Fig. 10.32 N. faciali1 Mil in 1he petrou1 part of the temporal bone, 0. temporal•, Pars petroN, right eide; posterior view; petrous bone partially removed; facial canal and tympanic cavity opened.
After removal of the Proc. mastoideus and opening of the facial canal and the tympanic cavity, the entire course of the N. facial is lVIII and its branches in the bony canal become visible(-+ Fig. 12.148).
Clinical Remarks Injuries to the N. facial is lVIII can occur during fractures of the petrous bone, inflammation of the middle ear or mastoid process, and surgical intervention in response to these scenarios. For proper diagnOIIil of the location of a lesion and follow-up examinations of facial nerve palsy, a variety of tests ara employed: SCHIRMER's test (function of the lacrimal gland), stapedius reflex, testing of taste and sometimes sialometry (testing the function of the salivary glands) to examine the Chorda tympani as well as electromyography IEMGI
and electroneuronography (ENoG) for the testing of the mimic muscles. The Chorda tympani courses through the middle eer and is vulnerable to injuries during operations in the middle EMir. An isolated functional I - of the Chorda tympani with dry mouth and loss of taste sensation on the affected side is common during middle ear infections.
147
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
N. facialis [VII), topography Plexus ~leu. CIII'O!Icotympllllk:la (PIIIXI.Ia camtlcualntamua)
N. fllr:lallll [VII)
Chorda tplpanl
N. fllcillk (VII]
Rg. 10.33 N. fiCliiii(VII], N. glouoph1ryng1us (IX], 1nd N. vagus (XL right lld1; frontal view; petrous bone partially removed; nerves are shown transparently. The N. pM~osus m•Jor is the first branch to leave the N. facia lis lVIII at the Ganglion geniculi. The N. petrosus major projects frontomedially and exits the Os temporale at the Hiatus nervi petrosi majoris below the Dura mater on the Facies anterior of the Pars petrosa ossis temporelis. This nerve provides preganglionic parasympathetic fibres to the Ganglion pterygopalatinum for the innervation of lacrimal and nasal glands. Shortly after passing through the Foramen stylomastoideum. the N. facia lis (VII) releases the N. 1Urlcul1rfs postlrlor for the inner-
vation of the auricle. Shown are also the R. auricularis of the N. vagus [X] for the sensory innervation of the external acoustic meatus and the N. tympanicus which branches off theN. glossopharyngeus shortly before this cranial nerve passes through the Foramen jugulare. Together with branches derived from a sympathetic network {Plexus caroticus internus, Nn. caroticotympanicil surrounding the A. carotis interne, the N. tympanicus participates in 1he formation of a neuronal plexus in the mucosal layer of the Promontorium. This Plexus tympanicus innervates the entire mucosa of the middle ear as well as the mucosal layer of the Tuba auditiva [auditorial and the mastoid process.
Fige. 10.341 to c Tempor1l bone, 0. tempor~le, with micldle •nd inner 11.r, left ..,; computed tomographic section ICTI, inferior view.
High·T&$01ution CT is able to visualize in detail all structures of the mid· die end inner ear. For example. this imaging techniQue allows for the evaluation of the internal acoustic: [auditory] meatus. the pneumatisation of the mastoid process, the positioning of the auditory ossicles, and the labyrinth.
[10)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The N. facialis lVIII can be accessed surgically through the mastoid process, for example to provide relief for an inflamed and swollen
148
facial nerve. Upon careful removal of the mastoid bone, the posterior section of the facial canal is e.xposed.
Inner ear
-+
Hearing and equilibrium
Auditory tube Fig. 10.35 C.rtllag• of 1M auditory tube, C.rtllago tube• •udlthr.., rfght 1lde; inferior view; exposed at the base of the skull. Projecting in an oblique angle from a cranial posterolateral to a frontomedial caudal position. the approximately 4 em long auditory tube !Tuba auditive [auditorial. EUSTACHIAN tube) connects the tympanic cavity with the nasopharynx (nasal part of the pharynx). It serves in pressure equalisation. The requirement for optimal transmission of sound waves is equal air pressure in both the tympanic cavity {the tympanic membrane is impermeable to air) and the external acou$tiC me&tus oompanment. If this is not the case. e.g. during the ascent or descent flight of a plane. impaired hearing results.
0. pUrtfnum, l:amlna hartzantalla
madlalla} O.IIPhtnOICIIIe, l:amlna -.!Ia Proe. ptllygoldllll
Oltlum ~ U!Maudltlvlle l:amlna
Oa apiHineill:lala, Alii maJOr, Faclea temponlll8
lltWIIIa} Clt'tlllgo
Lamr. mad lalla
~ 8II.ICittvN
Farwnan CMIIe
Fig. 10.38 M. lnator veil pala1fnl, M. tanaor veil palattnl, and cartll•g• of th• auditory tub•, Cartllago tub•• auditive•; inferior view. The Tuba auditive [auditorial (bony part not shown) initiates at the Ostium tympanicum tubae auditivae of the anterior wall of the tympanic cavity (Paries caroticus) and ends at the Ostium pharyngeum tubae auditivae which protrudes in the posterior lateral aspect of the nasopharynx. One can distinguish a bony part (Pars osseal and a cartilagi-
nous part (Pars cartilaginea) twice the length of the bony part. The latter consists of a trough-shaped elastic cartilage (Cartilage tubae auditivae) in an upsidEH1own position with connective tissue (lamina membranacea) on its medial side, thus creating a slit·like canal. Contractions of the Mm. tensor und levator veli palatini during swallowing result in the opening of the Tuba auditive [auditorial.
I-+T31
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The epithelial lining of the Tuba auditiva [auditorial is composed of respiratory pseudostretified ciliated epithelium and goblet cells. The cilia beat in the direction of the nasopharynx (mucociliary escalator). When the protective mechanisms of the tube fail, ascending infections can cause an infl•mmlltion of 1ft. Tube auditiv• (auditorial
and the middle ear. Similar to swallowing. yawning, and chewing, the moderately forceful exhalation with the mouth closed and the nose pinched shut IVALSALVA's maneuver) can open a blocked Tuba auditiva [auditorial and restore proper aeration of the middle ear.
149
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Auditory tube
1\lba aud111va [auci!O!!IIJ, Pars-
F".g. 10.37 Auditory tube, TuiNI •ucl"ltiv• (•uditori•J, right •icl&; cross-section through the Canalis musculotubarius at the level of the Pars ossea; lateral view. The osseous part of the Tuba auditiva [auditorial is located in a triangular bony canal (Semicanalis tubae auditivae of the Canalis musculotubarius} of the Pars petrosa ossis temporalis. Separated by a thin bony layer lias the M. tensor tympani in the Semicanalis musculi tansoris tympani of the Canalis musculotubarius.
DurtmaterCfllnielis
aphenope!niU
1\IH auclltwa (aulltortl]
b
• Figs. 10.3811 •nd b AudHorytul», 1\lbe eudtttv. [•udHorfiiL right side; cross-section at the level of the lateral pert of the Pars cartilaginea; lateral view. a closed tube b opened tube; arrows indicate the effect of muscle contraction on the auditory tube Swallowing involves the contraction of the Mm. tensor and levator veli palatini. Contr•ction of theM. tentOr veli pelri'ni causes a pull at the
Pars membranacea and the upper rim of the cartilaginous part of the auditory tube resuhing in a dilation of ttte tube lumen. Contraction of the M. levator veil pallltlnl causes the muscle to bulge out and this muscle belly pushes against the cartilaginous part of the tube from below. As a result, the slit-shaped lumen bends such that it causes the lumen of the auditory tube to dilate. Occlusion of the auditory tuba involves the M. salpingopharyngeus (not shown}.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Cleft palate coincides with a loss of function of the Mm. tensor and levator veli palatini, as these muscles have lost tttair attachment point (Punctum fixuml at the hard and soft palata, respectively (... Fig. 10.36). Thus, the contraction of both muscles fails to
150
open the Tuba auditive (auditorial. In patients with cleft palate and no treatment, the middle ear is not aerated and mucosal adhesion processes occur. These children usually have major impairments in hearing and speech.
Inner ear -+ Hearing and equilibrium
Bony labyrinth
N.¥Mt~Un
Fig. 10.39 lnn1r 11r, Auri• intema. 1nd N. v..tibulococ:hiNrit [VIII]; superior view; inner ear projected onto the petrous part of the temporal bone illustrating its natural position.
The tip of the Cochl&e is pointed anterolateral. The semicircular canals !Canales semicirculares} position in a 45" angle in relation to the main planes of the skull (frontal, sagittal, and horizontal planes). This is important information to lcnow when examining CT scans of the skull.
Forwnen rotunclum
-------~- N. fldds (YII], Ganglion ,_.lUI
Duotua Mmlolroulllrta polterfor
Fig. 10.40 Inner 11r, Aurie intema. with N. fac:ialie [VIII and N. vfttibulocochl11rie [VIII), right 1id1; superior view onto the petrous part of the temporal bone. When entering the Porus acusticus intemus, the N. facialis [VII) and its intermedius part position on top of the N. vestibulocochlearis [VIII) On clinical terms often referred to as N. statoacusticus}, which is composed of the Nn. cochlearis and vestibularis. The nerves distribute within 1t1e petrous bone. The N. cochiNrfs arches forward to the cochlea. The N. vMdbul1rle arches backward end, just before reaching the labyrinth, divides into a Pars superior for the anterior and lateral semicir-
euler canals and the saccule as welles into a Pars inferiorfor the utricle and the posterior semicircular canal. The perikarya of the neurons of both parts are jointly located in the G1nglion vlltibulll"'. The N. facialis [VII) runs above and in between the cochlea and vestibular organ in the facial canal. At the outer facial knee, the facial nerve bends downward in an almost oo• angle. The N. petrosus ml,lor branches off the N. facialis [VIII at the Ganglion geniculi. The nerve runs in a duplication of the dura on top of the petrous bone towards the Foramen lacerum and contains preganglionic parasympathetic fibres for the innervation of lacrimal and nasal glands.
-+ dl•••ctlon llnlc
151
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Bony labyrinth Cellulla tymp~~~lcu
Canalis 118M facial•
Can•h ....lllftlu..... anllertor
.........
----~1-l--.....l!l!l--Can•h ....lcft:u.....
~-dcu·
ln•mu•
- -+--....... .
Synehondnlllla petraocclplm.. Sulcu• elnuo poolralll lnl811or11
$,j~ 8lrl.ls lllgmoldel
Fan1men jugullnl
SynchDn<*aooll sphanopetRIH. $,j~UIJ naM pai!WI mi)Drls
- -r:-..._....__....
Fcnm1n lac:erum
Figs. t0.41a and b Bony ..byrlnth, Labyrtnthua oauua, rfght aida; hollowed out of the petrous part of the temporal bone; posterior and superior view (1}, superior view (b). The inner ear (Auris internal is a complex of bony canals and ampullary extensions in the Pars petrosa of the Os temporal& (bony labyrinth).
Contained within it is a system of membranous tubes and sacs, known as membranous labyrinth. It harbours the vestibular and cochlear organ (Organum ves1ibulocochleare). • opening of the Canaliculus posterior
canalis spllllll8 modlol
Lamlramodlol
-
Madllllu•
LMIIIMI epll'llh
cochiC.INIIII IIPirda cachl-
&alii tympani
e-ll•
11119tUdlnd• modioli
Tractus spnlia forwnlnotUI
~-dcu•lnlllmua
F"..,.
10.42 Spiral canal of the cochlea, Ce.nalilepiralia cochl..e, right aide; superior view; opened along the axis of 1he modiolus. The Cochlea consists of a spiral canal (Canalis spiralis cochleae) of 2~ turns around a central modiolus (Modiolus cochleae). The Ganglion spirals cochleae, con1aining 1he perikarya of the bipolar neurons of theN. cochlearis, is loca1ed wi1t1in the Canales spiralis and longi1udinalis modioli. Originating from the modiolus, 1ha Lamina spiralis ossea protrudes in1o the cochlear canal.
Fig. 10.43 Internal acoustic meatus. Meatut acuricua internua. and fundua of the intemal acouric meatua, Fundus meatua acu.tici interni, right aide; medial view; after penial removal of 1ha posterior wall. The internal acoustic meatus ini1iates a11he Porus acusticus intarnus and projects laterally for approximately 1 em. Here it ends in a perforated bony plate. The N. facialis [VIII and N. vestibulocochlearis lVII II run in 1his 1 em long segmen1.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The acou.tic neurinoma (also known as vestibular schwannoma, acoustic neuroma, acoustic neurilemmoma, acoustic neurofibroma) is a benign tumour of the SCHWANN's cells and most frequen11y affects the vestibularis nerve. As it originates in the Meatus acu-
152
sticus internus and grows into the posterior cranial fossa, it presses on adjacent structures (cerebello-pon1ine angle tumour). Early symptoms include asymmetric hearing impairment, dizziness, and loss of balance.
Inner ear -+ Hearing and equilibrium
Bony labyrinth
Fig. 10.44 Bony labyrinth, Ulbyrinthu. OMIUI, ritht tide; view from an obliQue posterior angle; the osseous lining of the membranous labvrinth has been hollowed out of 1he petrous part of the temporal bone.
Ampula- pclltllrfor
Fig. 10AS Bony l1byrfrrtlt, Llbyrlnthus OIHUI, right slde; lateral view; the osseous lining of 1t1e membranous labyrinth has been hollowed out of the petrous part of the tempore! bone.
fig. 10.48 Bony lebyrlnth, labyrtnthUI GIIIUI, right tld1; anterolateral view; cavities have been hollowed out. The bony labyrinth consists of the Vestibulum, three bony semicircular canals (Canales semicirculares ossei), the bony cochlea (Cochlea), and
the internal acoustic meatus {Meatus acusticus intemusl. Cochlea and semicircular canals originate from the Vestibulum which connects with the tympanic cavity through the oval window.
153
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Membranous labyrinth
Ampulla
DuotuaN'Iri.w
UtrfNIIII
f/~f+-I+Tv---
lalla -ubull
~~~~---o~.~~
~-;;.;..,_ ~~·--- ac.•~·
Fig. 10.47 Membr.noualabynnttl, Labyrlnthua membrlniCIUS, right side; longitudinal section through the petrous part of the tempon~l bone; frontal view, schematic drawing. (81 The membn~nous labyrinth contains potassium rich and sodium poor endolymph. A perilymphatic space filled with perilymph separates the membn~nous labyrinth from the bony labyrinth. According to its function, the membranous labyrimh divides into a vestibular and cochlear
compartment. The vutlbullr ldryrfnth includes the Sacculus and Utriculus located in the vestibulum, the Ductus utriculosaccularis, the three semicircular canals, and the Ductus endolymphaticus with the Saccus endolymphaticus. The latter is located on the rear side of the petrous bone and represents an epidural sac for the resorption of the endolymph. The eoch'"r l1byrinth forms the Ductus cochlearis. The Ductus reuniens connects the vestibular and cochlear labyrinths.
Ampul it. membrln- anterior
Ami)Uia memllrlllaca lltlrala
Fig. 10.48 N. vH1f'buloeochiHrls [VIII) 1nd membranous llbyrtnth, Llbynnthus membr.n•ceus; semi-schematic overview, dorsal view. The membranous labyrinth includes the Ductus cochlearis, the Sacculus, the Utriculus as well as the three membranous semicircular canals (Ductus semicircularesl. The latter ones connect with the Utriculus. At
154
the border to the Utriculus, each Ductus semicircularis develops an ampulla-shaped dilation (Ampulla membranacea). At one end, the superior and posterior semicircular canal unite to form one common canal (Crus commune). Each ampulla contains sensory epithelium !Crista ampullaris, not shown).
Inner ear -+ Hearing and equilibrium
Blood supply and innervation of the membranous labyrinth Ductua semicircularill
Fig. 10.48 lnn•rvrion of th• inn•r . .r, Auris intern•, right sid•; longitudinal section through the petrous part of the temporal bone; frontal view, schematic drawing. 181 The inner ear is composed of the compact bone of the petrous bone
surrounding the bDny l•byrinth (Labyrinthus osseus) and, enclosed within it. the membranous labyrinth (Labyrinthus membranacaus). which resembles a system of membranous tubes.
Vv. aqu~ YIIStii:IUi
A. spirals modioli
Fig. 10.60 Blood supply •nd lnn•rntlon of the Inner . .r, Aurls intama, of the right eida; medial view. (according to [2]) The branches of the A. labyrinth! (.... Fig. 12.96) provide the complete blood supply to the inner ear; the Vv. labyrinthi drain the venous blood.
A. and V. inferior anterior cerebelli project into the intemal acoustic meatus for a few millimeters (not shown) before the A. and Vv. labyrinthi branch off to provide blood supply to the labyrinth (caVNt: the A. labyrinthi is a terminal artery).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Being a terminal artery, thrombo11c ocduelon ot ttle A. l•byrlnttll or its contributing branches causes a loss of balance and hearing impairment. Attacks of vertigo, unilateral hearing loss, and unilateral tinnitus constitute the triad of symptoms characterising MENIERE's diSHse.
Its etiology is not clear, but a hydropic swelling of the membranous labyrinth due to impaired resorption of endolymph (cochlear hydrops) is discussed. The pressure imposed by the increased volume of endolymph damages the sensory cells of the vestibulocochlear system.
155
Ear
Overview
-+
Outer ear
-+
Middle ear
-+
Auditory tube
-+
Cochlea Fit. 10.51 Spiral canal of the codiiH, Coc:hiN; cro..·etc:tion; schematic drawing. [8) The REISSNER's membrane and the basilar membrane divide the Canalis spiralis cochleae into three spaces: • The Scala VM11bull stretches from the Vestibulum to the Helicotrema and is filled with perilymph. • The Ductue cochiHri• is filled with endolymph. • The Scala tympani extends from the Helic01reme to the round window in the mediel well of the tympanic cavity end is filled with perilymph. Scala vestibuli and Scale tympani join at the helicotrema.
Soala tyii'IJNinl
Lamtnaapnlll-
N. cochiNrfa Ug.aphlla
F'~t. 10.52 Spiral canal of tha cochlea. Codllea; cross-section through a tum of the Organum spirale; schematic drawing. [8) The basilar membrane (lamina basilaris) forms the base of the Ductus LAIIT*la bllllllrls cochlearis and supports the cochlear organ !Organ of CORTI or CORTI's organ). The Stria vascularis at the lateral bony wall of the Cochlea p~ duces the endolymph. ~meplrala
* REISSNER's membrane
~n~----~~ii~~~~~~~-c~~l~~,~~ !nnw pUivQIII
Outet
pit.. cell
Lamina 81lh118-
IScU tyrnpWltl Fig. 10.53 Organum spiral• (Ortan of CORTI); schematic drawing. [24)
This is a simplified presentation of the complex afferent and efferent innervation of the hair cells.
The organ of CORTI represents the actual cochlear organ. Cochlear sensory cells (hair cells) together with different supporting cell types re~ on the basilar membrane and a gelatinous membrane (Membrana tectorial covers their apical cell surface. The organ of CORTI stretches along the whole length of the Ductus cochlearis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . nnnltu1 is frequently the consequence of damage to the hair cells, e.g. after exposure to loud music or an explosion. Tinnitus aurium,
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or Tinnitus for short (Mringing of the ears"), is a symptom where the affected individual perceives sounds in the absence of real sounds.
Inner ear -+ Hearing and equilibrium
Mechanoelectrical sound conduction and equilibrium (balance) organ
Rg. 10.64 Mechenoelectrlcal sound conduction. [8) Sound propagates by sound waves which recch the outer ear (auricle and external acoustic meatus} and are transmitted by the tympanic membrane and the chain of auditory ossicles through the base of the Stapes to the perilymph. Vibrations at the oval window initiate movements of perilymph causing migrating wavw running along the wells
of the Ductus cochlearis (particularly the basilar membrane). These wtNes cause a deflection of the basilar membrane and the organ of CORTI. Consequently, stereocilia of the inner hair cells deflect. The sensory cells transduce this .biomechanic event into a receptor potential lmechanoelectrical transduction!.
Fig. 10.66 Structure of thl crista ampullarla. (according to [25)} The vestibular labyrinth is filled with endolymph and consists of the SIICC\IIus {Macula sacculi -vertical linear acceleration). Utriculus (Mecula utriculi- horizontal linear acceleration}, and the thi"H Mmlctrcular canall !Cristae ampullares with their Cupulae- rotational acceleration).
The sensory cells of the vestibular organ possess a long ldnocilium and stereocilia which extend into a gelatinous substance (Cupula). Movements of the Cupula result in the deflection of these cellular processes on the surface of the sensory cells. This presents a stimulus for the synaptic activation of efferent fibres of the N. vestibularis.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . U.bylfn1flltls with dysequilibrium and/or dizziness. nystagmus, nausea, and anxiety can accompany cholesteatoma (destructive and expanding growth of keratinising squamous epithelium dislodged from the outer sida of the tympanic membrane into the middle ear with chronic putrid inflammation of the middle earl, acute otitis media, mastoidi1is, and trauma to the skull. Entry ports for infectious
agents are the round and oval window, breaches in the bony labyrinth (caused by trauma and bone erosion due to infected pneumatic spaces!, or ascending inflammation of the meninges by nerves and vessels, Canaliculus cochleae, or Canaliculus vestibuli. The result is sensorineural hHrlnglmpatnnlllt with hearing loss and destruction of the vestibular organ.
157
Ear
Overview -+ Outer ear -+ Middle ear -+ Auditory tube -+
Hearing and equilibrium
Fig. 10.56 HNrlng. Collloolus ~lerlor Nucleus lamnlscllllleralls
NuclelaiW.. Nucllua corporis lr8p8zCiidei
Primary nuclei (purple): Nuclei cochlearis anterioras and posterioras; other nuclei (brown): upper olivary complex. Nuclei lemnisci, Colliculi inferiores, Corpora geniculata medialia. The neuronal network of primary and secondary groups of nuclei constitutes the auditory pathway and is shown in .... Figure 10.58. The chain of auditory ossicles amplifies the amplitude of the sound waves physically.
.
&f···. f···
Nucl.... CUIIIOIILB (Nuclluscan1rall&
eollumnae~
~--------=::::
(Nuclei CDI'I'
musculorum coli~
.
i5
Fig. 10.57 Control of equililnium and mbiliaation of the viaual field. Afhrant ftbres originate in the muscles of the eye, the equilibrium organ, and the muscles of the neck; llfferent fibres modulate the muscles of the eye and the body. The cerebellum plays a predominant role in this coordination.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Objectively assessing a patient's vertigo and localising the lesion within the vestibular system requires testing of the equilibrium (balance) system as an important part of a physical exam. Commonly used tests are the ROMBERG's tnt (Patient stands upright with feet together, eyes closed, and arms stretched forward) and the UNTERBERGER's stepping test {Patient is asked to walk on the spot with eyes closed) when assessing the body's sense of positioning or a tendency to fall for that matter. Another method is the nystagmus test (nystagmus = involuntary rapid eye movements) using FRENZEL's lenses (FRENZEL's glasses). Rapid shaking of the
158
patient's heed provokes a nystagmus. This test is performed with the patient holding the head in different positions. This examination will also reval any latent nystagmus. A caloric nystagmus test examines the responses by the labyrinth on one side. The patient is lying in a supine position (elevated head) in a room with dimmed light and the ear on each side is irrigated with cold and warm water. Cold water will initiate a physiological nystagmus to the opposite side. whereas warm water will stimulate a nystagmus to the same side of the labyrinth tested. A reduced or lacking nystagmus is pathological and suggests a peripheral functional impairment.
Inner ear -+ Hearing and equilibrium
Auditory pathway
Fig. 10.58 Auditory pathway; overview. The function of the ascending auditory pathway is to transmit acoustic signals to the brain, to process this information C4'.1ntrally, and to create an acoustic awareness. 1. neuron: bipolar cell• in tha Ganglion apirale eodllaae • After exiting the small apertures of the Tractus spirelis foraminosus deep within the internal acoustic maatus, the fibres fonn the N. cochlearis unite with the N. vestibularis at the floor of the internal acoustic meatus to form theN. vestibulocochlearis lVIII). • Fibres from the basal cochlear part traverse to the Nucleus cochle~r ris posterior and those from the apical parts tannin at& in the Nucleus cochlearis anterior. Z. neuron: multipolar cell• of the Nuclei coch'"rw • The fibres from the Nucleus cochlearis anterior pass mainly to the olivary complex on the same or opposite side.
• Apart of the fibres crosses to the opposite side and, without synapsing, run in the Lemniscus lateralis to the Colliculus inferior. • Fibres that reach the olivary complex on the same side, either ascend to the Nucleus lemnisci lateralis, synapse, cross to the opposite side, synapse again, and than reach the Colliculus inferior or they ascend directly in the Lemniscus latarelis to reach the Colliculus inferior. 3. or 4. neuron: From the Colliculus inferior connections are made to the Corpus geniculatum mediale. 4. or 5. neuron: The acoustic radiation {Radiatio acustica} connects the Corpus geniculatum medial& with the transverse temporal HESCHL's gyri or convolutions and the WERNICKE's centre in the temporal lobe.
159
Ear
Overview
-+ ••• -+
Hearing and equilibrium
Equilibrium (balance) pathway
Nucleu• V81ttlullula mlldLII•'"
Fig. 10.59 Equlnbrtum lb1l1nce) plthway; overview. The equilibrium (balance) pathway coordinates eve movements and movements of the torso, neck, and extremities. 1. neuron: • The efferent fibres of the Ganglion vestibular& mainly project into the Nucleus vestibularis medialis (SCHWALBE's nucleus). the Nucleus vestibularis superior (nucleus of BEKHTEREV), and the Nucleus vestibularis inferior (ROLLER's nucleus). • Afferent fibres of the Cristae ampullares of the semicircular canals mainly course to the nucleus of BEKHTEREV and SCHWALBE's nucleus as well as into the vestibulocerebellum via the direct sensory cerebellar pathway. • Afferent fibres of the Utriculus project into the medial vestibular nucleus, afferent fibres of the Sacculus project into the lateral vestibular nucleus. • The lateral vestibular nucleus (DEITERS' nucleus) also receives collateral fibres from the vestibular pathways and, in particular, connections from the Cerebellum.
160
2. n1uron: from the vestibular nuclei efferent fibres project • to the Cerebellum !Tractus veS1ibulocerebellarisl • to the spinal cord ITillctus vestibulospinalisl • to the nuclei controlling the extraocular muscles !Fasciculus longitudinalis medielis) • to the Thalamus {via the Tractus vestibulothelamicus to the Nucleus ventralis posterior inferior and from there via the Radiatio thalami to the Gyrus postcentralis) "
"* """
""*"
SCHWALBE's nucleus ROLLER's nucleus DEITERS' nucleus nucleus of BEKHTEREV
Neck Muscles .................... ... .. .. 164 Pharynx .. . ... ... .. ................ 176 Larynx ................... ... . . . . . . 180 Thyroid Gland .............. .... ... 192 Topography ............... . ....... 196
The Neck Seamless Connectivity Boundaries The boundaries of the neck (Collum/Cervix) towards the head, trunk, and shoulder girdle are diffuse. Fish have no necks; their heads adjoin to the trunk and shoulder girdle. Terrestrial animals possess necks, however, the neck is not a fundamental novelty, rather the head-trunkboundary was stretched or protracted, so to speak. This explains many features such as the fact that cranial nerves participate in the innervation of the shoulder muscles and that the arm is innervated by nerves which emerge from the cervical vertebral column (see below). If not the soft tissues but the bony structures are used to determine the boundaries of the neck, the upper borders of the neck are defined by the mandible and occipital bone and the lower borders by the clavicle and superior margin of the Scapula. Towards the centre of the chest. the neck transitions into the thoracic aperture (i.e. through the bony ring comprising of the first rib, the first thoracic vertebra, and Sternum) into the medi;~stinum of the thor;~x.
Nape If one touches the b;~ck of the neck, the n;~pe (Regia cervic;~lis posteriori. one palpates almost nothing but muscles: below the thin muscular layers of the M. trapezius on both sides of the vertebral column the powerful strands of the autochthonous (intrinsic) bacl: muscles (-+ p. 76, val. 1I are located. They act as muscles of the neck and insert at the base of the occiput. The spinous processes of the upper six cervical vertebrae (Vertebrae cervicalesl cannot be palpated as they lie below a dense sagittal tendon sheath, the nuchal ligament (Lig. nuchae). However, the spinous process of the 7111 cervical vertebra is visible and pa 1pable, hence its name Vertebra prominens.
Anterior Cervical Region If one applied the same force to grab the anterior cervical region (Regia cervicalis ;~nterior =Trigonum calli ;~nteriusl as is possible for the n;~pe, this would result in very unpleasant and painful sensations. As much as muscles determine the appearance of the nape, sensitive organs such as the viscera of the mediastinum extend into the anterior aspect of the neck. The lateral borders of the anterior cervical region are marked by both the Mm. sternocleidomastoidei which tum the head. Turning the head to either side causes the slim, actively flexed muscle belly of the M. stemocleidomastoideus of the opposite side to protrude. The jugular fossa (Fossa jugularisl is located at the base of the anterior cervical region between the clavicles ;~nd immediately ;~bove the Sternum. Applying pressure with one's finger directly at the jugular fossa compresses the Trachea and causes a feeling of being strangled. The Oesophagus is located posteriorly to the trachea and extends towards the Larynx. The Oesophagus is impalpable, but one feels its posterior proximity to the Trachea when swallowing an overly large and hardedged bolus. The bolus presses ventrally on the Trachea, since the extensibility of the Oesophagus is limited dorsally by the proximity of the Oesophagus to the cervical vertebral column. Palpating along the Trachea from the jugular fossa towards the head, one reaches the skeleton of the Larynx: in men, the Adam's apple (Prominentia laryngeal projects prominently. At about the level of the Adam's apple, the Larynx separates the airways (anterior) and the ali-
162
mentary passage (dorsaD. The Larynx is very mobile, and is held only by muscle loops. When swallowing, it moves crania lly by as much as one entire cervical vertebra. The thyroid gland (G landu Ia thyroideal, locat ed next to the Trachea and t he lower part of t he Larynx, consists of two large right and left lobes, which are hardly palpable- except in case of a goitre, an abnormal e nlargement of the thyroid gland. The cavity located cranially to the Larynx is named the Pharynx. Airways and alimentary passage cross at this point Mouth and nasal cavities also open into t he Pharynx. Pressing the t humb and index finger on both sides of the Larynx and moving t hem upward along the side of the neck towards the mandible while applying pressu re causes major discomfort. This area is referred to as the Trigonum caroticum, w here the pulse of the common carotid artery, A. carot is communis, is palpable very easily. This is where the common carotid artery divides into its two terminal branches, the A. carot is externa and the A. carotis interna. If one slightly increases the external pressure, a bone is palpable in this region: the greater horn of the hyoid bone (Os hyoideum). Provided one has the courage to swallow w hile applying pressure, one notices the upward movement of the hyoid bone and Larynx. In f act, the hyoid bone is a " tension rod" of the Larynx, w here some pharyngeal muscles attach ;~nd engage w hen swa llowing. With further increased firm pressure the A. carot is is pressed against the hyoid bone (and t he thyroid cartilage)- which can result in faint ing (syncope)- or the hyoid bone can fracture, and in this case the blocking of the passage to the Larynx leads to suffocation. Therefore medical examiners invest igate the hyoid bone meticulously in doubtful causes of death. Ensheathed in a common fascia (Vagina carotica), the A. carotis communis, the V. jugularis interna, and the N. vagus IXJ descend bilaterally along the continuum of the Trachea, the Oesophagus, the Larynx, and the Pharynx. The A. carotis communis arises from the aortic arch on the left-hand side or the Truncus brachiocephalicus on the rig ht-hand side. The V. jugularis interna collects blood from t he intracranial sinuses and the viscerocranium. The N. vagus (X], a cranial nerve, descends towards the mediastinum and into the abdominal cavity. In the lower part of the anterior cervical region and in close proximity to the clavicle the M. sternocleidomastoideus largely overlies this neurovascular bundle.
The Lateral Cervical Region The lateral cervical region (Regia cervicalis lateralis = Trigonum calli laterale) is confined cauda lly by the clavicle (Clavicula), media lly by the M . sternocleidomastoideus and dorsally by the M. trapezius. The broadly defined inner space of the Trigonum extends- w ithout sharp margins -under the clavicle and into the armpit (Axilla). The Trigonum colli laterale contains the large neural pathways descending steeply from t he cervical vertebral column to the arm. Most nerves supplying the arm (Plexus brachia lis) emerge from the cervical vertebral column. The Trigonum also encompasses t he great vessels of the arm (AN. subclavia), which come from the mediastinum, through the superior thoracic aperture, and descend behind the clavicle first into the Trigonum and then into the Axilla. There is hardly anything palpable, not even the pulse of the A. subclavia, because it lies deep in t he Trigonum, slightly behind the clavicle. There is also hardly anything visible as in a slim neck the skin covering the Trigonum over the clavicle forms the Fossa supraclavicularis major. Somet imes, the large cutaneous vein of the neck, the V. jugularis externa, is visible th roug h the skin; if one grimaces, the great cervical cutaneous muscle (Platysma) stretches t he thin skin of the neck.
Clinical Remarks---------. NICk InJuries are usually dangerous because the neck acts as conduit between head and torso. With the exception of the cervical part of the vertebral column, all important saft structures of the neck are easily accessible, includinq major blood vessels, nerves. Trachea. and Oesophagus. The neck contains approximately 200 to 300 lymph nodes which receive lymph fluid from the entire head and partially also from the torso. Tumours of the head can metastasis& to the cervical lymph nodes. Due to their exposed location. swelling of these lymph nodes can be a more obvious sign than the primary tumour itself. Also, the large numberoflymph nodes in the neck is the reason why generalised diHnH ofth•lymphatlc systMn,like HODGKIN's disease, aften become symJJtomatic in 111e neck region first. Diseases affecting the thyroid gland can usually be spotted easily. The neck and its visoera are also important for the physician. The blood vessels can be used for venous puncture or as en •cc... rom., the anaesthetist inserts the intubation tube through the nose or mouth, 111roat, and Larynx into the Trachea. The Larynx represents the tightest narrowing of all the airways. Diseases of the Larynx or the aspiration of foreign bodies coincide with shortness of breath and in severe cases this can require a tracheotomy or an emergency coniotomy.
-. Dl•••r:tltJn Llnlr DfutiCtlon of the neck from ventre!: After exposing and reflecting the Platysma superiorly, the epifascial nerves of the Plexus oervicalis are demonstrated. Subsequently, the superficial fascia of the neck is removed, followed by dissection of the M. sternocleidomastoideus, the anterior border of the M. trapezius and 111e N. accassorius lXII in the lateral triangle of the neck:. Upon removal of the middle fascia of the neck and exposure of the infrahyoid muscles, the Vagina carotica is exposed together with the Aa. carotides communis, extema and interna, the V. jugularis intema, and the N. vagus [X). The M. stemocleidomastoideus is severed at the clavicle and deflected superiorly. The bilateral exarticulation of the clavicle is followed by the complete representetion of the infrahyoid muscles with Ansa cervicalis. by the detachment of the infrahyoid muscles which insert at the Sternum, the visualisation of the thyroid gland and its ventral blood supply as well as the dissection of the large vessels between head and arm. and of Mm. scaleni, Plexus brachialis, N. phrenic:us. Glandula submandibularis and its adjaoent vessels, and the Larynx from ventral and lateral. Subs~ quently, after the presentation of the sympathetic trunk on the cervical vertebral column. the head is exarticulated at 111e atlanto-occipital joint of 111& cervical vertebral column and, together with attached cervical structures, removed from the torso. After preparation of the Pharynx from the dorsal side and illustration of the cerebral nerves, the Pharynx is opened dorsally in the median line. This is followed by the dissection of the Larynx from the dorsal side with a presentation of the vocal folds end the laryngeal muscles. Finally. the ventral aspect of the Larynx is dissected.
EXAM CHECK LIST
• Development of the thyroid gland (Ductus thyroglossalis), the parathyroid gland, Larynx,. and Pharynx • neck fasciae, Fascia bucoopharyngea • infrahyoid muscles, neck muscles (Platysma, Mm. aternocleidomaatoideua, trapezius, sc.leni), prevertebral muscle8, short neck muscle. • vertebral triangle • Pharynx • oervic:al section of the Oeaophagu• • larynx • oervic:al section of the Trachea • thyroid gland, epithelial bodies • Glomus carotlcum • Nn. craniales (Nn. glossopharyngeus (IX], vagus (.X], accessorius [XI), hypoglossus (XII)), cervical nerves (Rr. dorsales, Rr. ventrales, Plexus cervicalis) • autonomic innervation (Sympathicus, Parasympathicusl of vessels • A. cerotis communis, A. cerotis intema, A. cerotis externa, V. jugularis interne, Angulua venosua • superficial and deep cervical lymph nodes, confluence of major lymphatic collector avstems • surfeoe anatomy of the neck • Spatium peripharyngeum • region• of the neck • imaging techniques
163
Neck
Muscles -+ Pharynx -+ Larynx -+
Regions of the neck
M. dlgiMIIrlala, V.nter poetellar
1Hganum IUIIIII'IUidiiUIIII'It ......
M. omol!yOideU8, Vlrrter tiUDeriOI'·-
Fig. 11.1 Ant•lar and lmral n1glans of h neck; Reglonu c.rvlc.ln antllrlor lrt llrtenlllt, lift slda; lateral view. 181 Boundaries of 1he anterior triangle of 1fle neck IRegio cervicelis anterior !Trigonum cervicele enteriusll are the lower rim of the mandible, the anterior rim of the M. sternocleiclomastoideus. encl the Linea mediana cervicis. Located within the anterior triangle of the neck: are the Trigonum submandibulare (margins: lower rim of the Mandibula, Venter anterior and Venter posterior of theM. digastricus). the Trigonum submentale (margins: Os hyoideum, Venter anterior of the M. digastricus, Linea medians cervicis}. the Trigonum musculare (margins: Os
164
hyoideum, Venter superior of the M. omohyoideus, M. stemocleidomastoideus, midline of the neck:}, and the Trigonum caroticum {margins: Venter superior of the M. omohyoideus, the lowest part of the M. stylohyoideus, Venter posterior of the M. digastricus, M. sternocleidomestoideusl. Boundaries of the pomrior triangla of 1fla nack (Regio cervicalis posterior [Trigonum cervicale posterius)) are the posterior rim of the M. stemocleidomastoideus. the anterior rim of the M. trapezius, the upper rim of the clavicle and the Os occipitale.
Thyroid gland -+ Topography
Neck muscles
Glandula paro11dee
Fig. 11.2 Muldes of the 1rrt1rlor •nd lat~n~l neck regions, Reglonn cervte~~lu Interior .t l•t••lls, superfrclalley•; 11ft side; lateral view. The Platysma Ia mimetic muscle without fascial is a thin muscular plate and locates superficially directly under 1he skin. It extends from the mandible, across the clavicle, and onto the Thorax. The posterolateral part of the superficial neck: fascia has been removed. The upper part of the M. S1ernocleidomastoideus is a r&fer&nce point during surgical inter-
ven1ions. Located further posterior and inferior. the anterior rim of the M. trapezius becomes visible. The lower pole of the Glandula parotidea lies between the Platysma and the M. stemocleidomastoideus and can extend into the neck region to a variable degree. The M. levator scapulae is visible deep in the poS1erior 1riangle of the neck.
I-+T1f,el
-+ dl•••ctlon llnlc
165
Neck
Muscles
-+
Pharynx
-+
Larynx
-+
Neck muscles and tracheotomy
-----M. al)iollycldeua - - - M.IIMIICI"-pulu M.~
IJG. Cflcotllyroldeum mldllirAm fu:IIQII'f!Cllh. Ulntna ~~~~ Pluus bnlehlllte, Parsaupraell'l!cuflllt M. tellenue antel!or M. omollJOideut, Vllntar tnfellar M. ttap«
V.Nxfavla
Fia. 11.3 N.ck mu.cl•. Mm. colli: ventral view; chin elevated. The euperfici•l M. stemocleidomastoideus has two origins (Caput stern ale and Caput clavicula rei and extends to the Proe. mastoideus. Its caudal section covers the origin of the lnfrahyofd muiCIH with the Mm. stemohyoideus. stemothyroideus. thyrohyoideus and omohyoideus. which stretch between the Sternum, thyroid cartilage, hyoid bone, and Scapula (M. omohyoideus}. TheM. omohyoideus is composed of two bellies separated by an intermediate tendon aHixed to the conneo-
v. Jug '*'It am.1cr
tive tissue of the carotid sheath (Vagina carotical and serves to keep the lumen of 1he V. jugularis open. The is1hmus of the thyroid gland, the paired M. cricothyroideus (en outer laryngeal muscle!. the thyroid cartilage, and the hyoid bone are located beneath the infrahyoid muscles (from caudal to cranial). Above the hyoid bone, the M. mylohyoideus forms the floor of the mouth.
1-+ Tl-11 I
Fig. 11A SurglcalacciS& to the 'lhlchee; ventral view; with 1he neck hyperextended dorsally. During conlotomy, an incision or puncture through the Lig. crico1hyroideum medianum !Lig. conicum, ~ Fig. 11 .28) in between the thyroid end cricoid cartilages is performed to access the laryngaallumen shortly beneath the vocal folds. Performing a tr.cheotomy, 1here are 1hree possible access routes: (i) an upper access above the isthmus of the thyroid gland, (ii} a middle access route by cutting through the isthmus, and (iii) a lower access below the isthmus of the thyroid gland (~ Fig. 11.50). • coniotomy •" upper tracheotomy • "* lower tracheotomy
166
-+ dluactlon llnlc
Thyroid gland -+ Topography
Neck muscles
M. clglllltrtr:4.!t, v.nt.r p08!a'tDr
F1g.11.6 Neck muscln, Mm. colll; lateral view. All muscle fascias, the Platysma, and the middle portion of the M. sternocleidomastoideus were resected. From anterior to posterior the following structures cen be seen: the infnlhyoid mutel• with the Mm. stemohyoideus, omohyoideus (Venter superior; the Venter inferior runs above the clavicle in the 19terel triangle of the neck). thyrohyoideus end stemothyroideus. parts of the pharyngeal muscles (M. con-
stricter pharyngis inferior}, the Mm. scaleni (anterior, medius, and posterior!, theM. levator scapulae, theM. splenius capitis, and theM. trapezius. Above the hyoid bone, three supn~hyold muscln IM. digastricus with Venter anterior and Venter posterior, M. mylohyoideus, and M. stylohyoideus) are visible.
1-+TS-111
167
Neck
Muscles -+ Pharynx -+ Larynx -+
Prevertebral muscles
N • ..._cepltle l118111lle --4..~
N • ..._ cepltle M1Mfor Attlculll1fo adantoulalla lateral Ia, c.puallltlcullria M.IIMdar acapula&
M. acellnua medlua
A. IUbciiMI 81nll1ra
Fig. 11.6 Pmlll'twral musdH and Mm. salanl; ventral view. The prevarabral muldu are located on both sides of the vertebral bodies of the cervical and upper thoracic vertebral column and are c~ vered by the Lamina prevertebralis of the Fascia cervicalis. The M. rectus capitis anterior stretches between the anterolateral parts of the Atlas end the Axis. In addition to the M. rectus capitis anterior, the M. longus capitis and theM. longus oolli are prevertebral muscles. As pert of the ventrolateral muscle group, the M. rectus capitis lateralis has migrated into the pravertebral region. The Mm. salanl anterior, medius, and posterior insert at the first ribs and form a triangular-shaped muscle plate in the lateral region of the cervical vertebral column. Together with the upper rim of the rib I, the M. scalenus anterior and M. scalenus medius create the satan. hla·
168
tut. Th& A. subclavia and th& Plexus brachialis pass through the scalene hiatus (not shown). Some authors distinguish between an anterior and posterior scalene hiatus. The anterior scalene hiatus represents the oourse of the V. subclavi& anterior of the M. scalenus across rib I, while the posterior scalene hiatus marks the space between the Mm. scaleni anterior end medius for the A. subclavie and the Plexus brachialis to cross rib I. Since the anterior scalene hiatus is not a tl'\le gap, the temn scalene hiatus should only be used for the space between the M. scalenus anterior and M. scalenus medius.
I-+T11,121
Thyroid gland -+ Topography
Fasciae of the neck
..........
Llmlnll pretn~la
~':~=~~j{ ..,.:..,;~::W,--A.ca/0118 communi&
-
LllmNtuperftclllla
-
LimN P!81n~CMIIIIII LimN pnMIII'tebraJia
--jjj_:;~~:=;~~:_:::S~~l\-- N. vaguefXl
Or;•n "'"'•
Fia. 11.7 Cervic:lll f81ciae, Fuciae 1:41rvi1:41IM; transverse see1ion 1hrough the neck. 181 A muscle fascia with three laminae can be distinguished from a neurovascular fascia, and an organ fascia with two laminae. Muacle t ..ct..: • Lamina superficialis (superficial lamina, encases the whole neck and ensheathes theM. sternocleidomastoideus as well as the Mm. levator scapulae and trapezius in the neck region) • Lamina pre1rachealis (middle !amine, ensheathes the infrahyoid muscles) • Lamina prevel18bralis (deep lamina, enwraps the Mm. scaleni, prevertebral muscles. the M. ree1us capitis lateralis, and merges with the fascia of the intrinsic [autochthonous) muscles of the back)
-
Gennl Ofllln 111ecia
-
Special 0191n fucla
NeuroviiiCQiar faacia: • carotis sheath (ensheathes the Ae. carotides communis. interne and externa. V. jugularis intema. N. vagus [)(]) Oraen ftdlclle: • general organ fascia (encases all neck structures like Pharynx, Larynx. thyroid gland, parathyroid gland, upper part of the Trachea, Oesophagus with Pars cervicalisl • special organ fascia =organ capsule (ensheathes each of the organs of the neck. e.g. Fascia oesophageal
Fig. 11.8 Schematic drawing of the cervical fascfae, Fuclae 1:41rvlcaln; sagittal section through the neck at the level of the Larynx. Above the Sternum, the Spatium suprasternal& is formed between the superficial and middle cervical fasciae. The Spatium periviscerele is located in front of the Trachea and in between the middle cervical fascia and the general organ fascia. The Spatium retropharyngeum lies in e prevertebral space delineated by the middle cervical fascia end the general organ fascia (-o Fig. 11.17).
ll f'\\Mii!l+-l-l--$pa1fum NII'OphiiiYIIQIUM
M'**f'UciM -
UlmtlUI'*"<:IIIIII Lamtlap-.a Uimtlapi1MIItabrlllt
Or;•l'l fMclele -
GII'MM'II Dillin fucla 8peelalo'91"fucla
169
Neck
Muscles
-+
Pharynx
-+
Larynx
-+
Fasciae of the neck
----FtUCia ptn:I!Gie.
'VIQil&cetOtic:e-----<
CIIMcula----
Fig. 11.9 Muscl• fuel•• of th1 nKII:. FasciH cervfe.lu; ventral view. The Platysma was removed on both sides. On the ri111ht side, the superficial lamina of the cervical fascia is intact end ensheathes the M. sternocleidomastoideus. On the left side. most of the muscles end the superficial lamina of the cervical fascia were resected. Above the
Larynx. a small part of the middle cervical fascia was removed to demonstrate the M. sternohyoideus, a muscle normally ensheathed by the middle cervical fascia, and the general organ fascia located below. The fenestrated carotid sheath and the deep cervical fascia are visible at the posterior margin of the M. omohyoideus.
Fig. 11.10 Parapharyngulabscels,l.tt s1d1; ventral view.l131 The abscess extends along 1he anatomically defined space !Spatium lateropharyngeuml in the cervical region (black arrow tips).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . During surgical procedures in the cervical region {e.g. neck: dissection}, the filscial laminae of the neck and the spaces of connective tissue delineated by them serve as reference structures for the surgeon. Bleedings and abscesses can distribute in between the fascial laminae and descend caudally into the mediastinum. The weakness
170
of the walls of 1he Pharynx can result in an invasion of micro-organisms into the parapharyngeal and retropharyngeal spaces {p• rapharyngHI (peripharyngeal!. ~ Fig. 11.1 0, or nrtropharyna••l
alMceMJ.
Thyroid gland -+ Topography
Fasciae of the neck
Proc.lltylaldeua
M. cmcllyoldeue, Venter lnflllor
Tri.gonum cmocllroicullte )lgutn stem a
Fig. 11.11 C.r¥1cal f11cl11, Fuc1a Cll'lllalllt,llft sl.-; ventrolateral view. The superficial lamina of 1he cervical fascia (Fascia C4'.1rvicalis, Lamina superlicialis) has been opened and detached in various places. The superficial lamina of the C4'.1rvical fascia that ensheathes 1he M. stemoc:leidomastoideus has been opened also and the middle portion of theM. sternocleidomastoideus has been resected. Thus. the fascial sheath and the deep part of the superiicial fascia become visible. From the Incisura jugularis of the Sternum to the level of the Larynx the superf~ ciallamina of the cervical fascia has been slit open and folded sideways to open up the Spatium suprasternal&. Upon removal of the adipose
tissue !frequently 1tte Arcus venosus jugularis can ba found here. ~ Fig. 11.17}, the pretracheal (middle! lamina of the cervical fascia (Fascia C4'.1rvicalis, Lamina pretrachealis) becomes visible, which forms the posterior wall of the Spatium suprasternal&. In addition. the superficial lamina of 1he C4'.1rvical fascia has been resected at the mandible and was folded downwards to demonstrate the tendon of the M. stylohyoideus. the M. mylohyoideus. and 1tte Venter anterior of the M. digastricus. In the posterior triangle of the neck, the superficial cervical fascia has been removed from the clavicle and folded upwards. Beneath, the V. jugularis externa and the Venter inferior of the M. omohyoideus. ensheathed by the middle cervical fascia, are visible.
-+ dl•••ctlon llnlc
171
Neck
Muscles -+ Pharynx -+ Larynx -+
Pharyngeal muscles
Ug. aph8nomandlbUare
Mandllulll Glandul• umandlbulllril M. slylogloallul
M. stylohyoideus
M. GCI~phelyng.. lnlwlar
1 2 S 4
Pin pterygophlryngea } Para buccopharyni»M M. conntr:tar Pin ~ophlryngea phelyng.. •upeltor Para gklsaaphlryng•
OeiCiphagus, TuniCII muscularis
Fig. 11 .12 Ph•rynge•l muldn. Mm. ph•ryng•: dorsal view. The pharyngeal muscles (Tunica muscularis pharyngisl consist of the camtrfctar muscles {Mm. constrictores pharyngis) and three paired IIIV•tar muscles elevating the Pharynx (Mm. levatores pharyngis). Tela submucosa and Tunica adventitia combine to form the Fascia pharyngobasilaris in a muscle-free upper part of the pharyngeal wall. Con81ricting and elevating pharyngeal muscles mainly act during swallowing, choking, and during speaking and singing. The Mm. conltrlctorn phuyngls superior, medius, and inferior consist of different parts. The muscles enclose the pharyngeal lumen like a horseshoe and overlap, with the lower muscle slightly covering the lower margin of the muscle above. The Pars cricopharyngea of the inferior constrictor muscle is composed of two muscle parts which together form a triangle weak in muscle fibres (KILLIAN's dehiscence, also called KILLIAN's triangle). On the dorsal side, at the transition from
the Pars fundiformis of the inferior constrictor pharyngeal muscle to the Oesophagus, muscle fibres projecting upwards from the Oesophagus form a muscular triangle ILAIMER's triangle). The tip of the LAIMER's triangle points in the opposite direction to the tip of the KILLIAN's triangle. The Pars fundifonnis (of the Pars cricopharyngea of theM. constrictor pheryngis inferior) is the base of both triangles. The muscles elevating the pharynx ere the Mm. palatopharyngeu.. ulplngopheryngeus, end stylaph•ryng.us.
1-+T&
• KILLIAN's triangle or dehiscence • • LAI MER's triangle ••• Pars fundiformis of the Pars cricopharyngea (KILLIAN's muscle)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The KILLIAN's triangle or dehiscence marks a weak spot in the pharyngeal muscles and often creates a problem in aged men. The increased intraluminal pressure causes the pharyngeal wall to bulge out through the muscular weak spot and creates a pheryngo-
172
-+ dluutlon llnlr
o..aphageel diverticulum (ZENKER's diverticulum) into the retropharyngeel space. This can cause regurgitation of ingested food back into the mouth.
Thyroid gland
-+
Topography
Facial and pharyngeal muscles
M.IMdor wll PIIIUnl
ttylo~
Hem•s ptlluygoiciUg. atylchyoldelm RapN pwygomaruilbiiiiiS
Pars chcnd~pheJyngea} M. conetrk:tor
·; ,u----
Para C*ldapheJyngea
Jlharrn11le nwdlua
M. ttylohyalde~.a
1'11'81tlyropheJyngea}
M. conetrfctor
~lnfertor
Fig. 11.13 Ph1rynge11 mUKIII. Mm. ph1ryngl1, and facial muacl•. Mm. faciei.left eide; lateral view. The pharyngeal muscles divide into constrictor muscles (Mm. constrictores pharyngis superior, medius. and inferior1 and levator muscles (Mm. stylopharyngeus. salpingopharyngeus. end palatopharyngeus).
This lateral view displays Ute different parts of the Mm. constrictores pharyngis and the M. stylopharyngeus.
I~T1e.sl
-+ dl•••ctlon llnlc
173
Neck
Muscles -+ Pharynx -+ Larynx -+
Clinics
M. atykll!yOideua -----l~~~llt M. digle1ltcua, VtnteniO&tlerlef• - - - - - '"'-~h.J
M. atyiOI!yOide~--~,.......;~~ , _,._ ~_ ,
M. d~ VtniiH'POI'blrletr---~'~
•
b
S ..hlped CQU1118 of lh& A. C.WOb lnlamll ~
Figs. 11.1.C. to d Variations In the couru of 1he Pars cervlctlls of the A. cuotls lnt•n• In nlatlon to 1fle pharyngeal wall. a straight variant !frequency 66%1 b curved variant lfraquency 26.2%) c S-ehaped course (frequency 6%, 2.8% thereof in close association with the pharyngeel wall)
I.Dap famulllan or1M A. caratl81ntllma (callng)
d loop formation (frequency 1.8%, 2.8% thereof in close association with the pharyngeal wall) The $-shaped course and the loop formation are classified as din· eerou• carotid loop• {c and d).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The close topographic relationship between the A. carotis interns and the tonsils (location of the Tonsilla palatine at the posterior margin of the Isthmus fauciuml and the presence of a clangerou• ca-
174
rotld loop can result in injuries to the carotid artery with accidental fatal bleeding during tonsillectomy or opening of a peritonsillar abscess.
Thyroid gland
-+
Topography
Clinics
PM88gtlofmatemal m i l k -
Fig. 11.1& Head of an lnftlnt; midsagittal section at the level of the nose and Larynx. [91 Contrary to adults and children, an infant can drink and breath simuluneously. Since the Larynx locates relatively high in the neck, the Epi-
glottis reaches the Nasopharynx. Fluids {e.g. the breast milk from the moU1er) pass through 1t1e Recessus piriformes of 1t1e Larynx into the Oesophagus without entering the lower airways.
Tanalla phalyngee.
• Figs. 11.18a and b Nasopharynx; endoscopy of 1t1e Nasopharynx; posterior view at the Choanae, the opening of the Tubae auditivae and the Tonsilla pharynges. The endoscopic view from posterior into the nasopharyngeal space
shows the posterior tips of the inferior nasal conchae on both sides and the pharyngeal opening of the Tuba auditive [auditorial (Ostium pharyngeum tubae auditivae). The inconspicuous pharyngeal tonsil (Tonsilla pharyngea) locates at the roof of the Pharynx.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Hyperplasia of the pharyngeal tonsil (adanoldst occurs frequently in children. It can lead to the occlusion of 1t1e opening of the Tuba auditive (auditorial. and cause recurring middle ear infections. In young children, this condition can result in hearing impairment and subsequently causes a daley in development. In these cases a surgical removal of the pharyngeal tonsil (adenectomyt is indicated.Pharynge-
al pituitary tissue (hypophysis ph1ryngull1) represents remnant tissue derived from 1t1e stalk of the embryonic RATHKE's pouch and can be found in the connective tissue located anterior to the Tonsilia pharynges underneath the sphenoid bone. The hypophysis pharyngealis can be the source of a a1niophlryngeoma in young people.
175
Neck
Muscles -+ Pharynx -+ Larynx -+
Inner relief of the pharynx
O..m ptl~tieae IIUdltlvllll TOI\It tube,._
Tlllllllla phlryngee
'fkiY~~0--""arynx ~c.JI!!~~?'t- Spdumnlb'optl~ Llg. lllyttll1yclcleum mecllanum
LJ;. hyaeplglatticum
cartlaao ep_,ottlca Corp\111 ~m preeptglottfe~m Ug. tllyroeplgtottlcum
F-* -w:d1, Lamina IIUPirfll:lll~t/ F81011 owvtaalll, LM!Ina pl'ltraol'lalll
Fig. 11.17 Orel cavity, C.vit.. ori1, phtrynx, Ph1ryrur,. end l1rynx, L1rynx; midsagittal section. Relationships of the different levels of the Pharynx to neighbouring
structures: • The Nasopharynx connects with the nasal cavity and 1tle middle ear through the choanae and the Tuba auditive, respectively. • The Oropharynx represents the junction between the superior and inferior pharyngeal levels and ronnects with the oral cavity through the Isthmus feucium.
• The Le.ryngoph1rynx has an anterior connection with the Larynx through the Aditus laryngis and transitions caudally into the Oesophagus. Airways and alimentary passage cross within the Pharynx. The WALDEYER's ring consists of lympho-epithelial tissue, and is part of the immune defence of the body. Situated in the transitional space between the nasal and oral cavity, the WALDEYER's ring is composed of the Tonsillae pharynges, tubariae (not shown), pelatinae and lingualis as well as lateral strands of lymphoid tissue located on the Plicae salpingopharyngeae.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . lngntd foreign bodln frequently reach the Valleculae epiglotticae at the base of the tongue and, by exerting pressure on the Epiglottis, can occlude the airways. Death can occur from a bolus aspiration, if an oversized bite (bolus) becomes irreversibly stuck. in the Laryngopharynx and cannot be expelled by coughing. This can
176
-+ dluactlon llnlc
cause reflexive cardiovascular arrest due to vagal stimulation of the highly sensitive networlc of nerves in 1tle Pharynx and Larynx which responds to the acute stimulation by the ingested bolus. Smaller pointed foreign bodies, like fish bones or pieces of chicken bones, most often get stuck. in the Tonsilla palatine.
Thyroid gland -+ Topography
Levels and innervation of the pharynx
Fig. 11.18 Levell of 1he pharynx; midsagittal section. According to its openings, the Pharynx can be devided into three levels:
• upper laval: Pars nasalis pharyngis, Epipharynx, Nasopharynx • middle level: Pars oralis pharyngis, Mesopharynx, Oropharynx • lower level: Pars laryngea pharyngis, Hypopharynx. Laryngopharynx
Rg. 11.19 Sentory rnnerv•tlon of 111• phuynx; midsaginal section. Sensory fibres of the second trigeminal branch (R. pharyngeus, a branch of the Rr. ganglionares INn. pterygopalatinil of the N. maxillaris [V/211 contribute to the innervation of the Nasopharynx. Branches of theN. glossopharyngeus [IX) end theN. vagus lXI (N. laryngeus superior) innerve1e the rest of the Pharynx. Together with autonomic nerve fibres
of the Truncus sympathicus, these fibres form a neuronal network a1 the outer surface of the Pharynx (Plexus ph•rynge•lla). Afferent and efferent fibres of this Plexus pharyngealis are part of the vital swallowing and choking reflexes which remain active during sleep. The coordination of these complex reflexes takes place in the Medulla oblongata.
177
Neck
Muscles -+ Pharynx -+ Larynx -+
Vessels and nerves of the parapharyngeal space
N. •cc:etMttu. pel], R.llntlmu. M. CCI't81l'lctot' PIIIII'Ynal8 814)1111or
N. earcr- ~lc«lt suJ)911or
(I'I'Uncllt sympetlllcus)
V. Ju8IIW lnWma
M. c:onat!lttcr pluuyn;la hl'lnlcr
S..lulnferlor -.aejll{lullria ,.,...__......,. __ R.
PIIIIIY"Gilll~
~.,..._--;.__Ganglion C«VVc«
Rg. 11.20 Ve111l1 1nd nii'VII of till phlrynx,. Ph1rynx,. 1nd th1 peraphlrynglllsplce, Spatlum llltlropharyng1um; dorsal view. The main source of blood supply is the A. pharyngEHJ ascendens. This artery ascends to the base of the skull in the parapharyngeal space medial of the neurovascular bundle of the neck. Its terminal branch, the A. meningaa posterior. enters the posterior cranial fossa through the Foramen jugulare. Additional blood supply comes from the A. palatina ascendens in the region of the pharyngeal opening of the Tuba auditiva [auditorial (Ostium pharyngeum tubae auditivae) and from the A. thyroidea inferior in the Hypopharynx. The entire submucosa of the pharynx contains a venous plexus {Plexus pharyngeusJ. v1nous drainqe is performed by the Vv. pharyn-
n..
178
-+ dluactlon llnlc
gEHJe into the V. jugularis interne and into the Vv. meningeae in the nasopharyngeal region. The lymphatic draln•a• of the Tonsilla pharyngea and the pharyngeal wall reaches the Nodi lymphoidei retropharyngeales and the Nodi lymphoidei cervicales profundi (not shown). lnnerv.tion: In addition to the Plexus pharyngealis end the N. pheryngeus of the N. maxillaris [V/21 (see sensory innervation of the Pharynx ~Figs. 11.19 and 12.144), theN. glossopharyngeus (IXJ provides motor innervation for the superior and some medial pharyngeal constrictor muscles and for the levator pharyngeal muscles; 1t1e N. vagus lXI innervates the lower part of the medial pharyngeal constrictor muscles and the inferior pharyngeal constrictor muscles.
Thyroid gland -+ Topography
Vessels and nerves of the parapharyngeal space
N.~IISP
Bulbua tupe!!Or venu jugulolria A. caratla lntllma
T-- - Qenglion ctMcelt auperUI (Truncuaeympathk:ul)
1.1. tenaot V1!li par11n M. ccnalrietorp~ aupellar
M • .qllngopharyngM.palltD~
:--...;-- - Sulculblrmll\llt ~--
- --
Donurn llnDWM, Pmpoeltllor
- - Eplglotlb
.... arylenoldii!S 11'l1n1Y1111Uit; M. atytenaldaua oblq~Ut M. crlcoelytanaldaua poatafar
Qenglion ctMcelt medium
A. thytoldae lnferillf
Fig. 11.21 VIII:MIS 1nd n1rves of thl ph1rynx,. PINirynx. 1nd the panapharyngHI tplc.t, Spattum latwophuyngiUm; dorsal view. Pharynx opened from the dorsal side. The pharyngeal opening of1tle Tuba auditiva [auditorial (Ostium pharyngeum tubee auditivae} lies roughly at the level of the inferior nasal meatus. At its posterior and superior side. this opening displays en ale~ 1ion. the T0n11 tub1rlua. Caudally. the Torus tubarius extends into a longitudinal mucosal fold (Plica salpingopharyngeal which is created by 1tle M. salpingopharyngeus. The inferior part of the Ostium pharyngeum tubae auditivae displays ano1tler elevation. the Torus llvatortus. which is formed by the M. levator veli palatini. This orifice is the en-
trance to the Tube auditive (auditorial (EUSTACHIAN tube! end connects the Pars nasalis pharyngis with the tympanic cavity. Immediately behind the Torus tuberius there is a fossa (Recessus pheryngeus, fossa of ROSENMOLLER) extending upwards to the roof of the Pharynx. The M. palatopharyngeus creates the lateral margin of the Isthmus faucium. The dorsal view also shows the dorsum of the tongue (Dorsum linguae). the dorsal side of the laryngeal wall. and the entrance to the Oesophagus. On either side of the posterior laryngeal wall lies the Recessus piriformis. Note the side difference in the course of the N. laryngeus recurrens; on the left side the nerve winds around the Arcus aortae and on the right side around the A. subclavia.
-+ dl•••ctlon llnlc
179
Neck
Muscles
-+
Pharynx
-+
Larynx
-+
Skeleton of the larynx
Pramintntil
IIIIY"IJIM
F'11. 11.22 Thyroid cartilage. Cartilago 1hyroidea; view from the left side. The thyroid a~rtilage is composed of two laminae ll.amina dextra and Lamina sinistral with a superior and an inferior hom.
F'11. 11.23 Thyroid cartilage. Cartilago 1hyroidea; ventral view. Both laminae of the thyroid a~rtilage join at an angle of 90" and 120" in men and women, respectively.
Rg. 11.24 cricoid cartilage, Cartllago crlcoldH, and arytenoid CllrtllagH, CartllaglnH arytenoldaae; ventral and dorsal views. The Lig. cricoarytenoideum posterius extends between the cricoid and arytenoid cartilages.
Fig. 11.2& Cricoid Cllrtllage, Cartllago crlcoldH, and arytenoid CllrtllagH, Cartllaglnas arytenoldua; view from the left side. The Articulatio cricoarytenoid ea. a diarthrotic joint. connec1s the cricoid and arytenoid cartilages.
Fig. 11.26 Epiglottic cartilage, Cartilago apiglottica; dorsal view. In contrast to the other major hyaline laryngeal cartilages, the Epiglottis is made of elastic cartilage.
F".g. 11.27 cricoid Cllrtilage, Cartilago cricoidH; ventral end dorsal view. The cricoid cartilage has the shape of a signet ring.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , At about 30 years of age, the o85ifia~tion of the hyaline laryngeal (thyroid, cricoid, and arytenoid cartilages) begins and progresses with age, with men displaying stronger ossifia~tion then women. Fractur• of the laryngHI dulleton (e.g. car accidents) can result in severe obstruction of the airways with difficulties in phonation and breathing. a~rtilege
180
After surgical excision of the thyroid cartilage, for example during the hemilaryngectomy of a laryngeal carcinoma, the remaining laminae of the thyroid cartilage can be adjusted and connected with material used for osteosynthesis. In rare cases, a congenital softening of the laryngeal cartilage llaryngomalacial can cause difficulties in breathing (dyspnea).
Thyroid gland -+ Topography
Hyoid bone and skeleton of the larynx
Fig. 11.28 U.rynx. U.rynx. •nd hyoid bon•, 01 hyoldeum; ventral view. Developmentally and functionally, the hyoid bone has a close relation-
ship with the laryngeal skeleton. The individual parts of the laryngeal skeleton connect by syndnmOHS and true joints (dluthrOHS).
Llg. cd~noldlum
..,._ _ _ .ArtlcUdo
~Idee.
C1peull~
Fig. 11.29 U.ryngNI ce11lllf1H, C.rtfllgln.. l1ryngle, •nd hyoid bone, 01 hyoldeum; dorsal view. Beneath the Membrana thyrohyoidea an adipose body (Corpus adiposum preepiglotticum) extends in a cranial direction to the Ug. hyoepiglotticum and in a dorsocaudal direction to the frontal side of the Epiglottis. The Lig. thyroepiglotticum attaches the stalk of the Epiglottis (Petiolus epiglottidis) to the inside of the thyroid cartilage.
True joints of the Larynx are the Articulrio cricothyroid~~, the paired joint between the cricoid cartilage (Cartilage cricoidea) and the inferior horns of the thyroid cartilage (Cartilago thyroideal as well as the Artfcu· llt1o crlcoll'ytllnoldN between the cricoid and arytenoid cartilages !Cartilage arytenoidea). The Lig. cricoarytenoideum and the Lig. cricopharyngeum act as dorsal reins for the arytenoid cartilage.
181
Neck
Muscles -+ Pharynx -+ Larynx -+
Hyoid bone and skeleton of the larynx
Ug. tllyi'Oeplgl011~m
Fig. 11.30 Larynx, Larynx, and hyoid bone, 0. hyoldeum; view onto the Lig. vocale and the aJYtenoid cartilage from the left side; the left lamina of thyroid cartilage has been removed. The cricoid (Cartilago cricoidea) and aJYtenoid cartilages !Cartilago arytenoidea} articulate in the Articulatio cricoaJYt&noidea. The articular surfeces of the cricoid cartilage are convex and oval in size !cylinder-
shaped, ~ Fig. 11.271: the articular surface of the aJYtenoid cartilage is concave and more round. This shape of the articular cartilaginous components and the Lig. cricoarytenoideum (posterius} provide stability to the joint. Functionally, this ligament guides the aJYtenoid cartilage and counteracts the fonces of the Lig. vocals.
F'.g. 11.31 Larynx, Larynx, and hyoid bone, 0. hyoideum; superior view. The cricoaJYtenoid joint permits hinge and sliding motions parallel to the cylindrical axis; this joint primarily supports the opening and closure of the space between the vocal ligaments (Glottis, Rima glotlidis} and also keeps tension on the vocal ligament (Lig. vocalel. A hinge-like outward rotation results in elevation and abduction of the Proc. vocalis and, consecutively, an opening of 1fle Glottit. Inward rotation through
the hinge as well as depression and adduction of the Proc. vocalis cause the occlu•ion of th• Olotti.. These hinga·like movements can combine with gliding motions. whereby ventral or dorsal movement occurs during abduction and adduction of the arytenoid cartilage, respectively. The Lig. vocals and the Lig. vestibular& connect the aJYtenoid and thyroid cartilages. • BROYLE's tendon
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Dislocation of the arytenoid cartilage in a dorsolateral or medioventral direction, called aryfuxatlon, is a potential complication during endotracheal intubation or extubation, laryngoscopy, and bronchoscopy. The patient has a hoarse voice since the vocal ligament on the affected side is immobile. Displacement of the aJYtenoid cartilage can be caused by bleeding into the articular cavity or inflammatory
182
swelling upon injury of synovial membrane folds. The displaced arytenoid cartilage is kept in place by muscle contractions. This condition can result in adhesions of articular surfaces and subsequently ankylosis can occur. An aryluxation must be distinguished from a nerve lesion.
Thyroid gland -+ Topography
Skeleton of the larynx 0. hyaldBinl Ug. hyOeplglottl~m ~ lnfnlhvcikiBII..._
Fig. 11.32 U.rynx. U.rynx. 1nd hyoid bon•, 01 hyoldeum; median section, medial view. The Articulationes cricothyroideae connect thyroid and cricoid cartilages. The cricoid and arytenoid cartilages articulate in the Articulatio cricoarytenoidea. The arytenoid and thyroid cartilages are connected by
the Lig. vocale and the Lig. vestibulare. The Lig. cricoarytenoideum and Ug. cricopharyngeum act as a dorsal rein of the arytenoid cartilage. Lateral and in front of the Epiglottis the Corpus adiposum preepiglotticum is visible.
Fig. 11.33 U.ryngNI c.rtill,.., C.rtikgin• l1ryngi1, lnd YOCII lig1ment, Lig. voeell; crenioventral view. The paired Lig. vocale stretches between the Pro c. vocalis of the aryt~ noid cartilage {Cartilage arytenoidea} and the inside of the thyroid cartilage shortly below the Incisura thyroidea superior. The Conus elasticus
is an elastic membrane and extends between the Lig. vocale and the upper rim of the cricoid cartilage. The Conus elasticus directs the airflow from the lungs in the direction of the Ligg. vocalia. The strong Lig. cricoarytenoideum is visible on the dorsal aspect of the arytenoid cartilage.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The cricCHirytenoid joint not only contains the same extraoallular matrix as joints of the extremities, but can also be aHiicted by the same joint diseases as the larger joints of the limbs. Degenerative alterations of the cartilage (tr1fuoti• or clegenerati¥1 arthritial are
common in older persons and affect phonation and quality of voice due to improper occlusion of the Glottis by the vocal ligaments. In addition, the cricCHirytenoid joint can develop lnfecUo111 arthriU• and rheumlltoid arthritia.
183
Neck
Muscles
-+
Pharynx
-+
Larynx
-+
Laryngeal muscles
,4-- -
Llg. ~lelel.m lldtnlle
[ tP-- - c.tlago 1lltae
F".g. 11.34 Cricothyroid muecle, M. cricothyroid1u1; venttel view from the left side. The cricoid cartilage (cartilage cricoidaa) and the thyroid cartilage {Cartilage thyroidea) articulate in the left and right Articulatio cricothyroidea. These are spheroidal joints with a firm joint capsule. This joint allows
Fig. 11.35 Cricothyroid muecle, M. crlcothyroldeua; lateral view. Contraction of the M. cricothyroideus causes the anterior part of the thyroid cartilage (Cartilago thyroidea) to rock towards the arch of the cricoid cartilage (Arcus cartilaginis cricoideae). This results in the elongation of the vocal ligament which is now under increased tension. During this rocking movement, the arytenoid cartilages (Cartilagines atytenoideael are stabilised by 1he actions of the M. cricoatytenoideus posterior and 1he Lig. cricoarvtenoideum.
hinge·like motions in the transverse axis end smell gliding (translatory) movements in the sagittal plene. Contraction of the M. cricothyroideus increases the tension of the vocal folds {-> Fig. 11.35}.
1-+T&
I
Blomechenlcs of 1he voce! toldl: The structures at the insertion site of the vocal ligaments (Noduli elll1lcl entedores and poaterfores, BROYLE's tendon of the Lig. vocale, -> Fig. 11.48) have biomechanical functions during the vibration of the Plicae vocales by equalising the different elastic modules of the vocal ligament, cartilage, and bone. This prevents 1he vocal ligaments from rupturing at their insertion points during vibration.
I-+T61
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Benign or malignant •tter•tlons In the region of the vocal folds result in incomplete occlusion of the Glottis, hoarseness, and in dyspnoea breathing at advanced stages of the disease. The Lig. eric~ thyroideum medianum {Lig. conicum) extends between the thyroid
184
and cricoid cartilages and can be easily palpated here. In an emergency case, if breathing functions are compromised, the li!Jilment can be split to insert a breathing tube{... Fig. 11.41.
Thyroid gland
-+ Topography Laryngeal muscles
Cllllllllg~J cunelfonnle
,_-4-- M.p.,.IIYI8nOidiUI obi(\W8, atyeplglotllce ~---.1-- Cattllllgo comlalllta
.;.._-!-- - Olltlla,;o IIY!enOidea ~T---M •• ~1111.,._..11f
Fia. 11.38 Laryngeal muld11, Mm.l1ryngia; dorsal view. The actions of the Mm. laryngis determine the shape of the Rime glottidis and the tension of the vocal ligement. The M. crico1ryt1noi-.. pottlt'lor (•podcut•J is mainly responsible for the abduction and elevation of the Proc. vocalis of the arytenoid cartilage resulting in the widening of the Glottis as part of the inspiration. All other muscles that act on the space between the vocal folds cause the narrowing of the Glottis and include the M. arytllnoldlus tr1nnenus and M. lfYWnO•
ideu• ollliquu• as well as the Mm. crico1rytenoidei lltlt'alel
I• Fig. 11 .371. Whispering is made possible by the isolated contrection of the M. cricoarytenoideus lateralis, which results in the so-called "'wha.p~rlng trl1ng11•, the formation of a small triangular opening in the posterior part of the Rima glottidis (-> Fig. 11.43).
1-.Tsl
M.IIY!Inoid-. Para obii-----!M. aryWnold8UI, Part ti'IU'I8VIIIM·--.....-
:n
Fig. 11 Laryngeal mutc111, Mm. l1ryngia; dorsal view from en oblique angle. In this particular view, the M. cricoarytenoideus lateralis and the Pars intema of theM. thyroarytenoideus (M. vocalisl are visible. The M. cricoarytenoideus lateralis closes the Rima glottidis. •f1ne-tunlng"' of 1h• vocal folch is performed by the M. voallt (Pars intema of the M. thyroarytenoideus). Its muscle fibres run parallel to the Lig. vocale and
to the vocal fold. The muscle creates a cushion which acts like the mouthpiece of a pipe. The tension of this mouthpiece is regulated by isometric muscle contractions and its length is shortened by isotonic muscle contractions. Thus, the actions of the M. vocalis have an important impact on sound quality and vocalisation.
I-+T81
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The paramedian positioning of the Plica vocalis is caused by the isolated unilateral parelpls of 1h• posterfor crfcoa.rytenofd mulde; its bilateral paralysis results in a narrowing of the Glottis with difficulties in breathing and potential death by choking.
Dysphonia refers to all signs of a phonation disorder. This includes hoarseness of the voice in patients with unilateral paralysis of the posterior cricoarytenoid muscle. Aphonia is the inability to speak.
-+ dl•••ctlon llnlc
185
Neck
Muscles -+ Pharynx -+ Larynx -+
Levels and inner relief of the larynx
081!yakleum, Comu m1n1.11
0s h)'OieltUm, Cornu l!lfjut Eplglottfa Cattllllgo tlltlcea
M. uyteno~tranwa C.r11ago arytenOICIM M.lfYI!InaleltUa obllqu1.11 Plica YO!:«! Is
fig. 11.38 Ltrynx, Ltrynx: dorsal view; the Larynx was sectioned from dorsal in the median plane and separated with hooks. On the left side, the mucosal lining is shown; on the right side, the laryngeal muscles (M. vocalis [=Pars interna of theM. thyroarytenoideus), Mm. cricothyroideus, and cricoarytenoideus lateralis}, the cartilages !Epiglottis, arytenoid, cricoid, and thyroid cartilages as well as the small laryngeal cartilages!, and 111e mucosal folds (Plicae vestibularis and vocal is! are depicted. T 6
M. CIIQotii)'1)1CieUt M. aico.wyttnoieilus lltM!i& M. Clfco.wyltnOICieUt poelellor
1-. 1
Rg. 11.38 Compartments of th• larynx. Larynx. Clinicians dMde the larynx into the following spaces: Supl'lglcrtdc tpace (SupraglotU•I: This space extends from the Aditus laryngis to the level of the vestibular folds (Plicae vestibularesl and is divided into: • Epilarynx: laryngeal area of the Epiglottis, Plicae aryepiglotticae and aryepiglottic folds • Vestibulum laryngis: Petiolus epiglottidis, Plicae vestibulares = ve~ triculares, Ventriculus laryngis = MORGAGNI's ventricle Glottic 1111ce (Glottis): The area extends from the free rim of the v~ cal folds as opposed to the "transglottic space" which encompasses the space between Glottis. vestibular folds. and Ventriculi laryngis. The anterior part of the Glottis including the anterior commissure !Commissura anterior) is known as Pars intermembranacea; the dorsal part of the Glottis between the arytenoid cartilages is the Pars intercartilaginea 1-+ Fig. 11.43) and constitutes tw~thirds of the Rima glottidis. In their dorsal part, the vocal folds end at the transition of the Pars intercartilaginea into the Plica interarytenoidea (-> Fig. 11.43}. Subglottic IP.C. ISubglottls): The Subglottis is the space that extends below the vocal folds to 1he lower rim of the cricoid cartilage !Cartilage cricoideal. It is a conical space between the free margin of the vocal fold, 111e area below the vocal fold, and the lower margin of the cricoid cartilage. The cranial border of the Subglottis is the mac~ scopically visible Linea arcuate inferior(-> Fig. 11.49} of the Plica vocalis. The caudal border is at the level of 111e lower rim of the cricoid cartilage. Craniolaterally, it is confined by the Conus elasticus, and further caudally by the cricoid cartilage. The caudal part of the Subglottis assumes a cylindrical shape, and tapers off at its cranial end due to the shape of the Conus elasticus. The ventral border is the Lig. cricothyroideum medianum (Lig. conicuml, and the cricoid cartilage is the dorsal demarcation.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The above mentioned compartmentalisation of the Larynx is important in diagnostic imaging techniques for the staging of the extwrt of loc.l tumour growth. The spiral computed tomography (spiral CTI with thin slicing mode is the recommended diagnostic procedure for
186
-+ dluactlon llnlc
Larynx imaging. Although magnetic resonance imaging IMRI} has the highest sensitivity of all imaging techniques for tumour staging, this method is prone to imaging artifacts by patient movements.
tahir99-VRG & vip.persianss.ir
Thyroid gland -+ Topography
Laryngoscopy
• Figs. 11.4h and b Laryngoscopy. • indirect laryngoscopy b direct, endoscopic laryniiJoscopy
CCimmisaura antoltltlr-Nodllut tllllllcutii!W!!Or (Maeula lll'l'url~~~l)---:
Tlben:uUrl comlculdum
Fig. 11A1 Direct llryngecopy; respiratory position.
Plea Vlmlbulallt
Plea W!"'IIGIO!Uea
Fig. 11A2 Dfrect llryngscopy; phonation position.
Fig. 11.43 Direct laryntpCOpy; whispering position.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Persons who stress their voice in a strenuous or abusive manner are at risk of developing YOCII cord or llngM"s nodules located at the free margin of the vocal ligament. Weakness of the M. arytenoideus may result in an incomplete occlusion of the Pars intercartilaginea of
The most frequently observed benign tumours of the Plica vocalis are polyps; squamous cell carclnomn are the most frequent malignant tumours. Prolonged intubation can lead the formation of an Intubation granuloma in the Pars intercartilaginea.
the glottis (open whisper triangle}, resulting in a weak. and breathy voice.
tahir99-VRG & vip.persianss.ir
Neck
Muscles -+ Pharynx -+ Larynx -+
Inner relief of the larynx
'lfMIIIWum laryngle
Ug. ~deum meclanum
1\lbti'Cillum cunelfonne .....-illbelrc:Q~Im eomk:U1111111
M. tuytanaldaLia triUWYanlua
rtg. 11.44 larynx. larynx; midsagittal see1ion. The paired vocal iold (Plica vocelis) locates below the peired vestibular fold (Plica ve31ibuleris} in the middle laryngeal compartment. The largest part of the laryngeal cavity (cavitas laryngisl is lined by reeplratory ep!th4111um. Non-lc.er4111nlzecl strllt1fted squamoua eplthallum is commonly present in some areas of the Larynx_ while in other areas this type of surface epithelium is only observed occesionally with large interindividual variations. Non~eratinised 31ratified squamous epitheli-
urn is commonly localised to the vocal folds covering the Lig. vocale. This epithelium spreads along the mucosal lining of the arytenoid cartilages ancl seamlesslv transitions into the stratified squamous Epithelium of the Hypopharynx. Squamous epithelium covers the lingual area of the epiglottis. The distribution of respiratory and squamous epithelium on the Plicae vestibulares and in the entire laryngeal cavity is subject to significant variations specific to each individual. With increasing age, laryngeal areas covered with squamous epithelium increase.
Tuberallum eomall1111111
Ug. ~lattloum
r~g. 11.45 larynx. larynx. po.ition of the Epialottil durina •w•llowina: midsagittal section.
Swallowing involves a change in the position of the strue1ures of the laryngeal orifice. The Epiglottis is pushed downward. The prCH~piglottic fat body moves dorsally, the Aditus leryngis becomes narrow.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - , The clinicaltenn *vocal cord" is anatomically incorrect; this tenn should be reserved for 1tle Lig. vocale.
188
In the Larynx, the amount of squamous epithelium increases with age and can be the source of malignant laryngeal --.u•mou cell cercinom•.
tahir99-VRG & vip.persianss.ir
Thyroid gland -+ Topography
Arteries and nerves of the larynx
Oa hyllldalnl, Comu m~a N. ~
""*"''• R.ln1wnll8
t•U.~-:!'if--- N.l&lyneeu- tupertol;
Ar. llmleml
+ -11-- - - Maml:nna 1hyrahyaldlla
Fig. 11 AI ArteriH and nervH of the larynx. Larynx. and root of 1fl1 tongue, Radix linguae; dorsal view. The A. larynges superior branches off the A. thyroides superior, perforates 1tle Membrana thyrohyoidee below the Comu majus of the hyoid bone, and divides into smaller branches within the mucosa of the Recessus piriformis. Here. the A. larynges superior has multiple anastomoses and colleterals with the A. larynges inferior. The Larynx receives bilateral innervation through two bl'elnchH of the N. vagus [XJ: • The N. laryngeussuperlor dMdes into a R. intemus and a R. externus (-> Fig. 11.81}. The R. internus projects lateral in the wall of the Pharynx and, jointly with the A. larynges superior, passes through the Membrana thyrohyoidea into the Larynx where it provides sen-
sory innervation for the supraglottic mucosa, the mucosa of the Valleculae epiglotticae, and the Epiglottis. Sensory innervation of the laryngeal mucosa is very dense {cough reflex). Apart from its motor and sensory fibres, 1tle N. laryngeus superior also contains many parasympathetic fibres for the innervation of glands. • The N. laryngeu• I"'CUrl'tnl (inferior1 provides motor innervation for the inner laryngeal muscles. The innervation of the paired M. cricoarytanoidaus posterior and M. arytanoidaus on the posterior side of the Larynx is shown. The connection between the N. laryngeus superior and the N. laryngeus inferior is called Ansa GALENI (GALEN's anastomosis). For demonstration of the course of 1tle Nn. laryngei recurrentes -> Figures 11.21 and 11.56.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lulons of1hl N.llryngeussupertor cause a reduction in sensory abilities (frequent choking), and paralysis of the M. cricothyroideus. Insufficient tension on the vocal folds will result in the incomplete occlusion of the Glottis and phonation disorders.
Acute oedema at th1 entl'elnce of the Larynx (e.g. due to allergic reactions) can develop quickly in the loose connective tissue and cause severe difficulties in breathing. Acute bactllrlaltrrflctfons of the El!lglottfs occur most frequently in children and can cause acute and life-threatening obstructions of the airways.
-+ dl•••ctlon llnlc 189 tahir99-VRG & vip.persianss.ir
Neck
Muscles -+ Pharynx -+ Larynx -+
Larynx, transverse sections
M. tllynlelytanalda~.a
M. canllrlctor pluuyngla medl~~t
M. c:onllllfl;tor plllllyn~'
lnfel!or
190
F".g. 11.47 L.trynx, L.trynx; transverse section at the level of the vestibular folds. Tha vestibular folds (Plicae vestibulares) contain multiple seromucous glands (Glandulae laryngeales) which serve to moisten the vocal folds.
The white arrow indicates 1ha connection between the laryngeal ventricle and the laryngeal saccule. Posterior to the Larynx, the laryng~ pharynx with the Recassus piriformis are visibla.
Fig. 11.48 L.trynx, L.trynx; transverse section at the level of the vocal folds, Plicae vocales. The section at the level of the true opening of the vocal ligaments (Glottis, Rima glotlidis) displays the mucosa (Tunica mucosa) of the vocal ligaments. The following structures are arranged from the inside to the outside of the Glottis: the vocal ligament (Lig. vocalel, the M. vocalis (Pars inteme of the M. thyroary1enoideusl, end the Pars exteme of the M. tnyrCHJry1enoideus. The cartilage-free part of the vocal fold is the
Pars intermembranacee. the pert between the two ary1enoid cartilages is tha Pars intercartilaginea (-> Fig. 11.43). In the front. the vocal folds converge on the thyroid cartilage. The insertion site is described as the anterior commissure. Here. the vocal folds insert via Noduli elastici anteriores and the tendon of the vocal ligament IBROYLE's tendon•) at the thyroid cartilage. Dorsally the Lig. vocale attaches at the Proc. vocalis of the arytenoid cartilage vie the Nodulus elasticus posterior.
tahir99-VRG & vip.persianss.ir
Thyroid gland -+ Topography
Larynx, frontal section
O.hyaldeum
Fig. 11.48 Larynx. Larynx,. and thyroid gland, Glandula thyroldN; frontal section. Normally, the vocal folds !Plicae vocales) extend beyond the vestibular folds (Plicae vestibulares) and protrude more into the lumen of the larynx, which makes them accessible for inspection by laryngoscopy. The vocal folds are composed of en outer mucosa. the Lig. vocal&. followed caudally by the Conus elesticus. end 1he M. voc:alis (Pars in1ema of the M. thyroarytenoideus), and the Pars externa of the M. thyroarytenoideus. Located at both sides is theM. cricoarytenoideus lateralis. Both vocal folds demarcate the opening of the vocal ligaments !Glottis,
M. thyro.wylenOideua, Para tlly!Qej)lglottlca [(M.1flyraeplglotllcua)J
Rima glottidis} which represents the part of the Larynx responsible for phonation. The Lig. vocale is lined by a loose subepithelial connective tissue layer between the Linea arcuate superior and Linea arcuate inferior which provides a flexible potential space (REINKE's space, arrow). The Ventriculus laryngis extends in between the vocal and vestibular folds. The elastic Membrana quadrangularis forms the connective tissue fram&work: for the laryngeal ventricle. The thyroid gland with its two lobes is located between the cricoid cartilage and the upper tracheal semicircular cartilages.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . An accumulation of fluid in the REINKE's space creates a swelling of the vocal folds, which extends into the Glottis and results in hoarseness and dyspnoeaiREINKE's old1ma). The REINKE's oedema has to be distinguished from a glottic oed1m1. In the latter, fluid collects in the Lamina propria of the mucosa in the supraglottic space
(e.g. due to allergic reactions) and, thus, the oedema is located above the Glottis. The oedema restricts the airflow through the Glottis. Its symptoms can range from stridor (pitched wheezing sound) to hoarseness, dyspnoea and potentially asphyxia.
191
tahir99-VRG & vip.persianss.ir
Neck
Muscles -+ Pharynx -+ Larynx -+
Thyroid gland
PtOminentialatyngea
GllndUII ~ldH, Lolll.a da.tllr
Rg. 11.50 Pos111on of the thyroid gland, Glandula1hyroldN; ventral view. The thyroid gland (weight in an adult 2~25 g) is located below the
Larynx. The Glandula thyroidea surrounds the upper part of the Trachea with bila1eral lob&S (Lobus deX1er and Lobus sinister) and an anterior isthmus.
Spetium auprMtll'nlle ll. Jugularft anteriOr M.~hyO!d-
M. ltlm011!yr01deue
N.~-~
v. Jugularft ln!ema A. eM~U8 camiiU'tla
M.~QOII
fig. 11.51 Thyroid gl1nd, Ol1ndull thyroicltl; horizontal section. The thyroid gland covers the upper tracheal part from lateral and ventral. It is the largest endocrine gland in the body and secretes the hormones thyroxine !tetraiodothyronine, T41. triiodothyronine (Ts). and calcitonin. The gland is ensheathed in its own capsule and, together with the larynx, Trachea, Oesophagus, and Pharynx, is surrounded by the general organ fascia.
Placed at the posterior side of each glandular lobe there are two grainsized epithelial bodies {parathyroid glands, Gl•ndull• p•r~thyroldHI) weighing 12-60 mg, which produce the parathyroid hormone {PTH). On both sides, the N. laryngeus rwcurnns courses between the Trachea and the Oesophagus. The nerve is located outside of the special organ fasciae but inside the general organ fascia.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Thyroid gl1nd surg.., requires the ventral opening of the Fascia pretrachealis and the joint special and general organ fascia at the anterior side of the thyroid gland. Surgeons refer to it as outer (fascia pretrachealisl and inner {organ fascial capsule of the thyroid gland. Hyperplasia, adenoma. or carcinoma of the parathyroid glands can
192
-+ dluactlon llnlc
result in an hyperfunction with the development of a primary hyperparathyroidism. The increased secretion of parathyroid hormone {PTHI causes an increase of the serum calcium levels and is associated with complications affecting the bones, kidneys, and gastrointestinal tract.
tahir99-VRG & vip.persianss.ir
Thyroid gland
--+
Topography
Development of the thyroid gland
WeekS
Fig•. 11.52a and b Dlmllopmant of the thyroid gland. [21] From day 24 after fertilisation onwards, epithelium from the ektodermal stomodaeum grows caudally past the hyoid bone and the Larynx to form the Ducmn thyroglossus (a). When 1t1e Ductus thyroglossus has reach ad its final location at the thyroid cartilage of the Larynx at week 7, it forms the isthmus and the two lobes of the thyroid gland [b). The cranial part of the Ductus thyroglossus regresses. The proximal opening
of the Ductus thyroglossus persists as Faramen - m behind the Sulcus terminalis and frequently a LobUli pyramidalill (thyroid gland tissue) is found along the passageway of the primitive Ductus thyroglossus (.... Fig. 8.162). Protruding from the fifth pharyngeal pouch, the ultimobranchiel body gives rise to C-cells (produce calcitonin) which migrate into the thyroid gland. The epithelial bodies {produce parathyroid hormone) derive from the 1t1ird and fourth pharyngeal pouches.
b - - - - - - - l.acdan af ----...118tulu 0 t)O
LDcaUon ol
nw opening of ceMctll~u
CenriCIJeysl-----
LDcaUon ol - - - -
out• opening ol cerv1CIJ fllturu
c Figa. 11.53a to d Cervical cym and cervic.l fitrtulaa. 1201 a possible locations of cysts derived from the Ductus thyroglossus (arrows show the location of the Ductus thyroglossus during the descent of the thyroid gland from the Foramen caecum to the final position in the anterior cervical region)
d
b computed tomography of a thyroglossel duct cyst in front of the thyroid cartilage c possible locations of cervical cysts and cervical fistulas d lateral cervical cyst; notice the swelling on the lateral side of the neck.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Persistence of parts of the Ductus thyroglossus can lead to a medi· an cerviall c:pt or a median cervical filltula (.... Figs. 11.53a and b). Clinically, both only become a concern when infected. A lateral cervical fistula or cyst is caused by the imperfect obliteration of the lateral aspects of the branchial clefts or the Sinus cervica-
lis. Lateral cervicel fim.la• usually open at the anterior margin of theM. stemocleidomastoideus (.... Fig. 11.53cl; the accumulation of fluid within the lateral cervical cy.tl results in a swelling at the side of the neck [-+ Fig. 11.53d).
193
tahir99-VRG & vip.persianss.ir
Neck
Muscles -+ Pharynx -+ Larynx -+
Vessels and nerves of the thyroid gland
F".g. 11.54 Arterie. of the thyroiclga.ncl, Oa.ndule thyroidH; ventral view. Being an endocrine organ. the thvraid gland has an exquisite blood sup. ply through the A. 1tlyroldN superfor (with Rr. glandulares anterior and posterior) from the A. carotls ext11rn1 as well as through the
......._,.,.ID'IItl l
..
·J~~=-
A. thyroidee inftrior from the Truncus thyrocervicalis. Sometimes, e small A. thyroidee ima from the Truncus brac:hiocephalicus or the Arcus aortae also contributes to the blood supply (not shown). The blood vessels also supply blood to the epithelial bodies{-> Fig. 11.56}.
TIWICIMI
1il)1'o<:elllle18
Rg. 11.&& Veins of the1hyrold glend, Glendua. thyroldH; ventral view.[8) Three paired veins collect the blood of the thvraid gland. The Vv. thy· roldue supedar 1nd medle drain into the V. jugularis intema. whereas the V. thyroiciH inferior leads the blood into the left V. brachiocephalice.
Fig. 11.1i6 All. thyroldHesup•lor end lnftrlor .. well u Nn. l1ryngel I'HQrrentes slnlst• 1nd demr; dorsal view. [8) The thvraid gland has a close topographic relationship with the Nn. Ia· ryngei recurrentes (Nn. laryngei inferiores). In the grove between the Trachea and the Oesophagus these nerves course cranially to the La· rynx (• Fig. 11.461.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Resection of a goitre operations (thyroidectomy; mostly performed as subtotal strumectomy} are the most frequent cause of Plfllysls of the leryngul muiCIH. The enlargement of the thyroid gland disrupts the normal topography of the N. laryngeus recurrens. Even in the cese of a goitre the nerve maintains close relationships with
194
the thyroid gland and the A. thvraidea inferior. but is more difficult to localise and cen be injured easily. An enlarged thvraid gland cen com· press the Trachea. In advanced stages, which can result dyspnoea often require surgical intervention.
tahir99-VRG & vip.persianss.ir
Thyroid gland
-+
Topography
Imaging and clinics
Fia. 11.57 Thyroid gland. Glandula thyroiclee: ultrasound image, normal thyroid. transverse section at the level of the isthmus of the thyroid gland. [27)
Fla. 11.58 Thyroid gland, Glandula thyroldla; scintigraphic seen, ventral view. 161 Scintigraphy is a diagnostic procedure which provides topographic and functional information of the thyroid gland. This image was taken :ZO minutes after intravenous injection of technetium-99mi)ertechnetate and shows a "cold nodule" (arrowheads) in the right thyroid lobe extanding into the isthmus. The left thyroid lobe displays a homogeneous distribution of nuclides. The *cold node• represents functionally inactive thyroid tissue.
Fig. 11.58 Enlareement of1fle thyroid a land (Struma multinodOM). Three large nodes are visible (multinodular goitre).
Fit. 11.80 Patlant with andocffna ophthalmopathy.: exophthal· mus and retraction of the upper eyelid due to hyperthyroidism. 151
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The pathology of the thyroid gland is complex. Dltfu.. l-> Fig. 11.581 and focal 1- Fig. 11.69) att.ratlons rn 1hl thyroid gland can be distinguished. Both types may have multiple causes. In addition, a deficient lhypDthyroldllm) or excessive production (hyperthyro· ldllm) of the hormones thyroxine and triiodothyronine can occur. One example is the hyperthyroidism associated with diffuse goitre (GRAVES' diMaaa) caused by immunological (autoimmune) pro-
cesses. It is frequently associated with orbitopathy. This is lilcely the result of circulating antibodies against an antigen derived from the external ocular muscles. These antibodies cross-react with the microsomal fraction of the thyroid follicular epithelial cells. An exophthalmus can result from a retro-orbital oedema. deposition of glycosaminoglycans, lymphocytic infiltrates and progressive fibrosis 1- FiiJ. 11.60).
195
tahir99-VRG & vip.persianss.ir
Neck
Muscles -+ Pharynx -+ Larynx -+
Vessels and nerves of the neck
v. occlpltala N. tl'anllllanlla calli, - - f ' l
Rr.aul*fot'M
Nn. auprada.vlcularM lntennedl
Rg. 11.11 Veu111 •nd nii'V.. of th1 1nt11rlor •nd llrtwll cervlcel regions, Region• arvfceln 11'1Urlor d lltll'llll; lateral view. The superficial fascia of the neck has been removed dorsally of the Platysma. The N. •uricullril magnu• and the N. occipitlllil minor come from behind the M. stemocleidomastoideus and curve around this muscle in an anterior and superior direction. Both are sensory nerves derived from the Plexus cervicelis (C1-C4) and innervate the skin in front of and below the auricle to the occiput region. The N. oc-
dpltllll m1)or passes through the tendinous origin of the M. trapezius at the Linea nuchae superior and provides the sensory cutaneous innervation to the occipitel region. It is the R. dorsalis of the spinal nerve C2. TheN. acc11110riu• [XI] lies on top of theM. levator scapulae end courses through the lateral triangle of the neck from the M. sternocleidomastoideus to the M. trapezius. the two muscles innervated by this nerve. The N. accessorius (XII has its origin in the brain stem end the upper cervical spinal cord(-> Fig. 12.160).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The N. acce110riU1 lXII is at risk of being injured during surgical interventions in the lateral cervical region (e.g. during removal of lymph nodes or neck dissection). Nerve lesions in this cervical region
196
-+ dluactlon llnlc
most frequently affect the function of the M. trapezius !paresis}. A:s a result, the patient is unable to elevate the arm above the horizontal plane.
tahir99-VRG & vip.persianss.ir
Thyroid gland -+ Topography
Vessels and nerves of the neck
N. occiP*I.. minor A. occipitali&
(Ansa ceMcala auperflclella = R. communk:IIM cum nervo ftlellll)
IF-- - - - - - - - , , - - - - N. IUrkcilub n111C111W
11---------- M.llfllanklaC8pl!la N.-"-DCJJ "'r-- - - Nodi lymphoidei CIIW:eiK llbnlaa, Nodllympllaldal auperllclallle
Nn. aup111davlalil1118lalenllaa M. om~, Venter nferlcr ~;..,:::~..------- Pleltusllnl<:lllllla
Fig. 11.&2 Blood YMMit encl "'"'"of thelaterel cervic.l r.glon, Reglo cerv'lclll• llter.ll•, lift aide; lateral view. Parts of the platysma were deflected upwards, and the Lamina superlicialis of the Fascia cervicalis was largely removed. The sensory nerves of the Plexus cervicalis emerge at the posterior margin of the M. sternocleidomastoideus and penetrate the superficial fascia of the neck. The Nn. supraclaviculares, N. transversus colli, and
Fig. 11.83 Sensory lnnerntlon ofthesktn In the cervlcel region (cutllneous nerves). The sensory innervation of the skin is provided by the Nn. supraclaviculares. transversus colli. auricularis magnus. occipitalis minor, occipitalis major and occipitalis tertius (not shown}.
N. auricularis magnus ell emerge in a confined area. called Punctum nervo•um (ERB's point), midway of the M. stemocleidomastoideus. The Punctum nervosum also includes theN. occipitalis minor although it exits far more cranially. TheN. accessorius [XI), the M. omohyoideus, and the V. transversa colli are visible in the posterior triangle of the neck. The V. transversa colli drains into the V. jugularis externa, which has a variable course across the M. sternocleidomastoideus.
Nn. aupnu:la~culanle
-+ dl•••ctlon llnlc
197
Neck
Muscles -+ Pharynx -+ Larynx -+
Vessels and nerves of the neck Fig. 11.64 Sentory innertl'*tion of the tkin in the h ..d and neck reaton .. well e• ..amentel mepp1ng of the cuteneou• er... 181 The cervical segments C2, C3, and C4 provide the innervation to the skin in the neck region. The Rr. anteriores of the spinal nerves innervate the ventral area of the neck, while the Rr. posteriores provide the sensory innervation to the dorsal part of the neck.
Rr. poilterkl .... (C2-<:4)
V. auric!Mri& ~
N. occ~ltalla miner
N. occ~ltalla m~~,lar
!An• cavlcalla profundl),
Radix tul)ei!Or (PIMUa ceMcellt)
v.. traJwvaiU Cllll, R. prof\lncu. Vllr.)
Rg. 11.86 VMIIIS 1nd RM'VIS of 1111 Interior 1nd lltlrel cervfcel regions, Reglonn cervtcela anterior .t lat•allll, 11ft si.S.; lateral view; after removal of the super1icial and middle fascia of the neck. The anterior triangle of the neck depicts structures normally covered by
198
-+ dlsuctlon llnlc
the carotid sheath (A. carotis extema, N. vagus [X], V. jugularis internal; displayed in the posterior triangle of the neck are the Plexus brachialis and the A. subclavia in the scalene hiatus, which are crossed by the Vanter inferior of the M. omohyoideus.
Thyroid gland -+ Topography
Vessels and nerves of the neck
N. eurlcul•rla poetelfor (N. facial~
N. ocelpllllla mtnor
~~---- PfiiXI.Ia brw:hl•la. Truncus eupelfor
.l-- - -r M. cmallyoidlua, Venter superior
A. tran- co111, R. auJ)tlftelllla
llliL-- - - - - M.1nlpazlue
M. sttmloelllelomlwlO!Iileut~'
Fig. 11.66 v....ll 1nd nerve. of th• lmrel cerwic.l region, R•aio cervic.lit ltt••lit, left lid•; lateral view: after almost complete removal of the M. stemocleidomastoideus. The removal of theM. stemocleidomastoideus permits an unobstructed view of the A. c.rotls communis in the lower neck region, the A. carotfs •mm• in the upper cervical region as well as the N. v1gus 00 and the V. )ugul1rls lrrtema. In the upper cervical region, the Anu Cll'llicllit (profundll with its Radices superior and inferior encloses
the V. jugularis interne. The Radices superior and inferior provide branches to the infrahyoid muscles. Lateral to the V. jugularis intema. theN. pht'lnlcu• branches off the Plel
-+ dl•••ctlon llnlc
199
Neck
Muscles -+ Pharynx -+ Larynx -+
Vessels and nerves of the neck N. hypogbleus LXII)
M. ttemoc:leldommoldlue
N.~(XJ)
A. CMI11s c:ommunlll
V. juguleria extwna
Fig. 11.67 v...,,, •nd nti'Vt• of1fl• lmrel cervicel..-gion, R•tio cerviceli• laterelit, dHp 18yer, lift 8id•; lateral view. Upon removal of 1he V. jugularis intema. the medially located A.tubcfa· vii, the A. vartabralls and the nuncus 1hyrocM'VIc.llls branching off the A. subclavia are visible. The A. subclavia courses dorsal to the M. scalenus anterior and, together with the Plexus brachialis, passes through the scalene hiatus
• A. thyroidea inferior -
A.laryngea inferior Rr. glandulares Rr. pheryngeeles Rr. oesophageales Rr. tracheales
• A. cervicelis ascendens - Rr. spinales
• A. suprascapularis - R. acromialis • A. transversa colli - R. superficialis - R.profundus •
(A.
dorsalis scapulae)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A proximal high-grade stenosis (narrowing) of the A. subclavia sinistra, less frequently of the A. subclavia dextra, can result in a retrograde {reversed) flow in the A. vertebra lis of the affected side during
200
-+ dluactlon llnlc
intense physical actMty of the arm (tubclavlan .teal ayndrome; SSS). The resulting reduction in the blood perfusion of the brain can cause dizziness and headaches.
Thyroid gland -+ Topography
Vessels and nerves of neck and axilla
V. ~IJI'Illla lntema
Rr. QOITITIUn~ {TNIIO.IIIIIYI!lpa!hiCXI8)
N. occ~ltalla mhcw
N. ocelpllall& ma)Or
~kin--*"" .up.-lu•
(II'IIIICU Qlllpdrlc:ul)
N.~apcq
(Qulgllon Qlllpdrlaum -l'tlm)
- - - -a
V. tllyroldaaauparlar -------l,llf;~W~ A. !llyroi!Ma lnftllof ------t.f/i,?fi~~
Gllnglon - - - ----t!i!Hhff":: OM'IIflllllll medium
~~~---------~~~ A.~-------:t~
A. ti!OI'IIdca ~lima·-----~
M. daltDidaua
M. pectonlir. minor, Tendo
Pluue bnu:HIIIIt,
Para infnlcl~18118. Fuclcuh• medlllla
V.allllrte
Fig. 11.88 Vnsels and nii'Vft of th1lateral c.l"fle&l nglon, R1gio cerviealillatwalit, and th1 axillary region. Regio axill1ri.. The numbers V to VIII mark 1he ventral branches of the corresponding cervical nerves. After the removal of the anterior two-thirds of the clavicle. the ~ br1dt11111 and 1he A. tubdiiVII passing through the scalene hia1us (between M. scalenus anterior and M. scalenus medius), and the course of the V. subclavia (in front of the M. scalenus an1erior) across rib I into the upper extremity are visible. In some cases, the upper part of the Plexus brachialis can penetrate the M. scalenus medius. In the cerviall region, the Plexus bn!chialis provides a number of smaller branches
and, after multiple exchanges of fibres, forms fascicles which are located shonly below the clavicle lateral of the A. subclavia. Only in the middle of the Axilla they reach the topographic position depicted in their name. On top of the deep cervical muscles lies the sympathetic trunk tTrun· CUitympathiCUII with the Ganglia cervicalia superius and medium (in the upper cervical region the sympathetic trunk runs within the general organ fascia, in the lower cervical region between the Fascia prevertebralis and the general organ fascia, not shown). The N. laryngeus recurrens is visible below the thyroid gland between the Trachea and the Oesophagus.
-+ dl•••ctlon llnlc
201
Neck
Muscles -+ Pharynx -+ Larynx -+
Plexus cervicalis N. -.o~~uaiXfl
N. occ.,ilalill mejor (R. do ~~tit C2) M. stemocllliclamllltoideus N. auriculeris magnus N. ocdpltllla minor Rr. m~~~e'*'-t {Mm.rectus cap~t~t amtrtor. niCtus cepitia et longus coli~
M. lhyrollyoideua
- - - M. li'III>Ghl&
- -=-.. . ._
Atrae. ~cali& pi'Ofirde, Radix 81,4*for - - -...;:i?=;r-::J-AMa ceM:ala praflnla, R8dlx Inferior ---'!"""''P"-.~- N. tni~WV~n~colll-----:--=.-+-~r~r-
Rr. m~~~et*Ns (Mm. ronoue ~
lang~ col II, liMiter -pulu, 8Ctlanut amtl'lor et 8etlenut medkal N. phn~nicur.
• M. omcflyokHUII, Vllntet lnfllrior M. ~amutcldeua
Flg1. 11.69.1and b PIIXUI ~Ill, un10ry and motor
bNnches. The Ansa cervicalis profunda and the N. phrenicus constitute !he motor branches of the Plexus brachialis. The Ansa c.rvlcalls profunda consisting of a Radix superior from segment C1 and a Radix inferior from segments C2 and C3 serves to innervate the infrahyoid muscles IMm. thyrohyoideua. sternohvoideus. stemothyroideus. and omohyoideus).
202
Additional motor branches innervate the suprahyoid M. geniohyoideus, the prevertebral muscles, theM. rectus capitis anterior, the Mm. scaleni anterior and medius as well as parts of the M. levator scapulae. The N. phNnlcus derives from the segments C3 to C5, runs caudally, and enters the thoracic cavity through the upper thoracic aperture.
1-.nl
Thyroid gland -+ Topography
A. vertebralis and Truncus costocervicalis
• Pars trllnsverurla
[_,._1111 - Rr. spinales - Rr. radiculares - As. meclullares segmentales - Rr. musculares
• Para intraCI'IInialia - Rr. meningei - A. inferior posterior cere belli - A. spinalis posterior - R. tonsil lee cerebelli - R. choroideus ventriculi quarti - A. spinelis antarior - Rr. medulleres mediales et lateralas
Vertlobra cervlc.lla VII
• A. cervicalis profunda • A. intercostalis suprema - A. intercostalis posterior prima
- A. intercostalis posterior
A. ln141roostalle poeltrlor II
sacunda - Rr. dorsales - Rr. spinales
Fig. 11.70 Branches of the A. subclllvlll and A. vertebr~~lll n well •• 1\'uncus CDitocervlcelll; lateral view.
10"
a
c
b 1K
891>
•
Figa. 11.71• to f V.rilltiana in br~~nching typeaof the A. aubclllvia end the Trunc:u~ thyrocervicaliL
f
Fig. 11.72 V.ri.tion• in the level of entry of the A. nrtllbrali• into the Foramina tranaverAria.
-+ dlsuctlon link
203
Neck
Muscles -+ Pharynx -+ Larynx -+
Veins of the neck M. digMtrieut, Ventet anterior, Tendo
V. trln1M11'8Uclll
v. ceplwllca M. pectoralis
me,ier
A. 4:11lantus antti!Or pectoralis
Rr. perfot'anttos " : v. thonu:lce Y. 1flrnlldM
Rg. 11.73 Veins of the neck. Collum; ventral view. The M. sternocleidomastoideus was largely removed on the left side. All fasciae of the neck have also been removed. Superficial veins of the neck ere the Vv. juguleres anteriores and the Vv. jugulares externae which drain venous blood into the Vv. jugulares internee. subclaviae. and brachioc:ephalicae.
v. lhotfoCOf.CI'Ol'llilllis V.IIXIIIUIII
DMp veins of the neck are the Vv. jugulares internee und thyroideae superiores, the V. thyroidea inferior and the Plexus thyroideus impar {not shown). The course of the superficial veins is very variable.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . lntravenou1 tM thii'IIPY' is one of the most frequently employed invasive procedures in the emergency case prior to reaching a hospital. The V. jugularis externa provid&s a good accessibility for IV
204
-+ dluactlon llnlc
treatment, ev&n if the other superficial veins are in a poor condition. The guidelines for cardiovascular r&suscitation recommend this IV access route as the first choice.
Thyroid gland -+ Topography
Vessels and nerves of the neck and upper thoracic aperture
M. cl;ut~~o.e. Vtntlr e.nt811or, Tendo
phnlnicua
Plexus br&chilllis, Ptn .upw:llwlculalf8
M. omollyOicl-
CllvicUe.
Fig. 11.74 V.U.Is •nd n•rves of th• neck, Collum, •nd 111• upper 1flort~elc •perture, Apertur• thor•ck su.,.Jor; ventral view.
The stemum, parts of the clavicle, Mm. sternocleidomastoidei, and parts of the infrahyoid muscles were removed. Presentation of the venous tributary of the V. cav• sup1rlor Nv. br. chiocephelicae, jugulares internee, jugulares externae, and subclaviael
with particular emphasis on the venous drainage of the Glandula thyroidea 1-+ Fig. 11.55). Also visible are the Plexus brachialis as well as the A. and V. subclavia running between the clavicle and rib I, the course of the N. phrenicus across the M. scalenus anterior, and the lett N. laryngeus recurrens curving around the aortic arch.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The term PANCOAST's tumour (apical sulcus tumour) describes a rapidly growing peripheral bronchial carcinoma at the pulmonary apex (Apex pulmonis; -+ Fig. 11.79} which quickly expands onto the ribs, soft tissues of the neck, brachial plexus, and vertebrae. Other
structures affected may involve the N. phrenicus, the N. laryngeus recurrens, the A. and V. subclavia, and the Ganglion stellatum !with HORNER's syndrome: enophthalmus, miosis, ptosis [drooping of upper eyelidll.
-+ dl•••ctlon llnlc
205
Neck
Muscles -+ Pharynx -+ Larynx -+
Lymph vessels and lymph nodes of the neck
M. acelenua meclua
M. cmohyoicala, Vent• inferior
F"tg. 11.75 Superficial lymph WNIII, Va.. lymphetica tuparficialie, and lymph no dee, Nodi lymphoidei, of the hNd and neck of a child. The neck region contains 200 to 300 lymph nodes. The majority thereof assemble in groups along the neurovascular bundle{-+ table,... Fig. 8.86}.
Lymphatic fluid of the right side of the head and neck drains into the
Ductu•lymphricu• dexter 1-+ Fig. 8.86}, whereas the left side of the head and neck drains into the Dum. thoracfcut. For entry of the Ductus thoracicus into the left venous angle ... Figure 11.81.
Lymph No•• of 'Ill• Neck (Nodllympholdelcervlc•I•J Nocllymphol•l CIIVIcel• •nterlores
Nodllympholdel cervlcliles let8r11l11
• Nodi lymphoidei superficiales
• Nodi lymphoidei superficiales
• Nodi lymphoidei profundi - Nodi lymphoidei infrahyoidei - Nodi lymphoidei prelaryngei - Nodi lymphoidei thyroidei - Nodi lymphoidei pretracheales - Nodi lymphoidei paratracheales - Nodi lymphoidei retropharyngeales
• Nodi lymphoidei profundi superiorea - Nodus lymphoideus jugulodigastricus - Nodus lymphoideus lateralis - Nodus lymphoideus anterior • Nodi lymphoidei profundi inferiores - Nodi lymphoidei juguloomohyoidei - Nodus lymphoideus lateralis - Nodi lymphoidei anteriores • Nodi lymphoidei supraclaviculares • Nodi lymphoidei accessorii - Nodi lymphoidei retropharyngeeles
206
Thyroid gland -+ Topography
Lymph vessels and lymph nodes of the neck
Fig. 11.78 Classification of dn~ln•g• regions of the hHd •nd nKII: Into comp•rtments; according to the classification of the American Joint Committee of Cancer (AJCC).
Fig.11.77 Lymph v....-. and lymph nodes of the larynx. Larynx. thyroid gl•nd. Gl•ndul• thyroidaa. •nd ti'IIChH. Tn~cM&: ventral view. [10] All three organs drain into the deep lymph nodes of the neck..
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , According to the classification of the American Joint Committee of Cancer (AJCCJ. lymph node metastat• of the neck. are divided into six zones (comp•rtment. I-VI; ... Fig. 11 .76). These compartments serve as reference zones for the elective surgical removal
of metastases in lymph nodes due to the lymphogenic spread of malignant tumours of the head and neck. region (neck. dissection). Injuries to the Ductus thoracicus during surgical interventions in the neck region can lsad to the development of a chylous fistula.
Neck
Muscles
-+
Pharynx
-+
Larynx
-+
Vessels and nerves of the Trigonum submandibulare
N. mytahyoidllus
M. dlgutrlcue, Venter antertor
Fig. 11.78 V...... and narv" of the Trigonum eubmandlbulere; inferoletaral view. Upon dissection of the submandibular gland (Glandula submandibularisl and the neurovascular bundle as well as after the removal of the fascial lavers, the N. hypogloeeue [XIII becomes visible. This cranial
nerve separates from the neurovascular bundle in the parapharyngeal space, crosses the A. carotis externa end passes between 1he M. hyoglossus and 1he intermediate tendon of theM. digestricus until it disappears beneath theM. mylohyoideus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Inflammations in the region of the lower premolars and molars ~n lead to an abHeM fonnation in the faRial c:omparbnent of the Glandula IIUbmandibulari• and the sublingual compartment. Abscesses from the wisdom teeth can even reach the fascial compartment of the Fossa retromandibularis and descend from here along the fascia of the neck. into the mediastinum to ~use a life-threatening infection.
208
Injury to the N. hypogloHu• [XIII, e.g. as a result of a tumour infiltration into a cervical lymph node (metastasis), is easily diagnosed: when stretched out, 1he tongue deviates to the side witn impaired nerve function, since the muscle force generated on the healthy side of the tongue exceeds that of the affected side.
Thyroid gland -+ Topography
Vessels and nerves of the neck and upper thoracic aperture
R. intetg&nljliollaria
"'nnn- eymp~~lhk:H, O.nelon oerwlollle meclum T~
auperior}
Tr\I!CIIt meet IllS Ywltbnl QIMCllllt VII, Proc. tnnMniiS A. vertebrde Truna~athyroceMcella
-
Ple-lndlllb
Truna~alnfarlor
7"';-,4 1111
A.; v. ceMcdll P'Ofunda =::::....,.::7'=:::.._::111"'1~'-JJ
Fig. 11.79 V...le •nd nervH In the tr1nllllon zon• from the
neck to the thorex •nd to the upper extremity. Visible are the pleural cupula. the scalene hiatus, the lower and middle sympathetic ganglia !Ganglion cervicale inferius/cervicothoracicuml stellatum on top of the head of rib I and Ganglion cervical& medium on
top of the M. longus calli), the course of the N. phrenicus. the course of the A. vertebralis. Trunci of the Plexus brachialis and the A. subclavia. Numbers IV to VIII mark the ventral branches of the corresponding spinal nerves.
Fig. 11.80 NICk. Collum; radiograph in anteroposterior (AP) beam projection. 181 Bilateral cervical ribs are visible (Costa cervicalisl.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Anatomic variations in the region of the scalene hiatus {cervical rib (cervical rib syndrome!. narrow scalene hiatus. accessory M. scalenus minimus. or abem1nt muscular fibres (collectively called scalenus anticus syndrome), or narrowing of the space between rib I end clavicle (costoclavicular syndrome)) ere the cause for the thorac:il;
outlet syndrome (TOS). TOS can result in the compression of the Plexus brachialis end the A. subclavia. The scalene hiatus is also the site for the administration of an Inter·
.c.lene braclli•l plun block.
-+ dl•••ctlon llnlc
209
Neck
Muscles-+
-+ Topography
Pleural cupula and entry of the Ductus thoracicus
Mamtuww.ltl)'nlii:Saa
llrynaeu. euper1or, R. '"""'"' N. ~ eupertor, R. awmut ~eupettor
"or"· --
A. <*'f!CIIIa Sl4)trftCIIIIt, lluncus JugiiiUia
"''ii:::"flk--·Ac donsalis -pulu
v. wrtebrallll
N. 111/yn~
rec:u"'"'
N. PhnlniCU8, N. phrwnk:ul-tua
Ganauan .mou.
Rr. c:orm~unlcant.. to C7, CIJ lllld
M.IOngU8 col II
Fig. 11.81 Pravertebr1l1nd ptlr1VI'rtell1111 atructu1111 of1fle neck 1nd the upper 1floraclc 1pertu111; ventral view. On the right side of the body, 1t1e great blood vessels were removed to permit an unobstructed view onto the pleural cupula and the symp~ thetic trunk. The Gengllon ciii'VIcall trrferlus {Ganglion cervicoU1oracicum [stellatumll rests on the head of rib I and Gentlion cervicale me· dium lies on top of 1t1e M. longus colli. The pleural cupula extends
210
beyond the upper thoracic aperture. On the left side, the great blood vessels and the left thyroid lobe were left in place. Visible are the blood supply to the thyroid gland, the R. intemus of the N. laryngeus superior and the Vasa larynges supariora, the entry of the Ductus thoracicus into the left venous angle as well as the course of the N. vagus lXI between the A. caro1is communis and the V. jugularis interne.
Brain and Spinal Cord General ........................... 214 Meninges and Blood Supply ...... 216 Brain .............................. 228 Sections . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Cranial Nerves .................... 290 Spinal Cord ........................ 324
The Central Nervous System Pressing Constriction and Open Expanse Commonly the term .. central .. refers to those parts of the nervous system, the brain (Encephalon) and spinal cord (Medulla spinalis), which are located within the cranial cavity (Cavitas cranii) and in the vertebral canal (Canalis vertebral is), respectively. The locations where cranial and spinal nerves (12 Nn. craniales, 31 Nn. spinales) enter and exit the CNS mark. the border between the central nervous system (CNSJ and the peripheral nervous system (PNS). Distal to this border in the PNS, nerve fibres are coated with an insulating sheath formed by SCHWANN's cells; in the CNS this insulating layer is provided by oligodendrocytes.
The Maters Three membranes, known as meninges, completely surround the brain and spinal cord. Directly beneath the outer, tough, parchment-like membrane of, the Dura mater ("tough mother.. ). lies a softer membrane of, the Arachnoidea mater (.. spider-like mother"), from which fine and cob-webbed fibres emerge to the surface of the CNS. The narrow space between the Arachnoidea mater and Pia mater- the subarachnoid space- is filled with cerebrospinal fluid (CSF, Liquor cerebraspinalis). in which the CNS floats. Directly on the surface of the CNS lies the very delicate Pia mater nender mother"), which serves as an attachment site for the fibres of the arachnoid mater.
Brain ... The skull is a space of pressing constriction: the brain fills the cranial cavity almost completely, only in a few areas (especially in the area of the occipital foramen, Foramen magnum), the subarachnoid space extends beyond a few millimetres. The brain of an adult weighs on average 1300 grams. In the dissection laboratory-that is in its fixed state -the brain has a rubber-like consistency. In the natural unfixed state, its consistency is more that of a soft pudding. This consistency is due to its high moisture content: The brain consists of 85% water, whereas the rest of the body only contains about 65% water. The embryonic brain comprises five parts and consists of five successively arranged hollow cysts. In the adult brain, only three parts are still recognisable. The brain is hollow inside. The inner cavities are called ventricles and contain cerebrospinal fluid. The largest of the three brain parts is the Cerebrum, which takes up almost the entire interior of the skull with the exception of the area above the Foramen magnum. The cerebrum consists of a right and a left hemisphere. The surface of these hemispheres is enlarged by coarse gyri (Gyri) and called the Cortex cerebri. Likewise, the Cerebellum consists of two hemispheres and lies in the upostero-inferior" region of the skull, above of and bilateral to the Foramen magnum. Its surfaces also contain folds which are much finer and more regular. These leave-resembling folds are called Folia cerebelli, encompassing the Cortex cerebelli, the cerebellum's own cortex. The unpaired brainstem (Truncus encephali) is about as thick. as a thumb, located at the cranial base and extends through the Foramen magnum into the spinal cord. Extensive peduncles (Pedunculi) connect the brainstem to the cerebrum and cerebellum. Ten out of twelve cranial nerves emerge from the brainstem. In contrast to the cerebrum and cerebellum, its surface appears white, because it is mainly composed of nerve fibres (white matter, Substantia alba), whereas the grey cortices mainly consist of cell bodies (grey matter, Substantia grisea).
212
... and Spinal Cord The spinal cord has a w hite surface and resides in a spacious spinal canal. The spinal cord is about as thick. as a pencil; however, t he inner diameter of the vertebral canal almost reaches the width of a th um b. More caudally tow ards the sacral bone the vertebral canal becomes narrower; in this lower region, it does not contain any spinal cord, but rather roots of lumbar and sacral spi nal nerves, each exiting the spinal canal "much low er" th rough their respect ive intervertebral f oramina. The subarachnoid space is relat ively w ide, and a space filled wit h abundant adipose t issue and veins remains in between the Dura mater and the bony wall of the Canalis vetebralis. Encompassing the Medulla spinalis, the dural sac extends dow nwards to t he coccyx. However, the caudal tip of the spinal cord concludes at t he level of the second lumbar vertebra. The diameter of the spinal cord varies. Compared to the segments that innervate the less muscular trunk, the cervical spinal cord is thicker at the site of the motor neurons responsible fo r the in nervat ion of the arm muscles. The ca udal part of the spinal cord providing innervat ion to the lower extrem it ies again shows an increased diameter. These two enlarged regions are termed lnt umescentia cervicalis and lntumescent ia lumbosacralis, respectively. The radicular filaments (Fi Ia radicularia) of the dorsal sensory roots of the spinal nerves enter the spina I cord bilate rally sides along two longitudinal lines at its dorsal surface. O n its ventral surface, the Fila radicularia of the ventral motor roots exit in a similar manner. Five to ten Fila radicularia bundle t o f orm the dorsal and vent ral roots (Radix posterior and Radix anterior); in the foramen intervertebrale, ante rior and posterior roots merge t o form the spinal nerve, w hich passes through the intervertebral foramen and exits both the vertebral column and the d ural sac.
Caveat! .. Beware I .. applies t o the CNS and especia lly to the brain. The above summary is about the surface of the orga n and - deliberately - superficial in a contextual sense. Internally, no other organ is as complex as the brain: If one has seen and understood a small part of the liver. one comprehends the ent ire liver. However, if one has seen a part of the brain, one cannot draw conclusions about the other parts, as no two cells are identical (although they can be classified). Only a synoptic approach, involving the anatomy, physiology, and psychology/psychiatry, lets one appreciat e the brain's complexity. It should be noted also that the relat ionship of the brain to its products, the thoughts, is st ill a mystery. This myst ery and the complexity of the brain are often exploited as an excuse to ind ulge in superlatives, to speak of .. the miracles " of the brain, t o unit e huma n and brain, and to emphasise uniq ueness by saying: "Look. t his and only this is YOU !.. Sometimes, establishing an essentia lly sarcastic distance t o this " miraculous organ .. as well as t o one' s ow n thought s is helpful. For example, with the (slightly altered) w ords of the physiologist Carl Vogt (1817-1895), a notorious scoffer: .. The brain t reats the t hought as the liver the bile and the kidney the urine: it discharges its products ...
Clinical Remarks---------. Comprising about 16% of all fatalities, stroke is the third most frequent cause of death in Western industrialised countries, only surpassed by myocardial infarction (Mil and malignant tumours as the first and second most frequent causes of death. Ischemic strokes form 1tle largest group (85%}. Strokes are the most frequent cause of acquired disability in adults resultinliJ in need of care. There are 182 stroke cases per 100,000 in the population. Annually, 150,000 new cases of stroke and 15.000 r¤ces occur. The major neurological diseases of the elderly are ALZHEIMER's disease (progressive impairment of cognitive functions). PARKINSON's disease, and cerebral microangiopathy IBINSWANGER's disease}. ALZHEIMER's diiNH is a neurodegenerative disease. In its most frequent form, it affects elderly people over 65 years of age and comprises approximately 60% of the about 24 million cognitively impaired (demential patients worldwide. PARKINSON'• d-... is a degenerative disease affecting the e)(trapyramiclal motor system. Typical symptoms include slowness of movement (bradykinesia}, increased muscle tonus (rigidity), resting tremor, as well as various sensory, autonomic, psychological, and cognitive impairments. Currently, some 10 million people are estimated to suffer from PARKINSON's disease worldwide. BINSWANGER'• ciMue is the most frequent cause of vascular dementia. This is the result of a subcortical arteriosclerotic encephalopathy with arterial hypertension and subsequent mien> angiopathy. An incidence of more than 3% in the aclvanced age group can be estimated. These three age-related diseases commonly share many symptoms. Patients with PARKINSON's disease often suffer from dementia, and many patients with BINSWANGER's disease display the same impairment in movement as patients with PARKINSON's disease. Patients with stroke are predisposed to develop ALZHEIMER's disease; PARKINSON's disease increases the risk of stroke. No causal treatment is available for these three neurodegenerative diseases and the clemage to the brain is irr¶ble.
EXAM CHECK LIST ~
Dln•ctlon Link Upon removal of the brain from the skull, the blood vessels and cranial nerves in the region of the cranial base and at the base of the brain as well as the removed brain itself ere inspected. For visualisation of the superficial cerebral veins. the erechnoid mater is removed from the brain. The cerebral arterial circle !Circulus arteriosus! with adjacent vessels is dissected next. The Circulus arteriosus is detached at the branching points of the blood vessels, glued to a sheet of paper and labelled. For the dissection of the ventricles. remnants of the Leptomeninx are removed, and the remaining blood vessels are traced, studied and removed. With the brain knife. a horizontal cut above the Corpus callosum is now baing conducted and the lateral ventricles are opened from cranial. Severing the two Crura fomicis and deflection of the Fornix opens the third ventricle. In the following step, the dissection of the Cornu inferius of the lateral ventricle, located in the temporal lobe. exposes the Hippocampus formation. Thereafter. the cerebellum is inspected externally, dissected, the cerebellar nuclei are e)(amined and the Pedunculi cerebelli are removed from the brainstem, e)(l)osing the fourth ventricle. The brainstem is severed: the midbrain (Mesencephalon), Pons, and Medulla oblongata are sectioned in planes for examination. Frontal and horizontal sections through each of the brain hemispheres serve to study the basal ganglia. Finally, medial and lateral tracts (including the visualisation of 1tle Insula, Capsula interne, and optic tract} as well as the pyramidal tract. and the middle and upper cerebeller peduncles are examined. The spinal oord is best visualised on the preserved prosected demonstration specimen, where the spinal cord, the lntumescentiae, the Cauda equina surrounded by meninges and the outgoing spinal nerve pairs are visible in the opened vertebral canal.
• Structure of the nervous system • superficial artsrial and venous systems of the skull• meninges: Spatium subarachnoideum, types of bleeding injuries (epidural, subdural, subarachnoid bleedinge), Dura mater, tourae of the A. cerotis interne, Sinus caverno.us, Sinus durae metria and arachnoid mater • development and structure of the CNS • Telencephalon: Cortsx cerebri, hemispheres, Gyri, Sulci, cerebral cortical areas, Fomlx, Hippocampus, basal ganglia, Umble system, clinical relevance • Diencephalon: Epithalamus (Glandula pine
213
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Nervous system, overview
·7 rNn.c:tanlel118
r~g. 12.1 Stntcture of the nervoua ayltem. Syetema nervo1um: ventral and dorsal views. The nervous sy81em is divided into a central (CNS} and e peripheral nervous system (PNS). The brain and spinal cord constitute the CNS which regulates complex functions, including the storage of experiences (memory), the creation of imaginations (!noughts) and emotions. The CNS assists the whole body in adapting quickly to changes occurring in the environment and wilhin the body. The PNS is mainly composed of spinal nerves !with connections to the spinal cord) and cranial nerves !with connec1ions to the brain). Its function is to enable communication between the organs
214
and the CNS, to control the activity of muscles and viscera, and to provide an essential link between the surrounding environment and the body interior. Functionally, the nervous system is divided into an autonomic (vegetative visceral, control of visceral activity, mostly involuntary) and a soma11c (animalic. innervation of sl:eletal muscles, voluntary perception of sensory input, communication with the surrounding environment) nervous system. Both systems are closely interlaced and interact with each olher. Besides the nervous system, tile endocrine system also participates in the regulation of body functions.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Directional and positional informations
Superior. par!&tal, top
Colllcullsupa!lor et lnrenor
Rostral, antarlor, front
OcCipital, poetenor, back
Caudal, bottom
-
Fia. 12.2 Directional and politional information• conc•nina the central n.vou• ~m (CNS and apinal cordi; median see1ion. During brain development. the neural tube bends and, thus. the longitudinal axis of the forebrain (Prosencephalon = Diencephalon and Telencephalon) tilts forward. Consequently, a unique nomenclature was generated as is shown in the figure. For example, parts formerly
Medula obJcroata Medui&811NIIa
positioned dorsally, e.g. the Metencephalon, relocated to a parietal site, yet, their position is still referred to as dorsal.
The FOREL'e uie 1•1 refers to the topographic axis between the Telencephalon and Diencephalon, while the axis projecting through the centre of the brainstem (Truncus encephalil is called MEYNERT'e axle (••).
-+ dl•••ctlon
llnlc
215
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Arteries of the head
R.fl'cntalill A. tllmpol'll.. aupertlclda
{ R. perietala
R. fl'ontalle A. mtlllingea media
{
R. perietalle
A. .upr110rtlltale
A. Oflhlhlllmlca
{
A. aupralrocNNIIa
All. tlmpol'll.. pro1\lldu
A. bt.aillril
A. merin;M mad !a
A. phlryllfN -net..
Fig. 12.3 Extllrnalart•'les of the hAd. The A. caro1is communis bifurcates (Bifurcatio carotid is! into the A. carotis externa and A. carotis intema at the level of the fourth cervical vertebra. The A. carotil extern• provides the following branches: Aa. thyroidee superior. lingualis. facialis. pharyngea ascenclans. occipitalis.
auricularis posterior, maxillaris. and temporalis superficialis; the A. c. rotls fntllrn• ascends cranially without giving off branches {... Fig. 12.15), passes through the skull base into the cranial cavity, and primarily supplies blood to the brain.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Frequently, the carotid bifurcation is the site of petflologJc.l al· teratlonsln vasculature (extracranial arteriosclerosis: plaques, stenosis, and occlusion}. Located within the carotid bifurcation is the Glomus caroticum (not shown in the figure, ... Fig. 12.155). As a paraganglion, it contains chemoreceptors wich respond to changes of the pH. 0 2• and C02 content of the blood.
216
-+ dluactlon llnlc
The cuotld slnua ayndrome constitutes a hypersensitivity of the pressoreceptors located in the carotid sinus. Frequently, ro1ational movements of the head can trigger a reflex causing a sudden decrease in heart beat (vasovagal refleX}. This can result in major circulatory complications and cardiac arrest.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Arteries of the head
Fig. 12A Internal arteriH of tha hHd. Four larga arteries supply blood to tha brain: the pair&d Aa. carotides intemae and the paired Aa. vertebrales. These four blood vessels feed into the Circulus uterl01111 cer.br11WILUSil,- Fig. 12.96)1ocated at the base of the brain, which creates an anastomosis between the Aa. carotides intemae and the As. vertebrales and releases paired branches of the cerebral arteries As. cerebri anterior, cerebri media, and cerebri posterior.
• Figs. 12.&a and b Internal c.rotld artery, A. c.~rotls lrrterna; radiographs after unilateral injection of contrast medium {angiogramsl. The contrast medium distributes to the vessels of the contralateral side via the Circulus arteriosus cerebri (WILLIS! I).
The anastomosing blood vassals within the Circulus arteriosus cerebri (WILLISII; circle of WI LLISI often are so narrow that thay will not permit a sufficient axchange of blood. At normal intracranial pressure. the ipsilateral A. c.trotla lnt.rna and the A. anbrl pomrlor usually supply blood to each cerebral hemisphere. In about 10% of cases, both Aa. cerebri anteriores branch off the same A. carotis interne on one side. Also. in 10% of cases the A. cerebri posterior derives from the A. communicans posterior, which, in turn, branches off the A. carotis interne.
b
a AP radiograph, digital subtraction angiography (DSA) b lateral radiograph, digital subtraction angiography IDSAJ
217
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Veins of the head V. llualemalltllllta auperlor
V. emiiMMII .,.MW!Ie Srt.J• eegllllllle lnfellor V.lnlemacerab~
V. oplt'lhMmlr:e lnfllrtllr
F".g. 12.6 Internal end ext.rnel Y~int of the held. The internal and external veins of the head communicate via by numerous anastomoses. This includes the Vv. emissariae and ophthalmicae as well as the Plexus venosi.
• ••
••• ......
vein of GALEN ROSENTHAL's vein vein of LABB£ TROLARD's vein
Clinical Remarks---------.. Injuries to the scalp can result in 1he spr•d of genns vii the Vv. eml11ulae and the Vv. diploicae of the Diploe 1~ Fig. 12.8) into the Sinus durae matris and the intracranial space.
218
-+ dluactlon llnlc
Em-.ry V.i.... Vv. em-.n.e- P....1e Throu1h the Slkull
v........,••
SlteofP....II
V. emissaria parietalis
Foramen parietale
V. emissaria mastoidea
Foramen mastoideum
V. emissaria occipitalis
Opening in the area of the Protuberantia occipitalis extema
V. emissaria condylaris
Canalis condylaris
Plexus venosus canalis nervi hypoglossi
Canalis nervi hypoglossi
Plexus venosus foraminis ovalis
Foramen ovale
Plexus venosus caroticus internus
Canalis caroticus
Brain
-+
Sections
-+
Cranial nerves
-+
Spinel cord
Veins of the head
Os par11111&
D1111111111111r GIWUI.. Anlchnoidet. m.ter
CIIIIUI.. PI• llllllllr cnnl1lla
Fig. 12.7 Calvaria, Calvaria, m•nlngu, Menlna••· and dural vanous slnu-. Sinus dura• matrls; frontal section. In the adult, the cerebrospinal fluid is mainly reabsorbed into the venous system through the PACCHIONIAN gr~~nul8tlans (Granulationes arachnoideae, arachnoid protrusions into the Sinus sagitta lis superior or
Fig. 12.8 Diploic canala. Canal• diplaici. and diploic veins. Vv. diploica•. of the calveria. Calveria. right sid•; superior oblique view; after tne extemallayer of the compact bone has been removed from the Calvaria.
the Lacunae laterales) along the Sinus sagittalis superior. Additionally, reabsorption occurs through the lymphatic sheaths of small vessels of the cranial Pia mater and through the perineural sheaths of the cranial and the spinal nerves (not shown).
Passing through the diploic space are diploic canals, which harbour the
Vv. diploicae. They communicate with the Vv. emissariae and the Sinus durae matris.
219
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Blood supply of the Dura mater
Dura nwlllr cranial•
A. manlng1111 medii, R. parllltd8
Fig. 12.9 Cranial dura mater, Dura mater cranialil, and Sinua Agittalia auparior with aGmll LKunHIIIterales; superior view. The Calvaria has been removed. On the left side of the body, the Dura mater cranial is has been opened along the LM:una• l..•ralu and the confluence of the Vv. m..,ln. . .e mediae into the lacunae is shown. The PACCHIONIAN granulations (Granulationes arachnoideael reside
-
within the lacunae. On the right side of the body, the Grenuletiones arachnoideae are visible as they rise above the level of the dura. The latter extend into the calvarian bone. Here they generate characteristic impressions and communicate wittl the Vv. diploicae. • confluence of the Vv. meningeae mediae into the Lacunae lateralas
Fig. 12.10 ProJection or the Rr. frontalla and parletalla or the A. mening" media onto the aide of the ekull. Circles mark the projections of the main branches of the A. meningea media. The main branches of the A. meningea media are located where the upper horizontal line crosses the vertical line passing through the middle of the zygomatic arch and the vertical line passing through the posterior part of the Proc. mastoideus. •
clinical term: Linea horizontalis euriculoorbitalis (FRANKFORT horizontal line) •• clinical term: Linea horizontalis supraorbitalis • •• vertical line through the middle of the Arcus zygomaticus •••• vertical line through the posterior part of the Proc. mastoideus
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Meningioma are the most frequent benign intracranial tumours. Often, they develop in the region of the PACCHIONIAN granulations {Granulationes arachnoideae), alongside the Falx cerebri, in the region of the sphenoidal wings (clinoidall, and in the olfactory pit. A blunt impact trauma against the side of the head can result in a fracrtura of the skull. The most likely location for a fracture is where
220
the upper horizontal line (positioned above the orbit) crosses the two vertical lines passing midway through the zygomatic arch or through the posterior part of the mastoid process. An epidural heematoma results in the event of a rupture of either the R. frontalis or the R. parietal is of the A. meningee media(--. Fig. 12.1 1l.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Intracranial bleeding
Skull fnlctunt h vicinity of theA. men~ media
Fig. 12.11 Epidul'81 h1emlltom1; frontal section; frontal view. An injury to the A. meningee media on 1he right side of the bocfy has resulted in an arterial bleeding between the Celvaria and Dura mater.
The pressure of the haematoma causes the midline to deviate sideways and results in parts of the temporal lobe .being $Queezed underneath the Tentorium cerebelli through the Incisura tentorii.
Fig. 12.12 Subdural haemlltoma and intrace1'8bnl.bleed'ing; frontel section; frontal view. Ruptures of bridging veins resulted in an acute subdural haematcma en the right side and a subdural haematoma with intracerebral bleeding into the temporal lobe on the left side.
Fig. 12.13 Subdul'81 hHmltome; superior view at the brain. [5) Large fresh bilateral traumatic subdural haematoma (arrows) on the inner aspect of the Dura mater Ired arrow = Falx cerebri}. The dura above the haematoma has been deflected.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Head trauma, e.g. caused by car accidents, can result in injuries to the A. meningea media, which supplies blood to the Dura mater. Often. the patient seems to have no apparent injuries and remains without symptoms during the first 30 minutes. The onset of an arterial bleeding causes the Dura mater to detach from the inside of the skull and an epidural ha1m1toma develops. This results in the displae& ment of parts of the brain and increasing pressure on the brain, brainstem, and cranial nerves with serious neurological deficits and pathological reflexes. Elderly people often have more fragile veins and even
small injuries can lead to the 1'\lpture of bridging veins !connecting veinsbetweencranialveinsandSinusduraematris},causingtheformetion of a eubdur•l h11matoma. Thereby, acutely or in a more subtle way (sometimes over weeks). venous blood collects between the Dura mater and the arachnoid mater. Patients show general and uncharacteristic symptoms like dizziness, headache, fatigue, listlessness, or confusion. Subdural haematoma can also coincide with intracerebral bleeding and corresponding acute neurological deficits 1-- pp. 240, 256,267, and 270).
221
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Dural venous sinuses and parts of the A. carotis interna
SlnUIINS~Ittabaupertar
..J.L------....:;...~rf-v.lllllllr~~~_..brt 1\----------~--lnclaura tento~l 81111111~
222
r~g. 12.14 Cranial dura mater. Dura mater cr~~niali•. and dural venou•linllll, Sinu• durae matri1; superior oblique view; Tentorium cerebelli partially removed. The cranial dura mater lines the cranial cavity completely and tightly adheres to the skull bones. The Sinus durae matris course within the dura. The Falx ceTMirl protrudes in the sagit1al plane in a sickle·like shape and stretches from the Crista galli to !he ridge of the Tentorium cerabelll. This, in tum, spans the posterior cranial fossa and is attached
along the Sinus transversus and the pyramidal edge. The margins of the Incisura tentorii envelope the midbrain (Mesencephalon) and taper off into the Plicae patroclinoideae which project to the Procc. clinoidei anterior and posterior. The Falx cerebri and the Tentorium cerebelli divide the cranial cavity into three spaces that are incompletely separated from one another, containing the two cerebral hemispheres and the Cerebellum.
Fig. 12.1& Parts of 1M A. carotls tnterna. [8) The A. carotis interna divides into four parts: Pars cervicalis, Pars petrosa, Pars cavernosa, and Pars cerebralis. Along its course t:hrough the base of the skull, the A. carotis intema passes through the Aperture extema canalis carotici, the Aperture interns canalis carotici, and
through the Dura mater. In the Pars cervicalis small vessels .branch off. • carotid artery siphon •• passage through the Dura mater cranialis in the region of the Diaphragms sellae
Brain
-+
Sections
-+
Cranial nerves
-+
Spinel cord
Sinus cavernosus
1--....,...,...---- A. ophi!IMnlea A. c=-roU.Inlilrn8, Pan~ ceNbralls
N. mlllllllmta (Y/2]
Fig. 12.11 Pltulhlry gland, Hypophysis [Glandula pltultarlaL and Sinus canrnosus; frontal section; posterior view. The pituitary gland is surrounded by the right and left Sinus cavernosus, which communicate via the Sinus intercavemosi. The A. carotis interna and lateral thereof the N. abducens [VI) run through the centre of the
the Sinus cavernosus; the Nn. oculomotorius [1111, trochlearis (IVJ, ophthalmicus IV/11, and maxillaris IV/21are located in the wall of the Sinus cavemosus. The Sinus sphenoidalis is located beneath the Sella turcica which contains the pituitary gland.
N. oc:ulomoto~ua 010 N. trachltoarl• [IV]
N. ophthamlcuiiiVI11 N. maxJin LVI2J
N. mlltldibularis IVJ3l Ganglion lllgemlnale
Fig. 12.11 Sinue cavemOIUI, left side; lateral view; the lateral part of the Dura meter contributing to the formation of the sinus wall has been removed; the Ganglion trigeminale was deflected laterally.
The course of the Pars cavernosa of the A. carotis interne and the passage of theN. abducens LVII through the Sinus cavemosus is shown.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , A disease of the Sinus cavemosus (cnemou• ainue eynnme; cavernous sinus thrombosis, tumour, metastasis, aneurysm of the A. carotis interns, inflammatory infiltration! coincides with unilateral palsy of the abducens and oculomotor nerves in combination with sensory deficits of the first trigeminal branch IN. ophthalmicus IV/1 J). Acute onset of these symptoms in combination with signs of impaired venous drainage, like venous stasis of the content of the orbit
with a swelling of eyelids and conjunctiva as well as a Protrusio bulbi (proptosis) suggest a venous thrombosis and/or a fistula between the A. carotis interne and the Sinus cavernosus. Arteri01elerotic alteratione in the vaRU.Iar wall are relatively frequent at the site where the A. carotis interns branches off the A. carotis communis as well as in the Pars cavernosa of the internal carotid artery.
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223
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Dural venous sinuses
S~u• marginalia
Sinus~ lnfllrtar
Snuaocqaltlllla
F".g. 12.18 Du,.l vtnout •inu••· Sinue du,.• matrie; corrosion cast; superior view. The dural venous sinuses are rigid venous canals devoid of valves that drain the venous blood from the brain via so-called bridging veins. The main drainage from within the skull occurs via the Sinus slgmollhl into the Vv. jugulares internee !initially fanning the Bulbus superior venae jugularis). Additionally, the Vv. ophthalmicae superiores (in the orbit, not visible but indicated by the arrow, communication via the Fissura orbitalis superior) and the highly variable Vv. emi$$8riae 1-+ Fig. 12.6)
form a series of smaller. likewise valveless. venous connections between the intra- and extra cranial regions. The two Sinus cavemotl assume a central position by being situated in the middle cranial fossa to both sides of the Sella turcica. They communicate with each other through the Sinus intercevemosi and either directly or indirectly with most other sinuses and with the veins of the orbit and the infratemporal fossa. • vein of LABB~ to the Vv. mediae superficiales cerebri
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Thrombosis In th• Sinus dura• mlltrll, e.g. caused by cerebral contusion or inflammations like middle ear infections, can lead to a partial or complete blockage with resulting brain oedema and
224
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haemorrhagic infarction due to a stasis-induced diapedetic bleeding. Symptoms include headaches, nausea, vomiting, and epileptic seizures.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Superficial vessels of the brain
~ \~
Fig. 12.19 Sup•rficill•mrie. •nd vein• of the brain; superior view: after removal of the cranial dura mater and sectioning of the Sinus sagittalis superior; cranial arachnoid mater removed. The superficial arteries and veins supply the cerebral cortex and the subjacent .basal ganglia. Superficial veins are the Vv. superiores cerebri, the V. media superiicialis cerebri, and the Vv. inferiores cerebri !not
shown). Anastomoses usually connect the larger veins N. anastomotica superior [TROLARD's vein,- Fig. 12.8) and V. anastomotica inferior [vein of LABBt - Figs. 12.6 and 12.18)). The Vv. superiores cerebri drain into the Sinus sagittalis superior directly or, via dura materpiercing small bridging veins, connect with the Lacunae lateralas which then drain into the Sinus sagittalis superior.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . lnJurln to th• bridging veins result in the accumulation of blood between the dura and the arachnoid mater and can cause a subdural haematoma {... Fig. 12.12). Particularly those elderly patients with age-related atrophy of the brain and fragile bridging veins have a
greater tendency to develop a chronic wbdural haam1tom1. This type of haematoma is overlooked easily due to the subUe nature of the venous bleedinlil and the inability of 1he patient to rea~ll the initiating small trauma.
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225
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Leptomeninx
F"19. 12.20 Brain, Encephalon. with cranial arachnoid mlltlr, ArachnoidN mmr cr11nial~; superior view. The cranial arachnoid mater (l()vers the brain. The Falx cerebri (a duplication of th& Dura mater cranialis). normally residing within the Fluur• long1tudlnalla ctnbrl, divides the two cerebral hemispheres into a right and a left half and extends down to the callosal commissure (Corpus callosum, not visible!. To .b01h sides of the Fissura longitudinalis
226
-+ dluactlon llnlc
c:erebri, multiple PACCHIONIAN granulations (Granulationes arachnoideael are visibla. Th6$e extend above the level of the arachnoid mater and assist in the reabsorption of cerebrospinal fluid. In addition, a numbar of cerebral veins rvv. superiores oerebri, Vv. pariatalas) are visible, which were severed from the bridging veins (small veins piercing the Dura mater cranialis on their way to the Sinus sagittalis superior) during the removal of the brain from the skull.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Leptomeninx
N.llb
N. veetibiACICOCIIIeeria (VIII)
Fig. 12.21 Bn~in. Encephalon, wida cranillarachnoid mater, Arachnoid.. mater cnniali•; inferior view. Removal of the brain from the skull was accomplished by cutting the brainstem at the level of the Medulla oblongata and severing the Aa. vertebrales, the A:a. carotides, and the twelve pairs of cranial nerves
olfactorius). The cranial arachnoid mater covers the .brain. Nerves and ve$$6IS run in the Spatium subarachnoidale. The cauciel part of the frontal. temporal, and occipital lobes and the Cerebellum are shown. The Circulus arteriosus cerebri IWILLISIII is preserved but only partiallv visible. Further, the location of the Cisternae cerebri is demonstrated.
(the Fila olfactoria of the first cranial nerve are teared off at the Bulbus
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227
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Development of the brain
Week4
Week4
Prosencephalon Flexura cervlcalla
Meeencephalon
Rhombencephalon
P~mary
brain vesicles
Primary brain vesiclea
Fig. 12.22 Development of the brain: primary brain vesicles; schematic frontal section. [21] The neural tube openings are closed in waak 4. The rostral end begins to enlarge and forms the three successive primary brain vasiclas: forebrain (Prosencephalon). midbrain (Mesencephalon). and hindbrain (Rhombencephalon).
Fig. 12.23 Development of the brain: primary brain vesicles; schematic lateral view. [21] During waak 4, the midbrain flaxura (Fiexura mesencephalica) forms between the forebrain (Prosencephalon) and the midbrain (Mesencephalon). The cervical flaxura (Fiexura cervicalis) develops between the hindbrain (Rhombencephalon) and the spinal cord.
Week5
WeekB
Telencephalon
Telencephalon
Secondary brain vesicles
Seoondary brain vesicles
Fig. 12.24 Development of the brain: secondary brain vesicles; schematic frontal section. [211 In waak 5, parts of the Prosencephalon located on the right and left side of the midline enlarge to form the Talancaphalon which generates the cerebral hemispheres. In addition, the Diencephalon derives from the Prosencephalon. The third ventricle evolves between the Diencephalon and Mesencephalon. Forming beneath the Mesencephalon is the Metencephalon with its two main components, the Pons and the Cerebellum. The Myelencephalon follows caudally; it includes the fourth ventricle and the Medulla oblongata and transitions into the spinal cord. The three primary brain vesicles gave rise to six secondary brain vesicles (the paired vesicles of the Telencephalon and the Di-, Mes-, Met-, and Myelencephalon).
Fig. 12.25 Development of the brain: secondary brain vesicles; schematic lateral view. [211 In waak 6, the Telencephalon, Diencephalon, Mesencephalon, Metencephalon, and Myelencephalon are clearly delineated. The optic cups become visible between the Telencephalon and the Diencephalon. The development of the Cerebellum starts as a lateral extension of the Rhombencephalon. The developing Cerebellum is visible at the dorsal aspect of the Metencephalon.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Failure of the neural tube to close in its rostra I section (open Neu roporus rostral is) prevents the proper development of the three brain vesicles. Misguided induction processes merely cause the formation of diffuse, underdeveloped neuronal tissue. This lack of proper
228
brain development entails improper skull formation. A facial skull (Viscerocranium] is formed but brain and brain case (Neurocranium) are not present (anencephaly). This malformation is fatal.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Development of the brain Week8
Week2D
Fig. 12.28 Denlopment of th• brain; median section. In w.•k 8 the indMdual brain structures are clearly distinguishable. Telencephalon and Diencephalon derived from the Prosencephalon. The Thalamus in the Diencephalon and theN. oculomotorius [Ill[ exiting the Mesencephalon become visible. The Rhombencephalon has differentiated into the Metencephalon and the Medulla oblongata (Myeloencephalonl. Pons and Cerebellum derive from the Metencephalon. The Medulla oblongata is followed by the Medulla spinalis.
Ag. 12.27 Dev•lopment of the brain; view from the left side. At w.•k ZO (With a foetal crown-rump length of 20 em}, the growth of the Telencephalon has progressed significantly. It is already composed of the Lobi frontalis, parietal is, occipitalis and temporal is. However, the Lobus insularis is not yet fully covered by the Lobi frontalis, parietalis, and temporalis. Of all the structures of the brainstem, only parts of the Pons, tha Cerebellum, and the Medulla oblongata are still visible.
Week14
Week2e
Dhm~>~phlllan
lnaua [lobUs lnaularlll]
...,,. InfundibUlar mlk
Week 3D
Sulcus lllltnll8
C1rebelum
L.ollllalllmporalls
Ctnlbellum
c
Figs. 12.a. to d DIIV8Iopment of the left cerebr•l hemlsph••· dle~~ee~»halon and brelnetem; schematic drawings; lateral view. [20[ At week 14, the surface of the Telencephalon is still smooth. Thereafter, the cerebral cortex undergoes successive stages in the develop-
ment of grooves(sulcl) and convolutions (gyri). In addition, the formation of the Insula becomes overlapped by the Lobi frontalis, parietalis, and temporalis.
229
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Development of the brain
Skul dllfect arc
Foramen rnacJ~Um
Part ol the Ulbus ocdpllals Dura mater cranlalla
b
Figs. 1Z.Z9e to d crenlum bmdum fonnlltlon end Vllrlaus typu of h~rn..tlon of "the b,.ln end/or menlngn, schematic presentation. [201
a Head of a newborn with an extensive herniation in the occipital region. The upper red circle marks the defect of the small fontanelle, the lower red circle indicates the defect in the area of the Foramen magnum.
d
b Meningocele: the herinal sac is formed by skin and meninges and is filled with cerebrospinal fluid. c Meningoencephalocele: the herinalsac comprises prolapsed parts of the Cerebellum and is covered by meninges and skin. d Meningohydroencephalacele: the herinal sac consists of prolapsed parts of the Lobus occipitalis and of the posterior horn of the lateral ventricle.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , An encephelocele (Hernia cerebri, outer brain prolapse, cranium bifiduml is a defect caused by incomplete closure of the neural tube during foetal development with a median gap in the skull (at the root of the nose, forehead, cranial base, or occiput). Parts of the meninges
230
(meningocele} or brain (menlngoencephelocelel without participation of brain ventricleslcenencephaloc:elel, or including ventricular parts (enct~phelocptocele. meningohydroencephelocelel can protrude into the gap.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Organisation of the brain
Fig. 12.31 Org1nl11tlon of the centre! nervous1ystem; median section; schematic drawing. The parts of the brain that constitute the brainstem, Truncus encephali, are marked by a star(*). Based on the development of the brain from three primary brain vesi-
cles (forebrain [Prosencephalon), midbrain [Mesencephalon), and hin~ brain [Rhombencephalon)), the brain (Encephalon) divides into Telencephalon, Dienoephalon, Mesenoephalon, Pons, Cerebellum IMB1Bnoephalonl. and Medulla oblongata.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The average brain volume is between 1000 and 14{)0 cm3 • Often but not always, smaller brain volumes coincide with mente! impairment. However, no correlation exists between the size of e brain
and intelligence. On the other hand, not all cases of mental impairment coincide with a small brain size.
231
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Telencephalon, cortex
SuaJa troolalalnfellor
8UICUI central It
Fig. 12.32 Ctrrebrum, C.rabnlm; superior view, after removal of the leptomeninx. The Cerebrum constitutes the major part of 1he brain. It is composed of two hemi1pher" which are separated by the FiNura longitudinalie Cll"'bri. During early stages of development, the surface of the Cere-
brum is smooth. Strong growth results in 1he formation of quite variable grooves (Sulcll and convolutions IGyrtl. This folding dramatically increases the cerebral surface area and, as a result, two-1hirds of the cerebral surface area are invisible to the eye.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Atrophy of the brain occurs with advanced age. This coincides with enlarged sulci and narrowed gyri. The progressive difficulty to memorise with advancing age is not a direct result of atrophy of the brain but is ceused foremost by the shorter duration of slow-wave sleep (deep sleep) phases. The deep sleep phases diminish signifi-
232
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cantly with advancing age. While deep sleep makes up to 19% of the sleep in individuals up to 28 years of age, 1his proportion decreases to 3% in the age groups of 38 to 50 years. Studies demonstrated 1hat this correlates with decreased memory functions.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Telencephalon, organisation of the lobes
Fig. 12.33 Lobes of the Cerebrum, Lobi c•ebrt; superior view. Towards the end of the 8111• month of foetal development, the primary grooves become visible (-> Table). These are regularly present in all humans. The view from the top shows the Sulcus centralis end the Sulcus parietooocipitalis.
Rg. 12.34 Lolln of 1he Cerebrum, Lobi arebr1; view from the left side. Each cerebral hemisphere divides into four lobes: • frontal lobe (Lobus frontalis) • parietal lobe (Lobus parietalisl • temporal lobe !Lobus temporalisl • oocipitallobe (Lobus occipitalis}
I.Dbua temporal Ia
Fig. 12.36 Lobu of 1fle Cerebrum, Lolli cerabrl; inferior view. In addition to the four lobes of the Cerebrum listed in the legend to Figure 12.34, the Lobus llmblcus !composed mainly of the Gyrus cinguli and the Gyrus perahippocampalis with the Uncus) and the Lobus insularis (Insula, not visible, since covered by the opercula of the fron181, parie1al, and temporal lobes) can be distinguished.
Rg. 12.38 Lobes of the C•ebrum, Lobi cerebrf; medial view. Secondary and tertiary grooves in the Telencephalon show indMdual variability. In many places. the margins drawn between the indMdual lobes are arbitrary (e.g. Incisura preoccipitalis).
Pllmery Groove8 of 1lle C.rebr11l Cortex Sulcu•
Locrion/Projection
Sulcus centralia
extends between the fron1al and parie1allobes; separates the (motor) Gyrus precentralis from the (sensory) Gyrus postcentralis
Sulcus lateralis
separates the frontel, parietel, and temporal lobes; deep within lie the Fo$$8 leterelis and the insula
Sulcus parietooocipitalis
extends from the upper rim at the medial surface of the hemisphere to the Sulcus calcarinus; separates the parie1al and occipital lobes
Sulcus calcarinus
like the Sulcus parietooocipitalis it extends at the medial surface of the hemisphere and both enclose the Cuneus
Sulcus cinguli
separates the Gyrus cinguli (lobus limbicusl from the frontal end parietal lobes
233
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Telencephalon, cortex
Oyruallngualla AquediiCtva m188001phal
Fig. 12.37 Gyri, Gyri, •nd grooves, Suld, of 111• anbr•l hembphent; inferior view; the midbrain has been sectioned. The Telencephalon occupies the majority of the cerebral base. Here, the Bulbi olfactorii and Tractus olfactorii overlying the Gyri orbitales are
234
-+ dluactlon llnlc
located. In addition, the Chiasma opticum, the Gyrus parahippocampalis in the Lobus temporalis with its characteristic anterior bend, the Uncus, the Gyri temporales, and the Polus occipitalis are also visible. The dark coloured Substantia nigra is clearly visible in the Mesencephalon.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Telencephalon, cortex OpercuUrl ft'oriUIJe.; OpercuUrl !Hirteliele Qyrua fnlnllllalnfllrior, Para apan:ulsria
Sulcualalllnlla, R. pollb!lrior
Fig. 12.38 Gyri. Gyri, 1nd groans, Sulci, of the C«Ar•l hemlspher•; view from the left side. Although the indicated Gyri and Sulci ere present in 88Ch human brain (e.g. Sulcus centra lis, Sulcus lateralis, or Gyrus temporalis superior), no two brains or even two hemispheres of the same brain display an iden-
tical pattern of Gyri end Sulci. Similar to a fingerprint, the cerebral cortex is unique.
Fig. 12.39 Gyri. Gyri, •nd groov•, Sulci, of the C«Arel hemlspher•; view from the left side; after removal of the parts of the frontal, parietal, and temporal lobes covering the insula. The cortical regions of the frontal, parietal and temporal lobes that
surround the Sulcus lateralis are called the opercula and have been removed to demonstrate the Insula (-+ Fig. 12.381. In the Region of the Insula olfactory, gustatory, and visceral informations are processed. In general the Insula is considered a lobe of its own.
• SYLVIAN fissure • • fissure of ROLANDO or central fissure
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235
Brain and Spinal Cord
General
-+
Meninges and blood supply
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Telencephalon, cortex
S..lcua perietoocclpltalla
F1g. 12.41 Gyri, Gyri, of the cenbral hemlsphera; view from 1t1e left side.
The Gyrus frontalis divides into a Pars ortlitalis, a Pars triangularis, and a Pars opercularis.
celaM~m
Carpua oaloaum 1 Ge~
2 Rosll'llm 3 Tnr.cua 4 Splenium
F1g. 12.41 Gyri, Gyri, of the c.-ral hemllphet"N; medial view. The Corpus callosum is composed of the Rostrum, Genu, Corpus, and
236
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Splenium. In addition, the Fornix. 1t1e anterior commissure, 1t1e Thala· mus, and the Septum pellucidum are visible.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Telencephalon, cortical areas
Prtnii'Y somatomotor eortex
Q)fUS frontalis Inferior.
Plfm.wy 11!1Uill eortax
f'llnl Opei'C\IIaria
Fig. 12A2 Fundanal cortical areas of the e~~rlllll'lll hembpheres; view from the left side. Higher cortical fune1ions, like speech, require the cooperation of multiple different cortical areas. One can distinguish primary cortical areas (e.g. Gyrus prec:entrelis. primary somatomotor cortex! from sooondary and association areas of the cortex !e.g. premotor cortex, supplementary motor cortex). Primary and ucondary cortical 11'1111 process specific sensory informations (e.g. perception and interpretation of visual impulses by !tie visual cortex in the occipital lobe). Cortical associ·
atlon an1n !e.g. prefrontal association cortex) occupy most of the cortex and serve to integrate different and complex information patterns. The outline of the human-like character (homunculus) reflects the somatotopic strue1ure in the primary somatomotor cortex. Primary and secondary auditory cortices and the WERNICKE's centre extend along the upper rim and inner surface of the temporal lobe.
Fig. 12.43 Fundanal cortical areu of the cerllll'lll hem11pheres; medial view.
The schematic outline of the homunculus illustrated in this figure and in ... Figure 12.42 roughly reflects the somatotopic organisation.
237
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Telencephalon, Fornix
Corpua m1m111re
Corpua Clllaeum, Truncua
Fornlll, Commlllaure
Rg. 12.44 Fornix,. Fambc; inferior view; after removal of the basal parts of the brain. The Fornix is a paired structure composed of the crus, commissure, body and column. It originates from the Hippocampus and Subiculum in
the temporal lobe and arches above the third ventricle towards the Cor· pus mamillare. The fornices from both sides merge (Commissure fornicisl before they reach the mamillary bodies !Corpora mamillarial. At the commissure, an exchant• offibretl occurs. Fombl;. CoriNU'
Corpua ClliO&um, S!:llenium
Fig. 12AS Fomix,. Fornix; inferior medial view; The Fornix is an important tract of the limbic system. Fibre conn~e1ion• exist to the anterior hypothalamic nuclei. the Thalamus. end the
Habenulae. The figure shows the topographic relationships of the Fornix.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Like the Fornix and the Hippocampus, the Corpore mamillaria are part of the limbic system. Although their eXBct role is unknown, the mamillary bodies are likely involved in memory processes. Chronic: alcoholism can result in the destruction of the Corpora mamillaria
238
-+ dluactlon llnlc
with memory loss, disorientation, end confabulation !creation of false memory and beliefs) !KORSAKOFf's syndrome). The patient tries to create false *stories" to conceal his memory gaps.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Telencephalon, Fornix and anterior commissure
N. ocoJamlllllrlua PIQ
comm...ul'll antwtor
N. trach.,.rlll [IV]
N.IJ1glllrinusM
N. abct.lcem~ LVII
N. laclalla [VIq
N._.tua[XII
Fig. 12.48 Antarlor commlssur., Commlssur. ant•lor, and br.lnstem, Truncus ancephall; inferior view; after partial removal of the basal parts of the Cerebrum. The Commissura anterior is composed of commissural fibres. Located in the anterior wall of the third ventricle, it represents the commissural
11-. antllrlar
Comm._ enteltor {
system of the paleocortex. The rostral part of the Commissura anterior is small and connects the two Tractus olfactorii with the olfactory cortex of both hemispheres. The much more developed dorsal part facilitates the exchange of fibres between the rostral parts of the temporal lobes (particularly the cortex and Corpora amygdaloidea).
Carp.a c.ollaaJm, Spleni.Jm
11-. poeterior
Flmbrlllhlppoct~mpl
Fig. 12.47 Ant•ior commiMur., CommiMura an..,ior, fomix, Fornix. and Hippocampua formation, lndulium gri. .um; view from the left side. All strucrures shown here are part of the limbic ~J*m, a functional concept with input from the Telencephalon, Diencephalon, and Mesencephalon. Relevant structures are the Hippocampi, the Corpora amygdaloid ea. the Gyri cinguli, and the Nuclei septales. The limbic system regulatas numerous functions, such as impulse, learning, memory, emotions, but also the regulation of food intake, digastion, and reproduction by the autonomic nervous system.
The CommiMura an~r is a fibre system (commissural Iibras) composed of a Pars anterior and Pars posterior. The Pars anterior connects the Tractus otfactorii and the olfactory cortices of both sidB8. The Pars posterior connects the rostral parts of the temporal lobes (particularly cortex and Corpora amygdaloidea). The Corpus amygdaloideum connects with the Hippocampus. The HippDC8mpua displays the DigitationB8 hippocampi of the Pes hippocampi and the Fimbria hippocampi which transition into the crus of the Fornix. An exchange of fibres occurs in the region of the column. In its rostral part, the Columnae of the Fornix continue as Pars Iibera and Pars tecta and end in the Corpora mamillaria. The Pars tecta connects to the Corpus mamillare.
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239
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Telencephalon, basal ganglia Sln~a aglltallo .,porlor
Slnua Sl(lltblls lnfllrlor
v. ~oetr1111a~
lneula
A. C8NII~ media, Pars sphenoidalIa A. Cllftlbri poetertar
Pans
Fig. 12.48 Blood supply of the bM8Ipnglle; frontal section; posterior view; the arteries are shown on the right side and the veins on the left side. The basal ganglia are supplied by the branches of the A. cerebri media. On its way to the Fossa lateralis, the A. cerebri media provides the Aa.
a...
F"IIJ. 12A9 l genglie end Thelamua; view from the left side. This figure depicts the topographic relationships between the Ventriculus lateralis, Nucleus caudatus, Corpus amygdaloideum, Putamen, Globus pellidus. and Thalamus. Many of these nuclei are collectively named basal ganglia. This includes the illustrated striatum (Nucleus caudatus und Putamen) and the Globus pallidus es welles the Nucleus subtnelamicus and the Substantia nigra in the Mesencephalon (both not visible).
Cl8tema pgntgctrVbllln
centra Ies anterolaterales {Aa. tha lamostriatae anterolatera les, Aa. lenticulostriatae) for the basal ganglia and the Capsula interna. The venous blood is drained by the V. media profunda cerebri and the V. intema cerebri.
The basel ganglia are an integllll pert of different cortical feedbeclt loops (cortex- basal ganglia- Thalamus- cortex} and participate in the motor cortical output. Their main function is to modulate the motor activity (strength, direction, range of movement). Impulses reaching the basal ganglia are modulated either to directly enhance onto indirectly inhibit motor activity.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The All. centralee antln'olateraln branch off the A. cerebri media in an almost right angle and this can easily lead to turbulences in blood flow and a secondary formation of arteriosclerotic plaques at these sites. Individuals with high blood pressure (arterial hypertension) frequently develop occlulona at these critical branching points.
240
-+ dissection link
Occlusions as well as bl. .dinga from these blood vessels cause a necrosis in the region of the basal ganglia and the internal capsule with resulting contralateral hemiplegia. Depending on the location of the damege to the be1al ganglia.. a severe hyper- or hypokinetic movement disorder can result (dystonia).
Brain
-+
Sections
-+
Cranial nerves
-+
Spinal cord
Diencephalon
Araaoubc:BIDIIII
Lamln•
181m...,...
Hypathalamus
- +*-- -
~ ....,.uptlcue
a!...,• opticum
"CII•rlrt.JI• PINel•
'Com•NBII... pDeteltor
Co!pus mamllllw sr.strum
A. celllb~ poetertar -
- -• '"-. - . -
mesencaphal ~ ""IUIKu:IUO ITHIIIIIncephal
Fig. 12.&0 Third v.ntrlcl•, V•ntrfculus tllrtlus, and diMtCaphalan, Dienceph11lon: median section. Phytogenetically, the Diencephalon derives from the Prosencephalon and is located between the Telencephalon and the Mesencephalon. The Diencephalon surrounds the third ventricle and divides into the Epithalamus, Thalamus (dorsalis), Hypothalamus, and the Subthalamus
0
(Thalamus ventralis). The Commissura anterior and the Lamina terminalis represent the rostral margin of the Diencephalon (Commissura anterior to the Chiasma opticum). The Commissura posterior, tne Commissura habenularum, and the pineal gland (Glandula pinealis) constitute the inferior margin of the Diencephalon.
MIIIIIIDnln
Glandula pNalla
Fig. 12.51 Neural circuitry involved in the regulation of the plnHI gland. Glandula plnnlls; schematic median section. laccording to [2]) The Epithalamus is composed of the Striae medullares thalami. the Habenulae, tne Nuclei habenulares, the Commissura habenularum, the Commissura posterior (epithalamica), the Area pretectalis, and the Glandula pineal is. The production of mel11tonln in pinealocytes of the Glandula pineal is is light dependent. Melatonin is an important regulator of circadian rhythms and does so by affecting the function of other endocrine organs. In addition, melatonin acts on the Nucleus suprachi-
asmaticus and via a feedback loop modulates its role in synchronising endogenous with environmental rhythms. The clrcuhry initiates at the photoreceptors of the retina which send signals to the Nucleus suprachiasmaticus in the Hypothalamus ITrectus retinohypothalamicus). This information is conveyed to the hypothalamic Nucleus paraventricularis, from here projects to the Ganglion cervicale superius of the sympathetic system, and then reaches the pinealocytes of the Glandula pines lis. The production of melatonin increases in the darX..
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241
Brain and Spinal Cord
General
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Meninges and blood supply
-+
Diencephalon, Thalamus
antarlo-
Nuclllua p.w11faadcullula
Nucllll do lAIN: Nuclllua poltl!lrlor, Nuci;IJl'A111n•,...
•
Figs. 12.&2a to d Nuclll and cortical pro)ectlons of 1fl• Thalamus. Corresponding nuclei and cortical projections are indicated by the same colour. a horizontal section through the left cerebral hemisphere b left cerebral hemisphere from 1he left (lateral) side e right cerebral hemisphere from the medial site d view onto both thalami from a superior oblique angle The Thalamus is regarded as the •gateway to consdousnns•. All sensory input to the body is synapsed and integrated in the Thalamus !with the exception of olfactory sensations} prior to this information re-
242
aching the cortex. In addition. the Thalamus participates in the modulation of autonomic and motor activities. The Thalamus is composed of specific and nonspecific groups af nuclei (more than 100 nuclear regions, includin~;~ the Corpora geniculate leterale and medial& [see visual and auditory pathways; • Fig. 12.59)). Specific thalamic nuclei (Palliothalamusl connect with defined cortical regions (primary cortical p~ jection end association fields); non..,.afic thalamic nuclai (TI'\lncothalamusl project broadly into the brainstem and diffusely into some cortical areas.
1-+Ttol
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Diencephalon, Thalamus
Fig. 12.53 Th1l1mlc rldlatlon, Rldldanes th1l1ml, and lnt•n•l ca,!IUie, C.JNtUII lrrtema; view from 1he left side; dMded into two parts by a frontal section.
Thalamic nuclei mainly project into 1he cortex. Their projections con1ribute 10 1he formation of the Crus anterius and 1he Crus posterius of 1he Capsula interne. The Radiationes thalami an1eriores and posteriores are part of 1hese projections as are 1he Fibrae cortic01halamicae and 1he Fibrae thalamoparietales.
stmullot ..ablnB11iJic ftlna oflleb,..ellm
e =Excitatoly action
e ~ rlllbltoly acuon; v.tllout conaldallng to apeclftc llllllmle nUClei
Fig. 12.64 Ascending Ntlcular activation sptlm (ARAS); specific thalamic nuclei have been excluded. 1231 The Nucfel medl1nl and the 1ntralamlnu group of nuclei, of which the Nucleus centromedianus is the largest nucleus, belong to the group of nonspecific thalamic nuclei. Corresponding to 1he broad and diffuse connections with the cortex. the intralaminar group of nuclei is involved
in the nonspecific and general excitation of the cortex. This puts the body in a state of alertness and readiness. This state of arousal is controlled by signals from the ARAS of the Formatio reticularis reaching the intralaminar thalamic nuclei which then activate 1he entire cortex via 1he nonspecific connections.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lulons of the nonspecific thalamfc nuclei, e.g. due to disturbances in blood circulation. result in an impaired consciousness with reduced awareness. Depending on the location. damage to 1he tpKific th1l1mic nuclei
may cause sensory impairment (Nucleus ventralis posterolateralis}. hemianopsia. pain (thalamic pain). motor disorders like paralysis, ataxia !Nucleus anterior ventrolateralisl as well as personality changes.
243
Brain and Spinal Cord
General
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Meninges and blood supply
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Diencephalon, hypothalamus and pituitary gland
Nucleua para~~W~Irlcularla
Nudooua dDniDmtdllllo Nucleua dorsaiiB hypothalami Nucllus anttlftat' - - hypalhalaml
AnNI hypothaiBmica 11114nlle FaaclcuiU& 1T11111111olhlllamk:uo
Nu~ DUpt'liC>PiieiUI _ . -
(Nuclei catpOria
1T111111IIarloj Nucleua Nber
Nucleua va'III'Dmedialia hypothalami
Nuclol tubandlool Ill III:UIII Dnft.lndlbu'-1
Rg. 12.66 Hypoth•l•mus; medial view; overview, nuclei illustrated translucently. Forming the floor of the diencephalon, the hypothalamus is the supervisory regulatory centre of the autonomic nervous system. The hypothalamus is composed of multiple groups of nuclei, which, according to their location, divide into the anterior, middle, and posterior groups of hypothalamic nuclei: • The •nmrlor group of hypothalamic nuclei comprises the Nucleus supr.achiasmaticus (centr.al pacemaker of the circadian rhythm, sleep-wake cycle, body temper.ature. blood pressure). the Nuclei paraventricularis and supraopticus (production of antidiuretic hormone [AD H) and oxytocin and axonal transport [Tractus hypothalamohypophysialis)to the Neurohypophysis), and the Nuclei preoptici (participation in the regulation of blood pressure. body temper.ature. sexual behaviour. menstrual cycle, gonadotropin). • The middle group of hypothalamic nuclei comprises the Nuclei tu-
ber.ales, dorsomedialis, ventromedialis, and arcuatus [infundibularis = semilunaris] (production and secretion of releasing and releaseinhibiting hormones, participation in the regulation of water and food intake). • The posblrtar group of hypothalamic nuclei comprises the Nuclei corporis mamillaris in the Corpora mamillaria which are integrated into the limbic system by receiving afferent fibres from the Fornix and projecting efferent fibres to the Thalamus (Fasciculus mamillothalamicus). They modulate sexual functions and play an important role in activities related to memory and emotions. These nuclei connect to the Tegmentum mesencephali via the Fasciculus mamillotegmentalis. In the caudal aspect of the hypothalamus. the Infundibulum (pituitary stalk) connects the pituitary gland to the rest of the hypothalamus. The pituitary gland divides into the anterior (Adenohypophysis) and posterior (Neurohypophysis) lobes.
F"IJI. 12.56 The foot of e patient with ecromeg•ly (left eidel compered to • foot of • haeltfly pereon of •imiler height. [7[ Acrom~aly is the result of an overproduction of the growth hormone somatotropin (STH) in the adenohypophysis caused by a benign tumour in the anterior lobe of the pituitary gland, a pert of the Diencephalon.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . , Damage to the Nucleus paraventricularis and particular1y to the Nucleus supr.aopticus causes a deficiency in ADH. Consequently, the inability to reebsorb weter in the renal collecting tubules results in diabet.. inaipidu1. Patients urinate excessively and excrete up to 20 liters of urine daily. Acromegaly describes the distinct enlargement of the limbs and protruding body parts (acr.al like hands, feet (-+ Fig. 12.56), chin, mandible, ears, nose, eyebrows, or genitals. This is caused by an
244
overproduction of the growth hormone STH in the anterior lobe of the pituitary gland, mainly resulting from a benign and more rarely from a malignant tumour. Giganti110 with excessive growth and height results from an 5TH-producing tumour in the anterior lobe of the pituitary gland that has formed prior to the completion of the growth phase. Once the epiphyseal plates (growth plates) are ciDSed, enlargement is restricted to the acra.
Brain
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Sections
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Cranial nerves
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Spinel cord
Mesencephalon Vwmia cerebel " " Tec:tum, Collci&Ja auper1ar
N. aculomotorkls PIQ
Ag. 12.57 Midbrain, M...nc.phalan; cross-section at 'ltle level of the Colliculi superiores; anterior view. The Mesencephalon is composed of the base, the tegmentum, and the tectum. Both, tegmentum and base are collectively named Pedunculus cerebri. The Basis m...nc.phall comprises the cerebral crura (Crura cerebri) which contain of different fibre tracts (e.g. Fibrae corticonucleares). The Tagmentum m ....-phall comprises the Substantia grises centra lis surrounding the Aqueductus mesencephali (participates in the central suppression of pain, facilitates fear and flight reflexes, regulates
autonomic ne!Wus processes) and the Substantia nigra as part of the basal ganglia. Additional structures of the Tegmentum mesencephali include the Nucleus ruber, an important relay station of the motor system, the mesencephalic parts of the Formatio reticularis, the nuclei of the cranial nerves II and IV, as well as ascending and descending tracts. The Tam..m m-caphall (lamina tecti [Lamina quadrigeminal) includes the Colliculi superiores and inferiores. These are important relay stations for visual reflexes (Colliculi superiores) and the central auditory pa'ltlway (Colliculi inferiores).
Cliuma op11cum
ctnbrl} Tegmentum m11Hn08phllll
Fig. 12.58 Micl»rain, meeencephalan. and dienc.phalon, Dienc.phalon; inferior view; after oblique section of the midbrain. The illustration demonstrates the division of the Mesencephalon into basis, Tegmentum, and Tectum. Structures distinctly separate of the
~Uncu1118
DMibrt
midbrain ere the Substantia nigra, 'ltle Nucleus ruber, end 'ltle Aqueductus mesencephali with the surrounding Substantia grises centra lis. The Substantia nigra subdivides into the Pars reticuleris end Pars compacta.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - , The primary cause of PARKINSON._ d'IH8ae is the greatly reduced dopamine synthesis, particularly in the Substantia nigra. The decrease in dopamine results in a syndrome (paralysis agitans, shaking palsy) characterized by hypokinesis, rigor, and resting tremor. In addition, these patients suffer from increased secretion of saliva,te.ars, sweat, and sebum. Also, 1hese patients display cognitive and mood disturbances. PARKINSON's disease affects approximately 1% of individuals over 60 years of age. A PARKINSON-like dise.ase can de-
velop after encephalitis, intoxications, long-term psychotropic drug medication, etc. l..eaion• of the Nucleu• ruber cause symptoms similar to cerebellar lesions, including cerebellar (intention) tremor and reduced muscular tonus, due to the inclusion of this nucleus in 1he important neuronal circuitry between "Cerebellum- Nucleus ruber- Cerebellum - N. olivaris inferior- Cerebellumu.
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245
Brain and Spinal Cord
General
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Meninges and blood supply
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Mesencephalon and brainstem
Rg. 12.69 Bl'lllnstem, 1\'uncus enceph1ll; lateral view; oblique view on the floor of the fourth ventricle after sectioning of the cerebellar peduncles. The brain!Jtem consists of the midbrain IMasencephalonl, Pons, and the Medulla oblong9tQ. The Me..nc:ephelon extends from the Diencephalon to the upper margin of the Pons. The Pedunculus cerebri is located at its anterior side. The Colliculi superiores and inferiores of the Tectum mesencephali form the dorsal side and create the particular shape of the quadrigeminal plate {lamina tecti (Lamina quadrigeminal!. The Glandula pinealis and the fourth ventricle are positioned superior and inferior to the quadrigeminal plate. respectively. The C.re!MIIum has been sec:tion&d at the cerebellar peduncles {Pedunculi cerebellares). Visible are the cranial neJVes IV. V. and VII to XII exiting the brainstem. Their nuclei are located in the brainstem. The nuclei of the cranial neJVes Ill and VI are also loceted in the brainstem but these neJVes exit at the anterior side and, thus, are not visible in this figure.
Gllndullplnalla
N. laclfJ'- l.'llq - --.::----'Pill" N. ~buloeod'iM!SlVfiQ -~-::oo:!!...' ~~medullae oblOngatae
Emr.entla
medlllla PedunaliLIII _......... tuperior
Pecluncuh111 ceNbtll•rtt medkl•
8tltl meclul.ta ventltcul quertl
Fae<:icuklt gracilis
246
~ dluactlon llnlc
Fit. 12.60 Rhomboid to.., FoiM momblod11; posterior view; view onto the floor of the fourth ventricle after dissection of the cerebellar peduncles. The Fossa rhomboidea forms the floor of the fourth ventricle. The cerebellar peduncles (Pedunculi cerebellaresl. the Pons, and the Medulla oblongata provide the margins of the rhomboid fossa. A$ part of the area of the Fossa momboidea. important nuclei responsible for the l'llgullnlon of th1 ayltlm1c drcul•· 11on and the nucl1l of the cnn1al nerves V to X. and partially cranial neJVes XI and XII. are loceted in the Pons and Medulla oblongata. In the Fossa rhomboidea one can distinguish the Sulcus medianus, the Colliculus facialis !fibres of the N. facialis [VII)), the Striae medullares ventriculi quarti as part of the central auditory pathway, the Area vestibularis !vestibular nuclei). the Trigonum neJVi hypoglossi (nucleus of the N. hypoglossus [XII)), the Trigonum neJVi vagi (nuclei of the N. vagus (X) and N. glossopharyngeus IIXII. and the Araa postrema !vomiting centre. see circumventricular organs,~ Fig. 12.911.
Brain
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Sections
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Cranial nerves
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Spinal cord
Mesencephalon and brainstem
Brachium coliNI MApertciN
Fig. 12.81 Mklbrllln, Mnencephllon, 1nd plnNI gllnd, Gl1ndul1 pln11lls; posterior superior view. At the dorsal side of the brainstem, the midbrain extends from 1he Diencephalon to the Pedunculi cerabellares, the Velum medullare superius, and the Fosse rhomboidea. The Quadrigeminal plate (Lemina tecti [Lamina Quedrigemina)) is the charac1eristic feeture of the dorsal
side. It is composed of the Colliculi superiores and 1he Colliculi inferiores and forms 1he Tec1um mesencephali. To each side, the corresponding colliculi connee1 with U1e Diencephalon (Corpora genicula1a mediate ancllateralel 1hrough fibre bundles (Brachia colliculi superioris and inferiorisl. Below 1he Colliculi inferiores. 1t1e N. 1rochlaeris [VII is the only cranial nerve to exit the brainstem at its dorsal side.
.;;;..._~~k-r 12.81
12.82
Nuclllua cwdllu., Corpua
Sll!a tlrninda
BniCfllum coU!ellU SYI*!OIIt Colllctllla ....,tar
1llgonum habtn.llal9 ---1~-r----:
Corpuagenlcllii!Um medllle
Comm!NUI'II ~or ClllniUa pi_. . -~,..·~
Fig. 12.82 Br~~lnstMn, nuncus encephall; posterior superior view; the Pons and major parts of the Cerebellum have been removed, 1he Tela choroidea of the fourth ventricle has been sectioned in the median plane and reflected to U1e right side.The Glandula pinealis attaches to the Commissura posterior and is located between the two Colliculi su-
BniCflium ccllieuli inferioril
periores. The third ventricle lies above. The brainstem contains important centrH {Nuclei ruber, pontis, olivares inferiores, vestibulares and the Formatio reticularisl which coordinate critical life-saving functions. including circulation, breathing, and consciousness IARAS ~Fig. 12.541.
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247
Brain and Spinal Cord
General
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Meninges and blood supply
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Brainstem and Cerebellum
Foramen lnteMifl!lfellare C«p~celoeum,
Glandula pineal II
Rollrum
V: ~mgna cenlbt
CorrmlaaUra anttii!OI' lamina111rmlnala Hypoti\IIIUllUS
Cor(l1.11 m.wnlllle ClliMma opllcllm - - - F AeceHu& il'lfundibuli Fceca intetped'""leri' Hypapllylll
Ki'!tr----,-+--
Oeci¥11 l.obiAus centl'llil
Ungula ceAiballl Folium \WIIllt
fiutigium
Decusa.ttio l*func~IIOI'Um cel1!balllllum aupalfOI'Um Sliwa bul>opon1fnLII
Tubllr-.nla
A..YIII'IIIbnllia Apeitu1111T111dlllna ven!rlcull Canal Ia centralia
Flg.12.83 Bralnltllm, lnlncus encephall, with fourth ventricle, Ventrfculu• quartua, and cM'ebellum. Cerebellum: median see1ion. The median section reveals the cherecteristic structure of the sex: ailed tree of life (Arbor vitae) of the Cerebellum created by the di~nct grooves !surface enlargement) of the cerebellar cortex. The Fossa momboidaa lies anterior to the Cerebellum and forms the floor of the fourth ventricle. The brainstem with Mesencephalon, Pons,
Lobua
and Medulla oblongata are positioned anterior to the fourth ventricle and even further anterior the A. besilaris runs alongside the brainstem. In the median see1ion, the Velum medullare superius constitutes the rostral wall of the fourth ventricle and stretches from the Cerebellum to the Quadrigeminal plate (lamina tecti [Lamina quadrigemine)). The pineal gland (Glandula pinealis) and the Corpus callosum are located on top.
-..bell.,....{ LobUUII !ll!ll:IIM. Lobuua quadtMQuiMt palltluior
Fig. 12.&4 Cerebellum, Cerebellum; posterior superior view. The Cerebellum divides into the vennl1 (Vermis cerebelli) and two hemisphere~. The Tuber vermis, folium, declive, culmen, as well as the Lobulus cantralis and the Lingula cerebelli are shown. The cerebel· tar hemispheres divide into thrHiabes (-+ Fig. 12.711:
248
-+ dluectlon llnlc
• Lobus cerebelli anterior • Lobus cerebelli posterior • Lobus flocculonodularis (nodule+ flocculus-+ Figs. 12.66 and 12.66) The lobes subdivide further into lobuli, such as Lobulus quadrangularis anterior, Lobulus quadrangularis posterior !Lobulus simpleX), and the Lobuli semilunares superior and inferior.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Cerebellum, cortex
Fig. 12.8& C.rlll1llum, C1rlll1llum; posterior inferior view. The tuber of vermis, pyramis, uvula, and nodule .become visible from this angle. Visible are also the paired tonsil of the Cerebellum {Tonsilla
cerebelli} as well as the Lobuli semilunares superior and inferior, separated by the Fissura horizontalis. The Lobulus biventer is located below the Lobulus semilunaris inferior and above the flocculus.
~lllterall8
wnlriculi qu111i
\1111~11• CM!beli
Fig. 12.86 C.rlll1llum, C1rlll111um; anterior view: after dissection of the cerebellar peduncles. The anterior surface depicts the cerebellar peduncles which connect the Cerebellum to the brainstem: Pedunculi cerebellares superior, medius, and inferior. The Velum medullare superius divides the vermis
(Vermis cerebell~ and connects both cerebellar peduncles. The paired Velum medullare inferius located on the left and right side of the nodule continues bilaterally towards the flocculus. The cerebellar hemispheres constitute the outer parts.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . In tha avant of increased intracranial pressure (e.g. due to a t~r mour or bleeding}, the most caudal structure of the Cerebellum, the area of the cerebellar tonsils, is at risk of being squeezed between .bone and Medulla oblongata in the region of the Foramen magnum. The resulting pressure exerted on the Medulla oblongata can cause a loss of vital functions, e.g. respiration, and cause death. This tonsillar herniation, also named downward cerebellar hernia-
tion. resemblas an tntrmntollll h~rnlltlon type, which must be distinguished from a supr1tentor'lll hernllltlon, like the central herniation, also named transtentorial herniation. Here, squeezing af the parts of the Diencephalon and Mesencephalon in the Incisura tentorii can result in a loss of function of the Formatio reticularis and corticobulbar and rubrospinal trects. The supratentorial herniation can precede an infratentorial herniation.
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Nuclei of the cerebellum
FNnulum wl ~In Tegmen ..-icUi superiorill { ....,tl Velum ~fare 111perlus
Corpus madLIIIIII C81'11bell
Velum medulliN
250
Fig. 12.87 c.r.t..llum, tw.ll•llum; oblique section; posterior view. An oblique section through the Cerebellum reveals the structure at the grey substance which consists of the cortex (Cortex cerebelli) and medulla (Medulla cerebelli). Visible in the medulla is the biggest of the four
cerebellar nuclei, the Nucleus d•ntatus, with its grey substance showing a jagged and gyreI configuration. This nucleus is not only located in both cerebellar hemispheres (Pontocerebellum) but also has multiple close functional connections with the cerebellar cortex.
F"~g. 12.61 c.r.t..llum, tw.ll•llum, with cerebellar nuclei, Nuclei cereiMIIIi: oblique section through the upper cerebellar peduncles; posterior view. The Cerebellum is composed of the medull•ry centre (Corpus medullare cerebelli) with embedded cerebellar nuclei and the surrounding cereiMIII•r cortex (Cortex cerabelli). The oblique section reveals all four cerebellar nuclei in both hemispheres (Pontocerebellum). The Nucleus dentatus is U-shaped and jagged. Medial to the Nucleus dentatus lies
the Nucleus interpositus anterior (emboliformisl and even further medial the Nucleus interpositus posterior (globosus), both collectively named Nucleu• int.rpu.itw. Both nuclei share functional similarities and connect with the paravermal and vermal zone of the Cerebellum (Spinocerebellum). Located in the medulla of the vermis are the right and left Nucleus fastigii which have close functional connections with the cortex of the Lobus flocculonodularis (Vestibulocerebellum) (-+Figs. 12.65 and 12.66).
-+ dissection link
Brain
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Sections
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Cranial nerves
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Spinal cord
Cerebellar connections
• Nuclei pontia • Spinal cord • Formatlo raticullll'is • Nuclei veartibularas
Fig. 12.69 Schemlltic structure of the besic flow of informetion from and to the Cerebellum. 1141 Blue arrows indicate the systems providing input for the Cerebellum, red arrows demonstrate the parts of the CNS receiving output information from the Cerebellum.
Cerebellar corlllx ntocerabellarta
Tractu& Vfll
Nuclei vestbulaNe
1-- - - - - - . 1
Fig. 12.70 Schemlltic presentlltion of the cerebellar compartments with corresponding afferent and efferent connections. 1141
251
Brain and Spinal Cord
General
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Meninges and blood supply
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Cerebellum, organisation Ungula ceAIIHIII }
. - - - - - - - - - - - - L o b u l U s c:«~llllllll
LollUaeerablll am.1cr
.-----------Cumen
~~------nm•~•
~~~~------~~~Ia '----------uwlavennlll 1--------------Nodulu&
F".g. 12.71 Part• oftM cerebellar vermil, Vermi• ctrebelli, I to X; median section; overview. Th& Splnocenbellum consists of th& vermis, the bilateral paravarmal zone and the major part of the Lobus cerebelli anterior with the exception of the nodule. Functionally, it controls the muscular tonus and regulates body and limb movements. The Spinocerebellum receives the
majority of its afferent proprioception input from the spinal cord CTn~c tus spinocerebellares anterior end posterior, Tractus cuneocarebellaris). Additional afferent fibers come from th& Formatio reticularis and the Nuclei olivares inferiores. The nodule is part of the Ves11bulocer• bellum.
Structu... of 1M C.l"'bellar Verm•. V.nni1 cerabelli (Roman numbers according to the cla88ification by LARSELU
I
Lingula cerebelli
11.111
Lobus centralia
IV.V
Culmen
F'INU... prima VI
Declive
VIlA
Folium vermis FiMura horizortU~Iil
VIIB
Tuber vermis
VIII
Pyramis vermis
IX
Uvula vermis
X
Nodulus
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Leaion• of the Spinocerebellum result in largely irreparable deficits in th& coordination movement sequences. Loss or severely impair&d coordination between muscle agonists and antagonists results in postural maladjustment with wide-based stance, gait ataxia and lacl: of coordination of movements (dysmetria!. Intention tremor is a typical symptom of l11lons of th• Pontoce· I'IIMIIum. This tremor becomes more intense in the extremities
252
during voluntary movements end is particularly severe towards the end of the movement. The disturbed muscular coordination involves asynergies as demonstrated by dysmetria {incoordinated movements of the hand, arm, leg, or eye undershooting or overshooting an intended position} and c:tysdiadocholdnesis (inability to execute rapid changes of antagonistic movements).
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Cerebellum, organisation
_...,
Vtrm18
r--------'------~~
'
:'
Ungula Clllllbelll }
'' '
~---- Lob\11\Je C\4fl!nllle
Labl.e cerebellll1tl!rlar
--------------cumen
Labl.e flacculanodullula
Fig. 12.72 Cerelu~ller cortex. Co ~'tell eerebelli, end eerebeller vermia, Vermia c«ebeeli; diagram of the cerebellar cortex outstretchEKI: overview. With the exception of the Lobus cerebelli anterior, the hemispheres are separated by the vermis and include the areas H II to H IX of LARSELL's classification. They constitute the Pontoc-.bellum CCerebrocerebellum!. The Pontocerebellum receives its afferent fibres primarily from the pontine nuclei (Nuclei pontis). This part of the Cerebellum has close
connections with the cerebral cortex via the Pons and participates in the planning of voluntary movements. Collectively named the Lobulua flocculonodulerla, the nodule and flocculus ()(and H X) are the essential components of the Vutlbulocerebellum. The extensive connections with the vestibular system of the inner ear provide the majority of afferent fibres to ttte Vestibulocerebellum. The main function of the Vestibulocerebellum is to regulate balance.
Structure of the Carebell•r HemiiPh•r•IRoman numbers according to the classification by L.ARSELLI Hll,lll
Ala lobuli centralia
HIV,V
Lobulus quadrangularia anterior Fi11ur• prime
HVI
Lobulus quadrangularis poeterior (Lobulus simplex)
HVIIA
Lobulus aemilunaris superior Fi11ure horizontalie
HVIIA
lobulus aemilunaria inferior
HVIIB
Lobulus gracilis
HVIII Aund B
Lobulus .biventer
HIX
Tonsilla oere.belli
HX
Flocculus
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Lesions of the Vutlbuloeerebellum mainly result in an impaired balance and control of eye movements. This includes the inability to translate vestibular input during head tums into coordinated eye movements and causes difficulties in controlling the postural mu:r
cles during standing, walking, or sitting (ataxia affecting the torso, stance, and gait; incoordination of movement). The incoordination of eye movements results in spontaneous nystagmus and involuntary saccadic eye movements.
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Brain and Spinal Cord
General
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Meninges and blood supply
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Association and commissural tracts
Fig. 12.73 Association tracts, NauroflbrH anoc:ldonas, and arcuate flbrft,. A bra a arcuata; overview; view from the left side. The majority of fibres in the white matter are association fibres. They connect different regions within one hemisphere end facilitate association end integrative functions by linking functionally distinct areas. Short ...aclatlon flbrae, known as Fibrae arcuatae cerebri, are
located near the cortex and their U-shaped structure is ideally suited in connecting neighbouring gyri. Long association flbrn located deeper in the medulla interconnect the lobes. Functionally important essociation tracts are the Fesciculi longitudinalis superior, longitudinalis inferior. and uncinatus as well as the Fibree arcuatae cerebri and the Cingulum.
Fo~mtnor
Commllaura llll'lllrfor {
Ptnl Mlelfor Ptnl pcetel!or
F'19. 12.74 Comminural tract., Neurofibraa comminuraiH; topographic overview; view from the left side; after extensive remove! of the corpus callosum in the paramedian plane, single fibres of the corpus callosum are shown. Commissural (transverse) fibres facilitate 1he information exchange between 1he two cerebral hemispheres, e.g. to generate a complete visual image composed of the visual input to each cerebral hemisphere. Homotopic commissural fibres connect corresponding cerebral areas, het•otopic commissural fibres facilitate the exchange between noncorresponding cerebral areas.
254
-+ dluactlon llnlc
Eacn phylogenetic cerebral part has its own commissure: for the paleocortex. this is 1he Commissure anterior, for the erc:hicottex, it is the Commissure fomicis, and the Corpus callosum serves this function in the neocortex. The latter consists of the Rostrum, Genu, Truncus, and Splenium. The Corpus callosum is shorter than the cerebral hemispheres and, thus, the rostral and occipital fibers create fan-shaped projections into the corresponding lobes (Radlatlo carports calloll, projections of the Corpus callosum with Forceps minor and Forceps major).However, some homotopic cerebral areas do not connect via commissural fibers. These include the primary visual cortex. the primary auditory cortex, and 1he somatosensory areas for hand and foot.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Projection tracts
Carpu• callaeum,
Fig. 12.75 ProJection tracta, Nauroftbr. . proJICtlonn; view from the left side; 1he internal capsule and the pyramidal tract have been exposed. Projection tracts consist of projection iibres which connect the cortex with subjacent structures of the CNS (e.g. thalamus, brainstem!. In the area of the striatum and pallidum, th&Se fibres have to pass through narrow spaces where all fibres converge. These bottleneck areas are
the Capsula interna and the Capsula externa between the Nucleus lentiformis and Claustrum as well as the Capsula extrema between the insular cortex and the Claustrum. The Cq~sulalrrt8ma is the main passageway for projection fibres. The Capsula axt.rna and the Cap!IUII extrema mainly contain long association fibres. The Corona radiate describes the radial arrangement of projection fibres between the cerebral cortex and the Capsula interne.
MM·--
~Rod. .
Flbral P«
9-
Fig. 12.78 Internal c.psula, Cq~aula lntern1, and pyramidal tract, n.ctua pyramldllla; functional overview; view from the left side. At the Capsula interne, almost all cortical projection tracts converge in a narrow space. This is exemplified with the pyramlclll tract derived irom the Gyrus precentralis shown in red, which continues as Tractus corticospinales lateralis and anterior into the spinal cord.
• •• •••
C.reballum
fibres to the quadrigeminal plate and to the nuclei of the Rhombencephalon perikarya of the pyramidal tract perikarya of area 6 and 8 lpremotor cortical field)
255
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Internal capsule
Mm. <:lngull pectvraJI8 Mm.thonlcill
en. poatarl..; Fllne ccrtlcoapr.aJee; Flbru cllfllcarubrales; Flbru COrtlcoNtlciJIAI8; Fib11111 corticothllllmicu; Flbru lhlllmaperlelakle; Rlldlallonee lhal1111l centralea
___ /
Mm. """"'""'urlnart•; Mm. AICII
Fig. 12.77 Internal capsul•, Capsula lnt.ma; functional structure. The Capsula intema is clinically highly relevant because it contains almost all cortical proJactlon tncts concentrated in a small space. The margins of the Capsula interna are formed by the Nucleus caudatus in the anterior medial part, the Thalamus in the posterior medial section, and the Globus pallidus and Putamen laterally. In the horizontal section, the Capsula interna has a bend shape. An anterior limb (Crus anterius), Tract~ and Arterl•lllood Supply of the Clpeul• lntema
Locations
a genu (Genu), and a posterior limb (Crus posterius) are distinguishable. The descending tracts within the capsula intema have a som.mtaplc arrangement. The corticonuclear fibres run in tne genu, while the corticospinal fibres for the upper extremity, torso, and lower extremity are somatotopically arranged in an anterior to posterior direction in the Crus posterius.
[14]
Tractl
Blood Supply
(due to elin ical practise the terms Fibrae and Trectus are used i nterchangeebly hera) Anterior limb (Crus anterius)
• Tractus frontopontin us (from frontal lobe to Pons) • Radiatio thalami anterior (from Thalamus to frontal cortex)
Aa. centrales anteromedia-
Genu
• Trectus cortioonuclearis (part of the pyre m idaI tract)
Aa. centrales anterolatera-
les (from A. cerebri anterior)
les (from A. cerebri media) Aa. lenticulostriatae
=
Posterior limb (Crus posterius)
• Trectus cortioospi nalis • Tractus cortioorubralis and Tractus corticoreticularis • Radiatio centra lis thalami (from rostral thalamic nuclei to motor cortex) • Radiatio thalami posterior (from Corpus geniculatum laterale and additional thalamic nuclei to the parietal and occipital lobes) • Tractus parietotemporopontinae and Tractus occipitopontinus (from Lobus tempera lis or Lobus occipitalis to Pons) • Rediatio optica (optic radi8tion; from Corpus geniculatum laterale to occipital Iobel • Radi8tio acustica (auditory radiation; from Corpus geniculatum medial& to temporal lobe)
Rr. capsulae internee (from A. choroidee anterior)
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . The blood vessels to the Capsula intema are terminal arteries. Not infrequently, vucul•r occluaicm or m - biHding into the internal capsule caused by rupture of blood vessels (particularly the As.. centrales anterolaterales) occur. Destruction of the fibre tracts and
256
atrob are the consequences. The extent of the stroke depends on its location within the Capsula interna and can involve a contralateral panalysis (hemiplegia), sensory deficits, and blindness on the contralateral visual field (hemianopsia!.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Pyramidal tract
1-111
Fig. 12.78 Pynlmldal tract, Thlctus pyramidalis, and biNI gangll.. Nuclal baNI..; oblique staggered section through the posterior limb of the internal capsule, the cerebral peduncles, and the medulla oblongata; anterior view; pyramidal tracts shown in colour, right: pink, left: green. The pyramidal tract transmits motor impulses from the motor cortex to the motor efferent nuclei of the cranial nerves (Fibrae corticonucleares) and the motor neurons in the anterior horn of the spinal cord (Fibrae corticospinales). The fibres orlglnm in the gyrus precentralis. in secondary motor fields, and in somatosensory cortical areas. The con·
=
1fllllllmlc nuclei, Nuc:lallhal1ml: Nuclei medlllnl • Nuclei antlllNuclei wnt11111Mt
1
;
11 111
=
varglng fibres create the Corona radiata. Somatotopically arranged, the fibres pass through the genu and posterior limb of the Capsula interne I• Fig. 12.771. In the Mesencephalon, the fibres enter the Crura cere· bri. Along the way through the brainstem, the Fibrae corticonucleares exit the pyramidal trect at different levels. At the decussation of pyramids (Dtcu..ltio PYJ'*miclum), the major part of the remaining fibres (Fibrae corticospinales) cross to the opposite side, a smaller fraction courses on the ipsilateral side downwards and crosses to the opposite side only within the spinal cord.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . l.Mion• of the pyremidal trect first result in a flaccid pa!lllysis of the muscles on the contralateral side. despite the fact that propagation of action potentials remains intact in the peripheral nervous system and in the muscles. Particularly, fine motor skills of the hands and feet are impaired, while gross movement patterns in the proximal extremities and the torso are usually unaffected. Pyramidal lesions evoke primitive reflexes previously blocked by the corticospinal motor system, like the BABINSKI's reflex. Up to 2 years of age, the nerve fibres of the pyramidal tract are not fully myelinated and,
thus. primitive reflexes. suches the BABINSKI's reflex (sc!lltching of the lateral side of the foot sole causes a dorsal extension of the big toe} are considered as a normal and thereafter as a pathological reflex nesponse. With time, patients with a lesion of the pyramidal tract develop an increased muscular tonus and extensor reflexes, but weakened flexor reflexes. However, this syndrome of spastic paralysis reflects an additional damage to reticulospinal !extrapyramidal) tracts.
~ dl•••ctlon llnlc
257
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Ventricles of the brain
258
Fig. 12.79 VentrfcfH of the br•ln, Ventr1cullenc.ph•ll; view from the lett side. The inner subarachnoid space consists of the ventricular system and the central canal {Canalis centralis) of the spinal cord. The ventricular
system is composed of the petred l1terel ventricle• !Ventriculi laterares) with Cornu frontale, Pars centralis, Cornu occipitale, and Cornu temporals, the 1ttlrd ventrfcf• !Ventriculus tertius}, the Aqueductus mesencephali, and the four1tt ventrfciiiVentriculus quartus}.
Rg. 12.80 V•ntrfciH of the bretn. Ventl1cull enc.phell; anterior view. In this anterior view. the paired lateral ventricles and the medially lcr
cated third and fourth ventricles have been projected onto the brain.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Inner and outer subarachnoid spaces
Ag. 12.81 lnnlf sub1rachnold sp.aca, Ventriculi lfiCIPhlll; corro.ion cut epecimen: oblique view from the left side. Each of the lateral ventricles connects with the third ventricle by a separate Foramen intetventric:ulare (foremen of MONRO). The third ventricle communicates with the fourth ventricle through tha Aqu..
ductus mnerte~~~hlll. The fourth ventricle contains three openings IAperturaeJ to the outer subarachnoid spae4'l: the Aperture me diana !foramen of MAGENDIE) and the paired Aperturae laterales (foramina of
LUSCHKA).
PIIXIIII choroldiLIII ventltculllltlll'lll..
~~...,....--P-1-f-;--- Slnue rectu. ~:.,._......!.-:::":~.....::::~71--j'-- Ventrii:Utus ql*ll.le c~-*tuum
Fig. 12.82 VentridM of the brein, Ventriculi enc.pheli, end eubtrlchnoiclepec., Spetium 1ubtrechnoideum: schematic drawing of the circulation (arrows) of the cerebrospinal fluid from the inner to the outer subarachnoid space. The space in between the arachnoid and pia mater constitutes the outer subarachnoid space. It surrounds the brain as well as the spinal cord. The Plexus choroidei in the ventricles produce the major part of the C4'lrebrospinal fluid !Liquor cerebrospinalisl. The circulating fluid volume (150 ml) is exchanged permanently (daily production volume approx. 500 ml).
The cerebrospinal fluid (CSFI has multiple functione. It serves as a cushion to protect the CNS from mechanical forces. reduces the weight of the CNS (the CSF creates buoyancy which causes a 97% weight reduction from 1400 g to 40 g), supports the metabolism of the CNS, removes toxic substances, and transports hormones (e.g. leptin). • clinical term: foramen of MONRO •• clinical term: aqueduct of SYLVIUS
259
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Ventricles
Fissura IOnjjl!Udnalla ctNbll
F".g. 12.83 CCMPu• C4111otum; superior view; after removal of the upper parts of the cerebral hemispheres. A superior view onto the Corpus callosum reveals the rostral to occipital orientation of the Striae longitudinales mediales and laterales of the Indusium griseum (considered a cortical part of the limbic svstem) as well as the A. pericallosa {A. cerebri anterior). The Corpus callosum consists of the Rostrum, Genu, Truncus, and a thickened posterior end
(Splenium;-. Fig. 12.127). It creates the roof of the lateral ventricles and is composed of commissural fibres connecting one hemisphere with the other. It contains approximately 200 million axones. The function of the Corpus callosum involves the information exchange and coordination between the two hemispheres, with each hemisphere having partially different tasks in the processing of information.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The surgical sectioning of the Corpus callosum has been used for the treatment of some severe forms of epilepsy (almost always the splenium was kept intact). The rationals for this drastic therapy was to prevent the propagation of the irregular brain excitations onto the unaffected cerebral hemisphere. A significant reduction in the frequency and severity of epileptic seizures occurs. However, this
260
-+ dluactlon llnlc
operation, also known as spllt-llrt~ln OJNI'don or callosotoml•. results in patients suffering from severe cognitive impairment and a split-brain syndrome. Therefore, this surgery has bean largely abandonded. A vMd description of a patient with spllt·bratn syndrome is presented in the book by Oliver Sacks, a neurologist and author of the 1985 novel "The Man Who Mi!rtaok His Wife for a Hat•.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Ventricles
Ag. 12.84 Llrteral verrtllciM. Ventrlcullllrtei'IIIN: posterior superior view from the left side; efter removal of the upper parts of the cerebral hemispheres. View into both lateral ventricles. The oourse of the Pl...,. choroicleu• is visible in the left lateral ventricle. The Plexus c:horoideus has been lifted up with a probe at the transition from the Pars centralis to the Pars temporalis of the lateral ventricle. The Plexus choroideus pro· dUCM an~brosplnal fluid.
The roof and 1he lateral wall of the Cornu occipitale are formed by the tapetum IRadiatio corporis callosi, Radiatio optical (not visible). The eelcar avis forms the medial wall. and the Trigonum oollaterale end the Eminentia c::ollateralis create the floor. The roof and lateral wall of the Cornu 1emporale are part of the Cauda nuclei ceudati and the 1&petum (not visible), tha Fimbria hippocampi and the Plaxus c:horoidaus form the medial wall, and the floor consists of 1he Eminentia oollateralis and the Alveus hippocampi 1-> Figs. 12.87, 12.123 to 12.126).
Fimbri• hipp~i
nteonum colletefala Sulcua hippocampal Ia
Ag. 12.8& L..tt tMnpol'lll horn, Comu tMnpol'llle, of the llterel ventrlcfe, Ventriculus laterails; frontal section after removal of the temporal wall; posterior superior view. The Hippocampus, the Alveus hippocampi, the Fimbriae hippocampi, and the Pes hippocampi form parts of the floor of the Cornu temporale
of the lateral ventricle. The Trigonum collaterale is also visible. The Hippocampus formation with the Gyrus parahippocampalis is visible in the frontal section. The Hippocampus is a central element of the limbic: system{-+ Fig. 12.471 and is involved in processes of learning, memory, and emotions.
-+ dl•••ctlon llnlc
261
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Ventricles
Gyrutdngull
8eptumpel~
FOft'lllr.Columna Foramen lntllrventrtcullre
v. ~atuuperiOr
Fmblla hlppoca!ll)l
Glanut choraldeum
262
Fig. 12.88 a.at.ral wntrlciK, Vantrkullllteraln; superior view: after removal of the upper part of the cerebral hemispheres and the central part of the Corpus callosum. This view shows the Cornu frontale, the Pars centralis and the Cornu occipital& as well as the transition of both lateral ventricles to the Cornu temporals. The margins of the Comu frorrtale are the Genu of the Corpus callosum (anterior wall), the Truncus of the Corpus callosum !roof. not visible. because the Corpus callosum was detached at the genu and the splenium!. the Septum pellucidum (medial wall}. the c&-
put of the Nucleus c:audatus (lateral wall!. as well as the rostrum of the Corpus callosum (floor). The Foramina interventricularia (fon~mtna of MONRO) in the Cornu frontale are also visible. Like the Pars frontalis, the roof of the Pars centralis is formed by the Truncus of the Corpus callosum (removed). The crus of the fornix and the Septum pellucidum create the medial wall, the Corpus of the Nucleus caudatus forms the lateral wall, and the floor consists of the Lamina affixa of the Plexus choroideus and the crus of the fornix.
Fig. 12.87 TempoNI horn, Cornu tempon~le, of the llteNI ventricle, Ventriculus leterallt; schematic frontal section. The scheme demonstrates the topographic relationsship of the lateral ventricle and the Hippocampus formation. The Plexus choroideus pro-
trudes into the lateral ventricle. The walls of the ventricle are coloured in bright green. while the cerebrospinal fluid and the internal ventricular space ere shown in white.
-+ dluectlon llnlc
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Ventricles Fluura longitudinal Ia cenlb~
Corpua callaa~Mn, Roatrum
Nuc:la1.11 ca.dlllua, Cauda
Hippocampus T!lganum colllllenlla
Glandula pin.! II v.m~~gna~bll
Fig. 12.88 Lateral ventllcles, Ventrlcullllt8111lu; superior view; after removal of the central part of the corpus callosum and the columns of the fornix. Shown is the Tela choroidea overarching the third ventricle. The Vv. intemae cerebri gleam through and drain into the V. magna cerebri. The
Cornu frontale, Pars centralis, and the Cornu occipitale of the lateral ventricles are visible. Laterally, the Plu:us choroldeus continues alongside the Hippocampus into the Comu temp orale.
l
Fllauralangltudhalll
~ /
v. lrrtlma ~bll
,;:>'!~~!!-----
Nuc111Uacauda1ua
v. 1l\allim01111111aauper!Or
TMnll tlllllani
Fig. 12.88 Plexus chorofd1us In thellt8111l ventricles, Ventrlwll lltll'aln, and In 1IHt third ventricle, Ventrfculus tllrtlus; schematic frontal section. (according to f21l The Plu:u1 choroideua produces cerebrospinal fluid (CSF) and is present in the paired lateral ventricles (left first and right second lateral
ventricle} as well as in the third and the fourth ventricles (not shown}. In the Plexus choroideus, capillary blood and CSF space are separated by a blood·CSF banllr.
-+ dl•••ctlon llnlc
263
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Ventricles CatpUa callollum, Genu
Ccwm lll!pti pelluddl
Septum palucldum Nudlua c:audlltull, C11put
Fornix, COlumna
Stllawmlnala
Nucleua caucil.tua, Cauda
- +----CGmmr- poetartar "-LIIplnlllll
V. lntema cenlbll
Fig. 12.90 umr•l v.mrfciK, V•ntrlculllmr•ln, 1nd 1fllrd Vlntrlcle, Ventriculus t_.lus; superior view; parts of the cerebral
hemispheres, the central part of the Corpus callosum as well as the Fornix and the Plexus choroideus have been removed, the Tela choroidea of the third ventricle has bean reflected. The m1rgine of the third ventricle are: • roof: Tela choroidea and Plexus choroideus • anterior wall: Columnae fornicis. Commissura anterior. Lamina terminalis. Recessus triangularis, and Recessus supraoptic:us
• lateral wall: Thalamus, Stria medullaris thalami, Sulcus hypothalamicus, and Hypothalamus {wall} • posterior wall: Commissura habenularum, Commissura posterior, Recessus suprapinealis, and Recessus pinealis • floor: Recessus infundibuli • Adhesio interthalemic:a cut in the median plene
O~um~b·~icala~~~~ Orgenum vaacuiOeun larrinaetemmllllo&--
Rg. 12.91 Clrcumventrlculu ort•n•, median sagittal section. Characteristic features of the circumventricular organs are strong vascularisation, a modified ependyme (tanycytes with tight junctions), and the formation of a blood·CSF barrier instead of a blood-brain barrier. Circumventricular organs include the neurohypophysis, the Eminentia mediana, the pineal gland !Glandula pinealisl es well as the Organum
vasculosum laminae terminalis and the Organum subfomicale {both: regulation of blood volume and blood pressure, secretion of hormones like angiotensin, somatostatin, inducing fever), the Organum subcommissurale {present only in the foetus and newborn, secretion of a glycoprotein·rich product), end the Area postrema (triggers vomiting).
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Clinics
•
b
Fige. 12.92a and b Comput.d tomographic (CT) ~ione of the h..d. 1231 • CT scan of a patient with a cerebrospinal fluid block: caused by ol> struction in the cerebral aquEKiuct (Aqueductus mesencephali). The
cerebral ventricles ere greatly enlarged (hydrocephalus) at the expense of the cerebtlll parenchyma. The patient showed massive mental disabilities and significantly impaired gait. b CT scan of a healthy person
Fig. 12.93 Ocular fun due, Fundue oculi: left aide; anterior view; ophthalmoscopic image of the central area with papilloedema caused by increased intracranial pressure. The examination of the ocular fundus reveals a swelling of the Papilla nervi optici resulting from an intraventricular neurocytoma WHO grade
II. As theN. opticus 1111 is surrounded by meninges end cerebrospinal fluid. the optic disc bulges out into the bulbus of the eye. • clinical term: optic disc or blind spot !discus =Papilla nervi opticil
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . . The circumventricular organs(,. Fig. 12.911 lack the blood-brain berrier end, thus, are capable of monitoring the plasma-blood milieu. This is not only of pharmacological interest. The Area postrema contains numerous dopamine and serotonin receptors. Dop~ mine and serotonin antagonists are effective anti-emetic drugs. In addition, the activation af chemoreceptors in the area of the Area postrema presents a protective mechanism for the .body as exemplified by the centrally induced vomiting as a response to the ingestion of spoiled food. This will remove the major pal1 of potentially harmful substances from the body.
The impeired drainege of cerebro1pinel fluid (CSFl can be the result af tumours, deformities, bleedings, or other causes end, due to the increased intracranial pressure. coincide with haacleches. nausea. and optic papilla protrusion (papillo9demal 1~ Fig. 12.931. A hydrocepheluelntemue 1- Fig. 12.92) is caused by the blockage of the inner (intracerebral) subarachnoid space with accumulation of CSF in the ventricles, whereas accumulation of CSF in the outer subarachnoid space is a characteristic feature of Hydrocephelus ext•nus. A Hydroct~phelus e vacuo results from an increase in ventricular size due to a rarefication of brain matter, as it occurs in AUHEIMER's disease.
265
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Arteries at the cranial base
A.-*' !Mdla, Parainauleria (Sejpnenllnl 1.42]
N. WH&tlbulocochlelula (VII~
A. <*'tbrt poeU!rtor,
Pet& pt8CCII!lmlriellla (Beg mentum P1) A._..,.or
_.....
Fig. 12.84 Amnln of 1h• b111ln; inferior view. The figure demonstrates the location of the arteries at 1he cranial base. The Aa. vertebrales converve to form 1he A. basilaris which releases the Aa. cerebri posteriores and branches for the brainstem, the Cerebellum, and the inner ear lso-<:alled vert.br•li• triluteryl. Small connecting arteries (A&. communicantes posteriores) provide 1he link between 1he Aa. cerebri posterioras and the two Aa. carotides internae. Each of the latter contributes one A. cerebri media and one A. cerebri anterior which collectively provide the major part of 1he blood for the hemispheres lsCH:alled carotls tributary). The A. communicans anterior connects both Aa. cerebri anteriores. Clinically, the Aa. cerebri anterior, media, and posterior era divided into segments. The A1 segment (Pars precommunicalis) corresponds to the part of the A. cerebri anterior proximal to the A. communicans anterior
and the part distal of the A. communicans anterior is the A2 segment (Pars infrecallosal. The A3 segment !Pars precallosal describes the pert of the A. cerebri anterior located in front of the Corpus callosum and the part located on top of the corpus callosum constitutes the A4 segment (Pars supracallosal. Clinicians cell the part of the A. cerabri anterior distal to the A. communicans anterior the A. pericallosa. The A. cerebri media is composed of the segments M1 (Pars sphenoidalis), M2 {Pars insularis), M3(Pars opercularis), and M4 (Pars terminalis). The A. cerebri posterior divides into four segments: P1 (Pars precommunicalis; proximal to the A. communicans posterior), P2 (Pars postoommunicalis; up to the posterior rim of the brainstem), P3 !Pars quadrigemina; up to the point where the A. cerebri posterior enters the Fissura calcarine), and P4 (no Latin term; division into two arterial branches). Some segments ere visible in the figure.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . One of the most frequent forms of cerebral ischemia in the vertebralis tributary is called WAU.ENBERG'a syndrome (dorsolateral medulla oblongata syndrome). Caused by an occluded or largely
blocked A. inferior posterior cereballi, the symptoms include nystagmus, difficulties in equilibrium and swallowing !dysphagia}, uncontrollable singultus, dysphonia, and dizziness.
Brain
-+
Sections
-+
Cranial nerves
-+
Spinal cord
Arteries at the cranial base, Circulus arteriosus
R. nervi OCIJiomotaril A. lhalamotubtf'lll& R. hypo1twllmlcua Aa. tubtrll elleNI
A.lnfllrtar poltllrtor e«eblll
Rg. 12.15 Art11rl1l drcle of 1h1 breln, Circulus ut•losus c..brl (cln:le of WIU.ISJ; superior view. The Ae. communicantes posteriores on both sides connect the Ae. cerebri posteriores with 1he Partes cerebrales of the Aa. carotides inter-
nae. In front. the A. communicans anterior connects the two Ae. cerebri enteriores. This generates a closed arterial circle which provides an anastomosis between the two Ae. carotides internee and the vertebralis tributary.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Of all carabrel •neury~ma, more than 90% oocur at the cerebral vessels that make up the Circulus arteriosus cerebri (circle of WILLIS). The A. communicans anterior followed by the A. carotis intema are the most frequently affected cerebral vessels. Most cerebral aneurysms are the result of congenital defects in the Tunica media of the vascular wall close to branching points. Often. aneurysms are associated with other diseases.
such as polycystic kidneys or fibromuscular dysplasia. Most of the aneurysms are asymptomatic. However, the aneurysmal sac may cause a compression of neighbouring cranial nerves. Cerebral aneurysms have a tendency to ruptunt and are the most frequent cause of subarachnoid bleedings. Upon rupture, immediate and strong headaches combined with vomiting and changes in consciousness oocur.
267
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Vessels and nerves at the cranial base
Nn. alfacto~l (1] A.~IJ!mblrklr
.
.
{ P. . poatccmmlrolcalla
A.. cerellri entenor P. . ll"'CXXImlUnlr:«
A. caro\f~t lnfaona, Pant cen!bnlla A. oph1hllmlca
\l ophtN!mica superior
N.IICIIITIIIIs
N.llbducana [II~ N. nuocmall&
N. oculomO!o!l~~& 0111 A. oarollllln141rna. PantQMimotMI
N. mull lalla [VIZ)
A. cammunlcana p04ItWtar PlliXue car~~tlew lnttrnue
N. mllndibullrft [V/3)
A. carellrl polltllrklr R. mar~ng'aus---
A. menlntM medlll N. pelnlaLII mr.ar
N. pel.-. majcr A. ltiMIIII.rtll A. Ill~ N. faclall11 [VII) N. ~bUocotiiiNriii[VliQ N.~•IXII
A. merino.. poetertor
N.wauaiXl N. gloeeophaoyngeu• [lXI
'*"' hypogllolll N. hypogloeaua [XI~
Rg. 12.18 Passageways of veualland nwvu 1ttrough 1tte lntemalsurrac. of the cranial baM, Balls cranlllnt.rna, and the arabral art•lal drde, Circulus arttlrlosus e~~rlllrf (circle of WIWS); superior view. From a superior view, the Circulus arteriosus cerebri projects onto the Fossa hypophysialis. The A. ophthalmica branches off the A. caroti• intema at the Canalis nervi oPtici end, together with the N. opticus [II),
268
enters the orbit through this bony canal. The A. bullarfs runs on top of the clivus. The A. Inferior anterior arabelll derives from the A. basilaris and releases the A. labyrfntftl while passing the Porus acusticus internus or entering it in an S-shaped detour. For an overview of the passageways through the intemal surface of the cranial base • Figures 8.16and 8.17.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Arteries of the brain
fa'TIIx, Corpua
Plaxua choro~ ventriculi tllftl Tell choroldell ~llfcul tertii
Ccl'p~~a caiONn, Splltllum V.~~~~~gnaceNbrl
A.-*' poltllrtor
Corpua aallaaum, Genu
Fig. 12.97 Medl1lsul'fac. of th1 br1ln, F1cles m1dlllls h•mllllh• rll CII'Arl, dllnclph1lon, Dl1ncephllon, and br~lmtlm, Truncus •nciphali; staggered median section; view from 1he left side. Once the A. communicans an18rior has branched off 1he A. cerlbri Interior, 1he Pars postcommunic:alis (A. peric:allosal of the letter PB&ses around 1he rostrum and genu of the Corpus callosum end 1'\lns alongside the upper surface of the Corpus callosum. Its extensions
reach 1he Sulcus parietooccipitalis. The A. cerebri anterior supplies blood to the medial area of the frontal and parietal lobes as well as the hemisphere! rim and a small area alongside 1hereof at the cerebral convexity 1-- p. 271). The A. cerebri pomrior courses to the oocipitellobe. the basal pen of the temporal lobe. the lower pan of the striatum (not visible). and to the Thalamus.
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269
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Arteries of the brain
A. aulcl canlralla A. aucl pracentraiB
A. J)lllatals poarlor
Fig. 12.98 Br1ncb• of tha A. cerebrl mM111 In tha lnsullr region, 1nd .t the outer c•rebrel cortex; view from the left side. (according to (211 The A. cerllbri media enters the Fossa lateralis from the lateral side and divides into four parts (-+ Fig. 12.94):
• • •
Pars sphenoidalis (not visible; M1) Pars i nsularis with short branches for the insular cortex (M21 Pars opercula ris for the cortex of the temporal lobe (A. frontobasal is lateralis and Aa. temporales; M3) • Rr. terminales inferiores and superiores (Pars terminalis; M4) for the cortex in the area of the Sulcus central is and the parietal lobe
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Occlusion of the A. cerebri media shortly after branching oH the A. carotis interna due to arteriosclerosis or embolus results in cef8bral Infarction (ischaemic strolce) with severe symptoms. These include a contralateral, predominantly brachiofacial hemiplegia with wealcness and loss of sensation (hypaesthesia, local or general decrease in touch and pressure sensation of the slcin). If the dominant hemisphere is affected, additional symptoms occur. These include apha-
270
-+ dluutlon llnlr
sia (speech impairment), agraphia (inability to write words or text, despite existing motor and intellectual capabilities), and alexia (inability to read). In patients with high blood pressure (hypertension), changes in the wall of cerebral vessels can cause a vascular rupture and bleeding into the cerebral parenchyma (up to the extent of a massive bleeding). The basal ganglia are particularly prone to this scenario.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Arteries of the brains
-
Amuupplad by1ha A. cen~bll madla
Fig. 12.91 Arteri11 of 1fle right hemi1ph1re of ttt. bn~in; view from the left side. The A. cen~bri Interior supplies the medial side of the frontal end p~ rietal lobes ex:tending past the hemispheral rim and up to the Sulcus parietooccipitalis. The occipital lobe and the base of the temporal lobe receive their blood supply from the A. cerllllrf posterior.
Fig. 12.100 ArtttriH of the 111ft hemi•phere of the bn~in; view from 1fle left tide. The A. cerebri 1nt.rior supplies blood to en area of the frontal end parietal cerebral cortex extending approximately 1 em past the hemispheral rim onto the cortex convexity. The A. cenbrl polterlor sup. plies blood to the occipital pole and the inferior rim of the temporal lobe. The remaining outer cortical area receives blood from the A. ce .... brt medii. The area of the Gyri precentralis and postcentralis receives blood via both the A. cerebri anterior and the A. cerebri media.
A. cnbll media
Ag. 12.101 Arteria In 1he region of the Gyrvs precentr1lll 1nd their tribublry in nllrtion to 1he homunculu. of 1he prim1ry motor cortex. The A. cerebri 1nt.rior supplies blood to the cortex of the GYI'\ls precentralis up to approximately 1 em past the hemispheral rim onto the
cortical convexity. It supplies those precentral cortical areas representing the lower extremity, the pelvis, and the thorex as depicted by the homunculus. The A. cerebri medii supplies the representational cortex areas representing the upper extremity and the entire head.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Due to the blood supply of the particular cortical area in the Gyrus precentralis, a blockage of the A. cerebri anterior results in pertly• • predominanUy of the lower extremitiH; en impaired perfusion by the A. cerebri media causes predominandy bnc:hiofteial
par.tpa. The svmptoms of the patient (lower extremity or brachiofacial paralysis) can indicate the affected cerebral blood vessel.
271
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Arteries and veins of the brain
Fig. 12.102 ArtMIM •nd velnt of 111• br•ln, All. und Vv. c.rebrl; superior view. Upon removal of the parietal parts of the brain the o1herwise hidden courses of the Aa. cerebri an1erior, media, and pos1erior become visible on the lift sld• of th• body. The A. choroidea anterior derives from 1he A. cerebri media and supplies the Plexus choroideus of 1he lateral ventricle. The A. choroidea en1erior continu&S as a R. choroicleus posterior which extends into the tip of 1he Plexus choroideus of the Comu frantale in the le1erel ven1ricle.
272
-+ dluactlon llnlc
On the right •i• of 1M body e1 the floor of the Cornu frontele of the lateral ventricle lies the V. anterior septi pellucidi and further posterior the V. 1halamostriata superior. Both drain blood into 1he V. interna cerebri which drains into the V. magna cerebri (vein of GALEN). This group of veins drains the venous blood from the ventricular system, 1he basal ganglia, and 1tte internal capsule.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Veins of the brain
v. ant~r!Or eepU ptlucldl
Y. mqna oel'llllrt
Fig. 12.103 DHp velna of the brain, Vv. profunclle carellrl; superior view. The Vv. internee cerebri run in the Tela choroidea ventriculi tertii. The veins of the ventricular system, the basal ganglia, and the internal cap-
sule belong to the deep veins of the brain. The blood from these structures is drained through the Vv. thalamostriatae superiores into the Vv. cerebri internee and from here into 1he V. magna cerebri {vein of GALEN}.
Pulw~UIJ' thalami
v. CllOI'OICIMinl'e!lor
V.!Mdil protun• cerebri
Rg. 12.104 DHp velna of the brain, Vv. profunclle carllllrl; posterior view from the right side. After removal of 1he Cerebellum, the basal veins d111ining the Rhoml.r encephalon. Mesencephalon. and Insula bEKXlme visible. Like the Vv.
internee cerebri, the venous blood vessels of this region. the paired V. media profunda cerebri and the V. basalis {ROSENTHAL's vein!, drain into the V. magna cerebri !vein of GALEN}.
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273
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Brain, MAl
12.1011 12.107 12.105
Celll*ol e1l'lnolclal88
BUbulloeul N.opUc:UIPQ
CN-.opllaum
lnf\lndlbu~
\fentl1eljfll811111'11118, Comu11tmpa11111t
ti~mWt
Cllltema lnterpeduna.t.la
PeGlnD~IIII-brt
Tqmentum m-phtrll Ylrmll -.bell AQUiductua m8MilCePild
8ul- c.lctrfnllll
274
Teetum-ctl)lllll
Fig. 12.105 Brain, Enc.,halon; magnetic resonance tomographic image IMRI); horizontal section at the level of the Mesencephalon and 1he temporal homs of the lateral ventricle; superior view.
The Chiasma opticum and the Pedunculi cerabri of the Mesencephalon are visible. In addition, the cerebellar vermis IVarmis cerebellil appears in this sectional plane. The Sulcus calcarinus is discernible in the occipital lobe.
Fig. 12.1GIS Brain, Enc.,halon; magnetic resonance tomographic image (MRI); horizontal section at the level of the central parts of the lateral ventricles; superior view. Visible are the Cornua frontala and occipitale, the Septum pellucidum, and U1e crus of fornix. The left side of the image also shows the Lobus insularis.
Fit. 12.107 B111ln, Encaph1lon; magnetic resonance tomographic image (M Rl); horizontal section at the level of the third ventricle and the temporal horns of the lateral ventricles: superior view. In addition to the Lobuli insulares and the structures shown in ~ Figure 12.108, the Thalamus and the column of U1e fomix are visible.
Brain
-+
Sections
-+
Cranial nerves
-+
Spinel cord
Brain, MRI
8eptum pelu:lclum* Cotpua callosum, 8pla11um C
COrpu• m•mllln TIIC!Um me&IIICePhall Chluma aptlcum
A. beailaris
Medulla ablangala
Ungua
Cistema cenlbllllomeclulari&
Medulla aplnallo
Fig. 12.108 Bn~ln, Enc.phalan; magnetic resonance tomographic image (MRI); median section. This MRI scan clearly delineates all brain structures. for example the Gyrus cinguli, Septum pellucidum, Ventriculus tertius, Thalamus, Aque-
ductus mesencephali, Corpus mamillare, Hypothalamus, Hypophysis, Mesencephalon, Pons, Cerebellum, and Medulla oblongata. The structures marked with a star (•) appear partly falsified as a consequence of the "partial volume effect".
12.108 12.108
IIIMA [Lobua Nlllarhl
Bulbutoeul
Sl,...malllllrla
Fig. 12.109 Bn~in. Enc.phalon; magnetic reaonance tomographic image IMRI); 88gittal section at the level of the Mesencephalon and the temporal horns of the lateral ventricle; view from the left side.
The sagittal section includes the Cerebellum and the Sulcus centra lis. A small part of the Cornu temporale of the lateral ventricle also lies within this sectional pia ne.
275
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Brain, MAl
Nucllua rentttormre
A. Clrellrt medii
fig. 12.110 Br1in, Encephelon; magnetic resonance tomographic image (MRI}; frontal section at the level of the anterior part of the third ventricle; anterior view. On the right side, the course af the A. cerebri media projecting towards
the Sulcus lateralis is visible. On both sides. the large gyri of the Lobus frontalis and Lobus temporalis are shown. Among the basal ganglia. this imaging technique allows the Nucleus caudatus, the Capsula interna, and the Nucleus lentiformis to be distinguished.
Ventrtauu 11111n111, Parecentnlle
Ccrpus nuclei ceucll1i
F1g. 12.111 Brarn, Encephalon; magnetic resonance tomographic image (MRII; frontal section at the level of the Thalamus; anterior view.
276
This image shows the Comu temporale of the lateral ventricles and the Hippocampus. Further cranial. the Pars cantralis of the lateral ventricle is imaged. In the midline from cranial to caudal, the Truncus corporis callosi, the Fornix, the Ventriculus tertius, the Fossa interpeduncularis of the brain~m. and the Pons can .be distinguished.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Brain, frontal sections Mougo auperlur A. CIIIDIIDmouglnalla A. Clrllbri antllriar, A. pericalllllll
Fig. 12.112 Bl'llln, Enc.phalon; frontal section at the level of the anterior parts of the fronta I horns of the lateral ventricles; posterior view.
Visible are the two Ventriculi laterales, above them the Corpus callosum, and lateral to them the Nucleus caudatus and the Putamen.
Cllpaula ~Crus anleltua
111r.;;-~~~.-r::==---=:o.;.,.q.-- Corpua calloaum,
Raorlrun
Cllpaula - . . . v; m«
~
Cllllema perlcalloA;
Cllltemo laml,_ termlnalla
Fig. 12.113 Br~~in, Encaphalon; frontal section at the level of the posterior parts of the frontal horns of the lateral ventricles; posterior view.
A. c:et~~bri Interior, Par& precam,...,icalis
Margo tll8romeclalll
Above the Ventriculi lateralss the Truncus of the Corpus callosum is discernible, lateral to the Ventriculi laterales lies the a~put of the Nucleus caudatus and the Putamen, and between them the Crus anterius of the Capsula interne is visible.
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277
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Brain, frontal sections Gyrua frontllls aupe!for
Gyyus chep.~ll GYM~ flonbllle medius
Fornix, Corpu•
Capallalnl11m11, Gan.o
capsule IIXIema
QyN& t.,pcnlia superior
------t---
r- r - - • : ;.
Gyrllr•ll• Olobul pelldus meclillil --k::---!1111~--:t~'--
Capsula exlr8ma
• .Aij~
CistemalosMe lalllllllls C«~~brl -t-~""':::-~--..:;......_...,.
G)'nl8 temporalla lnr.lor
Fig. 12.114 Bnlln, Enc..,halon; frontal section at the level of the Foramina interventricularia; posterior view. The pituitary gland is sectioned in the centre. Inferior to the Ventriculi
laterales the Caput of the Nucleus caudatus, the Capsula intema, the Globus pallidus, the Putamen, the Claustrum, and some Gyri insulae are visible.
Capsula exlr8ma
Gyrl ........
Ven111cukls tertklll ctaUIINm -...,z:::Q~
eyruo lllmparal• aupwtDr Glat>ua palldu• latsrallll
=f:~~==~::::;;:::=;;--
Giobua palldw medlllla G)'nl818mporall• medlua
Nuc18ua cauc111us, cauda Corpua ounygdalaldeum OyNs 1er!¥10r"lil inf«ior
TlllllamUII Gyru• acdpllotllmparalla meclllllla Qyrua pftlippociiTlpalla
F'11. 12.115 Bnlin. Enc..,halon; frontal section at the level of the Corpora mamillaria; posterior view. At the level of the Corpora mamillaria, the lumen of the third ventricle is
278
-+ dissection link
Clalllmalntarpedunculllrla
a.-. paniDC
located below the Ventriculi laterales. Lateral thereof from inside to outside lie the Thalamus, Capsula interns, Globus pallidus, Putamen, Capsula externa, Claustrum, Capsula extrema, and Gyri insulae.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Brain, frontal sections lndUiium griYum, Striae longltudhlllea medlolla at literal Ia
Fillaura longiluclnaia cnbri
Suk:cltll~··
COIPUI etltoeum, ~
_..,..=-.. .
lnaula[lobueln.,llrll) -4---..::.....~F Gy!w !en'f>ai'IIIIIUperiar _ _L::::""-!::~-"'IC CIIua!run --
Gyn.ta tmmpcnlle medlue
CO!PU8aen~llltum raterale --t~::::===7j~5~~p..-~ Nuele<.lt C«
Ve~lutlatenllle.
Comu !en1>01'11t Cily!usltmpcnllalnfellor
Nucle<.ltrublll'
~------~~====~~:::;;:~~~~~~~mma 8ulcua hypo1twllmk:ll•
7 1
G)'rllll oc:e~llotempords literals GyNa oc:elpllo~ralt medtalt GyNt plnhlppcal1'4:111t
Vantriculue111rt.._
<(
Med~tta oblong
Fig. 12.118 Brain, Encephalon; frontal section at the level of the central part of the third ventricle; posterior view. At this level, the right and left Thalamus are often cross-connected by
-~=:::-
'llw:tut P'1!11111kllllt
Pan a
a
the Adhesio interthalamica. Inferior to the Thalamus the Nucleus ruber is visible. The Pons and the Tractus pyramidalis present prominently in the brainstem.
Th~.. -,---------L--~~ Gy!w teqlaf'IIIIIUpellar Putamen ~umporalla medlue
NUCIIUI C*ICSIIIU8, Clwda
Fig. 12.117 Brain, Encephalon; frontal section at the level of the posterior wall of 1he third ventricle; posterior view. Inferior to the Ventriculi laterales a number of thalamic nuclei are visible
Fmblta hlppoc:ampr Vtnllfcu.._lllllnlit, Com.!ltmi)ONII
and further caudal the occipital part of the Hippocampus is shown. The brainstem has bean sectioned at the level of the Aqueductus mesencephali.
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279
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Brain, frontal sections
A. _..bri medii Cillllrnll fGaaM lateralis ctNilri
~--~~~~--~~----1-- FmbkH~~
Qyrus t~mporall& medius
CIBIBm• lllril!.1a CGicuUI auperiar Gyrua 141mporall8 lnl'wlor
Alveua hlppoc:ourfll Plexu& charaideul wntrlculllaterall8 ~ denl:al\l8
Qyrua parahl~a Gyruaaccl~rdolateralla ~ OQI:Ipllolemporalllo mediJII•
Fig. 12.111 Bnln, Enc..,halon; frontal section atthe level of the pineal gland and the fourth ventricle; posterior view. The Splenium of the Corpus callosum and the Glandula pinealis are displayed in the centre of the image. Lateral thereof the Colliculi supe-
riores and the PuMnar thalami are shown. The Pedunculi cerebella res s uperiores are visible in the lateraI bra instem slightly above the Ventriculus quartus.
Ca
,.,_------~-Ventrlcuklalaltrds,
Comu occipital&
Rg. 12.119 Brain, Encaphalon; frontal section at the level of the occipital horns of the lateral ventricles; posterior view.
280
-+ dissection link
The Nucleus dentatus and large parts of the Vermis cerebelli are discernible in the Cerebellum.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Brain, horizontal sections
A. lllnbrl.,lerlor, R. flllntalls poat.anedlallll
Sulc.. llllenlllll,
Asmus poelerlor
Fig. 12.120 Br11in, Encephalon: horizontal section just 9bove the Corpus callosum; superior vi9w. The brain has been sectioned immediately above the Corpus callosum. At this level, there are still no nuclei visible. In the broad band of white matter, fibres projecting from the Thalamus to th9 Cortex (Corona ra-
r -------_::__:::__ _l),_A. celllbrllllllertar, R. pr8QI'IMIS
diata) mix with commissural fibres of th9 Corpus c911osum connecting the two h9mispheres (Radiatio corporis callosi). In addition, fibre tracts converging on the Capsula interne contribute to the white matter (-.Figs. 12.74 to 12.76). Age-related atrophy of the brain makes the subarachnoid space appear wider (-. Figs. 12.1 21 to 12.1301.
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281
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Brain, horizontal sections
FIIIN'IllcrCt!Udlllllla cenlbn A. Cftbri antericr, A. celoecmiiJVi!ualia A. pellcalloq
Ventricukl•latenlla. Camu frattale
•:::----:7~L--l_Pf_ChQI'Oicj vt~rtrb111 lllerda
C
Sulcue pulllloocclpltllla
Fig. 12.12.1 B111ln., Enc.ph1lon; horizontal section at 1tle level of the central part of the lateral ventricles; superior view. The Septum pellucidum extends between the body and fornix (not visi· blel of the Corpus callosum and separates the Ventriculi laterales.
282
-+ dluactlon llnlc
Lateral to the Ventriculi laterales, the head and body of the Nucleus caudatus are sec1ioned. The Capsula intema is located lateral to the nucleus.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Brain, horizontal sections
A cerabll madill, Rr. tatm-
a ;:::--..;:::- - ---.jL
Plexus chCIRiid- wntrialli llltarallt
F
SUtc111 tlmpof'lllt tuper!Or
Fig. 12.122 Brain, EnCII'phalon; horizontal section at the level of the floor of the central part of the lateral ventricles; superior view. This central section shows parts of the Thalamus lateral to the Ventriculi latereles. Anterior end posterior to the Thalamus, the head and tail of the Nucleus ceudatus are visible. respectively. Lateral to the Thai~
mus, the Capsula interne, Putamen, Capsula externa, Claustrum, Capsula extrema, and Gyri insulae are arranged from medial to lateral. The genu of the Corpus cellosum locates to the anterior midline and its splenium is visible in the posterior midline.
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283
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Brain, horizontal sections
~-.....;.:
_ _ _ _,....:......_ _ _ _-:t-v.ntriCUtu. teiUue
iJt,"f;:-..;_---....1.:..-----~~- Rece&1lu8 MJJ)Nilinealis
~~~---~~----:~;t.~f:J~~~~~--------~H---v.r~amec.ab~ c.puar~..,.,
Rlldlatlo optk:41 Fmblla hlppotllll)l
Pltxllll ehOro~ Vll'lllblll latlralla
Carpua catkllum, Fcn:apa mljar
Fig. 12.123 Brain, Enc.,halan; horizontal section at the level of the upper pert of the third ventricle; superior view. In the centre! pert of the image, the Ventriculus tertius is shown, with parts of the Ventriculi laterales as well as the Genu and Splenium of the Corpus callosum depicted anterior and posterior of the Ventriculus tar-
284
-+ dluactlon llnlc
tius. Head and tail of the Nucleus caudatus, Thalamus, Putamen, and Claustrum constitute the cerebral nuclei. The Capsula intema with its characteristic genu runs in between the large nuclei. In addition, the Radiatio optica of the Capsula interne is visible.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Brain, horizontal sections
A. ce..tl~ ant.-tor, A. t:al~lftlllllnale A. Clnlbri antllrior, A. periCIIIola
Gyrua frarrtallo lnferlar lfllntrlcuhal-..lls, C....... fmntal•
C.peula lntema, Crus ant.lus
Clalolrum
Gynal tempgrde .uP«far Adheslo lm.1hallwnlca
--j:.
--;t""r-----l'F.......::.--~--~
()lobi pallldlllllldlalla et iablnol• Hypothallwnua
Tlwllamua
CommiNura pgiJieflor
Gyrustempcralla medius
Hatanula C.ptula ;,...,., Rediatio oplica
FlsaUIIIIongHudlnallt cenlbrl
Fig. 12.124 Brain, Encephelon; horizontal section through the centre of the third ventricle at the level of the Adhesio interthalamica; superior view. The section is centered through the Glandula pinealis and the Adhesio
interthalamica. Lateral thereof the Thalamus, Capsula interne, Globus pallidus, Putamen, Capsula extema, Claustrum, Capsula extrema, and the Lobus insularis are located. The Fimbria hippocampi, the Alveus hippocampi, and the Gyrus parahippocempalis are also discernible.
-+ dlsuctlon link
285
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Brain, horizontal sections
Fissura lllt'lgltlldln•llll ctnbt1 Aa. """'brl anlllrla188, /w.. perlciiiDIIU
Byrue tempanolle modue
\.oJt1!~~ ,,lb;;"="- - - -.....--J,-
Flntlrta hlppocempl Alvaue hiPfllll*"pl
Gyrua temparallll medius
F".g. 12.125 Brein, Encephalon; horizontal section through the third ventricle at the level of the opening of the cerebral aqueduct; superior view. Due to its reddish colouration,the Nucleus ruber prominently figures in this section plane. The close rela1ionship between the Nucleus cauda-
286
-+ dissection link
Phlxus chOrcideus ventrlcul lld:aral•
tus end Putamen also becomes obvious. The Crus anterius of the Capsula intema runs between both nuclear structures. The section is located at the transition from the third ventricle to the Aqueductus mesencephali, with both structures being sectioned. The upper rim of the Vermis cerebelli is sectioned as well.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Brain, horizontal sections
Hypothalamu• Fosu.lnllrptldunculluta Cifltai'M intarpect.l'lcullris
Subslantlll nlg111 A. Clllllbrt palllallar
FranuU.. ¥Ill madullluta ..pertart•
Allu111 langHudlnalla Clllllbrl
Fig. 12.126 Brain, Encephelon; staggered horizontal section through the floor of the third ventricIe at the IeveI of the Corpora mamillaria; superior view. The Tractus optici, the Hypothalami, the Corpora mamillaria, ttle Crura cerebri, the Nuclei rubri, and the Colliculi inferiores of the Tectum
mesencepheli ere sectioned. On the right side, the Hippocampus is visible. on the left side the grey and white matter of the temporal and occipital lobes are shown. Removal of the occipital pole on the right side allows an unobstructed view on the Hemispherium cerebelli.
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287
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
Brain, sagittal sections Pluus chomid-llllltrtculi ll.lllrlie
Sulc,. calcar1n,.
288
Fig. 12.127 Brain, Encephalon; sagittal section through the left hemisphere at the level of the head of the Nucleus caudatus; view from the left side. A paramedian section shows the Corpus callosum in its entire rostraoccipital dimension. The Ventriculus lateralis positions below the Cor-
pus callosum and, further below, the Nucleus caudatus, Thalamus, Capsula intema, and N. opticus [II] are located. The A. basilaris runs in front of the brainstem. The Pedunculus cerebellaris medius mar!(s the transition from the Pons to the Cerebellum.
Rg. 12.121 Brain, Encephalon; sagittal section through the left hemisphere at the level of the body of the Nucleus ceudatus; view from the Ieft side,
Apart from the body of the Nucleus caudatus, the Crus anterius of the
-+ dissection link
Capsula intema, the Thalamus, the Putamen, the Globus pallidus, and the Uncus of the Gyrus parahippocampalis have been sectioned. The Nucleus dentetus visualises prominently in the section plane through the Cerebellum.
Brain -+ Sections
-+
Cranial nerves
-+
Spinel cord
Brain, sagittal sections
Fig. 12.121 Br~~ln, Enuphalon; sagittal section 1hrough the left hemisphere at the level of the Corpus amygdaloideum; view from the left side.
This section reveals the Hippocampus, the Fimbria hippocampi, and the tail of the Nucleus caudatus posterior to the Corpus amygdaloideum. In addition, the Putamen, 1he Globus pallidus, and the Capsula interna are discernible. The inferior part of this section shows 1he Hemispherium cerebelli.
Emlnlllllla cclllllenllla
Fig. 12.130 Br~~in, Enuphalon: sagittal section 1hrough the left hemisphere at the level of the apex of the Cornu temporele of the Ventriculus lateralis; view from the left side.
This lateral section shows the Lobus insularis and includes the Hippocampus with the Gyrus parehippocampalis, the Claustrum, and the Putamen.
-+ dlsuctlon link
289
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Overview
N. olfactortua [I)
I
Fig. 12.131 Cranial nerves. Nn. craniaiK; functional overview of the Telencephalon. Cerebrum, brainstem, Truncus encephali. and Cerebellum; inferior view. Twelve pail"$ of cranial nerves exit the cranial base. They are numbered in Roman digits (I-XIII according to the order in which they exit the brainstem from anterior to posterior. The Fila olfactoria constitute the first cranial nerve, collectively named N. olfactorlus [1]. Through the fila, the bipolar olfactory neurons {an unnamed sensory ganglion is located within the olfactory mucosa} project into the Bulbus olfactorius, a part of the Telencephalon that was relocated cranially during development. Thus, the bulbus is the Nucleus terminationis for the N. olfacto-
290
rius (1), with the ext4lption that this nucleus does not reside in the brainstem but locates outside on the Lamina cribrosa. The fact that the neurons of the first cranial nerve are very short end the Nucleus terminationis resides outside of the breinstem are distinguishing features, separating the first from the other cranial nerves. The N. optfcut (II) is exceptional as it includes the 3"' and possibly 4111 neuron of the visual pathway. Contrary to all other cranial nerves, the optic nerve is a protru· sion of the Diencephalon and not actually a peripheral nerve.
Brain
-+
Sections
-+
Cranial nerves
-+
Spinal cord
Overview Overview of the'IWelve er.nlal Nerv• and their Mo.t lmporhlnt lnnervetlon Sites [141 A detailed presentation of the innervation sites for each cranial nerve is shown on pp. 296-323. GSA: general somatCHifferent; GSE: general somatc:H3fferent; GVA: general viscerCHifferent; GVE: general viscerc:H3fferent; SSA: specific somatCHifferent; SVA: specific viscerCHifferent; SVE: specific viscero-efferent Cranial Nerve
Quality
Important Innervation Sit•
N. olfactorius [I]
SSA
olfactory mucosa
N. opticus [Ill
SSA
retina
N. oculomotorius [Ill]
GSE, GVE
intra-<>eular and extra-ocular muscles
N. trochlearis [lVI
GSE
extra-<>eular muscles
SVE, GSA
masticatory muscles, facial skin
N. abducens [VII
GSE
extra-<>eular muscle
N. facialis [VIII
GVE, SVE, SVA, GSA
mimic muscles, gustato ry organ, glands
N. vestibulocochlearis lVIII]
SSA
equilibrium and hearing
N. glossopharyngeus IIXl
GVE,SVE,GSA,GVA,SVA
pharyngeal muscles, parotid gland
N. vagus [X]
GVE,SVE,GSA,GVA,SVA
pharyngeal muscles, larynx, inner organs
N. accessorius lXII
SVE
Mm. trapezius and st ernocleidomastoideus
N. hypoglossus lXIII
GSE
muscles of the tongue
N. trigeminus
M
Overview of Cranial Nerves with TWo or More Nuclei In the Brelnatem [141 The Nn. trochlearis IM, abducens lVII, accessorius [XI], and hypoglossus lXIII each possess only a single identically named nucleus and are therefore not mentioned here. Cranial Nerve
Corresponding Nuclei
N. oculomotorius [Ill]
• •
Nucleus nervi oculomotorii Nucleus accessorius nervi oculomotorii
• • • •
Nucleus motorius nervi trigemini Nucleus mesencephalicus nervi trigemini Nucleus pontinus (sensorius principalis) nervi trigemini Nucleus spinalis nervi trigemini
N. facialis lVIII
• • • •
Nucleus nervi facial is Nucleus salivatorius superior Nucleus spinalis nervi trigemini Nuclei tractus solitari i
N. vestibulocochlearis [VIII]
• •
Nuclei vestibulares Nuclei cochleares
N. glossopharyngeus [lXI
• • • •
Nucleus salivatorius inferior Nucleus ambiguus Nucleus spinalis nervi trigemini Nuclei tractus solitari i
N. vagus [X]
• • • •
Nucleus dorsalis nervi vagi Nucleus ambiguus Nucleus spinalis nervi trigemini Nuclei tractus solitari i
N. trigeminus
lVI
Overview of Nuclei In the Bralnatam with Dlvl8lona Al oated to TWo or Mora Cranial Nerv• [141 All other nuclei can be associated with a specific cranial nerve. Nucleus
Corresponding Cranial Nerve
Nucleus ambiguus
• • •
N. glossopharyngeus [lXI N. vagus [X] N. accessorius lXII (Radix cranialis)
Nuclei tractus solitarii
• • •
N. facia lis [VIII N. glossopharyngeus [lXI N. vagus [X]
Nucleus spinalis nervi trigemini
• • • •
N. N. N. N.
trigeminus M facia lis [VIII glossopharyngeus [lXI vagus [X]
291
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Topography
S~Uanlgra
Nu*'t"'*'
N. alldu_,• (VI]
:Jcf.::;J~;==::=:imt===~ earpu• ca~~oeum. Splllnlum
-----l
!::I~:::=:----7JfH+-----v. magnaceNbll
N. trfg.mlnut M - - - - -
.fto. .i ..._.L
TentCI'km cerwbelll-------'.:..:: N. fldd8 ( V I I ] - - - - -..;..:
GlancUaf*us.lla
N. -ubuloMoi!IHI'tiii,VIIIJ - - - - - -
N.
eloallopharvne•~.~~~ I.1X3 =====::::::::::::~~~~=~:::::; N. Y8fUII txJ N.a--'uaiXJl
1\lbe/l:lllum o.~~enm Medulla tPinallt
Flg. 12.132 CourM of the Cl'llnlal n..,.., Nn. cranl1lu, In the .ubarachnoid lfllce; posterior superior view from the left side; the left hemisphere of the Cerebrum end the Cerebellum as welles the Tentorium cerebelli have been removed. The cranial nerves III-XII exit the brainstem in chronological order from cranial to caudal. Some exit as a loose bundle of nerve roots and farm
292
-+ dluactlon llnlc
the actual cranial nerve IIX-XIIllater. The N. trochlearis IIVJ not only is the thinnest cranial nerve but also uniquely exi1s from the posterior side of the breinstem. The N. abducens lVII has the longest intradural course before exiting through its opening at the cranial bese.
1-+nsl
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Topography
Clatema ambllna;
PedunC\Auaanb~
N.II'OChleMIIM
------~~~
N. ophlhalmlccle (V/1] N. mllllll.rti(VIIJ
Fig. 12.133 Caurn of th• aanlal nM"Ws, Nn. cranfaiH, In th• middle cranlll fossa, Fossa aanlf medle; view from the right side. Large parts of the frontal and temporal lobes were removed to allow an unobstructed view on the cranial base below. The Cavum trigeminale !MECKEL's cave) has been opened. Located within is the Ganglion trigeminal• N. Ganglion semilunare, clinical term: Ganglion GASSER!).
with the three main branches of the N. trigeminus (N. ophthalmicus N/11. N. maxillaris IV/21. N. mandibularis IV/31). In addition to the N. trigeminus M. parts of the Nn. opticus [II), oculomotorius IIIII and trochlearis !lVI and arteries originating from the Pars cerebralis of the A. carotis intema {A. ophthalmica, A. cerebri anterior) are visible.
I~T581
N. ocllomnnf~~e [111]
(PI lea peii'Oellnoklla
anterio" N. trfgemln1n' (¥], Radix rnotarta
N.lbdueene (VI]
N. opfltNimie..e(V/1]
N. 11111111n lVI2l
N. fadalla (VII]
N. -ubulllcocb.._. (VJIIJ N. llla'ldlbulutll (VI.f.l
Rg. 12.134 Art•Jn and narvn In 1fl• teglan of the Salla turcica and the Sinus cavernasus; view from the right side. The Cavum trigeminale (MECKEL's cave) has been opened by removing the Dura mater cranialis and the Arachnoidea mater at this site. Visible is the Ganglion trigaminale f\1, Ganglion semilunare, clinical term: Ganglion GASSER!) with the three trigeminal nerve branches. In addition, the course of the cranial nerves Ill. IV. and VI to VIII from exiting
the brainstem to entering the cranial base is shown. The Pars cavemr> sa of the A. carotis intema transitions into the Pars cerebra lis wftich lies close to the N. opticus [II). The Chiasma opticum is located above the hypophyseal stalk !Infundibulum}.
293
Brain and Spinal Cord
General -+ Meninges and blood supply -+
Nuclei of the cranial nerves VIII
V. VII, IX. X
VII, DC, X
" - I l l , VII, IX. X V. VII, IX, X. XI
O&W
" ------111,11/,VI,lCJI
Fig. 12.135 Cranial nerw•. Nn. Cl"'lniaiM; schematic cross-section through the rhomboid fo888 demons1rating the nuclei. In the breinstem. nuclei wilh similar functions ere arranged in e column in e cranial to caudal direction. Due to spatial restrictions. the nuclei form four longitudinal nuclear columns and are arranged alongside
-
Oentnlaomllo-effiln!nt nuclei (GSE)
-
Oentnll ~~ro-.11--.t nuclei (GVE)
-
Spec~t~r: vtewo-~ nuelel ($VE)
-
Ganenll and apedllc vtewo-~ nucllll ~Aif!NA)
-
Oentnlaomllo...al'fen!nt nuclei (GSA)
-
Sl*lllt toml!o-aft'ftnt nuelel (SSAJ
each other. This includes in a mediaiU> lateral direction a somato-efferent. a viscer
Nuclaua ea!Mitariualnfarlor
ll.lclaua amblguua
Nuclaua aplnella nervi trigemini
F".g. 12.136 Craniel nerve., Nn. Cl"'lnialee; topographic overview of the nuclei; posterior view. With the exception of the cranial nerves I and II, all cranial nerves (IIIXII) have nuclei located in the brainstem. The Mesencephalon contains the nuclei of the cranial nerves Ill and IV, the nuclei of the cranial nerves V to VII lie in the Pons, and the Medulla oblongata contains the nuclei of the cranial nerves VII to XII. It is easy to understand the topographic arrangement of the nuclei of the cranial nerves if one keeps in mind the separation into functional
294
nuclear columns 1~ Fig. 12.135}. On the left side ere the nuclei of origin (Nuclei originisl which contain the perikarya of the efferent neurons projecting into the periphery. In the terminal nuclei (Nuclei terminati~ nes) on the right side, the afferent fibres derived from the periphery synapse onto the 2nd neuron of the sensory tract. • clinical term: Nucleus sensorius principalis nervi trigemini
I-+T571
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Nuclei of the cranial nerves
Nucleua motorta n.vt
iriaemini
Pane
N. faclalls[VIQ
N. veatibuiOcochlllrii[VIIO /
NuciiUitpiNIII 118M trftlmlnl
-
Gt!neraJ -.,llt01i'felwlt nuclei (QSE)
-
a-&111!~Nntnuclel (GVE)
-
SJ)ICiftc ~-e1'f'erant niiCiel (SVE)
-
Ganel'lll and •pecllle vlllc:IHo·afrerant nucla! (GVA/$1/A)
-
Gt!neraJ -.,llto-den!nt nuclei (QSA)
-
SJ)ICiftc semltlHIII'erant niiCiel (SSA)
Fig. 12.137 Cranial nerv•. Nn. cnmial•; topographic overview of the nuclei of the cranial nerves Ill to XII in the meclien plane. Nuclei of origin (Nuclei originisl with perikarya of the efferent/motor fibres divide into: • general somato-efferent nuclei (Nuclei nervi oculomotorii [Ill. extraocular muscles), trochlearis [IV, M. obliquus superior), abducens [VI, M. rectus lateralis), and hypoglossi lXII. muscles of the tongue)) • general viscera-efferent nuclei (Nuclei accessorius nervi oculomotorii [Ill, Mm. sphincter pupillae and ciliaris), salivatorius superior [VII, Glandulae aubmandibularia, sublingualis, lacrimalis, nasalas and palatinales), salivatorius inferior [IX, Glandula parotideal. dorsalis nervi vagi OC viscera)) • spacial viscera-efferent nuclei (Nuclei motorius nervi trigemini [V, masticatory muscles, muscles of the floor of the mouth), nervi fa. cialis [VII, mimic muscles), ambiguus [IX, X. Radix cranialis of XI, pharyngeal and laryngeal muscles] and Nucleus nervi accessorii lXI. Radix spinalis, shoulder muscles)}
Tenninal nuclei (Nuclei terminationes) are targeted by afferent/sensory fibres and divide into: • general viscero-afferant nuclei (Nuclei tractus solitarii, Pars inferior [IX. X. sensory innervation of smooth muscles (Viscera))) • special viscera-afferent nuclei (Nuclei tractus solitarii, Pars superior [VII, IX. X], taste fibres) • general somato-afferent nuclei !Nuclei mesencephalicus nervi trigemini IV, proprioception of maS1icatory muscles), pontinus lsensorius principalis) nervi trigemini [V, touch, vibration, position of temporomandibular joint), spinalis nervi trigemini IV, pain and temperature sensation in the heed region)} • special somato-afferent nuclei (Nuclei vestibulares superior, lateralis, medialis and inferior [VIII, vestibularis part equilibrium) as well as Nuclei cochleares anterior and posterior [VIII, cochlear part, hearing) • clinical term: Nucleus sensorius principalis nervi trigemini
I-+T&71 295
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
N. olfactorius [II
ArM llbciiiDaa; Gy!u• pwaorracto~ua
Gyrua plf8l8m'lillli&
S1rla o1111cto11a mlldlals
Nuclalla Olracta~ua ant.r1ar Dura mater crwlalll
ltl;on1111 arracto~. Tuberculum alfactrlrium
F'~g. 12.138 N. olfactoriu• [1], with olfactory nai'Vft. Nn. olfactorii (Fila olfactorial, and olfactory tract; view from the left side. Ar1 area of 3 cm2 of olfactory mucosa (Regio olfactoria) locates to both sides at the roof of the nasal cavity. It contains approximately 30 million receptor cells (olfactory sensory cells) which respond to chemical signals. These are bipolar neurons (olfactory neurons, 1st neuron, SSAI. On the one side, they connect with the outer environment and on the other side their &lWns form the Fila olfac:toria. The olfactory neurons have a short life span of 3o-60 days and are replaced by neuronal stem calls throughout life.
296
The Fila olfactoria are collectively named N. olfactorius 111. In each bulbus. they converge onto approximately 1000 glomeruli. From here. the olfactory information reaches different areas at the cranial base and the temporal lobe (primary olfactory cortical area) and, through direct and indirect connections, projects to secondary olfactory cortical areas and other brain regions, including the Hypothalamus. That way, the conscious realisation of olfactory stimuli and the connection with other sensory perceptions is accomplished. 1-+Tiila
I
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. olfactorius [I)
SlgnellnlnllcU::tlan In the BUbl..a all'actarl..
Periglam~n~lw cell
-
CillamefUI.. -
""""""- -......!.....l.........O:r-"\ .;....-- -
Fig. 12.139 Schem• of the pro)IC'tlans and synaptlc cannectlons of th• Fila olfactorfa; view from the left side. In each bulbus, all Fila olfactoria converge onto approximately 1000 glomeruli {in the figure two glomeruli are demonstrated as an example) which collectively form the Tractus olfactorius. Multiple synapses within 1he glomeruli finally converge on the mitral cell• (2nd neuron).
The axons of all neurons possessing the identical odorant receptor reach the glomerulus that is specific for each of the approximately 1000 different olfactory receptors. Mitral cells of the olfactory bulb project to diHerentareas at the cranial baseand the temporal lobe(... Fig. 12.138). Feedback mechanisms increase the discrimination of odorant stimuli and involve granular cells that connect back with different mitral cells.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Viral infections, chronic sinusitis, obstruction of the nasal passage to the olfactory mucosa, e.g. due to allergy, side effects of medication. brain tumour or head trauma with injury to the olfactory ner-
ves during their passage through the Lamina cribrosa, can result in hypoemla (decreased ability to perceive odours) or anoemla (inability to perceive odours).
297
tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General -+ Meninges and blood supply -+
N. opticus (II]
The centnl dllllt •pot .. the Mae'*tlutea The brightBr · - repr88tllt the man ocular flalcla of vlllan, YoMr8u the dll'br areu repment owr!lppl~ fltlda ol vlllon Eadl quadrant Ia depleted In a
4111'1rent eolo ur
Projection Into the left
Cotpua gena.larum
Outalde af the fO'IM e.nlnllla (mult~l&rod
cella converge ontx>on. rodb~lar
ca!O
,_
Outalcle af the cenlnllle (llf ......lof muiUpla cana e.JI9 convw;a ontoon&OnarOII-cona bipolar eel)
~
la.bnla
c:enlnllla 0n4Mdual
connactlan frama
cone cell1o anOn-or 011-eana bipolar etiO
Pro)llctlan hto tha right Lcbua ocdpltallt
r19. 12.140 Neuronal n.twork in 1tte retina, RIJtina. and the central vieuel trM;t; strongly simplified schematic representation. Cone cellt 11" neuron} direct the infonnation to cone blpoler cell• (2nd
represented by an intraretinal chain of three neurons only applies to cone cells (for rod cells~ Fig. 12.141 and textbooks of histology). For the central visual tract-. pages 131 end 132.
neuron) and ganglion celll (31<1 neuron). Horizontal and amacrine cells modify the processing of information. The axons of the ganglion cells form theN. opticus (II). The above-mentioned network of connections
298
tahir99-VRG & vip.persianss.ir
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. opticus
Fig. 12.141 N. optlcus Dll and v'lllual triCt. [23) The visual tract starts at the retina which contains the first three projection neurons and intemeurons {horizontal cells, amacrine cells! c~ Fig. 12.140>. Up to 40 rod cella transmit their signals to a single rod bipolar cell. From here, the information is transmitted indirectly through amacrine cells (depending on the literature, today there are 20 to 50 different types described) to ganglion c.llt. Thus. an intraretinel chain of four neurons exists for the rod calls. The axons of the ganglion cells 1'\ln in theN. opticus to the Chllama optlcum, where the
[II)
fibres of the nasal part of the retina cross to the opposite side (red). The fibres of the temporal part do not cross (green). Directly following the chiasma is the Tractus opticus which contains the fibres with visual information of the contralateral visual field. The major part of these fibres !Radix lateralis} synapse in the Corpus geniculatum laterale ICGU. Some fibres (Radix medialis) divert before reaching the CGL and project into the Area pretectalis. the Colliculus superior. and into the Hypothalamus. The GRAnOI..ET• optic radi.tion {Radiatio optical originates from the Corpus geniculatum laterale and projects into the region around the Sulcus calcarinus to the areas 17 and 18 of the cerebral cortex (Area striata).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . • Lesions of the N. opticus [II) anterior to the Chiasma opticum. e.g. caused bv traumatic head and/or brain injury, result in blindn&SS of the effected eye 1~ Fig. 12.141). • Laterallasions of theN. opticus [II) at the level of the Chiasma op. ticum (right nasal fibres have already crossed to the contralateral side), e.g. caused by a tumour, result in a right nasal hamlanop· 111 and quadrant anopsia of the left upper temporal quadrant 1~ Fig.12.1411. • Median lesions to the Chiasma opticum, mostly caused by pituitary tumours, result in a bitemporal hemianopsia 1-- Fig. 12.141 ).
• Lesions to the Trectus opticus on the right side las exemplified in the figure), e.g. caused by a bleeding, result in left-sided homonymous hemianopsia 1~ Fig. 12.141). • Lesions of the anterior portion of the optic radiation located in the temporal lobe on the right side (as exemplified in the figure), e.g. due to ischemia, cause anopsia of the left·sided upper quadrants c~ Fig. 12.1411. • Lesions to the entire right optic radiation {as exemplified in the figure), e.g. caused bv a mass bleeding, result in left·sided homonymous hemianopsia 1~ Fig. 12.141).
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tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
N. oculomotorius (Ill], N. trochlearis [IV], N. abducens (VI]
N. elln IOng~~t Gan~ion ciiu.
N. 811Ynoldalla pcetllllor Rlldbc - r i a [naeor:lllluft] gan;lllellllrl8 Radbc IIY"'JHdhlce
N. cphtti.lhllcu• [V/1)
ellllle
N. oc:WomG1:Grtue
1111]
N. tnlcHNrb [IV]
A. C411'01b G.tllma; Plsxua cetolicua lntl!lmus
N.llbd.-J• (VI]
N. mllldii!IM (VI2)
N. mandibullria [V/31
N. owomcto~us Dill. R. tlt91or
M. rec11.1a mediiIa
Fig. 12.142 Nn. oculomotorfus [1111, trochiNrfiiJVI •nd •bduc.ns ML lift siCS.; lateral view; or.bit opened, orbital fat body removed, the
M. rectus lateralis was sectioned close to its insertion and deflected. The N. oculomotorius IIIII innervates the extra-ocular muscles with the exception of the M. obliquus superior (N. trochlearis IIVJl and the M.
300
rectus laterelis (N. abducens tvm. The parasympathetic part of the cranial nerve Ill innervates the M. sphincter pupillae end theM. ciliaris (two intre
1-+ T 68c, d, f I
tahir99-VRG & vip.persianss.ir
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. oculomotorius [Ill], N. trochlearis (IV], N. abducens (VI]
N. clllllla langua
Nn. l;lllllree ~
Raclx J¥1'pelhlca 9111911 ell lelia
N. 0Qlfomo1o!M (IIQ, R. auperiOt
N. ophtl\llm~a[V/1)
N•..._na[VI'J Radix pensaympelhlce. (oculamotaria] 91'1Q111 ella ria
N. ac'*'maiDII~a ~IQ, R. lnla>lcr
-
El'lelwlt
-
Sympathetic nt~tw
Fig. 12.143 Fibre qualltln of the Nn. oculomotorlus [1111, trochl11rls !M, and llldue~~ns ML left sldl; lateral view. The N. oculomotorlus [Ill] contains motor fibres !GSEl derived from the Nucleus nervi oculomotorii for the major part of extra-ocular mu9cles. In 1he orbit, the nerve divides into a R. superior to innervate the Mm. rectus superior and levator palpebrae superioris eno a R. inferior for the innervation of the Mm. ree1us medialis, rectus inferior, ano obliquus inferior. The Nucleus accessorius nervi oculomotorii (EDINGERWESTPHAL) contributes parasympaltletic fibres (GVE l which reach 1he Ganglion ciliare 1hrough the R. inferior as well as a Radix parasympathica loculomotoriaJ. In the Ganglion ciliara, pre911nglionic parasympathetic
fibres synapse onto postganglionic neurons. The postganglionic fibres project alongside the Nn. ciliares breves to the Bulbus oculi, traverse its wall, and reach the intra-ocular Mm. ciliaris and sphincter pupillae. The N. 17ochleariaiiVJ contains motor fibres (GSEI for the M. obliquus superior from the Nucleus nervi trochlearis in the brainstem. The N. abducena Ml contains motor fibres IGSEI from the Nucleus nervi abducentis for the M. rectus lateralis. • EDINGER.WESTPHAL nucleus
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Letiona of individual craniel narvet thn innarv.t. extra-ocular muteln lead to the paralysis of the corresponding extraocular mu9cles with resulting deviations of the eyeballs. The direction and extent of this deviation of the eye depends on the stronger action of the still intact extra-orbital muscles !and corresponding intact cranial nervelsll as opposed to the paralysed muscle(sl. For more details ... page 113.
A complete oculomotor narve parnia results in Ptosis, mydriasis. the inability to accommodate, and a bulbus pointing down and outwards {down and out). An abdue~~ns nerve p1rllls is panicularly frequent due to the long extradural course of the N. abducens lVII and its passage through the Sinus cavernosus. When the patient is asked to move the affected eye 10 the temporal side, the bulbus remains pointing straight ahead since the M. rectus lateralis is paralysed.
301
tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General
N. trigeminus (V]
N. nuacll l l a
A. menlngeus ...wm~na [R. lllnta!YI)
-+
Meninges and blood supply
-+
N. apMI\IIImiCUI
[V/1)
Ganglion 111geml"* Rr. temparale8 tupe!\'lclll. .
N.IIIQ'tnals
Radix 88necrif. [neeacililrie] OIIIIOii cililri&
N. lrigeminua M
N.maxllllllla~12]::-::~:f~t~~=rr~== ~!:===~~~~~;;::::
R. zygometicotemponalis A. menlngeus
R.~~~~~~:::::;~zj~~~==!!~==-----;~
N.~omeue:~==-========~~~~~~========~~~~~~
N. flci8l i& l\1 0
N. c.wll8 plef)'galdelN.lhfntarbltJ!Ia
Gqion
pterygapallltfn~n~
Rr.nuale8
Chorda tympani
paeteriOAIS MJperiota; N. nucp.lllllnUa
Rr. ~ tulHI!IaNII
Nn. !tmpa1111ee Jlfl)lllndl N. maatua 8CUlltlcl exleml,
Nn. aurlc:UaNSan1811oNS
Rr. parotldel; Rr. ccmmunieanter. a.m ntNi facilli
N. muKCJII terwarla veil pelll1fnl; N. ptarygOICIIIIIS mlldllllt
N. mandlbUlltie
[Vf.!l
N. a!Yeollult tlfwlor
N. llnQUIIII
Fig. 12.144 N. trfg1mtnus (V], 11ft side; lateral view. The trigeminal nerve lVI is 1he nerve of the first pharyngeal arch and divides into the 1hree main branches: Nn. ophthalmicus IV/1) (bright green}, maxillaris IV!ll (orange), and mandibularis IVfJI (turquoise). It mainly carries general somet~>efferent IGSAJ fibres. some special vi&cero-efferent (SVEI fibres. and motor fibres (VfJJ. Th& N. ophthllmlcut(V/1] innervates the eye (including oorn&a and oonjunctiva}, the skin of the upper eyelid, forehead, back of the nose, the nasal and paranasal muoosa. Parasympathetic fibres innervate the lacrimal gland and associate with the peripheral course of the N. ophthalmicus IV/11. The N. maxill1ril [V/2] innervates the skin of the anterior temporal region end the upper cheek as well as the skin below 1he eye. In addi-
302
tion, this nerve provides sensory fibres to the palate, the tee1h of the upper jaw, the gingiva, and the mucosa of the Sinus maxillaris. TheN. m1ndibularil [V/3) innervates the masticatory muscles, two muscles at 1he floor of the mouth (M. mylohyoideus and Venter anterior of the M. digastricus}. as well as the Mm. tensor veli palatini anci tensor tympani. It also contributes sensory branches to the skin of the posterior t&mporal region, the cheek, and the chin, and innervates the teeth and gingiva of the lower jaw. Parasympathetic fibres for the large salivary glands as well as taste fibres for the tongue associate with branches of the N. mandibularis IV/31. The latter also provides sensory fibres for the anterior two-thirds of the tongue.
I-+T58•1 tahir99-VRG & vip.persianss.ir
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. trigeminus
[VJ
N.tr!gemiiUIM
--------Tractuaeteplnallll NU~*'-
neNI trigemini
N. menclbiMIII LVI3l
Fig. 12.145 Fibre qu1lltles of th1 N.1r1gemlnus lVJ, lift side; lateral view. Nuclei of origin and terminal nuclei of the N. trigeminus M are the Nucleus masencephalicus nervi trigemini (somato-sensory), the Nucleus pontinus (sensorius principalis) nervi trigemini (somato-sensory). the Nucleus spinalis nervi trigemini (general somato-afferent. GSA!. and the Nucleus motorius nervi trigemini (specific viscero-efferant, SVE). The N. trigeminus lVI consists of a Aedlx sensorf1 (Portio major) and a
-
Efferent (moto" fibte&
-
AITftnt (ttneor)') flbm
-
P.uympalheli: flbree
Radix motorl1 (Portio minor). After exiting the Pons, the trigeminal nerve passes over the Clivus and reaches the Ganglion trigeminale (Ganglion semilunar&, clinical term: Ganglion GASSER!, contains pseudCHAnipolar neurons which provide the Nuclei pontinus and spinalis nervi trigemini with protopathic and epicritic sensory stimuli) and divides into its three main branc:has Nn. ophthalmic:us IV/11. maxillaris IV/21. and mandibularis [V/3).
303
tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General
-+
Meninges and blood supply -+
N. trigeminus [V] Branchea of the N. ophhlrn~ IV/1 J (exclusively 10mllto-effwent) Main Branch
Minor Branches
R. meningeus recurrens [R. tentorius] N. frontalis
parts of the meninges
N supraorbitalis
skin of forehead and mucosa of the frontal sinus
No supratrochlearis
skin and conjunctiva at the nasal canthus
0
lacrimal gland (postganglionic parasympathetic fibres from the No zygomaticus for secretory innervation associate with the No lacrimalis). skin and connective tissue of the nasal canthus
No lacrimalis
No nasociliaris
Innervation Area
(-+Table below)
nasal sinuses, anterior part of the nasa I cavity and iris, Corpus ciliare, cornea of the eye (-+Table below)
Branch• of thaN. naoc:IU.rls (from V/11 [141 Branch
Couru
Innervation Am
Radix sensoria ganglii cilaris [Ro communicans cum ganglio ci liaril
contributes the sensory component for the Ganglion ciliare which generates the Nn ci liares breves
Bulbus oculi and its conjunctiva (jointly with the Nno ciliares longi]
Nno ciliares longi
associate with the No opticus and course with the Nno ci liares breves from the Ganglion ciliare to the Bulbus oculi; they also contain sympathetic fibres from the Plexus caroticus
Bulbus oculi and its conjunctiva; the sympat hetic f ibres innervate the Mo dilatator pupillae
No ethmoidalis posterior
passes through the identically named foramen to reach the posterior ethmoidal cells and the sphenoidal sinus
mucosa of the posterior ethmoidal cells and the sphenoidal sin us
No ethmoidalis anterior
passes through the identically named foramen back into the anterior cranial fossa, courses through the Lamina cribrosa into the nasa I cavity; ends in the Rro nasales externi in the skin of the dorsum of the nose
mucosa of the anterior nasal cavity and the anterior ethmoidal ce lis, skin of the dorsum of the nose
No infratrochlearis
courses to the nasal canthus inferior to the Trochlea
skin of the nasal canthus
0
Branch• of tha N. rnaxlllarls IV/2] (exclusively somato-affanntl Main Branch
Minor Branches
Ro meningeus No zygomaticus
304
Innervation Am parts of the meninges
Ro zygomaticotemporal is
skin of the temporsl region
Ro zygomaticofacialis
skin of the upper cheek region; for the secretory in nervat ion of the lacrimal gland, postganglionic parasympathetic fibres associate with the No zygomaticus which contributes to the No lacrimalis
Rro ganglionares ad ganglion pterygopalatin urn
(-+Table, at top of Po 305)
contribute sensory f ibres for the Ganglion pterygopalat inum , innervat ion of palate and nose(-+ Table at top of po 305), sympathetic and parasympathetic fibres for the Glandulae nasales and palatinae (special viscero-ilfferent) and taste fibres
No infraorbitalis
N n. a lveolares superiores with Rr. alveolares superiores posteriores, medii and anteriores
mucosa of the maxillary sin us. teeth of the upper jaw and corresponding gingiva
with
skin and Conjunctiva of the lower eyelid, lateral skin area of the nasal wings, skin of upper lip and lateral cheek region between lower eyelid and upper lip
tahir99-VRG & vip.persianss.ir
Brain
-+
Sections
-+
Cranial nerves
-+
Spinal cord
N. trigeminus lVI Branches of the Rr. ganglonares ad ganglion pterygop8latlnum !from V/21 [141 Branch
CourM
Innervation Area
N. palatinus major
passes across the Canalis palatinus major and through the Foramen palatinum majus
mucosa of the hard palate, Glandulae palatinae, palat ine tast e buds
Nn. palatini minores
exit the Canalis palatinus major through the Foramina pa latina minora
mucosa of the soft palate, Tonsilla palatine, Glandulae palatinae, palatine taste buds
Rr. nasales posteriores superiores laterales et mediales
pass through the Foramen sphenopalatinum into the nasal cavity and branch off the N. nasopalati nus which reaches the hard palate through the Canalis incisivus
mucosa of the nasal conchae. nasal sept um. mucosa of the anterior part of the hard palate, upper incisors and Gingiva, Glandulae nasales
Branches of the N. manclbul8rls IV131 (somato-.tf..m and vlscenHfferentl Main Branch
Minor Branches
Innervation Area
R. meningeus
parts of the meninges
N. massetericus
M. masseter
Nn. temporales profundi
M. temporalis
N. pterygoideus lateralis
M. pterygoideus lateralis
N. pterygoideus medialis
M. pterygoideus medialis
N. musculi tensoris veli palatini
M. tensor veli pa latin i
N. musculi tensoris tympani
M. tensor tympani
N. buccalis
skin and mucosa of the cheek and gingiva of t he lower jaw
N. auriculotemporalis
N. lingualis
Rr. parotidei
associated postganglionic parasympathetic fibres from the Ganglion oticum innervate the parotid gland
Rr. communicantes cum nervo facia li
associated postganglionic parasympathetic fi bres from the Ganglion oticum innervate the parotid gland
N. meatus acustici externi
external acoustic meatus. tympanic membrane
Nn. auriculares anteriores
skin anterior to the auricle
Nn. temporales superficiales
skin of the posterior temporal reg ion
Rr. isthmi faucium
mucosa of the soft palate
N. sublingualis
mucosa of the floor of the mouth sensory in nervation of the ant erior two-th irds of the tongue, taste fibres of the anterior two-thirds of t he tongue, association of preganglionic parasympathetic fibres derived from the Chorda tympani for the Ganglion submandibulare
N. alveolaris inferior
teeth and Gingiva of the lower jaw N. mylohyoideus
M. mylohyoideus and Venter ant erior of t he M. digastricus
N. mentalis
skin of the chin
305
tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
N. trigeminus lVJ
rtg.
12.146 Innervation ere• of the facial ekin, exit point. for nervee, encl protopathic Mnsibility. On the left side of the face, 1he somatotopic order of the protopathic sensibility is demonstrated. The right side of the face shows the innervation areas and exit points for the three branches of the trigeminal nerve.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Often IMio.,. of the N. trigeminue M are associated with deficiencies in blood supply, with selective or partial nuclear areas rather than the complete N. trigeminus lVI being affected. These lesions can for example manifest as an ipsilateral palsy of the masticatory muscles or a selective loss of the epicritic sensory quality. The afferent fibres with protopathic sensibility reach the Nucleus spinalis
nervi trigemini in e somatotopic order<~ Fig. 12.146). A defined segment of the Nucleus spinalis nervi trigemini innervates a concentric area of the facial skin. To assess the extent of a nuclear lesion, one can test the protopathic sensibility along the concentric SOELDER's
lln11.
Fig. 12.147 Zoltln ophthalmlcul.(161 Patient with Zoster ophthalmicus (skin in the innervation area of the first trigeminal branch is affected by the infection with varicella zoster virus, facial herpes zoster). The involvement of the suriace epithelium of the eve !Cornea and Conjunctiva) is particularly dangerous (risk of blindness) and painful. The redness of the conjunctiva and the narrowing of the eyelids are clearly visible.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Loss of sensibility in the innervation area of a trigeminal branch suggests a perlpheraiiHion of the nerve. For theN. ophthalmicus IV/1 I and the N. maxillaris IV/21 potential causes are a cavernous sinus thrombosis (-> p. 223), tumours of the cranial base, and skull fractures. Sensory deficiencies in the region of the mandible or paralysis of masticatory muscles often have an iatrogenic cause (dental work}. The frequent end still not fully understood 1rigeminal neun~lgia presents with hypersensitivity of the N. trigeminus M end paroxysmal
306
episodes of intense. stabbing pain in the sensory innervation area of the affected trigeminal branch. Even light touch of the area of the corresponding exit point of the branch (-> Fig. 12.146) can trigger pain. Infections of the first trigeminal branch by varicella zoster virus (~ Fig. 12.1471 can cause a post-zoster neuralgia of theN. ophthalmicus IV/1 I, known as hiiJIM zolter oplrthalmicu..
tahir99-VRG & vip.persianss.ir
Brain
-+
Sections
-+
Cranial nerves
-+
Spinal cord
N. facialis [VII]
Oenglian gericui
N.ltapedll.-
N. facllllai,VII]
Tube. auditMI [lud~Orit.l, --~IP"Ji
PantA. Cll'Citis intima
M. cigatricul, Vent• poetlriar
Fig. 12.148 Cour... of 1he N. facial it [VII]; vertical section through 1he Canalis fecialis; view from the left side. Approximately 1 em after the N. faeialis [VIII enters the petrosal part of 1he temporal bone through the Porus aeustieus intamus (not shown), the nerve makes a sharp bend, mown as the external genu of the facial nerve. Here, the Ganglion geniculi is located. The main stem of the
facial nerve runs within a bony canal towards the Foramen stylomastoideum. Along its wav through the petrous bone, theN. facialis [VII) releases the Nn. patrosus major, stapedius. and the Chorda tympani (-+Table, p. 31 0).
I-+T58g
I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . The close topographic relationship between the Cenalis facialis and the tympanic cavity puts the N. facialis [VII) at risk during petrous bone fractures. micldle ear ancl mastoid infections, and surgical interventions involving the middle and inner ear. The symptoms depend on the location of the lesion. Lulons loc.rted close to or Interior to 1fle G1ngllon genlcull result in paralysis of all mimic muscles. Furthermore. the M. stapedius is paralysed {hyparacusisl and gustatory impairment diminished tear production as wall as reduced nasal and salivary secretion occur. If the INion loc.atN below the br•nching point of 1tte N . diu1, paralysis of the mimic muscles occurs and the Chorda tympani
.w.,.
fibres for taste and glandular secretion are affected. Isolated injury to the Chorda tympani is possible during middle ear infections (-+ p. 147) or surgical procedures conducted in the middle and inner ear because of its unprotected course between the Malleus and Incus in the tympanic cavity of the middle ear. The biggest problem in patients with peripheral facial palsy is l1gophth1lmos (due to the paralysis of theM. orbicularis oculi, the eve cannot be closed properly; .... Fig. 12.151cl causing the cornea to dry out (blindness due to lack of blinking end reduced production of lacrimal fluid).
307
tahir99-VRG & vip.persianss.ir
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
N. facialis [VII) N. peti'OSIIII prol\llldi!S (PIIIM euoUc~~S lntsn'l.lll) N. pe!tOeUII m.tjor
N. C~llllllls pttl'ygolcMI\ Ganglion ptaf'YQDfllllill1lnunn\
Mm.aurlci.IIINII '1111nnlnll motor illnllot... 1 Rr. teqlaralee 2 Rr. zygomatlcl 3 Rr. bUCCllilllf; 4 Rr. m.Wnalee nwndlbulae 6 Rr. com
Fig. 12.149 N. &ci•li• [VIIL left •ide; lateral view. TheN. fec:ialis [VII), theN. intermedius (a part of theN. facialisiVIII but often viewed as a separate nerve), and the N. vestibulocochlearis [VIII) jointly exit the cerebellopontine angle. Shortly thereafter, the N. intermedius and N. fac:ialis lVIII unite. TheN. facialis lVIII and N. vestibuloc:ochlearis lVII II project towards the petrous pert of the temporal bone and enter the bone through the Porus and the Meatus acusticus internus. Upon release of the Nn. cochlearis and vestibularis, the N. facialis lVIII enters the Canalis facialis ,... also Fig. 12.153). Here the facial nerve makes a posterior inferior tum in an almost right angle {extemal
308
genu of the facial nerve;~ Fig. 12.148}. The Ganglion geniculi is located just prior to the location of the tum of the facial nerve. Along its course within the Canalis facialis, this cranial nerve provides a number of branches(-> Table, p. 31 0). Upon exiting the cranial base through the Foramen stylomastoideum, the facial nerve tums rostral, provides addi· tional branches, and then enters the Glandula parotidea. Here, the nerve divides into its terminal motor branches (Plexus intraparotideus; ... Table, p. 310). I-+T68g
I
tahir99-VRG & vip.persianss.ir
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. facialis [VII)
N. e8111111a PltfYOOidiiii/IDIANUS]
NUI:Ieu. nervi facials
NUI:Ieus trattua aollw11
Nuclllua aplnalla neNI llfgamtll
--
El!--.t {Motcrl nbNI El!_._t {Mm10ry) nm.
Sptn«~nm. ~tlllcflbtw
Plii'UymPf,tl!ttic fi:uw
Fig. 12.150 Fibre qulliti• of th N. f1ci1lil [VII], lift 1id1; lateral view. The N. facialis [VII) is the nerve of the second pharyngeal arch and has several different fibre qualities. Its motor flbrH !special viscero-efferent, SVEl derive from the Nu· cl1u1 nll"fl flcl1ll1. These fibers course around the Nucleus nervi abducentis in a posterior arch (internal genu of the facial nerve). The upper pert of the nucleus contains the neurons for the innervation of the mimetic muscles for the forehead and external orbit, whereas the lower part of the nucleus harbours the neurons innervating all mimic muscles located below the eye. The upper nuclear portion receives double innervation from both cortical hemispheres (~ Fig. 12.152). Thus, it receives corticonuclear fibres from the ipsilateral and contralateral sides. By contrast, 1he lower portion of the Nucleus nervi facia lis exclusively receives corticonuclear fibres from the contralateral sides. Pragangllonfe Pllrnympatllltlc flbrH derive from the Nucl1us ull· vatoriu1 IUperior {general viscera-efferent, GVE). They run with the intermedius part across the N. facialis [VII), course via the N. petrosus
major to the Ganglion pterygopalatinum or associate with the Chorda tympani and reach the Ganglion submandibulare via the N. lingualis (from V/3). Synapsing onto the postganglionic fibres occurs in 1hese ganglia. These postg1ngflonlc flbriS proj~M!t into the lacrimal, nasal and palatine glands, and into the Glandulae sublingualis and submandibularis (~ N. trigeminus M.p. 302!. Special viscero-efferent (SVA! fibres of the anterior two-thirds of the tongue for the perception of taste project into the upper part of the NuciiUI1nctu•IOiiblni. These fibres reach the N. facialis lVIII via the N. linguelis and Chorda tympani and then enter the brainstem. General somat
309
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
N. facialis [VII) Branch• of the N. fllciali• Mil [28) Branch
CourM
Innervation Are.
N. petrosus major [Radix parasympathica pterygopalatini)
exits the facial nerve at the external genu of the N. facialis lVIII end courses through the canalis nervi r:uwosi majoris into the middle cranial fossa; passes through the Foramen lacerum to enter the Canalis pterygoideus. Here, it forms the N. cenalis pterygoidei together with the sympathetic N. petrosus profundus, which then projects to the Ganglion pterygopalatinum {synapses of parasympathetic fibres)
GVE (vie branches of the N. maxillaris IV/2)): Glandulae lacrimalis. nasales. palatinae, pharyngeales SVA {via branches of the N. mandibularis IVfJ)): taste buds of the palate
N. stapedius
exits in the lower part of the Canalis facia lis
SVE: M. stapedius
Chorda tympani
shortly before the distal end of the Canalis facial is it engages in a retrograde course through its own bony cenal to enter the tympanic cavity, which it traverses freely between Manubrium mallei end Crus longum of the incus behind the tympanic membrane; after passing through the Fissura petrotympanica, it associates with the N. lingualis (from VfJJ
GVE (via the N.lingualis, synapsing in the Ganglion submandibularel: Glandulae submandibularis end sublinguelis SVA {via N. lingualis): anterior two-thirds of the tongue
N. auricularis posterior
branches off shortly after exiting the Canalis facialis
SVE: M. occipitofrontalis, muscles of the outer ear
R. digastricus and R. stylohyoideus
small branches to the muscles
SVE: M. digastricus. Venter posterior.
Plexus intraparotideus
branches with motor fibres to the mimic muscles divide the Glandula parotidea into a Pars temporofacialis and a Pars cervicofacialis; these motor branches subdivide into five terminal branches: Rr. temporales. Rr. :zygomatici, Rr. buccales. Rr. marginales mandibulae, R. colli (or Rr. colli, ~Fig. 8.81)
•
M. stylohyoideus
b
Figs. 12.151a to e Peripheral paralysis of the N. fadalls (VII], right side. a Admission status of the patient. Skin folds on the right side of the face have disappeared. b When the patient is asked to raise the eyebrows, only the left side of the forehead displays wrinkles (paralysis of the M. occipitofrontalis. evidence for a peripheral facial palsy). e When the patient is asked to shut both eyes. this is not accomplished at the side of the damaged facial nerve (lagophthalmos).
d
SVE: mimic muscles, including
M. buccinator and platysma
•
When eyelids are closed, the eyeball automatically turns upwards. Due to the inability to close the eye properly, the white sclera of the eye becomes visible at the side of facial palsy {BELL's phenomenon). d When the patient is asked to wrinkle his nose this is impossible on the right side of the face. e When the patient is eskeci to whistle. no tone is produced but the air escapes through the lips at the paralysed side.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Central tacl•l pal.-y (also named lower facial palsy) is caused by a eupranuclaar l11lon (lesion of the coniconuclearfibras, e.g. through infarction in the Capsula intema). In contrast to an intranuclear lesion and due to the .bilateral innervation of the mimic muscles of the eye and forehead, only the lower contralateral part of the face displays motor defects(-+ Fig. 12.152). An intranuclear l11ion {inferior to the facial nucleus), e.g. ceused by a malignant parotid tumour. results in the paralysis of all motor
310
branches of theN. facialis [VIII on the affected side (p1rlph1ral,... dalpal.-y). An acou111cus n•urfnoma (~ p. 313) derives from SCHWANN's cells of the N. vestibulocochlearis lVIII) or the N. facialis lVII). Sooner or later, this slowly growing benign tumour will displace end damage both nerves. A peripheral facial palsy results and ell topodiagnostic tests(~ p. 311) are negative. The diagnosis is concluded by MRI or CT imaging.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. facialis [VII)
Nucleua nenol facial ill _..~~-To-- Ganglion genlcull
~7'i\'~___;~-N. aapediU8
N. feci lit IVlO
Fig. 12.152 CorticonudHr conneetioM and peripheral courH of theN. facialil Mil. (according to [2)) On the left side, the oentral connections to the Nucleus nervi facielis are shown in a simplified schematic representation. The corticonuclear tracts to the upper part of the nucleus (for Rr. temporales; green) derive
from both hemispheres. The lower part of the nucleus (for Rr. zygomatici, buoceles, marginales mandibulee, and R. colli} connec1s exclusively with the conttaleteral hemisphere {red). On the right side. the peripheral efferent fibres (SVEI derived from the upper and lower part of the Nucleus nervi facialis are shown.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - . Loc.ll:urtfon of the Lulon In Peripheral Feclal Palsy With the advent of modem high resolution imaging procedures, the importanoe of classical topodiagnostic procedures has diminished because of their unspecific and low prognostic value when compared to electrodiagnostic procedures. However. the individual test has clinical relevance. • The SCHIRMER's test provides information about the normal pre> duction of lacrimal fluid 1- Fig. 9.27).
• The stapedius reflex test determines the function of theN. stapedius. • Gustometry (testing teste perception) assesses the functionality and intactness of the Chorda tympani. • Nerve excitability tests allow the electrical stimulation of mimic muscles. • The difference of the conduction velocity of electrical potentials on the healthy and damaged side is determined by electrone.r rography.
Sit• af the Lulan
Topodl..naslle Procedure
ea... of Leslan
inferior to the nuclear area within the brain stem
MRI, CT. SCHIRMER's test !functional test for the lacrimal gland)
e.g. acousticus neurinoma
after N. petrosus major has branched off
stapedius reflex test
e.g. otitis media
after Chorda tympani has branched off
gustometry !testing taste perception)
e.g. otitis media
after passing through the Foramen stylomastoideum
testing facial motor functions
e.g. malignant parotid tumour
311
Brain and Spinal Cord
General
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Meninges and blood supply
-+
N. vestibulocochlearis [VIII]
N. pelnlaua mljar [Radix ptu•ympathlca genglll pletygap.llttllr.l]
Fig. 12.153 N. vntlbulocochlurll lVIIIJ, course In th• Pars p.trosa of th• Os t•mporaa.; superior view; the Pars petrosa has been opened. The N. cochluril is composed of nerve fibres generated in the organ of CORTI of the cochlea. The perikarya of these fibres ere loc:eted in the Ganglion spirale cochleae within the modiolus (bipolar neurons) and the central axons form the N. cochlearis. The vestibular organ also possesses bipolar neurons. Like the cochlear neurons, they receive sensory input from hair cells. Their perikarya reside in the Ganglion ves· tibulare which is located at the floor of the internal acoustic meatus. The central neuronal projections form the N. wltlbularll. The nerve
312
merges wiltl theN. coc:hlearis to form theN. vestibulocochlearis lVIII) !clinically frequently referred to as N. statoacuS1icusl at the Meatus acusticus internus and enters the brainstem at the cerebellopontine angle. Also demonstrated is the course of the N. facialis lVIII in the internal acoustic meatus and the Canalis facialis. In aclclition, the Ganglion geniculi, the separation of the N. petrosus major and the course of the N. facialis (VII) in the tympanic cavity are shown. The Chorda tympani runs between the Malleus and the Incus.
1-+T&ah
I
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. vestibulocochlearis [VIlli
N. Wlllllbul1rla, Plrs lnfellor
Nuclau. Wlllllbutlria lnfllllar [ROLLER)
Fig. 12.154 Fibre qu1lltln of th• N. vntlbulocar.:hiNrlt MIIJ; superior view; Pars petrosa of the Os temp orale has been opened. The inner hair cells of the organ of CORTI and hair cells of the semicircular canals as well as utricle and aaccule of the vestibular apparatus transmit sensory information to the specific somata-afferent neuronal fibres (SSAI. These fibres constitute the peripheral projections of bipolar neurons (1a neuron of the central auditory and vestibular tracts). The perikarya of these bipolar neurons reside in the Ganglion spirale cochleae and the Ganglion vestibulare, respectively. The centrll praflc>o
t1ons of the G1ngl1on t~~lrall merge to form theN. cochlllrls, course through the internal acoustic meatus, and reach the brainstem via the cerebellopontine angle. Here they connect with the Nuclei cochleares anterior and posterior. The central projection• of the 1wt n1uron of the v.-tibul1r tract ISSA) form the N. v1ttibular~ and also pass through the cerebellopontine angle into the Medulla oblongata. Here they project to the Nuclei vestibulares medialis (SCHWALBE). superior IBECHTEREWl. inferior {ROLLER), and lateralis (DEITERS).
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A sudden decrease in hearing, tinnitus, disturbances in balance, and vertigo can all be the first signs of an acoustlcus n1urfnoma. This is a benign tumour composed of connective and neuronal tissues. In most cases, the tumour derives from SCHWANN's cells of the vestibular part of the N. vestibulocochlearis lVII II {vNtibularia
sr.:hwannom1) and locates in the cerebellopontine angle or the internal acoustic meatus. In 5% of cases, the acousticus neurinoma occurs bilaterally. Due to the joint course with the N. facialis lVIII. a peripheral facial palsy can result.
313
Brain and Spinal Cord
General
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Meninges and blood supply
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N. glossopharyngeus [IX]
PI8XIIt t)'mpanlc:llt
c.vttu tyn.,.-.1 N. carotlcotympanlo..- (PI- carol~ trt:emus)
N. petroNI prolluldut [Raclx tYmP«lhk:41 QIIUlllll ptai)'IICipQIUnl]\
-~------ fo1811'11!njU!91Mre
..._;_...:......=---A. QOmm\ft~:W~e~
rwno aurblllrl ntr\11 VJIGI
N. tympanlcul [JA00B$0N)
muacull atylaph•IY"gal
Rr. tonlil~~n~~~
Fig. 12.155 N. glossophlnyng1us [IX]; schematic median section; view from the left side. The N. glossopharyngeus [1)(], the N. vagus IXJ, and the N. accessorius lXII exit 1he brainstem in the Sulcus retroolivaris and pass through the Foramen jugulare at the cranial base. Within the foremen lies the smaller of two ganglia, the Ganglion superius. followed immediately .by the caudal Ganglion inferius. Once the glossopharyngeal nerve has passed through the cranial base, it courses caudally in between the V. jugularis interne and the A. carotis intema and by arching forward and running between the Mm. stylopharyngeus and styloglossus enters the root of the tongue. In its course, the N. tympanic us branches off and projects to the tympanic cavity. Here the tympanic nerve divides into the intramucosal Plexus tympanicus and exits the tympanic cavity as N . .,.tro· ..,. minor. TheN. peti'O$us minor runs parallel to theN. petrosus major at the anterior aspect of the petrous bone and passes through the Foramen lacerum to reach the Ganglion oticum. Fibres of the N. glos-
314
sopharyngeus IIXJ passing through this ganglion innervate the parotid gland. Additional brand!H are 1he R. musculi stylopharyngei to the M. stylopharyngeus and the Rr. pharyngeales to 1he Mm. constrictor pharyngis superior, palatoglossus. and palatopharyngeus as well as sensory fibres to the pharyngeal mucosa anci to the Glandulae pharyngeales. Together with the sympathetic trunl: and theN. vagus IXJ. additional fibres generate the Pllxus phlryngMJS which innervates the Mm. constrictor pharyngis inferior, levator veli palatini, and uvulae. The Rr. tonsillares supply sensory fibres to the Tonsilla palatine and the muoosa of the Isthmus faucium, the Rr. linguales contain gustatory (taste) fibres for the posterior 1hird of the tongue. The R. sinus carotici transmits sensory input from mechano- and chamoreceptors at the Sinus ceroticus and Glomus c:aroticum to the brainstem.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. glossopharyngeus [lXI
Flg.12.1SI Rbnt quaiHiu of11te N. glouopharyngausiiXJ; schematic median section, view from the left side. Motor fibres ISVEI of 1tle N. glossopharyngeus IIXI derived from the Nucleus ambiguus and from the N. vagus lXI (also from the Nucleus ambiguus. SVEI jointly innervate the muscles of the soft palate. P1....-ymp1thetic fibres IGVE) from the Nucleus selivetorius inferior project to the Ganglion oticum via the N. tympanicus, Plexus tympanicus, and N. petrosus minor. In the Ganglion oticum. the preganglionic fibres synapse to postganglionic neurons. The postganglionic fibres as· societe with the N. auriculotemporalis (from V/31 and theN. facialis lVIII to reach the Glandula parotidea. Additional parasvmpathetic fibres (GVEI reach the pharyngeal glands. Numerous gtii'Hirll141111to·affennt
-
Eft'nnt(moto"nb!M
-
All'llrent (Mmory) nblw
-
sp~na~n~:~n~a
-
P.-ympl!lhllllc flbnltt
fibres (GSA) that project to the Nucleus spinalis nervi trigemini derive from the tympanic cavity, the pharyngeal mucosa, and the posterior third of the tongue. Ganeral vi.cero-effennt fibres IGVAJ transmit 1tle sensory input of mechanorecePtors in the Sinus ceroticus !determine blood pressure) and of chemoreceptors in 1tle Glomus caroticus {measure partial pre&sure of 0 2 and C02 and pH of the blood). The brainstem integrates this sensory input and issues reflexive changes in the frequency of brealhing and of the central blood pressure. Specific viscero-efferent fibres ISVAJ conduct taste sensations to the Nucleus and Tractus solitarius of the posterior third of the tongue.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Llslona of th1 N. glouophlrvn&IUI(IXJ result in swallowing dif· ficulties (paralysis of the M. constrictor pharyngis superior, failure to form the PASSAVANT's ridge), a deviation of the Uvula to the healthy side {paralysis of the Mm. levator veli palatini, palatoglossus, palatopharyngeus, uvulae!, en impaired sensibility of the pharyngeal region (lack of gag reflex}. a lack of taste sensation at the posterior
third of the tongue, as well as disturbances in the secretion by the Glandula parotidea. In most cases. damage to the N. glossopharyn· geus IIXJ is not an isolated event. Frequently, fractures, aneurysms. tumours, and thrombosis of cerebral blood vessels supplying the brein in the region of the Foramen jugular& also affect the N. vagus IX1 and N. accessorius lXII.
315
Brain and Spinal Cord
General
N. vagus [X]
Fig. 12.157 N. v•au.IXJ; schematic median see1ion in the region of the head. For a detailed description of the course of theN. vagus IXJ-. page 318.
316
1-+ T 58J
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Meninges and blood supply
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Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. vagus [XI
N. 1111QUS LXJ, R. man~geua
_Jj~<:~_.::o....--1l'lctua et l\kiCI8U8 ap~lllll n.v1 tllgll!llnl
:..:!;~---~----Ganglion eupellua(lC)
N.l~ recurnsna •~lltar
Plllllu• pulmCIWlla at Rr.l:lranclllalaa
-
EII-I (motCI! fibnll
-
All'ftnt (senacryl llbnll
-
l'«
Fig. 12.158 Fibre quaiiUH of the N. vagu• LXI: schematic median section in the region of the head. For e detailed description of the iibre qualities of the N. vagus lXI ~ page318.
317
Brain and Spinal Cord
General
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Meninges and blood supply -+
N. vagus [XI
N. vagus [X] .... Fig. 12.157 Together with the Nn. glossopharyngeus [lXI and accessorius lXII. the N. vagus lXI exits the brainstem in the Sulcus retroolivaris and traverses the cranial base through the Foramen jugulare. The Ganglion superius locates in the Foramen jugulare and releases the R. meningeus which re-enters the cranial cavity to provide sensory innervation to the meninges of the posterior cranial fossa. Also branching off is the R. auricularis for the innervation of the outer wall of the external acoustic meatus. The Ganglion inferius locates slightly below the Foramen jugulare. The N. vagus (X] crosses the neck and the thoracic cavity and enters the abdominal cavity. In its course, the N. vagus [X] progressively loses its appearance as a coherent nerve. At the level of the oesophagus, two distinct trunks can still be discerned (Trunci vagales anterior and posterior), but from the stomach onward the fibres distribute more widely and form multiple Plaxua to reach the liver, pancreas, spleen, kidney, adrenal gland, small intestine, and colon. The fibres of the N. vagus [X] terminate at the level of the CANNON-BOHM point (left colic flexure). In its cervical passage, the N. vagus [X( provides Rr. pharyngeales to the Plexus pharyngeua. This plexus also receives contributions from the N. glossopharyngeus (IX] and from sympathetic fibres (innervation of the Mm. constrictor pharyngis medius and inferior, levator veli palatini, uvulae- motor function ISVEJ. Glandulae pharyngeales- parasympathetic function (GVE(, and pharyngeal mucosa - sensory function IGVA]). Additional vagal branches are the R. lingualis (taste fibres from
the root of the tongue and epiglottis, SVAJ. the N. laryngeus superior (with the R. externus for the Mm. cricothyroideus and constrictor pharyngis inferior as well as the R. intern us for the sensory innervation of the laryngeal mucosa above the vocal cords) and the Rr. cardiaci cervicales superiores and inferiores to the Plexus cardiacus at the heart (which affects the regulation of the blood pressure). In its thoracic part, the N. vagus IXJ releases the N. laryngeus recurrens. The latter loops around the aortic arch on the left side and the A. subclavia on the right side and projects back cranially to the larynx. Here the N. laryngeus recurrens innervates all laryngeal muscles (with the exception of the M. cricothyroideus) and the mucosa below the vocal cords. Additional thoracic vagal branches include the Rr. cardiaci thoracici for the Plexus cardiacus at the heart. The Rr. bronchiales reach the Plexus pulmonalis and innervate muscles and glands of the bronchial tree. The pulmonary vagal innervation registers the tension within the lung tissue and adjusts breathing by a reflectory neuronal feedback loop. Right and left N. vagus lXI form a web-like plexus (Plexus oesophageus) at the middle part of the oesophagus. The plexus eventually contributes to the formation of the Truncus vagalis anterior (mainly fibers of the left N. vagus IXJJ and the Truncus vagalis posterior (mainly fibres of the right N. vagus IXJJ. Both Trunci accompany the Oesophagus during its passage through the diaphragm into the abdominal cavity. From the stomach onwards, the Trunci diversify further to create numerous plexuses for the above-mentioned abdominal organs.
Fibre qualities in theN. vagus [X] ... Fig.12.158 Parasympathetic fibres (GVEJ of the N. vagus lXI originate from the Nucleus dorsalis nervi vagi in the Medulla oblongata and innervate glands and smooth muscles of the viscera. General vlscero-afferant fibres (GVAJ of the same organs project into the Nucleus dorsalis nervi vagi and the Nucleus tractus solitarii. Specific viacaro-affarant fibres (SVE) originate in the Nucleus ambiguus and innervate the skeletal muscles of the palate, Pharynx, Larynx. and Oesophagus.
General viscero-afferent fibres (GVAJ from the mucosa of the same structures project into the Nucleus dorsalis nervi vagi end the Nucleus tractus solitarii. General somato-afferent fibres (GSA) of the external acoustic meatus and the meninges of the posterior cranial fossa project into the Nucleus spinal is nervi trig emin i. Gustatory fibraa (SVA) at the root of the tongue and the Epiglottis connect with the Nucleus tractus solitarii.
N . vagus[X]
318
Nuclei (quality)
• • • •
Nucleus Nucleus Nucleus Nucleus
Exit points in the brain
•
Medulle oblongate: Sulcus retroolivaris
Position within the subarachnoid space
• Cisterna basalis
Passage through the cranial base
•
Innervation area
motor: • pharyngeal muscles (caudal part), M. levator veli palatini, M. uvulae • laryngeal muscles specific ...,.ory: • root of the tongue ...,.ory: • Dura mater of the Fossa cranii posterior • Meatus acusticus extern us (sickle-shaped deep part) • Membrana tympani (outer surface) paraayrnpathatk: • organs of the neck, thorax, and abdomen up to the CANNON-BOHM point
ambiguus (SVE) solitarius (SVA. GVAJ spinalis nervi trigemini (GSA) dorsalis nervi vagi (GVE. GVAJ
Foramen jugulare
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. vagus [XI
N.l~geus 814)111for
Rr. cerdlllcl &:aMcaleaa~ r~-.,q,..,...- N. ~ racurrane
V"H-- - Rr. cetdlltcl cervlcalee lnferia1118
gutlfci antlri01811
Rr. htp111c:l
Fig. 12.159 N. vagu• [XJ; both nerve branches; anterior view. The image emphasises the slightly different course of the Nn. vagi dexter and sinister and the course of their branches until the Trunci vagales anterior and posterior enter the abdominal cavity.
l-tT58j
I
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Complete I!Nions of 1fl• N. vagus (X] mainly occur at the Foramen jugulare. Frequently, the Nn. glossopharyngeus [IX] and accessorius lXII are also affected. Depending on the location of the lesion, the symptoms include a difficulty in swallowing and deviation of the Uvula to the healthy side !damage of the Plexus pharyngeusl. sensory deficits in the Pharynx and the Epiglottis (lack. of gag reflex.
gustatory impairment), hoarseness (paralysis of laryngeal muscles}, tachycardia and arrhythmia (innervation of the heart}. The unilateral damage has little effect on the autonomic vagal functions. However, bilateral damage of the vagal nerve can result in severe respiratory and circulatory problems that can cause the desttt of a patient.
319
Brain and Spinal Cord
General
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Meninges and blood supply
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N. accessorius [XII
N. w.gua pq, (illnglan lnflnla (nadaeum) N. ceovic:eJia (C1]
Fig. 12.180 N. acanorfus(XI]; anterior view; vertebral canal and skull have been opened. The N. accessorius lXII exits the brainstem in the Sulcus retroolivaris toge1her with the N. glossopharyngeus [I)(] and the N. vagus IX1 and all three cranial nerves traverse the cranial basa through the Foramen jugulare. The N. accessorius [XI) has two different roots. The Radix en· ni1lit of theN. ecoessorius [XI) originates from the Nucleus ambiguus in the Medulla oblongata. At the level of the Foramen jugulare, it joins the Rlldlx t~~lnalls of the N. accessorius (XII which consists of fibres derived from the anterior and posterior segmental roots in the cervical spinal cord. According to current textbook knowledge, the fibres of the
320
Radix cranialis form the R. intemus and converge on the N. vagus [X] inferior to the Foramen jugulare !according to newer preliminary findings which require further analysis, theN. accessorius lXII has no cranial root and no connection to the N. vagus [X]). The Radix cranialis participates in the innervation of the pharyngeal and laryngeal muscles and, strictly speaking, is not part of the N. accessorius lXII. The fibres of the Radix spinalis project caudally to the M. sternocleidomastoideus, course through the lateral cervical triangle to the anterior margin of the M. trapezius, and innervate both muscles.
I-+T58k
I
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. accessorius [XII
N. -~"'(XI], Radix cranlalle
Fig. 12.181 Fib,. qu1lltln of th• N. 8CCK1orlus [XI]; anterior view, vertebrel canal and skull have been opened. TheN. accessorius lXII innervates theM. sternocleidomastoideus
I
:
and M. trapezius with t~~eclftc vllcaro-tlff•ent fibres ISVE) from the Nucleus nervi accessorii. • forM. sternocleidomastoideus and M.trepezius
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - . L.Niona of thl N. ac:c.ttOrfu• [XI) are frequent due to its superficial course in the lateral triangle of the neck. Iatrogenic lesions (as consequence of medical actions. e.g. extirpation of lymph nodes) are particularly common. Injuries to the neck ere another cause for nerve lesions. If the N. accessorius lXII is injured superior to the M. sternocleidomastoideus, the patient is incapable of turning the head to the heahhy side (paralysis of the M. sternocleidomastoideus). In
addition. an elevation of the arm above the horizontal plane is impossible (paralysis of the M. trapezius). In most cases, however, the lesion locates inferior to the branches supplying theM. stemocleidomastoideus in the lateral triangle of the neck. The shoulder on this side drops deeper compared to the heahhy side and elevation of the arm above the horizontal plane becomes challenging.
321
Brain and Spinal Cord
General
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Meninges and blood supply
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N. hypoglossus [XII]
oervlcdt (C1), (R. man~geua) N. ~oeaua (XII)
M. atamathy\'oldaua
Fig. 12.182 N. hypoglossus lXII]; sch1mat1c mldl1n HCtfon; view from the left side. The Nucleus nervi hypoglossi in the Medulla oblongata provides the fibres for the N. hypoglossus [XII). The fibres exit the brain!rtem as multiple small .bundles between the pyramid end olive in the Sulcus anterolateralis. They join to form the N. hypoglossus [XIII which passes through the C.nalla nervi hypogloul. Inferior to the cranial base, fibres of the spinal nerves C1 and C2 accompany the hypoglossal nerve for a short distance and part again, first as Radix superior of the AnN cervlc.lls profunda and then as a branch to the M. geniohyoideus. Together with fibres from C2 and C3, these fibres form the Ansa cervi-
322
calis profunda end, in addition. innervate theM. geniohyoideus. Posterior to the N. vagus lXI in the neurovascular bundle .behind the Pharynx, the N. hypoglossus lXIII passes caudally and, in en arch-shaped .bend of 90°, tl.lms rostrally and medially. It runs at the upper margin of the Trigonum caroticum, crosses the A. carotis externa at the .branching point of the A. linguelis end reaches the tongue between the M. hyoglossus and M. mylohyoideus. The N. hypoglossus [XII) innervates all internal muscles of the tongue and the Mm. styloglossus. hyoglossus, and genioglossus.
I-+T681
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
N. hypoglossus [XIII
N. c.Mcalla [C1J, (R. menlnoeuel N. hypoglaeeua [XIq
NucleusiWVi ~oeai
Fig. 12.183 Flb1r qu1lltln of th1 N. hypoglouus [XIII; schematic median see1ion; view from the left side. The N. hypoglossus lXIII consists of general somato«ferent fibres
-
EII-I (motCil fibres
-
All'nnd {MIWOOO ~b!W
!GSEI from the Nucleus nervi hypoglossi and innervates the internal muscles of the tongue and the Mm. styloglossus, hyoglossus, and genioglossus.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . A unilateral Inion of thl N. hypoglossus lXII]. e.g. caused by a frae1ure of the cranial base. causes the tongue to deviate towards the affected side because the intact lingual muscles of the opposite side push the tongue to the paretic side. In the case of a persistent
paralysis of lingual muscles, signs of muscle atrophy are visible on the paretic side. In addition, dysphagia (difficulty in swallowing) and dysarthria {poor articulation) are the result of a paralysis of lingual muscles.
323
Brain and Spinal Cord
General
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Meninges and blood supply
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Spinal cord segments
tegmenta~ (T1-T12]
..................,{ Sltll'llllta ucnllll (81-85] { Setmenta OOOGYfl8 [Co1-ca3) {
,0_____ _ '<-::\---------\._!.-.)
---------------RldiCII nervorum lumiNIIUn
t~J
tJ
.)
Radlc:etl,_rum coccweorum
F".g. 12.1M Spinel cord Mtmente, Setmenta medullee epinelie; schematic median section; view from the left side; regional segments highlighted in different colours. The spinal cord is composed of eight cervical segments (Segmenta cervicalia [C1-csn. twelve thoracic segments (Segmenta thoracica [T1-T12Jl, five lumbar segments (Segmenta lumbalia [LH..Sil. fives~ cral segments (Segmenta sacralia ($1-55)), and one to three coccygeal segments (Segments coccyges [Co1-Co3)1. In the adult, 1he spinal cord extends only to the level of 1he lumbar vertebra LI-Lli.
A$ the spinal cord doas not follow the faster growth of the vertebral column. the course of the spinal roots (Radices nervoNm) towards their corresponding segmental intervertebral foramina becomes steeper and longer from cranial to caudal within the vertebral canal. Below LI-Lli the arrangement of spinal nerves in the vertebral canal resembles a horse tail, thus. the name Cauda aquina.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Any narrowing of the vertebral canal causes an irritation of the corresponding segmental neurons. Tumours or median disc prolepses inferior to the spinal cord segment S3 can result in a conu. medullaril.,n*ome (lesion of spinal cord segments S3-Co31 or caucla
324
equine syndrome ICES; lesion of the spinal nerve roots in the area of the Cauda equine). The symptoms are sensory deficiencies (saddle anaesthesia!. flaccid paralvsis, incontinence, and impotence.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Spinal cord segments
~ '
c:::i
lntum.._.,. amcab [C1-ca:J
(::)
0
<:::>
f)
~ Q:::, ~
t)
&
t5) Padcullii'Cuum ll«''abnnlum
~
61
~}
.....,_,mw-.. ~
0 0
0
Q
lntumNC111111 amcale
0
Gangl an •plnaJa
€)
0 0 0 0 0 [f1-T12J
0
g
0
li)
()
0
·--kH. {I
()
lntu-mlalumb--.118
Conu.~larte
0
Q Clul4a equti\11
[l1-l.5]
Fig. 12.165 Spin11 cord teamentt, Segment. medull1e tPinelie; schematic frontal section; ventral view. [8) As the spinal cord does not follow the faster growth of the vertebral column and is much shorter than the vertebral column, the course of the spinal roots towards their corresponding segmental intervertebral foramina becomes steeper and longer from cranial to caudal and more oblique for those fibres located more lateral within the vertebral canal. In adults, the spinal cord ends at the level of LI-lli (ranging from TXII to LIIJLIII). Therefore, the Radices anteriores end posteriores locate at higher segments of the vertebral column than the corresponding spinal nerve exiting the vertebral cenal. Inferior to the Conus meclullaris, the Radices anteriores and posteriores of the bundled lumbar, sacral, and coccygeal nerves extend caudally to reach their intervertebral foramina to exit the vertebral canal. This collection of nerve roots is named the Cauda equine.
Fig. 12.166 Spinal cord, Medulle epinelie; ventral view. 181 The spinal cord is the part of the CNS located in the upper two-thirds of the vertebral canal. In the adult, it extends from the Foramen magnum to approximately the level of LIJLII. In the newborn, the spinal cord reaches to the level of Llll or even LIV. The distal end has the shape of a conus !Conus medullarisl. The Conus medullarb contains a fine network of connective tissue (Filum terminals}, derived from parts of the Pie meter, which extends caudally into the vertebral canal. The diameter of the spinal cord increases in the areas with spinal nerve roots dedicated for the extremities. The upper enlargement (lntum..c.ntle c.rvlcelle, C5-T11 contains neurons for the innervation of the upper extremities, the lower enlargement (lfttllmelcentfe lumboiKrllll) lies at the level of the spinal nerve roots L1-S3 and serves for the innervation of the lower extremities.
325
Brain and Spinal Cord
General
-+
Meninges and blood supply
-+
Somatic and visceral nerve plexuses 8111111111cp..._
R.pumando
Pluua bruhlah{ Rr.am.t;vw C6-T1
Trunci YIIQIIM
Pluua Unblll.. -
Rr.anillriDNa
L1-L4
Pluusacnl - { Rr. an1arla,....L4 or L.6-S4
Fig. 12.187 Som.tlc: •nd v~ece...l nerve plu:uaM.(8( Tne nature of nerve plexuses can be somatic (left side of the image) or visceral (right side of tne image) and include fibres of different qualities and levels. Nerves that originate from a plexuses project towards different targettissues and organs. The plexuses of the enteric nervous system can generate reflex activities independent of the CNS. Tne extensive eom.tic: plexueM originate from the Rr. enteriores of the spinal nerves: Plexus cervicalis (C1-C4), Plexus brechialis (C5-T1}, Plexus lumbelis {L1-l4), Plexus sacral is (L4-S4), end Plexus coccygeus (55-Co). With the exception of the spinel nerve all Rr. anteriores of
n.
the thoracic spinal nerves are independent and do not participate in the formation of the plexus. The vlec:er•l plexuaM form in conjunction with the viscera and normally contain efferent (sympathetic end parasympathetic) end afferent parts. Visceral plexuses are the Plexus cardiacus and pulmonalis in the thorax as well as the Plexus prevertebralis anterior to the aorta in the abdomen, which extends caudally to the lateral walls of the pelvis. The Plexus prevertebralis projects efferent fibres to all abdominal and pelvic organs end receives efferences from the same organs.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . Rmr...dp8in. sometimes also named reflective pain, is viewed as a misinterpretation by tne brain of pain derived from inner organs. In the case of referred pain, visceral pain is not felt at the site of origin but is projected to a distant area of the skin !HEAD'• zane}. Normally, referred pain involves a region with a low number of sensory afferences, such as the intestine. These visceral afferences
326
converge at the same level in the spinal cord with those of a specific cutaneous area that comprises a high number of sensory afferences. The bra in erroneously localises the visceral pain to the corresponding skin area. A typical example is the pain referred into the left shoulder and/or arm during Angina pectoris or myocardial infarction.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Spinal nerves
~=ulaobiOI'Iglta
Obex
N.~ost~~~~ ~ .
it- N. ~ lXII
DOQ
;-'
~
I
Dec:l.i--.tlo py!WnldUm ANura mecUana anttlfor
~ Rldbt I)Otttltor (C8)
' Seamenta lharaclce (1-12] • Para thoraelce
Dura mater sPinal Ia
Funlou~alll.1llnlla
Funlcuka pcMitllrtor Funleulua tmerklr lnturnaoentlalumb-onlla SeQmenta hmbelie { (Hi]= Pant Ur1balla
l'ltJix posterior {L1)
V.J,U'~-OangkiNI'I8CII!a ntN:~FUm tplnallum
{81-6)
•
1
Fllumtermlnale, Pantduralt
Flgt. 12.168.1 and b Spinal cord, Mldulla eptnallt, and aplnal nervas, Nn. aplnalas; 1t1e vertebral canal and the dural sac have been opened. a dorsal view b ventral view The spinal cord has the shape of a sword and a diameter of 1-1.5 em. It extends from the Medulla oblongata of 1t1e brain stem. Its cervical end lumbar segments increase in diameter to form the lntumescentia cervicalis (C5-T11 end the lntumescentia lumbosacrelis (l2-$3). These ere the location of multiple neurons and nerve fibres conc:emad mainly
N. tplnalt C1 exllt!lll be1Wetn lkiJI bMe andaUaa
Nn. aPinalll C2-7 .ntng above the Pedlculut an:ua vertebrae } 7
' c s - N. &p;n.tls cs exitillll belOw CVII
l
Nn. epll\lles T1-Co.ntng HIOW !heir 1'181)8e!tte Pedlculut an:ua V81t8brae
b
with the innervation of the extremities. The Conus meclullaris is the caudal tip of the spinal cord. The surface of 1t1e spinal cord displays characteristic longitudinal groovas. In 1t1e midline on the ventn~l side 1t1is is the Fissura mediana anterior and on the posterior side tile Sulcus medianus posterior. The Funiculus anterior located to both sides ofthe Fissun~ mediana anterior, is followed by the Sulcus ventrolaten~lis which separates the Funiculus anterior from the Funiculuslateralis. On the dor881 side and bilaterally to the Sulcus medianus posterior are the Funiculi posteriores. The letter are separated from the Funiculi laterales by the Sulci posteroleterales.
Fig.12.18t Nomenclature of1fl••pinal nerves. [8) In contrast to the other spinal cord segments, the number of spinal cord segments in the c.I'Yieal epinal cord is not identical with the number of vertebrae. The cervical region has eight cervical segments but only seven cervical vertebrae. The first pair of cervical nerves exits between the cranial base and the atlas (CI vertebra}. The spinal nerve pairs C2-c7 each exit su,.tor to the corresponding Pediculus arcus vertebrae. At the transition from the 7"" cervical vertebra to the 111 thoracic vertebra, the nomenclature changes since 1t1e 8111 spinal nerve exits inferior to the 7"" cervical vertebra. All pairs of spinal nerves n-co that follow will always exit inferior to the corresponding vertebral arch.
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Brain and Spinal Cord
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Arteries of the spinal cord
A. medulari& segmentalis
Fig. 12.110 Artei'IIM of the eplnal cord. Medulla eplnallt; ventral view; not all segmental spinal arteries are shown. [8] Tnere are three sources of arterial supply for the spinal cord: • through the A. eubclevia (cervical) via the A. spinalis anterior and Rr. radic~o~lares anteriores and posteriores from the~- vertebralis, cervical is ascendens, and carvicalis profunda
• through the Aortll thorKict~ (thoracic) via the A. intercostalis suprem a and~- intercostales posteriores • through the Aorta abclomlnallt (lumbosacral) via Aa. lumbales Tne A. iliaca intema supplies the Cauda eo;uina through tne A. iliolumbelis and A. sacralis lateralis. All these arteries provide Rr. spinales. Tne largest R. spil'l81is is tne A. radicularis magna (ADAMKIEWICZ; vertebra TXII-LII) which is usually found on the left side of the body.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - - - - , Tne A. spinalis anterior (supply area ... Fig. 12.171) can be occluded by thrombosis, tumours, etc. This results in an anterior epinal artery ..,..nme. Damage of the anterior homs occurs at the level of the occlusion, resulting in a flaccid paresis of tne muscles and muscles parts innervated by the corresponding spinal cord segment. Simuhaneously, the tracts in the Funiculus anterolateralis become nonfunctional. Those body regions innervated by the spinal cord segments below the site of injury will display spastic parapareses, loss of pain and temperature perception but preservation of touch,
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vibration, and postural sensation, as well as deficits in micturition, defecation, and sexual functions. Blockage of the blood supply from the largest of the anterior radicular vessels, the A. radicularis magna or artery of ADAMKIEWICZ, results in a greater radicular artery ..,..nme. Depending on the level of the blockage, a paraplegia in the lower thoracic or upper lumbar regions with complete loss of the entire caudally located spinal cord functions is observed.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Arteries and meninges of the spinal cord
R.n&dlcul.wfa.,lellar
Fig. 12.171 Segmenul ertllllll1upply of 1fl•epln•l cord. [8) Blood supply to the spinal cord is achieved through the A. spln1lll 1nt11rtor and the AI. epln1ln pomrlorn, longitudinal blood vessels running alongside the spinal cord which originate in the cervical region. Additional contributors are feeder arteries (spinal segmental arteries from the Aa. vertebrales, the deep cervical arteries, the Aa. intercostales end the Aa. lumbales) which enter the vertebral canal through the
Foramina intervertebralia and divide into Rr. radicular• anurlorn and postertora at the level of each spinal cord plane. The Radices anteriores and posteriores follow the spinal nerves and supply them with blood. At different planes, the spinal segmental arteries release segmental AI. mltdullaru which project to and anastomose with the longitudinal arteries.
Ag. 12.172 Menlng~S of thesplnll card,. Menlngn; oblique ventral view. [8) Like the brain, the spinal cord is surrounded by the three meninges, which provide protection and suspension of this CNS structure within the vertebral canal. The Dura mater eplnelfa is the strongest of the three meninges and is located farthest to the outside. The laterally exiting spinal nerves and their roots are surrounded by a tubular dural sheath which radiates into and fuses with the nerve sheath !epineurium) of the spinal nerves. Inside the dura follows the spinal arachnoid mater which is separated from the Pia meter spinalis by the subarachnoid space filled with cer. brospinal fluid (Liquor cerebrospinalis). Delicate trabaculations ITrebeculee arachnoideae. not shown) connect the spinel arachnoid mater of
one side with the Pia mater spinalis on the other side. This connective tissue also surrounds the blood vessels located within the subarachnoid space. The Pi1 m1terepin1li1 is a membrane rich in blood vessels and tightly attached to the surface of the spinal cord. It extends deeply into the Fissura mediana anterior, creates a sheath-like lining around the Radices posteriores and anteriores of the spinal nerves and accompanies them on their way through the subarachnoid space. In the exit and entry areas of the radices, the Pia mater spinalis transitions into the AriiChnoldu mater epln1ll1. The Ligg. denticulate are lateral extensions of the Pie mater spinalis to the spinal arachnoid and Dura mater along both sides of the spinal cord. They serve to attech the spinal cord in the centre of the subarachnoid space.
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Brain and Spinal Cord
General
~
Meninges and blood supply
~
Venous plexus of the spinal cord R.lld lx paeterio r
Fig. 12.173 Veins of tM wmbral canal, Canalis vertebra lis; oblique ventral view. 181 The veins draining the spinal cord mainly form longitudinal collecting vessels running alongside the spinal cord. Two pairs of longitudinal veins group around the exit and entry points of the Radix anterior and Radix posterior out of and into the spinel cord. respectively. In addition. the V. apfnalla anterior and V. aplnalla pottar1or course alongside the
Fissura medians anterior and the Sulcus medianus posterior, respectively. These veins drain into the Plexus venosus varteluallslntemus in 1he epidural space of the vertebral canal. The venous plexus connects with segmental veins which, like the azygos system, drain into the large collecting veins of 1he body. The Plexus venosus vertebralis internus also communicates with intrac:reniel veins.
Pant lumballa dllpln.gm.111a, Crura
v.rumbtls
N.lumballa [1.4)
Fig. 12.174 Position of the spinal cord within th• vartllbral canal; dorsolateral view. 181 The dural tube positions ventral to the Lig. longitudinal& posterius and is surrounded by the Plexus venosus vertebral is intemus. The vertebral
330
arches of the first two lumbar vertebrae have been removed. The topographic relationship of the nerve ro01 to the intervertebral disc below the spinal nerve L2 is shown. The Lig. flevum provides the dorsal cover for 1he dural1ube.
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Sections
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Clinics
v.rtvbnllumballa V
Rg. 12.115 Schematic repraenution of a mediolateral herniation of the intervertebl'lll d"IH blltwllen the 4"' and 5"' lumbar Vllrtllbra•; lateroventral superior view. 1231
This disc prolapse results in the compression of the spinal nerve root L5 located one segment below; the more medially positioned L4 root exiting in the same segment remains unaffected.
N. lumbalis [I.A), R. lnlllllor
Dloocua~ralll beMan Vertebra kftlbllls V and Os sacn.m
Fig. 12.116 Epldu,.llperldu,.llan...th.... and eplnal anaaattw.i•. [23] Anaesthetics are injected into the epidural space [epidural or peridural anaesthesia) to anaesthetise indMdual spinal neNes. The local adipose tissue prevents the anaesthetic from affecting other spinaI cord segments. In contrast to the epidural anaesthesia, in spinal ananthHIII the anaesthetics are applied directly into the subarachnoid space. The media~tion mixes with the cerebrospinal fluid but, as a result of g-force, re-
mains below the injection site lin an upright sitting patient) and, thus, exclusively anaesthetises neNe fibres l0a1ted below the injection site. For lumbar punl:bll'll, the back must be maximally bent forward and the needle is inserted between the spinous processes of the lumbar vertebrae Ill and IV or IV and V. Then. the needle is pushed forward carefully until the Dura mater spinalis is punctured and the tip of the needle rests in the subarachnoid space. Now, cerebrospinal fluid can be drawn for diagnostic purposes or an anaesthetic can be applied.
331
Brain and Spinal Cord
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Spinal cord and vertebral canal, imaging
Ug.longlludl~e
poetne
Spatium epidunllt
Cl8tlma U!lball8 ----+'*f"'.::f-:--~ l.lg.IOnglludtlllle IIIIIHIUS --llr-~-r-r.
ug. lnttl1f:lln«le
Dura matenplnallt Fium radiCIAIIte
Promontort.lm
Ouaerum
Fig. 12.177 Lumb1r p1rt of the v.mtbr1l column; magnetic resonance tomographic image (MRI), T1-weighted; median section of the lumbar and lower thoracic parts of the vertebral column. [27)
The border between the end of the spinal cord at the level of LVLII and the beginning of the Cauda equine, which only partially occupies Ute vertebral canal, is clearly visible.
Vertabra lumbllllalll
Fcrwnen inteMMtebrale
Teminlllcn afthe ell raJ eae
o. a&en~m (SI) 0. 81.Cf!Jm (SIQ
F1g. 12.178 Myelography of the lumbosar.:r~l transition; radiograph in lateral beam projection. 1271 The contrast medium has distributed within the subarachnoid space.
332
The dural sac {subarachnoid space) terminates at the level of the 2"d sacral vertebra (SII).
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Clinics
Fig. 12.119 Vertebrel can1l, C.nelit vertebr1li1, witi11pin1l cord. Mldull1 1pin1lit; magnetic resonance tomographic image {MRII: median section of the lower thoracic and lumbar parts of the vertebral column. paraplegia due to a spinal tumour. [23) In the MRI images. the tumour presents as a white mass against the surrounding spinal cord. This is a metastasis of a known bronchial carcinoma. The patient was admitted with complete paraplegia of the lower extremities and loss of all sensory functions below dermatome L'l.
Fig. 12.110 Spin• bifide cptica. 1201 Infant with Spina bifida cystica (meningomyelocele) in the lumbar region.
Fig. 12.181 Spin• bifida occulhl. 1201 The hairy skin area in the lumbosacral region is the visible sign of the underlying Spina bifida occulta.
Clinical R e m a r k s - - - - - - - - - - - - - - - - - - - - - - - - - . . Damage or compreufon of th1 epln•l cord can be caused by intramedullary( ... Fig. 12.179) or extramedullary tumours. medial disc prolepses, dorsal spondylophytes. or traumatic injury. A complete p•r~q~legl• results in the loss of all qualities of sensation, motor function. and autonomic functions below the site of the lesion. In the EHJrly stages, a flaccid paralysis develops below the lesion {spinal shock}, which then converts into a spastic paralysis. The BROWN..S~OUARD'• eyndrome describes a spinal hemiplegia with spastic paresis below the site of the lesion plus a dissociated impairment of sensor functions with loss of proprioception, vibration and epicritic sensibility (dorsal tracts) on the site of the injury and loss in pain and temperature sensation on the contralateral side !lateral tracts; ... Fig. 12.192). Spina bifid• is a congenital defective closure of the vertebral column and spinal cord caused by teratogenic factors !e.g. alcohol, medication! or missing induction of 1he Chorda dorsalis.
The Sptn• bifid• occulta (... Fig. 12.181) e)(clusivaly involves the vertebral arches. In most cases, unfused arches are found in one or two vertebrae and the corresponding overlying skin is often covered with hair and is more intensely pigmented. Usually, these patients show no symptoms. In the case of a Spina bifid• cptica I• Fig. 12.180}, the vertebral arches of a number of neighbouring vertebrae are not closed; a cyst-like protrusion of the spinel meninges extends into the defect (meningocele). A meningomyelocele exists if the meningeal cyst contains spinal cord and nerves (coincides with functional deficits). Spin• .blflcll •pertl (rachischisis. myeloschisis) is the most severe form of spina bifida with underlying defect in the proper closure of the neural folds. With no skin cover to protect it. the undifferentiated neural plate is exposed on the back. Newborns with such defects usually die shortly after birth.
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Brain and Spinal Cord
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Spinal cord, sections
FormatiD reticullris
C01um1111 pcMterior, Cornu PDI!.t.IS
a
COlumna
I)OIIel1or, Cornu ~
b
I
b
c d
F'111. 12.112a to d Spinal cord, Medulla epinalia; cross-sections; myelin stain; approximately 500%. a cervical part, Pars ce rvicalis b thoracic part., Pars thoracica c lumbar part, Pars lumbalis d sacral part, Pars sacralis The spinal cord has a symmetrical mirror-image structure and all spinal cord segments (a-G) consist of grey and white matter. The grey matter ISubstantia griseal consists mainly of the perika rys of neurons, it has the shape of a butterfly in cross-sectional images, and is surrounded by white matt.r (Substantia alba). Tha latter is mainly composed of
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neuronal fibres and glia cells and divides into tracts (Funiculi). The centre of the butterfly structure contains the canalia centralia. Although part of the inner CSF space, this canal has a caudal blind end, preventing the circulation of the cerebrospinal fluid. The wings of the butterfly represent columna: an anterior column (Columna anterior), an intermediate column (Columna intermedia), and a posterior column (Columna posterior). These columns form the anterior hom (Cornu anterius), lateral horn (Cornu laterale), and posterior horn (Cornu posterius). The Commissurae griseae (not shown) connect the intermediate columns from both sides.
Brain -+ Sections -+ Cranial nerves -+ Spinal cord
Functional organisation of the spinal cord Nuelell& margtlllls -.~,....~
COIUmM potU!..-,
Comu poetell~~&
All~~~e-- NucleU• UlOI'ICioJ8 poetellor
Rg. 12.183 Spin II cord. Medull1 aplnllll; laminar organisation of the grey matter according to its cytoarchitecture [according to REXED, 1952). exemplified by the tenth thon~cic segment (T1 0}. Histologically (cytoarchitecturally), the grey metter (Substantia grisee) divides into a number of llytl'l (Laminae} which ere numbered I to X from dorsal to ventral (extent and number of the layers vary in different segments of the spinal cord}. In addition. various nuclei are distinguished and can stretch over more than one cytoarchitectural neuronal layer. The structure of the Laminae reflects functional aspects.
The paltlrlor homs (laminae I-VI: Nucleus thoracicus posterior [CLARKE's column), Nucleus proprius, Substantia gelatinosal contain releis neurons for the transmission of efferent sensory input (sensory information from the skin. proprioceptive information. perception of pain from the periphery). The l1ter11 ho"'* (Lamina VII) harbour neurons (Nucleus intermediolateralis) for autonomic efferences. The ente· liar hams (Columna anterior. Cornu anterius; Laminae VIII. IX) contain the efferent neurons (someto-efferent root cells) for the muscles.
+I I
1 • eldn 2 - tltemeuront 3 motoneuron of lhalllll.-lar hom -4 ; motor and·plale 6 - muecluplndlt
=
Rg. 12.184 Rdexu of1fl1spln11 cord, Mldull1 spln1lls. The spinal cord contains a eyatlm thlt connect. it wida IMIJirllpin•l centr• end a locel 1utonomic •r-tem capable of eliciting spinal reflexes without the input from supraspinal neuronal structures. Spinel reflexes for example are important in l:eeping an adequate muscle tonus during different activities or to protect against harmful stimuli (e.g. withdrawal reflex from a painful stimulus}. The type of connectivity and complexity distinguishes two forms of refl•x cln:4.1Mry: monosynaptic and polysynaptic reflexes. Supraspinal centres can modify polysynaptic reflexes.
Left side of the image: reflex circuitry of a monosynaptic. bineuronal, proprioceptive reflex Ia typical stretch reflex (ike the knea·jerk [!patellar)) reflex, etc., collee1ively named myotactic or deep 1endon reflexes [DTRs)). Right side of the image: complex reflex circuitry of e polysynaptic. polyneuronal reflex {typical flexor or withdrawal reflexes are initiated by cutaneous receptors and include the abdominal, cremaster reflex_ foot sole reflex etc.).
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Brain and Spinal Cord
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Fasciculus septomarglnalls++ Fasciculus interfascicularis+ Fasciculi proprii posteriores
Fasciculi proprlllaterales
Tractus cortlcosplnalls
(pyramidalis) lateralis lhlctus rubrosplnallll Tractus spinocerebelleris anterior•• lhlctus ratlculosplnslls
'Tractus spinothalamicuslateralis
Flbrae ollvosplnaiN'' ••• Tractus apinothalamicua anterior; Tractus spinotectal is
Tractus ratlculosplnalls; Tractus tectosplnalla
Fig. 12.186 Spinal cord, Medulla spinalis; schematic organisation of the white matter exemplified by a lower cervical segment. Afferent (= ascending) pathways in blue; efferent (= descending) pathways in red. The regions indicated with +. ++. and+++ designate descending collateral tracts of the posterior fasciculi.
*
clinical term: FLECHSIG' s tract clinical term: GOWERS' trsct *-* clinical term: GOLLS' tract **** clinical term: BURDACH's tract *****The actual existence of these fibres has not definitely been documented. + SCHULTZE's comms trsct (cervicsl psrt) ++ oval bundle of FLECHSIG (thoracic part) +++ triangle of PHILIPPE-GOMBAULT (lumbar and sacral parts]
*-
lmportent Strech Reflexes of the Spinal Cord [1 41 Reflex
Segment
Reflex Trigger
Target Organ
Nerve (afferent and afferent limb)
Biceps
C5,C6
tapping the biceps tendon
M. biceps brachii
N. musculocutaneus
Brachioradial is
C6,C6
tapping the brachioradialis insertion tendon or the periosteum
M. brachioradialis, M. brachialis, M. biceps brachii
N. radialis, N. musculocutaneus
Triceps
C6-CB
tapping the triceps tendon
M. triceps brachii
N. radialis
Knee-jerk (patellar)
L2-L4
tapping the Lig. patellae
M. quadriceps femoris
N. femoralis
Ankle-jerk (Achilles)
L6-S2
tapping the Achilles tendon
M. triceps surae
N. t ibialis
lmportent Rexor Rdex• of the SpiMI Cord 1141
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Reflex
Segment
Reflex Trigger
Target Organ
Afferent Umb
Efferent Limb
Abdominal
T8-T12
stroking of the abdominal skin
abdominal m uscles
Nn. intercostales (T8-T111. N. iliohypogastricus, N. ilioinguinalis
Cremaster
L1, L2
stroking of the skin at the inside of the thigh
M. cremaster
R. femora lis and R. genitalis of theN. gen it ofemoralis
Foot sole
S1,S2
stroking of the lateral side of the foot sole
flexor muscles of the toes (2-6)
Nn. plantares of t he N. t ibial is
N. t ibialis
Anal
S3-S5
stroking of the anal region
M. sphincter ani extern us
Nn. anococcygei
N. pudend us
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Sections
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Cranial nerves
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Spinal cord
Tracts of the spinal cord
Gyrus postcentral Is
Nuclei nervi trigemini
Decll9satlo lemnlacorum -Tractus splnothalamlcus lateralls} -Tractus s~nothalamlcus anterior (Fasciculus -Tractus SJl!nOrallcu!ans antarolaterslls) - Tractus spmotectal111 - 'lhlctus splnoollvarls
Fig. 12.186 Pathways for epicritic (blue) and protopathic (green) sensibility (afferent tracta). Pathway of epicritic sensibility (touch pathway, serves the perception of precise differentiation of pressure and touch as well as proprioception): • 1• neuron (uncrossed): from receptors (exteroceptors) in the skin and the mucosa, the periosteum, the joints and the muscle spindles etc., to the Nuclei gracilis and cuneatus in the Medulla oblongata via the Fasciculi gracilis and cuneatus in the Funiculus posterior (perikarya in the spinal ganglia); additional descending collaterals • 2"d neuron (crossed): from the Medulla oblongata (Nucleus cuneatus, Nucleus gracilis) to the Thalamus (Lemniscus medialis, perikarya in Nucleus cuneatus and Nucleus gracilis) • 3n1 neuron (uncrossed): from the Thalamus (Nucleus ventralis posterolateralis) to the cerebral cortex, particularly to the Gyrus postcentralis (thalamocortical fibres, perikarya in the Thalamus)
Pathway for protopllthic sensibility (pain pathway, serves the pain, temperature and general pressure sensation): • 1"' neuron (uncrossed): from receptors (exteroceptors) of the skin and the mucosa etc., to the posterior horn, Laminae I to V (perikarya in the dorsal root ganglia) • 2nd neuron (crossed, some fibres possibly uncrossed): from the posterior horn to the Thalamus, in the Formatio reticularis and to the Tectum mesencephali (Tractus spinothalamici anterior and latera lis, Tractus spinoreticularis, Tractus spinotectalis; perikarya in the posterior column) • 3 111 neuron (uncrossed): from the Thalamus among others to the cerebral cortex, particularly to the Gyrus postcentra lis (thalamocortical fibres, perikarya in the Thalamus)
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Brain and Spinal Cord
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Tracts of the spinal cord
Fig. 12.187 Pathway of unconscious proprioception (afferent tract}. Pathway of unconscious proprioception (unconscious, but precise spatial differentiation as a prerequisite for movement coordination by the Cerebellum) via the anterior apinocaraballar tract (black): • 1"' neuron (uncrossed): from receptors (propriocaptors) in muscles, tendons, and in the connective tissue to the nuclei in the Zona intermedia and the anterior column (perikarya in the spinal ganglia). • 2... neuron (two times crossed): from the anterior horn within the anterior spinocerebellar tract of the anterolatera I tract via the superior cerebellar peduncle to the Cerebellum (perikarya in the intermediate zone and the anterior horn).
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Pathway of unconscious proprioception via the posterior spinocerebellar tract (yellow): • 1"' neuron (uncrossed): from end organs (proprioceptors) in muscles, tendons, and in the connective tissue to the nuclei of the posterior column and to the Nucleus thoracicus (perikarya in the dorsal root ganglial. • 2"11 neuron (uncrossed): from the posterior horn and the thoracic nucleus within the posterior spinocerebellar tract of the lateral tract via the inferior cerebellar peduncle to the Cerebellum (perikarya in the thoracic nucleus and at the base of the posterior column).
Brain
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Tracts of the spinal cord
Gyrus precentralls
Thalamus
Thalamus
Substantia nigra
Cerebellum, Nucleus dentatus
- Tll!Cius rubn:>spinalis -Tractus reticulaspinalis
- Tll!Cius 1188tlbulasplnalls - Tll!Ciua tectasplnalla
Cornu anterius
N. spinalis
Fig. 12.188 Pathways of the motor system (efferent tracts). The motor system comprises a large number of nuclear regions and tracts. The "final motor pathway" are the motoneurons. Despite the extraordinary complexity of these circuits, the traditional organisation will be maintained for didactic reasons. Pyramidal tract: • (Central) neuron (crossed]: from the cerebral cortex through the internal capsule and the cerebral peduncles to intemeurons within the anterior and posterior columns (Tractus corticospinal is lateralis, Tractus corticospinal is anterior, perikarya in the Gyrus precentralis]. • (Peripheral] neuron (final motor pethway, a-motoneurons): from the anterior horn to the motor end plates of the skeletal muscles (motaneurons, perikarya in the anterior horn]. Cranial narvas: • From the Trectus corticospinalis anterior of the pyramidel tract fibres branch off for the nuclei of the cranial nerves (Fibrae corticonucleares and Fibrae corticonucleares bulbi).
Extrapyramidal motor system: • Central neurons: (crossed and uncrossed]: from the cerebral cortex. particularly the Gyrus precentralis and the adjacent anterior cortical areas including synapses to the basal ganglia, Thalamus, Nucleus subthelamicus. Nucleus ruber, Substentia nigra, Cerebellum, etc. and feedback loops to interneurons of the anterior column (Tractus rubrospinalis, Tractus reticulospinalis, Tractus vestibulospinales medialis and latera lis, Tractus tectospinal is]. • Peripheral neuron (motor end pathway, o:-motoneurons): from the enterior horn to the motor end plates of the skeletal muscles (motoneurons, perikarya in the anterior horn).
* motor nuclei of cranial nerves
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Brain and Spinal Cord
General -+ Meninges and blood supply -+
Tracts of the spinal cord, Clinics
340
Ag. 12.1n Dysfunctional cuunaaus lnnerntlan due to pa.lsy of c.taln, frequently effected spinal nerves.
Fig. 12.110 Campl.te paraplegia at the level of the 1 , ... thoracic segment (T11).
A disc prolapse frequently affects the spinal nerves L4. L5, and 51.
Paralysis of the whole motor and sensory system in the hatched area.
Fig. 12.191 Peralyeh of the tram of the right ponerfor funiculus at the level of the 11111 thoracic "llment (TU).
Fig. 12.192 HemlplaglaiBROWN·SEOUAADJ due ta a hemilateral riglrt-siclad dieruption of the spinal cord at the level
Loss of fine tactile sensation as well as loss of postural sense and vibration (gross touch sensation remains functionally normal).
of the 11t1o thoracic Hgment IT11 1. On the right side (ipsilateral): loss of motor function (initially flaccid, later spastic); loss of fine discriminative tactile sensation as well as loss of postural sense and vibration (gross touch sensation remains functionally normal). On the left side (contralateral): loss of pain and temperature sensation!... Fig. 12.186).
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Spinel cord
Autonomic nervous system, functional overview
"Prag•nglanlc" ·~glionic"
Fig. 12.1" Autonomic n81Y0ua..,nem CSympathicuaand Paroympathi-1. [22] The autonomic nervous system comprises the sympathetic (green), parasympathetic (purple), and the enteric nervous system (blue). The neurons of the Sympathi- locate in the intermediolateral horn of the thoracolumbar section of the spinal cord. Their axons project to the sympathetic chain of ganglia and to the ganglia of the enteric system. Here they synapse to postganglionic neurons which project to the target organs. The sympathetic activation servas to mobilise the body in case of an emergency. The adrenal medulla is part of the sympathetic system and secretes adrenaline and noradrenaline.
Nucleer arees of the Paraaympathi-locate in the brainstem and the sacral part of ttl e spinal cord. Their alWns project to ganglia adjacent to the target organs which locate in the head, thorax, and the abdominal cavity. Here synapsing onto postganglionic neurons occurs, which reach the target organs via short alWns. The parasympatnetic system has important roles in food intake and digestion, sexual arousal, and opposes the sympathetic system. The ant.ric nlmfCiu ..,nem regulates the intestinal activity and is modulated by sympathetic and parasympathetic influences.
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Brain and Spinal Cord
General
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Spinal cord
Central motor system Components of the Motor System •nd their Functions 1141
Components
Functions
Spinal cord (Medulla spinalis)
• •
autonomous execution of elementary functions (stretch and flexor reflexes) 7 spinal basic system target organ for supraspinal motor commands
Centres in the brainstem (i.e. Nucleus ruber, Formatio reticularis, lower olivcuy nuclear complex, Nuclei pontis)
•
• •
regions and the extrapyrs mid aI tracts arising from them contributing to the fine-tuning of voluntary movements centres for the motor regulation of ocular movements
Cerebellum
• • •
control of equilibrium control of stance and precision movements coordination and timing of precision movement s {fine-tuning and modulation)
Basal ganglia (Striatum, Pallidum, Nucleus subthalamicus and Substantia nigra)
•
programming of precision movements (fine-tuning and modulation)
Motor cortex regions and pyramidal tract
•
initiation of movement strategies and programs through associat ion areas and secondary motor cortex areas execution of voluntary movements via the precentral motor cortex 7 pyramidal tract 7 spinal cord
particulary involuntary motor regulation of posture and gait as we ll as coordination of movement s (7 ordered sequence of voluntary movements) through numerous nuclear
•
Action impulse
Action plan
Programming
Nuclelollvan~S
inferiores
Exec:ullon
Recepton;
Fig. 12.194 Simplified schemo~tlc representilltlon of the organisetion of the somatomotor system. [141 The current assumption is that the inner motivation for motor activity (the initial motor action impulse) initiates in the limbic system. From here, these impulses reach association areas {e.g. in the prefrontal cortex) and a strategic action plan for this movement is created. The realisation requires the inclusion of secondary motor areas which plan the details of the intended movement and fine-tune the motion program through feedback from the Cerebellum and the basal ganglia. Once the pl•nning phase of the intended movement is com plated, the so modu-
342
lated motion program is transmitted to the Thalamus and from here to the motor areas, particularly to the motor cortex that signals the beginning of the execution phase. The pyramidal tract originates at the motor cortex and projects into the spinal cord, where the information reaches the muscles. The inferior olivary nucleus and the Cerebellum receive copies of the motion program to initiate modulations and/or corrections of the motor action in a timely fashion. In addition, extensive sensory feedback loops exist between peripheral receptor systems and all structures involved in the motion program to ensure a smooth execution of the motor action.
Appendix Picture Credits .................... 345 Abbreviations, Terms, etc. . . . . . . . . . 347 Index ............................. 349
Picture Credits The editors sincerely thank all clinical colleagues that made ultrasound, computed tomographic and magnetic resonance images as well as endoscopic and intraoperative pictures available: Prof. Altaras, Center for Radiology, University of Giessen (Figs. 2.18; 2.39; 2.40) Prof. BrOckmann and Dr. Linn, Neuroradiology, Institute for Diagnostic Radiology, University of Munich (Fig. 4.148) Prof. Daniel, Department of Cardiology, University of Erlangen (Fig. 10.39) Prof. Galanski and Dr. Schafer, Department of Diagnostic Radiology, Hannover Medical School (Figs. 2.97; 5.3; 5.1 03; 6.31; 6.129) Prof. Gebel, Department of Gastroenterology and Hepatology, Hannover Medical School (Figs. 6.73; 6.75; 6.76; 6.94; 6.95; 7.25) Dr. Greeven, St. Elisabeth Hospital, Neuwied (Figs. 4.96; 8.96) Prof. Hoffm
Additional illustration• were obtained from the following textbooq: 1 Benninghoff-Drenckhahn: Anatomie, Band 1 (Drenckhahn D., editor), 17. Aufl., Urban & Fischer 2008 2 Benninghoff-Drenckhahn: Anatomie, Band 2 (Drenckhahn D., editor), 16. Au fl., Urban & Fischer 2004 3 Benninghoff-Drenckhahn: Taschenbuch Anatomie (Drenckhahn D., Waschke, J., editors), Urban & Fischer 2007 4 Berchtold, R., Bruch, H.-P., Trentz, 0. (editors): Chirurgie, 6. Aufl., Urban & Fischer 2008 5 Boeker, W., Denk, H., Heitz, P. U., Moch, H. (editors): Pathologie, 4. Aufl., Urban & Fischer 2008 6 Classen, M., Diehl, V., Kochsiek, K., Berdel, W. E., Bohm, M., Schmiegel, W. (editors): lnnere Medizin, 5. Aufl., Urban & Fischer 2003 7 Classen, M., Diehl, V., Kochsiek, K., Hallek, M., Bohm, M. (editors): lnnere Medizin, 6. Aufl., Urban & Fischer 2009 8 Drake, R. L., Vogl, A. W., Mitchell, A., Paulsen, F. (editors): Gray' s An atom ie tar Studenten, 1. Aufl., Urban & Fischer 2007 9 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Anatomy for Students, 2nd ed., Churchill Livingstone 2010 10 Drake, R. L., Vogl, A. W., Mitchell, A.: Gray's Atlas der Anatomie, Urban & Fischer 2009 1 1 Fleckenstein, P., Tranum-Jensen, J.: Rontgenanatomie, Urban & Fischer 2004 12 Forbes, A., Misiewicz, J., Compton, C., Ouraishy, M., Rubesin, S., Thuluvath, P.: Atlas of Clinical Gastroenterology, 3'd ed., Mosby 2004 13 Franzen, A.: Kurzlehrbuch Hals-Nasen-Ohren-Heilkunde, 3. Aufl., Urban & Fischer 2007 14 Garzorz, N.: BASICS Neuroanatomie, Urban & Fischer 2008 15 Kanski, J. J.: Klinische Ophthalmologie, 5. Aufl., Urban & Fischer 2003 16 Kanski, J. J.: Klinische Ophthalmologie, 6. Aufl., Urban & Fischer 2008 17 Kauffmann, G. W., Moser, E., Sauer, R. (editors): Radiologie, 3. Aufl., Urban & Fischer 2006 18 Lippert, H.: Lehrbuch Anatomie, 7. Aufl., Urban & Fischer 2006 19 Mettler, F. A. (editor): Klinische Radiologie, Urban & Fischer 2005 20 Moore, K., Persaud, T.V. N., Viebahn, C. (editors): Embryologie, 5. Aufl., Urban & Fischer 2007 21 Schulze, S.: Kurzlehrbuch Embryologie, Urban & Fischer 2006 22 Speckmann, E.-J., Hescheler, J., Kohling, R. (editors): Physiologie, 5. Aufl., Urban & Fischer 2008 23 Trepel, M.: Neuroanatomie, 4. Aufl., Urban & Fischer 2008 24 Welsch, U.: Sobotta Lehrbuch Histologie, 2. Aufl., Urban & Fischer 2005 25 Welsch, U., Deller, T.: Sobotta Lehrbuch Histologie, 3. Aufl., Urban & Fischer 2010 26 Welsch, U.: Atlas Histologie, 7. Aufl., Urban & Fischer 2005 27 Wicke, L.: Atlas der Rontgenanatomie, 7. Aufl., Urban & Fischer 2005 28 Rangier, F.: BASICS Leitungsbahnen, Urban & Fischer 2009 The following illustrators have developed the new illustrations: Dr. Katja Dalkowski: Figs. 8.42, 9.52, 10.12, 10.15, 10.26, 10.50, 11.63, 11.76, 12.10, 12.51 , 12.87,12.89, 12.91, 12.98, 12.152, 12.175,12.176 Sonja Klebe: Figs. 8.153, 8.163, 9.22, 10.9, 11.9, 11.14, 11.31, 11.35, 11.37, 11.39, 11.81, 12.11, 12.12,12.99, 12.100, 12.138,12.139, 12.141, 12.142, 12.148, 12.153, 12.154 Jorg Mair: Figs. 9.19, 11.69, 12.1, 12.131, 12.142, 12.143, 12.144, 12.145, 12.149, 12.150, 12.155, 12.156, 12.157, 12.158, 12.160, 12.161, 12.162, 12.163 Stephan Winkler: Figs. 8.57, 8.144
345
1. List of abbreviations Singular: A. Lig. M. N. Proc. R.
v.
Var.
Plural: Arteria Ligamentum Musculus Nervus Processus Ramus Vena Variation
Aa. Ligg. Mm. Nn. Procc. Rr.
Vv.
Artariaa Ligamenta Musculi Nervi Processus Rami Venae
female male
Percentages: In the light of the large variation in individual body measurements, the percentages indicating size should only be taken as approximate values.
2. General terms of direction and position The following terms indicate the position of organs and parts of the body in relation to each other, irrespective of the position of the body (e.g. supine or uprightl or direction and position of the limbs. These terms are relevant not only for human anatomy but also for clinical medicine and comparative anatomy.
longitudinalis= parallel to the longitudinal axis (e.g. Musculus longitudinalis superior of the tongue) sagitta/is = located in a sagittal plane transversalis = located in a transverse plane transversus= transverse direction (e.g. Processus transversus of a thoracic vertebral
General terms
anterior- posterior= in front- behind (e.g. Arteriae tibiales anterior et posterior) ventralis - dorsalis = towards the belly -towards the back superior-inferior= above- below (e.g. Conchae nasales superior et inferior) crania/is- cauda/is= towards the head- towards the tail dexter- sinister= right -left (e.g. Arteriae iliacae communes dextra et sinistral intemus- externus = internal- external superficialis- profundus= superficial- deep (e.g. Musculi flexores digitorum superficia lis et profundus) medius, intermedius= located between two other structures (e.g. the Conchs nssslis medis is locsted between the Conchse nsssles superior and inferior) medianus = located in the midline (Fissura mediana anterior of the spinal cord). The median plane is a sagittal plane which divides the body into right and left halves. medialis -latera/is= located near to the midline -located away from the midline of the body (e.g. Fossae inguinales medialis et latera lis) frontalis= located in a frontal plane, but also towards the front (e.g. Processus frontalis of the maxilla)
Terms of direction and position for the limbs proxima/is - distalis = located towards or away from the attached end of a limb or the origin of a structure (e.g. Articulationes radioulnares proximalis et distalis)
for the upper limb: radialis- ulnaris = on the radial side- on the ulnar side (e.g. Arteriae radialis at ulnaris) for the hand: palmaris- dorsalis= towards the palm of the hand- towards the back of the hsnd (e.g. Aponeurosis pslmsris, Musculus interosseus dorsalis) for the lower limb: tibialis- fibularis =on the tibial side- on the fibular side (e.g. Arteria tibialis anterior) for the foot: plantaris -dorsalis = towards the sole of the foot - towards the back of the foot (e.g. Arteriae plantares latera lis et medialis, Arteria dorsalis pedis)
3. Use of brackets [ ]: Latin terms in square brackets refer to alternative terms as given in the Terminologia Anatomica (1998), e.g. Ren INephros[. To keep the legends short, only those alternative terms have been added that differ in the root of the word and are necessary to understand clinical terms, e.g. nephrology. They are primarily used in figures in which the particular organ or structure plays a central role.
( ): Round brackets are used in different ways: - for terms also listed in round brackets in the Terminologia Anatomica, e.g. (M. psoas minor) - for terms not included in the official nomenclature but which the editors consider important and clinically relevant, e.g. (Crista zygomaticoa lveolaris) - to indicate the origin of a given structure, e.g. R. spinalis (A. vertebralis).
347
Index
A Abdominal reflex 336 Abducens nerve palsy 114,223,301 Abduction, temporomandibular joint 37 ACHILLES tendon reflex 336 Acoustic awareness 158 Acoustic meatus 138, 140, 152 Acoustic neurinoma 152, 310,313 Acrocephaly 21 Acromegaly 244 Acromion 167, 198 ADAMKIEWICZ' s, artery of [A. radicularis magnal 328 Adduction, temporomandibular joint 37 Adenectomy 175 Adenohypophysis 223, 241,244 Adenoids 175 Adhesio interthalamica 242, 248, 259, 263264, 269,285, 292 Aditus - laryngis 83, 175, 189 - orbitalls 107 Aequator Iantis 125, 128 Aerotympanal conduction 138 Age-dependent macular degeneration (AMDJ 129 Agger nasi 65 Akromegaly 244 Ala - cristae galli 12 - lobuli centralis 249, 253 - major [Os sphenoidale) 6, 12, 14, 18, 27-31, 44, 78, 102- 103, 109, 112, 114, 121, 149 - minor [Os sphenoidalel 6, 28-31, 102 - nasi 58 - vomeris 14, 24 Alexia, cerebral infarction 270 Alveolus[-i) dentalis[-es) 23, 29 - molaris 85 Alveus hippocampi 261-262, 279-280, 285286 ALZHEIMER's disease 265 Amacrine cells, Retina 298 Amaurosis, cortical blindness 132 AMD [age-dependent macular degenerationl 129 Amiculum olivare 257 Ampulla - canaliculi lacrimalis 111 - membranacea - - anterior 154, 312 - - lateralis 154,312 - - posterior 154, 312 - ossea - - anterior 153 - - latera lis 153 - - posterior 153 Anal reflex 336 Anencephaly 228 Angiogram - A . carotis interna 217 - digital subtraction angiography [DSAJ 217 Angulus - iridocornealis 125 - mandibulae 6, 34-36, 45 -oculi - - lateralis 104, 106 - - medialis 104, 106 - scalenovertebralis 210 - sphenoidalis 6 Ankle-jerk reflex 336 Anophthalmia 101 Anosmia 67, 297 - septum deviation 63 Ansa - cervicalis 51, 199, 202,208 --profunda 89,198-202,204-205,322323 - - superficialis 47, 197 - GALEN I [GALEN's anastomosis) 189 - subclavla 209-210 - tendin is (M. digastricusl 84
Anterior cervical region 162, 164 - vessels and nerves 196, 198 Anterior commissure 239 Anterior cranial base 14, 26 Anterior cranial fossa 12, 122 Anterior epithelial layer of the lens 101 Anterior lateral fontanelle 19 Anterior scalene hiatus 168 Anterior spinal artery syndrome 328 Anterior spinocerebellar tract 338 Anterior triangle of the neck 164 Antihelix 139 Antitragus 139 Antrum mastoideum 145 Anulus - fibrocartilagineus 141 , 143-144, 146-147 - iridis - - major 127 - - minor 127 - tendineus communis (tendinous anulus of ZINNI 112, 114- 115, 300 - tympanicus 18, 20 Anvil [lncusl 142 Aorta 329-330 - abdomina lis See Pars abdominalis aortae - thoracica See Pars thoracica aortae Apertura - canaliculi - - cochleae 33 - - vestibuli 33 - externa canalis carotici 15-16, 33, 82, 149, 222 - interns - - canalis carotici 17, 222 - - canalis optici 13 - lateral is ventriculi quarti (Foramen of LUSCHKAI 246- 248, 258-259, 288 - mediana ventriculi quarti 258-259, 292 - piriformis 5, 18, 26 - sinus - - frontalis 25 - - sphenoidalis 25, 30, 65 - thoracis superior 205 Apex - cornu posterioris (Medulla spinalis) 334 - cuspidis 70 - linguae 81, 86-87 - partis petrosae 33, 152, 268 - radk:is dentis 70 Aphasia, cerebral infarction 270 Aphonia 185 Aplasia, paranasal sinuses 63 Aponeurosis - linguae 83 - palatine 82, 149 Apoplexy 256, 270 Apparatus lacrimalis 11 0- 111 Aqueductus - mesencephali 234, 241, 245, 248, 252, 258-259,264,269, 274-275,279,286-287 - vestibu li 152 Arachnoid mater 226-227 - cranialis 219,226-227, 229, 268, 277, 281 - spinalis 325, 329 ARAS (asecending reticular activation system) 243 Arbor vitae 248 Arcus - alveolaris (Mandibulal 34-35 - aortae 209, 319 - cartilaginis cricoideae 166, 175-176, 180184,188 - dent alis - - mandibularis 69 - - maxillaris 69 - palatoglossus 68, 80-82 - palatopharyngeus 68, 80, 82, 175-176, 179 - palpebralis - - inferior 107, 118 - -superior 107, 118 - supercilia ris 5, 22 - venosus jugularis 166, 197, 204 - zygomaticus 5, 7, 14-15, 27, 42-44, 62, 76
Area - cochleae 155 - cochlearis 152-153 - hypothalamica lateralis 244 - nervi facialis 152 - postrema 246, 264 - striata 131 - subcallosa 241, 266, 277,285- 286,296 - vestibularis 246 - - inferior 152 - - superior 152 Arteria(-ae) - alveolaris - - inferior 48-52,63,76, 94, 216 - - superior - - - anterior 49, 5276, 79 - - - posterior 49, 52, 76, 79 - angularis 46,48-52, 107, 216 - auricularis - - posterior 48, 51- 52, 139, 196, 199, 216 - - profunda 49, 52 - axillaris 201 , 203 - basilaris 216-217, 227, 240-241, 248, 266270, 275, 278,288, 292 - buccalis 48-52, 216 - callosomarginalis 217, 225, 240, 277, 282, 285 - canalis pterygoidei 49, 79, 222 - caroticotympanicae 222 - carotis - - communis 43, 51- 62, 56- 67, 89, 166, 168-169, 178- 179, 192, 194, 198-201, 203-206,209-210,216-21~314, 319,
322 - - externa 48-50, 52-53,76, 88, 107, 139, 174, 178, 194, 198-201, 208, 216-217, 300,314 - - - branches 52 - - interne 45, 48, 50, 52, 77, 79, 91, 107, 109, 115-119, 121, 131-132, 147-148, 150-151,174,178-179, 200-201,21621~222-223, 22~266-269,288,293,
308, 314, 322 - - - angiogram 217 - - - arteriosclerotic alterations 223 - - - DSA 217 - - - parts 222 - - - radiograph 217 - centralis(-esl - - anterolaterales 240, 256, 267 - - - bleedings/occlusions 240 - - anteromediales 256, 267 - - posteromediales 267 - - retinae 63, 100, 116, 118, 126, 131 - cerebri - - anterior 217,222, 260, 266, 269, 271272,27~281-288, 292-293
- - media 217, 222, 240, 266-268, 270-272, 276-277,280,283,287-289 - - - branches 270 - - posterior 131, 217, 240-241, 266-269, 271-272,278- 279, 285- 289,293 - cervicalis - - ascendens 199-201,203, 210, 328 - - profunda 203, 209-210,328 - - superficialis 199- 200,203, 210 - choroidea anterior 131, 222, 266-267, 272 - ciliares 119, 131 - - anteriores 118, 126 - - posteriores - - - breves 116, 126 - - - longae 116, 118, 126 - cochlearis 155 - communicans - - anterior 266-269, 277, 287 - - posterior 217, 222, 266-268, 278, 287288 - conjunctivales - - anteriores 118, 126 - - posteriores 118 - dorsalis - - nasi 50, 116, 118-119 - - scapulae 200, 210
349
Index
Arteria(-ae) - episclerales 118, 126 - ethmoidalis - - anterior 66, 116-1 20 - - posterior 66, 116, 118-120 - facial is 46-52, 63, 90, 93, 166, 178,200-
201,204-205,208,216 -
- branches 52 frontobasalis 266 - lateralis 266, 270 - medialis 272 hyaloidea 100-101 hypophysialis - inferior 222 - superior 222 inferior - anterior cerebelli 217, 266-268,270 - posterior cerebelli 203,217, 266-268,
270 - infraorbitalis 49, 51-52, 76, 79, 107, 120,
124,216 -
infratrochlearis 107 insulares 240 intercostalis - posterior 203, 328-329 - - prima 203 - - secunda 203 - suprema 203,210 labialis - inferior 52 - superior 52, 66 labyrinthi 155, 266, 268 - thrombotic occlusions 155 lacrimalis 107, 109, 116-119 laryngea - inferior 189, 200 - superior 52, 87, 95, 173, 179, 189-190,
Arteria(-ae) - scapularis descendens 203 - sphenopalatine 49, 51-52, 66, 79, 216 - spinalis - - anterior 203, 266-267, 328-329 - - posterior 203, 328-329 - - segmentalis 328-329 - spiralis modioli 155 - stylomastoidea 52 - subclavia 168, 179, 194, 198-201, 203,205,
209-210,316,319,328 -
216 -
temporalis - media 49, 51-52 - profunda 216 - - anterior 49, 52 - - posterior 49,51-52 - superficialis 43, 46-49, 51-52, 107, 139,
-
- - branches 52 thalamotuberalis 267 thoracica interna 200-201, 203, 209-21 0 thoracoacromialis 201 thyroidea - inferior 178-179, 189, 192, 194, 200-201,
216
203,210
194,198-200,208,210 - lenticulostriatae 256 - lingualis 48, 50-52,63,88-89, 93, 95, 178, -
194,199,208,216 - branches 52, 88 lumbales 330 masseterica 48-50, 52 maxillaris 48-52, 76, 79,216 - branches 49, 52 - variations of the course 49 medullaris segmentalis 203, 328-329 meningea - media 49, 51-52, 117, 216, 220, 268 - posterior 52, 178, 268 mentalis 48 mesencephalicae 267 nasales posteriores laterales 52, 66 nasopalatine 52, 66 occipitalis 48, 51-52, 89, 91, 179, 196-198,
200-201, 216 - - branches 52 - - medialis 280-281 - ophthalmica 115-121, 123-124, 131-132,
216-217,222-223,268,292-293 - - branches 118 - palatina[-ae) - - ascendens 51-52, 178, 189 - - dascendens 49,52, 79,216 - - major 52, 66, 79-80 - - minores 52 - palpebrales - - laterales 107, 118 - - mediales 107, 118 - parieta lis posterior 225, 270 - pericallosa 240, 260, 269, 277-278, 280-
286
-
pericardiacophrenica 21 o pharyngea ascendens 52, 178, 216 - branches 52 pontis 267 profunda linguae 52, 88 pterygomeningea 49 radicula ris magna [artery of ADAM Kl EWI CZ)
328 - disruption (radicular artery syndrome) 328 - sacralis latera lis 328
350
- stenosis 200 - variations in branching 203 sublingualis 51-52, 88, 95, 194 submentalis 49, 51-52, 93, 199-201,216 sulci - centralis 225, 270 - postcentralis 225, 270 - precentralis 225, 270 superior cerebelli 266-268, 288 supraorbitalis 47, 107, 116-119, 124,216 suprascapularis 198,200-201, 203, 210 supratrochlearis 48-49, 107, 116, 118-119,
- - superior 52, 93, 175-176, 178, 194, 198-
201,205,208,210,216 -
- - branches 52 transversa - calli 198-201,205 - faciei 49, 52, 107, 216 triangularis 270 tuberis cinerei 267 tympanica - anterior 49, 52 - inferior 52 - posterior 52, 143 - superior 52 vertebralis 91, 192, 200, 203, 209-21 0, 216-21~22~248,266-270,288,328
- - branches 203 - - variations of the level of entry 203 - vestibu laris anterior 155 - zygomaticoorbitalis 48-49, 52 Arteriola - macularis - - inferior 129 - - superior 129 - medialis retinae 129 - nasalis retinae - - inferior 129 - - superior 129 - temporalis retinae - - inferior 129 - - superior 129 Arteriosclerotic alterations of the Pars cavernosa (A. carotis internal 223 Arthrosis - crico-arytenoid joint 183 - temporomandibular joint 38 Articulatio(-nes) - atlantoaxialis lateral is 168 - cricoarytenoidea 180-1 82, 184, 190 - cricothyroidea 1B1, 183 - incudomallearis 142-143 - incudostapedialis 142-143 - ossicu lorum auditus 143 - temporomandibularis 7, 36-39, 42-44 Ascending reticular activation system (ARAS) 243
Association areas, cerebral hemispheres 237 Association areas, cortical 237, 342 Association tract 254 - long fi bras 254 - short fi bras 254 Ataxia 253 - lesions of the thalamic nuclei 243 Atlas 168 Auditory cortex 237 Auditory ossicles 136, 138, 142-143 - development 136 - differentiation 136 - ossification mode 20 Auditory pathway 159 Auditory pit 136 Auditory tube 137-138, 141, 146, 149-150,
155,308,314 - cartilage 82, 149 - development 136 - inflammation 149 - occlusion 143 Auricle 138-140 - arteries 139 - cartilage 140 - defects 137 - development 136 - dysplasia 137 - muscles 140 - rudimentary 137 - sensory innervation 139 Auricula 138-140 - interna 155 Auricular hillocks 136 Auricular perichondritis 140 Auris 138 - interna 138, 151, 155 - media 138, 148 Autonomic ganglia ofthe head 96 Autonomic nervous system 214, 341 Axillary region 201 Axis - externus bulbi 125-126 - internus bulbi 125-126 - lentis 128 - opticus 125
B BABINSKI's reflex, lesions of the pyramidal tract 257 Basal ganglia 240, 257, 342 - blood supply 240 - damage 240 - motor activity 342 Basal lamella, para nasal sinuses 65 Basal lamina 156 Basis - cochleae 153 - (Cornu posterius, Medulla spinalis) 334 - cranii - - externa 14-16 - - interne 12-13, 17, 268 - mandibulae 34 - stapedis 142 BECHTEREW, nucleus of (Ncl. vestibularis superior) 160, 294, 313 BELL's phenomenon, paralysis of theN. facialis 105, 310 Biceps reflex 336 BICHAT's fat pad (Corpus adiposum buccae) 40, 42, 90 - cachexia in tumour patients 42 B ifurcatio carotidis 52, 194 Bipolar ganglionic cells, Retina 131 Bitemporal hemianopsia 132, 299 BLANDIN's gland (GI. lingua lis anterior) 83, 96 Blepharitis 108 - seborrheic 108 Blind spot (Disc us nervi optici) 125, 129 B load-brain barrier, lack of 265 Blood-CSF barrier 264 Blow-out f racture 103
Index
BOETTCHER's cells, organ of CORTI 156 Bolus aspiration 176 Bone conduction 138 Bony labyrinth 152-153, 155 BOWMAN's membrane (lamina limitans anterior) 125 Brachiofacial paralyses 271 Brachioradia lis reflex 336 Brachium colliculi - inferioris 246-247 - superioris 131, 246-247 Brain 131. 226-227 - arterial circle/ring 267-268 - arteries 225, 266, 272 - atrophy 232 - average volume 231 - deep veins 273 - development 228-229 - fronta I section 277-280 - herniation 230 - horizontal section 281 -287 - medial surface 269 - MRI 274-276 - sagittal section 288-289 - superficial arteries 225 - veins 225, 272 - ventricles 258 Brain abscesses, Otitis media 144 Brain vesicle 100 Brainstem 239,246-248, 251, 269 - development 229 - functional overview 290 Brainstem centres, motoric function 342 Bregma 8 Bridging veins 225 - lesions, subdural haematomas 225 BROWN-S~QUARD syndrome 333 - hemiplegia 340 BROYLE's tendon (tendon of the vocal ligament) 182, 190 BRUCKE's muscle (M. ciliaris) 127 Bucca 68 Bulbus - corn us posterioris (Ventricu Ius latera lis) 283 - inferior venae jugularis 178-179, 199 - (Medulla oblongata) 231 - oculi 112, 119, 121, 124-126, 130-132, 274-
275 - - external and internal bulbar axes 126 - - testing the function of the extra-ocular muscles 113 - olfactorius 60, 67, 227, 234, 238, 266, 288,
292,296-297 - superior venae jugularis 178-179, 218,224 Bulla ethmoidalis 65-66 BURDACH's tract (Fasciculus cuneatus) 246-
247, 334, 336-337 Bursa infrahyoidea 183, 188
c Calcar avis 261-263,280, 284-285 Callosotomy, epilepsy 260 Caloric nystagmus test 158 Calvaria 10-11, 219 Ca lvarian bones, fractures 11, 220 Camera - anterior bulbi 125, 127, 130 - articula ris - - inferior (Art. temporomandibularis) 37 - - superior (Art. temporomandibularis)
37 - posterior bulbi 125, 127 - postrema (vitrea) bulbi 125, 130 CAM PER plane 7 Canaliculus - lacrimalis - - inferior 110-111 - - superior 110-111 - mastoideus 14, 16 - - contents 16 - posterius (labyrint h us osseus) 152
Canalis(-es) - caroticus 13-15,33, 82, 144-146, 149-150,
152,268 -
- contents 16-17 centralis 248, 258-259, 269, 334-335 condylaris 12, 14-1 7 - contents 16-17 diploici 219 incisivus 10, 24-25, 59 infraorbitalis 28-29, 76, 102 mandibulae 75-76 musculotubarius 33 nasolacrimalis 26, 102 nervi - facialis 145-147, 152, 312 - hypoglossi 10, 12-17,36, 268,322 - - contents 16-17 opticus 12-13, 17,28-29,31, 102, 115, 117,
120-121,130,268 - - contents 17 - - neurovascular structures 115 - palatinus major 29, 78 - palatovaginalis 78 - pterygoideus (VI DIAN canal) 29-30, 78 - radicis dentis 70 - semicircularis(-es) 138, 143, 155 - - anterior 151-155 - - lateralis 146, 148, 151-154 - - posterior 151-1 54 - spiralis - - cochleae 152 - - modioli 152 - vertebralis 330, 333 CANNON-BOHM's point 318 Capsula - articularis - - (Art. temporomandibularis) 36-37, 42-45 - - cricothyroidea 181, 184-185 - externa 240, 255-257, 277-279, 283-285 - extrema 255-257, 277-279, 283-285 - interna 240, 242-243,255-257, 261,263,
272,276-280,282-286,288-289,293 - - arteries and tracts 256 - - vascular occlusions 256 - Iantis 128 Caput - (Cornu posterius, Medulla spinalis) 334 - inferius [M. pterygoideus lateral is) 44-45 - mallei 142, 144, 146,312 - mandibulae 34-35, 37-38, 44-45, 140 - nuclei caudati 240, 247, 256-257, 262-264,
274,276-278,282-286,288 - stapedis 142, 146 - superius (M. pterygoideus lateralis) 44-45 Carotid artery siphon 222 Carotid bifurcation 21 6 Carotid loop 174 - peritonsillar abscess 174 - tonsillectomy 174 Carotid sheath 169 Carotid sinus syndrome 216 Carotid tributary 266 Cartilage-free area, nose 58 Cartilago[-ines) - ala ris(-es) - - major 58-60 - - minores 58 - arytenoidea 180-186, 190 - auriculae 91 - corniculate 180-181, 183, 185-186 - cricoidea 95, 166, 180, 182, 185-186, 191 ,
210 -
cuneiformis 185-186 epiglottica 83, 175-176, 180-183, 188, 191 laryngis 181. 183 nasi 58 - accessoriae 58 - latera lis 58, 60, 91 septi nasi 58-59 thyroidea 83, 87, 95, 166, 173, 175-176,
179-186,188-194,210 - tracheales 173, 181-182, 184-186, 188,
191 - 192
Cartilago (-ines} - triticea 181, 184-186 - tubae auditivae 82, 149-150, 179 Caruncula - lacrimalis 104, 110-1 11 - sublingualis 92, 94-95 Cataracta sen ilis 128 Cauda - equina 325, 327, 330, 332 - helicis 140 - nuclei caudati 240, 263-264, 278-280,
283-286, 289 Cauda equine syndrome 324 Cavernous sinus syndrome 223 Cavernous sinus thrombosis 223 Cavitas - conchae 139 - coronae 70 - dentis 70 - infraglottica 188, 191 - nasi 25, 28, 36, 60, 62, 66, 91, 122, 130,
175 -
oris 68, 80, 176 - propria 68, 82 pharyngis 190 tympani 77, 137-138, 140-141, 143-147,
152, 312,314 Cavum septi pellucidi 262-264, 282 Cellulae - ethmoidales 27-28, 61, 63-64, 103, 114,
121-122,124, 130,274 - - anteriores 60, 62 - - entrance 60 - - posteriores 60, 62 - mastoideae 145, 148 - pneumaticae 150 - tympanicae 145, 152 Cementum 70 Cenencephalocele 230 Central facial nerve palsy 54, 310 Central venous thrombosis 124 Centrum semiovale 239,260 Cerebellar compartments, afferent and efferent connections 251 Cerebellar cortex 250-251, 253 - LARSELL's classification 252-253 - overview 252 Cerebellar hemispheres, structure 252 Cerebellar nuclei 250-251 Cerebellar peduncles 246 Cerebellar vermis 253 - overview 252 Cerebellopontine angle, tumour (vestibularis schwannoma) 313 Cerebellum 215, 229, 231 , 246, 248-250, 255,
258,270,275, 279,339, 342 - basic flow of information 251 - functional overview 290 - medulla 250 - motor function 342 - paravermal zone 251 Cerebral aneuryms - Circulus arteriosus cerebri [WILLIS II) 267 - rupture 267 Cerebra I cortex, primary grooves, location/projection 233 Cerebral fluid, production 261 Cerebral hemispheres - arteries 271 - association areas 237 - functional cortical areas 237 - grooves 234-235 - gyri 234-236 - primary cortical areas 237 - secondary cortical areas 237 Cerebra I infarction (ischaem ic stroke) 256, 270 Cerebrospinal fluid, impaired drainage 265 Cerebrospinal fluid rhinorrhea 67 Cerebrum 131, 215, 232 - functional overview 290 - gyri 232, 234-236 - lobes 233 - sulci 232, 234-235
351
Index
Cerumen obturans 141 Cervical cysts 193 Cervical fasciae 169, 171 Cervical fistulas 193 Cervical flexure (flexure cervicalisl. primary brain vesicles 228 Cervical lymph node metastases, injury of the N. hypoglossus 208 Cervical part of tooth 70 Cervix - (Cornu posterius, Medulla spinalis) 334 - dentis 70 Chalazion 108 Cheek glands 91 Cheilognathopalatochisis 80 Chiasma opticum 112, 115, 131-132,223, 234, 238-239,241 , 245,248,259,266,269, 274-275, 278, 292-293,299 - median lesions 299 Choana 15, 20, 36 Cholesteatoma 157 Chorda tympani 51 , 89, 96, 143-144, 146-148, 302,307-310, 312 - functional loss 147 - injury 307 - testing 147 Choroidea 101, 125-127 - primordium 100 Chylous f istula 207 Ciliae 104, 106, 123 Ciliary body 127 Cingulum 254 Circulus arteriosus - cerebri (WILLIS II) 217, 268 - - cerebral aneurysms 267 - iridis - -major 126 - - minor 126 Circumventricular organs 264 Cisterna - amblens 227, 279-280, 285-288, 293 - basalis 318 - cerebellomedullaris 227, 275 - chiasmatica 227, 259, 287 - fossae lateralis cerebri 227, 277-280, 283287, 289 - interpeduncularis 227, 241, 259, 274, 278, 287 - laminae terminalis 277 - lumbalis 332 - pericallosa 259, 277, 279-280, 283, 285286 - pontis 278 - pontocerebellaris 227, 240, 259, 278 - quadrigeminalis 280 CLAUDIUS' cells, organ of CORTI 156 Claustrum 240, 256-257, 277-279, 283-286, 289 Clavicula 166-167, 170- 171, 198, 201. 203, 205 Cleft pa leta 82, 150 Clivus 12- 13, 25, 31, 36 Closed-angle glaucoma 127 CNS (central nervous system) 214 - directional and positional informations 215 - organisation 231 Cochlea 134, 137-138, 148, 151-153, 155-156 - basal vortex 148 Cochlear labyrinth 138, 154, 159 Colliculus 180 - facialis 246, 259 - inferior 158-159, 215,243,246-247, 280, 287, 292 - superior 131- 132,215, 234,243, 245-247, 280, 286,292 Collum 204-205, 209 - mallei 142, 147 - mandibulae 35, 37-38 Columella 58 Columna - anterior (Medulla spinalis) 334-335 - fornlcis 238-239, 247-248, 257, 262-264, 274,278,283-286
352
Columns
Corpus(-ora) adlposum
- intermedia (Medulla spinalis) 334-335 - posterior (Medulla spinalis) 334-335 Coma, protrusion of the tongue 86 Commissura - alba 334 - - anterior 334 - anterior 182, 187, 236, 238-239, 241, 247248, 254, 259, 264,269,275, 278,285286, 288-289,292,296 - fornlcls 238-239, 284 - habenularum 241,254, 264 - lateralis palpebrarum 104, 106 - medialis palpebrarum 104, 106 - posterior 241, 247, 254, 264, 269,285 Commissural tracts 254 - heterotopic/homotopic fibres 254 Complete paraplegia 333, 340 Computed tomography (CTJ - chronic sinusitis 64 - eye 130 - head 265 - inner ear 148 - middle ear 148 - parapharyngeal abscess 170 - thyroglossal cyst 193 Concha - auriculae 139 - nasalis - - inferior 5, 25-26, 28, 59-61, 63-64, 66, 110 - - media 6, 25, 28, 59-61, 63-64, 66, 91, 110, 124 - - superior 25,60-61, 66 - sphenoidalis 30 Conductive hearing loss 142 Condylar fracture, temporomandibular joint 38 Condylus occipitalis 7, 14-15, 149, 173, 322 Cone (bipolar) cells, retina 131, 298 Confluens sinuum 218, 222, 224, 259, 292 Congenital deafness 137 Coniotomy 166 Conjunctiva 106 - inflammation 104 Conjunctivitis 104 Conus - elasticus 182-183, 185, 188, 191 - medullaris 325, 327, 332 Conus medullaris syndrome 324 Cornea 101, 123. 125, 127-128 - radius of curvature 126 - refractive Index 126 Corneal transplantation 124 Cornu - anterius (Medulla spinalis) 334-335, 338339 - frontale (Ventriculus lateral is) 239-240, 247, 258-259,262-264,272, 274,276-278, 282-285, 288,293 - inferius (Cartilage thyroidea) 180-181, 184185, 189 - laterale (Medulla spinalis) 334-335 - majus (Os hyoideum) 45, 51, 68,84-87, 94, 172-173, 181, 184-186, 189, 192 - minus (Os hyoideum) 68,84-87, 181, 184, 186, 192 - occipita Ia (Ventriculus latera lis) 230, 240, 242, 258-259. 261- 263, 274,280,284-285, 289 - posterius (Medulla spinalis) 334-335 - superius (Cartilage thyroidea) 179-181, 183186, 189, 192 - temporals (Ventriculus latera lis) 239-240, 257- 259, 261- 262,274-276,278-280, 286- 289,293 Corona - ciliaris 127 - clinics dentis 70 - radiata 256, 281 Coronal suture 8, 19 Corpus(-ora) - adiposum - - buccae (BICHAT's fat pad) 40, 42, 90
- - orbitae 63, 112, 115, 117, 123-124, 130 - - preepiglotticum 175-176, 181, 183, 188 - amygdaloideum 238-240, 278, 287, 289, 296 - callosum 233-234, 236, 238-240, 247-248, 254-255, 25~260-264,269,275-280,
-
282- 285, 288, 292 cavernosum (Saccus lacrimalis) 110 clliare 125, 127, 130 fornicis 238-241, 262, 269, 278, 283 geniculatum - laterals 131-132, 245-247, 255-256,279, 286,299 - mediale 158-159, 245-247, 279,286 incudls 142, 144, 146 linguae 81 , 86 mamillere 234, 238-239, 241 , 245, 248, 25~269,275, 278, 287
- destruction 238 - - alcohol abuse 238 - - memory loss 238 - memory function 238 mandibulae 6, 34-35, B4 maxillae 23, 102 medullare cerebelli 250 nuclei caudati 240, 243, 247, 261-264, 276, 278-279,282, 288 - ossis - - hyoidei 68,84-86, 184, 192 - - sphenoldalis 25, 29-30, 36, 102 - pineale 216 - striatum 339 - vertebrae 332 - vitreum 125, 130 Cortex 251 - cerebelli 250, 263 - cerebri 219 - Iantis 128 CORTI, organ of (Organum spirals) 134, 156 - BOTTCHER's cells 156 - CLAUDIUS' cells 156 - HENSEN's cells 166 - inner border cells 156 -inner hair cells 156,313 - inner phalangeal cells 156 - inner pillar cells 156 - interdental cells 156 - outer border cells 156 - outer hair cells 156 - outer phalangeal cells 156 - outer pillar cells 156 - outer tunnel 156 - tympanic amorphous substance 156 Cortical amaurosis 132 Cortical association areas 237, 342 Cortica I blindness 132 Cortica I projection tracts 256 Cranial arachnoid mater 2 26-227 Crania I base - external surface 14- 16 - - foramina (contents) 16 - fractures 8, 16 - internal surface 12-13, 17 - - foramina (contents) 16-17 - - passageways of vessels and nerves 268 Cranial defects 230 Cranial nerves 290, 294, 339 - course in the middle cranial fossa 292-293 - innervation sites 291 - nuclei 294-296 - nuclei of origin 295 - terminal nuclei 295 Cranlopharyngeoma 176 Craniostenoses 21 Craniosynostosis 21 Cranium 5, 19- 20 - bifidum 230 - of a newborn 18 Cremaster reflex 336 -
Index
Crico-arytenoid joint - arthrosis 183 - rheumatoid arthritis 183 Cricoid cartilage 180 Cricothyroid muscle 184 Crista - ampullaris 157 - arcuata 180 - conchalis 23 - ethmoidalis 23, 25 - fenestrae cochleae 153 - frontalis 11-12 - galli 10, 12, 24-25,28,222 - infratemporalis 14, 30,44 - lacrimalis - - anterior 23, 28-29, 102, 11 1 - - posterior 28-29, 102, 111 - nasalis 5, 10, 26, 59 - occipitalis - - externa 15 - - interna 12, 31 - sphenoidalis 24, 30 - supramastoidea 32 - transversa 152-153 - vestibu li 153 - zygomaticoalveolaris 23, 27 Crown of tooth 70 Crus(-ra] - anterius - - (Capsula internal 243, 255-256, 277, 284-286,288 - - (Stapes] 142, 146 - antihelicis 139 - breve (Incus] 142, 146 - cerebri 245, 257, 287, 293, 295 - fornicis 238-239, 261-263, 274, 279-280, 282-283,288 - hal icis 139 - laterale (Cartilage alaris major) 58, 60 - longum (Incus) 141-142, 146-147 - mediale (Cartilage alaris major) 58-59 - membranaceum - - commune 154 - - simplex 154 - osseum - - commune 152-153 - - simplex 153 - posterius - - (Capsula internal 243, 255-256, 284-286 - - (Stapes) 142, 146 Cryptae tonsillares 81 Culmen 248-249, 252-253 Cuneus 233,236,238,282-284 Cupula 157 - cochleae 152-153 - pleurae 21 0 Cuspis dentis 70 Cyclopia 101 Cymba conchae 139
D Dacryoadenitis 108, 111 - reduced eyelid opening 108 Dacryocystitis 111 Dacryolithiasis 111 Dacryostenosis 111 - persistent HASNER's membrane 111 Deafness, congenital 137 Declive 248-249, 252-253 Decussatio - lemniscorum 337 - pedunculorum cerebellarium superiorum 248,250 - pyramidum 255, 257, 327 DEITERS' nucleus (Ncl. vestibularis lateralis] 160,294,313 Dens(-tes) - axis 275 - caninus 69-73, 75-76, 80, 92 - decidui 18, 71,74 - ext ract us 85
Dens(-tes) - incisivus(-i) 69-73, 75-76, 80, 92 - molaris(-es) 28, 63, 69-73, 75-76, 80, 92 - - (serotinus] 69, 72-73, 75, 80, 92 - permanentes 72-74 - premolaris(-esl 69, 72-73, 75-76, 80, 92 Dental alveoli, upper jaw 23 Dental arch - lower jaw 69 - upper jaw 69 Dental fluorosis 73 Dental formula 71 - milk teeth 71 - of the adult 71 Dental root 70 Dentinum 70 DESCEMET's membrane (Lamina limitans posterior) 125 Desmodontium 70 Diabetes insipidus 244 Diaphragma - oris 84 - sellae 223 Diarthrosis 181 Diastatic fractures 8 Diencephalon 215, 228-229,231, 233, 241, 245,269 - development 229 Diffuse off-ganglion cells, retina 298 Digital subtraction angiography IDSAJ 217 Diploe (Calvaria) 11, 219-220 Diplopia - lesions - - of the N. abducens 112 - -of theN. trochlearis 112 - palsy of the oculomotor nerve 113 Disc prolapse 331 Discus - articularis (Art. temporomandibularis) 3739,44-45 - intervertebralis 330-332 - nervi optici (blind spot) 125, 129, 265 Distal 69-70 Dithalamic joint 37 Diverticulum, pharyngo-oesophageal 172 Dorsum - linguae 68, 80-82, 86, 89, 179 - sellae 10, 12-13, 24, 30,36 Dorsum of the tongue - innervation 81 - taste qualities 81 Drooping eye 41, 111 Dry eye 79 Dry mouth syndrome 92 DSA (digital subtraction angiography) 217 Ductuli excretorii (GI. lacrimalis) 107, 110 Ductus - cochlearis 154-157 - endolymphaticus 154-155 - lymphaticus dexter 57, 206 - nasolacrimalis 110-111 - - entrance 60 - parotideus (STENON's duct) 40, 42-43, 46, 90,92-93, 173 - reuniens 154 - semicircularis(-es) 137, 155 - - anterior 151, 154 - - lateralis 146, 151, 154 - - posterior 151, 154 - sublingualis(-es) - - major 94-95 - - minores 94-95 - submandibularis 63, 93-95 - thoracicus 206, 21 0 - thyroglossus 193 - - cyste 193 - utricu losaccula ris 154 Dura mater 154, 220-222 - cranialis 63, 115, 150, 219-220, 222-223, 225,229,268,296-297 - dural venous sinuses 224 - spinalis 175-176, 327, 329-332
Dural sac (subarachnoid space) 332 - opened 327 Dural venous sinuses 219, 222,224 Dysarthria, lesions of the N. hypoglossus 323 Dysdiadochokinesia 252 Dysmetria 252 Dysostosis mandibulofacialis (FRANCESCHETTI's syndrome) 137 Dysphagia, lesions of theN. hypoglossus 323 Dysphonia 185 Dystonia 240
E Ear 133-160 - cholestatoma 157 - development 136 Ear placodes 136 EDINGER-WESTPHAL nucleus (Ncl. accessorius nervi oculomotorii] 118, 291, 294-295, 301 Electroneurography, peripheral nerve palsy 311 Eminentia - a rcuata 10, 33 - collateralis 261, 286-287,289 - cruciformis 31 - medialis 246-247 - pyramidalis 145-147 Enamel defects - hypovitaminosis D (rickets) 73 - tetracyclines 73 Enamelum 70 Encephalo(cystolcele (Hernia cerebri) 230 Encephalon 214, 225-229,231, 274-282, 284-289 Endocrine orbitopathy 123 Endolymphatic space 157 Endoscop~ nasopharynx 175 Endotracheal intubation 182 Enophthalmos, blow-out fracture 103 Enteric nervous system 341 Ependymum 262 Epicritic sensibility, neurons 337 Epidural anaesthesia 331 Epidural bleeding 220 Epidural haematoma 11, 221 Epiglottic cartilage 180 Epiglottis 81, 89, 179, 185-187, 189 - acute bacterial infections 189 - position during swallowing 188 Epilarynx 186 Epilepsy - callosotomia 260 - split-brain operation 260 Epiphora 41, 111 Epistaxis, locus of KIESSELBACH 66 Epithelium anterius 125 Epitympanon 143 Equilibrium (balance) pathway 160, 313 - testing 158 ERB's point (Punctum nervosum) 47, 197 Ethmoid bone 22 Ethmoidal cells 122 - inflammation 28 EUSTACHIAN tube (Tuba auditiva laud itoria]) 137-138, 141, 144, 146, 149-150, 155, 308,314 - development 136 Excavatio disci 125 Exophthalmus 195 - hyperthyroidism 195 External acoustic meatus 140 External carotid artery 53 External genu of the facial nerve 307 External surface of cranial base 14-16 - foramina (contents) 16 Extra-ocular muscles 112, 114, 130 - function 113 - innervation 113 - nerve lesions 301 - palsies 114 Extrapyramidal motor system 339
353
Index
Eye movements, incoordination 253 Eye (Oculus) 104 - arteries 116 - computed tomography 130 - development 100-101 - developmental defects 101 - dryeye 79 - MRI 130 - nerves 121 - refractive index 126 - tear film, slit lamp examination 108 - ultrasound examination 130 - veins 116 Eye surfaces, structures 106 Eyeball (Bulbus oculi) 125, 130 - blood vessels 126 - dimensions 126 Eyelids 106 - inflammation 108
Facies posterior
Fissura(-ae) olbitalis
- - partis petrosae 33, 150 - temporalis - - (Ala major ossis sphenoidalis) 30, 149 - - (Os frontale) 43 - - (Os temporale) 22, 32 - vestibularis (Dens molarisl 70 Falx cerebri 219, 221-222, 272, 276, 292 Fascia - cervicalis 40-42, 90, 93, 166, 169-171,
- - superior 5, 12-13, 17, 28,30-31 , 102,
175-176, 191-192 - masseterica 90, 93, 171 - oesophagea 169 - parotidea 41, 90, 170 - pharyngobasilaris 172-173, 179 - temporalis 42 Fasciculus(-i) - anterolateralis 337 - cuneatus IBURDACH's tract) 246-247, 334,
336- 337 - gracilis (GOLL's tract) 246-247, 334, 336-
F Face, cleft formations 80 Facial muscles 40-43, 105, 173 Facial nerve, diagnosis 147 Facial nerve palsy 54 - BELL's phenomenon 105,310 - electroneurography 311 - narrowing of the palpebral fissure 104 - SCHIRMER's test 108,311 - stapedius reflex test 311 - testing of the motor functions 311 Facial region - ascending transmission of germs, cavernous sinus thrombosis 116 - Inflammations, sinus thrombosis 53 Facial skin, innervation 306 Facies - anterior - - (Iris) 125 - - (Lens) 127-128 - - (Maxilla) 23 - - palpebrae 106 - - partis petrosae 12, 33 - artlcularis - - (Art. temporomandibularis) 44 - - arytenoidea cricoideae 180 - - (Incus) 142 - - (Malleus) 142 - - (Os temporale) 32, 38 - - thyroidea 180, 182 - cerebralis - - (Os sphenoidale) 30 - - (Os temporale) 33 - contactus (Dens molaris) 70 - distalis (Dens molaris) 70 - externa - - (Os frontale) 22 - - (Os parietale) 43 - inferior linguae 83, 87, 92 - infratemporalis (Maxilla) 23 - interns - - (Os frontale) 29 - - (Squama frontalis) 24 - latera lis (Os zygomaticum) 5 - lingualis (Dens molarisl 70 - maxillaris (Os sphenoidale) 30 - medialis hamispherii carabri 269 - masialis (Dans molaris) 70 - nasalis (Maxilla) 23 - orbitalis - - (Ala major ossis sphenoidalisl 6, 28-30,
102 -
354
- (Maxilla) 23, 102-103 - lOs frontalel 102-103 - (Os temporale) 22 - (Os zygomaticumJ 5, 28, 102 posterior - (Cornea) 127 - (Iris) 125, 127 - (lens) 125, 128 - palpebrae 106
337 - interfascicularis (SCHULTZE's comma tractl 336 - interventricularis (triangle of PHILIPPEGOMBAULTJ 336 - longitudinalis - - inferior 254 - - medialis 158, 160, 248,250,257,336 - - superior 254 - mamillotegmentalis 244 - mamillothalamicus 238, 244, 257, 286 - medialis (Plexus brachialis) 201 - muscularis accessorius 172 - proprii - - anteriores 336 - - laterales 336 - - posteriores 336 - septomarginalis (oval bundle of FLECHSIG) 336 - uncinatus 254 Fastigium 248, 259 Fenestra - cochleae 145, 153-154, 157 - vestibuli 145, 152-153, 157 Fibrae - arcuatae cerebri 254 - circulares (M. clllarisl 125 - corticonucleares 243, 311 - corticoreticulares 243, 256 - corticorubrales 243, 256 - corticospinales 243, 255-256, 339 - corticothalamicae 243, 256 - meridlonalas (M . clliarisl 125 - occipitopontinae 255 - olivospinales 336 - parietooccipitopontinae 243 - parietopontinae 255 - pontocerebellares 339 - temporopontinae 255 - thalamoparietales 243, 256, 337 - zonulares 127 Filum(-a) - olfactoria 60, 67, 296 - - projections and synaptic connections 297 - radicularla (Nn. spinales) 332, 334 - terminale 325, 327, 332 Fimbria hippocampi 238-239,261-262, 279-
280,284-286,289,296 Fissura(-ae) - calcarine 298 - cerebelll 250 - horizontalis (Cerebellum) 245, 249, 252-253 - infraorbitalis 78 - longitudinalis cerebri 226, 232-234, 239, 25~260, 263,274,277-287
-
medians anterior (Medulla spinalis) 327, 334 nodulofloccularis 253 orbitalis - inferior 5, 14-16, 27-28, 78-79, 102-103,
109, 112, 115 - - - contents 16
114-115, 268 -
- - contents 17 petrooccipitalis 12 petrosquamosa 12, 32, 38 petrotympanica (GLASERIAN fissure) 32-
33, 38 - posterolateralls 249, 262-253 - prima (Cerebellum) 248, 252-253 - pterygoidea 30 - pterygomaxillaris 102 - secunda (Cerebellum) 252-253 - sphenopetrosa 13, 15-17, 38, 150,223, 308 - - contents 16-17 - transversa cerebri 283 - tympanomastoidea 32 - tympanosQuamosa 38 FLECHSIG, oval bundle of (Fasciculus septomarginalisl 336 FLECHSIG's tract (Tractus spinocerebellaris posterior) 261, 336, 338 Flexor muscle reflexes of the spinal cord 335-
336 Flexura - cervicalis 228 - mesencephalica 228 Flocculus 239, 247,249, 251, 253, 280 Floor of the mouth, muscles 85 Fluorapatite 74 Fluorescence angiography, ocular fundus 129 Folium vermis 248, 252- 253 Fontanalla(s) 18-20 - sinus maxillaris, accessory opening in the medial wall 65 Fonticulus - anterior 18- 19 - mastoideus 18-20 - posterior 18-20 - - defect 229-230 - sphenoidalis 18-19 Foot sole reflex 336 Foramen(-ina) - alveolaria 23, 27, 78 - apicis dentis 70 - caecum 10, 12, 193 - - linguae 81-83 - cribrosa 10, 12, 17,22,24-25, 59, 103,268 - ethmoidale - - anterius 28-29, 102 - - poster ius 28-29, 102 - frontalis 102 - incisivum(-a) 14-16,23,26 - - contents 16 - infraorbitale 6, 18, 23, 28, 62, 102 - interventricular& (foramen of MONRO) 218,
-
229,238, 241,247-248,258-259,262-264, 269,273,284,292 intervertebral& 332 jugulare 12- 17, 161-152, 178, 268, 314-316, 318-320 - contents 16-17 lacerum 12-17,149,161-152,268 - contents 16-17 linguale 35 MAGENDII 259 magnum 12- 14, 16- 17, 20, 31,222,268 - contents 16-17 - various types of herniation 230 mandibulae 34-35, 69, 85 mastoideum 9-10, 12, 14, 16, 32-33 mentale 6-7, 18, 34-35, 40, 69, 75-76, 85 of MONRO See Foramen interventriculare ovale 12-17,27, 31, 149-152,268 - contents 16-17 palatinum(-a) - majus 14- 16, 26, 69, 80 - - contents 16 - m inora 15- 16,26 - - contents 16 parietale 8-10 rotundum 12-13, 17, 29-31, 78, 151, 268 - contents 16-17
Index
Foramen (-ina) - singulars 152 - sphenopalatinum 25, 29, 67, 78, 102 - spinosum 12-17, 27, 31, 151, 268 - - contents 16-17 - stylomastoideum 14-16,33, 145, 147,307308 - - contents 16 - supraorbitale 5, 1B. 102-103 - venae basivertebra lis 332 - zygomaticofaciale 5, 27-28, 102 - zygomaticoorbitale 29, 102, 109 Forceps - major 254 - minor 254, 282, 284-285 Foreign bodies, aspiration 1 76 Formatio reticularis 251, 334 - motor function 342 Fornix 236,238-241,247-248, 257, 261-264, 269,274-276,278-280,282-286,288,292 - conjunctivae - - inferior 104, 110, 123 - - superior 11 0, 123 - fibre connection 238 - sacci lacri rna lis 11 0 Fossa - canina 23 - cerebellaris 13, 31 - condylaris 15 - cranii - - anterior 13, 122 - - media 13, 148 - - posterior 13, 148, 318 - digastrica 34-35 - glandulae lacri ma lis 22, 102-1 03 - hypophysialis 12, 24, 31, 36,223 - incisive 14-16, 26, 59 - incudis 145-146 - i nfraorbitalis 112 - infratemporalis 15,27 - interpeduncularis 234, 248, 257, 276, 287 - iugula ris 14, 33, 162 - lateralis cerebri 233-234, 236, 261, 276277 - mandibularis 15, 32-33,37-39, 44-45, 82, 149 - pterygoidea 10, 30, 59 - pterygopalatine 27, 29, 78-79, 102 - - arteries 79 - -veins 79 - retromolaris 34 - rhomboidea 246-248 - sacci lacri ma lis 7, 27, 29, 102-103 - scaphoidea 30 - subarcuate 12, 33 - supraclavicularis minor 4, 171 - supratonsillaris 68, 82 - temporalis 122 - triangularis 139 Fossula[-ae) - fenestrae - - cochleae 145, 147, 153 - - vestibuli 145 - petrosa 14, 33 - tonsillares 81 Fovea - centra lis 125, 129, 298 - inferior 246 - oblongs 180 - pterygoidea 34, 38 - sublingualis 34-35 - submandibularis 34-35 - superior 246 - triangularis 180 - trochlearis 102 Foveola[-ael 129 - granule res 11 - suprameatalis 32 FRANCESCHETTI's syndrome (Dysostosis mandibulofacialis) 137 Frankfurter (Germani horizontal line [Linea horizontalis auriculoorbitalis) 7, 220
Frenulum - labii - - inferioris 68 - - su perioris 68 - linguae 83, 87, 92 - veli medullaris superioris 246-247, 250, 287 FRENZEL's lenses (glases), nystagmus 158 Frons 5 Frontal bone 5, 22, 122 Frontal lobe 233 Frontal sin us 122 - development 64 Frontal suture 19 Functional cortical areas - of the cerebral hemispheres 237 Fundus - meatus acustici interni 152 - oculi 129,265 Funiculus - anterior (Medulla spinalis) 327, 334 - lateralis - - (Medulla oblongata) 246 - - (Medulla spinalis) 327, 334 - posterior [Medulla spinalis) 279,327, 334
G Gag reflex 84 - lack of 315 Galea aponeurotica 40-43, 63, 219-220 GALEN's anastomosis (Ansa GALEN I) 189 GALEN's vein (V. magna cerebri) 131, 218, 222,248,259,263-264,269,272-273,280, 285,292 Ganglion cells, retina 131, 298-299 Ganglion(-ia) - cervicale - - inferius 210 - - medium 178-179, 201, 209-210 - - superius 79, 132, 178-179, 201, 241, 314 - cervicothoracicu m (stellatum) 178-179, 209, 341 - ciliare 96, 118-119, 121, 132, 300, 302-303, 341 - coeliaca 316-317,341 - geniculi 77. 79, 147, 151,307-308, 311 - - lesions 308 - impar 326 - inferius - - (N. glossopharyngeus) 148, 178, 314-315 - - (N. vagus) 178-179, 316-321 - mesentericum - - inferius 341 - - superius 316-317, 341 - oticum 96,302-303,314-315,341 - pterygoideum 77 - pterygopalatinum 77-79,96, 109, 121, 300, 302-303,307,309,341 - sensoria nervorum spinalium 327 - sensorium nervi spinalis 337-338 - spinale 325 - spirale cochleae 159, 312-313 - sublinguale 96 - submandibulare 51, 89, 93,95-96,302303, 307, 309, 341 - superius - - (N. glossopharyngeus) 314-315 - - (N. v agus) 178,316-320 - sympathicum accessorium 201 - trigeminale (Ganglion semilunare, Ganglion GASSERI) 77, 117-118, 147, 150, 223, 293, 302-303 - vestibu Iare 151, 160, 312-313 General somato-afferent fibres (GSA) 294295,309 - N. glossopharyngeus (IX] 315 - N. vagus [XI 318 General somato-efferenttibres (GSE) 294295,309 - N. hypoglossus lXIII 323 - N. vagus [X[ 318
General viscera-efferent fibres (GVE) 294295,318 - N. glossopharyngeus [IX[ 315 - N. vagus lXI 318 Geniculum 312 Genu - capsulae internee 243, 255-256, 278, 284285 - corporis callosi 236, 238, 254-255, 262264,269,275,283-284,288 German (Frankfurter] horizontal I ine [Linea horizontalis auriculoorbitalis) 7, 220 Gigantism 244 Gingiva 68-69, 92, 94 Glabella 5, 22 Glands of the head, innervation 96 Glandula(-ae) - buccales 91 - labiales 68, 91 - lacrimalis 63, 79, 96, 107, 109-110, 112, 116-119, 121, 124, 341 - laryngea lis 190 - lingualis(-es) 83, 91, 95-96 - - anterior (gland of BLANDIN-NUHN) 83, 96 - molares 91 - nasales 59, 96 - palatinae 80, 91. 96 - parathyroidea - - inferior 172, 179, 189, 191-192, 194 - - superior 172, 189, 194 - parotidea 40, 46, 54, 57, 90-91, 93, 96, 140, 165-16~ 170,172,196,204-205,208, 314 - - accessoria 42, 90, 93 - - swellings 42 - pha ryngeales 172 - pinealis 241, 245-248, 263-264, 269, 280, 285,292,295 - pituitaria 61 - sa livariae - - majores 91,95 - - minores 91 - - oris 91, 341 - sublingualis 51, 63, 88, 91, 93-96, 307 - submandibularis 42, 91,93-96, 166, 172, 198-199,204,208,307 - suprarenalis 341 - tarsales (MEIBOMIAN glands) 106 - thyroidea 57, 166-167, 169, 172, 178, 189, 191-195,199-200,205,207 GLASERIAN fissure (Fissura petrotympanica) 32-33, 38 Glaucoma 127, 129 Globus pallidus 240 - lateralis 240, 256-257, 278, 285, 288-289 - medialis 240, 256-257, 278, 285, 288-289 - motor function 342 Glomerulus, Fila olfactoria 297 Glomus - caroticum 314 - choroideum 262, 272, 289 Glottic oedema 191 Glottis [glottic space) 186, 190 - opening/closure 182 Gnathion 5 Goitre 194 GOLL's tract (Fasciculus gracilis) 246-247, 334,336-337 GOWERS' tract (Tractus spinocerebellaris anterior) 251, 336, 338 Granular cells, Fila olfactoria 297 G ranulationes a rach noideae [PACC H10 NIAN granulations) 219-220, 225-226, 259 GRATIOLET's radiation (Radiatio optical 131132,243, 255-256,284-286,298-299 - lesions 132 GRAVES' disease 123, 195 GSA igeneral somata-afferent fibres) 291, 294-295,309 - N. glossopharyngeus IIXI 315 - N. vagus [XI 318
355
Index
GSE (general somata-efferent fibres) 291,
294-295 - N. hypoglossus (XII) 323 Gustatory fibres, N. vagus lXI 318 Gustatory impairment, lesions of the N. vagus lXI 319 Gustatory sweating (FREY's syndrome) 90 Gustometry, facial nerve palsy 311 GVA (general viscera-afferent fibres) 291,
294-295, 318 - N. glossopharyngeus IIXI 315 - N. vagus [XI 318 GVE (general viscera-efferent fibres) 291,
294-295,309 - N. facialis lVIII 310 - N. vagus [XI 318 Gyrus(·il - ambiens 287, 296 - angularis 232, 235-236, 280, 282 - breves insulae 235 - cerebri 219, 232, 234-236 - cinguli 233-234, 236, 238, 255, 260, 262,
275-286,288 - dentatus 238-239,261-262,279-280,286,
296 -
fasciolaris 238-239, 260 frontalis - inferior 235-237, 276-279, 283-286 - medius 232, 235-236, 260, 276-279,
281,283 - - superior 232, 235-236, 260, 276-279,
281-282 -
insulae 257, 276-278 lingual is 234, 280, 286-287 longus insulae 235 occipitales 282-284, 286 occipitofrontalis - lateralis 279 - medialis 279 occipitotemporalis - lateral is 234, 236, 278-280, 287 - medialis 234, 236, 262, 278-280 orbitales 130, 234, 236, 277, 287 pallid us lateralis 278 parahippocampalis 233-234, 236, 238,
261-262,276,278-280,285-289,296 - paraolfactorius 296 - paraterminalis 236,241,277, 286, 288 - postcentral is 232, 235-237, 260, 279-283,
337 281-283, 311,339 - arteries 271 preterminalis 296 rectus 234, 238, 277, 287-288 submarginalis 235 supramarginalis 232, 236, 280-281 temporalis - inferior 234-236, 276-280 - medius 235-236, 278-280, 284-286 - superior 235-236, 276-280, 283-286 - transversus anterior 237
H Habenula 285 Hair cells, organ of CORTI 156, 313 HALLER's cells 65 Hamulus - laminae spiralis 153 - pterygoideus 10, 14, 24-25, 27,29-30, 36,
45,59,68,80,82,149, 173 Hard palate 26, 80 HASNER's valve (Plica lacrimalisl 65, 110 - persistent, dacryostenosis 111 Head - arteries 49, 51, 216-217 - autonomic ganglia 96 - classification of the drainage regions 207 - frontal section 63 - innervation of the glands 96
356
253,266,280,287-289 HENSEN's cells, organ of COATI 156 Hernia, Tonsilla cerebri 221 HESCHL's transverse convolutions 159 Heterotopic commissural tracts 254 Hiatus - can a lis nervi petrosi majoris/minoris 268 - maxillaris 25 - oesophageus 319 - semilunaris 25, 65-66 Hilum nuclei - dentati 250 - ol ivaris inferioris 257 Hippocampus 239-240, 261-263, 274, 276,
278, 286-289 - formation of the 239 Hoarseness, lesions of theN. vagus 319 HODGKIN's lymphoma 163 Homonymous hemianopsia 132, 299 Homotopic commissural tracts 254 Homunculus 237 Hordeolum 108 Horizontal cells, retina 298 HORNER's muscle (M. orbicularis oculi) 40-
43,46,105-106,110-111,123,307
- precentral is 232, 235-237, 255, 260, 279, -
Head - lymph nodes 56, 206 - nerves 46-51 - regions 4, 46-51 - sensory skin innervation 198 - skin innervation 55 - superficial lymph vessels 56,206 - veins 218 - vessels 46-48, 50 HEAD's zones 326 Heart, innervation 341 Helicotrema 154, 156 Helix 139 Hemianopsia 299 - bitemporal 132, 299 - homonymous 132, 299 - intracerebral infarction 256 - lesions of the nuclei of thalamus 243 Hemilaryngectomy 180 Hemiplegia - BROWN-SEQUARD 340 - contralateral 240 - intracerebral infarction 256 - stroke 270 Hemispherium cerebelli 227, 239,245, 249,
- paralysis 41 Hydrocepha Ius - e vacuo 265 - externus 265 - internus 265 Hydrops cochleae 155 Hyoid bone 84-85, 181-183 Hypaesthesia, cerebral infarction 270 Hyperacusis 146 Hyperparathyroidism 192 Hyperthyroidism 195 - exophthalmus 195 - ophthalmopathy 195 Hypophysis - (GI. pituitarial 115, 222-223, 227, 248, 268-
269,275,278 - pharynges lis 175 Hyposmia 297 - septum deviation 63 Hypothalamic nuclei, anterior, middle and pos· terior group 244 Hypothalamus 215,241, 244, 248, 269,278,
285-287 Hypothyroidism 195 Hypotympanon 143 Hypovitaminosis D (rickets), enamel defects 73
lmpressio(·nes) - gyrorum 12 - trigeminalis 145, 150 Impression fracture of the sku II 8 Incisor 70 Incisura - anterior 139 - frontalis 22, 28, 102 - intararytenoidea 187, 189 - intertragica 139 - jugularis 31 - lacrimalis 23, 102 - mandibulae 34, 39 - mastoidea 9, 15, 32-33 - nasalis (Maxilla) 23 - parietalis 32-33 - preoccipitalis 233, 235-236 - pterygoidea 30 - sphenopalatine 23 - supraorbitalis 22, 103 - ten tori i 222 - thyroidea - - inferior 180 - - superior 180-181, 183-185 - tympanica 147 Incus 136, 138, 141-143, 146-148, 157,308,
312 Indusium griseum 239, 279, 283-284 Inferior nasal concha 26, 59 Infiltrative anaesthesia 77 - of the teeth 77 - upper jaw 77 lnfrahyoid muscles 166-167 I nfratentorial herniation 249 Infundibulum 223, 229, 234, 245,269, 274,
292-293 - ethmoidale 65 - maxillare 65 Inion 9 Inner border cells, organ of CORTI 156 Inner ear 134, 136-138, 151 - blood supply 155 - computed tomography 148 - innervation 155 Inner hair cells, organ of CORTI 156, 313 Inner jugular vein See Vena jugularis interne Inner limiting membrane, retina 298 Inner phalangeal cells, organ of CORTI 156 Inner pillar cells, organ of COATI 156 Inner subarachnoid space 259 Insula (Lobus insularis) 229, 240,256, 261-
263,266,270,274-275,279,283-285,289 Interdental cells, organ of CORTI 156 Internal acoustic meatus 152 Internal capsule 243, 255-256 - somatotopic organization 256 Internal genu of the facial nerve 309 Internal surface of the cranial base 12-13, 17 - foramina 17 - - contents 16-17 - passageways of vessels and nerves 268 Interpupillary distance 126 lnterscalene brachial plexus blockade 209 lntestinum tenue, innervation 341 Intracerebral bleeding 221 I ntraretinal chain 298 I ntraretinal space 100-1 01 Intubation - endotracheal 182 - granuloma, Plica vocal is 187 I ntumescentia 325 - cervica lis 325, 327 - lumbosacralis 325, 327 I ridocorneal angle 127 Iris 101, 104, 125, 127 Isthmus - faucium (oropharyngeal isthmus) 68, 80 - glandulae thyroideae 175-176, 188, 192,
194,204 - gyri cinguli 234, 236, 285 Impaired bala nee, vestibulocerebella r lesions 253 Impedance matching 138
Index
J JACOBSON's nerve (N . tympanicus) 77. 96, 146. 148. 314- 315 Jugular fossa (fossa jugularisl 14, 33, 162 Jugular pulse 53 Jugular thrombosis, Otitis media 144 Jugum(-al - alveolaria 23 - sphenoidale 31
K Keratitis 41 Keystone area, nose 58 KIESSELBACH 's area of the nasal septum 59, 66 Kl LLIAN's muscle (Pars fundiformis, Pars cricopharyngea) 172 KILLIAN's triangle 172 - pharyngo-oesophageal diverticulum 172 Knee-jerlc reflex 336 KORSAKOW's syndrome 238
L LABB~. vein of (V. anastomotica inferior) 218. 224-225 Labium - inferius 82- 83 - superius 82 Labyrinth ltls 157 - otitis media 144 Labyrinth us - cochlearls 138, 154, 169 - ethmoidalis 22, 103 - membranaceus 154-155 - - development 136 - osseus 152-153, 155 - vestibularis 138, 154, 160 Lacertus musculi recti latera lis 114 Lacrimal anastomosis 96 Lacrimal apparatus 110-111 Lacrimal gland - impaired function 96 - - SCHIRMER's test 108 - inflammation 108 - innervation 109. 121 Lacrimal puncta 105 Lacunae laterales 219-220, 225 Lacus lacrimalis 104, 110 Lagophthalmos 41. 105 - peripheral facial nerve palsy 307 LAIMER's triangle 172 Lambda 8 Lambdoid suture a. 19 Lamina - affixa 247, 262-263, 272, 279, 282 - alba (Cerebellum) 250 - arcus vertebrae 330 - basilaris 156 - cartilaginis cricoideae 175-176. 180-183, 188,190 - choroidocapillaris 126 - cribrosa - - ossis ethmoidalis 10. 12-13, 22, 24-25, 28,59. 103,296-297 - - - contents 17 - - sclerae 125 - dextra (Cartilage thyroldeal 180-181 - externa (Calvaria) 11,219-220 - horizontalis (Os palatinum) 14, 20, 23-26, 149 - interna (Calvarial 11, 219-220 - lateralis - - (Cartilago tubae auditivael 82, 149-150 - - !Proc. pterygoideus ossis sphenoidalisl 10, 14, 24, 26, 29-30, 36, 82, 149, 173 - limitans - - anterior (BOWMAN's membrane) 125
Lamina limitans - - posterior (DESCEMET's membrane) 125 -medialis - - (Cartilago tubae auditivae) 82, 149-150 - - (Proc. pterygoideus ossis sphenoidalis) 10, 14, 24-26, 30, 36, 68, 82, 149 - medullaris - - lateralis 257, 278. 285 - - medialis 257, 278, 285 - membranacea (Tuba auditiva) 149-150 - modioli 152-153 - orbitalis (Os ethmoidale) 27-29, 61, 102-103 - papyracea lOs ethmoidalel 28 - perpendicula ris - - lOs ethmoldalel 10, 22, 24, 28, 36, 59, 103 - - (Os palatinum) 23, 25, 27, 78 - pretrachealis (fascia cervicalisl 166, 169171. 175-176, 191-192 - prevertebralis (fascia cervicalis) 169-170, 175-176, 192 - profunda (Fascia temporal is) 42 - sinistra (Cartilage thyroidea) 180 - spiralis - - ossea 152- 153, 166 - - secundaria 152-153 - superficialis - - (Fascia cervicalis) 40-42,90,93, 169171, 175-176, 192 - - (Fascia temporalisl 42 - tecti 246, 260, 252 - terminalis 238, 241, 248,269, 278,285287,292 - vasculosa (uveal 126 Large fontanelle 19 Large salivary glands 91, 95 LARS ELL's classification, structure of the cerebellar vermis 252-253 Laryngeal cartilages 181, 183 Laryngeal cavity, respiratory epithelium 188 Laryngeal muscles 185 - paralysis 194 Laryngeal slceleton, fractures 180 Laryngomalacia 180 Laryngopharynx 176 Laryngoscopy 187 Larynx 176, 181-183,186,188-191,207 - acute oedema at the entrance 189 - arteries and nerves 189 - compartments 186 - extent of local tumour growth 186 - frontal section 191 - lymph vessels end lymph nodes 207 - midsagittal section 188 - squamous cell carcinoma 188 - transverse section 190 Lateral assortment of MALT 89 Lateral cervical cysts 193 Lateral cervical fistula 193 Lateral cervical region 164 - vessels and nerves 196- 201 Lateral triangle of the neclc 162 Lateral ventricle 261-264 - Plexus choroideus 263 - temporal horn 262 LE-FORT's classification of midfacial fractures 6 LE-FORT's fractures 5 Lemniscus - lateralis 159 - medialis 337 Lens 101. 125, 127- 128, 130 - anterior epithelial layer 101 - f ibres 101 - luxation, MARFAN's syndrome 127 - placode 100 - refractive index 126 Ligamentum C-al - anulare(-ia) 181, 183 - - stapediale 143 - cricoarytenoideum 181-183 - - posterius 180 - cricopharyngeum 181-183
Ugamentum(-a) - cricothyroideum medianum (conicum) 166, 175-176, 181-184,188, 192,194, 210 - cricotracheale 181, 191 - denticulatum 329 - flavum 330 - hyoepiglotticum 176- 176, 183, 188 - incudis - - posterius 143, 146 - - superius 143, 146 - interspinale 330, 332 - laterale (Art. temporomandlbularls) 36, 4243 - longitudinale - - anterius 175, 209, 332 - - posterius 330, 332 -mallei - - anterius 143 - - laterale 143-144 - - superius 143- 144, 146 - ossiculorum auditus 143 - palpebrale - - laterale 107 - - mediale 40, 42, 105, 107, 110-111 - pterygospinale 36 - sphenomandibulare 36, 45, 50-51, 68, 172 - spirale 156 - stylohyoideum 68, 85, 87, 167, 171-173 - stylomandibulare 36, 68, 172 - suspensorium bulbi (LOCKWOOD's ligament) 124 - thyroepiglotticum 175-176, 181-183, 188 - thyrohyoideum - - laterale 181, 184 - - medianum 166, 175-176, 181-184, 188 - vestibular& 183, 191 - vocale 180, 182- 186, 190- 191 Limbic system 239 - motor function 342 Limbus - anterior palpebrae 104, 106 - corneae 125 - posterior palpebrae 104, 106 - spiralis 156 Limen - insulae 236 - nasi 60 Linea - arcuata - - inferior 191 - - superior 191 - horizontalis - - auriculoorbitalis (Frankfurter !German) horizontal line) 7, 220 - - supraorbitalis 220 - mylohyoidea 34-36 - nuchalis - - inferior 9, 14-15 - - superior 9, 14 - obliqua - - (Cartilage thyroidea) 180, 184 - - (Mandibulal 34 - temporalis - - inferior 7-8, 43 - - superior 7-8 Linear fractures of the skull 8 Lingua 62-63. 81-83, 86, 88- 89, 92, 95, 275 Lingual 69 Lingual glands 91 Lingual tonsil 89 Lingula - cerebelli 50. 247- 250, 252- 253 - mandibulae 34-35 - sphenoidalis 12, 30-31 Lip glands 91 Lobulus - auriculae 139 - biventer 249, 253 - centralis 248-249, 253 - floccu lonodularis 253 - gracilis 253 - paracentra lis 236
357
Index
Lobulus - parietalis - - inferior 232, 235-236, 280, 282 - - superior 232, 235-236, 280 - quadrangularis - - anterior 248, 253 - - posterior 248, 253 - semilunaris - - inferior 248-249, 253 - - superior 248-249, 253 - simplex 248, 253 Lobus(-iJ - central is 252 - cerebelli - - anterior 248, 252-253 - - posterior 248, 252-253 - cerebri 233 - dexter (G I. thyroidea) 95, 172, 192, 194 - flocculonodularis 248, 250, 252-253 - frontalis 130, 229, 233, 235, 258 - insularis (Insula) 229,240, 256,261-263, 266,270,274-275,279,283-285,289 - limbicus 233 - occipitalis 229-230, 233, 235, 238, 258 - parietalis 229, 233, 235, 257-258 - - inferior 280 - pyramidalis 95, 193 - sinister (G I. thyroideal 166-1 67, 172, 192, 194 - temporalis 130, 229, 233, 235, 258 Lockjaw 45, 82 LOCKWOOD's ligament [Lig. suspensorium bulbi] 124 Locus - caeruleus 246 - KIESSELBACHI 59, 66 Loss of teeth, fractures of the lower jaw 35 Lower canine, permanent 70 Lower extremity, paralyses 271 Lower facial nerve palsy 54 Lower jaw 6, 34-35, 75, 85 - articular process 38 - infiltrative anaesthesia 77 - of an old person 3 5 - of a newborn 35 - panoramic radiograph 76 Lower tracheotomy 166 Lumbar puncture 331 Lumbar vertebral column, MRI 332 Lum bosacra I transition, myelography 332 Lungs, innervation 341 Luxation of the lens 101 - MARFAN's syndrome 127 Lymph node metastases of the neck, AJACclassification 207 Lymphatic system, diseases 163
M Macula - cribrosa - - media 153 - - superior 153 - flava - - anterior 182, 184-1 85, 187 - - posterior 182, 184, 187 - lutea 125, 129 Macular degeneration, age-dependent (AMD) 129 Magnetic resonance tomographic imaging (MRI) - brain 274-276 - eye 130 - lumbar vertebral column 332 - vertebra I canal 333 Major alar cartilage 58 MALASSEZ' epithelial cells rests 73 Malleus 136, 138, 142-143, 147-148, 157, 308 Mandibula 5-6, 18, 20, 34-35,44, 51, 68, 7576, 83, 85-87, 167, 170-172 - fractures 35
358
Manubrium - mallei 141-144, 146-147 - sterni 203 MARFAN's syndrome, luxation of the lens 127 Margo - ciliaris (Lens) 127 - frontalis (Os sphenoidale) 31 - gingivalis 70 - inferolatera lis hem ispherii cerebri 236, 277 - inferomedialis hemispherii cerebri 236, 277 - infraorbita lis - - (Maxilla] 23 - - (Orbital 6, 102 - lacrimalis (Maxilla) 23 - lambdoideus (Os occipitalel 31 - latera lis (Orbital 102 - linguae 81 - mastoideus (Os occipitalel 31 - medialis (Orbital 102 - occipitalis (Os temporals) 32-33 - parietalis - - (Os sphenoidale) 30 - - (Os temporals] 22, 32-33 - pupillaris 127 - sphenoidalis (Os temporale) 32-33 - squamosus (Os sphenoidale) 30-31 - superior - - hemispherii cerebri 236, 277 - - partis petrosae 12, 33, 62 - supraorbita lis - - (Orbital 102-103 - - (Os frontale) 5, 22 - - (Os temporals) 22 - zygomaticus (Os sphenoidale) 30 Mass bleeding 256 - cerebral infarction 270 Masticatory muscles 40, 42-43, 45, 91 Mastoiditis 145 - Otitis media 144 Maxilla 5-7, 14, 18, 20, 23-26,28-29, 58-60, 64,74-76, 78,82,91,102-103, 10~ 110111, 123, 175-176 Maxillary sinus 26, 122 - development 64 Maxillary sinusitis 64 - odontogenic 28 Meatus - acusticus - - externus 14, 16,32-33,38-39, 43, 76, 136-138, 140-141, 144-145, 147-148, 157,318 - - internus 10, 148, 152, 155,307, 309, 312 - - - contents 17 - nasi - - inferior 25, 28, 59, 64, 91, 11 0 - -medius 25 - - superior 124 Mechano-electrical sound conduction 157 - perilymph movements 157 MECKEL's cartilage 20 Median cervical cysts 193 Median cervical fistula 193 Medulla - cerebelli 250 - oblongata 215, 227, 229, 231,239, 246, 250,255, 258,268-269,275,279,312,327 - - dorsal syndrome 266 - spinalis 214-215, 229, 231, 247, 251-252, 25~275,292,325,327-328,333-336
- - motor function 342 MEIBOMIAN glands (Gil. tarsales) 106 Melatonin - circadian rhythm 241 - pinealocytes 241 Membrana - basilaris 156 - quadrangularis 191 - stapedialis 143, 146 - synovialis (Art. temporomandibularis) 37 - tectoria 156 - thyrohyoidea 87, 95, 173, 181-184, 189, 192, 194,210
Membmna - tympanica 137-138, 140-141, 143-144, 146, 155, 157, 308 - vestibularis (REISSNER's membrane) 156 Membranous labyrinth 154-155 - development 136 Memory functions, Corpora mamillaria 238 Meninges 219,329 Meningioma 220 Meningitis, Otitis media 144 Meningocele 230 Meningoencephalocele 230 Meni ngohydroencephalocele 230 Meningomyelocele 333 MENIERE's disease 155 Mesencephalon 131, 215, 228-229, 231, 233, 245-247 Mesial 70 Mesotympanon 143 Metathalamus 245, 247 Metencephalon 215, 228-229, 231 Microcephaly 21 Microtia 137 Midbrain 245-247 - infratentorial herniation 249 - supratoria I herniation 249 Midbrain flexure (Flexure mesencephalica), primary brain vesicles 228 Middle cranial base 14-15 Middle cranial fossa 12 Middle ear 134, 137-138 - computed tomography 148 - development 136 - inflammation See Otitis media Midfacial fractures, classification of LE-FORT 5 Midget off-ganglion cells, retina 298 Midline deviation, epidural haematoma 221 Milk molar tooth, second 70 Milk teeth 71 - dental formula 71 - upper jaw 74 Mitral cells, Fila olfactoria 297 Mesial 69 Modiolus cochleae 152, 156 Molar teeth 70, 72 Monosynaptic reflexes 335 MORGAGNI. ventricle of (Ventriculus laryngis) 83, 186-188, 190-191 Motivation, somatomotor system 342 Motor cortex 237, 342 Motor cortical output 240 Motor impulse, somatomotor system 342 Motor speech centre (BROCA's central 237 Motor system - function 342 - pyramidal tract 339 Mouth, muscles of the floor 85 Movement disorders, hyper-/hypokinetic 240 Mucosa olfactoria 297 MULLER's muscle (M. ciliaris) 127 Multinodular goitre 195 Multipolar ganglion cells, retina 131 Mumps (Parotitis epidemical 90 Musculus(-i) - antitragicus 140 - arytenoideus 185, 189 - - obliquus 179, 185-186, 190 - - transversus 179, 185-186, 188, 190 - auricularis(-es) 140, 307 - - anterior 41, 140 - - posterior 41, 140 - - superior 41, 140 - buccinator 40, 42-43, 48, 63, 68, 80, 90, 173,307 - bulbi 112-114, 130 - chondroglossus 86-87 - ciliaris 96, 125, 127, 300 - - (Fibrae circulares, MULLER's muscle) 127 - - (Fibrae meridionales, BRUCKE's muscle) 127 - calli 166-167 - constrictor(-es] pharyngis 87, 172
Index
Muscu/us(-i) constrictor(-es) pharyngis - - inferior 43, 87, 93, 95, 167, 172, 178, 190, 201,316 - - medius 86-87, 172-174, 178, 190, 316 - - superior 51, 80, 86-87, 89, 172-174, 178179,316 - - - paralysis 315 - corrugator supercilii 40, 42-43, 105, 307 - cricoarytenoidaus - - latera lis 185-186, 191 - - posterior (posticus) 179, 185-186, 189190 - cricothyroideus 95, 166, 173, 184, 186, 191192,194,316 - deltoideus 167, 198, 200-201 - depressor - - anguli oris 40-43, 90, 307 - - labii inferioris 40-43, 307 - - septi nasi 40, 105, 307 - - supercilii 40-43, 105 - digastricus 42-43, 56-57, 63, 68, 84-85, 93-95,147, 164,166-16~171-174,178, 198-200,204-208,307-308 - dilatator pupillae 127, 300 - epicranius 40-43, 46, 123, 196 - erector spinae 330 - faciei 40-43, 105, 173 - genioglossus 45, 51, 63, 68, 83, 85-89,9395, 175-176, 322 - geniohyoideus 45, 51, 63, 68, 83,85-87, 89,93-94,175-176,194,202,322 - halicis - - major 140 - - minor 140 - hyoglossus 51, 68, 84, 86-89, 93-95, 166, 173,194,204-205,208,322 - infrahyoidei 169 - laryngis 185 - levator(-es) - - anguli oris 40, 42-43, 105, 307 - - labii su perioris 40-43, 105, 307 - - - alaeque nasi 40-43, 105, 173, 307 - - palpebrae superioris 63, 107, 112, 114120,123-124,130,300 - - - paralysis causing ptosis 112 - - pharyngis 172 - - scapulae 46, 56-57, 165-168, 196-197, 200,206 - - veli palatini 68, 82, 149-150, 172-173, 316 - - - contraction 150 - linguae 83, 87 - - externi 86-87 - - interni 83 - longitudinalis - - inferior 83, 86-87, 322 - - superior 83, 322 - longus - - capitis 68, 166, 168, 209-210 - - calli 168, 192,209-210 - masseter 40,42-46,90,93, 166-167, 171 - masticatorii 40, 42-43, 45, 91 - mentalis 40-43, 307 - mylohyoideus 45, 57, 63, 68, 83-85, 89, 93-95, 166-16~ 171, 173, 175-176, 199200,204-205,208 - nasalis 40-43, 105,307 - obliquus - - auriculae 140 - - inferior 110-114, 116, 120, 123,300 - - superior 63, 112-120, 124, 130, 300 - occipitofrontalis 40-43, 46, 105, 196, 307 - omohyoideus 45, 56, 95, 164, 166-167, 171, 197-200,202,204-20~322
- orbicularis - - oculi (HORNER's muscle) 40-43, 46, 105-106, 110-111 , 123, 307 - - - paralysis 41 - - oris 40-43, 48, 68, 105, 307 - - - paralysis 41 - orbitalis 114 - palati 80 - palatoglossus 80- 81,86- 87, 89, 316
Muscu/us(-i) - palatopharyngeus 80-81, 89, 179,316 - pectoralis - - major 167, 204-205 - -minor 201 - pharyngis 172-173 - posticus (M. cricoarytenoideus posterior) 179, 185-186, 189-190 - procerus 40-42, 105, 307 - psoas major 330 - pterygoideus - - lateralis 37-38, 44-45, 49, 51, 68, 91, 172 - - medialis 44-45,50,68,94, 172 - quadratus lumborum 330 - rectus - - capitis - - - anterior 168 - - - lateralis 168 - - inferior 63, 112-116, 120, 123-124, 130, 300 - - lateralis 63, 109, 112-121, 124, 130, 300 - - medialis 63, 112-115, 119-121, 124, 130, 300 - - superior 63, 112-120, 123-124, 130,300 - risorius 40-42, 90 - salpingopharyngeus 179, 316 - scalenus(-i) 168-169 - - anterior 56-57, 166-168, 198-199, 201, 206,209-210 - - medius 56-57, 166-168,206,209-210 - - posterior 56, 167-168, 206, 209-210 - semispinalis capitis 41, 167 - sphincter pupillae 96, 125, 127,300 - splenius - - capitis 41, 47, 56-57, 167, 197-198, 200, 206 - - cervicis 166 - stapedius 143, 146-147, 307-308 - - function 146 - sternocleidomastoideus 40-43, 47-48, 5657, 90, 164-167, 169-171, 192-193, 196200,202,204-206,208,320 - - paralysis 321 - sternohyoideus 45, 87, 95, 166-167, 170171,192,198,202,205,322 - sternothyroideus 95, 166-167, 175-176, 192,198,201-202,322 - styloglossus 86-89, 93, 95, 171-173, 322 - stylohyoideus 43, 68, 84-85, 93, 95, 147, 164, 166-16~ 171-174,199,204,208,307308 - stylopharyngeus 86-87,89, 167, 172-173, 178,314,316 - suprahyoidei 84-85 - temporal is 38,43-46,51, 91 - - origins 43 - temporoparietalis 40-42 - tensor - - tympani 141, 143-144, 146-147, 150, 308 - - - function 146 - - veli palatini 68, 82, 149-150, 173, 179 - - - contraction 150 - thyroarytenoideus 185, 190-191 - thyroepiglotticus 191 - thyrohyoideus 45, 87, 93, 95, 166-167, 173174,194,205,322 - tragicus 140 - transversus - - auriculae 140 - - linguae 83, 322 - trapezius 41,46-48,56-57, 164-167, 169170, 196-19~ 199,204,206, 320 - uvulae 80, 82, 149, 179 - vertical is linguae 83, 322 - vocalis 185-186, 190-191 - zygomaticus - - major 40-42, 90, 105, 307 - - minor 40-42, 105, 173,307 Myelencephalon 228, 231 Myelocele 333 Myelography, lumbosacral transition 332 Myringotomy 141
N Nape See Neck Nasal bone 5, 22 - fractures 6 Nasal cartilage 58 Nasal cavity 66, 122 - arteries 66 - innervation 67 - lateral wall 25, 60, 65 - veins 67 Nasal cycle 59 Nasal mucosa 59 Nasal septum 59 - haematoma 58 - osseous 24 - septum deviation 24 Nasal skeleton 58 Nasal tip cartilage 58 Nasal visual field 299 Nasion 5 Nasopharynx 176 - endoscopy 175 Neck 161-216 - classification of the drainage regions 207 - cutaneous innervation 55 - deep lymph nodes 57 - descending abscess 170 - intravenous access route 204 - lymph node metastases 207 - - classification of the AJAC 207 - lymph nodes 56, 206 - muscle fascias 169-170 - neurovascular fascia 169 - organ fascia 169 - prevertebral and paravertebra I structures 210 - radiographs 209 - regions 4, 46-47 - segmental mapping of the cutaneous areas 198 - sensory innervation of the skin 197-198 - superficial lymph vessels 56, 206 - veins 204 - venous access route 163 - vessels and nerves 46-47, 205 - - transition to the upper extremity 209 Neck dissection 170 - lesion of the N. accessorius 196 Neck muscles 166-167 - superficial layer 165 Nervous system, structure 214 Nervus(-il - abducens [VI] 45, 113, 115, 117-120, 124, 14~223,22~239,266,268,288,290,
-
292-293,295,300 - fibres qualities 301 - important innervation sites 291 - lesions, diplopia 112 - quality 291 accessorius [XI] 46-47, 56, 147, 178-179, 196-202,205-206,208,22~239,266,268,
-
288,290,292,295,316,320-321,327 - fibres qualities 321 - important innervation sites 291 - lesions 321 - - neck dissection 196 - - shoulder dysfunction 47 - quality 291 alveolaris(-esl - inferior 45, 48-51,63, 77, 94,302-303, 305 - superior(-es) 49, 67, 77 - - anterior 77-78 - - medius 77-78 - - posterior 77-78 ampullaris(-es) - anterior 154 - lateralis 154 - posterior 154 auricularis(-es) - anteriores 302, 305 - magnus 46- 47, 139, 196- 197,202
359
Index
Nervus(-i} auricu/aris(-es)
Nervus(-i} msndibulsris [V/ 31
Nervus(-iJ trigeminus (VJ
- - posterior 48, 51, 54, 148, 196, 199, 307311 - auriculotemporalis 46-48, 50-51 , 55, 96, 139, 19~302 , 305 , 3 1 4-315 - buccalis 48-51, 55, 302, 305 - canalis pterygoidei (VI DIAN canal) 77, 79, 109, 148,302,30~309 - cardiacus cervicalis 309 - - inferior 210 - - medius 178, 201,210 - - superior 178, 201 - caroticotympanicus 148,314 - carotlcus lnternus 77, 79, 178 - cervical is 89, 199-200,320-323 - ciliares --breves 96,119, 300-302 - - longi 119, 300-302, 304 - cochlearis 151, 154-156, 158-159,312-313 - cranlales 214, 229, 290, 292-295 - ethmoidalis - - anterior 48, 67, 119-120, 300,302, 304 - - posterior 119-120, 300, 302,304 - facialis [VII] 48, 50- 51, 54, 77. 93, 96, 109, 139, 146-148, 151, 155, 197-198, 227,239,
- - branches 50- 51 , 305 - massetericus 48-51, 302, 305 - maxillaris [V/21 55, 67, 77-78, 96, 109, 117118, 120-121, 147, 177, 198,223,268, 293, 300, 302-303,306 - - branches 304 - meatus acustici externi 51, 302, 305 - mentalis 47- 48, 50, 55, 77. 302, 305 - musculi tensoris - - tympani 302, 305 - - veli palatini 302,305 - mylohyoideus 49-51 , 199-201, 208,302, 305 - nasociliaris 115, 117-119, 124, 268,300, 302-304 - - branches 304 - nasopalatinus 60, 67, 302 - occipitalis - - major 47- 48, 55, 196-198, 201-202 - - minor 46- 48, 139, 196-199,201-202 - oculomotorius [Ill) 45, 96, 113-115, 117-120, 124, 132, 14~223, 22~229,239,245,266, 268,278,288, 290, 292-293,295,300301, 341 - - fibres qualities 291, 301 - - important innervation sites 291 - - nuclei in the brainstem 291 - olfactorii Ill 60, 67, 268, 290, 296-297 - - fibres qualities 291 - - important Innervation sites 291 - ophthalmicus [V/11 55, 77-78, 96, 109, 115, 117- 120, 14~198,223,293,300-303,306 - - branches 304 - - course 117 - opticus (Ill 45, 63, 77, 101, 109, 112, 114121, 123-124, 130-132,222-223,22~238, 245,266,268, 274 - pa latinus[-i) - - major 67, 78, 80, 302, 305 - - minores 78, 302, 305 - petrosus - - major 77, 79, 96, 109, 146-148, 151, 268, 307- 310, 312 - - minor 77. 148, 268, 302, 308, 314-315 - - profundus 77, 79, 109, 307, 309, 314 - pharyngeus 78, 302 - phrenicus 199-202, 205, 209-210 - - accessorius 209-210 - pterygoideus - - lateralis 51, 302, 305 - - medialis 150, 302, 305 - saccularis 154 - sacralis 331 - spinalis 337- 339 - splanchnicus[-i) - -major 326 - - minimus 326 - -minor 326 - - pelvici 326 - - sacraies 326 - stapedius 307- 308,310-311 - - lesions 308 - subllngualls 88, 95, 305 - supraclaviculares 47, 197 - - intermedii 196-197,202 - - iaterales 196- 197, 202 - - mediales 196- 197, 202 - supraorbitalis 46-48, 50, 55, 107, 109, 117118, 124, 302 - suprascapularis 201 - supratrochlearis 47-48, 51, 55, 107, 117118, 302 - temporales - - profundi 51, 302, 305 - - superficiales 305 - thoracicus longus 201 - thoracodorsalis 201 - transversus colli 47, 196-197, 202 -trigeminus [VI 45, 51, 77. 96, 109, 117-120,
-
246, 25~266,268,288,290, 292-293, 295,
302, 307- 308,311-312,341 - branches 310 - - GVE, SVA and SVE 310 - corticonuclear connections 311 - course 307 - diagnosis 147 - fibres qualities 309 - important innervation sites 291 - Intranuclear lesion 310 - injuries 105 - nuclei in the brainstem 291 - peripheral course 31 1 - peripheral palsy 54, 310 - quality 291 - supranuclear lesion 310 - terminal branches 54 frontalis 115, 117, 123-124,268,300, 302304 - glossopharyngeus [lXI 77, 81, 89, 96, 147148, 177-1 79, 189, 227, 239, 246, 266, 268,
-
288, 290, 292,295,302,30~314-316,341
-
-
- branches 314 - fibres qualities 315 - important innervation sites 291 - injuries 315 - nuclei in the brainstem 291 - quality 291 hypoglossus (XIII 43, 51,88-89,93-95, 178-179,194,199-202,204-205,208,239, 246, 266,268, 288,290,292,295,322323,327 - fibres qualities 291,323 - important innervation sites 291 - injuries/lesions 88, 323 - - cervical lymph node metastases 208 infraorbital is 43,47-48, 50-51, 55, 63, 67, 77-78, 10~ 109-110, 114, 120, 123-124, 300, 302- 304 infratrochlearis 48, 51, 55, 107, 119-120, 302,304 intarcostobrachialis 201 intermedius 77. 227, 290, 307 jugularis 178 lecrimalis 55, 79, 107, 109, 115, 117-119, 121, 124,268,300,302-304 laryngeus - recurrens 179, 189, 192, 194, 201, 205, 210,316-317,319 - superior 81.87-88, 95, 173, 178-179, 189-190, 194,200,208,317,319 - - lesions 189 lingualis 45, 49-51, 77. 81, 88-89, 93-96, 205, 302-303, 305,30~309
- lumbales 330-331 - mandibularis (V/31 51, 55, 77-78, 81, 96, 109, 117-118,120,150,198,223,268,293, 300,302-303,306,314
360
14~ 198,22~239,245-246,266,273,290,
292-293,296,302-303,337 - - branches 55, 304
- exit points 306 - fibres qualities 291, 303 - important innervation sites 291 - lesions, deficiency in blood supply 306 - loss of epicritic sensory quality 306 - nuclei in the brainstem 291 - origin nuclei 303 - protopathic sensibilty 306 - - testing along the SOLDER's lines 306 - terminal nuclei 303 trochlearis [lVI 45, 113, 115, 117- 119, 124, 223, 239,246-24~268,288,290,292-293,
-
295, 299- 301 - fibres qualities 291, 301 - important Innervation sites 291 - lesions 299 - - diplopia 112 tympanlcus !JACOBSON's nerve! 77, 96, 146,148,314- 316 utricularis 154 utriculoampullaris 154 vagus [XI 43, 51 , 77. 81, 139, 147-148, 169, 177-179, 192, 194, 198-201, 205,208,210, 22~239, 246, 266, 268,288,290,292 , 295,
314, 316- 321,326,341 - - abdominal part 318 - - branches 189 - - cervical passage 318 - - exit points in the brain 318 - - fibres qualities 317- 318 - - important innervation sites 291 - - innervation area 318 - - lesions 319 - - nuclei in the brainstem 291 - - position within the subarachnoid space 318 - - quality 291 - - thoracic part 318 - vestibularis 161, 164-165, 160, 312-313 - vestibulocochlearis [VIII) 138, 147, 151, 154155, 15~ 159-160,22~239, 246,266, 268, 288, 290, 292-293,296 - - course 312- 313 - - fibres qualities 291, 313 - - important innervation sites 291 - - nuclei in the brainstem 291 - zygomaticofaciaiis 55 - zygomaticotemporalis 56, 109 - zygomaticus 48, 78- 79, 109, 120-121, 124, 300, 302,304 Neural tube 100 - failure to close 228 Neurofibrae - associationes 254 - commissurales 254 - projectiones 255 Neurohypophysis 223, 241,244, 264 Neurons - auditory pathway 159 - epicritic sensibility 337 - protopathic sensibility 337 Neuroporus rostralis 228 Nodulus - cerebelli 248-253 - elasticus - - anterior 182, 184- 185, 187 - - posterior 182, 184, 187 Nodus(-i) lymphoideus(-i) - accessorii 206 - anteriores jugulodigastrici 206 - buccinatorius 56, 206 - capitis 56 - cervicaies 206 - - anteriores 206 - - - profundi 57 - - laterales 56-57, 197, 206 - - - profundl - - - - inferiores 56- 57, 206 - - - - superiores 56- 57, 206 - - - superficiales 56, 197, 206 - faciales 56, 206 - infraauriculares 56
Index
Nodus(-i) lymphoideus(-i) - infrahyoidei 206 - in trag landu lares 56 - jugulodigastricus 56, 206 - juguloomohyoideus 56, 206 - linguales 56 - malaris 56 - mandibularis 56 - mastoidei 56, 206 - nasolabialis 56 - occipitales 56, 206 - paratracheales 206-207 - parotidei - - profundi 56-57 - - superficiales 56, 206 - preauricu lares 56 - prelaryngei 206-207 - pretracheales 206-207 - profundi (membri superioris) 206-207 - retropharyngeales 57, 206 - submandibularas 56, 93, 206-207 - submentales 56-57, 93, 206-207 - supraclaviculares 206 - thyroidal 57, 206 Nonspecific thalamic nuclei 242 - lesions 243 Nose - cartilage-free area 58 - keystone area 58 - major alar cartilage 58 - minor alar cartilage 58 - soft triangle 58 - supratip area 58 - triangular cartilage 58 - upper lateral cartilage 58 - weak triangle 58 Nucleus(-i) - accessorius nervi oculomotorii (EDINGERWESTPHAL:s nucleus) 96, 118, 291, 294-
295, 301 -
ambiguus 291, 294-295, 315,317-318, 321 anterior hypothalami 244 arcuatus 244 basales 257 caudatus 240,243,247,256-25~261-264,
-
centralis (Medulla spinalis) 158, 337 centromedianus (Thalamus) 242 cerebelli 250 coch learis(-es) 158-159, 291, 295 - anterior 159,313 - posterior 159, 313 comus anterioris musculorum calli 158 corporis - genicu lati - - lateral is 242 - - medialis 242 - mamillaris 244 - trapezoidal 158-159 cuneatus 158,160,337 dantatus 250-251, 280, 288, 339 dorsalis(-as) - hypothalami 244 - nervi vagi 291, 294-295, 317-318 - thalami 242 dorsomedialis 244 fastigii 250-251 gracilis 158, 337 intermediolateralis 241, 335 interpositus 250-251 - anterior (am boliform is) 250 - posterior (globosus) 250 interstitial is 160 lemnisci lateralis 158-159 lentiform is 257, 276 Iantis 128 marginalis (Medulla spinalis) 335 mediales thalami 242 mediani thalami 242-243 mesencephalicus nervi trigemini 291, 294-
274,277-280,283-286,288-289
295,303 - metathalami 242 - motorius nervi trigemini 291,294- 295, 303
Nuc/eus(-i) - nervi - - abducentis 158, 160, 294-295,301,309 - - accessorii 294-295, 321 - - facialis 291, 294-295,309,311 - - hypoglossi 294-295, 323 - - oculomotorii 158, 160,291, 294-295, 301 - - trigemini 337 - - trochlearis 158, 160, 294-295, 301 - olfactorius anterior 296-297 - olivaris(-es) 158 - - inferiores 159, 251, 257, 342 - - - motor function 342 - - superiores 159 - parafascicularis (Thalamus) 242 - paraventricularis 241, 244 - - lesions 244 - pontinus (Ncl. sensorius principalis) nervi trigemini 291, 294-295,303 - pontis 251, 339 - - motor function 342 - posterior - - hypothalami 244 - - thalami 242 - preoptici 244 - principalis posterior 294 - proprius (Medulla spinalis) 335 - pulvinares (Thalamus) 242 - reticulares (Thalamus) 242 - ruber 244-245, 251, 279,286-287, 292,
295,339 - lesions 245 - motor function 342 salivatorius - inferior 96, 291, 295,315 - superior 96, 291, 294-295, 309 sensorius principa lis (N cl. pontin us) nervi trigemini 291, 294-295, 303 - solitarius 318 - spinalis - - nervi trigemini 291, 294-295, 303,309, -
315,317 -
- nervi vagi 318 subthalamicus 257, 342 suprachiasmaticus 241, 244 supraopticus 244 - lesions 244 tegmentales 244 thoracicus posterior 335, 338 tractus - olfactorii lateralis 296 - solitarii 291, 294-295,309,315, 317 tubera les latera les 244 ventralis(-es) - anterior thalami 242 - intermedius thalami 242 - posterolateralis thai ami 242 - posteromedialis thalami 242 ventromedialis hypothalami 244 vestibularis(-es) 158, 251, 291, 294-295 - inferior (ROLLER's nucleus) 160, 294,313 - lateral is (DEITERS' nucleus) 160, 294, 313 - medialis (SCHWALBE's nucleus) 160,
294,313 - - superior (BECHTEREW's nucleus) 160,
294,313 NUEL:s space 156 Nystagmus, FRENZEL:s lenses 158
Oculomotor nerve palsy 113, 301 - diplopia 113 - narrowing of the palpebral fissure 104 - unilateral 223 Oculus 104, 116, 121 Odontogenic maxillary sinusitis 28, 64 Oesophagus 169, 172-173, 175-176, 178-179,
192,210 Off-cone bipolar cells, retina 298 Off-ganglion cells, retina 298 0 !factory cells 297 Olfactory mucosa 297 0 !factory nerves 296 - glomerulus 297 - granular cells 297 - mitral cells 297 - periglomarular cells 297 - tufted cells 297 0 !factory tract 296 Oliva 279-280 0 n-cone bipolar cells, retina 298 0 n-ganglion cells, retina 298 ONODI's cells 65 Open-angle glaucoma 127 Operculum - frontale 229, 235 - parietale 235 - temporale 229 Ophthalmoparasis 115 0 phthalmopathia, hyperthyroidism 195 0 phthalmopleg ia (Ophthal moparesis) 115 Ophthalmoscopic image, ocular fundus 129 0 ptic cup 100, 228 Optic disc, glaucoma 129 Optic disc oedema, retinal ablation 129 0 ptic stalk 100 Optic vesicle 100 Ora serrata 125-126 Oral cavity 68, 80, 176 Oral region 84 0 rbicu Ius ciliaris 125, 127 Orbit (Orbital 5, 28, 62, 64, 76, 102, 116-121,
123 - axes 114 - fracture of the floor 103 - frontal section 124 - horizontal section 121 - lower level 120, 123 - middle level 119, 123 - roof 103 - upper level 117, 123 0 rbital cavity 28, 102, 123 - arteries 107, 116-120 - floor of the 27, 103 - frontal section 124 - horizontal section 121 - lateral wall 29, 102 - medial wall 29, 102 - nerves 107, 117-121 - opening 107 - topographical relationships 122 - veins 107, 116 Orbital hernia, blow-out fracture 103 Orbitopathy, endocrine 123 Organum - spirale 156-157 - subcommissurale 264 - vasculosum laminae term ina lis 264 Oropharyngeal isthmus (Isthmus faucium) 68,
80
0 Obex 246, 327 Occipital 215 Occipital lobe 233 Occiput 8 - See also Os occipitale Occlusa I plane 7 Oc ular angle plane, reference lines for the teeth 7 Ocular fundu s 129, 265 - fluorescence angiography 129 - ophthalmoscopic image 129
Oropharynx 170, 176 Os(-sa) - cranii 6-10 - ethmoidale 6, 10, 22, 24-25, 27-29,36, 59,
61,64,102-103,115,124,296-297 - fronta le 5, 7, 18-19, 22, 28-29, 43, 60, 102-
103, 109, 114, 123-124 - hyoideum 43, 45, 51, 68, 76, 83-87, 90,
94-95, 164, 166-16~ 170, 172-176, 181186,188-189,191-194,205,208,210 - incae 9 - incisivum 20, 26 - interparietal& 9
361
Index
Os(-sa) - lacrimale 6-7,24-25,27, 29, 102-103, 111,
115 - nasale 5, 7, 18, 22,24-25, 28-29, 58, 60,
102-103, 105 - occipitale 9, 14, 18-20, 25, 31, 229 - palatinum 10, 14, 20, 23-29, 78, 102-103,
115,149 - parietale 6-9, 18-20,29,43,219 - sacrum 331-332 - sphenoidale 6-7, 12, 14, 18, 20, 24-25,27-
31,36,78, 102-103, 109, 112, 114, 121, 149 - suturalia 9 - temporals 7, 9-10, 12, 14, 18, 20, 28-29,
32-33,36,39,44,138,147-150 - zygomaticum 5, 7, 18, 27-29, 37, 44, 78,
102-103, 124 Ossicula auditus 136, 138, 142-143 Osteomeatal complex 65 Ostium - pharyngeum tubae auditivae 60, 149, 175-
176, 179, 314 - tympanicum tubae auditivae 145-146 Otic pit 136 Otic placodes 136 Otic vesicle 136, 193 Otitis - externa 138 - media 141, 144 Otosclerosis 142 Outer border cells, organ of CORTI 156 Outer brain prolapse 230 0 uter ear 134, 137 0 uter hair cells, organ of CORTI 156 0 uter phalangeal cells, organ of CORTI 156 Outer pillar cells, organ of CORTI 156 Outer tunnel, organ of CORTI 156 Oval window (Fenestra vestibuli) 145 Overlapping visual field 299
p PACCHIONIAN granulations (Granulationes arachnoideae) 219-220, 226,259 Palate - cleft formations 80 - development 81 Palatina I 69 Palatine arches 80 Palatine bone 23 Palatine glands 91 Palatine muscles 80 Palatine process 81 Palatine tonsil 89 Palatum - durum 15, 26, 60, 68, 76, 80 - molle 45, 60, 76, 78, 80, 82, 175-176 Pallidum See Globus pallidus Palliothalamus 242 Palpebra - inferior 104, 106, 109, 123, 130 - superior 104, 106, 109, 123, 130 Palpebra I fissure - reduced - - dacryoadenitis 108 - - paralysis of the ocular nerve 104 - widening, facial nerve palsy 104 Palpebra lliga ments 107 Palsies of the extra-ocular muscles 114 PANCOAST's tumour 205 Panniculus adiposus 41 Panoramic radiograph, upper jaw and lower jaw 76 Papilla nervi optici (Discus nervi optici) 125,
129,265 Papilla(-ae) - ductus parotidei 92 - filiformes 81 - foliatae 81-82, 86-87 - fungiformes 81 - incisiva 80 - lacrimalis 110
362
Papil/a(-aa) lacrimalis - - inferior 104 - - superior 104, 11 0 - nervi optici (Discus nervi optici) 129 - vallatae 81-82,86, 189 Paralysis - brachiofacial 271 - damage of the thalamic nuclei 243 - of the lower extremities 271 - of the tracts of the right posterior funiculus 340 Para lytic ectropion 41 Paranasal sinuses 61 - access 60 - basal lamella 65 - clinical terms 65 - endonasalaccess 64 - fontanelle 65 - radiograph 62 Parapharyngeal abscess 170 - computed tomography 170 Parapharyngeal space, vessels and nerves 179 Paraplegia 333 Parasympathicus 341 Paravermal zone, cerebellar cortex 251 Paries - caroticus (Cavitas tympani) 144 - inferior orbitae 27, 103, 130 - jugularis (Cavitas tympani) 144 - labyrinthicus (Cavitas tympani) 144-145 - lateralis - - (Cellulae ethmoidales) 130 - - orbita a 29, 102 - mastoideus (Cavitas tympani) 144-145 - medialis - - (Cellulae ethmoidalesl 130 - - orbitae 29, 102 - membranaceus - - (Cavitas tympani) 144, 146 - - (Trachea) 179, 183, 185, 188, 192 - posterior (Meatus acusticus externus) 141 - superior - - (Cellulae ethmoidales) 130 - - orbitae 103 - tegmental is (Cavitas tympani) 144 Parieta I lobe 233 PARKINSON's disease 245 PARKINSON-like disease 245 Parodontopathies 74 Parodontosis 74 Parotid gland 90-91 - damage of the N. facial is 90 - excretory duct 92 - tumours 74 - - FREY's syndrome (gustatory sweating) 90 Parotitis epidemics (mumps) 42, 90 Pars - abdominalis aortae 328 - alveolaris (Mandibula) 34 - anterior - - (Commissura anterior) 239, 254 - - (Dorsum linguae) 81 - - (lobulus quadrangularis anterior) 248 - aryepiglottica (M. arylenoideus obliquus) 185 - ascendens aortae (Aorta ascendens) 205 - atlantica (A. vertebralis) 203 - basilaris (Os occipitale) 14, 31 - buccopharyngea (M. constrictor pharyngis superior) 172-173 - canal is ( N. opticusl 115 - cartilaginea (Tuba auditive) 149-150, 308 - cavernosa (A. carotis internal 151, 216-217,
Pars cervicalis (A. carotis intema) - - - variations in course 174 - - (Medulla spinalis) 334 - chondropharyngea (M. constrictor pharyngis medius) 86-87, 172-173 - ciliaris retinae 125, 127 - compacta (Substantia nigra) 245, 257 - cricopharyngea (M. constrictor pharyngis inferior) 172-173 - cuneiform is vomeris 24 - cupularis (Cavitas tympani) 144 - descendens aortae (Aorta dascendens) 179 - duralis (Filum terminale) 325, 327 - externa (M. thyroarylenoideusl 191 - fibrocartilaginea 140 - flaccida 141 - fundiformis (Pars cricopharyngea, KILLIAN's muscle) 172 - glossopharyngea (M. constrictor pha ryngis superior) 80, 86-87, 172-173 - inferior - - (N. vestibularis) 312-313 - - (Orbita) 64 - infraclavicularis (Plexus brachialis) 201 - insularis [A. cerebri media) 266-267, 277 - interca rtilaginea (Rima glottidis) 187, 190 - intermembranacea (Rima glottidis) 187, 190 - intermuscularis (A. maxillaris) 49 - interne (M. vocalis) 185 - intracranialis - - (A. vertebralis) 203 - - (N. opticusl 115 - iridica retinae 127 - labialis (M. orbicularis oris) 40, 173 - lacrimalis (M. orbicularis oculi) 105, 111 - laryngea pharyngis (Hypopharynx, Laryngopharynx) 177, 275 - lateralis - - (M. pterygoideus medialis) 44 - - (Os occipitale) 18, 20, 31 - Iibera (Columna fornicis) 238-239, 278 - lumbalis - - diaphragmatis 330 - - (Medulla spinalis) 327,334 - mandibularis (A. maxillaris) 52 - marginalia (M. orbicularis oris) 40, 105 - medialis (M. pterygoideus medialis) 44 - mylopharyngea (M. constrictor pharyngis superior) 172-173 - nasalis - - (Os temporals) 22 - - pharyngis (Epipharynx, Nasopharynx) 177,
275 -
oblique - (M. arytenoideus) 185, 189 - (M. cricothyroideusl 173, 184 opercularis (Gyrus frontalis inferior) 235-237 optica retinae 125 oralis pharyngis (Mesopha rynx, Oropharynx) 68, 177, 275 orbitalis - (GI.Iacrimalis) 107, 109, 112, 117-119 - (Gyrus frontalis inferior) 235-236 - (M. orbicularis oculi) 40-42, 105 - (N. opticus) 115 - (Os frontal e) 5, 22, 28, 102 ossea (Tuba auditive) 140, 149-150,308 palpebralis - (GI. lacrimalis) 107 - (M. orbicularis oculi) 40-42, 105-106 petrosa - (A. carotis internal 217, 222 - (Os temporale) 12, 18, 20, 32, 147, 149-
-
pialis (Filum terminale) 325 plana (Corpus ci liare) 127 plicate (Corpus ciliare) 127 postcommunicalis - (A. cerebri anterior) 267-269, 277, 293 - (A. cerebri posterior) 266-268 posterior - (Commissura anterior) 239, 254
150
222-223,268,293 - - arteriosclerotic alterations 223 - centralia [Ventriculus lateralis) 240, 257-
259,261-263, 276,278-280,282-283,288 - ceratopha ryngea (M. constrictor pharyngis medius) 86-87, 172-173 - cerebralis (A. carotis internal 115, 217, 222-
223,267-268,293 - cervicalis - - (A . carotis internal 21 7, 222, 327
Index
Pars posterior - - (Dorsum linguae) 81, 179 - precommunicalis - - (A. cerebri anterior) 266-268, 277 - - (A. cerebri posterior) 266-268, 278 - prevertebralis (A. vertebralisl 200-201, 203 - profunda - - (GI. parotidea) 91 - - (M . masseter) 43-44 - pterygoidea (A. maxillaris) 52 - pterygopharyngea (M. constrictor pharyngis superior) 172-173 - recta (M. cricothyroideus) 173, 184 - reticula ris (Substantia nigra) 245 - retromandibularis (A. maxillaris) 49 - sacralis (Medulla spinalis) 334 - sphenoldalls (A. cerebri medial 240, 266-
267 - sphenopalatine (A. maxillaris) 49 - squamosa lOs temporalel 7, 10, 12, 18, 20,
28-29, 32- 33 -
sternocostalis (M . pectoralis major) 167 superficialis - (GI. parotidea) 90-91 - (M. masseter) 43-44 superior (N. vestibularlsl 312-313 supraclavicularis (Plexus brachialis) 56, 166,
-
supratarsalls (Palpebra superior) 104 tarsalis (Palpebra superior) 104 tecta (Columna fornicis) 238-239, 278 tensa 141 thoracica - aortae (Aorta thoracica) 319, 328 - (Medulla spinalis) 327, 334 thyroepiglottica (M. thyroarytenoideus) 185,
198, 205-206
191 - thyropharyngea (M . constrictor pharyngis inferior) 87, 172- 173 - transversa - - (M . arytenoldeusl 185, 189 - - (M. constrictor pharyngis inferior) 172 - transversaria (A. vertebra lis) 203, 209 - triangularis (Gyrus frontalis inferior) 236 - tympanies (Os temporale) 20, 32 PASSAVANT's ridge 315 Patellar reflex 336 Pediculus arcus vertebrae 325, 330 Pedunculus(-i) - cerebellaris(-esl 246, 251, 292 - - inferior 246- 247, 249, 312, 338 - - medius 246- 247, 249, 255, 257, 279-
280,288 - - superior 246-247, 249-250, 280, 338 - cerebri 131, 234, 243, 245-247, 255, 257,
274,276,292-293,295 - flocculi 247, 249 Pericranium 42-43 Peridural anaesthesia 331 Periglomeru lar cells, Fila olfactoria 297 Perilymphatic space 157 Periodontium 70 Periorbita 112, 114-115, 123-124 Periorbital region 107 Peripharyngeal abscess 170 Peripheral facial nerve palsy 54, 310 - acusticus neurinoma 313 - lagophthalmos 310 - localisation of the lesion 311 Peritonsillar abscess, carotid loop 174 Permanent teeth 72-74 Personality disorders, damage of the thalamic nuclei 243 Pes hippocampi 239, 257, 261-262, 287 Petiolus epiglottidis 180-182 Pharyngeal isthmus (Isthmus faucium) 80 Pharyngeal lymphoid ring !WALDEYER's tonsillar ring) 89 Pharyngeal muscles 172-173 - constrictor muscles 87, 172-173 - levator muscles 172 Pharyngeal pouch, remnants 193 Pharyngeal space, vessels and nerves 178
Pharyngeal tonsil 89 - hyperplasia 175 Pharyngo-oesophageal diverticulum 172 Pharynx 162, 175-179, 183 - levels 177 - sensory innervation 177 - vessels and nerves 178-179 PHILIPPE-GOMBAULT, triangle of (Fasciculus interventricularis) 336 Photorecetor cells, retina 131 Pia mater - crania lis 219,227, 268 - spinalis 329, 334 Pineal gland 247 - regulation, neural circuitry 241 Pinealocytes, melatonin 241 Pituitary gland 223 Plagiocephaly 21 Planning phase, somatomotor systems
342 Plantar reflex 336 Platysma 40-41,45-46,63, 68, 90, 93, 165,
169,171, 173, 192,
196-19~200,307
Pleura parietalis 209 Plexus - aorticus thoracicus 326 - basilaris 222, 224, 240- 241 - brachialis 56, 166, 197-199, 201,205-206,
209,214, 320,326 -
- interscalene plexus blockade 209 cardiacus 316-317, 319, 326 caroticus - communis 178-179 - internus 79, 109, 148,268,300, 307, 309,
-
cavernosus 59,91,300 cervicalis 46, 55, 198, 200, 214,326 - sensory and motor branches 202 choroideus 261, 272,279 - ventriculi lateralls 131, 240, 259, 262-
314
263,276-260,282-286, 288-289 - - - quarti 239, 247-248, 250, 259, 264,
266,288, 292 - - - tertii 240- 241 , 248,259, 262-264,
269,278-279, 292 - coeiiacus 316-317 - dentalis - - inferior 50, 77, 302 - - superior 77 - hepaticus 316- 317 - hypogastricus - - inferior 341 - - superior 341 - intraparotideus 47, 307, 310 - lumbalis 326 - lumbosacralis 214 - oesophageus 316-31~319,326 - pharyngeus 17~314,316-318 - prevertebralis 326 - pterygoideus 50, 53, 76, 79, 218 - pulmonalis 316- 317, 319 - renaiis 316- 317 - sacraiis 326 - splenicus 316-317 - suprarenalis 316-317 - thyroideus impar 192, 205, 210 - tympanicus 148, 314-315 - venosus - - canalis nervi hypoglossi 218 - - caroticus intemus 150, 218 - - fora minis ova lis 150, 218, 224 - - pharyngeus 190 - - pterygoideus 116 - - vertebralis internus 330 Plica(-ae) - aryepiglottica 179, 187 - ciliares 127 - fimbriate 83, 87, 92, 95 - glossoepiglottica - - lateralis 81 - - medians 81-82 - interarytenoidea (Rima glottidisl 187 - iridis 127
Plica(-aeJ - iacrimalis (HASNER's valve) 65, 110 - mallearis anterior 141, 144, 146- 147 - - posterior 141, 146-147 - - superior 141 - nervi laryngei superioris 179 - palatinae transversae 80 - petroclinoidea anterior 292- 293 - salpingopalatine 175-1 76 - salpingopharyngea 82, 176-176, 179 - semilunaris conjunctivae 104, 110 - su bl ingualis 92, 94-95 - triangularis 81 - vestibularis 175-176, 186-188, 190-191 - vocalis 175-176, 186- 188, 190-191 - - intubation granulomas 187 - - squamous cell carcinomas 187 PNS (peripheral nervous system) 214 Polus - anterior - - bulbi 125 - - Iantis 125, 128 - frontalis 232-235, 238, 260, 284-285 - occipitalis 232-235, 238, 260, 284-285 - posterior - - bulbi 125 - - Iantis 125, 128 - temporalis 233-235,261,277 Polyps, Plica vocal is 187 Polysynaptic reflexes 335 Pons 215,229,231, 239- 241, 245-246,248,
255,258,269,275- 276,279, 288,295,319, 327 Pontocerebellum 250-251, 263 - lesions 252 Porus acusticus - externus 7, 15, 36- 37 - intern us 10, 12-13, 17, 33, 151, 268 - - contents 17 Posterior cranial base 15 Posterior cranial fossa 13 Posterior lateral fontanelle 19 Posterior scalene hiatus 168 Posterior spinocerebellar tract 338 Posterior triangle of the neck 164 Posticus (M. cricoarytenoideus posterior) 179,
185-186, 189-190 - paralysis 185 Post-zoster neuralgia 306 Pre-auricular skin tag 137 Precuneus 236, 280,282-283 Premotor cortex 237 Presbyopia 128 Prevertebral muscles 168 Primary auditory cortex 237 Primary brain vesicles 228 - cervical flexure (Fiexu ra cervicalis) 228 - midbrain flexure (Flexure mesencephalica) 228 Primary cortical areas, cerebral hemispheres 237 Primary palate 81 Primary somatomotor cortex 237 Primary somatosensory cortex 237 Primary visual cortex 237 Primordial lens 100 Primordium choroid 100 Processus(-us) - aiveolaris (Maxilla) 6, 23, 28-29, 61 - anterior (Malleus) 142 - c iliaris 127 - clinoideus - - anterior 12, 30, 268 - - medius 223 - - posterior 12, 30, 268 - cochleariformis 144-146 - condylaris (Mandibulal 34-36, 38-39, 62,
76,91 - coronoideus (Mandibula) 34-37, 39, 62, 91 - ethmoidal is (Concha nasal is inferior) 25 - frontalis (Maxilla) 5-6, 18, 23-24, 58, 62,
102, 107, 110-111 - intrajugularis 31, 33
363 tahir99-VRG & vip.persianss.ir
Index
Processus(-us} - jugularis 31 - lateralis (Malleus) 142, 147 - lenticularis (Incus) 142, 146-147 - mastoideus 7, 9, 14-15, 32-33, 37, 91, 138, 144-145,147,168,173,178,308 - museu laris - - (Cartilage arytenoidea) 180, 183 - - (Cartilage cricoidea) 180 - orbitalis (Os palatinum] 27-29, 102-103 - palatinus (Maxilla) 10, 14, 20, 23-26, 28, 59, 64 - posterior (Cartilage septi nasi) 59 - pterygoideus - - (Os sphenoidale) 14, 20, 24-27,29-30, 68, 78,82, 102,149,173 - - (Os temporals) 36 - pyramidalis (Os palatinum) 14, 26-27, 102, 308 - spinosus 332 - styloideus (Os temporals) 7, 9-1 0, 14, 3233,36-37,43, 68, 87, 91, 138, 144-145, 171-173, 178 - temporal is (Os zygomaticum) 44 - uncinatus - - (Os ethmoidale) 65-66 - - (Os sphanoidale) 25 - vagina lis (Os sphenoidale) 30 - vocal is (Cartilage arytenoideal 180, 182184, 190 - zygomaticus - - (Maxilla) 14, 23, 26, 29 - - (Os frontale) 5, 22, 102-1 03 - - (Os temporale) 14, 22, 32-33, 36, 44 Programming, somatomotor system 342 Projection tracts 255 Prom inentia - canalis - - nervi facialis 145 - - semicircularis lateralis 145 - laryngea 180, 192, 204 - mallearis 141 Promontorium 144-148,332 Prosencephalon 2 28-229, 231 Protopathic sensibility - N. trigeminus IV] 306 - neurons 337 Protrusion, temporomandibular joint 37 Protuberantia - mentalis 6-7, 34, 85 - occipitalis - - externa 9-10, 15, 198 - - interne 12, 31 Pterygopa latina fossa 27 - lateral access route 27 Ptosis 104 - paralysis of theM. levator palpebrae superioris 112 Pulp cavity 70 Pulpa - coronalis 70 - dentis 70 - rad icularis 70 Pulvinar thalami 243, 245-247, 273, 280 Punctum - lacrimale 104-105, 110 - nervosum (ERB's point) 47, 197 Pupilla 104, 127 Putamen 240, 256-257, 277-279, 283-286, 288-289 Pyramidal tract 255, 257, 339 - lesions 257 - - BABINSKI's reflex 257 - motor function 342 Pyramis 255 - medullae oblongatae 246 - vermis 248-249, 252-253
a Quadrant anopsia 299 Quadrigeminal plate 246
R Radiatio - acustica 159, 243, 255-256 - centra lis thaI ami 256 - corporis callosi 254, 257, 277, 281 - optica (GRATIOLET's radiation) 131-132, 243,255-256,284-286,298-299 - - lesions 132 - thalami 243 - - anterior 243, 256 - - central is 255-256 - - posterior 243, 256 Radicular artery syndrome 328 Radii lentis 128 Radiograph - A. carotis interne 217 - neck 209 - paranasal sinuses 62 - temporomandibular joint 39 Radix[-ces) - anterior [motorial (Nn. spinales) 246, 330, 334,339 - clinica 70 - cranialis (N. accessorius) 246,316,320-321 - dentis 70 - facialis [N. canalis pterygoidei) 148 - inferior (Ansa cervica lis] 199, 202, 322-323 - lateralis (Tractus opticusl 131 - linguae 81, 83, 86, 94, 188-189 - motoria (N. trigeminus) 246, 293, 303 - nervorum - - cervicalium 324 - - coccygeorum 324 - - lumbalium 324 - - sacralium 324 - - thoracicorum 324 - parasympathica - - (Ganglion pterygopalatinum] 77, 310, 312 - - loculomotorial (Ganglion ciliarel 96, 119, 300 - posterior - - (Medulla spinalis) 334 - - (Nn. spinales] 246, 327, 330, 334 - sensoria - - (N. trigeminus) 119, 246,293, 303 - - [nasociliarisl ganglii ciliaris 300-302, 304 - spinalis (N. accessorius) 246, 292, 295, 320-321 - superior - - (Ansa cervicalisl 89, 199, 201-202, 204205, 208, 322-323 - - (Plexus cervicalis) 198 - sympathies ganglii - - ciliaris 300-301 - - pterygopalatini 77, 309, 314 Ramus[-iJ - acromialis (A. suprascapularis) 200 - a lveolares superiores - - anteriores 77 - - medii 77, 302 - - posteriores 49, 51, 77 - anastomoticus cum a. meningea media (A. lacrimalisl 118 - anterior - - (N. auricularis magnus) 196 - - (N. cervicalis) 198-200, 322-323 - - (Sulcus lateralis) 235 - articulares (N. spinalis) 329 - ascendens (Sulcus lateralis) 235 - auricula ris(-es) - - (A. auricularis posterior) 52, 139 - - anteriores (A. temporalis superficialis) 52, 139 - - (N. auricularis posterior) 307, 309 - - (N. vagus) 51, 148, 178,316-317, 319 - basales tentorii (A. carotis internal 22 2 - bronchiales (N. vagus) 316-317,319 - buccales (N. facialis) 46, 54, 307,309,311 - calcarinus 131 - capsulae i nternae (A. choroidea anterior) 256
Ramus(-i} - cardiaci - - cervicales - - - inferiores (N. vagus) 316-317, 319 - - - medii (N. vagus) 210 - - - superiores [N. vagus) 178-179,201, 210,316-317, 319 - - (N. vagus) 326 - - thoracici (N. vagus) 316-317, 319 - cervicofacialis (N. auricularis posterior) 54 - chiasmaticus 267 - choroideus - - posterior (A. choroidea anterior) 272 - - ventriculi quarti (A. inferior posterior cerebelli) 203 - coeliaci (N. vagus) 316-317 - calli (N. facialis) 46-47, 54, 93, 197-198, 307, 309, 311 - communicans(-tesl --cum - - - ganglia ciliari (N. nasociliaris) 304 - - - nervo faciali 96, 197, 302, 305 - - - nervo glossopharyngeo 319 - - - nervo zygomatico 109, 121 - --ramo - - - - auricu lari nervi vagi 314-315 - - - - sinus carotici 316-317 - - (Truncus sympathicus) 201, 210 - cricothyroideus - - (A. thyroidea superior) 52, 175-176, 210 - - (V. thyroidea superior] 175-176 - cutaneus anterior pectoralis (N. intercostal is) 204 - dentales - - (A. alveolaris inferior) 49 - - (A. alveolaris superior posterior) 49, 52 - descendens (A. occipitalis) 52 - digastricus (N. facialis) 48, 51, 147,308,310 - diploicus (A. supraorbitalis) 118 - dorsales - - (A. intercostalis suprema] 203 - - linguae (A. lingua lis) 52, 88-89 - externus - - (N. accessorius) 178-179 - - (N. laryngeus superior) 178, 210,316-317 - - (N. vagus) 320-321 - frontalis - - (A. meningea media) 216, 220 - - - projection onto the side of the sku II 220 - - (A. temporalis superficial is) 45-46, 48, 52,216 - - posteromedialis (A. cerebri anterior) 281 - ganglionares - - ad ganglion pterygopalatinum 77-78, 304-305 - - trigeminales (A. carotis internal 222 - gastrici anteriores (N. vagus) 316-317,319 - glandularis(-es) - - (A. thyroidea inferior) 194, 200 - - (A. thyroidea superior) 52, 194 - - anterior [A. thyroidea superior) 194,210 - - posterior (A. thyroidea superior) 21 0 - gyri angularis (A. cerebri media) 225, 270 - hapaticus (N. vagus) 316-317,319 - hyoideus (A. lingualis) 88 - hypothalamicus 267 - inferior(-esl - - (N. oculomotorius) 113-115, 119-120, 124,300 - - (N. transversus calli) 196 - infrahyoideus (A. thyroidea superior) 52, 198 - interganglionaris (Truncus sympathicusl 209 - internus - - (N. accessorius) 178-179 - - (N. laryngeus superior) 88, 178, 189-190, 194,210,316-317 - - (N. vagus] 320 - intestinales (N. vagus) 316-317 - isthmi faucium [N. lingual is) 305 - lateralis - - (N. supraorbitalis) 47-48,50, 117-118 - - nasi (A. facialis) 52
364 tahir99-VRG & vip.persianss.ir
Index
Ramus(-i) - linguales - - IN. glossopharyngeusl 81 , 189, 314-315 - - (N . vagus) 3 16- 317 - mandibulae 6, 34-37, 43-44, 50, 68, 85, 171 - marginalis mandibularis (N. facialisl 46, 54, 208, 307, 309, 311 - mastoideus (A. occipitalis) 52, 201 - medialis (N. supraorbitalis) 47-48, 50, 117118 - medullares - - latera les (A . spinal is anterior) 203 - - medlales (A. spinalis anterior) 203 - meningeus - - (A . carotis internal 222 - - (A . carebri posterior) 268 - - (A. occipitalis) 52 - - (A. ophthalmica) 115 - - (A. vertebralls) 203 - - anterior (A. ethmoidalis anterior) 117-120 - - (N . cervicalis) 322- 323 - - IN. mandibularis) 117, 305 - - (N. maxillaris) 302, 304 - - (N. spinalis) 329 - - (N. t rigeminus) 302 - - (N. vagus) 316- 317, 319 - - recurrens - - - (A . ophthalmica) 115-116, 118 - - - (N. ophthalmicus) 302, 304 - mentalis (A. alveolaris inferior) 49, 52 - musculares - - (A. vertebralis) 203 - - (N . pterygoideus medialis) 150 - musculi stylopharyngei (N . g lossopharyngeus) 314-316 - mylohyoideus (A. alveolaris inferior) 49 - nasalisl-esl - - anteriores laterales (A. ethmoidalis anterior) 118 - - externus - - - (A. ethmoidalis anterior) 66 - - - (N. ethmoidal is anterior) 48, 67, 302 - - - (N. trigeminus) 55 - - interni - - - IN. ethmoidalis anterior) 302 - - - IN. infraorbitalis) 67 - - posteriores - - - inferiores (N . palatinus major) 67 - - - superiores 78, 302 - - - - latera las 67, 305 - - - - mediales 305 - nervi occulomotorii (A. communicans posterior) 267 - occipitalis - - (A. auricularis posterior) 52 - - (A. occipitalis) 52 - - IN. auricularis posterior) 307 - oesophageales - - (A. thyroidea inferior) 200 - - (N. laryngeus recurransl 189 - - (N. vagus) 316- 317 - orbitales (N. maxiliaris) 78 - paracentrales 225 - parietalis - - (A. meningea medial 216, 220 - - (A. occipitalis medialis) 281 - - lA. temporalis superficialisl 46, 48-49, 51- 52, 216 - pariatooccipitalis (A. occipitalis medialis) 225 - parotideus(-i) - - (A. auricularis posterior) 52 - - (A. temporalis superficialisl 52 - - (N. auriculotemporalis) 305 - - (N. facialis) 96 - - (N. trigeminus) 302 - perforantes - - (A. auricularis posterior) 139 - - (A . thoracica internal 204 - - (V. thoracica internal 204 - peridentales (A. alveolaris inferior) 49 - - (A . alveolaris superior posterior) 49, 52 - - (A. infraorbitalis) 49
Rsmus(-i) - pharyngealis(-es)/pharyngeus(-il - - (A. canalis pterygoidal) 79 - - (A. palatine descendens) 89 - - (A. pharynges ascendens) 52 - - (A. thyroidea inferior) 200 - - (Aa. palatinae minores) 52 - - (N. glossopharyngeusl 178, 314-315 - - IN. vagus) 178, 314, 316-317, 319 - posterior(-es) - - IN. auricularis magnus) 196 - - (Nn. cervicales) 198 - - (Sulcus lateralis) 235, 281 - precunealis lA. pericallosal 225, 280-281 - profundus (A. transversa colli) 198-200 - pterygoidal (A. maxillaris) 49, 52 - pulmonales IN. vagus) 326 - radicularis(-es) - - (A. vertebralis) 203 - - anteriores - - - (A. ethmoidalis anterior) 118 - - - (Nn. intercostales) 329 - - - INn. lumbales) 329 - - posteriores - - - (Nn. intercostales) 329 - - - INn. lumbalesl 329 - septalis - - (A. ethmoidalis posterior) 66 - - anterior (A. ethmoidalis anterior) 66 - - (N . ethmoidalis anterior) 67 - - posterior (A. sphenopalatine) 52, 66 - septi nasi (A. labialis superior) 52, 66 - sinus carotici (N. glossopharyngeus) 314315 - spinales - - (A. cervicalis ascendens) 200 - - (A. intercostalls suprema) 203 - - (A. vertebralis) 203 - sternocleidomastoideus - - lA . occipitalis) 52, 89, 200 - - (A. thyroidea superior) 52, 199 - stylohyoideus (N . facialis) 48, 147, 308,310 - superficialis lA. transversa collil 198-199, 201 - superior(-es) - - IN. oculomotorius) 113, 115, 118-119, 124, 300-301 - - (N. transversus coIIi) 196 - suprahyoideus (A. llngualls) 88, 198 - temporalis(-es) - - anterior (A. cerebri media) 270 - - medius (A. cerebri media) 270 - - (N. facialis) 46, 54, 307, 309, 311 - - superficialis (N. trigeminus) 302 - temporofacialis IN. auricularis posteriori 54 - tentorius - - (N. ophthalmicus) 302, 304 - - IN. trochlearis) 117 - terminales (A. cerebri media) 240, 283 - tonsillae cerebelli (A . inferior posterior cerebelli) 203 - tonsillaris(-es) - - (A. facialis) 52 - - (A. palatina ascendens) 89, 189 - - (A. pharyngea ascendens) 89 - - (N . glossopharyngeus) 81, 89, 189,314315 - - (Nn. palatini minores) 89 - t racheales - - lA. laryngea inferior) 189 - - (A. thyroidea inferior) 200 - - (N . vagus) 316-317 - tubarius (N. glossopharyngeus) 314 - ventralis nervi spinalis 214 - zygomatici (N. facialis) 46, 54, 307, 309, 311 - zygomaticofacialis - - IN . maxillaris) 302 - - (N. zygomaticus) 48, 78, 302 - zygomaticotemporalis IN. zygomaticus) 48, 78-79 Ranula 92 Raphe - mylohyoidea 84-85
Raphe - palati 68, 80- 81 - palpebralis latera lis 104, 107 - pharyngis 172 - pterygomandibularis 49, 51, 68, 80, 173 RATHKE's pouch 175 Recessus - cochlearis 153 - ellipticus 153 - epitympanicus 141, 143-144, 146 - frontalis 65 - infundibuli 241, 248, 259, 264, 278, 287 - lateralis ventriculi quart! 249, 259 - meatus acustici inferioris 140 - membranae tympanicae - - anterior 141 - - superior 141, 144 - pharyngeus 60, 150, 179 - pinealis 241 , 259, 264, 285 - piriformis 179, 187, 190 - sphenoethmoidalis 65 - sphericus 153 - supraopticus 241 , 269, 264,278, 287 - supraorbitalis 63 - suprapinealis 241 , 247, 269, 264, 284 - triangularis 247, 264, 278 - tubotympanicus 136 - - development 136 Rectum 341 Referred pain 326 Reflexes 335 - of the spinal cord 335- 336 Refractive index, cornea/lens 126 Regio - axillaris 201 - buccalis 4 - capitis 4 - cervicalis - - anterior 4, 164-165, 196, 198 - - lateralis 4, 164-165, 196-201 - - posterior 4, 164 -COlli 4 - deltoidea 4 - frontalis 4 - infraorbitalis 4 - mentalis 4 - nasalis 4 - occipitalis 4 - oralis 4 - orbitalis 4 - parietalis 4 - parotideomasseterica 4 - sternocleidomastoidea 4 - temporalis 4 - zygomatica 4 REICHERT's cart ilage 20 REINKE's oedema 191 REINKE's space 191 REISSNER's membrane (Membrana vestibuli) 156 Respiratory epithelium 297 - laryngeal cavity 188 Reticulum trabeculare 125, 127 Retina 125-126, 241, 298 - amacrine cells 298 - blood vessels 129 - cone cells 131, 298- 299 - diffuse off-ganglion cells 298 - diHuse on-ganglion cells 298 - ganglion cells 298-299 - horizontal cells 298 - inner limiting membrane 298 - inversion 131 - midget off-ganglion cells 298 - midget on-ganglion cells 298 - neural epithelium 100-101 - neuronal network 298 - off-cone bipolar cells 298 - on-cone bipolar cells 298 - on-ganglion cells 298 - pigment epithelium 100-101 - rod cells 131 , 298-299
365 tahir99-VRG & vip.persianss.ir
Index
Retinaculum - laterale 124 - mediale 124 Retinal ablation (Ablatio/Amotio retinae) 125, 129, 131 - optic disc oedema 129 Retro-articular venous plexus 38 Retropharyngeal abscess 170 Retrusion, temporomandibular joint 37 Rhachisch isis 333 Rheumatoid arthritis, crico-arytenoid joint 183 Rhinorrhea 67 Rhombencephalon 228-229, 231 Rhomboid fossa 246 - nuclei regulating the systemic circulation 246 Rima - glottidis 185, 187, 190-191 - palpebrarum 104, 106 - vestibuli 191 RIOLAN's muscle (Pars palpebralis, M. orbicularis ocu Iii 106 Rod bipolar cells, retina 131, 298-299 Rod cells, retina 131, 298-299 ROLAN DO, fissure or sulcus of (Sulcus centralis cerebri) 229, 232-233, 235-236, 255, 258,260,269,275,281-283,288-289 ROLLER's nucleus (Ncl. vestibularis inferior) 160,294,313 ROMBERG's test, vertigo 158 Roof of skull 10-11,219 - diploic canals 219 - diploic veins 219 Root apex of tooth 70 Root of the tongue 81 - arteries and nerves 189 Root of tooth 70 Root pulp of tooth 70 ROSENTHAL's vein [V. basilaris) 218, 240,273 Rostral 215 Rostrum - corporis callosi 236, 238, 248, 254,262263,269,27~285,288
- sphanoidale 30 Round window (Fenestra cochleae) 145
s Saccadic eye movements 253 Sacculus - laryngis 190-191 - vestibularis 134, 137, 154, 157, 312 Saccus - endolymphaticus 137, 154 - lacrimalis 110-111 Saddle anaesthesia, cauda equine syndrome 324 Sagittal suture 8, 19 Salivary glands 91 - anomalies of the excretory duct system 92 - inflammation 92 Scala - tympani 152-154, 156-157 - vestibuli 152-154, 156-157 Scalene hiatus 168, 201, 209 Scalenus anticus syndrome 209 Scapha 139-140 Scaphocephaly 21 SCHIRMER's test 108, 147 - impaired function of the lacrimal gland 108 - periphera I facial nerve palsy 31 1 SCHLEMM's canal (Sinus venosus sclerae) 125-127 SCHULTZE's comma tract (Fasciculus interfascicu laris) 336 SCHWALBE's nucleus (Ncl. vestibularis medialis) 160, 294,313 Scintigraphic image, thyroid gland 195 Sclera 101, 123-127 - development 100 - radius of curvature 126 Secondary auditory cortex 237
Secondary brain vesicles 228 Secondary cortical areas, cerebral hemispheres 237 Secondary motor areas 342 Secondary palate 81 Secondary somatosensory cortex 237 Secondary visual cortex 237 Segmenta - cervica lia 324, 327 - coccygea 324 - lumbalia 324, 327 - medullae spinalis 324-325 - sacral ia 324 - thoracica 324, 327 Sella turcica 10, 31, 60, 223 - arteries and nerves 293 Semicanalis - musculi tensoris tympani 145-146, 150, 308 - tubae auditivae 82, 146, 149-150, 152 Semicircular ducts 134, 157 - hair cells 313 Senile ectropion 41 Sensorineural hearing impairment 157 Sensory calls (olfactory cells) 296-297 Sensory dysfunction - blow-out fracture 103 - intracerebral infarction 256 - lesions of the thalamic nuclei 243 Septum - canalis musculotubarii 145-146, 150 - linguae 83, 87, 95 - nasi 59, 62-64, 76 - - osseum 6, 18, 24, 36 - orbitale 107, 111, 123 - pellucidum 236, 238, 247, 257, 262-264, 269,274-278,282-284,292 Septum deviation 24, 63 Seromucous otitis media 143 SERRE's bodies 73 Shoulder dysfunction, lesions of theN. accessorius 47, 321 SHRAPNELL's membrane 141 Sialoliths 92, 94 Singer's nodules 187 Sinus - caroticus 216,314 - cavernosus 115-116,218,222-224,293 - - arteries and nerves 293 - - thrombosis 108, 116 - durae matris 219, 222, 224 - - thrombosis 224 - frontalis 10, 24-25, 28, 59-64, 122, 130 - - development 64 - - entrance 60 - - position in the skull 61 - intercavernosi 222-224 - marginalis 222, 224 - maxillaris 23, 26,28-29, 61-64, 76-77, 91, 102, 110-112, 122-124, 130, 275 - - development 64 - - entrance 60 - occipitalis 222, 224, 268 - para nasalas 62 - - entrance 60 - petrosus - - inferior 222, 224 - - superior 222, 224, 293 - posterior (Cavum tympani) 145 - rectus 21 B, 222, 224, 259, 292 - sagittalis - - inferior 218, 222,240, 272, 292 - - superior 63,218-220, 222,224-225, 240,259,272,292 - sigmoideus 178-179, 218, 222, 224, 268 - sphenoidalis 10, 24-25,29-30, 36, 59-62, 121,130,223,275 - - entrance 60 - - position in the skull 61 - - sinusitis/tumours 120 - - surgical interventions 61 - sphenopariatalis 218, 222, 224 - transversus 147, 178-179, 222, 224 - tympani 145-146
Sinus - venosus sclerae (SCHLEMM's canal) 125127 Sinus thrombosis, inflammation in the facial area 53 Sinusitis 62 - computed tomography 64 - maxillaris 28 Siphon caroticum 217 Skull 5 - basal fractures 8 - diastatic fractures 8 - linear fractures 8 - of a newborn 18-20 - split fractures 8 Skull bones 6-10 - ossification 20 Skull fractures 8 - lesions of the A. men ingea media 221 Small alar cartilage 58 Small fontanelle 19 Small salivary glands 91 SOLDER's lines 306 Soft palate 80 Soft triangle, nose 58 Somatic nerve plexus 326 Somatomotor system 342 - planing phase 342 Somatotopic arrangement - internal capsule 256 - primary somatomotor cortex 237 Spatium(-a) - epidurale 331-332 - episclerale 123 - extradurale 330 - intervaginale subarachnoidale 125 - lateropharyngeum 178-179 - oesophagotracheale 175-176, 188 - perichoroideum (Retina) 125 - periviscerale 169 - retrooesophageum 175-176 - retropharyngeum 175-176 - subarachnoideum 219, 258-259, 268, 276, 329,331 - suprasternale 171, 192 - zonularia 127 Specia I somato-afferent fi bras (SSA) 294-295 - N. vestibulocochlearis 313 Special viscero-afferent fibres (SVA) 294-295 - N. glossopharyngeus IIXI 315 Special viscera-efferent fibres (SVE) 294-295, 309,318 - N. accessorius 321 Specific thalamic nuclei 242 - lesions 243 Sphenoid bone 30-31 Spina(-ae) - bifida [aperta, cystica or occulta) 333 - mentalis 34-35 - - superior 85 - nasalis 22 - - anterior 6-7, 23, 25-26, 59 - - posterior 14, 23-26 - ossis sphenoidalis 12, 14, 27, 30, 36, 149 - palatinae 26 - suprameatica 32 -tympanies - - major 147 - -minor 147 Spinal anaesthesia 331 Spinal cord 251, 324-325, 327,342 - afferent tracts 337-338 - arteries 328 - compression 333 - cross-sections 334 - directional and positional informations 215 - efferent tracts 339 - flexor reflexes 335-336 - laminar organisation - - of the grey matter 335 - - of the white matter 336 - layers 335 - lesions 333
366 tahir99-VRG & vip.persianss.ir
Index
Spinal cord - local autonomic system 335 - longitudinal grooves 327 - meninges 329 - motor function 342 - nuclei 335 - pathways of the motor system 339 - position w ithin in vertebral canal 330 - reflex circuitry 335 - reflexes 335 - segmental arterial supply 329 - segments 324-325 - stretch reflexes 335-336 - supraspinal centres 335 Spinal nerves 327 - lesions, dysfunctional cutaneous innervation 340 - nomenclature 327 Spinocerebellar tract, anterior/posterior 338 Spinocerebellum 250-252 - lesions 252 Spiral canal of cochlea 152, 156 Splenium corporis callosi 234, 236, 238-239,
254-255,262,269, 275,280,283-284, 288,292 Split lamp examination, eye 108 Split skull fractures 8 Split-brain operation. epilepsy 260 Split-brain syndrome 260 Spontaneous nystagmus 253 Squama - frontalis 5, 19, 22, 24, 29, 102-103 - occipitalis 9-10, 18- 20, 31 Squamous cell carcinoma - larynx 188 - Plica vocalis 187 SSA (special somata-afferent fibresl 291, 294-
295 - N_vestibulocochlearis 313 Stapedius reflex test, peripheral facial palsy 311 Stapes 136, 138, 141-144, 147, 154, 157, 308 STENSEN's (STENONI duct (Ductus parotideusl 40, 42-43,46,90, 92-93,173 STH (somatotropic hormone, growth hormone), overproduction 244 Stratum - granulosum (Cerebellum) 250 - moleculare (Cerebellum) 250 - nervosum (Retinal 125 - pigmentosum (Retina) 125 Stretch reflexes of the spinal cord 335-336 Stria(-ae) - longitudinalis - - latera lis 239, 260, 279 - - medialis 239, 260, 279 - mallearis 141 - medullaris(-es) - - thalami 241, 244, 278-279 - - ventriculi quarti 246, 259 - olfactorla - - latera lis 296 - - medialis 296 - terminalis 247, 262- 264, 278-279, 282-283 Striatum, motor function 342 Stroke See cerebral infarction Struma multinodosa 195 Subarachnoidal space 258, 325 Subclavian steal syndrome 200 Subdural haematoma 221,225 - chronic 225 - injuries of the bridging veins 225 Subglottis (subglottic space) 186 Subiculum promontorii 145 Sublingual gland 91,93-94 Submandibular gland 91 , 93-94 Substantia - alba 262, 280 - - (Medulla spinalisl 334 - gelatinosa 334- 335 - - central is (Medulla spinalisl 334 - grisea 262, 280 - - central is 245
Substantia grisea - - intermedia centralis 335 - - (Medulla spinalis) 334 - Iantis 128 - nigra 219, 234, 245, 257, 287, 292-293, 339 - - motor f unction 342 - perforate - - anterior 245, 296 - - posterior 234, 245, 266 Sulcus(-i) - anterolateralls 327, 334 - arteriae - - meningeae mediae 11 - - subclaviae 210 - - tempore lis mediae 32 - arteriosus - - lOs sphenoidale) 30 - - (Os temporals) 10-12, 33 - bulbopontinus 248 - calcarinus 131- 132, 233- 234, 237-238,
255,269, 274- 275, 280, 284- 285,288, 298-299 - - location/course 233 - caroticus 12, 30-31, 268 - centralis - - cerebri (fissure/sulcus of ROLAN DOl 229,
-
232- 233, 235- 236, 255,258, 260, 269, 275,281-283, 288-289 - insulae 235 cerebri 232, 234-235 cinguli 232-233, 238, 277, 282 - location/course 233 circularis insulae 235, 277 collateralis 233- 234, 261 - 262, 285-287 corporis callosi 265, 277 frontalis inferior 232 hippocampalls 233-234, 261-262, 286-287 hypothalamicus 241 , 264, 269, 279, 286 infraorbitslis 23, 27-29. 102-1 03 intermedius posterior 246, 334 intraparietalis 232, 235-236 lscrimalis 23, 102 lateralis 229, 233, 235, 258, 277, 279, 281 - cerebri 236 - location/course 233 limitans 246 lunatus 235, 283-285 media nus 246, 259 - linguae 81 - (Medulla oblongata) 246-247 - posterior (Medulla spinalis) 327, 334 mylohyoideus 34-36 nervi petrosi - majoris 12, 152 - minoris 12 occipitotemporalis 234 olfactorius 234 orb ita les 234 palatini 26 palpebralis superior 104 palpebronasalls 104 parietooccipitalis 232- 233, 235-236, 238,
255,269,280, 282-283, 288 - location/course 233 postcentralis 232 posterolateralis 246, 318, 327, 334 precentralis 232, 235 prechiasmaticus 31 , 223 promontorii 145 retroolivaris 319 sclerae 104 sinus - petrosi - - inferioris 12, 152 - - superioris 12 - sagittalis superioris 11-12 - sigmoidei 10, 12-13,31,33, 151-152, 268 - transversi 10, 12-13,31 spiralis intern us 166 subparietalis 280, 282- 283 temporalis - inferior 234-235 - superior 235, 280, 283-286
Sulcus(-i) - terminalis 179 - - linguae 81 - tubae auditivae 15, 30 - tympanicus 145 - venosi 11 Supercilium 104, 123 Supplementary motor cortex 237 Supporting cells, Crista ampullaris 157 Supraglottis (supraglottic space) 186 Suprahyoidal muscles 84-85, 167 Supranuclear lesion of theN _facialis 310 Supratentorial herniation 249 Sutura - coronalis 6-8, 10- 11, 18-19, 219 - ethmoidolacrimalis 29 - frontalis 18-19, 24 - frontolacrimalis 6-7 - frontomaxillaris 28, 58 - frontonasalis 5, 58 - frontozygomatica 6- 7, 62 - incisive 26 - intermaxillaris 6 - intemasalis 5 - lacrimomaxillaris 7 - lambdoidea 7-11, 18-1 9 - nasomax illaris 6- 7, 58 - occipitalis transversa 9, 20 - occipitomastoidea 7, 9, 12 - palatine - - mediana 14, 26 - - transversa 14, 23, 26, 59 - parietomastoidea 7, 9 - sagittalis 8-9, 19, 219 - sphenofrontalis 6-7, 12. 29 - sphenoparietalis 6 - sphenosquamosa 7, 12, 38 - sphenozygomatica 6- 7, 109 - squamosa 7, 9-10 - temporozygomatica 7 - vomeromaxillaris 59 - zygomaticofrontalis 28 - zygomaticomaxillaris 6 -7, 23,27- 28, 103 Sutural bones 9 SVA (special viscero-afferent fibres) - N. facialis lVIII 291, 294-295, 310 - N. glossopharyngeus [IX[ 315 SVE (special viscero-efferent fibres) 291 , 294-
295,309,318 - N . accessorius [XI) 321 - N . facialis lVIII 310, 321 Swallowing difficulties 316 Swallowing reflex 84 - lack of 315 - - lesions of the N. vagus 319 SYLVIUS, aqueduct of (Aqueductus mesencephalil 258 Sympathicus (sympathetic system) 341 Symphysis mandibulae 18, 35 Synchondrosis - petrooccipitalis 162, 172 - sphenopetrosa 151 - 152 Syndesmoses 181 Systema nervosum 214 Systemic circulation, regulation, nuclei of the rhomboid fossa 246
T Taenia - choroidea 247, 264 - fornicis 239, 263 - thalami 263-264 Tanycytes 264 Tapetum 254,280, 282-283,289 Tarsal plates 107 Tarsus - inferior 106-1 07, 123 - superior 106-107, 123 Tear film - break-up time 108 - components 106
367 tahir99-VRG & vip.persianss.ir
Index
Tectum mesencephali 131, 234,241, 245, 248, 252,269,274-275,286-287 Teeth - blood supply 76 - development 73 - form 70 - infiltrative anaesthesia 77 - innervation 77 - reference lines 7 - rules of orientation 70 Tegmen ventriculi quarti 249-250 Tegmentum mesencephali 234, 245, 248, 274, 279,286-287 Tela choroldea 279-280, 283 - ventriculi - - quarti 247 - - tertii 241 , 248, 262-264, 269, 272, 278279, 284,288 Telencephalon 215, 228-229, 231 - grooves 229 - hemispheres 229 - - development 229 Temporal bone 32-33, 148 - of a newborn 32 Temporal fossa 122 Temporal horn, lateral ventricle 261-262 Temporal lobe 233 Temporal lobe hernia 221 Temporal visual field 299 Temporomandibular joint 36-38, 44 - abduction 37 - adduction 37 - arthrosis 38 - articular disc 38 - condylar fracture 38 - fossa 38 - movements 37 - protrusion 37 - radiograph 39 - retrusion 37 - tubercle 38 Tendo intermedius (M . digastricus) 84-85, 208 Tendon of the vocal ligament (BROYLE's tendon) 182, 190 TENON's capsule (Vagina bulbi) 123 Tentorium cerebelli 221-222, 272, 292 Tetracyclines, enamel defects 73 Thalamic nuclei 242 - intralaminar group 243 Thalamic pain, lesions of the thalamic nuclei 243 Thalamic radiation 243 Thalamus 160, 215,229, 236, 238,240-243, 247,251, 256,263-264, 269,273-276, 278-279,283-285,288,33~339,342
- cortical projections 242 Thorax, transition to the upper extremity - vessels and nerves 209 Thrombophlebitis, Otitis media 144 Thrombosis - Sinus cavernosus 108 - Sinus durae matris 224 Thyroglossal duct cyst 193 - computed tomography 193 Thyroid cartilage 180 Thyroid gland 191-192 - arteries 194 - development 193 - diffuse and focal alterations 195 - lymph vessels and lymph nodes 207 - position 192 - scintigraphic image 195 - surgery 192 - ultrasound image 195 - veins 194 Thyroidectomy 194 Tic douloureux (trigeminal neuralgia) 55 Tinnitus 156 Tongue 81-83, 86 - extrinsic muscles 86-87 - intrinsic muscles 83 - motor Innervation 88 - muscles 83, 87
Tongue
Trigonum
- nerves 88- 89, 93, 95 - vessels 88- 89, 95 Tonsilla - cerebelli 248-250, 253, 280 - - hernia 221 - lingualis 81-82, 89, 175-176 - palatine 68,80- 82, 87, 89, 175-176, 179, 189, 193 - pharynges 60,68,89,175-176,179 - tubaria 89 Tonsillectomy 89 - carotid loop 174 Torus - levatorius 175- 176 - mandibularis 34 - tubarius 60, 175-176, 179 Trachea 166, 169, 172, 175-176, 179, 183, 185,188-189, 191-192,194, 201,207 - lymph vessels and lymph nodes 207 - surgical access 166 Tracheotomy 166 Tractus - bulboreticulospinalis 339 - cerebellaris 251 - cerebelloreticularis 251 - cerebellorubralis 279, 339 - cerebellothalamicus 251 - cerebellovestibularis 251 - corticonuclearis 256 - cortlcoretlcularls 256 - corticorubralis 256 - corticospinalis 256 - - anterior 255, 336 - - lateralis 256, 336 - cuneocerebellaris 251 - frontopontlnus 243, 255-256 - hypothalamohypophysialis 244 - occipitopontinus 256 - olfactorlus 60, 227, 234, 238, 266, 277, 292, 296-297 - olivocerebellaris 251 - optlcus 116, 131-132,238, 243, 245-246, 255, 257, 278, 287 - paraventriculohypophysialis 244 - parietotemporopontinus 256 - pontocerebellaris 251 - pyramidalis 255, 257, 279 - reticulocerebellaris 251 - reticulospinalis 336, 339 - retinohypothalamicus 241 - rubrospinal is 336, 339 - rubrothalamicus 339 - spinalis nervi trigemini 303,315, 317 - spinocerebellaris - - anterior !GOWERS' tract) 261,336,338 - - posterior (FLECHSIG's tract) 251,336, 338 - spinoolivaris 336-338 - spinoreticularis 337 - spinotectalls 336-337 - spinothalamicus - - anterior 336- 337 - - lateralls 336-337 - spiralis foraminosus 152 - supraopticohypophysialis 244 - tectospinalis 336, 339 - vestibulocerebellaris 251 - vestibulospinalis 339 - - medialis 336 - vestibulothalamicus 160 Tragus 7, 139 Transglottic space (glottic space, Glottis) 186 Transtentorial herniation 249 Triangular cartilage, nasal skeleton 58 Triceps ref lex 336 Trigeminal neuralgia (Tic douloureux) 55, 306 Trigeminal points 55 Trigonum - caroticum 4, 162, 164 - cervicale - - anterius 164 - - posterius 164
- collaterale 261-263, 285, 289 - habenulare 247 - lemnisci lateralis 247 - musculare (omotracheale) 4, 164 -nervi - - hypoglossi 246 --vagi 246 - olfactorium 234, 238, 245, 296 - omoclavlculare 4, 171 - retromolare 34 - submandibulare 4, 164 - - vessels and nerves 208 - submentale 4, 164 Trismus 45 Trochlear nerve, palsy 114 TROLARD's vein (V. anastomotica superior) 218, 225 Truncus(-IJ - brachiocephalicus 168, 179, 203, 209,319 - corporis callosi 236, 238, 240, 247, 254255,26~261,269,276-279,282,288,292
costocervicalis 203 - branches 203 encephali 239, 246- 248, 269 - functional overview 290 inferior (Plexus brachia lis) 209 jugularis 210 lymphaticus - bronchomediastinalis 210 - subclavius 210 medius (Plexus brachial is) 209 nervi accessorii 179, 320 superior (Plexus brachialisl 198-199, 209, 320 - sympathicus 79, 178-179, 201, 209-210, 314,341 - thyrocervicalis 179, 194, 200-201,203, 209, 328 - - branches 200 - vagalis(-es) 326 - - anterior 316-317, 319 - - posterior 316-317, 319 Tuba auditive [auditorial (EUSTACHIAN tube, Tuba EUSTACHII) 137-138, 141, 146, 149150,155,308,314 Tubal tonsil 89 Tuber - cinereum 131 , 234, 245 - frontale 8, 18, 22 - maxillae 23, 78 - parietale 7-8, 18-19 - vermis 248-249, 252-253 Tuberculum - anterius thalami 247 - articulare (Os temporale) 15, 32-33, 37-39, 44, 76, 139 - caroticum 168,210 - corniculatum 175-176, 179, 187- 188 - cuneatum 246-247, 292 - cuneiforme 175-176, 179, 186-188 - dentis 70 - epiglottlcum 186 - gracile 246-247, 292 - jugulare 31 - mentale 34, 85 - olfactorium 296 - pharyngeum 14 - sellae 12, 31 - thyroideum - - inferius 180 - - superius 180 Tuberositas - masseterica 34, 36 - pterygoldea 34-36 Tufted cells, olfactoric nerve 297 Tumour cachexia, BICHAT's fat pad 42 Tunica - conjunctiva - - bulbi 104, 125 - - palpebrarum 104, 106 - mucosa - - linguae 83
-
368 tahir99-VRG & vip.persianss.ir
Index
Tunica mucosa - - oris 69, 86-87 - - tuba aud itivae 150 Tympanic amorphous substance, organ of CORTI 156 Tympanic cavity 138, 144, 146-147 - development 136 - lateral wall 146 - levels 143 - medial wall 145 - recessus 141 - topography 144 Tympanic membrane (Membrana tympanica) 138, 141 - development 136 - perforation, Otitis media 144 - quadrant scheme 141
Vena(-ae) - alveolaris - - inferior 63, 76 - - superior anterior 76 - - - posterior 76, 79 - anastomotica - - inferior (LABBE's vein) 224-225 - - superior (TROLARD's vein) 225 - angularis 53, 107, 116, 218 - anterior septi pellucidi 272-273, 277, 284 - aqueductus - - cochleae 155 - - vestibuli 155 - auricularis posterior 196-198 - axillaris 201, 204 - basalis (ROSENTHAL's vein) 218,240, 273 - brachiocephalica 57, 168, 179, 200-201,
205, 209-210
u Ultrasound image - eye 130 - thyroid gland 195 Umbo membranae tympanicae 141, 144 Unconscious propriception 338 Uncus 233-234,236,238,261,287-288,
296 UNTERBERGER's stepping test, vertigo 158 Upper dental arch 69, 91, 93-94 - opening of the excretory duct 92 Upper eyelid 106 - ectropionised 104 Upper jaw 6, 23, 75 - cleft formations 80 - deciduous teeth 74 - dental alveoli 23 - dental arch 69, 74 - infiltrative anaesthesia 77 - milk teeth 74 - panoramic radiograph 76 - permanent teeth 74 - wisdom teeth 75 Upper lateral cartilage, nose 58 Upper molar tooth, first permanent 70 Upper thoracic aperture - prevertebral and paravertebral structures 210 - vessels and nerves 205 Upper tracheotomy 166 Utriculus 134, 137, 148, 154, 157, 312 Uvula 89 - bifida 82 - palatine 68, 80 - vermis 248-249, 252-253
v Vagina - bulbi (TENON's capsule) 123 - ca rotica 169-170 - externa - - (Anulus tendineus communis) 115 - - nervi optici 114, 123, 125 - interna (Anulus tendineus communis)
-
224-225 Velum - medullare - - inferius 246, 249-250, 292 - - superius 241, 246-250, 280, 292 - palatinum 68, 76, 80, 82
204-205,218 -
scalae - tympani 155 - vestibuli 155 sphenopalatine 67, 79 spinalis - anterior 330 - posterior 330 subclavia 57, 166, 168, 179, 199,205, 210 sublingualis 88-89,93,95 submantalis 48, 50, 53, 93, 199, 204 superiores cerebri 218, 222,225-226, 240 supraorbitalis 107, 116 su pratroch laaris 53, 107, 116 temporalis - media 48, 50 - superficia lis 50, 53, 107 thalamostriata 282 - superior 218, 240,261-264, 272-273,
-
thoracica interne 205, 209-21 0 thoracoacrom ialis 204 thoracoapigastricae 201 thymicae 205 thyroidea - inferior 194, 201, 204-205 - media 194,205 - superior 53, 93, 175-176, 194, 199, 201,
279-280,283-284,288
204-205 - transversa colli 47, 197, 204-205 - vertebralis 192, 209-210 - vestibulares 155 - vorticose 116, 126 Venter - anterior (M. digastricus) 42-43, 56-57, 63,
-
116,197-199,204-205,208,218 -
frontales (Vv. superiores cerebri) 225 inferiores cerebri 240 infraorbitalis 76, 79, 116, 124 infratrochlearis 107 interne cerebri 218, 240, 263-264, 273,
-
279-280, 284 - jugularis - - anterior 166, 192, 197, 204-205 - - externa 46-47, 53, 76, 93, 171, 196-201,
204-205,208 - - interne 43, 53, 56-57, 76, 89, 166, 169,
178,192,198-201,204-208,210, 218, 322
115 - processus styloidei 33 Vallecula - cerebelli 249 - epiglottica 81, 189 Vas(-a) - lymphatica superficialia, head/neck region 206 - sanguinea retinae 129 - spirale 156 Vein of LABBE (V. anastomotica inferior) 218,
cava superior 168, 179,205, 209 - venous tributary 205 centralis retinae 63, 126 - thrombosis 124 cephalica 201, 204-205 cerebri 272 cervicalis - profunda 53,209-210 - superficialis 204 choroidea - inferior 273 - superior 273 ciliaris anterior 126 comitans nervi hypoglossi 53, 95 conjunctivalis anterior 126 diploicae 219 - frontales 53, 219 - occipitales 53, 219 - temporales - - anteriores 53, 219 - - posteriores 219 dorsalis linguae 89 emissaria(-ae) 76 - condylaris 218 - frontalis 218 - mastoidea 53, 218 - occipitalis 218 - parietalis 53,218-219 - passage through the skull 218 - spread of germs 218 episcleralis 126 ethmoidalis - anterior 67 - posterior 67 facialis 47-48, 50, 53, 63, 76, 79, 90, 93,
Vena(-ae} - nasalis 67 - nasofronta lis 53, 116 - occipitalis 53, 196-198,204-205, 218, 225 - ophthalmica - - inferior 115-116,218 - - superior 115-116, 124, 218, 224, 268 - palatine descendens 79 - parietales 225-226, 240 - pharyngeae 53, 178 - profunda(-ae) - - cerebri 273 - - faciei 50 - - linguae 89 - retromandibularis 48, 50, 53, 76, 197-200,
-
labialis - inferior 53, 67 - superior 53, 67 labyrinthi 155 laryngea superior 87, 95, 173, 179, 190 latera lis ventriculi lateralis 273 lingualis 63, 88-89, 194 lumbalis 330 magna cerebri (GALEN's vein) 131, 218,
222,248,259,263-264,269,272-273, 280, 285,292 - maxillaris 50, 53, 76 -
media - profunda cerebri 240, 273 - superficia lis cerebri 225, 240, 277 m eningea media 220, 224
-
84-85,93-95,164, 166-16~ 171,173, 198-200,204-206,208 frontalis (M. occipitofrontalis) 40-43, 105, 307 inferior (M. omohyoideus) 56, 166-167, 171, 197-200,202,204, 206,322 occipitalis (M. occipitofrontalis) 41-43, 196, 307 posterior (M. digastricus) 43, 84-85, 93, 14~ 164,166-167,171-174,178,199,307308 superior (M. omohyoideus) 56, 95, 164, 167, 171,198-199,202,206,322
Ventriculus(-i) - encephali 258-259 - laryngis (MORGAGNI's ventricle) 83, 186-
188, 190-191 - latera lis 230, 239-240, 242, 247, 257, 259,
261-264,272,274-280,282-289,293 - quartus 228,248,250,252,258-259,269,
275,280,288,292 - tertius 228, 240-241, 247, 257-259, 263-
264, 269, 274-276, 278-279, 284-285, 287, 292 - - margins 264 - - Plexus choroideus 263 Venula - macularis - - inferior 129 - - superior 129 - medialis retinae 129 - nasalis retinae 129
369 tahir99-VRG & vip.persianss.ir
Index
Venula nasalis retinae - - inferior 129 - - superior 129 - temporalis retinae - - inferior 129 - - superior 129 Vermis cerebelli 245, 247-248, 251-253, 260,
262-263,274-275,280,285-288,292,338 Vertebral canal - MRI 333 - position of the spina I cord 330 - with spinal cord 333 - veins 330 - with opened dura I sac 327 Vertebralis tributary 266 - cerebral ischaemia, WALLENBERG's syndrome 266 Vertex 8 - corneae 125 Vertigo 158 - ROMBERG's test 158 - UNTERBERGER's stepping test 158 Vesica urinaria, innervation 341 Vestibular 69 Vestibular labyrinth (Labyrinthus vestibulaTis) 138, 154, 160
Vestibular organ 134, 251
Vestibular schwannoma 152,313 - cerebellopontine angle 313 Vestibulocerebellum 250-253 - lesions, impaired balance 253 Vestibulum - labyrinth i 153, 155 - laryngis 186, 188, 191 - nasi 60 - oris 68, 82-83 Vibrissae 68 VIDIAN canal (Canalis pterygoideus) 29-30, 78 VIDIAN nerve (N. canalis pterygoideus) 77, 79,
109,
148,302,30~309
Visceral nerve plexus 326 Visceral pain 326 Viscerocranium 28 - ossification mode 20 Visual axis 114 Visual field 158, 237,299 - stabilisation 158 Visual pathway 132, 299 - blood supply 131 Vitrectomy 124 Vitreous body 101 Vocal cord nodules 187 Vocal folds 190 - a Iterations 184
Vocal folds - biomechanics 184 - fine-tuning 185 Vocal ligaments 183, 188 Vomer 5-6, 10, 14, 20, 24, 28, 36, 59
w WALDEYER's tonsillar ring (pharyngeal lymphoid ring) 89, 176 WALLENBERG's syndrome - cerebral ischaemia in the vertebralis tributary 266 WERNICKE's centre (sensory speech centre) 159, 237 Whispering triangle 185 Wisdom tooth, upper jaw 75
z ZENKER's diverticulum 172 ZINN's anulus (Anulus tendineus communis) 112, 114-115 Zonula ciliaris 125, 127 Zoster ophtha lm icus 306
370 tahir99-VRG & vip.persianss.ir
