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Clinical Anatomy Applied anatomy for students and junior doctors Harold Ellis ELEVENTH EDITION Clinical Anatomy ECAPR 7/18/06 6:33 PM Page i To my wife and late parents ECAPR 7/18/06 6:33 PM Page ii Clinical Anatomy A revision and applied anatomy for clinical students HAROLD◊ ELLIS CBE, MA, DM, MCh, FRCS, FRCP, FRCOG, FACS (Hon) Clinical Anatomist, Guy’s, King’s and St Thomas’ School of Biomedical Sciences; Emeritus Professor of Surgery, Charing Cross and Westminster Medical School, London; Formerly Examiner in Anatomy, Primary FRCS (Eng) ELEVENTH EDITION ECAPR 7/18/06 6:33 PM Page iii © 2006 Harold Ellis Published by Blackwell Publishing Ltd Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1960 Seventh edition 1983 Second edition 1962 Revised reprint 1986 Reprinted 1963 Eighth edition 1992 Third edition 1966 Ninth edition 1992 Fourth edition 1969 Reprinted 2000 Fifth edition 1971 Tenth edition 2002 Sixth edition 1977 Reprinted 2003, 2004 Reprinted 1978, 1980 Greek edition 1969 Eleventh edition 2006 1 2006 Library of Congress Cataloging-in-Publication Data Data available ISBN-13: 978-1-4051-3804-8 ISBN-10: 1-4051-3804-1 A catalogue record for this title is available from the British Library Set in 9/12 Palatino by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in India by Replika Press Pvt Ltd Commissioning Editor: Martin Sugden Editorial Assistant: Ellie Bonnett Development Editor: Mirjana Misina Production Controller: Kate Charman For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. ECAPR 7/18/06 6:33 PM Page iv Contents Preface, xiii Acknowledgements, xiv Part 1:◊The Thorax Surface anatomy and surface markings, 3 ◊◊Surface markings of the more important thoracic contents, 3 The thoracic cage, 7 ◊◊The thoracic vertebrae, 7 ◊◊The ribs, 7 ◊◊The costal cartilages, 10 ◊◊The sternum, 11 ◊◊The intercostal spaces, 11 ◊◊The diaphragm, 14 ◊◊The pleurae, 18 The lower respiratory tract, 19 ◊◊The trachea, 19 ◊◊The bronchi, 23 ◊◊The lungs, 23 The mediastinum, 28 ◊◊The pericardium, 28 ◊◊The heart, 29 ◊◊The superior mediastinum, 42 ◊◊The oesophagus, 42 ◊◊The thoracic duct, 45 ◊◊The thoracic sympathetic trunk, 47 On the examination of a chest radiograph, 49 ◊◊Radiographic appearance of the heart, 50 Part 2:◊The Abdomen and Pelvis Surface anatomy and surface markings, 55 ◊◊Vertebral levels, 55 ◊◊Surface markings, 55 The fasciae and muscles of the abdominal wall, 58 ◊◊Fasciae of the abdominal wall, 58 ◊◊The muscles of the anterior abdominal wall, 58 ECAPR 7/18/06 6:34 PM Page v ◊◊The anatomy of abdominal incisions, 61 ◊◊The inguinal canal, 63 Peritoneal cavity, 65 ◊◊Intraperitoneal fossae, 68 ◊◊The subphrenic spaces, 69 The gastrointestinal tract, 70 ◊◊The stomach, 70 ◊◊The duodenum, 75 ◊◊Small intestine, 77 ◊◊Large intestine, 78 ◊◊The appendix, 79 ◊◊The rectum, 81 ◊◊Arterial supply of the intestine, 86 ◊◊The portal system of veins, 87 ◊◊Lymph drainage of the intestine, 88 ◊◊The structure of the alimentary canal, 88 ◊◊The development of the intestine and its congenital abnormalities, 90 The gastrointestinal adnexae: liver, gall-bladder and its ducts, pancreas and spleen, 93 ◊◊The liver, 93 ◊◊The biliary system, 98 ◊◊The gall-bladder, 99 ◊◊The pancreas, 101 ◊◊The spleen, 104 The urinary tract, 105 ◊◊The kidneys, 105 ◊◊The ureter, 109 ◊◊The embryology and congenital abnormalities of the kidney and ureter, 110 ◊◊The bladder, 112 ◊◊The urethra, 115 The male genital organs, 116 ◊◊The prostate, 116 ◊◊The scrotum, 119 ◊◊Testis and epididymis, 119 ◊◊Vas deferens (ductus deferens), 123 ◊◊The seminal vesicles, 124 The bony and ligamentous pelvis, 124 ◊◊The os innominatum, 124 ◊◊The sacrum, 125 ◊◊The coccyx, 126 ◊◊The functions of the pelvis, 126 vi Contents ECAPR 7/18/06 6:34 PM Page vi ◊◊Joints and ligamentous connections of the pelvis, 127 ◊◊Differences between the male and female pelvis, 128 ◊◊Obstetrical pelvic measurements, 128 ◊◊Variations of the pelvic shape, 130 The muscles of the pelvic floor and perineum, 132 ◊◊The anterior (urogenital) perineum, 133 ◊◊The posterior (anal) perineum, 134 The female genital organs, 136 ◊◊The vulva, 136 ◊◊The vagina, 137 ◊◊The uterus, 139 ◊◊The Fallopian tubes, 144 ◊◊The ovary, 145 ◊◊The endopelvic fascia and the pelvic ligaments, 146 ◊◊Vaginal examination, 147 ◊◊Embryology of the Fallopian tubes, uterus and vagina, 148 The posterior abdominal wall, 149 ◊◊The suprarenal glands, 151 ◊◊Abdominal aorta, 151 ◊◊Inferior vena cava, 153 ◊◊Lumbar sympathetic chain, 153 Part 3:◊The Upper Limb The female breast, 159 ◊◊Structure, 159 ◊◊Blood supply, 159 ◊◊Lymphatic drainage, 159 ◊◊Development, 161 Surface anatomy and surface markings of the upper limb, 162 ◊◊Bones and joints, 163 ◊◊Muscles and tendons, 164 ◊◊Vessels, 166 ◊◊Nerves, 167 The bones and joints of the upper limb, 168 ◊◊The scapula, 168 ◊◊The clavicle, 168 ◊◊The humerus, 169 ◊◊The radius and ulna, 171 ◊◊The bones of the hand, 174 ◊◊The shoulder, 176 ◊◊The elbow joints, 180 Contents vii ECAPR 7/18/06 6:34 PM Page vii ◊◊The wrist joint, 183 ◊◊The joints of the hand, 184 The arteries of the upper limb, 186 ◊◊The axillary artery, 186 ◊◊The brachial artery, 187 ◊◊The radial artery, 187 ◊◊The ulnar artery, 188 The brachial plexus, 189 ◊◊The segmental cutaneous supply of the upper limb, 191 The course and distribution of the principal nerves of the upper limb, 191 ◊◊The axillary nerve, 191 ◊◊The radial nerve, 192 ◊◊Branches, 194 ◊◊The musculocutaneous nerve, 194 ◊◊The ulnar nerve, 194 ◊◊The median nerve, 195 The anatomy of upper limb deformities, 197 The spaces of the hand, 200 ◊◊The superficial pulp space of the fingers, 200 ◊◊The ulnar and radial bursae and the synovial tendon sheaths of the fingers, 201 Part 4:◊The Lower Limb The anatomy and surface markings of the lower limb, 207 ◊◊Bones and joints, 207 ◊◊Bursae of the lower limb, 207 ◊◊Mensuration in the lower limb, 208 ◊◊Muscles and tendons, 211 ◊◊Vessels, 211 ◊◊Nerves, 214 The bones and joints of the lower limb, 216 ◊◊The os innominatum, 216 ◊◊The femur, 216 ◊◊The patella, 220 ◊◊The tibia, 223 ◊◊The fibula, 224 ◊◊A note on growing ends and nutrient foramina in the long bones, 225 ◊◊The bones of the foot, 225 ◊◊The hip, 226 viii Contents ECAPR 7/18/06 6:34 PM Page viii Contents ix ◊◊The knee joint, 229 ◊◊The tibiofibular joints, 233 ◊◊The ankle, 233 ◊◊The joints of the foot, 234 ◊◊The arches of the foot, 235 ◊◊The anatomy of walking, 237 Three important zones of the lower limb — the femoral triangle, adductor canal and popliteal fossa, 237 ◊◊The femoral triangle, 237 ◊◊The fascia lata, 238 ◊◊The femoral sheath and femoral canal, 238 ◊◊Femoral hernia, 239 ◊◊The lymph nodes of the groin and the lymphatic drainage of the lower limb, 241 ◊◊The adductor canal (of Hunter) or subsartorial canal, 242 ◊◊The popliteal fossa, 242 The arteries of the lower limb, 244 ◊◊Femoral artery, 244 ◊◊Popliteal artery, 246 ◊◊Posterior tibial artery, 246 ◊◊Anterior tibial artery, 246 The veins of the lower limb, 247 ◊◊Clinical features, 249 The course and distribution of the principal nerves of the lower limb, 249 ◊◊The lumbar plexus, 250 ◊◊The sacral plexus, 251 ◊◊The sciatic nerve, 253 ◊◊The tibial nerve, 255 ◊◊The common peroneal (fibular) nerve, 255 ◊◊Segmental cutaneous supply of the lower limb, 256 Part 5:◊The Head and Neck The surface anatomy of the neck, 261 ◊◊The fascial compartments of the neck, 262 The thyroid gland, 264 ◊◊The parathyroid glands, 267 The palate, 270 ◊◊The development of the face, lips and palate with special reference to their congenital deformities, 270 ECAPR 7/18/06 6:34 PM Page ix [...]... Hospital and Professor Adrian Dixon of Cambridge I am grateful to the following authors for permission to reproduce illustrations: The late Lord Brock for Figs 20 and 21 (from Lung Abscess); and Professor R G Harrison for Figs 12, 32 and 69 (from A Textbook of Human Embryology) Dr Colin Stolkin gave valuable help in revising the anatomy of the C.N.S Finally, I wish to express my debt to Martin Sugden and. .. the facts which students might reasonably be expected to carry with them during their years on the wards, through their final examinations and into their postgraduate years; it is designed for the clinical student Anatomy is a vast subject and, therefore, in order to achieve this goal, I have deliberately carried out a rigorous selection of material so as to cover only those of its thousands of facts... that there is still an unfortunate hiatus between the anatomy which the student learns in the pre -clinical years and that which is later encountered in the wards and operating theatres This book attempts to counter this situation It does so by highlighting those features of anatomy which are of clinical importance using a vertical blue bar, in radiology, pathology, medicine and midwifery as well as... artery and vein and the two vagi; 3◊◊the opening for the inferior vena cava (T8) which is placed in the central tendon and also transmits the right phrenic nerve In addition to these structures, the greater and lesser splanchnic nerves (see page 49) pierce the crura and the sympathetic chain passes behind the diaphragm deep to the medial arcuate ligament The development of the diaphragm and the anatomy. .. arteries Perforating branches pierce the upper five or six intercostal spaces; those of the 2nd–4th spaces are large in the female and supply the breast The intercostal nerves are the anterior primary rami of the thoracic nerves, each of which gives off a collateral muscular branch and lateral and anterior cutaneous branches for the innervation of the thoracic and abdominal walls (Fig 9) Clinical features... the side of the sternum and the 8th, 9th and 10th ribs to the cartilage immediately above The cartilages of the 11th and 12th ribs merely join the tapered extremities of these ribs and end in the abdominal musculature ECA1 7/18/06 6:31 PM Page 11 The thoracic cage 11 Clinical features 1◊◊The cartilage adds considerable resilience to the thoracic cage and protects the sternum and ribs from more frequent... lung, and a parietal layer lining the inner aspect of the chest wall, the upper surface of the diaphragm and the sides of the pericardium and mediastinum The two layers are continuous in front and behind the root of the lung, but below this the pleura hangs down in a loose fold, the pulmonary ligament, which forms a ‘dead-space’ for distension of the pulmonary veins The surface markings of the pleura and. .. vein, and vagus nerve) with sympathetic chain behind and left carotid artery, both arising from the arch of the aorta, the left brachiocephalic (innominate) vein, and the thymus; •◊◊posteriorly—oesophagus and left recurrent laryngeal nerve; •◊◊to the left — arch of the aorta, left common carotid and left subclavian arteries, left recurrent laryngeal nerve and pleura; •◊◊to the right—vagus, azygos vein and. .. system and its derivatives, 310 ◊◊Branchial cyst and fistula, 310 The surface anatomy and surface markings of the head, 311 The scalp, 312 The skull, 314 ◊◊Development, 316 ECAPR 7/18/06 6:34 PM Page xi Contents The accessory nasal sinuses, 318 ◊◊The frontal sinuses, 318 ◊◊The maxillary sinus (antrum of Highmore), 319 ◊◊The ethmoid sinuses, 320 ◊◊The sphenoid sinuses, 321 The mandible, 321 ◊◊The temporomandibular... clavicles and for the first and upper part of the 2nd costal cartilages on either side It is situated opposite the 3rd and 4th thoracic vertebrae Opposite the disc between T4 and T5 it articulates at an oblique angle at the manubriosternal joint (the angle of Louis), with the body of the sternum (placed opposite T5 to T8) This is composed of four parts or ‘sternebrae’ which fuse between puberty and 25 . Clinical Anatomy Applied anatomy for students and junior doctors Harold Ellis ELEVENTH EDITION Clinical Anatomy ECAPR 7/18/06 6:33. PM Page i To my wife and late parents ECAPR 7/18/06 6:33 PM Page ii Clinical Anatomy A revision and applied anatomy for clinical students HAROLD◊ ELLIS CBE,

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