Table of Contents Cover Image Front matter Copyright Preface to the twelfth edition Preface to the eleventh edition Preface to the tenth edition Acknowledgements Chapter Introduction to regional anatomy Part one Tissues and structures Part two Nervous system Part three Embryology Part four Anatomy of the child Upper limb Part one Pectoral girdle Part two Shoulder Part three Axilla Part four Breast Part five Anterior compartment of the arm Part six Posterior compartment of the arm Part seven Anterior compartment of the forearm Part eight Posterior compartment of the forearm Part nine Wrist and hand Part ten Summary of upper limb innervation Part eleven Summary of upper limb nerve injuries Part twelve Osteology of the upper limb Chapter Lower limb Part one Anterior compartment of the thigh Part two Medial compartment of the thigh Part three Gluteal region and hip joint Part four Posterior compartment of the thigh Part five Popliteal fossa and knee joint Part six Anterior compartment of the leg Part seven Dorsum of the foot Part eight Lateral compartment of the leg Part nine Posterior compartment of the leg Part ten Sole of the foot Part eleven Ankle and foot joints Part twelve Summary of lower limb innervation Part thirteen Summary of lower limb nerve injuries Part fourteen Osteology of the lower limb Chapter Thorax Part one Body wall Part two Thoracic wall and diaphragm Part three Thoracic cavity Part four Superior mediastinum Part five Anterior mediastinum Part six Middle mediastinum and heart Part seven Posterior mediastinum Part eight Pleura Part nine Lungs Part ten Osteology of the thorax Chapter Abdomen Part one Anterior abdominal wall Part two Abdominal cavity Part three Peritoneum Part four Development of the gut Part five Vessels and nerves of the gut Part six Gastrointestinal tract Part seven Liver and biliary tract Part eight Pancreas Part nine Spleen Part ten Posterior abdominal wall Part eleven Kidneys, ureters and suprarenal glands Part twelve Pelvic cavity Part thirteen Rectum Part fourteen Urinary bladder and ureters in the pelvis Part fifteen Male internal genital organs Part sixteen Female internal genital organs and urethra Part seventeen Pelvic vessels and nerves Part eighteen Perineum Part nineteen Male urogenital region Part twenty Female urogenital region Part twenty-one Pelvic joints and ligaments Part twenty-two Summary of lumbar and sacral plexuses Chapter Head and neck and spine Part one General topography of the neck Part two Triangles of the neck Part three Prevertebral region Part four Root of the neck Part five Face Part six Scalp Part seven Parotid region Part eight Infratemporal region Part nine Pterygopalatine fossa Part ten Nose and paranasal sinuses Part eleven Mouth and hard palate Part twelve Pharynx and soft palate Part thirteen Larynx Part fourteen Orbit and eye Part fifteen Lymph drainage of head and neck Part sixteen Temporomandibular joint Part seventeen Ear Part eighteen Vertebral column Part nineteen Osteology of vertebrae Part twenty Cranial cavity and meninges Part twenty-one Cranial fossae Part twenty-two Vertebral canal Chapter Central nervous system Part one Forebrain Part two Brainstem Part three Cerebellum Part four Spinal cord Part five Development of the spinal cord and brainstem nuclei Part six Summary of cranial nerves Part seven Summary of cranial nerve lesions Chapter Osteology of the skull and hyoid bone Part one Skull Part two Hyoid bone Biographical notes Index Front matter Last's Anatomy Commissioning Editor: Timothy Horne, Jeremy Bowes Development Editor: Sally Davies Project Manager: Elouise Ball Design Direction: Charles Gray Illustration Direction: Bruce Hogarth Artwork colouring: Ian Ramsden New artwork: Gillian Oliver Last's Anatomy Regional and Applied Twelfth Edition Chummy S Sinnatamby FRCS Formerly: Head of Anatomy, Royal College of Surgeons of England Member of Court of Examiners, Royal College of Surgeons of England Examiner in Anatomy, Royal College of Surgeons in Ireland Director of Studies in Anatomy, St Catharine's College and Hughes Hall, Cambridge External Examiner in Anatomy, University of Cambridge External Examiner in Anatomy, Trinity College, University of Dublin Copyright © 2011 Elsevier Ltd All rights reserved The right of Chummy S Sinnatamby to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) First edition 1954 Second edition 1959 Third edition 1963 Fourth edition 1966 Fifth edition 1972 Sixth edition 1978 Seventh edition 1984 Eighth edition 1990 Ninth edition 1994 Tenth edition 1999 Eleventh edition 2006 Twelfth edition 2011 ISBN 978 7020 3395 International ISBN 978 7020 3394 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Spinal cord injury 492 anterior spinal artery syndrome 492 central cord syndrome 492 complete transection 492 hemisection (Brown-Séquard syndrome) 492 level 16–17 micturition control 298 Spine iliac 288–289 anterior inferior 165 superior 165 posterior 165 ischial 165, 167, 168, 288–289 mental 511 nasal 373, 506 of scapula 99–100 suprameatal 507 vertebral 421–422 Spinoreticulothalamic pathway 490 Spleen 9, 270–272 surgical approach 271–272 Splenectomy 271–272 Splenium 461 Spur, scleral 405 Sternebrae 219 Sternotomy, median 188–189 Stomach 233, 241, 248, 249–252 Stomodeum 24, 28 Strabismus, ocular nerve paralyses 404 Striae of Gennari 464 medullary 483 of olfactory tract 466 terminalis 459 Stroke 472–473 Sturge–Weber syndrome 353 Styloid apparatus 369 Subarachnoid haemorrhage 447, 471 Subdural haemorrhage 447 Subiculum 466 Submandibular gland 337–339 development 338 surgical approach 338–339 Substance; substantia gelatinous 488, 490 nigra 477 perforated anterior 466, 472–473 posterior 470, 473 Sulcus; sulci 455 calcarine 458, 464, 467, 468 central (fissure of Rolando) 455, 456–458 cerebellar 484 chiasmatic 509 cingulate 456–458 circular 456 collateral 458, 467, 468 hippocampal 466 hypothalamic 469–470 intertubercular 101–102 lateral 455, 456 limitans 492 median 483 occipitotemporal 458 olfactory 458, 466 orbital 458 parahippocampal 467 parieto-occipital 455, 456, 458 posterior median of spinal cord 486 temporal 456 terminalis 199–200, 380 Superficial muscular aponeurotic system 358 Suprarenal glands 233, 287–288 surgical approach 288 Surfactant, pulmonary 217 Sustentaculum tali 175, 176 Suture coronal 503–504 frontozygomatic 504, 506 lambdoid 503 metopic 33, 503 sagittal 503 zygomaticomaxillary 505 Swallowing 195, 371, 382, 395, 418 Swelling, genital (labioscrotal) 29–30 Sympathetic nervous system 18–20 afferent fibres 20 cell bodies 18 efferent pathways see Trunk, sympathetic lower limb innervation 163 lumbar trunk 278, 280 postganglionic fibres 13 sympathetic trunk 13 thoracic trunk 211 Symphysis pubic 111, 165–166, 168, 288–289, 323, 325 Synapses 10 autonomic nervous system 18 reflex arcs 17 Synchondrosis spheno-occipital 33 Syndesmosis Synovial fluid T Taeniae coli 248, 255, 257, 258 Tail axillary 56–57 of pancreas 268 Talus 156 Tapetum 461–462, 468 Taste buds 381, 391, 394 Tectum 476 Teeth 376, 378–380 deciduous dentition 379 dental anaesthesia 379 development 379–380 eruption 33, 379–380 permanent dentition 378 position 379 Tegmen tympani 415, 507 Tegmentum 476, 477–478 Temporomandibular joint 411–413 movements 412–413 stability 412 Tendon(s) biceps 67 calcaneus (Achilles') 147–148 central of diaphragm 185 of perineum see Body, perineal conjoint 222, 227 extensor fingers 90 thumb 90 wing 90 flexor digitorum longus 152, 160–161 hallucis longus 152, 160–161 long of hand 86 digital attachments 89–91 thumb 90 of orbit (common tendinous ring) 399–400 patellar ligament 120 of peroneus longus 155, 161 quadriceps 120 of tibialis anterior 161 posterior 155 Tennis elbow 74 Tentorium cerebelli 440, 509–510 Testis 229–230 cryptorchid 230 descent 230 retracted 230 Tests Allen's 83–84 ascending spinal pathways 489 caloric 502 cranial nerve 500 pain sensation 490 Rinne's 502 Trendelenburg 125 Weber's 502 Thalamus 460, 465, 466, 469–470, 471 Thigh anterior compartment 111 medial compartment 121–123 posterior compartment 130–132 Thoracic outlet syndrome 349 Thoracotomy 188–189 Thorax 179–220 cavity 189–190 lymphatic drainage 209 movements 188–189 see also Respiratory movements in newborn child 34 wall 180–181 see also Body wall Thumb long tendons 90 movements 85–86 segmental innervation 16 web of 89 Thymus 9, 190–191, 196 Thyroid gland 339–340 accessory 339 development 340 surgical approach 340 Tibia 156, 171–174 Tongue 26, 377, 380–383 development 25, 383 movements 382–383 Tonsils cerebellar 485 lingual 381 palatine 9, 26, 387 pharyngeal 9, 387 tubal 386–387 Waldeyer's ring 9, 381, 387 Trabecula(e) carneae 200, 202 septomarginal (moderator band) 200 Trachea 26–27, 34, 190–191, 194–195, 329, 341 cervical part 341 Tracheostomy 341 Tracheotomy 33–34, 341 Traction injury, brachial plexus 96 Tract(s) 10 anterolateral 490 biliary 263–266 brainstem 481–482 corticonuclear 463 corticospinal 463 anterior 481–482, 491 lateral 460, 481–482, 491 cuneate 489 dorsolateral (of Lissauer) 490 gastrointestinal see Gastrointestinal tract gracile 489 hypothalamospinal 491 iliopubic 224 iliotibial 116 mamillo-thalamic 466 olfactory 458, 466 optic 464–465 reticulospinal lateral 482, 491 medial 482, 491 rubrospinal 482 spinal cord ascending 489–491 descending 491 spinocerebellar anterior 482, 490 posterior 482, 490 sympathetic lumbar 278, 280 tectospinal 482 uveal 406 vestibulospinal lateral 482, 491 medial 482, 491 Transplantation heart 207 heart–lung 207 liver 263 renal 286 Transverse colectomy 258 Triads, portal 263 Triangle Calot's 265 femoral 116–121 inguinal (of Hesselbach) 228 lumbar (of Petit) 221–222 neck 332–333, 344 anterior 332, 335, 344 carotid 344 digastric 344 muscular 344 posterior 332, 333–335, 344 submental 344 suboccipital 430–431 suprameatal (MacEwen's) 507 Trigone collateral 468 hypoglossal 479–480, 483 of urinary bladder 296–297, 298 vagal 479–480, 483 Trochanter greater 169–170, 288–289 lesser 169–170 Trochlea of humerus 62, 102–103 of orbit 401 peroneal 176 of talus 176 Trophoblast 22 Truncus arteriosus 30, 206 Trunk(s) brachial plexus 52–53, 91, 92 brachiocephalic 190–192, 193 coeliac 242–244, 249 costocervical 349 jugular 410 linguofacial 342 lumbar 280 lumbosacral 310 lymph intestinal 278 jugular 210 lumbar 278 subclavian 210 pulmonary 203 sympathetic 13, 18–19, 186 cardiac branches 19 cervical 329, 346 lumbar 278, 280 sacral 311 thoracic 211 vascular branches 20 visceral branches 19, 20 thyrocervical 348–349 vagal 266, 282 anterior 250–252, 499 posterior 250–252, 269, 499 Tube auditory 25, 386–387, 414, 415–416, 417–418, 507–508 heart 30 neural 23, 492 uterine 22, 301, 303–305 Tuber cinereum 470 vermis 485–486 Tubercle(s) articular 505 carotid (of Chassaignac) 342, 432–433 cuneate 479, 480 dorsal of Lister 103–104 genital 29–30, 321 Gerdy's 116, 172–173 gracile 479, 480 of humerus greater 102 lesser 101–102 of iliac crest 165 intercondylar (of tibia) 171–172 jugular 510 of Montgomery 57 pharyngeal 383, 507 pterygoid 507–508 pubic 165 of rib 181, 218 first 219 scalene 219 of scaphoid 107 sublime 106 supraglenoid 100–101 of talus 176 of trapezium 107–108 vertebral accessory 435 of atlas 433 cervical 432–433 Tuberculum sellae 508–509 Tuberosity calcanean 175–176 deltoid 102 of fifth metatarsal 178 gluteal 170 ischial 167–168 of maxilla 505–506 of navicular 177–178 omental 259 radial 103 of tibia 172–173 ulnar 106 Tubule collecting 285 convoluted distal 285 proximal 285 dentinal 378 mesonephric 286 seminiferous 230 Tunica adventitia albuginea of penis corpus 319 of testis 229, 305–306 intima media vaginalis 229, 230 U Umbilicus 224 Umbo 414–415 Uncus of cerebral hemisphere 458, 463, 466 of cervical vertebrae 424, 432 Undescended testis 228 Upper limb 37–110 dermatomes 13–14 general plan 37 nerve injuries 95 newborn child 34 segmental innervation of movements 16 Upper motor neuron lesions 18, 460, 491 Upper motor neurons 489 Upper thoracic ganglionectomy 211 Urachus 298 Ureters 233, 286–287, 298 Urethra 29–30 female 306, 307 male 320–321 membranous 317, 320 prostatic 299, 317, 320 spongy (penile) 317, 319, 320 Urogenital region female 322–323 male 317–320 Uterus 22, 301–303 bicornuate 304 position 304 supports 304 surgical approach 305 Utricle of ear 418, 421 prostatic (masculinus) 232, 299 Uvula of bladder 297 of vermis 485–486 V Vagina 29, 306–307 examination 307 Vagotomy 248 Vallecula 381, 387, 485 Valve(s) anal 315 aortic 199, 202–203, 206 heart 202–203 surface markings 202–203 iliocaecal 255 mitral 199, 201, 202–203, 206, 207 pulmonary 201, 202–203, 206 rectal (of Houston) 292 spiral of Heister 265 tricuspid 199, 200–201, 202–203, 206 veins Valvulae conniventes 253–254 Varicocele 229 Varicose veins 141–142 Vas(a) aberrantia 231–232 deferens 227, 228, 229, 231–232, 300–301 efferentia 230 Vasectomy 232 Vault, cranial 503, 508 Vein(s); vena(e) anastomotic inferior 473 superior 473 angular 355, 398 of arm 60 auricular 356 axillary 52, 179 azygos 31, 197, 208, 211, 212, 277 basal 473 basilic 13, 60, 71 basivertebral 428, 453 brachiocephalic (innominate) 33–34, 190–192, 193 bronchial 216 cardiac 205 anterior 205, 206 great 205 middle 205 small 205 cardinal 30–31 anterior 31 common 31 posterior 31 cava inferior 31, 203, 259, 276 tributaries 277–278 superior 31, 191, 193 of cavernous sinus 445–447 cephalic 13, 39, 60, 71 cerebral 473–474 anterior 473 great 473–474 inferior 473 internal 473–474 middle deep 473 superficial 473 minimus 445 superior 473 choroidal 473 comitantes 8, 60 of hypoglossal nerve 382 cordis minimae 205, 206 cubital 71 cystic 265, 266–267 development 30–31 diploic 442 dorsal of penis deep 319, 321 superficial 319 epigastric inferior 234 superficial 114 superior 186 facial, deep 355, 364 femoral 119 of forearm 71 median 71 gastric 208, 249, 266–267 left 244 right 244 short 244 gastroepiploic 249 left 244 right 244 gonadal 277 hemiazygos 31, 186, 211, 277 hepatic 259, 262, 277, 278 iliac common 277 internal 309–310 superficial circumflex 114 iliolumbar 277 intercostal 184 anterior 184 superior 183–184, 191–192 intervertebral 453 jugular anterior 329–330 external 333, 355 internal 329, 332, 343–344, 347 labyrinthine 421 laryngeal 396 lingual 382 deep 382 lumbar 277 ascending 277 mastoid emissary 356 maxillary 355, 364 meningeal 442 mesenteric inferior 246–247 superior 245 of nasal cavity 375 oblique of left atrium (of Marshall) 205, 206 oesophageal 244 ophthalmic 355, 398 inferior 364, 403, 445 superior 403, 445 ovarian 277 palatine (paratonsillar) 387 pancreaticoduodenal 244, 266–267 paraumbilical 179, 266–267 parietal emissary 356 phrenic 277, 278 popliteal 134 portal 244, 249, 259, 262, 266–267 posterior arch 141–142 posterior of left ventricle 205 prepyloric 244, 249 pudendal external 321 deep 114 superficial 114 internal 307 pulmonary 203, 216 rectal inferior 294, 315 middle 315 superior 246–247, 294, 315 renal 277–278, 284 retromandibular 355, 359 sacral lateral 277, 309–310 median 277 saphenous great (long) 13, 113–114, 141–142, 179, 321 small (short) 13, 134, 146, 147 of septum pellucidum 473 of skin 1–2 of sole of foot 155 spinal 492 splenic 244, 271 striate 473 subclavian 348 subcostal 186, 277 sublingual 382 supraorbital 355, 356 suprarenal 277, 278 supratrochlear 355, 356 temporal, superficial 355, 356 testicular 227, 277 thalamostriate 473 of thigh, superficial 113–114 thoracic internal 196 lateral 179 thoracoepigastric 114, 179 thymic 196 thyroid 194, 196, 340 inferior 340 superior 340 tibial 144 umbilical 30–31 of uterus 303 vertebral 349, 430 vitelline 30–31 vorticosae 406 Vellum, superior medullary 478, 482–483 Ventricles cerebral fourth 478, 479, 482–483, 493 lateral 466–468 third 469–471 of heart 30, 197–198, 199 left 198–199, 202 right 198–199, 200–201 Ventricular septal defect 206–207 Vermis 484, 485 Vertebral column 272, 421–422 cervical 329 atlantoaxial region 427 curvature 425 primary 421 secondary 421 development 422, 438–439 general features 421–422 joints 422 movements 423 muscles at back of neck 430–431 extensor 428–430 in newborn child 35 osteology 432–433 Vertebral (spinal) canal 452–454 Verumontanum 299 Vesicle(s) optic 409 seminal 300–301 Vestibule internal ear 418, 420 laryngeal 393 of mouth 377–378 of vulva 306, 322 Vinculum Vision, photopic/scotopic 408–409 Visual pathways 464–465 assessment 500–501 Vulva 322 W Wall abdominal anterior 221–226 peritoneal folds 234 posterior 272–274 respiratory movements 188, 225–226 of alimentary canal 248 body 11–13, 179–180 of pelvis 289–290 thoracic 180–181 White matter 10 cerebellum 486 cerebral hemispheres 459, 460, 464 spinal cord 487–488 Winged scapula 43 Wrist 78 segmental innervation of movements 16 Wrist drop 96 X Xiphisternum (xiphoid process) 180, 217, 218 Z Zones; zona orbicularis 128 of prostate 299 Zonule 410 Zygote 22 ... ossify in old age Elastic cartilage has a matrix that contains a large number of yellow elastic fibres It occurs in the external ear, auditory (Eustachian) tube and epiglottis Elastic cartilage... a copy of the second edition of Last' s Anatomy while preparing for the primary fellowship examination, in the oral section of which I was examined by Professor Last himself Little did I imagine... anatomy at the Royal College of Surgeons of England, R J Last published the first edition of Anatomy, Regional and Applied Forty-five years later Last' s ‘approach to the study of anatomy’ is still