(BQ) Part 2 book Netter''s surgical anatomy review P.R.N presents the following contents: Pelvis and perineum (anorectal diseases, pelvic fractures, prostate diseases,...), upper limb (pectoral girdle fractures, humerus fractures, forearm fractures,...), lower limb (hip and thigh fractures, knee and leg fractures, ankle and foot fractures).
Pelvis and Perineum Pelvis and Perineum This page intentionally left blank 16 Anorectal Diseases Anorectal Anatomy Rectum • Wider diameter than most of colon, except for cecum • 12-16 cm in length, starting at about the sacral promontory, extending to dentate line of anal canal • Anterior aspect of upper 4-6 cm is intraperitoneal, with serosal surface • Lower (majority of) rectum lies within extraperitoneal pelvis, with no serosa • Taeniae coli spread out at rectosigmoid junction to form a continuous, external longitudinal muscle layer • Three flexures of rectum usually correspond with transverse rectal folds (superior, middle, and inferior rectal valves) • Valves overlie thickenings of circular muscle • Ampulla: terminal portion rectum below inferior valve, supported by levator ani and anococcygeal ligament • Women: thin rectovaginal septum separates anterior inferior rectum from vagina • Men: prostate and seminal vesicles lie anterior to inferior rectum • Mucosa: columnar epithelium, down to dentate line 232 Anorectal Diseases 15–17 cm Transverse folds Superior of rectum Middle Inferior (valves of Houston) Peritoneal reflection 11–13 cm 8–9 cm Levator ani muscle Anal columns (Morgagni’s) Pectinate (dentate) line 5–6 cm Anatomical anal canal 0.5–1 cm Surgical anal canal 4–5 cm 2.5–3 cm Internal sphincter muscle Anoderm Anal glands Internal rectal venous plexus in submucous space General Anorectal Anatomy Anal Canal • 3-5 cm in length, from level of levator ani muscles to anal verge • Canal includes dentate line, anal glands, internal and external sphincter muscles, and hemorrhoidal vessels • External anal sphincter muscles: striated muscle, with somatic innervation under voluntary control • Internal anal sphincter muscle: continuation of inner, circular smooth muscle of hindgut, with autonomic (involuntary) innervation • Stratified squamous epithelium lines anal canal, beginning at dentate line Microscopic Anatomy • Mucosa n Epithelium: enterocytes (absorptive), goblet cells n Lamina propria n Muscularis mucosa • Submucosa n Strongest layer (connective tissue) n Meissner’s plexus (neuronal network) • Muscularis n Auerbach’s plexus: myenteric neurons n Inner circular muscle n Outer longitudinal layer: bands of colic taeniae coli merge into a continuous layer at rectosigmoid junction, down through sphincter level • Serosa n Peritoneum only on anterior superior part of rectum n Rest is extraperitoneal, in contact with endopelvic fascia Innervation • Parasympathetic n Preganglionic fibers via pelvic splanchnic nerves from S2-S4 spinal nerves n Postganglionic fibers from cells in Meissner’s plexus (inner submucosal) and Auerbach’s plexus (outer myenteric) of rectal smooth muscle • Sympathetic n Preganglionic fibers distributed via thoracic and lumbar splanchnic nerves through inferior 233 Anorectal Diseases 234 Anorectal Diseases Inferior mesenteric ganglion, and plexus Superior hypogastric plexus Superior rectal artery and plexus Sympathetic trunk and ganglia Hypogastric nerves Sacral splanchnic nerves (sympathetic) Inferior hypogastric (pelvic) plexus Rectal plexus Pudendal nerve Pelvic splanchnic nerves (parasympathetic) Inferior anal (rectal) nerve Rectal/Pelvic Nerves mesenteric, hypogastric, pelvic, and rectal plexuses n Postganglionic fibers from cells in inferior mesenteric ganglia to rectal smooth muscle • Somatomotor to external anal sphincter from S2-S4 spinal nerves via pelvic and rectal plexus • Sensory fibers n Segmental visceral afferents travel back parallel to sympathetic fibers, through inferior mesenteric plexus and splanchnic nerves n Segmental cutaneous and somatic afferents travel through pelvic plexus to S3 and S4 ganglia Vessels and Lymphatics Arterial Supply • Inferior mesenteric branches n Superior rectal (hemorrhoidal) artery: provides blood to upper rectum • Internal iliac branches n Middle and inferior rectal (hemorrhoidal) arteries provide blood to middle and lower rectum n Inferior vesical artery branches can contribute to rectal anastomoses Venous Drainage • Submucosal venous plexus connects with external rectal venous plexus running in adventitia • Rectal venous plexuses have connections to portal and caval venous drainage systems and are basis for formation of hemorrhoids (e.g., with portal hypertension in liver disease) 235 Anorectal Diseases 236 Anorectal Diseases Posterior view Sigmoid arteries Inferior mesenteric artery Median sacral artery Rectosigmoid arteries Internal iliac artery Internal pudendal artery Inferior rectal artery Superior rectal artery (bifurcation) Anorectal Arteries Middle rectal artery Anterior view Communication between internal and perimuscular rectal plexuses Inferior mesenteric vein (to portal vein via splenic vein) Superior rectal vein (bifurcation) Internal iliac vein Middle rectal vein Internal pudendal vein Inferior rectal vein Internal rectal plexus External rectal plexus Communication between internal and external venous plexuses Anorectal Veins 237 Anorectal Diseases 238 Anorectal Diseases • Portal venous system tributaries (left side) n Inferior mesenteric branches: rectal (hemorrhoidal) venous plexus drainage, down to dentate line • Internal iliac vein tributaries n External rectal (hemorrhoidal) venous plexuses, below dentate line Lymphatic Drainage • Parallels arterial supply • Upper rectum drains along inferior mesenteric artery branches into periaortic nodes • Middle and lower rectum drain along internal iliac branches into pelvic and (eventually) periaortic nodes Clinical Correlates Hemorrhoids • Internal hemorrhoids: most common locations are left lateral, right anterior, right posterior • External hemorrhoids: proper treatment involves excision, not incision and clot expression Anorectal Abscess • Most commonly believed to be of cryptoglandular origin • Abscess starts in an infected anal gland • Begins at dentate line and terminates within intersphincteric space • Infection can remain within this space or fistulize into ischiorectal, supralevator, or perineal spaces • Most common fistulas extend into ischiorectal space, with inflamed area in gluteal region Inferior mesenteric nodes Common iliac nodes Internal iliac nodes Left colic nodes Preaortic nodes Superior rectal nodes External iliac nodes Superficial inguinal nodes Perineal lymph vessels (drain largely to inguinal nodes) Middle rectal nodes Anorectal Lymphatics 239 Anorectal Diseases 240 Anorectal Diseases • Drainage can leave a fistulous connection between anal canal and skin • Crohn’s disease patients have a higher rate of abscesses than general population Anal Fissure • Small tear in the anoderm • Typically on posterior midline, but may be anterior • Associated with passage of large or hard stool or diarrhea • Might heal on its own or require medical or surgical management Colonic Ischemia • Results from disease or mesenteric artery emboli • Rectum typically is spared owing to internal iliac source of middle and inferior rectal (hemorrhoidal) arteries and anastomoses Rectal Cancer Colorectal Cancer • About 130,000 cases diagnosed in Americans per year Adenocarcinoma • Most common type • Ulcerative: most common, central depression with raised edges • Polypoid, large, as described in colon • Annular: apple core appearance on contrast study, associated with obstruction • Diffusely infiltrating n Thickening of bowel wall n Can be flat Right (ascending) colon Liquid fecal stream passes lesion Bleeding diluted by fecal stream Chronic lowgrade bleeding may lead to anemia Obstruction uncommon because of large lumen and liquid fecal contents Lesions of right colon often asymptomatic, or “silent,” until disease is in advanced stage Change in bowel habits may be first symptom of left colon lesions Solid stool Bleeding diluted by feces results in normal-appearing but guaiac-positive stool Cramping pain Constipation and obstruction Paradoxical diarrhea Tenesmus and urgency Bleeding Stool may be blood covered or mixed with blood Left (descending) colon Cancer of left colon and rectum frequently causes bleeding and bowel obstruction due to solid feces Clinical Manifestations of Colorectal Cancer 241 Anorectal Diseases 242 Anorectal Diseases Diffusely infiltrating disease difficult to diagnose n Can spread to external sphincter layer of rectum and anal canal n Prognosis • Rectal and rectosigmoid cancers have lower cure rates compared with tumors elsewhere in colon • Rectal cancers can metastasize to spine owing to direct (valveless) rectal connections to Bateson’s presacral venous plexus Treatment • Good oncologic resection requires total mesorectal excision for mid-rectal and distal tumors • Proximal ligation of inferior mesenteric vessels, distal to the left colic 17 Pelvic Fractures Anatomy of the Pelvic Skeleton Coxal Bones (Os Coxae; 2) Ilium: Parts and Landmarks • Crest, ala (wing), fossa (of false pelvis), articular surfaces • Posterior superior iliac spine (at posterior part of articular surface) • Iliac tuberosity: posterior sacroiliac ligament insertion • Anterior superior iliac spine (ASIS): sartorius, inguinal ligament insertions • Anterior inferior iliac spine (AIIS): rectus femoris, tensor fasciae latae, iliofemoral ligament (hip joint capsule) insertions • Greater sciatic notch: sciatic nerve, piriformis muscle, pudendal neurovascular bundle exit here • Ilium often used for cortical and cancellous bone grafts Ischium: Parts and Landmarks • Ischial spine: sacrospinous (SS) ligament insertion • Body • Ischial tuberosity: sacrotuberous (ST) ligament, hamstring insertions • Ischial ramus: fuses with pubic ramus to form medial rim of obturator foramen 244 Pelvic Fractures Iliolumbar ligament Posterior superior iliac spine Posterior sacroiliac ligaments Greater sciatic foramen Lesser sciatic foramen Ischial tuberosity Anterior longitudinal ligament Posterior view Iliac fossa Anterior superior iliac spine Sacrotuberous ligament Sacrospinous ligament Ischial spine Superior pubic ramus Inferior pubic ramus Anterior view Pubic tubercle Bony Pelvis and Ligaments Pubic symphysis Pubis: Parts and Landmarks • Tubercle: medial attachment of inguinal ligament (external oblique aponeurosis) • Superior public ramus: pecten pubis (pectineal line), along inner superior ridge • Symphysis: midline fibrous joint of superior pubic rami • Inferior pubic ramus • Arch: formed by inferior pubic and ischial rami • Acetabulum formed by portions of all three bones n Parts: articular surface, notch, limbus (margin) n Should fuse by age ~20 years • Arcuate line: medial ridge running from ilium (near superior sacroiliac joint) to pecten pubis • Linea terminalis n Bony upper border of the true pelvis, lower border of false pelvis n Sacral promontory to iliopectineal line: arcuate line + pectineal line Sacrum • Parts and landmarks: ala, sacroiliac articular surfaces, lumbosacral articular (disc) surface, promontory, fused bodies (5), anterior and posterior foramina, coccyx (~4 segments) • Sacral canal: continuation of vertebral canal with meninges and roots of spinal cord • Posterior: median and lateral sacral crests, superior articular facet (to L5 inferior facet), sacral hiatus (end of sacral canal, ref for caudal anesthesia) • Posterior and anterior sacrococcygeal ligaments 245 Pelvic Fractures 246 Pelvic Fractures Pelvic Joints • Sacroiliac (SI) n Synovial joints with minimal movement n Posterior pelvis stability, weight-bearing • Pubic symphysis: anterior pelvis • Coxal n Ilium, ischium, and pubis intersect in acetabular fossa n Typically fused by age 20 years Pelvic Ligaments • Sacroiliac n Anterior and posterior (more extensive) n Support SI joints • Sacrotuberous; lower border of lesser sciatic foramen • Sacrospinous: lower border of greater sciatic foramen, anterior to coccygeus fibers • Anterior longitudinal n Runs on anterior aspect of vertebral bodies onto sacrum n Prevents hyperextension of lumbar spine • Supraspinous and interspinous n Run between vertebral spines and onto median sacral crest n Prevent hyperflexion of lumbar spine Neurovascular Supply Nerves of the Pelvis • Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles • Sciatic nerve: anterior rami of L4, L5 (lumbosacral trunk), S1-S4, collect as trunk and pass out of greater sciatic foramen • Sacral plexus n Portions of anterior rami of S1-S4 supply pelvic floor muscles and regional sensation n Sciatic nerve motor and sensory to majority of lower limb n Parasympathetic preganglionic fibers from S2-4 lateral column neurons to viscera (pelvic splanchnics; nervi erigentes) n Sympathetic fibers from inferior mesenteric ganglion to pelvic viscera via hypogastric nerves and hypogastric plexus, running anterior to sacral bodies; also, contributions from sacral ganglia • Pudendal nerve (S2-S4, sacral plexus branch) n Motor to perineum and pudenda n Sensory to perineum and pudenda • Obturator nerve n Traverses lateral wall of lesser pelvis, exits through obturator foramen n L2-L4 supply to thigh adductors Arteries of the Pelvis • Common iliac arteries and their internal and external iliac branches supply bones and viscera within the pelvic cavity • Common iliac branches: internal, external, middle sacral • External iliac branches: inferior epigastric, deep circumflex iliac arteries 247 Pelvic Fractures 248 Pelvic Fractures Iliolumbar artery Right Left Common iliac arteries Internal iliac artery Lateral sacral arteries Superior gluteal artery Inferior gluteal artery Sagittal section Internal pudendal artery External iliac artery Obturator artery Arteries and Veins of Pelvis • Internal iliac branches n Posterior: iliolumbar, lateral sacral, and superior gluteal arteries n Anterior: umbilical, superior vesical, obturator, inferior vesical, prostatic or uterine/ vaginal, internal pudendal, middle rectal, and inferior gluteal arteries • Internal pudendal artery n Passes out through greater sciatic foramen, around ischial spine, into lesser sciatic foramen n Trauma can compromise perineal and cavernosal supply Venous Drainage • Pelvic walls and viscera drain largely into branches of internal and external iliac veins (caval venous return) • Visceral plexuses interconnect n Vesical, uterine/vaginal or prostatic, rectal n Drain mainly into internal iliac veins • Rectal plexus blood also drains into inferior mesenteric vein via superior rectal vein (portal venous return) • Lateral and middle sacral veins drain into internal and common iliac veins, respectively (anterior sacral region) • Iliolumbar veins drain into common iliac veins (iliac fossa region) • Deep circumflex iliac and inferior epigastric veins drain into external iliac (anterior greater pelvis region) Clinical Correlates Pelvic Fractures Mechanisms • High-energy force n Lateral more common, as in motor vehicle accidents 249 Pelvic Fractures 250 Pelvic Fractures Other injuries may be life-threatening, requiring emergency treatment n About 50% mortality with open fracture and GI or genitourinary injuries n Intact posterior sacroiliac ligament key to stability • Minor trauma n Fall, with osteoporosis n Single ramus fracture, stable • Stable avulsion fracture n ASIS: sartorius tendon avulsion n AIIS: rectus femoris tendon avulsion n Ischial tuberosity: hamstring tendon avulsion n Associated Injuries • Open wounds • Massive bleeding with internal blood loss (symptoms: flank swelling, ecchymoses) • Bleeding from pelvic venous plexuses: vesicular, prostatic, vaginal, uterine, rectal • Urethral, rectal, or vaginal injuries • Anterior fractures: venous bleeding more likely • Posterior fractures: arterial bleeding more likely Young and Burgess Classification • Anterior and posterior compression (APC) n I: Sacral compression, rami fractures; stable n II: Rami fractures, posterior sacroiliac ligament disruption; stable n III: Complete disruption of sacroiliac joint, pubic symphysis; unstable • Lateral compression (LC) n I: Sacral compression with rami fractures Anteroposterior Compression Anteroposterior Compression Type I (APC-I) Type II (APC-II) Anteroposterior Compression Type III (APC-III) Lateral Compression Type I (LC-I) Lateral Compression Type III (LC-III) Lateral Compression Type II (LC-II) Vertical shear Classification of Pelvic Fractures (Young and Burgess) 251 Pelvic Fractures 252 Pelvic Fractures Fracture of iliac wing These fractures usually not displaced or minimally displaced and generally require only limitation of activity until pain ceases Avulsions Avulsion of anterior superior iliac spine due to pull of sartorius muscle Avulsion of ischial tuberosity due to pull of hamstring muscles Avulsion of anterior inferior iliac spine due to pull of rectus femoris muscle Fracture of one pubic or ischial ramus Isolated fracture of one pubic or ischial ramus requires only bed rest until pain diminishes, followed by limited activity for 4–5 weeks, provided there is no visceral or vascular injury Fracture Fractures of sacrum of coccyx Impacted transverse fracture that is minimally displaced is most common type Conservative treatment sufficient unless there is nerve injury Sacral laminectomy and bone grafts from ilium used for sharply angulated fractures with nerve injury Fracture usually requires no treatment other than care in sitting; inflatable ring helpful Pain may persist for long time Fractures of Pelvis without Disruptions of Pelvic Ring LC-II: Ramus fracture, posterior SI ligament disrupted, stable n III: II + contralateral APC-III, unstable • Vertical shear n Anterior and posterior pelvic displacement injury n Vertically unstable n Acetabular Fractures • Typically from extreme force transmitted by femoral head (e.g., motor vehicle accident) • May be associated with life-threatening injuries: stabilize airway, breathing, heart, and other trauma Representative fixation for both-column fracture with associated iliac wing fractures Acetabular Fracture Fixation 253 Pelvic Fractures 254 Pelvic Fractures Forceful frontal impact causes anteroposterior compression of pelvis Fracture of pubic bone or rupture of pubic symphysis with wide anterior separation of pelvis and disruption of pelvic ring One or both sacroiliac joints often subluxated Application of crossover slings with enough weight to rotate halves of pelvis medially and anteriorly, thus bringing them together Reduction maintained for 3–4 weeks Spica cast, which permits walking, then worn for 4–6 weeks Anterior Posterior Compression Fracture Judet-Letournel Classification • elementary patterns of acetabular fractures: anterior wall, posterior wall, anterior column, posterior column, transverse • Associated fractures may include more than one type 255 Pelvic Fractures This page intentionally left blank 18 Prostate Diseases Basic Anatomy Prostate Proper • Largest accessory gland of the male genital tract • Partly glandular, partly fibromuscular • Glandular growth and maturation controlled by testosterone, which is converted to dihydrotestosterone (DHT) by 5-alpha reductase • Peri-urethral transition zone of the parenchyma: 50 years Risk factors: early menarche, nulliparity; 4-10ì increase in African-American women • Growth stimulated by estrogen, contraceptives, epidermal growth factor Ovarian Cysts • Typically arise from ovarian components: follicular cysts, luteal cysts, ovarian capsule Normal menstruation EstrogenEstrogen Estrogen progesterone excess deficiency imbalance (old age) Hyperplastic Abnormal and anaplastic secretory endometrium endometrium Hypoplastic endometrium A Dysfunctional Uterine Bleeding Continued 279 Uterus and Adnexal Diseases 280 Uterus and Adnexal Diseases Cancer (or sarcoma) of uterine body Tuberculosis Tubal or pelvic inflammation Cysts Fibroid (submucous) Endometrial polyps Adenomyosis Endocervical polyps Cancer of cervix or endocervix Endometriosis Erosion Chancre Trauma Tumors – granulosa cell, theca cell, cancer Local ovarian or adnexal disorders Local uterine disorders Chorio-epithelioma Ectopic pregnancy Psychogenic states Hypothyroidism, hyperthyroidism Debilitating states Abortion or premature separation of placenta Placenta previa B Defective enzymatic steroid metabolism Blood dyscrasias Hydatidiform mole Pregnancy disorders Systemic conditions Dysfunctional Uterine Bleeding—cont’d Histology of fibroid Pedunculated, subserous Interstitial (intramural) Subserous, displacing tube Subserous Pedunculated, submucous Intraligamentary Cervical Submucous Pedunculated, submucous, protruding through external os Uterine Fibroids (Leiomyomas) 281 Uterus and Adnexal Diseases 282 Uterus and Adnexal Diseases Low-lying cecum Distended bladder Simple serous cyst (Serous cystoma) Redundant sigmoid colon Appendiceal abscess Pregnancy, hydramnios, hydatid mole, hematometra, pyometra Differential Diagnosis of Ovarian Cysts • Ovarian cysts usually small, asymptomatic, often benign (>90%) • Diagnosis may be difficult, with many conditions manifesting as lower abdominopelvic masses Uterine tube Ovary In rectouterine pouch (of Douglas) Endometriosis of rectovaginal septum and posterior fornix Urethra In rectovaginal septum Vagina Rectum Endometriosis Endometriosis • Benign foci of endometrial tissue progressively developing in pelvis—ovary, rectouterine pouch, 283 Uterus and Adnexal Diseases 284 Uterus and Adnexal Diseases uterine ligaments, tubes—or elsewhere in peritoneum • Prevalence of endometriosis: ~5%-10% of women; ~30%-50% of infertile patients • Causes are multifactorial: genetic, menstrual backflow with spread of cells through tubes, vascular or lymphatic dissemination, or metaplasia of peritoneal epithelium • Risk factors: cervical or vaginal outflow obstruction, structural abnormalities Cancer Uterine Endometrial Carcinoma • Most common female reproductive tract malignancy • Risk factors: obesity and increased estrogen synthesis, estrogen replacement therapy without progestin, breast or colon cancer, early menarche or late menopause, diabetes, chronic anovulation Cervical Carcinoma • Squamous carcinomas: ~85%-90% of cases • Adenocarcinomas: ~10%-15% of cases • About 12,000 cases and ~4000 deaths in 2005 in U.S • Risk factors: early sexual activity, multiple partners, human papillomavirus infection, smoking, African-American ethnicity • Peak age range: 40-60 years Ovarian Tumors and Cancer • Origins of tumor tissues n Surface epithelium/stroma: 65%-70%; 85%-90% of all malignancies Ectopic pregnancy with hematocele Paraovarian cyst A pedunculated A or parasitic B intraligamentous C of round ligament C D cystic degeneration D B Uterus Papillary serous cystadenocarcinoma Epithelial stromal ovarian tumors Multilocular serous cystadenoma Serous adenofibroma Benign surface papilloma Clear cell carcinoma of ovary Pelvic mass (up to 30 cm) Partially cystic, 40% bilateral Papillary projections Ovarian Tumors 285 Uterus and Adnexal Diseases 286 Uterus and Adnexal Diseases Germ cell: 15%-10% Sex-cord stroma: 5%-10% • Risk factors: age, high-fat diet, family history, early menarche and late menopause, white ethnicity, high socioeconomic status • Age of occurrence or discovery n Benign tumors, 20-29 years n Malignant tumors, 50% occur in women >50 years n n Upper Limb Upper Limb This page intentionally left blank 20 Pectoral Girdle Fractures Anatomy of the Pectoral Girdle Clavicle • Parts and landmarks: sternal end/facet, impression for costoclavicular ligament, shaft (body), conoid tubercle, trapezoid line, subclavian groove, acromial end/facet Scapula • Parts: glenoid fossa (cavity) supraglenoid tubercle, infraglenoid tubercle, neck, coracoid process, suprascapular notch, superior border, superior angle, medial border, inferior angle, lateral border, subscapular fossa, spine, acromion, supraspinous fossa, infraspinous fossa Pectoral Girdle and Shoulder Joints • Sternoclavicular joint n Synovial, with articular disc (dual axes of movement) n Extremely strong: only joint attaching upperlimb girdle to the axial skeleton • Acromioclavicular (AC) joint n Synovial, gliding/plane n Supported by acromioclavicular ligament n Acts as a pivot point to increase range of arm motion (raise arm over head) 290 Pectoral Girdle Fractures Acromion Coracoid process Superior angle Superior border Suprascapular notch Neck Medial border Subscapular fossa Glenoid Lateral border Inferior angle Shoulder joint, anterior view Acromion Acromioclavicular joint capsule (incorporating acromioclavicular ligament) Trapezoid ligament Conoid ligament Coracoclavicular ligament Coracoacromial ligament Shoulder Bones and Ligaments Right clavicle Pos terio r Superior surface Acromial facet Subclavian groove (for subclavius m.) Posterior Conoid tubercle Trapezoid line Inferior surface Impression for costoclavicular lig Sternal facet Clavicle • Glenohumeral joint (also covered in Chapter 21, Humerus Fractures) n Synovial, ball and socket with labrum n Basis for upper limb positioning and transmission of forces to pectoral girdle n Involved in glenoid fractures (intraarticular) n Biceps (long) tendon inserts on supraglenoid tubercle n Triceps (long) tendon inserts on infraglenoid tubercle Ligaments • Coracoclavicular ligament n Very strong, two-part n Shares forces between clavicle and scapula 291 Pectoral Girdle Fractures 292 Pectoral Girdle Fractures Trapezoid: nearly horizontal, attaches to conoid tubercle and superior surface of coracoid n Conoid: nearly vertical inverted triangle, attaches to coracoid root n Parts may be separated by bursa n Base for supporting scapula and upper limb on the clavicular “strut” • Acromioclavicular ligament: strengthens AC joint superiorly • Coracoacromial ligament: limits superior displacement of humeral head • Costoclavicular ligament n Strong n Attaches near head of clavicle to 1st costal cartilage n Reinforces sternoclavicular joint, prevents displacement of clavicle n Neurovascular Supply Arterial Supply • Subclavian artery provides numerous branches, forming anastomoses around the scapula, glenohumeral joint, and proximal humerus n Dorsal scapular artery s Runs from base of neck along vertebral border of scapula s Anastomoses with medial suprascapular branches n Suprascapular artery s From mid-subclavian to scapula above transverse scapular ligament, above suprascapular notch s Has supraspinous and infraspinous branches to respective fossae Suprascapular artery Dorsal scapular artery Subclavian artery Acromial branch Anterior circumflex humeral artery Posterior circumflex humeral artery Circumflex scapular artery Dorsal scapular artery Subscapular artery Suprascapular artery Infraspinous branch of suprascapular artery Circumflex scapular artery Posterior circumflex humeral artery (in quadrangular space) and ascending and descending branches Subclavian and Axillary Artery Anastomoses 293 Pectoral Girdle Fractures 294 Pectoral Girdle Fractures Axillary artery s Thoracoacromial artery s Posterior humeral circumflex artery (in quadrangular space) s Subscapular artery, circumflex scapular branch; anastomoses with dorsal scapular and suprascapular branches n Venous Drainage • Veins of pectoral and scapular regions run parallel to the subclavian and axillary arteries and their major branches: valved, arterial counterpulsation effect pumps blood • Superficial tributaries n Cephalic vein: travels superficial to biceps to empty into axillary vein n Basilic vein: from superficial forearm and distal arm, empties into axillary vein • Deep tributaries n Axillary vein s Brachial vein • Axillary vein continues into subclavian vein • Axillary vein lies superficial to axillary sheath and parts of brachial plexus • Dorsal scapular veins drain into scapular circumflex, subscapular (axillary) tributaries, and dorsal scapular suprascapular (subclavian) tributaries Nerves Brachial Plexus • Vital nerves for upper limb pass deep to clavicle • Roots n C5-T1 anterior rami, arise in the neck at the levels of their vertebral foramina n Supraclavicular level • Trunks n Superior (C5, C6), middle (C7), inferior (C8-T1) arise from union of roots n Supraclavicular level n Nerve to subclavius: off superior trunk n Suprascapular nerve: to supraspinatus and infraspinatus; off superior trunk • Divisions n Anterior and posterior portions of each trunk n Clavicular level: at risk in medial fractures • Cords: infraclavicular level n Lateral: anterior divisions of superior and middle trunks n Medial: anterior divisions of inferior trunk n Posterior: posterior divisions only of all trunks • Terminal nerve branches: infraclavicular level • See Chapter 21, Humerus Fractures, for more information Clinical Correlates Scapula Fractures • Uncommon, 1 cm or angulated >45° • Proximal fractures and dislocations risk injury to axillary nerve, passing through quadrangular space at surgical neck of humerus • Two-part fractures, involving anatomical neck above tuberosities, split head and risk avascular necrosis from disrupted supply Humeral Shaft Fractures • Typically result from direct trauma, falls, penetrating wounds, vehicular accidents • Neurovascular assessment necessary: radial nerve injury can result from primary injury or manipulation • Compartment syndromes can easily occur Distal Humerus Fractures • Supracondylar n Extraarticular, through metaphysis n Rare in adults n Mechanism extension (>80%) or flexion n Imaging should be studied for intercondylar extension • Transcondylar n Primarily occur in elderly persons with osteopenia, with or without intercondylar extension n Most common distal humerus fracture in adults n May be displaced owing to muscle pulls • Condylar; very rare in adults, more commonly lateral (involving capitulum) • Supracondylar fracture treatment n Open reduction with internal fixation preferred n Closed reduction in children 311 Humerus Fractures This page intentionally left blank 22 Forearm Fractures Anatomy of the Forearm Ulna • Parts and landmarks: olecranon, trochlear notch, coronoid process, shaft, anterior border, styloid process • Cylindrical long bone; olecranon palpable subcutaneously at elbow joint; (medial) styloid process distal • Bears major forces transmitted across elbow joint Radius • Parts and landmarks: head, neck, radial tuberosity, shaft, styloid process, carpal articular fossa, scaphoid fossa, lunate fossa, ulnar notch • Cylindrical long bone with head in elbow joint; (lateral) styloid process distal • Radiocarpal joint has articular disc that articulates with carpals and ulnar styloid process • Bears major forces transmitted across wrist joint Elbow Joint • Compound joint involving humeral-radial, humeral-ulnar, and proximal radioulnar joints n Medial: trochlea of humerus with trochlear notch of the ulna n Median: proximal radioulnar joint n Lateral: capitulum of humerus with head of radius 314 Forearm Fractures Right radius and ulna in supination: anterior view Right radius and ulna in pronation: anterior view Olecranon Trochlear notch Coronoid process Radial tuberosity Ulna Ulnar tuberosity Radius Interosseous membrane Interosseous membrane Styloid process Interosseous border Styloid process of ulna Forearm Bones • Ulnar (medial) collateral ligament: from medial epicondyle of humerus to (1) coronoid process and (2) medial olecranon • Annular ligament passes around radial neck, stabilizing it via insertions into the ulna • Lateral (radial) collateral ligament passes from lateral epicondyle (humerus) to annular ligament • Large fibrous joint capsule underlies collateral ligaments Compartments of the Forearm • External investing antebrachial fascia is relatively tough and nonexpansile, with fascial septa between compartments • Proximal forearm n Anterior (flexors, pronators) s Median nerve, to all flexors except flexor carpi ulnaris and medial heads of flexor digitorum superficialis (ulnar nerve supplied) s Anterior interosseus nerve (deep branch median) innervates distal pronator quadratus and flexor pollicis longus n Interosseus membrane separates deep anterior and posterior compartments n Posterior (extensor): radial nerve > deep radial and posterior interosseus nerves • Lower forearm: flexor digitorum superficialis and profundus tendons, flexor pollicis longus, pronator quadratus • Spaces around flexors digitorum tendons and sheaths communicate with hand spaces: pathway for forearm-hand compartment syndrome • Dorsal antebrachial spaces communicate with dorsal hand and digit spaces Vessels and Nerves Arterial Supply of the Forearm • Brachial artery n Typically divides into main radial and ulnar artery branches in cubital fossa 315 Forearm Fractures 316 Forearm Fractures Radial a and superficial branch of radial n Ulnar n Radius Ulnar a and median n Superficial flexor muscles Deep flexor muscles Ulna and antebrachial fascia Ulnar a and n Median n Median n Ulnar a and n Forearm: Serial Cross Sections Deep Neurovascular Plane of the Forearm Radial artery Supinator muscle Pronator teres muscle (cut and reflected) Ulnar artery Common interosseous artery Median nerve (cut) Ulnar nerve Radial artery Flexor digitorum profundus muscle Anterior interosseous artery and nerve Forearm: Arteries and Nerves (Anterior View) 317 Forearm Fractures 318 Forearm Fractures Ulnar typically gives rise to common interosseus artery, with its anterior and posterior interosseus branches • Anastomoses between upper (collateral) and lower (recurrent) branches preserve blood flow across elbow joint, with both anterior and posterior connections from medial and lateral vessels • Lateral anastomoses n Anterior: radial collateral branch (profunda brachii) with radial recurrent branch (radial) n Posterior: middle collateral branch (profunda brachii) with recurrent interosseous branch (typically posterior interosseous) • Medial anastomoses n Anterior: inferior ulnar collateral (brachial) with anterior ulnar recurrent (ulnar) n Posterior: superior ulnar collateral (brachial) with posterior ulnar recurrent (ulnar) • Distally, main radial and ulnar arteries pass through deep anterior forearm laterally and medially (respectively) to enter wrist and palm n Veins of the Forearm • Highly interconnected superficial and deep vein networks drain hand and forearm • Superficial venous network n Originates in dorsal venous arch of hand n Cephalic vein: distal, at lateral wrist, runs the length of upper limb to pectoral triangle n Basilic vein: distal, at medial wrist, runs most of the length of upper limb to arm n Highly individual patterns of interconnections between cephalic and basilic tributaries • Deep veins accompany corresponding arteries: valved, arterial counterpulsation effect pumps blood n Brachial vein s Accompanies brachial artery s Merges with basilic vein to form axillary vein s Tributaries: ulnar and radial veins accompanying artery branches Nerves of the Forearm • Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles Median Nerve (C6-T1) • Enters the forearm anteromedially at elbow and passes through pronator teres • Deep portion, anterior interosseus nerve, travels in neurovascular bundle along interosseus membrane to pronator quadratus • Main portion travels along lateral border of flexor digitorum profundus, passing under flexor retinaculum, entering palm via carpal tunnel • Neurovascular plane of anterior forearm lies between flexors digitorum superficialis and profundus Ulnar Nerve (C7-T1) • Passes posterior to medial epicondyle of humerus, within the cubital tunnel, to penetrate flexor carpi ulnaris near its origin • Passes distally in forearm in the neurovascular plane, along medial aspect of flexor digitorum profundus 319 Forearm Fractures 320 Forearm Fractures • Enters the palmar space by passing lateral to the flexor carpi ulnaris tendon and pisiform bone Radial Nerve (C5-T1) • Passes anterior to lateral epicondyle of humerus after traversing radial groove of humerus • Posterior cutaneous nerve of forearm arises proximal to condyle • Superficial radial nerve (sensory) travels on surface of supinator, deep to brachioradialis and tendon, and supplies area on dorsum and eminence of thumb and lateral back of hand • Main nerve enters posterior compartment of forearm by penetrating supinator • Deep radial nerve exits supinator and travels distally as posterior interosseous division n Proximal and distal deep branches to distal extensor compartment muscles Clinical Correlates Antebrachial Compartment Syndrome • Distal radius, ulna, or carpal fractures and related tissue and vascular trauma can lead to increased compartment pressure(s), swelling, pain, or paresthesias • Anterior (volar) forearm is relatively prone to developing posttraumatic compartment syndrome • Causes: fractures of supracondylar humerus, ulna, radius, wrist Elbow Dislocations • Often associated with proximal ulna fractures involving coronoid process or olecranon Fracture of coronoid process of ulna with posterior dislocation of elbow Coronoid fracture may occur occasionally without dislocation Posterior dislocation Note prominence of olecranon posteriorly and distal humerus anteriorly Lateral dislocation (uncommon) Divergent dislocation, anterior-posterior type (rare) Medial-lateral type may also occur (extremely rare) Anterior dislocation of radius and ulna with fracture of olecranon Reduced and fixed as for olecranon fracture without dislocation Medial dislocation (very rare) Posterior dislocation with fracture of both coronoid process and radial head Rare but serious; poor outcome even with good treatment May require total elbow replacement Elbow Dislocation 321 Forearm Fractures 322 Forearm Fractures Type Monteggia fracture/dislocation with anterior dislocation of radial head and anterior angulation of proximal or middle third ulna fracture Less common type Monteggia fracture/dislocation with ulna fracture angulated posteriorly and radial head dislocated posteriorly Fracture of ulna treated with open reduction and internal fixation using compression plate and screws After reduction of ulna, radial head spontaneously reduced Preoperative radiograph shows Type I Monteggia fracture/dislocation Postoperative radiograph shows compression plate in place Extensor carpi ulnaris m Anconeus m If radial head does not reduce after angulation of ulna is corrected, open reduction of radial head dislocation and repair of annular ligament are needed Typically, this is done through a separate incision between the anconeus and extensor carpi ulnaris muscles Radius Supinator m (incised) Ulna Annular ligament (sutured) Fractures of the Ulnar Shaft Small chip fracture of radial head Large fracture of radial head with displacement Comminuted fracture of radial head Fracture of radial neck, tilted and impacted Elbow passively flexed Blocked flexion or crepitus indication for excision of fragments or, occasionally, entire radial head Hematoma aspirated, and 20-30 mL of xylocaine injected to permit painless testing of joint mobility Excision of fragment or entire radial head via posterolateral incision Radial head may be replaced with Swanson silicone implant in selected patients Small fractures without limitation of flexion heal well after aspiration with only sling support Comminuted fracture of radial head with dislocation of distal radioulnar joint, proximal migration of radius, and tear of interosseous membrane (EssexLopresti fracture) Fractures of Radial Head and Neck 323 Forearm Fractures 324 Forearm Fractures A B C D Tuberosity of radius useful indicator of degree of pronation or supination of radius A In full supination, tuberosity directed toward ulna B In about 40° supination, tuberosity primarily posterior C In neutral position, tuberosity directly posterior D In full pronation, tuberosity directed laterally Biceps brachii m Supinator m In fractures of radius above insertion of pronator teres muscle, proximal fragment flexed and supinated by biceps brachii and supinator muscles Distal fragment pronated by pronator teres and pronator quadratus muscles Pronator teres m Pronator quadratus m In fractures of middle or distal radius that are distal to insertion of pronator teres muscle, supinator and pronator teres muscles keep proximal fragment in neutral position Distal fragment pronated by pronator quadratus muscle Biomechanics of Forearm Fracture • Radial head may be involved with coronoid in posterior displacements and fractures: open reduction and fixation is preferred treatment in adults Ulna and Radius Fractures • Proximal n Olecranon: direct trauma or fall onto outstretched hand with triceps contraction n Radial head: direct trauma or fall with impaction of radial head into capitulum n Assess neurovascular deficits with history and physical exam • Mid-forearm n Diaphyseal fractures of ulna and radius often occur together, with forearm deformity n Monteggia: mid-ulnar fracture with angulation and radial dislocation n Galeazzi: radial diaphysis fracture with disruption of distal radioulnar joint n Open reduction and fixation preferred treatment in adults, with Monteggia and Galeazzi “fractures of necessity” • Distal n Radius: Colles fracture, proximal to styloid process, with dorsal deviation of distal fragment(s) and wrist 325 Forearm Fractures 326 Forearm Fractures Most commonly results from fall on outstretched dorsiflexed hand Immediate prehospital care: limb splinted, wrist elevated above level of heart on pillows or folded garment, ice pack applied Lateral view of Colles‘ fracture demonstrates characteristic dinner fork deformity with dorsal and proximal displacement of distal fragment Note dorsal instead of normal volar slope of articular surface of distal radius Dorsal view shows radial deviation of hand with ulnar prominence of styloid process of ulna and decrease of reverse of normal radial slope of articular surface of distal radius Colles’ Distal Radial Fracture 23 Wrist and Hand Fractures Anatomy of the Wrist and Hand Carpal Bones: Lateral to Medial • Proximal n Scaphoid, lunate, triquetrum, pisiform • Distal n Trapezium, trapezoid, capitate, hamate Metacarpals • Numbered I/1 (thumb) to V/5 (digiti minimi) • Parts: base, shaft, head • Shafts triangular in cross section • V/5 most commonly fractured metacarpal Phalanges • Proximal, middle, distal (3) in each finger • Proximal, distal (2) in thumb • Parts: base, shaft, tuberosity (in distal phalanges), head • Distal phalanx common fracture Joints of Wrist and Hand • Radiocarpal (RC) joint n Synovial joint between distal radius and articular disc (concave) and scaphoid, lunate, and triquetrum (convex) n Allows movement around axes: flexion/ extension, adduction/abduction (ulnar and radial deviation, respectively) 328 Wrist and Hand Fractures Carpal bones Right hand: (palmar) view Scaphoid and Tubercle Trapezium and Tubercle Trapezoid Lunate Triquetrum Pisiform Capitate Hamate and Hook Sesamoid bones Base Shafts Head Base Proximal Shafts phalanges Head Base Middle Shafts phalanges Head Metacarpal bones Right hand: posterior (dorsal) view Distal phalanges Base Shafts Tuberosity Head Carpal Bones Carpal bones Anterior (palmar) view Ulna Ulnar styloid process Radius Radial styloid process Lunate Scaphoid Triquetrum Tubercle of scaphoid Pisiform Bones of Wrist and Hand • Carpal joints n Synovial joints between carpals n Share common joint cavity n Limited movement contributes to positioning of hand, grasp • Carpometacarpal (CM) joints n Synovial, between distal row of carpal bones and metacarpal bases n Saddle joint between trapezium and thumb metatarsal more mobile than others: flex/ extend, abduct/adduct, rotate, circumduct n CM joints II-V s Synovial arthrodial/gliding s Range of movement increases medially: metacarpal greatest 329 Wrist and Hand Fractures 330 Wrist and Hand Fractures Joint capsules reinforced by palmar and dorsal ligaments and medial and lateral collateral ligaments • Metacarpophalangeal (MCP) joints n Synovial condylar n Between metacarpal heads and proximal phalanges n Joint capsules reinforced by palmar ligaments and medial and lateral collateral ligaments • Interphalangeal joints n Synovial hinge n Supported by palmar and medial, lateral collateral ligaments n Ligaments of Wrist and Hand • Supporting wrist (RC) joint: palmar radiocarpal, palmar ulnocarpal, dorsal radiocarpal ligaments • Flexor retinaculum (transverse carpal ligament) runs proximally between scaphoid (tubercle) and triquetrum and distally between trapezium (tubercle) and hamate (hook) and forms carpal tunnel • Multiple small ligaments run between adjoining carpal bones on their palmar and dorsal surfaces, reinforcing carpal joints • Deep transverse metacarpal ligaments: palmar bands interconnecting MCP palmar ligaments Wrist and Hand Compartments • Carpal tunnel n Space between flexor retinaculum and carpal bones n Contains flexors digitorum superficialis and profundus tendons, sheaths, and median nerve Ulnar artery and nerve Flexor retinaculum (transverse carpal ligament) Median nerve* Flexor carpi ulnaris tendon Flexor pollicis longus tendon in tendon sheath* Flexor carpi radialis tendon Flexor digitorum superficialis tendons* Flexor digitorum profundus tendons* Radial artery Hamate Trapezium Trapezoid Capitate *Contents of carpal tunnel Simple method of demonstrating arrangement of flexor digitorum superficialis tendons within carpal tunnel Transverse Section of Wrist Demonstrating Carpal Tunnel 331 Wrist and Hand Fractures 332 Wrist and Hand Fractures Common flexor sheath (ulnar bursa) Flexor digitorum profundus tendons Flexor digitorum superficialis tendons Thenar space (deep to flexor tendon and 1st lumbrical muscle) Midpalmar space (deep to flexor tendons and lumbrical muscles) Midpalmar space Palmar aponeurosis Common palmar digital artery and nerve Lumbrical muscle in its fascial sheath Profundus and superficialis flexor tendons to 3rd digit Septum between midpalmar and thenar spaces Thenar space Flexor tendons to 5th digit in common flexor sheath (ulnar bursa) Flexor pollicis longus tendon in tendon sheath (radial bursa) Palmar interosseous fascia Bursae, Spaces, and Tendon Sheaths of Hand • Forearm spaces around flexor digitorum tendons communicate with hand spaces and are pathways for forearm–hand compartment syndrome • Mid-palmar space: between flexor digitorum tendons and metacarpals/interosseous muscles • Thenar space: between flexor pollicis tendon and adductor pollicis • Hypothenar compartment: defined by hypothenar muscle fascia (abductor, flexor brevis, opponens digiti minimi) • Interosseous compartment: defined by interosseous muscle fascia and metacarpals • Ulnar bursa: common flexor tendon sheath runs from distal forearm through palm and into fifth digital tendon sheath (or more digits) • Radial bursa: tendon sheath around flexor pollicis longus travels into thumb • Dorsal antebrachial spaces communicate with dorsal hand and digit spaces, between extensor tendons and dorsal interossei Vessels and Nerves Arterial Supply • Distal ulnar (medial) and radial (lateral) arteries contribute to anastomotic vascular arches in the palmar spaces • Anastomoses between arches and other distal antebrachial branches of ulnar and radial arteries Superficial Palmar Arch • Terminal branch of ulnar artery and superficial branch of radial artery 333 Wrist and Hand Fractures 334 Wrist and Hand Fractures Radial artery Median nerve and palmar branch Superficial palmar branch of radial artery Recurrent (motor) branch of median nerve to thenar muscles Proper digital nerves and arteries to thumb Ulnar artery and nerve Superficial palmar (arterial) arch Common palmar digital nerves and arteries Proper palmar digital nerves and arteries Deep palmar (arterial) arch and deep branch of ulnar nerve Princeps pollicis artery Deep palmar branch of ulnar artery and deep branch of ulnar nerve Hook of hamate Radialis indicis artery Palmar metacarpal arteries Deep palmar branch of ulnar nerve to 3rd and 4th lumbrical, all interosseous, adductor pollicis, and deep head of flexor pollicis brevis muscles Communicating branch of median nerve with ulnar nerve Wrist and Hand: Vessels and Nerves • Branches n Common palmar digital arteries (3) n Bifurcate and form proper palmar digital arteries II-V n Proper palmar digital artery V, medial side Deep Palmar Arch • Terminal branch of radial artery and deep branch of ulnar artery • Branches n Princeps pollicis s Radialis indicis s Proper digital artery of thumb n Palmar metacarpal arteries (3) Venous Drainage • Networks of superficial and deep veins interconnect • Deep veins run with major arterial branches of palmar arches and ulnar and radial arteries • Superficial veins drain into venous network on dorsum of hand • Cephalic vein originates from lateral side of dorsal venous network and passes into lateral forearm via anatomical snuffbox • Basilic vein originates from medial side of the dorsal venous network and passes into dorsomedial forearm Nerves Median Nerve • Enters palmar space via carpal tunnel • Intermingled with deep and superficial flexor digitorum tendons 335 Wrist and Hand Fractures 336 Wrist and Hand Fractures • Recurrent branch n Arises in carpal tunnel n Supplies thenar muscles • Common palmar digital nerves n Innervate lumbricals and n Branch into proper palmar digital nerves that run along sides of digits 1-3 and lateral aspect of digit Ulnar Nerve • Enters palmar space by passing lateral to pisiform bone (Guyon’s canal) and around hook of hamate • Deep branch accompanies deep branch of ulnar artery, penetrates and supplies hypothenar muscles, and arches across palm to supply interossei, medial lumbricals, adductor pollicis, and articular branches to wrist • Superficial branch n Gives rise to common palmar digital nerve: innervates lumbricals and n Branches into proper palmar digital nerves that run along sides of digit 5, medial aspect of digit Radial Nerve • Superficial branch only part to run distally onto hand • Enters via anatomical snuffbox • Sensory to lateral thenar eminence and dorsum of hand to middle of digits 1-3 Clinical Correlates Compartment Syndrome • Distal radius, ulnar, or carpal fractures and related tissue and vascular trauma can lead to Capitate Usually caused by fall on outstretched hand with impact on thenar eminence Scaphoid (fractured) Trapezoid Trapezium Lunate Triquetrum Pisiform Hamulus (hook) of hamate Clinical findings: pain, tenderness, and swelling in anatomical snuffbox Less common fractures Fracture of middle third (waist) of scaphoid (most common) Tubercle Distal pole Vertical shear Proximal pole Because nutrient arteries only enter distal half of scaphoid, fracture often results in osteonecrosis of proximal fragment Fracture of the Scaphoid 337 Wrist and Hand Fractures 338 Wrist and Hand Fractures increased compartment pressure(s), swelling, pain, and paresthesias • Carpal tunnel syndrome n Median nerve compressed with superficial and deep flexor tendons n Flexor retinaculum release procedure may be indicated • Posttraumatic or reperfusional trauma can cause swollen hand from pressure in subcompartments (e.g., interossei, adductor pollicis) Scaphoid Fractures • Most common carpal fracture • Typically caused by a fall on an outstretched hand, with weight on thenar eminence • Fracture of the waist (mid 1/3) most common • Pain and swelling in anatomical snuffbox is often seen • Adequate healing depends on blood supply from palmar carpal branch of radial artery Metacarpal and Phalangeal Fractures • Phalangeal and metacarpal fractures are common • Border digits are most commonly involved • Mechanisms include bending and torsion (common in sports) • Crushing injuries often are associated with complex soft tissue injuries • 30%-50% open, more than half of these work related Mallet finger Usually caused by direct blow on extended distal phalanx, as in baseball, volleyball A B C Degrees of mallet finger injury A Extensor tendon stretched but not completely severed; mild finger drop and weak extensor ability retained B Tendon torn from its insertion C Bone fragment avulsed with tendon In B and C there is 40-45° flexion deformity and loss of active extension Avulsion of flexor digitorum profundus tendon Flexor digitorum profundus tendon may be torn directly from distal phalanx or may avulse small or large bone fragment Tendon usually retracts to about level of proximal Caused by violent traction interphalangeal joint, where it is stopped at its on flexed distal phalanx, as passage through flexor digitorum superficialis in catching on jersey of tendon; occasionally, it retracts into palm running football player Fracture of metacarpals Fractures of metacarpal neck commonly result from end-on blow of fist Often called street-fighter or boxer fractures In fractures of metacarpal neck, volar cortex often comminuted, resulting in marked instability after reduction, which often necessitates pinning Transverse fractures of metacarpal shaft usually angulated dorsally by pull of interosseous mm Stress test for ruptured medial (ulnar) collateral lig of thumb (gamekeeper thumb) Thumb injury other than fracture Adductor pollicis m and aponeurosis (cut) Torn medial collateral lig Ruptured medial collateral lig of metacarpophalangeal joint of thumb Finger Injuries 339 Wrist and Hand Fractures 340 Wrist and Hand Fractures Dorsal dislocation (most common) Usually reducible by closed means, immobilized with palmar splint for weeks, then active range-of-motion exercises begun Palmar dislocation (uncommon) Causes boutonnière deformity Central slip of extensor tendon often torn, requiring open fixation, followed by dorsal splinting to allow passive and active exercises of distal interphalangeal joint Rotational dislocation (rare) Note middle and distal phalanges seen in true lateral radiograph, proximal phalanx in oblique view After reduction, treated as for dorsal dislocation Dorsal dislocation of proximal interphalangeal joint with disruption of volar plate and collateral ligament may result in swan-neck deformity and compensatory flexion deformity of distal interphalangeal joint Volar dislocation of middle phalanx with avulsion of central slip of extensor tendon, with or without bone fragment Failure to recognize and properly treat this condition results in boutonnière deformity and severely restricted function Proximal Interphalangeal Joint Dislocations Lower Limb Lower Limb This page intentionally left blank 24 Hip and Thigh Fractures Anatomy of the Hip and Thigh Femur • Parts and landmarks: head; fovea (for round ligament); neck; greater trochanter; lesser trochanter; intertrochanteric line, crest, and fossa; pectineal line; gluteal tuberosity; linea aspera; shaft (body); popliteal surface; adductor tubercle; medial epicondyle; lateral epicondyle; medial condyle; lateral condyle; intercondylar fossa; patellar surface Coxal (Hip) Bones • Ilium, ischium, and pubis are fused in adults (See Chapter 17, Pelvic Fractures, for more bone information.) • Coxal bone epiphyseal plates intersect in the center of the acetabulum • Acetabulum n Peripheral lunate surface lined with hyaline cartilage n Fat within central acetabular fossa surfaced with synovial membrane Hip Joint • Synovial ball-and-socket, deepened by circumferential, fibrocartilaginous acetabular labrum 344 Hip and Thigh Fractures Anterior view Anterior superior iliac spine Iliofemoral ligament (Y ligament of Bigelow) Anterior inferior iliac spine Pubofemoral ligament Posterior view Ischiofemoral ligament Intertrochanteric line Ischial spine Ischial tuberosity Joint opened: lateral view Zona orbicularis Lunate (articular) surface of acetabulum Articular cartilage Head of femur Acetabular labrum (fibrocartilaginous) Neck of femur Ligament of head of femur (cut) Transverse acetabular ligament Hip Joint and Ligaments Anterior view Greater trochanter Head Neck Lesser trochanter Posterior view Intertrochanteric crest Linea aspera Medial lip Lateral lip Shaft (body) Lateral epicondyle Adductor tubercle Medial epicondyle Femur 345 Hip and Thigh Fractures 346 Hip and Thigh Fractures • Synovial membrane n Runs from edges of acetabular hyaline cartilage n Along inside of fibrous capsule n Extends to distal neck and periphery of articular cartilage of head • Round ligament (ligamentum teres) of head of femur n Intraarticular, covered by synovium n Runs from fovea to transverse acetabular ligament • Transverse acetabular ligament: spans acetabular notch, extending rim for a complete socket • (Collateral) ligaments: spiraling thickenings of fibrous joint capsule, passing from acetabular rim to intertrochanteric line or trochanters n Iliofemoral (Bigelow): anterior-superior, Yshaped, very strong, prevents hyperextension by screwing femoral head tightly into acetabulum n Pubofemoral: anterior-inferior, prevents hyperabduction n Ischiofemoral: posterior, weakest of three • Retinacula n Retinacular fibers surround neck proximal to head, binding down nutrient arteries to head n Anatomical basis for head ischemia with neck fracture Compartments of the Thigh • Circumferential deep fascia of lower limbs n Like strong elastic stockings n Limits expansion of muscles during contraction, important in upright gait Sartorius muscle Fascia lata Branches of femoral nerve Femoral artery and vein Adductor longus muscle Vastus lateralis muscle Sciatic nerve Gluteus maximus muscle Vastus medialis muscle Deep artery and vein of thigh Adductor magnus muscle Popliteal vein and artery Thigh: Serial Cross Sections 347 Hip and Thigh Fractures 348 Hip and Thigh Fractures • Fascia lata: investing deep fascia of thigh n Attaches proximally to inguinal ligament, pubic rim, Scarpa’s fascia, iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity n Attaches to exposed bone at knee and to crural fascia n Strengthened laterally by vertical-running fibers of iliotibial tract, a conjoint aponeurosis of gluteus maximus and tensor fascia lata • Intermuscular septa separate groups of muscles in thigh n Septa attach to linea aspera and fascia lata n Lateral intermuscular septum strongest • Gluteal compartment n Primarily hip joint abductor and rotator muscles: gluteus maximus, medius, and minimus; piriformis, superior and inferior gemellus, quadratus femoris n Vessels: superior and inferior gluteal (internal iliac branches) arteries and veins n Nerves: superior and inferior gluteal nerves and branches from sciatic roots, nerve to quadratus femoris • Anterior compartment n Hip flexor and knee extensor muscles: sartorius, rectus femoris; vastus lateralis, medialis, and intermedius (quadriceps femoris) n Vessels: femoral and deep femoral arteries and veins n Nerves: femoral nerve; posterior divisions of lumbar plexus • Posterior compartment n Hip extensor and knee flexor muscles: semitendinosus, semimembranosus, biceps femoris Vessels: perforating branches of deep femoral and popliteal arteries and veins n Nerves: sciatic nerve, tibial and fibular divisions • Medial compartment n Hip adductor muscles: adductor longus, brevis, minimus, and magnus n Vessels: branches of obturator arteries and veins n Nerves: obturator nerve, accessory obturator (when present), anterior division of lumbar plexus n Vessels and Nerves Arterial Supply to the Thigh and Hip Joint • Femoral artery (continuation of external iliac supply) n Primary source of blood for lower extremity n Gives off deep femoral (profunda femoris) proximally to supply deep compartments n Travels anteriorly initially under sartorius (in subsartorial canal; Hunter’s) n Continues as popliteal artery after passing through hiatus of adductor magnus posteriorly into popliteal fossa • Femoral artery branches n Superficial epigastric artery n Superficial external pudendal artery n Deep external pudendal artery n Deep femoral (profunda femoris) artery s Lateral femoral circumflex artery s Medial femoral circumflex artery s Perforating branches n Descending genicular artery 349 Hip and Thigh Fractures 350 Hip and Thigh Fractures External iliac artery Femoral artery Obturator artery Medial circumflex femoral artery Ascending branch, Transverse branch, Descending branch of Lateral circumflex femoral artery Profunda femoris (deep femoral) artery Femoral artery Perforating branches Femoral artery passing through adductor hiatus Popliteal artery (phantom) Arteries of Thigh Retinacular arteries (subsynovial) Superior Anterior Inferior Anterior view Anastomosis between medial and lateral circumflex femoral arteries Medial circumflex femoral artery Ascending, Transverse, Descending branches of Lateral circumflex femoral artery Profunda femoris (deep femoral) artery Coronal section Acetabular branch of obturator artery (often minute) Posterior view Medial circumflex femoral artery Acetabular labrum Retinacular arteries Acetabular branch Obturator artery Ischiofemoral ligament and joint capsule Anterior view in situ lliopsoas muscle Medial circumflex femoral artery Femoral artery Lateral circumflex femoral artery Profunda femoris (deep femoral) artery Medial circumflex femoral artery Arteries of Femoral Head 351 Hip and Thigh Fractures 352 Hip and Thigh Fractures Popliteal artery (continues as posterior tibial artery of leg) • Obturator artery (from internal iliac) n Artery to head of femur • Hip joint is supplied by anastomotic branches of medial and lateral femoral circumflex and artery to head of femur (from obturator artery) • Artery to head of femur runs along ligament of head; artery might contribute little blood to joint after adulthood • Immediate blood supply to hip joint provided by retinacular arteries, branches of circumflex vessels • Retinacular arteries from medial circumflex usually provide more blood and pass beneath unattached posterior border of joint capsule • Lateral circumflex retinacular arteries must pass through thick iliofemoral ligament and are fewer and smaller than medial branches • Circumflex arteries can variably arise directly from femoral artery proper n Veins of the Hip and Thigh • Run parallel to femoral artery and its major branches: valved; arterial counterpulsation effect pumps blood heartward • Femoral vein tributaries (external iliac drainage) n Greater and lesser saphenous: superficial drainage of thigh and leg n Lateral circumflex: from hip joint n Medial circumflex: from hip joint n Deep femoral (profunda femoris) n Distal femoral vein proper, drains popliteal vein (leg) Greater sciatic foramen Sciatic nerve (L4, 5, S1, 2, 3) Posterior femoral cutaneous nerve (S1, 2, 3) Common fibular (peroneal) division of sciatic nerve Tibial division of sciatic nerve Semitendinosus muscle Cutaneous innervation Long head (cut) of biceps femoris muscle Common fibular (peroneal) nerve Tibial nerve Posterior femoral cutaneous nerve Sciatic Nerve 353 Hip and Thigh Fractures 354 Hip and Thigh Fractures Nerves of the Hip and Thigh • Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles • Sciatic nerve (L4-S1) n Dominant nerve supply for lower extremity n Runs posterior, medially in deep thigh, separated from femur by adductor magnus n To posterior (extensor) compartment of thigh (hamstrings) and compartments in leg and foot n Tibial (anterior) and fibular (peroneal; posterior) divisions • Obturator nerve (L2-L4) n To hip adductors • Femoral nerve (L2-L4) n To hip flexors/knee extensors • Gluteal nerves (L4-S1) n To hip extensors, abductors, and rotators Clinical Correlates Compartment Syndromes • Relatively rare because large volume is required to cause pathological increase in tissue pressure • Compartment fascia blends with deep fascia of muscles and can allow extravasation of blood • Predisposing factors: vascular injury, severe blunt trauma to thigh, systemic hypotension, external compression of thigh, coagulopathy, deep vein thrombosis Hip Fractures • Risk highest in older white women • Risk factors include osteoporosis, inactivity, smok ing, dementia, and psychotropic medications Type I Impacted fracture Type II Nondisplaced fracture Type III Partially displaced Type IV Displaced fracture Vertical fracture line generally suggests poorer prognosis Anastomosis Artery of round ligament of femoral head Medial Lateral Circumflex femoral aa Blood supply to femoral head chiefly from medial circumflex femoral artery Branches traverse femoral neck and may be torn by fracture, resulting in osteonecrosis of femoral head Artery of round ligament usually insignificant Intracapsular Femoral Neck Fracture 355 Hip and Thigh Fractures 356 Hip and Thigh Fractures • Most fractures result from falls onto greater trochanter or from twisting injury of lower extremity • 12%-36% 1-year mortality rate in elderly • Broad classification into types: femoral neck (intracapsular) and intertrochanteric fractures Intracapsular Fractures • May be compression-type or tension-type • Tension-type typically occur on superior neck, more commonly in athletes or military trainees • Compression-type fractures typically occur along inferior neck, more commonly in elderly persons with osteoporosis • Pathological bone lesions and metastases can also cause fractures • High risk of avascular necrosis of femoral head in intracapsular fractures, owing to damage to retinacular arteries running on the neck Shaft and Distal Femur Fractures Diaphyseal Fractures • Typically occur with twisting injury in osteoporosis or with metastatic lesions • Usually treated surgically in adults • Classified by location • Subtrochanteric fractures n Begin below lesser trochanter but can extend proximally into piriform fossa or intertrochanteric region n Region contains cancellous bone with reduced vascularity; risk of delayed healing, failure of fixation Shaft fractures High transverse or slightly oblique fracture Spiral fracture Comminuted fracture Segmental fracture Distal fractures Transverse Intercondylar Comminuted supracondylar (T or Y) fracture fracture fracture extending into shaft Fracture of single condyle (may occur in frontal or oblique plane) Fractures of Shaft and Distal Femur 357 Hip and Thigh Fractures 358 Hip and Thigh Fractures • Shaft fractures n Spiral oblique or transverse n Treatment guided by pattern, amount of comminution, associated injuries n Falls, vehicle accidents, and gunshot wounds can cause vascular damage, compartment syndromes, knee injuries, and axial fractures n Occasionally accompanied by femoral neck fracture • Distal fractures n Occur within 9 cm of articular surface n Gastrocnemius can flex and posteriorly displace distal fragment n Extraarticular or intraarticular n Intraarticular may be unicondylar or bicondylar 25 Knee and Leg Fractures Anatomy of Knee and Leg Patella • Largest sesamoid bone, attached between quadriceps and patellar tendons • Patellar tendon attaches to tibial tuberosity • Inferior (deep) surface is hyaline cartilage that articulates with femoral condyles as part of complex knee joint Tibia • Parts and landmarks: intercondylar eminence (plateau), lateral and medial intercondylar tubercles, lateral and medial condyles, Gerdy’s tubercle (iliotibial tract insertion), tibial tuberosity, anterior border; lateral, medial, and posterior surfaces; interosseus border, soleal line, fibular notch, medial malleolus, inferior articular surface (for talus) Fibula • Parts and landmarks: apex, head, neck, interosseus border, medial crest, posterior border, lateral malleolus, malleolar fossa Knee Joint(s) • Fibrous capsule provides relatively little support to complex knee joint • Patellofemoral joint: synovial articulation between patella and femoral condyles 360 Knee and Leg Fractures Anterior view Intercondylar eminence Lateral Medial intercondylar intercondylar tubercle tubercle Posterior view Lateral Medial condyle condyle Apex, Head, Neck Gerdy’s tubercle of (insertion of fibula iliotibial tract) Tibial tuberosity Fibula Soleal line Tibia Bones of the Leg (Right) In extension: posterior view In flexion: anterior view Posterior cruciate lig Anterior cruciate lig Lateral condyle of femur Lateral collateral lig Lateral meniscus Posterior meniscofemoral lig Transverse lig Medial collateral lig Medial meniscus Knee Joint • Medial meniscus n Articular fibrocartilage between medial femoral and tibial condyles n More crescent-shaped, attached to tibial collateral ligament • Lateral meniscus n Articular fibrocartilage between lateral femoral and tibial condyles n More circular 361 Knee and Leg Fractures 362 Knee and Leg Fractures • Transverse meniscal ligament: between anterior aspects of menisci; stabilizing • Posterior meniscofemoral ligament (of Humphrey): from posterior lateral meniscus to medial femoral condyle; stabilizing • Anterior cruciate ligament (ACL): from posteromedial aspect of lateral femoral condyle to anteromedial tibial eminence • Posterior cruciate ligament (PCL): from lateral aspect of medial femoral condyle to posteromedial tibial eminence • Tibial (medial) collateral ligament n Medial femoral epicondyle to medial tibia and medial meniscus n Resists valgus angulation • Coronary ligament: stabilizes medial meniscus • Pes anserinus n Distal tendons of sartorius, gracilis, and semitendinosus inserting on medial sub condylar tibia, superficial to collateral ligaments n Resists valgus angulation • Lateral (fibular) collateral ligament n Lateral supracondylar femur to fibular head n Resists varus angulation Compartments of the Leg • Crural fascia n Tough, nonexpansible, deep fascial sheath surrounds leg compartments, attached to the tibia anteriorly n Continuous with fascia lata above knee n Fuses with deep intermuscular septa surrounding compartments Deep fascia of leg (crural fascia) Anterior compartment Extensor muscles Anterior intermuscular septum Lateral compartment Fibula Deep fascia of leg (crural fascia) Interosseous membrane Tibia Deep posterior compartment Deep flexor muscles Transverse intermuscular septum Superficial posterior compartment Superficial flexor muscles Cross section just above middle of leg Deep fascia of leg (crural fascia) Soleus muscle Gastrocnemius muscle Anterior tibial artery and veins and deep fibular (peroneal) nerve Interosseous membrane Fibular (peroneal) artery and veins Posterior tibial artery and veins and tibial nerve Leg: Cross Section and Compartments 363 Knee and Leg Fractures 364 Knee and Leg Fractures • Anterior compartment n Ankle/foot (plantar) extensor muscles: tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus (fibularis) tertius (when it exists) n Vessels: anterior tibial artery and vein n Nerve: deep fibular (peroneal) • Superficial posterior compartment n Knee and ankle/foot (plantar) flexor muscles: gastrocnemius and soleus (triceps surae), plantaris, tibialis posterior, flexor digitorum longus (fibular) branches n Vessels: posterior tibial and fibular (peroneal) arteries and veins n Nerve: tibial • Deep posterior compartment n Knee and ankle/foot (plantar) flexor muscles: popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus n Vessels: posterior tibial and fibular (peroneal) arteries and veins n Nerve: tibial • Lateral compartment n Evertors of ankle and foot: peroneus (fibularis) longus and brevis n Vessels: anterior tibial and fibular (peroneal) arteries and veins (perforating branches) n Nerve: superficial fibular (peroneal) Vessels and Nerves Arterial Supply • Popliteal artery (from femoral) gives rise to medial and lateral genicular branches above and below knee joint (superior and inferior) Popliteal artery and tibial nerve Inferior medial genicular artery Tendinous arch of soleus muscle Posterior tibial artery Inferior lateral genicular artery Common fibular (peroneal) nerve Anterior tibial artery Tibial nerve Tibialis posterior muscle Arteries and Nerves of Leg: Deep Dissection (Posterior View) 365 Knee and Leg Fractures 366 Knee and Leg Fractures • Tibial artery continues from popliteal and branches into the n Posterior tibial artery s Fibular (peroneal) artery branch runs laterally along fibula, between flexor hallucis longus and tibialis posterior s Anterior tibial artery emerges through uppermost interosseus membrane, providing an anterior tibial recurrent branch to genicular anastomosis • Anastomoses around knee include n Descending genicular artery, medial branch of distal femoral artery n Superior lateral genicular and superior medial genicular arteries, branches of popliteal artery n Inferior lateral genicular and inferior medial genicular arteries, branches of popliteal artery n Posterior and anterior recurrent branches of tibial artery • Dorsalis pedis artery typically arises from terminal portion of anterior tibial • Terminal, perforating branch of the (peroneal) artery typically anastomoses with dorsalis pedis Veins of the Knee and Leg • Main deep veins run parallel to popliteal and to anterior and posterior tibial arteries and their branches • Popliteal vein (tributary of the femoral) includes anterior and posterior tibial branches draining plantar and dorsalis pedis • Surface drainage along greater and lesser saphenous veins, into the proximal femoral vein Common fibular (peroneal) nerve Anterior tibial artery Superficial fibular (peroneal) nerve Anterior tibial recurrent artery and recurrent branch of deep fibular nerve Tibialis anterior muscle (cut) Deep fibular (peroneal) nerve Extensor digitorum longus muscle Arteries and Nerves of Leg: Deep Dissection (Anterior View) 367 Knee and Leg Fractures 368 Knee and Leg Fractures Nerves • Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles Sciatic Nerve (L4-S1) • Dominant nerve supply for lower extremity • Tibial divisions (anterior): posterior compartment of leg (and plantar foot), flexors • Fibular (peroneal) divisions (posterior) n Deep fibular (peroneal) nerve: anterior compartment extensors of ankle and foot n Superficial fibular (peroneal nerve): lateral compartment extensor and evertors Clinical Correlates Compartment Syndrome • Can occur with open tibial fracture or intramedullary nailing • Chronic: relatively common without accompanying fracture in runners and other training athletes • Dependent position of limbs promotes high compartment pressures • Common findings n Isolated pressure increase in deep posterior compartment most common n Anterior compartment pressure increase second most common Fractures of Knee Region and Leg Patellar Fractures • Typically result from direct blow • Displaced or nondisplaced Horizontal group: Superolateral Superficial nodes inguinal Superomedial nodes nodes Vertical group: Inferior nodes Great saphenous vein Superficial lymph vessels Popliteal vein Popliteal lymph nodes Deep fascia of leg (crural fascia) Small saphenous vein Veins, Lymph Vessels, and Nodes of Lower Limb 369 Knee and Leg Fractures 370 Knee and Leg Fractures Tibial plateau fracture I Split fracture of lateral tibial plateau II Split fracture of lateral condyle plus depression of tibial plateau IV Comminuted V Bicondylar split fracture of fracture involving media tibial both tibial plateaus plateau and tibial with widening spine Fracture of shaft of tibia Transverse fracture; fibula intact Spiral fracture with shortening III Depression of lateral tibia plateau without split fracture VI Fracture of lateral tibial plateau with separation of metaphysealdiaphyseal junction Comminuted frac- Segmental fracture with marked ture with marked shortening shortening Tibial Fractures Posterior cruciate lig Anterior cruciate lig (ruptured) Arthroscopic view Usual cause is twisting of hyperextended knee, as in landing after basketball jump shot Lachman test With patient’s knee bent 20-30˚, examiner’s hands grasp limb over distal femur and proximal tibia Tibia alternately pulled forward and pushed backward Movement of mm or more than that in normal limb indicates rupture of anterior cruciate ligament Anterior drawer test Patient supine on table, hip flexed 45˚, knee 90˚ Examiner sits on patient’s foot to stabilize it, places hands on each side of upper calf and firmly pulls tibia forward Movement of mm or more is positive result Result also compared with that for normal limb, which is tested first Rupture of the Anterior Cruciate Ligament 371 Knee and Leg Fractures 372 Knee and Leg Fractures 1st-degree sprain Localized joint pain and tenderness but no joint laxity 2nd-degree sprain Detectable joint laxity plus localized pain and tenderness 3rd-degree sprain Complete disruption of ligaments and gross joint instability Valgus stress may rupture tibial collateral and capsular ligaments “Unhappy triad” of O’Donoghue Rupture of tibial collateral and anterior cruciate ligaments plus tear of medial meniscus Sprains of Knee Ligaments • Classifications: comminuted, transverse, vertical, osteochondral, apical, or inferior pole fractures • Surgical treatment for open, comminuted, or >2 mm displacement or incongruity Tibial Plateau Fractures • Common result of falls and vehicle accidents • Lateral more common, often occur in low-energy trauma of fall in elderly person with osteoporosis • Medial fractures more commonly associated with ligament, peroneal nerve, meniscal, and popliteal vessel injuries; high-force injury • Schatzker classification n Type I: lateral plateau split n Type II: lateral plateau split depression n Type III: lateral plateau depression n Type IV: medial plateau and tibial spine fracture n Type V: bicondylar n Type VI: bicondylar with diaphyseal extension Tibial Shaft Fractures • Tibia relatively poorly supplied by posterior tibial artery nutrient branches • Periosteal supply from anterior tibial artery • Most common long bone fractures, resulting from direct or indirect trauma • Simple: transverse, spiral, or oblique • Comminuted n May be segmental n Result from high-energy torsion, bending, or crush injuries • Butterfly: result from twisting, bending 373 Knee and Leg Fractures 374 Knee and Leg Fractures • Stress: repetitive overuse (e.g., in dancers, sports, or military training) Fibular Fractures • Although non–weight bearing, fibula is often fractured with tibia • Interosseus membrane transmits forces from tibia • Shaft fracture types comparable to those of tibia • Pilon fracture n Fibular shaft fracture with tibial articular surface compression fracture n From vertical loading of ankle joint, fall from height, landing on heel Malleolar Fractures • See Chapter 26, Fractures of the Ankle and Foot 26 Ankle and Foot Fractures Anatomy of the Ankle and Foot Malleoli • Articulate with trochlea of talus • Medial malleolus: distal tibia • Lateral malleolus: distal fibula Tarsal Bones • Talus n Only bone articulating with tibia and fibula n Parts and landmarks s Head, neck, body, trochlea, lateral proc ess, posterior process (medial, lateral tubercles) s Lateral tubercle may be unfused n No muscular attachments n Flexor hallucis longus tendon runs between medial and lateral tubercles • Calcaneus n Has multiple facets, posterior largest n Sustentaculum tali s Supports talar neck, attached to spring ligament s Overlies flexor hallucis longus tendon n Calcaneal tendon (Achilles) attached to posterior superior tuberosity • Navicular: boat-shaped, with medial tuberosity for tibialis posterior insertion 376 Ankle and Foot Fractures Dorsal view Calcaneus Trochlea Talus Navicular Cuboid Lateral Intermediate Medial Cuneiform bones Plantar view Head of talus Tuberosity of 5th metatarsal bone Sustentaculum tali Metatarsal bones Proximal Phalanges Middle Distal Bones of the Foot • Cuboid s Tuberosity and cuboid groove inferior s Most lateral tarsal bone s Articulates with metatarsals IV and V s Inferior groove for peroneus longus tendon • Medial cuneiform n Largest of 3, for metatarsal I n Bears partial insertion of peroneus longus • Intermediate cuneiform n Shortest n Metatarsal II base is recessed, fracturable • Lateral cuneiform: articulates with both navicular and cuboid, as well as metatarsal III Metatarsal Bones • Anterior support of longitudinal arch • 5, numbered I-V, 1-5 • Base, body, head; characteristics of long bone • Peroneus brevis inserts on base of metatarsal V Phalanges • Digit (hallux): proximal and distal (2), sesamoid bones • Digits 2-5: proximal, medial, distal (3) Ankle and Foot Joints • Ankle joint n Synovial hinge (ginglymus) n Mortise-and-tenon structure with talus between malleoli • Numerous complex synovial joints exist between individual tarsals and between tarsals and metatarsals 377 Ankle and Foot Fractures 378 Ankle and Foot Fractures • Transverse tarsal joint (Chopart) n Calcaneus with cuboid + talus with navicular n Allows inversion and eversion • Transverse metatarsal joint (Lisfranc): between cuneiforms, cuboid, and metatarsal bases Ankle and Foot Ligaments • Inferior tibiofibular (syndesmosis) n Complex support of distal tibia and fibula n Anterior inferior tibiofibular (AITFL) n Posterior inferior tibiofibular (PITFL) n Inferior transverse n Interosseus ligament • Ankle ligaments (collateral) n Medial: deltoid (4 parts): tibionavicular, tibiocalcaneal, posterior and anterior tibiotalar n Lateral: anterior and posterior talofibular (ATFL, PTFL), calcaneofibular (CFL) • Intertarsal ligaments (named for paired bones) • Tarsometatarsal ligaments • Transverse tarsal ligaments • Interphalangeal and collateral ligaments Compartments of the Foot • Foot does not have muscular compartments comparable to leg and thigh • Blood and fluid retention tend to be confined to dorsal or plantar spaces • Dorsal: dorsalis pedis vessels lie subcutaneously and dorsal to interossei and bones of foot • Plantar: spaces occur between layers of foot muscles and tendons n Layer 1: abductors of digits and n Layer 2: flexor digitorum longus tendons and quadratus plantae Right foot: lateral view Components Posterior talofibular lig of lateral Calcaneofibular lig (collateral) Anterior talofibular lig lig of ankle Long plantar lig Fibularis (peroneus) longus tendon Fibularis (peroneus) brevis tendon Right foot: medial view Medial (deltoid) lig of ankle Posterior tibiotalar part Tibiocalcaneal part Tibionavicular part Anterior tibiotalar part Sustentaculum tali Plantar calcaneonavicular (spring) lig Posterior view with ligaments Short plantar lig Posterior tibiofibular lig Medial (deltoid) lig of ankle Posterior talocalcaneal lig Posterior talofibular lig Calcaneofibular lig Ankle Joints and Ligaments 379 Ankle and Foot Fractures 380 Ankle and Foot Fractures Layer 3: flexor digitorum brevis Layer 4: interossei, adductors of digits and 5, opponens • Medial and lateral plantar neurovascular bundles lie in space between layers and • Plantar neurovascular bundles enter foot by passing posterior to medial malleolus: fluid extravasation in posterior inferior leg can follow this route into foot n n Vessels and Nerves Plantar view Medial plantar n Sensitivity of skin of sole of foot, both sides of 1st, 2nd, 3rd, and medial toes, and medial aspect of the 4th toe, as well as joints of tarsus and metatarsus of the related toes Anterior tibial a Tibial n Proper plantar digital aa Common plantar digital aa Posterior tibial a Plantar arch Plantar metatarsal aa Lateral plantar n Sensitivity of skin of 5th toe and lateral aspect of the 4th toe; supplies deep mm of foot Arteries and Nerves of the Sole Arterial Supply • Posterior tibial artery (from tibial) gives rise to medial and lateral plantar branches above and below ankle joint n Medial plantar artery supplies medial aspect of plantar foot n Lateral plantar artery supplies lateral aspect of plantar foot • Anterior tibial artery typically gives rise to dorsalis pedis artery • Terminal, perforating branch of peroneal (fibular) artery typically anastomoses with dorsalis pedis artery • Peroneal (fibular) artery occasionally emerges through uppermost interosseus membrane to give rise to dorsalis pedis artery Venous Drainage • Runs parallel to anterior and posterior tibial arteries and their major branches • Deep plantar and dorsal tributaries drain into posterior and anterior tibial veins; tributaries of popliteal drain to femoral • Surface drainage along greater and lesser saphenous veins, into femoral and popliteal, resp Nerves • Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles Sciatic Nerve (L4-S1) • Dominant nerve supply for lower extremity • Tibial (anterior) divisions: plantar flexors of foot 381 Ankle and Foot Fractures 382 Ankle and Foot Fractures Medial plantar nerve: to abductor and short flexor hallucis, flexor digitorum brevis, medial lumbrical n Lateral plantar nerve: quadratus plantae, interossei, and lateral lumbricals; adductor hallucis; abductor and flexor digiti minimi brevis • Peroneal (fibular, posterior) divisions n Deep peroneal (fibular): anterior compartment extensors of ankle/foot: extensors hallucis brevis and digitorum brevis n Superficial peroneal (fibular): lateral compartment extensor/evertor n Clinical Correlates Ankle Fractures • Typically involve malleolar prominences of tibia and fibula, along with avulsion and rupture of supporting ligaments • Characteristic patterns of fractures accompany injuries caused by extreme forced movements in specific directions n Supination and adduction n Supination and external rotation n Pronation and abduction n Pronation and external rotation Tarsal Fractures Talus Fractures • Neck is most common site for talar fractures • Usually result from direct trauma or landing on foot after a fall • Hyperdorsiflexion impacts neck on distal tibia II I II IV I Talus Calcaneus Supination-external rotation (SER) Supination-abduction (SA) III IV III I II II I Pronation-abduction (PA) Pronation-external rotation (PER) Classification of Ankle Fractures 383 Ankle and Foot Fractures 384 Ankle and Foot Fractures Type A Avulsion fracture of lateral malleolus and shear fracture of medial malleolus caused by medial rotation of talus Tibiofibular ligaments intact Type C Disruption of tibiofibular ligaments with diastasis of syndesmosis caused by external rotation of talus Force transmitted to fibula results in oblique fracture at higher level In this case, avulsion of medial malleolus has also occurred Type B Shear fracture of lateral malleolus and small avulsion fracture of medial malleolus caused by lateral rotation of talus Tibiofibular ligaments intact or only partially torn Maisonneuve fracture Complete Torn deltoid lig disruption of tibiofibular syndesmosis with diastasis caused by external rotation of talus and transmission of force to proximal fibula, resulting in high fracture of fibula Interosseous membrane torn longitudinally Rotational Fractures Usual cause is impact on anterior margin of tibia due to forceful dorsiflexion Lateral radiograph shows type II fracture Type I No displacement Type III Fracture of talar neck with dislocation of subtalar and tibiotalar joints Type II Fracture of talar neck with subluxation or dislocation of subtalar joint Anterior tibial a Perforating branch of fibular a Posterior tibial a Artery of Artery of Avascular tarsal sinus Deltoid a tarsal canal necrosis of talar body evidenced Because of profuse intraosseous by increased anastomoses, avascular necrosis density (sclerosis) commonly occurs only when compared with surrounding soft tissue is other tarsal bones damaged, as in type II and III fractures of talar neck Fractures of the Talar Neck 385 Ankle and Foot Fractures 386 Ankle and Foot Fractures • Three types of talar fractures n Type I: nondisplaced n Type II: neck fracture with subtalar subluxation or dislocation n Type III: neck fracture with dislocation of tibiotalar and subtalar joints • Neck fractures can lead to avascular necrosis because most of blood supply passes through here Calcaneus Fractures • Most common tarsal fractures • Intraarticular n 75% of all calcaneal fractures n From forceful landing on a heel n Talus driven down on cancellous calcaneus • Extraarticular n Anterior process: avulsion caused by landing on plantar-flexed, adducted foot n Calcaneal tuberosity: avulsion due to sudden forceful contraction of gastrocnemius/soleus n Sustentaculum tali fracture: landing on inverted foot n Body fracture: jumping and landing on heel Metatarsal and Phalangeal Fractures • Please see p 388 Extraarticular fracture of calcaneus Avulsion fracture of anterior process of calcaneus caused by tension on bifurcate ligament Comminuted fracture of anterior process of calcaneus due to compression by cuboid in forceful abduction of forefoot Achilles’ tendon Avulsion fracture of tuberosity of calcaneus due to sudden, violent contraction of Achilles’ tendon Fracture of sustentaculum tali Fracture of medial process of tuberosity of calcaneus Fracture of body of calcaneus with no involvement of subtalar rticulation Intraarticular fracture of calcaneus Primary fracture line Talus driven down into calcaneus, usually by fall and landing on heel Primary fracture line runs across posterior facet, forming anteromedial and posterolateral fragments Fractures of the Calcaneus 387 Ankle and Foot Fractures 388 Ankle and Foot Fractures B A C D Fracture of proximal phalanx E F Types of fractures of metatarsal: A comminuted fracture, B displaced neck fracture, C oblique fracture, D displaced transverse fracture, E fracture of base of 5th metatarsal, F avulsion of tuberosity of 5th metatarsal Fracture of phalanx splinted by taping to adjacent toe (buddy taping) Dorsal dislocation of 1st metatarsophalangeal joint Crush injury of great toe Fracture of sesamoid bones (must be differentiated from congenital bipartite sesamoid bones) Metatarsal and Phalangeal Injuries Index Page numbers followed by f indicate figures A Aaron’s sign, 93 Abdominal wall, 147–153, 148f Abducens nerve (VI), Accessory nerve (XI), 10 Acetabular fossa, 246, 343 Acetabular fractures, 253, 253f, 255 Acetabular labrum, 343, 344f, 351f Acetabulum, 245, 343, 344f, 346 Achilles tendon, 375, 387f Acousticovestibular nerve (VIII), 10 Acromioclavicular joint, 289, 290f, 296f Acromion, 289, 290f, 295 Adamkiewicz, artery of, 36 Adductor hiatus, 349, 350f Adductor longus muscle, 347f, 349 Adductor magnus muscle, 347f, 349, 354 Adductor pollicis muscle, 333, 334f, 336, 338 Ala, sacral, 245 Alar ligaments, 33 Ampulla of Vater, 96f, 100, 131, 200, 201 endoscopy through, 106 obstruction of, 105f, 108 Anal canal See Anorectal entries Anal fissure, 240 Anal glands, 232, 232f, 238 Anal nerve, inferior, 234f Anal sphincters, 232, 232f, 233, 235 Anastomotic loops arterial, 216, 217f venous, 218f Angular artery, 5, 6f Angular notch (incisure) of stomach, 127, 128f Angular vein, 6f, Ankle, 375, 377–378, 379f–380f, 381–382 fractures of, 374, 382, 383f–387f Annular ligament, radial, 314, 322f Anorectal anatomy, 231–233, 232f arteries in, 235, 236f lymphatics in, 238, 239f nerves in, 233, 234f, 235 veins in, 235, 237f, 238 390 Anorectal diseases See also Rectum abscess, 123f, 238, 240 hemorrhoids, 114, 235, 238 Antebrachial compartment syndrome, 320 Antebrachial fascia, 315, 316f Antebrachial spaces, 333 Anterior cruciate ligament (ACL), 361f, 362 rupture of, 371f–372f Anterior drawer test, 371f Anterior inferior iliac spine, 243, 250, 252f, 344f Anterior longitudinal ligament, 32, 36, 37f lumbosacral, 244f, 246 Anterior superior iliac spine, 243, 244f, 250, 252f, 344f Antrum maxillary, 12f, 13 pyloric, 127, 128f, 129, 139 Anulus fibrosus, 30f, 32 Anus See Anal and Anorectal entries Aortic arch, 61, 62f, 66f Aortic (lumbar) lymph nodes lateral kidneys and, 171f, 172 large intestine and, 117 uterus and ovaries and, 277f Index Aortic (lumbar) lymph nodes (continued) prostate and, 263, 264f rectum and, 238, 239f small intestine and, 219 uterus/ovaries and, 277f, 278 Aortic plexus, 215f Aorticorenal ganglia, 167f, 168 Appendiceal abscess, 92f vs ovarian cyst, 282f Appendiceal (appendicular) artery, 86f, 88–89, 112 Appendiceal (appendicular) vein, 89, 89f Appendicitis, 85, 87f, 91, 92f, 93 Appendicular lymph nodes, 90, 90f Appendix, 85–93 abscess of, 92f, 282f anatomy of, 85, 86f–87f, 88 carcinoid of, 92f, 93 mucocele of, 92f vessels and lymphatics of, 86f, 88–90, 89f–90f Arcades, intestinal arterial, 213f, 216, 217f Arcuate line, 245 Arm, 302, 303f–304f, 305–307, 306f See also Forearm; Humerus Arteriae rectae, 113f, 213f, 217f Ascites, 192, 193, 197 Atlas (C1), 28f, 29, 39f Auerbach’s plexus, 110, 112, 129, 132, 214, 215, 233 Auricular artery, 5, 6f Auricular muscle, Auricular vein, 6f, Auriculotemporal nerve, 8f Axillary artery, 293f, 294, 304f, 305, 306f, 307 breast and, 47 Axillary lymph nodes, 49, 60, 154 Axillary nerve, 302, 306f, 307, 310 Axillary vein, 294, 305, 319 breast and, 49 Axis (C2), 28f, 29, 33, 39f Azygos system, 36, 49, 65, 67f, 68, 79 B Basilic vein, 294, 305, 318, 319, 335 Batson’s plexus, 242 Benign prostatic hyperplasia, 257, 262f, 263, 265–266, 267f Biceps brachii muscle, 291, 294, 299, 301f, 302, 303f, 305, 307, 324f Biceps femoris muscle, 348, 353f Bile and bile secretion, 100, 102, 104 391 Bile duct(s) See also (Common) bile duct intrahepatic, 95, 182, 183f, 184, 185f–186f Biliary colic, 105f Biliary function tests, 106 Biliary system, extrahepatic, 95–108 anatomy of, 95, 96f, 97, 98f, 99–100 diagnostic procedures of, 106 disease of, 108 hemorrhage in, 198 vessels and lymphatics of, 100–102, 101f, 103f Billroth procedures, 145 Bloodless fold of Treves, 86f, 88 Boerhaave’s syndrome, 73 Boutonnière deformity, 340f Boxer fracture, 339f Brachial artery, 303f–304f, 305, 315, 318 Brachial fascia, 302 Brachial plexus, 33, 35f, 294–295, 302, 305–307, 306f Brachial vein, 294, 303f, 305, 319 Brachiocephalic veins, 67f, 79 Brachioradialis muscle, 320 Index 392 Breast, 45–60 arterial supply of, 47, 48f axillary tissue of, 47 benign disease of, 50, 51f, 52, 53f, 54 diagnostic procedures of, 50 innervation of, 47 lymphatic drainage of, 48f, 49–50 structure of, 45, 46f venous drainage of, 48f, 49 Breast cancer, 49–50, 54–56, 56f–58f, 59–60 Broad ligaments, 271, 272f, 273, 276, 278 Bronchial arteries, 66f Buccal nerve, 8f Buck’s fascia, 262f Bulbourethral (Cowper’s) glands, 258f, 259 C C1 (atlas), 28f, 29, 39f C2 (axis), 28f, 29, 33, 39f Calcaneofibular ligament, 378, 379f Calcaneus, 375, 376f, 378 fractures of, 386f, 387f Camper’s fascia, 147 Canthal ligament, 14f, 15 Capitate bone, 327, 328f Cardinal ligaments, 271, 274, 276 Carotid arteries, 5, 6f, Index Carpal bones, 327, 328f–329f, 330 fractures of, 320, 336 scaphoid, 337f, 338 Carpal joints, 329 Carpal tunnel, 319, 330, 331f, 335, 336 Carpal tunnel syndrome, 338 Carpometacarpal joints, 329–330, 329f Cauda equina, 31, 35f Cavernous sinus, 7, Cecal arteries, 88, 89 Cecal vein, posterior, 89f Cecum, 109, 110f, 111 appendix and, 85, 86f–87f, 88, 93 Crohn’s disease of, 122f, 226f low-lying, vs cyst, 282f small intestine and, 212f volvulus of, 124 Celiac artery, 65, 66f, 100, 101, 101f, 130f, 133, 135f–136f, 137, 187, 188f, 189, 216 Celiac ganglion, 97, 133, 134f, 187, 202, 215 Celiac lymph nodes, 68, 69f, 102, 103f, 140f, 191f, 205, 206f, 220f Celiac plexus, 97, 133, 134f, 135, 166, 167f, 168, 184, 186, 202, 214, 215f, 216 Central veins, of hepatic lobules, 184, 186f, 189 Cephalic vein, 294, 305, 318, 335 Cerebral arteries, Cerebral veins, Cerebral venous sinuses, 3, 7, Cerebrospinal fluid leakage, 12f, 15 Cervical curvature, 27, 28f Cervical ribs, 27 Cervical spinal nerves, 8f, 10 Cervical vertebrae, 28f, 29, 34, 36 fractures of, 38, 39f Cervicothoracic (stellate) ganglion, 64f Cervix, uterine, 271, 272, 274, 276, 277f, 278 carcinoma of, 280f, 284 fibroids in, 281f Chance fracture, 37f Cholangiole, 186f Cholecystectomy, 99–101, 106–108 Cholecystitis, 105f, 107 Cholecystokinin, 100, 104, 214 Cholelithiasis, 104, 105f, 106–108, 205 Chondrosternal separation, 80f Chopart joint, 378 Chorio-epithelioma, 280f Cirrhosis, 193, 196f, 197 carcinoma with, 193, 195f Cisterna chyli, 117, 140f, 171f, 172, 205, 219, 220f 393 Clavicle, 289, 291–292, 291f, 294–295 fractures of, 296f, 297 manubrium and, 76, 76f Coccyx, 28f, 34, 245, 348 fracture of, 252f Colectomy, partial, 125f Colic arteries, 112, 113f, 125f Colic lymph nodes, 239f Colic veins, 114, 115f Colitis, 121, 122f–123f, 124 Collateral ligament(s) of ankle, 378, 379f of knee, 361f, 362, 372f Colles’ fracture, 325, 326f Colon, 109–125 anatomy of, 109–111, 110f arterial supply of, 112, 113f, 114 cancer of See Colorectal cancer diverticular disease of, 117, 118f, 119, 124 inflammatory disease of, 121, 122f–123f, 124 innervation of, 111–112 ischemia of, 240 kidneys and, 163, 164f lymphatic drainage of, 114, 116f, 117 obstruction of, 109, 119, 120f, 124 polyps in, 119, 123f venous drainage of, 114, 115f volvulus of, 124 Index 394 Colorectal anastomosis, 125f Colorectal cancer, 119, 120f metastases from, 193 obstruction in, 119, 120f, 124, 240, 241f rectal involvement in, 119, 120f, 125, 240, 241f, 242 resection of, 125f, 242 ulcerative colitis with, 123f (Common) bile duct, 96f, 99–100, 101f calculus in, 105f, 108 portal triad and, 179, 180f surgical trauma to, 108 variations of, 98f, 99 Common hepatic artery, 96f, 101, 101f, 187, 188f, 189, 203f gastroduodenal branches of, 135f–136f, 137 small intestine and, 216 Common hepatic duct, 95, 96f, 97, 185f arterial supply of, 101f variations in, 98f, 99 Compartment syndromes of leg, 368 of thigh, 354, 358 upper limb, 307, 310, 315, 320, 336, 338 Conjoined (conjoint) tendon, 150, 152 Index Conoid ligament, 290f, 292 Conus medullaris, 34, 35f trauma to, 38 Cooper’s (pectineal) ligament, 147, 156 Cooper’s ligaments of breast, 45, 46f, 55, 56f Coracoacromial ligament, 292 Coracoclavicular ligament, 290f, 291–292, 296f Coracoid process, 289, 290f, 292, 295 Coronary ligament of knee, 362 of liver, 179, 181f Coronoid process, 313, 314, 314f fractures of, 320, 321f, 325 Costal cartilages, 75, 76, 76f Costochondral separation, 80f Costoclavicular ligament, 289, 291f, 292 Costovertebral dislocation, 80f Cowper’s (bulbourethral) glands, 258f, 259 Coxal (hip) bones, 243, 244f, 245, 343, 344f Coxal joints, 246 Cranial nerves, 9–10 Cranium, 3, 4f arteries of, 5, 6f, veins of, 6f, 7, Cremaster muscle, 148f, 149, 155f Cremasteric artery, 153 Cremasteric fascia, 148f, 149, 153, 155f Cricopharyngeus, 61, 68, 70 Crohn’s disease, 121, 122f, 225, 226f, 227 abscess in, 240 Cruciate ligament, craniovertebral, 32–33 Crural fascia, 362, 363f, 369f Cubital tunnel, 319 Cuboid bone, 376f, 377, 378 Cuneiform bones, 376f, 377, 378 Cystic artery, 96f, 100–101, 101f, 108, 188f Cystic duct, 95, 96f, 97, 98f, 99, 101f, 102 ligation of, 108 obstruction of, 105f, 107 Cystic node, 103f, 191f Cystic veins, 102 Cystohepatic junction, 96f, 98f, 99 Cystohepatic triangle of Calot, 97, 101f D Deferential artery, 153 Deltoid ligament of ankle, 378, 379f, 384f Deltoid muscle, 302, 303f 395 Dens (odontoid process), 29, 32, 33, 39f Dentate line, 231, 232, 232f, 238 Diaphragm hiatal hernia of, 72, 142, 143f, 161f lymph nodes on, 189 Diploic spaces, 3, Discs, intervertebral, 30f, 31–32, 34, 41f Diverticula acquired jejunoileal, 222 colonic, 117, 118f, 119, 124 esophageal, 68, 70 Dorsalis pedis artery, 366, 378, 381 Ductal carcinoma in situ (DCIS), 54 Ductus (vas) deferens, 148f, 153, 154, 155f, 258f, 260 Duodenum, 130–132, 130f adenocarcinoma of, 142, 224 arteries of, 136f, 137, 203f (common) bile duct and, 96f, 99, 130f gallbladder and, 95, 96f greater papilla of, 131, 200 hepatopancreatic ampulla and, 96f, 100, 200 innervation of, 133, 134f, 135 Index 396 Duodenum (continued) lesser (minor) papilla of, 131, 201 ulcers of, 139, 142, 210f venous drainage of, 137, 138f, 139, 219 E Ectopic pregnancy, 280f, 285f Ejaculatory ducts, 257, 258f, 260 Elbow, 299, 302, 313–315, 317f, 318 dislocations of, 320, 321f–322f, 325 Emissary veins, 3, 5, 6f Endoabdominal fascia, 147, 151 Endopelvic fascia, 233, 259 Endoscopic retrograde cholangiopancreatog raphy (ERCP), 106, 108, 198, 205, 207 Epicranius, Epidural hematoma, 13 Epidural space, 33 Epigastric arteries, 150–154, 155f, 247, 349 Epigastric veins, 153, 154, 155f, 249 Epiploic (omental) appendices, 109, 118f Epiploic (omental) foramen (of Winslow), 179, 180f Index ERCP, 106, 108, 198, 205, 207 Esophageal varices, 68, 137, 196f Esophagitis, peptic, 71f Esophagus, 61–74 achalasia of, 70 anatomy of, 61, 62f, 63 arterial supply of, 65, 66f caustic injury to, 73–74 diverticula of, 68, 70 gastric reflux and, 70, 71f, 72, 142 hiatal hernia and, 72, 142, 143f, 161f innervation of, 63, 64f, 65 lymphatic drainage of, 68, 69f perforations of, 73 stomach and, 127, 128f strictures of, 71f, 72–74 surgical approaches to, 68 tumors of, 72–73 venous drainage of, 65, 67f, 68, 190f Essex-Lopresti fracture, 323f Ethmoid bone, 3, Ethmoidal nerve, 8f Exophthalmos, 22f Extensor digitorum longus muscle, 364, 367f External oblique fascia, 153 External oblique muscle, 147, 148f, 149, 152 Extraperitoneal fascia, 148f F Face, 5, 6f, 7, 8f, Facet joints, 32, 36 Facets, vertebral, 27, 29, 36 Facial fractures, 12f, 13, 14f, 15, 16f Facial nerve (VII), Facial skeleton, Facial veins, 6f, 7, Falciform ligament, 132, 179, 181f, 182, 188f, 190f Fallopian tubes See Uterine (fallopian) tubes (ducts) False pelvis, 243, 245 Fascia lata, 347f, 348 Femoral artery, 347f, 348, 349, 350f–351f, 352, 366 inguinal ligament and, 153, 154 Femoral cutaneous nerve, posterior, 353f Femoral head, 343, 345f arteries of, 351f, 352 avascular necrosis of, 355f, 356 Femoral neck, 343, 345f fractures of, 355f, 356, 358 Femoral nerve, 347f, 348, 354 397 Femoral vein, 347f, 348, 349, 352, 366, 381 inguinal ligament and, 153, 154 Femur, 343, 345f fractures of, 355f, 356, 357f, 358 knee joint and, 361, 361f Fibula, 359, 360f–361f, 362, 363f, 375, 378, 379f fractures of, 374, 382, 383f–384f Fibular (peroneal) artery, 363f, 364, 366, 381 Fibular (lateral) collateral ligament, 361f, 362 Fibular (peroneal) division of sciatic nerve, 353f, 354, 368, 382 Fibular (peroneal) nerve common, 353f, 365f, 367f deep, 363f, 364, 367f, 368, 382 superficial, 364, 368, 382 tibial fracture and, 373 Fibular (peroneal) veins, 363f, 364 Fibularis (peroneus) brevis and longus tendons, 377, 379f Finger injuries, 338, 339f, 340f Flail chest, 80f, 81 Flexor carpi radialis, 331f Flexor carpi ulnaris, 315, 319, 320, 331f Index 398 Flexor digitorum brevis, 380 Flexor digitorum longus, 378 Flexor digitorum profundus, 317f, 319 Flexor digitorum profundus tendons, 315, 330, 331f–332f, 333, 335, 339f Flexor digitorum superficialis, 315, 319 Flexor digitorum superficialis tendons, 315, 330, 331f–332f, 333, 335 Flexor hallucis longus tendon, 375 Flexor pollicis longus, 315 Flexor pollicis longus tendon, 331f–332f, 333 Flexor retinaculum, 319, 330, 331f, 338 Foot arterial supply of, 380f, 381 bones of, 375, 376f, 377 compartments of, 378–379 dislocation of, 388f fractures of, 382, 385f–387f great toe injury of, 387f joints of, 377–378 ligaments of, 378, 379f nerves of, 380f, 381–382 venous drainage of, 381 Foramen ovale, 7, Index Foramina transversaria, 29 Forearm, 313–326 anatomy of, 313–315, 314f, 316f arterial supply of, 315, 317f, 318 compartment syndromes of, 315, 320, 333 compartments of, 315, 316f fractures of, 320–326, 321f–326f nerves of, 306f, 319–320 veins of, 318–319 Frontal artery, 6f Frontal bone, 3, 4f, 14f, 15 Frontal vein, 6f G Galeazzi fracture/ dislocation, 322f, 325 Gallbladder, 95, 96f, 97, 99, 100, 101f, 102, 103f, 104 carcinoma of, 108 inflammation of, 105f, 107 Gallstones, 104, 105f, 106–108, 205 Gastric arteries, 65, 66f, 134f, 135f, 137, 187, 188f, 189 Gastric lymph nodes, left, 68, 69f, 103f, 140f Gastric veins, 67f, 137, 138f, 190f Gastrinoma, 209, 210f Gastritis, 139, 145 Gastrocnemius muscle, 363f, 364, 386 Gastroduodenal artery, 101f, 135f–136f, 137, 187, 188f, 216 pancreas and, 202, 203f Gastroesophageal reflux disease (GERD), 70, 71f, 72, 142 Gastrointestinal stromal tumor (GIST), 145, 224, 225 Gastro-omental (gastroepiploic) arteries, 134f, 135f, 137, 202 Gastro-omental (gastroepiploic) lymph nodes, 140f Gastro-omental (gastroepiploic) veins, 138f, 139 Genicular artery(ies), 349, 364, 365f, 366 Genitofemoral nerve, 148f, 153 Gerdy’s tubercle, 359, 360f Gerota’s fascia, 163, 177 Glenohumeral joint, 291, 292, 299, 300f–301f arterial supply of, 302 brachial plexus and, 307 Glenoid fossa, 289, 290f, 299, 301f fractures of, 291, 295, 297 Glenoid labrum, 299, 301f 399 Glossopharyngeal nerve (IX), 10 Gluteal arteries, 248, 248f, 249 Gluteal compartment, 348 Gluteal nerves, 354 Gluteus maximus muscle, 347f, 348 H Hallux (great toe), 377 crush injury of, 388f Hamate bone, 327, 328f, 330, 334f, 336, 337f Hand, 327–340 anatomy of, 327, 328f–329f, 329–330, 332f, 333 arterial supply of, 333, 334f, 335 compartment syndromes of, 336, 338 compartments of, 330, 331f–332f, 333 innervation of, 334f, 335–336 joints of, 327, 329–330 ligaments of, 330 venous drainage of, 335 Hangman fracture, 39f Hartmann’s pouch, 96f calculus in, 105f Haustra, 109, 111 Head and neck, 3, 5, 6f, 7, 8f, 9–10 Hemiazygos system, 49, 65, 67f, 79 Index 400 Hemorrhoidal venous plexus, 114, 238 Hemorrhoids, 114, 235, 238 Hepatic arteries, 96f, 97, 100–101, 101f, 187, 188f, 189 branches of, 182, 184, 185f–186f surgical trauma to, 108 Hepatic ducts, 95, 96f, 97, 98f, 99 Hepatic lymph nodes, 102, 103f, 191f, 206f Hepatic plexus, 134f, 184 Hepatic veins, 184, 189 cirrhosis and, 196f Hepatoduodenal ligament, 128f, 130, 179, 180f Hepatogastric ligament, 128f, 132, 179, 180f Hepatopancreatic ampulla See Ampulla of Vater Hepatopancreatic sphincter (of Oddi), 99, 100, 104, 201 Hernias, 154–161 femoral, 157 hiatal, 72, 142, 143f, 161f incarceration of, 154 incisional, 158, 159f inguinal, 152, 154, 155f, 156–157 lumbar, 160 obturator, 158, 160 overview of, 154, 159f parastomal, 160 perineal, 160 Index Hernias (continued) reduction of, 154 sciatic, 160 small bowel obstruction secondary to, 219 spigelian, 159f, 160 strangulation of, 154 umbilical, 157–158, 159f Hesselbach’s triangle, 152, 156 Hiatal hernia, 72, 142, 143f, 161f Hilton’s law, 246, 305, 319, 354, 368, 381 Hip bones, 243, 244f, 245, 343, 344f Hip joint, 343, 344f, 346 arterial supply of, 349, 350f–351f, 352 fractures of, 354, 355f, 356 innervation of, 353f, 354 veins of, 352 Humeral fractures, 307, 308f–309f, 310–311, 320 Humeral head, 299, 300f dislocations of, 310 fractures of, 308f, 310 Humerus, 299–311 anatomy of, 299, 300f–301f, 302 arteries in region of, 293f, 294, 302, 304f, 305 elbow joint and, 313–314 neck of, 299, 300f, 308f–309f, 310 Hypogastric nerves, 234f, 247, 261f Hypogastric plexus, 247 colon and, 112 prostate and, 260, 261f rectum and, 234f, 235 Hypoglossal nerve (XII), 10 Hypothenar compartment, 333, 336 I Ileocecal fold, 86f, 88 Ileocecal junction, 111 Ileocecal recess (fossa), 86f, 88 Ileocolic anastomosis, 125f Ileocolic artery, 86f, 88, 112, 113f, 215f, 216, 217f Ileocolic fold, 88 Ileocolic fossa, 88 Ileocolic lymph nodes, 90, 90f, 116f Ileocolic plexus, 215f Ileocolic vein, 89, 89f, 114, 115f, 218f, 219 Ileum, 211, 212f–213f arterial supply of, 213f, 216, 217f diverticula of, 222 leiomyosarcoma of, 225 lymphoma in, 225 Peyer’s patches in, 212, 213f, 219 401 Ileum (continued) terminal appendix and, 85, 86f, 88, 89 Crohn’s disease of, 121, 122f, 225, 226f venous drainage of, 218f, 219 Iliac artery(ies) common, 173f, 247, 248f deep circumflex, 247 external, 153, 247, 248f, 349, 350f internal, 247–249, 248f hip joint and, 349 prostate and, 262–263, 262f rectal branches of, 114, 235, 236f, 240 thigh muscles and, 348 uterus and, 274, 275f vagina and, 275f, 276 Iliac crest, 27, 243, 348 Iliac fossa, 243, 244f, 249 Iliac lymph nodes, 171f, 238, 239f, 263, 264f, 277f, 278 Iliac vein(s) common, 249 deep circumflex, 249 external, 89f, 153, 249, 352 internal, 114, 237f, 238, 249, 262f, 263, 276, 348 Index 402 Iliac wing, fracture of, 252f–253f Iliofemoral ligament, 243, 344f, 346, 352 Iliolumbar artery, 248, 248f Iliolumbar ligament, 244f Iliolumbar veins, 249 Iliopubic tract, 152, 157 Iliotibial tract, 348, 359, 360f Ilium, 243, 244f, 245, 246 Inferior mesenteric artery colectomy and, 125f colon and, 111, 112, 113f, 114, 117, 240 pelvic viscera and, 261f rectum and, 235, 236f Inferior mesenteric ganglion, 234f, 235, 247, 260, 261f Inferior mesenteric lymph nodes, 116f, 117, 222, 238, 239f Inferior mesenteric plexus, 112, 234f, 235, 261f Inferior mesenteric vein, 114, 115f, 189, 237f, 238, 249 Inflammatory bowel disease, 121, 122f–123f, 124, 219 Infraspinatus muscle, 295 Infraspinatus tendon, 299, 301f Inguinal hernia, 152, 154, 155f, 156–157 Index Inguinal ligament, 147, 148f, 149, 152–154, 157, 243, 245, 348 Inguinal lymph nodes, 154, 239f, 277f, 278, 369f Inguinal ring deep (internal), 148f, 150–154, 156 superficial (external), 149, 152, 155f, 156 Intercostal arteries, 34, 49, 77f, 78–79 Intercostal lymph nodes, 69f Intercostal muscles, 75, 77f, 78 Intercostal nerve block, 80f, 81 Intercostal nerves, 77f, 78 Intercostal veins, 49, 79 Intermesenteric (aortic) plexus, 215f Internal oblique muscle, 147, 148f, 149–150 inguinal canal and, 152 Internal thoracic (mammary) arteries, 47, 48f, 77f, 79, 188f Internal thoracic (mammary) veins, 48f, 49, 79 Interosseous arteries, 317f, 318 Interosseous compartment, 333 Interosseous fascia, 332f, 333 Interosseous ligament, tibiofibular, 378 Interosseous membrane of forearm, 314f, 315, 319, 323f of leg, 363f, 366, 381 fibular fractures and, 374, 384f Interosseous muscles of foot, 378 of hand, 333, 334f, 336 Interosseous nerve, 315, 317f, 319, 320 Interspinous ligament, 32, 36, 246 Intertrochanteric line, 343, 344f, 346 Intervertebral discs, 30f, 31–32, 34, 41f Intussusception, 219, 221f, 222 Ischial ramus, 243, 245, 252f Ischial spine, 243, 244f, 249, 344f Ischial tuberosity, 243, 244f, 250, 252f, 344f, 348 Ischiofemoral ligament, 344f, 346, 351f Ischium, 243, 244f, 246 J Jejunum, 211, 212f–213f arterial supply of, 213f, 216, 217f Crohn’s disease in, 226f 403 Jejunum (continued) diverticula of, 222 duodenum and, 130f, 131 leiomyosarcoma of, 225 venous drainage of, 218f, 219 Jugular foramen, 10 Jugular (suprasternal) notch, 22f, 76, 76f Jugular vein(s), 6f, 7, thyroid and, 17, 18f, 20f K Kidney stones, 172, 173f–174f, 175 Kidneys, 163–177 anatomy of, 163, 164f–165f, 166 arterial supply of, 168, 169f–170f cancer of, 174f, 175 innervation of, 166, 167f, 168 lymphatic drainage of, 171f, 172 obstructive uropathy and, 174f, 175 surgical approaches to, 176f, 177 venous drainage of, 168, 170f Knee, 359, 361–362, 361f arterial supply of, 364, 365f, 366 fractures in region of, 368, 370f, 373 Index 404 Knee (continued) innervation of, 365f, 368 ligaments of, 361f, 362, 371f–372f venous drainage of, 366, 369f L Lachman test, 371f Lacrimal bone, Lacrimal nerve, 8f Lactiferous ducts and glands, 45, 46f, 52 Lacunar ligament, 147, 152 Laminae, vertebral, 27, 30f fractures of, 36 Large intestine arteries of, 112, 113f, 114 lymphatic drainage of, 90, 90f, 114, 116f, 117 obstruction of, 124 in colorectal cancer, 119, 120f, 124, 240, 241f perforated cecum in, 109 veins of, 89, 89f, 114, 115f Laryngeal artery, 20f Laryngeal nerve recurrent, 18f, 20f, 21 esophagus and, 63, 64f superior, 18f, 20f Index Lateral malleolus, 375 fracture of, 384f Lateral meniscus, 361, 361f, 362 Le Fort fractures, 12f, 13, 15 Leg arterial supply of, 364, 365f, 366, 367f bones of, 359, 360f compartment syndrome of, 368 compartments of, 362, 363f, 364 fractures of, 368, 370f, 373–374 lymphatic drainage of, 369f nerves of, 365f, 367f, 368 veins of, 366, 369f Levator ani muscles, 231, 232, 232f, 259 Ligament of Treitz, 131, 210f Ligamenta flava, 32 Ligamentum nuchae, 32 Ligamentum teres, 180f–181f, 346 Ligamentum venosum, 181f Linea alba, 151, 159f Linea aspera, 343, 345f, 348 Linea semilunaris, hernia at, 159f, 160 Linea terminalis, 245 Lingual artery, Lisfranc joint, 378 Liver, 179–198 abscesses of, 197–198 arterial supply of, 187, 188f, 189 basic gross anatomy of, 179, 180f–181f cirrhosis of, 193, 195f, 196f, 197 functions of, 192 hemobilia and, 198 innervation of, 184, 186–187 lobes of, 180f–181f, 182, 183f lymphatic drainage of, 186f, 189, 191f, 192 segments of, 182, 183f, 184, 185f surfaces and bed of, 181f trauma to, 192, 198 tumors of, 192–193, 194f–195f vessel and duct system of, 184, 185f–186f Liver failure, 193, 197 Liver function tests, 106 Lobular carcinoma in situ (LCIS), 54, 55 Lumbar curvature, 27, 28f Lumbar lymph nodes See Aortic (lumbar) lymph nodes Lumbar ribs, 27 Lumbar vertebrae, 28f, 30f, 31, 34, 36, 38 Lumbosacral plexus, 34, 35f, 348, 349 405 Lumbrical muscles, 332f innervation of, 334f, 336 Lunate bone, 327, 328f–329f Lung, trauma to, 79, 80f, 81 Luschka, ducts of, 99 Lymph nodes abdominal wall and, 154 breast and, 49–50, 60 esophagus and, 68, 69f female pelvis and, 277f, 278 gallbladder and, 102, 103f kidneys and, 171f, 172 large intestine and, 90, 90f, 114, 116f, 117 liver and, 189, 191f lower limb and, 369f pancreas and, 103f, 206f prostate and, 263, 264f, 268, 270 rectum and, 239f stomach and, 69f, 140f, 191f M Maisonneuve fracture, 384f Mallet finger, 339f Mammary (internal thoracic) arteries, 47, 48f, 77f, 79, 188f Index 406 Mammary (internal thoracic) veins, 48f, 49, 79 Mandible, 3, 4f, 15, 16f, 27 Mandibular division of trigeminal nerve, 8f, Manubrium, 76, 76f, 78 Marginal artery, 113f, 114, 216 Maxilla, 3, 4f, 12f, 13, 14f, 15 Maxillary arteries, Maxillary division of trigeminal nerve, 8f, Maxillary veins, McBurney’s point, 87f, 93 Meckel’s diverticulum, 117, 219, 222, 223f, 224 Medial malleolus, 359, 375, 380, 384f Medial meniscus, 361, 361f, 362, 372f Median nerve, 306f in forearm, 315, 316f–317f, 319 in wrist and hand, 330, 331f, 334f, 335–336 Meissner’s plexus, 110, 111, 129, 132, 133, 214, 215, 233 Meniscus(i), 361, 361f, 362 injury to, 372f, 373 Mental nerve, 8f Mesentery(ies), 88, 109, 110f, 130, 130f, 132, 211 Mesoappendix, 85, 86f–87f, 88–90 Index Mesometrium, 271, 272f Mesosalpinx, 272f Metacarpal bones, 327, 328f, 338, 339f Metacarpal ligaments, 330 Metacarpophalangeal joints, 330, 339f Metatarsal bones, 376f, 377, 388f Metatarsal joint, 378 Metatarsophalangeal joint, 388f Middle meningeal artery, 13 Monteggia fracture/ dislocation, 322f, 325 Murphy’s sign, 107 Musculocutaneous nerve, 302, 303f, 306f, 307 Musculophrenic arteries, 79 N Nasal bone, 3, 4f, 12f, 13 Navicular bone, 375, 376f, 378 Nervi erigentes, 247, 260, 263 O Obturator artery, 275f, 349, 350f–351f, 352 Obturator foramen, 243, 247 Obturator lymph nodes, 263, 277f Obturator nerve, 247, 349, 354 Obturator veins, 349 Occipital artery, Occipital bone, 3, 10, 33 Occipital nerves, 8f Occipitofrontalis muscle, Oculomotor nerve (III), Odontoid process (dens), 29, 32, 33, 39f Olecranon, 313, 314, 314f fractures of, 320, 321f, 325 Olecranon fossa, 300f Olfactory nerve (I), Omental (epiploic) appendices, 109, 118f Omental (epiploic) foramen (of Winslow), 179, 180f Omentum greater, 109, 128f, 132, 212f lesser, 128f, 130, 132, 179, 180f Ophthalmic artery, 6f, Ophthalmic division of trigeminal nerve, 8f, Optic nerve (II), Orbital fractures, 12f, 13, 14f, 15 Ovarian arteries, 274 Ovarian cysts, 278, 280f, 282f, 283, 285f Ovarian tumors, 55, 284, 285f, 286 Ovarian veins, 276 407 Ovaries, 272f, 273–274 bleeding and, 280f endometriosis in, 283, 283f lymphatic drainage of, 277f, 278 P Palmar aponeurosis, 332f Palmar arch, arterial, 333, 334f, 335 Palmar digital arteries, 332f, 334f, 335 Palmar digital nerves, 332f, 334f, 336 Palmar interosseous fascia, 332f, 333 Palmar ligaments, 330 Palmar metacarpal arteries, 334f, 335 Pancreas, 199–210 anatomy of, 199–202, 200f arterial supply of, 136f, 202, 203f carcinoma of, 207, 208f duodenum in relation to, 130, 131f, 133 endocrine tumors of, 146, 193f, 207, 209, 210f functions of, 201–202 innervation of, 202 lymphatic drainage of, 103f, 205, 206f venous drainage of, 204f, 205 Index 408 Pancreatic duct, 200–201 accessory, 131, 201 common bile duct and, 96f, 100, 200 Pancreaticoduodenal arteries, 136f, 137, 202, 203f, 216, 217f Pancreaticoduodenal lymph nodes, 103f, 206f Pancreaticoduodenal veins, 138f, 139, 204f, 205 Pancreatitis, 108, 205, 207 Parathyroid glands, 19, 20f Parietal artery, 6f Parietal bone, 3, 4f, 13 Parietal vein, 6f Pars interarticularis, 30f Patella, 359, 368, 373 Patellar tendon, 359 Peau d’orange, 56, 58f Pecten pubis, 245 Pectinate line, 231, 232, 232f, 238 Pectineal ligament (of Cooper), 147, 156 Pectineal line, 245, 343 Pectoral girdle, 75, 289–297, 290f–291f, 293f fractures of, 295, 296f, 297 Pectoral nerves, 306f, 307 Pectoralis fascia, 45, 46f, 56f Pectoralis major, 45, 46f, 49, 75 Pectoralis minor, 75 Index Pedicles, vertebral, 27, 30f Pelvic fractures, 249–255, 251f–254f Pelvic plexus, 112, 234f, 235, 260, 261f Pelvis arteries of, 247–249, 248f in female, 275f joints of, 244f, 246 ligaments of, 244f, 246 lymph nodes of, prostate and, 263, 268, 270 nerves of, 234f, 246–247, 261f skeleton of, 243, 244f, 245–246 venous drainage of, 248f, 249, 250 Penis, 260, 261f–262f, 269f Perineum, 239f, 247, 249, 262f Peritoneal sac greater, 147, 148f lesser, 179 Peritoneum, 147, 148f Peritonitis, 91, 123f Peroneal (fibular) artery, 363f, 364, 366, 381 Peroneal (fibular) division of sciatic nerve, 353f, 354, 368, 382 Peroneal nerve See Fibular (peroneal) nerve Peroneal (fibular) veins, 363f, 364 Peroneus (fibularis) brevis tendon, 377, 379f Peroneus (fibularis) longus tendon, 377, 379f Pes anserinus, 362 Peyer’s patches, 131, 212, 213f, 219 Phalangeal fractures of foot, 388f of hand, 338, 339f, 340f Phalanges of foot, 376f, 377 of hand, 327, 328f Phrenic artery, inferior, 65, 66f, 188f Phrenic lymph nodes, 69f, 189, 191f Phrenic nerves, 33, 187 Phrenic vein, left inferior, 67f Pilon fracture, 374 Pisiform bone, 320, 327, 328f–329f, 336 Placenta, 280f Plantar arteries, 380f, 381 Plantar compartment, 378–379 Plantar ligaments, 379f Plantar nerves, 380f, 382 Plicae circulares, 131, 132, 211, 214 Popliteal artery, 347f, 349, 350f, 352, 364, 365f, 366, 373 Popliteal lymph nodes, 369f Popliteal vein, 347f, 349, 352, 366, 369f, 381 409 Porta hepatis, 181f Portal hypertension cirrhosis and, 193, 196f hemorrhoids in, 114, 235 Portal triads, 179, 180f, 184, 185f, 191f Portal vein, hepatic, 189, 190f branches of, 182, 184, 185f–186f carcinoma in, 195f esophagus and, 67f, 68 gastroduodenal drainage and, 137, 138f, 139 hepatoduodenal ligament and, 179, 180f, 189 pancreas and, 199, 204f, 205 rectal venous plexuses and, 235, 237f, 238 small intestine and, 218f, 219 superior mesenteric vein and, 89, 89f, 114, 115f, 188f, 189 Posterior auricular artery and vein, 5, 6f, Posterior cruciate ligament, 361f, 362 Posterior longitudinal ligament, 32, 36 Posterior meniscofemoral ligament, 361f, 362 Posterior superior iliac spine, 243, 244f Pouch of Douglas See Rectouterine pouch Index 410 Princeps pollicis artery, 334f, 335 Processus vaginalis, 155f, 156 Profunda brachii artery, 304f, 305, 318 Profunda femoris (deep femoral) artery, 349, 350f–351f Profunda femoris (deep femoral) vein, 352 Pronator quadratus muscle, 315, 319, 324f Pronator teres muscle, 317f, 319, 324f Proper hepatic artery, 96f, 100, 103f, 137, 179, 180f, 184, 185f, 187 Prostate, 257–270, 258f, 261f, 262f, 264f See also Benign prostatic hyperplasia Prostate specific antigen (PSA), 263, 265 Prostatectomy radical, 268, 269f, 270 transurethral (TURP), 265, 266, 267f Prostatic carcinoma, 263, 266, 268, 268f, 270 Prostatitis, 263 Proximal interphalangeal joint dislocations, 340f Pterion, 4f, 13 Pterygoid venous plexus, Pubic ramus(i), 243, 244f, 245, 252f Index Pubic symphysis, 244f, 245, 246, 250, 251f, 254f Pubic tubercle, 147, 149, 244f, 245 Pubis, 244f, 245, 246 fractures of, 250, 251f, 252f, 254f Pubofemoral ligament, 344f, 346 Pudendal artery external, 349 internal, 236f, 248f, 249 prostate and, 262f, 263 vagina and, 275f, 276 Pudendal nerve, 234f, 247 Pudendal vein, internal, 237f, 276 Pyloric lymph nodes, 103f, 206f Pylorus, 127, 128f, 129 Q Quadrate lobe, of liver, 180f–181f, 182, 183f, 189 Quadratus femoris, 348 Quadratus lumborum, 163, 164f Quadratus plantae, 378, 382 R Radial artery, 305 in forearm, 315, 316f, 317f, 318 Radial artery (continued) in wrist and hand, 331f, 333, 334f, 338 Radial bursa, 332f, 333 Radial nerve, 302, 303f, 306f, 307, 310 in forearm, 315, 316f, 320 in wrist and hand, 336 Radial vein, 319 Radialis indicis artery, 334f, 335 Radiocarpal joint, 313, 327, 329f Radiocarpal ligaments, 330 Radioulnar joint, 313 Radius, 313, 314f, 316f fractures of, 320, 321f, 323f–326f, 325, 336 Rectal arteries, 112, 114, 234f, 235, 236f, 249, 262f, 263, 275f Rectal veins, 112, 114, 237f, 249 Rectouterine pouch, 273 endometriosis in, 283, 283f Rectovaginal septum, 231 endometriosis in, 283f Rectovesical septum, 259 Rectum, 231, 232f, 233 arterial supply of, 111, 235, 236f cancer of, 119, 120f, 125, 240, 241f, 242 Crohn’s disease of, 227, 240 injuries to, 250 411 Rectum (continued) innervation of, 111, 233, 234f, 235 lymphatic drainage of, 238, 239f ulcerative colitis of, 124 venous drainage of, 235, 237f, 238 Rectus abdominis muscle, 147, 150–151, 153 Rectus femoris muscle, 348 Rectus femoris tendon avulsion, 250, 252f Rectus sheath, 149–151 Regional enteritis, 122f, 226f Renal fascia, 163, 177 Retinacular arteries, 351f, 352, 356 Retrocecal recess, 86f Retromandibular vein, 6f, Retropharyngeal danger space, 61 Ribs, 27, 29, 75–76, 76f fractures of, 75, 79, 80f, 81 Rocky-Davis incision, 93 Rotter’s nodes, 48f, 49 Round ligament of femoral head, 343, 346, 355f Round ligament of liver, 179, 180f–181f, 188f, 190f Round ligament of uterus, 149, 152, 278, 285f Index 412 Roux-en-Y gastrojejunostomy, 145 Rugae, 127 S Sacral artery(ies), 34, 236f, 247, 248, 248f Sacral curvature, 27, 28f Sacral ganglia, 247, 260 Sacral hiatus, 31, 245 Sacral lymph nodes, 264f, 277f Sacral plexus, 247, 260, 261f Sacral veins, 249 Sacral vertebrae, 31, 38 Sacrococcygeal ligaments, 31, 245 Sacroiliac (SI) joints, 244f, 245, 246, 254f Sacroiliac ligaments, 243, 244f, 246, 250, 253 Sacrospinous ligament, 243, 244f, 246 Sacrotuberous ligament, 243, 244f, 246, 348 Sacrum, 28f, 245 fascia lata and, 348 fractures of, 38, 250, 251f–252f, 253 Saphenous veins, 352, 366, 369f, 381 Sartorius muscle, 243, 347f, 348, 349 Sartorius tendon, 250, 252f, 362 Scalp, 3, 5, 6f, Index Scaphoid, 327, 328f–329f, 330 fractures of, 337f, 338 Scapula, 75, 289, 290f, 291, 292 fractures of, 295, 297 subclavian artery and, 292, 293f, 294, 302, 305 Scapular arteries, 292, 293f, 294, 302, 304f, 305 Scapular veins, 294 Scarpa’s fascia, 147, 348 Sciatic foramen greater, 244f, 246, 247, 249, 353f lesser, 244f, 246, 249 Sciatic nerve, 35f, 247, 353f, 354, 368 ankle and foot branches of, 380f, 381–382 ilium and, 243, 244f thigh compartments and, 347f, 348, 349 Sciatic notch, greater, 243 Scotty dog, radiographic, 40f Semicircular lines (of Douglas), 149–151 Seminal vesicles, 231, 258f, 260, 269f Semitendinosus muscle, 348, 353f, 362 Short gastric arteries, 66f, 135f, 137 Short gastric veins, 67f, 138f, 139 Short-bowel syndrome, 227 Shoulder arterial supply of, 292, 293f, 294, 302, 304f, 305 bones and joints of, 289, 290f, 291, 299, 300f–301f ligaments of, 291–292, 301f nerves of, 294–295 venous drainage of, 294 Sigmoid arteries, 112, 113f, 236f Sigmoid colon, 109, 110f diverticula in, 117, 119 innervation of, 111, 112 small intestine and, 212f volvulus of, 124 Sigmoid lymph nodes, 116f Sigmoid mesocolon, 110f, 111 Sigmoid veins, 114, 115f Skull, 3, 4f Skull fractures, 10, 11f, 13 Small intestine, 211–227 anatomy of, 211, 212, 212f–213f, 214 arterial supply of, 213f, 216, 217f Crohn’s disease of, 121, 122f, 225, 226f, 227 diverticula of, 222 endocrine functions of, 214 413 Small intestine (continued) innervation of, 214–216, 215f intussusception of, 219, 221f, 222 lymphatic drainage of, 219, 220f neoplasms of, 142, 224–225 obstruction of, 219, 224 short-bowel syndrome and, 227 venous drainage of, 218f, 219 Snuffbox, anatomical, 335 scaphoid fracture and, 337f, 338 Soleal line, 359, 360f Soleus muscle, 363f, 364, 365f, 386 Spaces of Disse, 186f, 191f Spaces of Mall, 191f Spermatic cord, 148f, 149, 152–154, 156 Spermatic fascia, 148f, 149, 152, 153, 155f Sphenoid bone, 3, 4f, 9, 13, 15 Sphincter of Oddi, 99, 100, 104, 201 (Spinal) accessory nerve (XI), 10 Spinal arteries, 34 Spinal cord, 33–34, 35f, 36 injury to, 38 Spinal nerve root compression, 41f Index 414 Spinal nerves, 31, 33, 34, 35f brachial plexus and, 295, 306 cervical, 8f, 10, 295 intercostal nerves and, 77f, 78 Spine, 27, 28f, 31–34, 36 Spinous processes, 29, 30f Spleen, 203f–204f Splenic artery, 65, 66f, 135f, 137, 202, 203f Splenic lymph nodes, 140f, 206f Splenic vein, 67f, 68, 114, 115f, 138f, 139, 189, 190f, 204f, 205, 206f Splenorenal ligament, 164f Spondylolisthesis, 40f Spondylolysis, 40f Spring ligament, 375, 379f Stellate ganglion, 64f Sternal angle of Louis, 78 Sternal facet of clavicle, 289, 291f Sternoclavicular joint, 289, 292 Sternocostal joints, 76, 78 Sternomastoid muscle, 10 Sternum, 76, 76f, 78 fractures of, 79, 80f Stomach arteries of, 135f, 137 functional anatomy and motility of, 127, 129 gastritis of, 139 Index Stomach (continued) hiatal hernia of, 142, 143f innervation of, 133, 134f, 135 lymphatic drainage of, 139, 140f malignancies of, 144f, 145, 146 parts of, 127, 128f ulcers of, 139, 141f, 142, 145 venous drainage of, 137, 138f, 139 Straight arteries (arteriae rectae), 113f, 213f, 217f Straight veins (venae rectae), 218f Styloid process, 313, 314f, 329f Subacromial bursa, 299, 301f Subclavian arteries, 79, 292, 293f, 302, 305 Subclavian veins, 65, 67f, 79, 294, 305 Subclavius muscle, 75, 289, 291f, 295 Subcostal arteries, 78 Subdeltoid bursa, 299, 301f Subsartorial canal, 349 Subscapular artery, 293f, 294, 304f, 305 Subscapular fossa, 289, 290f Subscapular veins, 294 Subscapularis muscle, 299, 301f Superior mesenteric artery colon and, 111, 112, 113f, 114, 125f common hepatic artery and, 189 cystic artery and, 101 duodenum and, 130f, 131, 133, 136f, 137 ileocolic artery and, 86f, 88 kidneys and, 164f left renal vein and, 168, 170f lymph nodes and, 219 pancreas and, 199, 200f, 202, 203f right hepatic artery and, 189 small intestine and, 216, 217f–218f Superior mesenteric ganglion, 133, 167f, 215, 215f Superior mesenteric lymph nodes, 90, 90f, 114, 116f intussusception and, 222 pancreas and, 205, 206f small intestine and, 219, 220f Superior mesenteric plexus, 112, 166, 168, 214, 215f, 216 Superior mesenteric vein colon and, 114, 115f gastroduodenal drainage and, 137, 138f 415 Superior mesenteric vein (continued) ileocolic vein and, 89, 89f pancreas and, 199, 200f, 204f, 205 portal vein and, 189, 190f small intestine and, 218f, 219 Supinator muscle, 317f, 320, 324f Supraorbital artery, 6f, Supraorbital nerve, 8f Supraorbital vein, 6f Suprascapular artery, 292, 293f, 294, 302, 305 Suprascapular nerve, 295 Suprascapular notch, 289, 290f, 292, 302 Suprascapular veins, 294 Supraspinatus muscle, 295, 299 Supraspinatus tendon, 299, 301f, 308f Supraspinous ligaments, 32, 246 Suprasternal (jugular) notch, 22f, 76, 76f Supratrochlear artery, 6f, Supratrochlear nerve, 8f Supratrochlear vein, 6f Suspensory ligaments of breast, 45, 46f, 55, 56f Suspensory ligaments of ovaries, 271, 272f, 274, 276 Index 416 Sustentaculum tali, 375, 376f, 379f, 386 Sutures, T Taeniae coli, 109, 110f, 111 appendix and, 85, 111 diverticula and, 117, 118f rectum and, 111, 231, 233 Talus, 375, 376f, 377, 378 avascular necrosis of, 385f, 386 fractures of, 382, 385f, 386 Tarsal bones, 375, 376f, 377 fractures of, 382, 385f–386f, 386 Tectorial membrane, 32 Temporal artery, 5, 6f Temporal bone, 3, 4f, 10, 13, 15 Temporal vein, 6f, Temporoparietalis muscle, Teres minor tendon, 299, 301f Testicular arteries, 148f, 153–154 Testicular veins, 148f, 153 Testis, 153, 154 Theca cell tumors, 280f Theca cells, 273 Theca lutein cells, 274 Index Thenar eminence, 336, 337f, 338 Thenar space, 332f, 333, 334f, 336 Thigh arterial supply of, 349, 350f, 352 compartment syndromes of, 354, 358 compartments of, 346, 347f, 348–349 innervation of, 353f, 354 lymphatic drainage of, 369f veins of, 352, 369f Thoracic cage, 75, 77f, 78–79, 80f, 81 Thoracic curvature, 27, 28f Thoracic duct, 69f, 205, 220f Thoracic vertebrae, 28f, 29, 34, 36, 38 Thoracoacromial artery, 294, 304f Thumb, 327 injury to, 339f proper digital artery of, 334f, 335 Thyroid gland, 17, 18f, 19–21, 20f arterial supply of, 18f, 19, 20f cancer of, 21, 23 Graves’ disease and, 21, 22f Thyroid gland (continued) lymphatic drainage of, 21 venous drainage of, 18f, 19–20, 20f Tibia, 359, 360f, 363f ankle ligaments and, 378, 379f malleoli of, 359, 375, 377, 380, 384f talus and, 375 Tibial arteries, 363f, 364, 365f, 366, 367f in ankle and foot, 380f, 381, 385f shaft fractures and, 373 Tibial division of sciatic nerve, 353f, 354, 368, 381–382 Tibial fractures at ankle, 382, 383f–384f pilon fracture, 374 compartment syndrome secondary to, 368 plateau, 370f, 373 shaft, 370f, 373–374 stress, 374 Tibial nerve, 353f, 364, 365f, 380f Tibial veins, 363f, 364, 366, 381 Tibialis anterior muscle, 364, 367f Tibialis posterior muscle, 364, 365f, 375 Tibiocalcaneal ligament, 378, 379f Tibiofibular ligaments, 378, 379f, 384f 417 Tibionavicular ligament, 378, 379f Tibiotalar joint dislocation, 385f, 386 Tibiotalar ligaments, 378, 379f Tietze’s syndrome, 47 Transversalis fascia, 147, 148f, 151–153, 156, 157 Transverse facial artery, 5, 6f Transverse facial vein, 6f Transverse processes, 27, 29, 30f, 76 Transversus abdominis muscle, 147, 148f, 150 Transversus perinei muscle and fascia, 259 Trapezium, 327, 328f, 329, 330 Trapezius muscle, 10, 75 Trapezoid bone, 327, 328f Trapezoid ligament, 290f, 292 Trapezoid line, of clavicle, 289, 291f Triangle of Calot, 97, 101f cholecystectomy and, 108 Triangular ligaments, 179, 181f Triceps brachii muscle, 302, 303f, 307 Triceps tendon, 291 Trigeminal nerve (V), 8f, Triquetrum, 327, 328f–329f, 330 Index 418 Trituration, 127, 129 Trochanter, 343, 345f, 356 Trochlear nerve (IV), Tunica albuginea ovarian, 274 testicular, 153 Tunica vaginalis, 152, 153, 155f U Ulcerative colitis, 121, 123f, 124 Ulcers in Crohn’s disease, 121, 227 duodenal, 139, 142, 210f gastric, 139, 141f, 142, 145 Meckel’s diverticulum with, 224 Ulna, 299, 313, 314f, 316f fractures of, 320, 321f–322f, 325, 336, 338 Ulnar artery, 305, 315, 316f, 317f, 318, 331f in wrist and hand, 333, 334f, 335, 336 Ulnar bursa, 332f, 333 Ulnar nerve, 303f, 306f, 315, 316f–317f, 319–320 in wrist and hand, 331f, 334f, 336 Index Ulnar vein, 319 Umbilical artery, 248 Umbilical hernia, 157–158, 159f Umbilical vein, 179, 181f Umbilicus, 190f, 223f “Unhappy triad” of O’Donoghue, 372f Ureteral obstruction, 173f–174f Ureters, 165f, 166 arterial supply of, 166, 169f–170f innervation of, 166, 167f, 168 uterine arteries and, 275f, 276 Urethra female, 274 prostate and, 257, 258f, 259, 260 Urethral injuries, 250 Urethral obstruction, 174f Urethral sphincters, 258f, 262f, 269f Urethral stricture, 267f Urinary tract obstruction, 174f, 175 Urogenital diaphragm, male, 259 Uterine arteries, 248–249, 274, 275f, 276 Uterine bleeding, dysfunctional, 279f–280f Uterine diseases, 278, 280f–281f, 283–284, 283f Uterine (fallopian) tubes (ducts), 272f, 273 endometriosis in, 283f, 284 lymphatic drainage of, 277f, 278 Uterine veins, 276 Uterosacral ligament, 271, 272f Uterovesical pouch, 273 Uterus, 271, 272, 272f arterial supply of, 274, 275f, 276 lymphatic drainage of, 277f, 278 V Vagina, 250, 274, 276 Vaginal artery, 248–249, 275f, 276 Vaginal veins, 276 Vagus nerve (X), 8f, 10 Valves of Kerckring, 213f Valvulae conniventes, 131, 132, 211, 214 Varices, esophageal, 68, 137, 196f Vas deferens, 148f, 153, 154, 155f, 258f, 260 Vasoactive intestinal peptide (VIP), 202, 209 Vastus intermedius, 348 Vastus lateralis, 347f, 348 Vastus medialis, 347f, 348 419 Venae rectae (straight veins), 218f Venous sinuses, cerebral, 3, 7, Vertebra prominens, 27 Vertebrae, 27 arterial supply of, 34 venous drainage of, 36 Vertebral arch (facet) joints, 30f, 32, 36 Vertebral artery, 7, 29, 34 Vertebral body, 27, 30f Vertebral foramen, 30f Vertebral fractures, 27, 36, 37f–41f, 38 Vertebral notch, 30f Vertebral venous plexuses, 242, 263 Vesical arteries, 235, 248, 262f, 263, 275f, 276 Vesical veins, 263, 276 Vesicouterine pouch, 273 Vestibule, 274 Vestibuloacoustic nerve (VIII), 10 VIP (vasoactive intestinal peptide), 202, 209 VIPoma, 209 Virchow’s node, 69f Viscerocranium, Volvulus, 109, 124, 219, 227 W Werner-Morrison syndrome, 209 Index 420 Whipple’s triad, 209 Wilms’ tumor, 175 Wrist, 327–340 anatomy of, 327, 328f–329f, 329–330, 331f, 333 arterial supply of, 333, 334f, 335 compartment syndromes of, 336, 338 compartments of, 330, 331f–332f, 333 fractures of, 320, 336, 337f, 338 innervation of, 334f, 335–336 joints of, 327, 329–330 ligaments of, 330 venous drainage of, 335 Index X Xiphoid process, 76f, 78 linea alba and, 151 Y Y ligament of Bigelow, 344f, 346 Z Zenker’s diverticulum, 68, 70 Zollinger-Ellison syndrome, 146, 209, 210f Zona orbicularis, 344f Zygomatic bone, 3, 4f Zygomatic fractures, 12f, 14f, 15 Zygomaticofacial nerve, 8f Zygomaticotemporal nerve, 8f ... type 25 5 Pelvic Fractures This page intentionally left blank 18 Prostate Diseases Basic Anatomy Prostate Proper • Largest accessory gland of the male genital tract • Partly glandular, partly... and bowel obstruction due to solid feces Clinical Manifestations of Colorectal Cancer 24 1 Anorectal Diseases 24 2 Anorectal Diseases Diffusely infiltrating disease difficult to diagnose n Can spread... mesenteric vessels, distal to the left colic 17 Pelvic Fractures Anatomy of the Pelvic Skeleton Coxal Bones (Os Coxae; 2) Ilium: Parts and Landmarks • Crest, ala (wing), fossa (of false pelvis),