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Part 1 book “Clinically oriented anatomy” has contents: Approaches to studying anatomy, anatomicomedical terminology, anatomical variations, anatomical variations, cardiovascular system, medical imaging techniques, vertebral column, fascia, efferent vessels, cutaneous innervation, and myotomes of upper limb,… and other contents.
Clinically Oriented Anatomy EIGHTH EDITION Keith L Moore, MSc, PhD, Hon DSc, FIAC, FRSM, FAAA Professor Emeritus in Division of Anatomy Department of Surgery Former Chair of Anatomy Associate Dean for Basic Medical Sciences Faculty of Medicine, University of Toronto Toronto, Ontario, Canada Arthur F Dalley II, PhD, FAAA Professor, Department of Cell and Developmental Biology Adjunct Professor, Department of Orthopaedic Surgery Co-Director, Brain, Behavior, and Movement Vanderbilt University School of Medicine Adjunct Professor of Anatomy Belmont University School of Physical Therapy Nashville, Tennessee Anne M R Agur, BSc (OT), MSc, PhD Professor, Division of Anatomy, Department of Surgery, Faculty of Medicine Division of Physical Medicine and Rehabilitation, Department of Medicine Department of Physical Therapy, Department of Occupational Science & Occupational Therapy Division of Biomedical Communications, Institute of Medical Science Rehabilitation Sciences Institute, Graduate Department of Dentistry University of Toronto Toronto, Ontario, Canada Acquisitions Editor: Crystal Taylor In-House Development Editor: Andrea Vosburgh Freelance Developmental Editor: Kathleen Scogna Editorial Coordinator: Annette Ferran Marketing Manager: Michael McMahon Production Project Manager: David Saltzberg Designer: Terry Mallon Art Director, Digital Content: Jennifer Clements Artists: Imagineeringart.com, Inc.; Dragonfly Media Group Manufacturing Coordinator: Margie Orzech Prepress Vendor: SPi Global Eighth Edition Copyright © 2018 Wolters Kluwer Copyright © 2014, 2010, 2006, 1999, 1992, 1985, 1980 Lippincott Williams & Wilkins, a Wolters Kluwer business All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 987654321 Printed in China Fifth edition translations: Albanian, 2010, Tabernakul Publishers Complex Chinese, 2008, The Leader Book Company, Ltd French, 2007, DeBoeck Superieur Indonesian, 2009, Penerbit Erlangga Italian, 2008, Casa Editrice Ambrosiana Japanese, 2008, MEDSI, Medical Sciences International Korean, 2008, Shin Heung MedScience, Inc Macedonian, 2010, Tabernakul Publishers Portuguese, 2007, Editora Guanabara Koogan Serbian, 2009, Romanov Publishing Group Spanish, 2007, Editorial Medica Panamericana, S.A Sixth edition translations: Arabic, 2012, al-Munajed Publishing/A-Z Books French, 2011, Deboeck Superieur Greek, 2011, Broken Hill, Ltd Korean, 2011, ShinHeung MedScience, Inc Portuguese, 2011, Editora Guanabara Koogan Romanian, 2012, Callisto Med/Science Publications Spanish, 2010, Wolters Kluwer Health Spanish Language Program Turkish, 2013, Nobel Tip Kitabevi Seventh edition translations: Simplified Chinese, 2015, Henan Scientific & Technological Press French, 2015, DeBoeck Superieur Italian, 2015, Casa Editrice Ambrosiana Japanese, 2015, MEDSI - Medical Sciences International Polish, 2015, Wydawnictwo Medyczne i Farmaceutyczne MedPharm Polska Sp zo Portuguese, 2015, Editora Guanabara Koogan Spanish, 2015, Wolters Kluwer Health Spanish Language Program Library of Congress Cataloging-in-Publication Data Names: Moore, Keith L., author | Agur, A M R., author | Dalley, Arthur F., II, author Title: Clinically oriented anatomy / Keith L Moore, Arthur F Dalley II, Anne M R Agur Description: 8th edition | Philadelphia : Wolters Kluwer, [2018] Identifiers: LCCN 2017013157 | ISBN 9781496347213 Subjects: | MESH: Anatomy Classification: LCC QM23.2 | NLM QS | DDC 612—dc23 LC record available at https://lccn.loc.gov/2017013157 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work LWW.com Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S Virgin Islands Acquisitions Editor: Crystal Taylor In-House Development Editor: Andrea Vosburgh Freelance Developmental Editor: Kathleen Scogna Editorial Coordinator: Annette Ferran Marketing Manager: Michael McMahon Production Project Manager: David Saltzberg Designer: Terry Mallon Art Director, Digital Content: Jennifer Clements Artists: Imagineeringart.com, Inc.; Dragonfly Media Group Manufacturing Coordinator: Margie Orzech Prepress Vendor: SPi Global Eighth Edition Copyright © 2018 Wolters Kluwer Copyright © 2014, 2010, 2006, 1999, 1992, 1985, 1980 Lippincott Williams & Wilkins, a Wolters Kluwer business All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services) 987654321 Printed in China Fifth edition translations: Albanian, 2010, Tabernakul Publishers Complex Chinese, 2008, The Leader Book Company, Ltd French, 2007, DeBoeck Superieur Indonesian, 2009, Penerbit Erlangga Italian, 2008, Casa Editrice Ambrosiana Japanese, 2008, MEDSI, Medical Sciences International Korean, 2008, Shin Heung MedScience, Inc Macedonian, 2010, Tabernakul Publishers Portuguese, 2007, Editora Guanabara Koogan Serbian, 2009, Romanov Publishing Group Spanish, 2007, Editorial Medica Panamericana, S.A Sixth edition translations: Arabic, 2012, al-Munajed Publishing/A-Z Books French, 2011, Deboeck Superieur Greek, 2011, Broken Hill, Ltd Korean, 2011, ShinHeung MedScience, Inc Portuguese, 2011, Editora Guanabara Koogan Romanian, 2012, Callisto Med/Science Publications Spanish, 2010, Wolters Kluwer Health Spanish Language Program Turkish, 2013, Nobel Tip Kitabevi Seventh edition translations: Simplified Chinese, 2015, Henan Scientific & Technological Press French, 2015, DeBoeck Superieur Italian, 2015, Casa Editrice Ambrosiana Japanese, 2015, MEDSI - Medical Sciences International Polish, 2015, Wydawnictwo Medyczne i Farmaceutyczne MedPharm Polska Sp zo Portuguese, 2015, Editora Guanabara Koogan Spanish, 2015, Wolters Kluwer Health Spanish Language Program Library of Congress Cataloging-in-Publication Data Names: Moore, Keith L., author | Agur, A M R., author | Dalley, Arthur F., II, author Title: Clinically oriented anatomy / Keith L Moore, Arthur F Dalley II, Anne M R Agur Description: 8th edition | Philadelphia : Wolters Kluwer, [2018] Identifiers: LCCN 2017013157 | ISBN 9781496347213 Subjects: | MESH: Anatomy Classification: LCC QM23.2 | NLM QS | DDC 612—dc23 LC record available at https://lccn.loc.gov/2017013157 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient The publisher does not provide medical advice or guidance and this work is merely a reference tool Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work The pus usually surfaces in the superior part of the thigh Pus can also reach the psoas fascia by passing from the posterior mediastinum when the thoracic vertebrae are diseased FIGURE B5.38 Psoas abscess (arrow) The inferior part of the iliac fascia is often tense and raises a fold that passes to the internal aspect of the iliac crest The superior part of this fascia is loose and may form a pocket, the iliacosubfascial fossa, posterior to the abovementioned fold Part of the large intestine, such as the cecum and/or appendix on the right side and the sigmoid colon on the left side, may become trapped in this fossa, causing considerable pain Posterior Abdominal Pain The iliopsoas muscle has extensive, clinically important relations to the kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes, and nerves of the posterior abdominal wall When any of these structures is diseased, movement of the iliopsoas usually causes pain When intraabdominal inflammation is suspected, the iliopsoas test is performed The 1278 person is asked to lie on the unaffected side and extend the thigh on the affected side against the resistance of the examiner’s hand (Bickley, 2016) The elicitation of pain with this maneuver is a positive psoas sign An acutely inflamed appendix, for example, will produce a positive right psoas sign (Fig B5.39) FIGURE B5.39 Anatomical basis of psoas sign Because the psoas lies along the vertebral column and the iliacus crosses the sacro-iliac joint, disease of the intervertebral and sacro-iliac joints may cause 1279 spasm of the iliopsoas, a protective reflex Adenocarcinoma of the pancreas in advanced stages invades the muscles and nerves of the posterior abdominal wall, producing excruciating pain because of the close relationship of the pancreas to the posterior abdominal wall Partial Lumbar Sympathectomy The treatment of some patients with arterial disease in the lower limbs may include a partial lumbar sympathectomy, the surgical removal of two or more lumbar sympathetic ganglia by division of their rami communicantes Surgical access to the sympathetic trunks is commonly through a lateral extraperitoneal approach because the sympathetic trunks lie retroperitoneally in the extraperitoneal fatty tissue (see Fig 5.98) The surgeon splits the muscles of the anterior abdominal wall and moves the peritoneum medially and anteriorly to expose the medial edge of the psoas major, along which the sympathetic trunk lies The left trunk is often overlapped slightly by the aorta The right sympathetic trunk is covered by the IVC The intimate relationship of the sympathetic trunks to the aorta and IVC also makes these large vessels vulnerable to injury during lumbar sympathectomy Consequently, the surgeon carefully retracts them to expose the sympathetic trunks that usually lie in the groove between the psoas major laterally and the lumbar vertebral bodies medially These trunks are often obscured by fat and lymphatic tissue Knowing that identification of the sympathetic trunks is not easy, great care is taken not to remove inadvertently part of the genitofemoral nerve, lumbar lymphatics, or ureter Pulsations of Aorta and Abdominal Aortic Aneurysm Because the aorta lies posterior to the pancreas and stomach, a tumor of these organs may transmit pulsations of the aorta that could be mistaken for an abdominal aortic aneurysm, a localized enlargement of the aorta (Fig B5.40A, B) Deep palpation of the midabdomen can detect an aneurysm, which usually 1280 results from a congenital or acquired weakness of the arterial wall (Fig B5.40C, D) Pulsations of a large aneurysm can be detected to the left of the midline; the pulsatile mass can be moved easily from side to side Medical imaging can confirm the diagnosis in doubtful cases FIGURE B5.40 A, B Aortic aneurysm C, D Palpation of abdominal aorta (aortic pulse) Acute rupture of an abdominal aortic aneurysm is associated with severe pain in the abdomen or back If unrecognized, such an aneurysm has a mortality rate of nearly 90% because of heavy blood loss (Swartz, 2014) Surgeons can repair an aneurysm by opening it, inserting a prosthetic graft, and sewing the wall of the aneurysmal aorta over the graft to protect it Many vascular problems formerly treated with open repair, including aneurysm repair, are now being treated by means of endovascular catheterization procedures When the anterior abdominal wall is relaxed, particularly in children and thin adults, the inferior part of the abdominal aorta may be compressed against the body of the L4 vertebra by firm pressure on the anterior abdominal wall, over the umbilicus (Fig B5.40C, D) This pressure may be applied to control 1281 bleeding in the pelvis or lower limbs Collateral Routes for Abdominopelvic Venous Blood Three collateral routes, formed by valveless veins of the trunk, are available for venous blood to return to the heart when the IVC is obstructed or ligated Two of these routes (one involving the superior and inferior epigastric veins, and another involving the thoraco-epigastric vein) were discussed earlier in this chapter with the anterior abdominal wall The third collateral route involves the epidural venous plexus inside the vertebral column (illustrated and discussed in Chapter 2, Back), which communicates with the lumbar veins of the inferior caval system, and the tributaries of the azygos system of veins, which is part of the superior caval system The inferior part of the IVC has a complicated developmental history because it forms from parts of three sets of embryonic veins (Moore, Persaud, and Torchia, 2016) Therefore, IVC anomalies are relatively common, and most of them, such as a persistent left IVC, occur inferior to the renal veins (Fig B5.41) These anomalies result from the persistence of embryonic veins on the left side, which normally disappear If a left IVC is present, it may cross to the right side at the level of the kidneys 1282 FIGURE B5.41 The Bottom Line DIAPHRAGM AND POSTERIOR ABDOMINAL WALL The diaphragm is the double-domed, musculotendinous partition separating the thoracic and abdominal cavities and is the chief muscle of inspiration • The muscular portion arises from the ring-like inferior thoracic aperture from which the diaphragm rises steeply, invaginating the thoracic cage and forming a common central tendon • The right dome (higher because of the underlying liver) rises nearly to the level of the nipple, whereas the left dome is slightly lower • The central portion of the diaphragm is slightly depressed by the heart within the pericardium and is fused to the mediastinal surface of the central tendon In the neutral respiratory position, the central tendon lies at the level of the T8–T9 IV disc and the xiphisternal joint • When stimulated by the phrenic 1283 nerves, the domes are pulled downward (descend), compressing the abdominal viscera When stimulation ceases and the diaphragm relaxes, the diaphragm is pushed upward (ascends) by the combined decompression of the viscera and tonus of the muscles of the anterolateral abdominal wall • The diaphragm is perforated by the IVC and phrenic nerves at the T8 vertebral level • The fibers of the right crus of the diaphragm form a sphincteric hiatus for the esophagus at the T10 vertebral level • The descending aorta and thoracic duct pass posterior to the diaphragm at the T12 vertebral level, in the midline between the crura, overlapped by the median arcuate ligament connecting them • Superior and inferior phrenic arteries and veins supply most of the diaphragm, with additional drainage occurring via the musculophrenic and azygos/hemiazygos veins • In addition to exclusive motor innervation, the phrenic nerves supply most of the pleura and peritoneum covering the diaphragm • Peripheral parts of the diaphragm receive sensory innervation from the lower intercostal and subcostal nerves • The left lumbocostal triangle and the esophageal hiatus are potential sites of acquired hernias through the diaphragm Developmental defects in the left lumbocostal region account for most congenital diaphragmatic hernias Fascia and muscles: Large, complex aponeurotic formations cover the central parts of the trunk both anteriorly and posteriorly, forming dense sheaths centrally that house vertical muscles and attach laterally to the flat muscles of the anterolateral abdominal wall • The thoracolumbar fascia is the posterior aponeurotic formation In addition to ensheathing the erector spinae between its posterior and middle layers, it encloses the quadratus lumborum between its middle and anterior layers • The anterior layer, part of the endoabdominal fascia, is continuous medially with the psoas fascia (enclosing the psoas) and laterally with the transversalis fascia (lining the transversus abdominis) • The tube-like psoas fascia provides a potential pathway for the spread of infections between the vertebral column and hip joint • The endoabdominal fascia covering the anterior aspects of both the quadratus lumborum and psoas is thickened over the superiormost aspects of the muscles, forming the lateral and medial arcuate ligaments, respectively • A highly variable layer of extraperitoneal fat intervenes between the endoabdominal fascia and peritoneum It is especially thick in the paravertebral gutters of the lumbar region, comprising the paranephric fat (pararenal fat body) • The muscles of the posterior abdominal wall are the quadratus lumborum, psoas major, and iliacus Nerves: The lumbar sympathetic trunks deliver postsynaptic sympathetic 1284 fibers to the lumbar plexus for distribution with somatic nerves and presynaptic parasympathetic fibers to the abdominal aortic plexus, the latter ultimately innervating pelvic viscera • With the exception of the subcostal nerve (T12) and lumbosacral trunk (L4–L5), the somatic nerves of the posterior abdominal wall are products of the lumbar plexus, formed by the anterior rami of L1–L4 deep to the psoas • Only the subcostal nerve and derivatives of the anterior ramus of L1 (iliohypogastric and ilio-inguinal nerves) have an abdominal distribution—to the muscles and skin of the inguinal and pubic regions All other nerves pass to the muscles and skin of the lower limb Arteries: Except for the subcostal arteries, the arteries supplying the posterior abdominal wall arise from the abdominal aorta • The abdominal aorta descends from the aortic hiatus, coursing on the anterior aspects of the T12–L4 vertebra, immediately left of the midline, and bifurcates into the common iliac arteries at the level of the supracristal plane • Branches of the aorta arise and course in three vascular planes: anterior (unpaired visceral branches), lateral (paired visceral branches), and posterolateral (paired parietal) • The median sacral artery may be considered a diminutive continuation of the aorta, which continues to give rise to paired parietal branches to the lower lumbar vertebrae and sacrum Veins: The veins of the posterior abdominal wall are mostly direct tributaries of the IVC, although some enter indirectly via the left renal vein • The IVC: ■ is the largest vein and lacks valves; ■ is formed at the L5 vertebral level by the union of the common iliac veins; ■ ascends to the T8 vertebral level, passing through the caval opening of the diaphragm and entering the heart almost simultaneously; ■ drains poorly oxygenated blood from the body inferior to the diaphragm; and ■ receives the venous drainage of the abdominal viscera indirectly via the hepatic portal vein, liver, and hepatic veins • Except for the hepatic veins, the tributaries of the IVC mostly correspond to the lateral paired visceral and posterolateral paired parietal branches of the abdominal aorta • Three collateral routes (two involving the anterior abdominal wall and one involving the vertebral canal) are available to return blood to the heart when the IVC is obstructed Lymph vessels and lymph nodes: Lymphatic drainage from the abdominal viscera courses retrograde along the ramifications of the three unpaired visceral branches of the abdominal aorta • Lymphatic drainage from the abdominal wall merges with that from the lower limbs, both pathways following the arterial supply retrograde from those parts • Ultimately, all 1285 lymphatic drainage from structures inferior to the diaphragm, plus that draining from the lower six intercostal spaces via the descending thoracic lymphatic trunks, enters the beginning of the thoracic duct at the T12 level, posterior to the aorta • The origin of the thoracic duct may take the form of a saccular cisterna chyli (chyle cistern) Board-review questions, case studies, and additional resources are available at thePoint.lww.com SECTIONAL MEDICAL IMAGING OF ABDOMEN Ultrasound, computed tomography (CT) scans, and magnetic resonance imaging (MRI) are used to examine the abdominal viscera (Figs 5.102 to 5.105) Because MRIs provide better differentiation between soft tissues, its images are more revealing An image in virtually any plane can be reconstructed after scanning is completed Abdominal angiographic studies may also now be performed using magnetic resonance angiography (MRA) (Fig 5.105C) 1286 FIGURE 5.102 Ultrasound scans of the abdomen A A transverse scan through the celiac trunk is shown B A transverse scan through the pancreas is shown C A sagittal scan through the aorta is shown (Courtesy of Dr A M Arenson, Assistant Professor of Medical Imaging, University of 1287 Toronto, Toronto, ON, Canada.) FIGURE 5.103 A–F.Transverse (axial) CT images of the abdomen at progressively inferior levels showing body wall, viscera, and blood vessels 1288 FIGURE 5.104 Transverse magnetic resonance images (MRIs) of the abdomen A Level of T10 vertebra and esophageal hiatus B Level of L1–L2 vertebra and renal vessels and hilum C Level of L5 vertebra and bifurcation of the aorta (Courtesy of Dr W Kucharczyk, Professor of Medical Imaging, University of Toronto, and Clinical Director of Tri-Hospital 1289 Resonance Centre, Toronto, ON, Canada.) 1290 1291 FIGURE 5.105 Magnetic resonance images (MRIs) and magnetic resonance (MR) angiogram of the abdomen A Coronal MRI through viscera (almost all intestine) of the anterior abdominal cavity B Sagittal MRI in the right midclavicular line C Anteroposterior MR angiogram demonstrating great vessels of the thorax and aorta and portal vein in the abdomen 1292 ... translations: Arabic, 2 012 , al-Munajed Publishing/A-Z Books French, 2 011 , Deboeck Superieur Greek, 2 011 , Broken Hill, Ltd Korean, 2 011 , ShinHeung MedScience, Inc Portuguese, 2 011 , Editora Guanabara... translations: Arabic, 2 012 , al-Munajed Publishing/A-Z Books French, 2 011 , Deboeck Superieur Greek, 2 011 , Broken Hill, Ltd Korean, 2 011 , ShinHeung MedScience, Inc Portuguese, 2 011 , Editora Guanabara... Title: Clinically oriented anatomy / Keith L Moore, Arthur F Dalley II, Anne M R Agur Description: 8th edition | Philadelphia : Wolters Kluwer, [2 018 ] Identifiers: LCCN 2 017 013 157 | ISBN 97 814 96347 213