Clinical Anatomy Applied anatomy for students and junior doctors Harold Ellis ELEVENTH EDITION Clinical Anatomy ECAPR 7/18/06 6:33 PM Page i To my wife and late parents ECAPR 7/18/06 6:33 PM Page ii Clinical Anatomy A revision and applied anatomy for clinical students HAROLD◊ELLIS CBE, MA, DM, MCh, FRCS, FRCP, FRCOG, FACS (Hon) Clinical Anatomist, Guy’s, King’s and St Thomas’ School of Biomedical Sciences; Emeritus Professor of Surgery, Charing Cross and Westminster Medical School, London; Formerly Examiner in Anatomy, Primary FRCS (Eng) ELEVENTH EDITION ECAPR 7/18/06 6:33 PM Page iii © 2006 Harold Ellis Published by Blackwell Publishing Ltd Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published 1960 Seventh edition 1983 Second edition 1962 Revised reprint 1986 Reprinted 1963 Eighth edition 1992 Third edition 1966 Ninth edition 1992 Fourth edition 1969 Reprinted 2000 Fifth edition 1971 Tenth edition 2002 Sixth edition 1977 Reprinted 2003, 2004 Reprinted 1978, 1980 Greek edition 1969 Eleventh edition 2006 1 2006 Library of Congress Cataloging-in-Publication Data Data available ISBN-13: 978-1-4051-3804-8 ISBN-10: 1-4051-3804-1 Acatalogue record for this title is available from the British Library Set in 9/12 Palatino by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in India by Replika Press Pvt Ltd Commissioning Editor: Martin Sugden Editorial Assistant: Ellie Bonnett Development Editor: Mirjana Misina Production Controller: Kate Charman For further information on Blackwell Publishing, visit our website: http://www.blackwellpublishing.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. ECAPR 7/18/06 6:33 PM Page iv Contents Preface, xiii Acknowledgements, xiv Part 1:◊The Thorax Surface anatomy and surface markings, 3 ◊◊Surface markings of the more important thoracic contents, 3 The thoracic cage, 7 ◊◊The thoracic vertebrae, 7 ◊◊The ribs, 7 ◊◊The costal cartilages, 10 ◊◊The sternum, 11 ◊◊The intercostal spaces, 11 ◊◊The diaphragm, 14 ◊◊The pleurae, 18 The lower respiratory tract, 19 ◊◊The trachea, 19 ◊◊The bronchi, 23 ◊◊The lungs, 23 The mediastinum, 28 ◊◊The pericardium, 28 ◊◊The heart, 29 ◊◊The superior mediastinum, 42 ◊◊The oesophagus, 42 ◊◊The thoracic duct, 45 ◊◊The thoracic sympathetic trunk, 47 On the examination of a chest radiograph, 49 ◊◊Radiographic appearance of the heart, 50 Part 2:◊The Abdomen and Pelvis Surface anatomy and surface markings, 55 ◊◊Vertebral levels, 55 ◊◊Surface markings, 55 The fasciae and muscles of the abdominal wall, 58 ◊◊Fasciae of the abdominal wall, 58 ◊◊The muscles of the anterior abdominal wall, 58 ECAPR 7/18/06 6:34 PM Page v ◊◊The anatomy of abdominal incisions, 61 ◊◊The inguinal canal, 63 Peritoneal cavity, 65 ◊◊Intraperitoneal fossae, 68 ◊◊The subphrenic spaces, 69 The gastrointestinal tract, 70 ◊◊The stomach, 70 ◊◊The duodenum, 75 ◊◊Small intestine, 77 ◊◊Large intestine, 78 ◊◊The appendix, 79 ◊◊The rectum, 81 ◊◊Arterial supply of the intestine, 86 ◊◊The portal system of veins, 87 ◊◊Lymph drainage of the intestine, 88 ◊◊The structure of the alimentary canal, 88 ◊◊The development of the intestine and its congenital abnormalities, 90 The gastrointestinal adnexae: liver, gall-bladder and its ducts, pancreas and spleen, 93 ◊◊The liver, 93 ◊◊The biliary system, 98 ◊◊The gall-bladder, 99 ◊◊The pancreas, 101 ◊◊The spleen, 104 The urinary tract, 105 ◊◊The kidneys, 105 ◊◊The ureter, 109 ◊◊The embryology and congenital abnormalities of the kidney and ureter, 110 ◊◊The bladder, 112 ◊◊The urethra, 115 The male genital organs, 116 ◊◊The prostate, 116 ◊◊The scrotum, 119 ◊◊Testis and epididymis, 119 ◊◊Vas deferens (ductus deferens), 123 ◊◊The seminal vesicles, 124 The bony and ligamentous pelvis, 124 ◊◊The os innominatum, 124 ◊◊The sacrum, 125 ◊◊The coccyx, 126 ◊◊The functions of the pelvis, 126 vi Contents ECAPR 7/18/06 6:34 PM Page vi ◊◊Joints and ligamentous connections of the pelvis, 127 ◊◊Differences between the male and female pelvis, 128 ◊◊Obstetrical pelvic measurements, 128 ◊◊Variations of the pelvic shape, 130 The muscles of the pelvic floor and perineum, 132 ◊◊The anterior (urogenital) perineum, 133 ◊◊The posterior (anal) perineum, 134 The female genital organs, 136 ◊◊The vulva, 136 ◊◊The vagina, 137 ◊◊The uterus, 139 ◊◊The Fallopian tubes, 144 ◊◊The ovary, 145 ◊◊The endopelvic fascia and the pelvic ligaments, 146 ◊◊Vaginal examination, 147 ◊◊Embryology of the Fallopian tubes, uterus and vagina, 148 The posterior abdominal wall, 149 ◊◊The suprarenal glands, 151 ◊◊Abdominal aorta, 151 ◊◊Inferior vena cava, 153 ◊◊Lumbar sympathetic chain, 153 Part 3:◊The Upper Limb The female breast, 159 ◊◊Structure, 159 ◊◊Blood supply, 159 ◊◊Lymphatic drainage, 159 ◊◊Development, 161 Surface anatomy and surface markings of the upper limb, 162 ◊◊Bones and joints, 163 ◊◊Muscles and tendons, 164 ◊◊Vessels, 166 ◊◊Nerves, 167 The bones and joints of the upper limb, 168 ◊◊The scapula, 168 ◊◊The clavicle, 168 ◊◊The humerus, 169 ◊◊The radius and ulna, 171 ◊◊The bones of the hand, 174 ◊◊The shoulder, 176 ◊◊The elbow joints, 180 Contents vii ECAPR 7/18/06 6:34 PM Page vii ◊◊The wrist joint, 183 ◊◊The joints of the hand, 184 The arteries of the upper limb, 186 ◊◊The axillary artery, 186 ◊◊The brachial artery, 187 ◊◊The radial artery, 187 ◊◊The ulnar artery, 188 The brachial plexus, 189 ◊◊The segmental cutaneous supply of the upper limb, 191 The course and distribution of the principal nerves of the upper limb, 191 ◊◊The axillary nerve, 191 ◊◊The radial nerve, 192 ◊◊Branches, 194 ◊◊The musculocutaneous nerve, 194 ◊◊The ulnar nerve, 194 ◊◊The median nerve, 195 The anatomy of upper limb deformities, 197 The spaces of the hand, 200 ◊◊The superficial pulp space of the fingers, 200 ◊◊The ulnar and radial bursae and the synovial tendon sheaths of the fingers, 201 Part 4:◊The Lower Limb The anatomy and surface markings of the lower limb, 207 ◊◊Bones and joints, 207 ◊◊Bursae of the lower limb, 207 ◊◊Mensuration in the lower limb, 208 ◊◊Muscles and tendons, 211 ◊◊Vessels, 211 ◊◊Nerves, 214 The bones and joints of the lower limb, 216 ◊◊The os innominatum, 216 ◊◊The femur, 216 ◊◊The patella, 220 ◊◊The tibia, 223 ◊◊The fibula, 224 ◊◊Anote on growing ends and nutrient foramina in the long bones, 225 ◊◊The bones of the foot, 225 ◊◊The hip, 226 viii Contents ECAPR 7/18/06 6:34 PM Page viii Contents ix ◊◊The knee joint, 229 ◊◊The tibiofibular joints, 233 ◊◊The ankle, 233 ◊◊The joints of the foot, 234 ◊◊The arches of the foot, 235 ◊◊The anatomy of walking, 237 Three important zones of the lower limb—the femoral triangle, adductor canal and popliteal fossa, 237 ◊◊The femoral triangle, 237 ◊◊The fascia lata, 238 ◊◊The femoral sheath and femoral canal, 238 ◊◊Femoral hernia, 239 ◊◊The lymph nodes of the groin and the lymphatic drainage of the lower limb, 241 ◊◊The adductor canal (of Hunter) or subsartorial canal, 242 ◊◊The popliteal fossa, 242 The arteries of the lower limb, 244 ◊◊Femoral artery, 244 ◊◊Popliteal artery, 246 ◊◊Posterior tibial artery, 246 ◊◊Anterior tibial artery, 246 The veins of the lower limb, 247 ◊◊Clinical features, 249 The course and distribution of the principal nerves of the lower limb, 249 ◊◊The lumbar plexus, 250 ◊◊The sacral plexus, 251 ◊◊The sciatic nerve, 253 ◊◊The tibial nerve, 255 ◊◊The common peroneal (fibular) nerve, 255 ◊◊Segmental cutaneous supply of the lower limb, 256 Part 5:◊The Head and Neck The surface anatomy of the neck, 261 ◊◊The fascial compartments of the neck, 262 The thyroid gland, 264 ◊◊The parathyroid glands, 267 The palate, 270 ◊◊The development of the face, lips and palate with special reference to their congenital deformities, 270 ECAPR 7/18/06 6:34 PM Page ix The tongue and floor of the mouth, 272 ◊◊The tongue, 272 ◊◊The floor of the mouth, 276 The pharynx, 277 ◊◊The nasopharynx, 277 ◊◊The oropharynx, 278 ◊◊The palatine tonsils, 279 ◊◊The laryngopharynx, 280 ◊◊The mechanism of deglutition, 282 The larynx, 284 ◊◊Blood supply, 287 ◊◊Lymph drainage, 287 ◊◊Nerve supply, 288 The salivary glands, 289 ◊◊The parotid gland, 289 ◊◊The submandibular gland, 292 ◊◊The sublingual gland, 293 The major arteries of the head and neck, 294 ◊◊The common carotid arteries, 294 ◊◊The external carotid artery, 294 ◊◊The internal carotid artery, 296 ◊◊The subclavian arteries, 298 The veins of the head and neck, 301 ◊◊The cerebral venous system, 301 ◊◊The venous sinuses of the dura, 301 ◊◊The internal jugular vein, 303 ◊◊The subclavian vein, 305 The lymph nodes of the neck, 306 The cervical sympathetic trunk, 308 The branchial system and its derivatives, 310 ◊◊Branchial cyst and fistula, 310 The surface anatomy and surface markings of the head, 311 The scalp, 312 The skull, 314 ◊◊Development, 316 x Contents ECAPR 7/18/06 6:34 PM Page x Contents xi The accessory nasal sinuses, 318 ◊◊The frontal sinuses, 318 ◊◊The maxillary sinus (antrum of Highmore), 319 ◊◊The ethmoid sinuses, 320 ◊◊The sphenoid sinuses, 321 The mandible, 321 ◊◊The temporomandibular joint, 322 ◊◊The teeth, 323 The vertebral column, 324 ◊◊The cervical vertebrae, 325 ◊◊The thoracic vertebrae, 327 ◊◊The lumbar vertebrae, 327 ◊◊The sacrum, 327 ◊◊The coccyx, 327 ◊◊The intervertebral joints, 328 Part 6:◊The Central Nervous System The spinal cord, 333 ◊◊Age differences, 333 ◊◊Structure, 333 ◊◊Descending tracts, 334 ◊◊Ascending tracts, 336 ◊◊The membranes of the cord (the meninges), 337 The brain, 339 ◊◊The medulla, 339 ◊◊The pons, 342 ◊◊The cerebellum, 342 ◊◊The midbrain, 344 ◊◊The diencephalon, 346 ◊◊The hypothalamus, 346 ◊◊The pituitary gland (hypophysis cerebri), 347 ◊◊The thalamus, 349 ◊◊The cerebral hemispheres, 349 ◊◊The cerebral cortex, 349 ◊◊The insula, 352 ◊◊The connections of the cerebral cortex, 352 ◊◊The basal ganglia, 353 ◊◊The long ascending and descending pathways, 354 ◊◊The membranes of the brain (the meninges), 360 ◊◊The ventricular system and the cerebrospinal fluid circulation, 361 The cranial nerves, 364 ◊◊The olfactory nerve (I), 364 ◊◊The optic nerve (II) and the visual pathway, 365 ECAPR 7/18/06 6:34 PM Page xi ◊◊The oculomotor nerve (III), 366 ◊◊The trochlear nerve (IV), 368 ◊◊The trigeminal nerves (V), 369 ◊◊The abducent nerve (VI), 374 ◊◊The facial nerve (VII), 375 ◊◊The auditory (vestibulocochlear) nerve (VIII), 377 ◊◊The glossopharyngeal nerve (IX), 379 ◊◊The vagus nerve (X), 379 ◊◊The accessory nerve (XI), 381 ◊◊The hypoglossal nerve (XII), 381 The special senses, 383 ◊◊The nose, 383 ◊◊The ear, 384 ◊◊The eye and associated structures, 388 The autonomic nervous system, 393 ◊◊Visceral afferents, 396 ◊◊The sympathetic system, 396 ◊◊The sympathetic trunk, 396 ◊◊The parasympathetic system, 399 Glossary of eponyms, 403 Index, 409 xii Contents Preface Experience of teaching clinical students at five medical schools and of examining them in sixteen cities and in eight countries has convinced me that there is still an unfortunate hiatus between the anatomy which the student learns in the pre-clinical years and that which is later encountered in the wards and operating theatres. This book attempts to counter this situation. It does so by highlighting those features of anatomy which are of clinical importance using a vertical blue bar, in radiology, pathology, medicine and midwifery as well as in surgery. It presents the facts which students might reasonably be expected to carry with them during their years on the wards, through their final examinations and into their postgraduate years; it is designed for the clini- cal student. Anatomy is a vast subject and, therefore, in order to achieve this goal, I have deliberately carried out a rigorous selection of material so as to cover only those of its thousands of facts which I consider form the necessary anatomical scaffolding for the clinician. Wherever possible practical appli- cations are indicated throughout the text — they cannot, within the limita- tions of a book of this size, be exhaustive, but I hope that they will act as signposts to the student and indicate how many clinical phenomena can be understood and remembered on simple anatomical grounds. In this eleventh edition a complete revision of the text has been carried out. New figures have been added and other illustrations modified. Repre- sentative computerized axial tomography and magnetic resonance imaging films have been included, since these techniques have given increased impetus to the clinical importance of topographical anatomy. The continued success of this volume, now in its forty-seventh year of publication, owes much to the helpful comments which the author has received from readers all over the world. Every suggestion is given the most careful consideration in an attempt to keep the material abreast of the needs of today’s medical students. Harold Ellis 2006 xiii ECAPR 7/18/06 6:35 PM Page xiii Acknowledgements xiv I wish to thank the many students who have sent suggestions to me, many of which have been incorporated into this new edition. To Mrs Katherine Ellis go my grateful thanks for invaluable secretarial assistance. New and revised illustrations were skilfully produced by Jane Fallows and new MR scans were provided by Dr Sheila Rankin of the Department of Radiology at Guy’s Hospital and Professor Adrian Dixon of Cambridge. I am grateful to the following authors for permission to reproduce illus- trations: The late Lord Brock for Figs 20 and 21 (from Lung Abscess); and Professor R. G. Harrison for Figs 12, 32 and 69 (from A Textbook of Human Embryology). Dr Colin Stolkin gave valuable help in revising the anatomy of the C.N.S. Finally, I wish to express my debt to Martin Sugden and the staff of Blackwell Publishing for their continued and unfailing help. Harold Ellis ECAPR 7/18/06 6:35 PM Page xiv