G R V - r 9 i . 9 s r & s i h n a a t i s r e p . p i v tahir99-VRG & vip.persianss.ir L A AST’S NATOMY tahir99-VRG & vip.persianss.ir CommissioningEditor:TimothyHorne,JeremyBowes DevelopmentEditor:SallyDavies ProjectManager:ElouiseBall DesignDirection:CharlesGray IllustrationDirection:BruceHogarth Artworkcolouring:IanRamsden Newartwork:GillianOliver tahir99-VRG & vip.persianss.ir L A AST’S NATOMY R e g i o n a l a n d A p p l i e d Twelfth Edition Chummy S. Sinnatamby FRCS G Formerly: R Head of Anatomy, Royal College of Surgeons of England V Member of Court of Examiners, Royal College of Surgeons of England Examiner in Anatomy, Royal College of Sur-geons in Ireland Director of Studies in Anatomy, St Cat9ha rine’s College and Hughes Hall, Camrbridge i . External Examiner in Anatomy, Un9iversity of Cambridge s External Examiner in Anatomyr, Trinity College,&University of Dublins i h n a a t i s r e p . p i v Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2011 tahir99-VRG & vip.persianss.ir #2011ElsevierLtd.Allrightsreserved. TherightofChummyS.Sinnatambytobeidentifiedasauthorofthisworkhasbeenassertedbyhimin accordancewiththeCopyright,DesignsandPatentsAct1988. Nopartofthispublicationmaybereproducedortransmittedinanyformorbyanymeans,electronicor mechanical,includingphotocopying,recording,oranyinformationstorageandretrievalsystem,without permissioninwritingfromthepublisher.Detailsonhowtoseekpermission,furtherinformationaboutthe Publisher’spermissionspoliciesandourarrangementswithorganizationssuchastheCopyrightClearance CenterandtheCopyrightLicensingAgency,canbefoundatourwebsite:www.elsevier.com/permissions. Thisbookandtheindividualcontributionscontainedinitareprotectedundercopyrightbythe Publisher(otherthanasmaybenotedherein). Firstedition1954 G Secondedition1959 Thirdedition1963 Fourthedition1966 R Fifthedition1972 V Sixthedition1978 Seventhedition1984 Eighthedition1990 - Ninthedition1994 r Tenthedition1999 9 i Eleventhedition2006 9 s. Twelfthedition2011 r & s ISBN9780702033957 i h n InternationalISBN9780702033940 a a BritishLibraryCataloguinginPublicationData t i AcataloguerecordforthisbookisavailablefromtheBritishLibrary s r LibraryofCongressCataloginginPublicationData e AcatalogrecordforthisbookisavailablefromtheLibraryofCongress p Notices . Knowledgeandbestpracticeinthisfieldareconstanptlychanging.Asnewresearchandexperience broadenourunderstanding,changesinresearchmethods,professionalpractices,ormedicaltreatment i maybecomenecessary. v Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledgeinevaluating andusinganyinformation,methods,compounds,orexperimentsdescribedherein.Inusingsuch informationormethodstheyshouldbemindfuloftheirownsafetyandthesafetyofothers,including partiesforwhomtheyhaveaprofessionalresponsibility. Tothefullestextentofthelaw,neitherthePublishernortheauthors,contributors,oreditors,assume anyliabilityforanyinjuryand/ordamagetopersonsorpropertyasamatterofproductsliability, negligenceorotherwise,orfromanyuseoroperationofanymethods,products,instructions,orideas containedinthematerialherein. The Publisher's policy is to use paper manufactured from sustainable forests PrintedinChina tahir99-VRG & vip.persianss.ir Preface to the twelfth edition Forthefirsttimeinitspublicationhistoryalltheillustrationsintheprevious(eleventh)editionof Last’s Anatomy appeared in full colour. This development transformed the illustrations and received very favourable readership response. In the light of such evaluation the publication of a twelftheditionhasprovidedtheopportunitytoaugmenttheillustrationsinthebookbytheinclu- sion of new photographs depicting anatomy of clinical, endoscopic and surgical relevance and additional photographs of prosections. Where necessary the colour, tone, shade and contrast of existingillustrationshavebeenenhanced.Colourconsistencyforrelatedstructureshasbeenmain- tainedthroughouttoensureeaseofcross-referencefromoneillustrationtoanother. Thetexthasbeenwhollyreviewedandrefinementsmadewhererequiredintheinterestsofrele- vance and readability. The anatomy of surgical approaches has been updated in the light of the continuingevolutionofsurgicalpractice,advancesinlaparoscopicsurgeryandtheincreasingscope of minimal access procedures. The limited field of vision provided by these latter techniques emphasises the need for a reliable knowledge of regional anatomy and structural relationships. Eponymsincommonclinicalusehavebeenadded. Curricular reforms and changes to surgical training programmes have resulted in a reduction of anatomystudytimeandprosectionexperienceformedicalstudents,andindifficultiesencountered bysurgicaltraineesinincludinganatomydemonstratorshipsintheircareerpathways.Thesedevelop- mentshavereiteratedthecontinuingneedforaregionallyarranged,clinicallyandsurgicallyrelevant anatomytextbookappropriateforbothundergraduatestudyandpostgraduateutilisation.Thetwelfth editionofLast’sAnatomyaimstofulfilthisroleandbeofvaluetomedicalstudents,surgicaltrainees andpractisingsurgeons. ChummyS.Sinnatamby 2010 v tahir99-VRG & vip.persianss.ir Preface to the eleventh edition Inresponsetoinnumerablerequests,alltheillustrationsintheeleventheditionappearinfullcol- our.Carehasbeentakeninthechoiceofandconsistencyinuseofcoloursforsimilarstructuresto facilitateeaseofrecognitionandenhancethereader’sappreciationoftheillustrations asamean- ingful adjunct to the text. Some of the illustrations in the first edition of R. J. Last’s Anatomy, RegionalandAppliedwerepartlycolouredastheyappearedinrelationtothetext.Intheseventhedi- tion several partly coloured illustrations were collectively positioned as plates at the front of the book, butthese were thenomitted from subsequent editions. Ithas been gratifying tobe able to restorecolourtoLast’sAnatomyandextenditsapplicationtofullcolourforalltheillustrationsas they remain integrated with the text. Several new illustrations, including clinical photographs, radiographs and magnetic resonance images, have been added, depicting normal anatomy and lesionsthathaveananatomicalbasis. Thetexthasbeenextensivelyrevisedwithseveraladditionstotheclinicalandappliedaspectsof anatomyandtextualchangesintheinterestsofclarityandaccuracy. Iamgratefultothemanyreaders,postgraduateandundergraduate,intheUKandabroad,who have communicated their appreciation of and comments on the tenth edition. Their input has encouragedandaidedthepreparationoftheeleventhedition. ChummyS.Sinnatamby 2005 vi tahir99-VRG & vip.persianss.ir Preface to the tenth edition In1954,aftersevenyearsofassociationwithpostgraduatestudentsofanatomyattheRoyalCol- legeofSurgeonsofEngland,R.J.LastpublishedthefirsteditionofAnatomy,RegionalandApplied. Forty-fiveyearslaterLast’s‘approachtothestudyofanatomy’isstillofvaluetoundergraduateand postgraduate students of anatomy. The chief assets of Last’s Anatomy were epitomised in its title. Intheassessmentandtreatmentofpatients’lesions,cliniciansencountertheanatomyofthehuman bodyonaregionalbasis,andthebookpresentedappliedanatomydataregionallyarranged.When R.M.H.McMinntookovertheeditorshipin1990heretained‘theflavourofearlierversions’and addedtotheappliedaspectsofthesubject. In preparing the tenth edition of Last’s Anatomy, I have maintained the overall structure and arrangementofthebook.Theentiretext,however,hasundergonecomprehensiverevisiondirected towards a reduction of its volume and greater clarity. Anatomical detail of no clinical relevance, phylogenetic discussion and comparative anatomy analogies have been omitted. Within the con- straintsofconciseness,clinicallycorrelatedtopographicalanatomyrelevanttotheexpandingfron- tiers of diagnostic and surgical procedures has been included. Surface anatomy pertaining to physicalexaminationispresented.Histologicalfeaturesanddevelopmentalaspectshavebeenmen- tionedonlywheretheyaidtheappreciationofthegrossformorfunctionoforgansandtheappear- anceofthecommonercongenitalanomalies. In keeping with the extensive textual changes in this edition, the illustrations have also under- gonemajorrevision.Whileseveralfigureswhichappearedinpreviouseditionsbutdidnotsignifi- cantlycontributetoorenhancethetext,havebeenremoved,97newillustrationshavebeenadded. Thelatterincludeoriginalartworkspeciallycommissionedforthisedition,figuresreproducedfrom Gray’sAnatomy(withthekindpermissionofthepublishers)onaccountoftheiranatomicalaccu- racyandclarity,andexamplesofcurrentdiagnosticimagingtechniques. Throughout the preparation of this edition the curricular reforms of undergraduate education andtherestructuringofsurgicaltraininghavebeenborneinmind.Timeconstraintsandtheinter- disciplinaryintegrationpertainingtobothhaverestrictedthestudyofanatomy.Nevertheless,ana- tomical knowledge is required for performing physical examination and diagnostic tests, interpreting their results and instituting treatment, particularly surgical procedures. In his preface to the second edition Last stated that: ‘While the text was written chiefly to help students who arerevisingtheiranatomyforanexamination,itisparticularlygratifyingtofindthatsomanyclin- iciansandsurgeonshavefoundthebookofvalueintheirpractice.’Itishopedthattheclinically relevantanatomicalinformationpresentedinthetenthedition,inasconciseaformasitscontent concedes, will be of use to students preparing for examinations, participants in basic and higher surgicaltrainingprogrammes,andpractisingsurgeons. Thirty-sevenyearsagoIpurchasedacopyofthesecondeditionofLast’sAnatomywhilepreparing fortheprimaryfellowshipexamination,intheoralsectionofwhichIwasexaminedbyProfessor Lasthimself.LittledidIimaginethenthatitwouldonedaybemyprivilegetopreparethetenth editionofLast’sAnatomy,therebymaintainingthelinkagebetweentheeditorshipofthispublica- tionandtheheadshipofanatomyattheRoyalCollegeofSurgeonsofEngland. ChummyS.Sinnatamby 1998 vii tahir99-VRG & vip.persianss.ir Acknowledgements Appreciative communications from the readership of the eleventh edition of Last’s Anatomy have inspired the publication of another edition of this textbook of regional and applied anatomy. Several people have contributed to the production of the twelfth edition. In particular I thank Timothy Horne, latelyof Churchill Livingstone and ElsevierLimited, for his encouragement, and SallyDavies,ElouiseBallandBruceHogarthofElsevierLimitedfortheirassistancewiththeprepa- ration of the manuscript and the colouring of figures. I am grateful to Dr Ruchi Sinnatamby of Addenbrooke’sHospital,Cambridge,forherhelpwiththeharvestingofnewclinicalillustrations. Iamgreatlyindebtedtomywife,Selvi,forherpatientsupportatalltimes. viii tahir99-VRG & vip.persianss.ir Contents CHAPTER 1: Introduction to regional 9. Posterior compartment of the leg...........146 anatomy 10. Sole of the foot...........................................151 1. Tissues and structures.....................................1 11. Ankle and foot joints.................................156 2. Nervous system................................................9 12. Summary of lower limb innervation.....162 3. Embryology.....................................................22 13. Summaryoflowerlimbnerveinjuries.....163 4. Anatomy of the child...................................32 14. Osteology of the lower limb....................164 CHAPTER 2: Upper limb CHAPTER 4: Thorax 1. Pectoral girdle................................................37 1. Body wall.....................................................179 2. Shoulder..........................................................44 2. Thoracic wall and diaphragm..................180 3. Axilla................................................................50 3. Thoracic cavity............................................189 4. Breast................................................................56 4. Superior mediastinum...............................190 5. Anterior compartment of the arm.............58 5. Anterior mediastinum...............................196 6. Posterior compartment of the arm............61 6. Middle mediastinum and heart...............196 7. Anterior compartment of the forearm......64 7. Posterior mediastinum..............................207 8. Posterior compartment of the forearm.....73 8. Pleura............................................................211 9. Wrist and hand..............................................78 9. Lungs.............................................................213 10. Summary of upper limb innervation........91 10. Osteology of the thorax............................217 11. Summary of upper limb nerve injuries....95 12. Osteology of the upper limb......................97 CHAPTER 5: Abdomen 1. Anterior abdominal wall...........................221 CHAPTER 3: Lower limb 2. Abdominal cavity.......................................233 1. Anterior compartment of the thigh........111 3. Peritoneum..................................................234 2. Medial compartment of the thigh..........121 4. Development of the gut............................238 3. Gluteal region and hip joint....................123 5. Vessels and nerves of the gut...................242 4. Posterior compartment of the thigh.......130 6. Gastrointestinal tract..................................247 5. Popliteal fossa and knee joint.................132 7. Liver and biliary tract................................259 6. Anterior compartment of the leg............141 8. Pancreas........................................................267 7. Dorsum of the foot....................................145 9. Spleen...........................................................270 8. Lateral compartment of the leg...............146 10. Posterior abdominal wall.........................272 ix tahir99-VRG & vip.persianss.ir