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1. e orax, 2
2. e Abdomen, Pelvis and Perineum, 20
3. e Upper Limb and Breast, 62
4. e Lower Limb, 80
5. e Head, Neck and Spine, 106
6. e Nervous System, 145
SECTION I
Anatomy
1
1
Aortic
Pulmonary
tube
arteriosus
The Thorax
DEVELOPMENT
Heart and Great Vessels
Heart (Fig. 1.1)
• Paired endothelial tubes fuse to become the primitive
heart tube.
• Primitive heart tube develops in the pericardial cavity
and divides into ve regions:
• sinus venosus
• atrium
• ventricle
• bulbus cordis
• truncus arteriosus.
• Heart tube elongates in pericardial cavity becoming
U-shaped and then S-shaped.
• Sinus venosus becomes incorporated into the atrium.
• Bulbus cordis becomes incorporated into the ventricle.
• Boundary tissue between the primitive single atrial cavity and single ventricle grows out as dorsal and ventral
endocardial cushions.
• e endocardial cushions meet in the midline, dividing
the common atrioventricular (AV) orice into a right
(tricuspid) and le (mitral) orice.
Truncus
• An interventricular septum develops from the apex up
towards the endocardial cushions.
• In the atrium a partition, the septum primum,
grows down to fuse with the endocardial cushions.
Before fusion is complete, a hole appears in the upper
part of the septum primum that is called the foramen
secundum.
• A second incomplete membrane, the septum secundum,
then develops to the right of the septum primum but is
never complete. It has a free lower edge that extends low
enough for it to overlap the foramen secundum in the
septum primum and eventually close it.
• e two overlapping defects in the septa form the valvelike foramen ovale.
• e septum secundum acts as a valvelike structure,
allowing blood to go straight from the right to the le
side of the heart in the fetus.
• At birth, where there is an increased blood ow through
the lungs and a rise in le atrial pressure, the septum
primum is pushed across to close the foramen ovale.
• e septum primum and septum secundum usually
fuse, obliterating the foramen ovale and leaving a small
residual dimple (the fossa ovalis).
SVC
Bulbus
cordis
Ventricle
Atrium
Sinus
venosus
Primitive heart
Fig. 1.1 The development of the heart. IVC, Inferior vena cava; SVC, superior vena cava.
Pulmonary
veins
Right
atrium
IVC
Left atrium
Right ventricle
2
arch
trunk
Left
ventricle
CHAPTER 1 The Thorax
Left subclavian
subclavian
Right and left
3
• e sinus venosus joins the atria, becoming the two
venae cavae on the right and the four pulmonary veins
on the le.
Great Vessels (Fig. 1.2)
• Truncus arteriosus gives o six pairs of arches.
• ese curve round the pharynx to join the dorsal aortae,
which fuse distally into the descending aorta.
• First and second arches disappear completely.
• ird arch remains as carotid artery.
• Fourth arch becomes subclavian artery on the right
and aortic arch on the le (giving o the le subclavian
artery).
• Fih arch disappears.
• Sixth arch (ventral part) becomes right and le pulmonary arteries with a connection to dorsal aorta disappearing on the right, but continuing as the ductus
arteriosus on the le connecting with the aortic arch.
• e above developmental anatomy explains the dierent positions of the recurrent laryngeal nerves on each
recurrent
Carotid
Right
Vagus
nerve
laryngeal
nerves
Vagus
nerve
Aortic
arch
II
III
IV
V
I
artery
Arch of
aorta
side. On the right, the h and sixth arches disappear to
leave the nerve hooked round the fourth, i.e. subclavian
artery. On the le it remains hooked round the sixth
arch (ligamentum arteriosum in the adult).
Fetal Circulation (Fig. 1.3)
• Oxygenated blood travels from the placenta along the
umbilical vein.
• Most blood bypasses the liver in the ductus venosus,
joining the inferior vena cava (IVC) and then travelling
to the right atrium.
• Most of the blood passes through the foramen ovale
into the le atrium so that oxygenated blood can enter
the aorta.
• e remainder goes through the right ventricle with
returning systemic venous blood into the pulmonary
trunk.
• In the fetus the unexpanded lungs present high resistance to ow so that blood in the pulmonary trunk
tends to pass down the low-resistance ductus arteriosus
into the aorta.
• Blood returns to the placenta via the umbilical arteries
(branches of the internal iliac arteries).
• At birth, when the baby breathes, the le atrial pressure
rises, pushing the septum primum against the septum
secundum and closing the foramen ovale.
• Blood ow through the pulmonary artery increases and
becomes poorly oxygenated as it now receives systemic
venous blood.
• Pulmonary vascular resistance is abruptly lowered as
lungs inate and the ductus arteriosus is obliterated
over the next few hours to days.
• Ligation of the umbilical cord causes thrombosis of the
umbilical artery, vein and ductus venosus.
Congenital Anomalies
Malposition
• Dextrocardia: mirror image of normal anatomy.
• Situs inversus: inversion of all viscera.
Pulmonary
trunk
VI
Ductus
arteriosus
Fig. 1.2 The development of the aortic arches.
Left-to-Right Shunt
Atrial septal defect (ASD)
• Fusion between the septum primum and septum secundum usually takes place about 3 months aer birth.
• May be incomplete in 10% of the population.
• If the septum secundum is too short to cover the foramen
secundum in the septum primum and ASD persists aer
the primum and septum secundum are pressed together
at birth, this results in an ostium secundum defect, which
allows shunting of blood from the le to the right atrium.
• ASD may also result if the septum primum fails to fuse
with the endocardial cushions.
4
Common iliac
Placenta
SECTION I Anatomy
SVC
Septum
secundum
Foramen ovale
Septum
primum
IVC
Liver
Aortic arch
Ductus
arteriosus
Pulmonary
trunk
Ductus
venosus
Umbilical vein
Umbilical cord
Umbilical
arteries
arising from
the internal
iliac arteries
Fig. 1.3 The fetal circulation. IVC, Inferior vena cava; SVC, superior vena cava.
• is is an ostium primum defect lying immediately
above the AV boundary and may be associated with a
ventricular septal defect (VSD).
Ventricular septal defect
• is is the most common abnormality.
• Small defects occurring in the muscular part of the septum may close.
Eisenmenger’s syndrome
• Pulmonary hypertension may cause reversed ow
(right-to-le shunting).
• is is due to an increased pulmonary ow resulting
from either ASD, VSD or PDA.
• When cyanosis occurs as a result of this mechanism it is
known as Eisenmenger’s syndrome.
• Larger ones occurring in the membranous part of the
septum just below the aortic valves may require repair.
Patent ductus arteriosus (PDA)
• e ductus may fail to close aer birth.
• is should be surgically corrected because it causes
increased load on the le ventricle and pulmonary
hypertension.
• In open surgery to close a patent ductus, care must be
taken to avoid the le recurrent laryngeal nerve.
Right-to-Left Shunt (Cyanotic)
Fallot’s tetralogy
• Fallot’s tetralogy consists of:
• VSD
• stenosed pulmonary outow track
• a wide aorta which overrides the right and le
ventricles
• right ventricular hypertrophy.
Abdominal
aorta
artery
CHAPTER 1 The Thorax
pleuroperitoneal
contribution
5
• Because there is a right-to-le shunt across the VSD
there is usually cyanosis at an early stage.
• e degree of cyanosis depends mainly on the severity
of the pulmonary outow obstruction.
Other congenital anomalies
Coarctation of the aorta
• Caused by abnormality of obliterative process, which
normally occludes ductus arteriosus.
• Hypertension in upper part of body with weak, delayed
femoral pulses.
• Extensive collaterals develop to try and bring blood
from upper to lower part of body.
• Enlarged intercostal arteries cause notching of the inferior borders of the rib seen on chest X-ray.
Abnormalities of valves
• Any valve may be imperfectly formed.
• May cause stenosis or complete occlusion.
• Pulmonary and aortic valves are more frequently
aected than mitral and tricuspid.
The Diaphragm (Fig. 1.4)
e diaphragm develops from the fusion of four parts:
1. septum transversum (the brous central tendon)
2. the mesentery of the foregut (the area adjacent
to the vertebral column becomes the crura and median
part)
3. ingrowth from the body wall
4. the pleuroperitoneal membrane (a small dorsal part).
ese close the primitive communications between
pleura and peritoneal cavities.
Clinical Points
Dierent types of congenital diaphragmatic hernias occur,
depending on which section has failed to close.
• Posterolateral hernia through the foramen of Bochdalek
(the pleuroperitoneal membrane)—more common on
the le.
• A hernia through a deciency of the whole central tendon.
• A hernia through the foramen of Morgagni anteriorly
between xiphoid and costal origins.
• A hernia through a congenitally large oesophageal hiatus.
THORACIC CAGE
e thoracic cage is formed by:
• vertebral column behind
• ribs and intercostal spaces on either side
• sternum and costal cartilages in front.
Ribs
• ere are 12 pairs.
• Ribs 1–7 connect via their costal cartilages with the sternum. ese are ‘true’ ribs articulating directly with the
sternum.
• Ribs 8–10 articulate with their costal cartilages, each
with the rib above. ese are ‘false’ ribs as they do not
articulate directly with the sternum.
• Ribs 11 and 12 are free anteriorly. ese are ‘oating
ribs’ as they have no anterior articulation.
• A typical rib comprises:
• a head with two articular facets for articulation with
the corresponding vertebra and the vertebra above
Right
pleuroperitoneal
membrane
Body wall
Oesophagus
Fig. 1.4 The development of the diaphragm.
Foregut (oesophageal)
mesentery
Left
membrane
Septum transversum
6
SECTION I Anatomy
• a neck giving attachment to the costotransverse
ligament
• a tubercle with a smooth facet for articulation
with the transverse process of the corresponding
vertebra
• a sha attened from side to side possessing an angle
which marks the lateral limit of attachment of erector spinae. e sha possesses a groove on its lower
surface, the subcostal groove, in which the vessels
and nerves lie.
Atypical ribs
First rib
• Shortest, attest and most curved.
• Flattened from above downwards.
• Bears a prominent tubercle on the inner border of its
upper surface for insertion of scalenus anterior.
• In front of the scalene tubercle the subclavian vein
crosses the rib.
• Behind the scalene tubercle is the subclavian groove
where the subclavian artery and lowest trunk of the brachial plexus are related to the rib.
• e neck of the rst rib is crossed by (medial to lateral):
sympathetic trunk; superior intercostal artery; and T1
to the brachial plexus.
• First digitation of serratus anterior attaches to outer
edge.
• Suprapleural membrane (Sibson’s fascia) is attached to
inner border.
Second rib
• Less curved than rst.
• Twice as long.
Tenth rib
• Only one articular facet on head.
Eleventh and twelfth ribs
• Short.
• No tubercles.
• Only single facet on head.
• Eleventh rib has shallow subcostal groove.
• Twelh rib has no subcostal groove and no angle.
Clinical Points
Rib Fractures
• May damage underlying or related structures.
• Fracture of any rib may lead to trauma to lung and
development of pneumothorax.
• Fracture of le lower ribs (ninth, tenth and eleventh)
may traumatize the spleen.
• Fracture of right lower ribs may traumatize the right
lobe of the liver.
• Rib fractures may also traumatize related intercostal
vessels leading to haemothorax.
Coarctation of the Aorta
• Collateral vessels develop between vessels above and
below the block.
• e superior intercostal artery, derived from the costocervical trunk of the subclavian artery, supplies blood to
the intercostal arteries of the aorta, bypassing the narrowed aorta.
• As a consequence, the intercostal vessels dilate and
become more tortuous because of increased ow eroding the lower border of the ribs, giving rise to notching
which can be seen on X-ray.
Cervical Ribs
• Incidence of 1:200.
• May be bilateral in 1:500.
• Rib may be complete, articulating with the transverse
process of the seventh cervical vertebra behind and the
rst rib in front.
• Occasionally a cervical rib may have a free distal extremity or may be only represented by a brous band.
• Cervical ribs may cause vascular or neurological
symptoms.
• Vascular consequences include poststenotic dilatation of the subclavian artery, causing local turbulence,
thrombosis and possibility of distal emboli.
• Subclavian aneurysm may also arise.
• Pressure on vein may result in subclavian vein
thrombosis.
• Pressure on the lower trunk of the brachial plexus may
result in paraesthesia of dermatomal distribution of
C8/T1 together with wasting of small muscles of hands
(myotome T1).
Costal Cartilages
• Upper seven connect ribs to sternum.
• 8, 9 and 10 connect ribs to cartilage immediately above.
• Composed of hyaline cartilage and add resilience to thoracic cage, protecting it from more frequent fractures.
• Calcify with age; irregular areas of calcication seen on
chest X-ray.
Sternum
e sternum consists of three parts:
• manubrium
• body
• xiphoid.
Manubrium
• Approximately triangular in shape.
• Articulates with medial end of clavicle.
• First costal cartilage and upper part of second articulate
with manubrium.
• Articulates with body of sternum at manubriosternal
intercostal
intercostal
joint (angle of Louis).
Relations
• Anterior boundary of superior mediastinum.
• Lowest part is related to arch of aorta.
• Upper part is related to le brachiocephalic vein; le
brachiocephalic artery; le common carotid artery; le
subclavian artery.
• Laterally it is related to the lungs and pleura.
Body
• Composed of four pieces (sternebrae).
• Lateral margins are notched to receive most of the second and third to seventh costal cartilages.
Relations
• On the right side of the median plane, the body is
related to the right pleura and the thin anterior border
of the right lung, which intervenes between it and the
pericardium.
• On the le side of the median plane, the upper two
pieces are related to the pleura and le lung; the lower
two pieces are related directly to the pericardium.
Xiphoid
• Small and cartilaginous well into adult life.
• May become prominent if patient loses weight.
CHAPTER 1 The Thorax
Vein
Artery
External
intercostal
Internal
Fig. 1.5 An intercostal space. A needle passed into
the chest immediately above a rib will avoid the neurovascular bundle.
Nerve
Innermost
7
Clinical Points
• Sternal puncture is used to obtain bone marrow from
the body of the sternum; one should be aware of the
posterior relations!
• e sternum is split for access to the heart and occasionally a retrosternal goitre, thymus or ectopic parathyroid
tissue.
• e xiphoid may become more prominent when a
patient loses weight (naturally or due to disease). e
patient may present in clinic because they have noticed
a lump, which was previously covered in fat.
Intercostal Spaces (Fig. 1.5)
• A typical intercostal space contains three muscles comparable to those of the abdominal wall.
• External intercostal muscle: passes downwards and
forwards from the rib above to the rib below; decient
in front where it is replaced by the anterior intercostal
membrane.
• Internal intercostal muscle: passes downwards and
backwards; decient behind where it is replaced by the
posterior intercostal membrane.
• Innermost intercostal muscle: may cover more than one
intercostal space.
• e neurovascular bundle lies between the internal and
the innermost intercostal.
• e neurovascular bundle consists of (from above
down): the vein, artery and nerve; the vein lying directly
in the groove on the undersurface of the corresponding
rib.
Clinical Points
• Insertion of a chest drain should be close to the upper
border of the rib below the intercostal space to avoid the
neurovascular bundle.
• Irritation of the intercostal nerves (anterior primary
rami of the thoracic nerves) may give rise to pain
referred to the front of the chest wall or abdomen in the
region of the termination of the nerves.
TRACHEA (Fig. 1.6)
• Extends from lower border of cricoid cartilage (level
of the sixth cervical vertebra) to termination into two
main bronchi (level of h thoracic vertebra)—11 cm
long.
• Composed of broelastic tissue and is prevented from
collapsing by a series of U-shaped cartilaginous rings,
8
lobe bronchus
lobe bronchus
Right lower lobe bronchus
SECTION I Anatomy
Right main
bronchus
Right upper
lobe bronchus
Carina
Right middle
lobe bronchus
Fig. 1.6 The trachea and bronchi.
open posteriorly, the ends being connected by smooth
muscle (trachealis).
• Lined by columnar ciliated epithelium containing
numerous goblet cells.
Relations
In the Neck
• Anteriorly: isthmus of thyroid gland over second to
fourth tracheal rings, inferior thyroid veins, sternohyoid, sternothyroid.
• Laterally: lobes of thyroid gland, carotid sheath.
• Posteriorly: oesophagus, recurrent laryngeal nerves in
the groove between the trachea and oesophagus.
In the Thorax
• Anteriorly: brachiocephalic artery and le common
carotid artery, le brachiocephalic vein, thymus.
• Posteriorly: oesophagus, recurrent laryngeal nerves.
• Right side: vagus nerve, azygos vein, pleura.
• Le side: aortic arch, le common carotid artery, le
subclavian vein, le recurrent laryngeal nerve, pleura.
Left main bronchus
Left upper
Left lower
Apical segmental bronchus
of lower lobe
BRONCHI (Fig. 1.6)
e trachea terminates at the level of the sternal angle,
dividing into right and le bronchi.
Right main bronchus:
• wider, shorter and more vertical than le
• approximately 2.5 cm long
• passes downwards and laterally behind ascending
aorta and superior vena cava (SVC) to enter hilum of
lung
• azygos vein arches over it from behind to enter
SVC
• pulmonary artery lies rst below and then anterior
to it
• gives o upper lobe bronchus before entering lung
• divides into bronchi to middle and inferior lobes
within the lung.
Le main bronchus:
• approximately 5 cm long
• passes downwards and laterally below arch of aorta,
in front of oesophagus and descending aorta
CHAPTER 1 The Thorax
9
• gives o no branches until it enters hilum of lung,
where it divides into bronchi to upper and lower lobes
• pulmonary artery lies at rst anterior to, and then
above, the bronchus.
Clinical Points
• e trachea may be displaced or compressed by pathological enlargement of adjacent structures, e.g. thyroid,
arch of aorta.
• e trachea may be displaced if the mediastinum is
pushed across, e.g. by tension pneumothorax displacing
it to the opposite side.
• Calcication of tracheal rings may occur in the elderly
and be visible on X-ray.
• Because the right main bronchus is wider and more vertical, foreign bodies are more likely to be aspirated into
this bronchus.
• Distortion and widening of the carina (angle between
the main bronchi), seen at bronchoscopy, usually indicates enlargement of the tracheobronchial lymph nodes
at the bifurcation by carcinoma.
Anatomy of Tracheostomy
• Either a vertical or cosmetic transverse skin incision
may be employed.
• A vertical incision is made downwards from the cricoid
cartilage passing between the anterior jugular veins.
• A transverse cosmetic skin crease incision may be used
placed halfway between the cricoid cartilage and suprasternal notch.
• e incision goes through the skin and supercial fascia
(in the transverse incision, platysma will be located in
the lateral part of the incision).
• e pretracheal fascia is split longitudinally.
• Bleeding may be encountered from the anterior relations at this point, namely anastomosis between anterior jugular veins across the midline, inferior thyroid
veins, thyroidea ima artery (when present).
• In the young child, the brachiocephalic artery, the le
brachiocephalic vein and the thymus may be apparent
in the lower part of the wound.
• Aer splitting the pretracheal fascia and retracting the
strap muscles, the isthmus of the thyroid will be encountered and may be either retracted upwards or divided
between clamps to expose the cartilages of the trachea.
• An opening is then made in the trachea to admit the
tracheostomy tube.
• Each has a blunt apex extending above the sternal end of
the rst rib.
• Each has a concave base related to the diaphragm.
• Each has a convex parietal surface related to the ribs.
• Each has a concave mediastinal surface related to the
pericardium.
• Each has a thin anterior border overlapping the pericardium and decient on the le at the cardiac notch.
• Each has a hilum where the bronchi and vessels pass to
and from the root.
• Each has a rounded posterior border that occupies the
groove by the side of the vertebrae.
Right Lung
• Slightly larger than the le.
• Divided into three lobes—upper, middle and lower—by
the oblique and horizontal ssures.
Left Lung
• Has only an oblique ssure and therefore only two lobes.
• e anterior border has a notch produced by the heart
(cardiac notch).
• e equivalent of the middle lobe of the right lung in the
le lung is the lingula, which lies between the cardiac
notch and oblique ssure.
Roots of the Lungs
• Comprise the principal bronchus, the pulmonary artery,
the two pulmonary veins, the bronchial arteries and
veins, pulmonary plexuses of nerves, lymph vessels,
bronchopulmonary lymph nodes.
• Chief structures composing the root of each lung are
arranged in a similar manner from before backwards on
both sides, i.e. the upper of the two pulmonary veins in
front; pulmonary artery in the middle; bronchus behind.
• Arrangement diers from above downwards on the two
sides:
• right side from above downwards: upper lobe bron-
chus, pulmonary artery, right principal bronchus,
lower pulmonary vein
• le side: pulmonary artery, bronchus, lower pulmo-
nary vein.
• Visceral and parietal pleura meet as a sleeve surrounding the structures passing to and from the lung. is
sleeve hangs down inferiorly at the pulmonary ligament. It allows for expansion of the pulmonary veins
with increased blood ow.
THE LUNGS
• Conical in shape.
• Conform to shape of pleural cavities.
BRONCHOPULMONARY SEGMENTS (Fig. 1.7)
• Each lobar bronchus divides to supply the bronchopulmonary segments of the lung.
10
Lateral Medial
1
SECTION I Anatomy
2
1
2
3
6
4
5
8
10
9
A
Lateral Medial
1
2
3
6
4
8
5
10
9
B
6
10
3
4
5
8
3
1
3
5
4
7
8
9
1
2
6
10
9
5
10
2
6
7
10
8
9
1
2
6
3
4
8
5
8
9
Fig. 1.7 Bronchi and bronchopulmonary segments for the lungs. Divisions of the main bronchi in the centre,
with corresponding pulmonary segments on the surfaces. (A) Right lung upper lobe: 1 = apical, 2 = posterior,
3 = anterior; middle lobe, 4 = lateral, 5 = medial; lower lobe, 6 = apical, 7 = medial basal (cardiac), 8 = anterior basal, 9 = lateral basal, 10 = posterior basal. (B) Left lung upper lobe: 1, 2 = apicoposterior, 3 = anterior;
lingula (middle lobe), 4 = superior, 5 = inferior; lower lobe, 6 = apical, 8 = anterior basal, 9 = lateral basal,
10 = posterior basal.
• ere are 10 bronchopulmonary segments for each
lung.
• Each is supplied by a segmental bronchus, artery and
vein.
• ere is no communication with adjacent segments.
• It is possible to remove an individual segment without
interfering with the function of adjacent segments.
• ere is little bleeding or alveolar air leak from the raw
lung surface if excision takes place accurately along the
boundaries (marked by intersegmental veins).
• Each segment is wedge-shaped with the apex at the
hilum and the base at the lung surface.
• Each segment takes its name from that of the supplying
segmental bronchus.
Blood Supply
• Pulmonary trunk arises from the right ventricle.
• Directed upwards in front of the ascending aorta.
• Passes upwards and backwards on the le of the ascending aorta to reach concavity of the aortic arch.
• Divides in front of the le main bronchus into right and
le branches.
Right Pulmonary Artery
• Passes in front of oesophagus to the root of the right
lung behind the ascending aorta and SVC.
• At the root of the lung it lies in front of and between the
right main bronchus and its upper lobe branch.
• Divides into three branches, one for each lobe.
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