Illustrated Clinical Anatomy This page intentionally left blank Illustrated Clinical Anatomy 2nd Edition Peter H. Abrahams MB BS FRCS(ED) FRCR DO (HON) Professor of Clinical Anatomy, Warwick Medical School, UK Director of Anatomy, West Midlands Surgical Training Centre, UHCW NHS Trust Extraordinary Professor, Department of Anatomy, University of Pretoria, South Africa Fellow, Girton College, Cambridge Professor of Clinical Anatomy, St George’s University, Grenada, West Indies Examiner to the Royal College of Surgeons, UK Family Practitioner, Brent, London, UK John L. Craven MD FRCS Formerly Consultant Surgeon, York District Hospital and past Chairman of the Primary Examiners of the Royal College of Surgeons of England, UK John S.P. Lumley MS FRCS FMAA (HON) FGA Emeritus Professor of Vascular Surgery, University of London Past Council Member and Chairman of Primary Fellowship Examiners, Royal College of Surgeons of England, UK Consultant Radiological Advisor: Jonathan D. Spratt BM BCHIR MA (CANTAB) FRCS (ENG) FRCS(GLAS) FRCR Clinical Director of Radiology, University Hospital of North Durham; Honorary Lecturer in Anatomy, University of Durham; Examiner in Anatomy, Royal College of Surgeons of England, UK First published in Great Britain in 2005 by Hodder Arnold This second edition published in 2011 by Hodder Arnold, an imprint of Hodder Education, a division of Hachette UK, 338 Euston Road, London NW1 3BH http://www.hodderarnold.com © 2011 Peter Abrahams, John Craven, John Lumley The illustrations listed in the acknowledgement page are © St Bartholomew’s Hospital and the Royal London School of Medicine and Dentistry of Queen Mary and Westfield College, London, 2005 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN: 9781 444109 252 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Project Editor: Stephen Clausard Production Controller: Jonathan Williams Cover Design: Amina Dudhia Illustrations: Cactus Design and Illustration Ltd Cover image: © Mehau Kulyk/Science Photo Library Typeset in 9.5/12 pt Sabon by Phoenix Photosetting, Chatham, Kent Printed in India What do you think about this book? Or any other Hodder Education title? Please visit our website at www.hodderarnold.com This eBook does not include access to the VitalBook edition that was packaged with the printed version of the book. C Contents Preface vii Acknowledgements ix INTRODUCTION 1 The structure of the body – the systems and organs 2 PART I The thorax 23 1. The thoracic wall and diaphragm 24 2. The thoracic cavity 35 3. The mediastinal structures 49 4. The pleura and lungs 59 PART II The abdomen 73 5. The abdominal wall and peritoneum 75 6. The abdominal alimentary tract 89 7. The liver, spleen and pancreas 101 8. The kidneys and posterior abdominal wall 110 9. The pelvis 121 10. The perineum 137 PART III The back 151 11. The vertebral column and spinal cord 152 PART IV The upper limb 163 12. The shoulder region 164 13. The elbow and forearm 185 14. The wrist and hand 203 PART V The lower limb 217 15. The hip and thigh 218 16. The knee, leg and dorsum of the foot 241 17. The foot 263 vi Contents PART VI The head and neck 277 18. The skull, scalp and face 279 19. The orbit, nose and mouth 292 20. The temporomandibular joint, pharynx and larynx 313 21. The ear, intracranial region and cranial nerves 328 22. The neck 345 23. Vessels, nerves and lymphatic drainage 356 24. The meninges and blood supply of the cranial cavity 368 Index 377 P Preface to the second edition Anatomy is an essential component of all clinical practice. In the first edition of this book our aim was to capitalize on our collective experience of over a century of teaching, publishing and practicing anatomy to produce a concise understandable and highly illustrated text, to pass on our personal enthusiasm for the subject to a future generation of doctors. So we were naturally delighted when it was awarded the Richard Asher Prize for the best new medical textbook at the Royal Society of Medicine/Society of Authors Book Awards, and was Highly Commended at the BMA Book Awards in 2005. This second edition has taken notice of recommendations and reviews as well as the 2007 document of the education committee of the Anatomical Society of GB and Ireland (Eur J Anat 11 3–18 2007), which complements the earlier American Association of Clinical Anatomists document (Clin Anat 9 71–99 1996) – both of which define their view of the core knowledge of clinical anatomy required by medical students. With both of these documents to hand as well as our own personal clinical experience we have tried to cover the major anatomical factual content needed for a young physician or surgeon of the 21st century and we have included within the blue shaded columns illustration and explanation of hundreds of common clinical conditions, which each have an anatomical diagnostic basis. Suggestions from students and colleagues have contributed to these changes. We have tried hard to keep the book short enough so as not to overwhelm students and have liberally illustrated it with clinical images and case presentations. The text is organized regionally but, since the basic clinical and diagnostic anatomy required for all doctors is essentially the same worldwide, it doesn’t really matter which educational system your own medical school uses. So it is also easy to use for a systems approach or even in a problem-based curriculum as virtually every common anatomical problem has been illustrated – all these illustrations are available for your own personal use as part of the Vitalsource e-book. It is irrelevant which exams you are preparing for; whether medical school, MRCS part A, or USMLE1. As examiners of decades of experience in each of these areas we know that the anatomy required is essentially the same. Details for postgraduates have been included in tables and with extra labeling on many illustrations as well as both clinical and radiological images. As in the first edition there are reasoned MCQs and applied problems at the end of every chapter, but we have now added extended multiple questions (EMQs) which are nowadays a common feature in all British postgraduate medical examinations. We are most grateful to Jonathan Spratt for upgrading many of the radiological images that illustrate both normal and pathological anatomy using many different imaging modalities such as cross sectional MR and CT. All of these complement over four hundred original drawings and a similar number of surface anatomy and clinical conditions in this highly visual textbook. These can all be transferred into your own study files by using the simple password from the front of this book. P Preface to the first edition This new textbook, focusing on clinically relevant anatomy, has been many years in the planning. Collectively we have over a century of experience teaching and examining in both medicine and anatomy, at undergraduate, postgraduate and specialist levels. This experience has allowed us to respond to the evolution of new integrated courses in medical schools worldwide and address the dichotomy between the needs of students and of trainee doctors. We have followed the American Association of Clinical Anatomists’ (AACA) core curriculum (Clinical Anatomy 1996 9: 71–99) as our guide to what is ‘core’, covering the clinical anatomy of most common diseases. So that medical students are not overwhelmed with detail we have kept the text simple and provided additional specialist anatomy in the illustrations and Tables. (For example, we have set out the details of muscular anatomy in a highly structured Table rather than describing them in the main text.) Clinical detail in the text has been clearly shaded blue so that our readers can easily identify it. We have focused on normal and abnormal living anatomy of the whole body, excluding the nervous system as it is a book in itself and well covered in separate texts. Although we have not included a separate chapter on embryology, fetal development and paediatric anatomy have been integrated in the appropriate sections where clinically relevant. Anatomy is a visually intense subject. Acknowledging the reduction in, or even disappearance of, dissection time in medical courses we have supplemented our text with a wealth of colour illustrations. Four hundred new anatomical drawings have been produced for the text; these include additional anatomical detail for specialist readers. With the help of Jonathan Spratt, we have taken advantage of new imaging techniques to show normal and abnormal living anatomy; each modality is well represented in its relevant area, particularly cross-sectional anatomy.