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Blackwell Publishing - Clinical Anatomy 11th Edition,Blackwell Publishing
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Search Metadata Search text contents Search TV news captions Search archived websites Advanced Search. God By Alister Mc Grath Dawkins Blackwell Publishing Item Preview. remove-circle Share or Embed This Item. EMBED for wordpress. com hosted blogs and archive. Want more? Advanced embedding details, examples, and help! Usage CC0 1. plus-circle Add Review. There are no reviews yet. Be the first one to write a review. download 1 file. The superior mediastinum This is bounded in front by the manubrium sterni and behind the first four thoracic vertebrae Fig. Above, it is in direct continuity with the root of the neck and below it is continuous with the three compartments of the inferior mediastinum.
Its principal contents are: the great vessels, trachea, oesophagus, thymus— mainly replaced by fatty tissue in the adult, thoracic duct, vagi, left recurrent laryngeal nerve and the phrenic nerves Fig. The arch of the aorta is directed anteroposteriorly, its three great branches, the brachiocephalic, left carotid and left subclavian arteries, ascend to the thoracic inlet, the first two forming a V around the trachea. The brachiocephalic veins lie in front of the arteries, the left running almost horizontally across the superior mediastinum and the right vertically downwards; the two unite to form the superior vena cava. Posteriorly lies the trachea with the oesophagus immediately behind it lying against the vertebral column.
The oesophagus The oesophagus, which is 10 in 25 cm long, extends from the level of the lower border of the cricoid cartilage at the level of the 6th cervical vertebra to the cardiac orifice of the stomach Fig. Course and relations Cervical In the neck it commences in the median plane and deviates slightly to the left as it approaches the thoracic inlet. vertebral fascia are behind it and on either side it is related to the common carotid arteries and the recurrent laryngeal nerves. On the left side it is also related to the subclavian artery and the terminal part of the thoracic duct Fig. Thoracic The thoracic part traverses first the superior and then the posterior mediastinum. From being somewhat over to the left, it returns to the midline at T5 then passes downwards, forwards and to the left to reach the oesophageal opening in the diaphragm T For convenience, the relations of this part are given in sequence from above downwards.
Posteriorly lie the thoracic vertebrae, the thoracic duct, the azygos vein and its tributaries and, near the diaphragm, the descending aorta. On the left side it is related to the left subclavian artery, the terminal part of the aortic arch, the left recurrent laryngeal nerve, the thoracic duct and the left pleura. In the posterior mediastinum it relates to the descending thoracic aorta before this passes posteriorly to the oesophagus above the diaphragm. On the right side there is the pleura and the azygos vein. Below the root of the lung the vagi form a plexus on the oesophagus, the left vagus lying anteriorly, the right posteriorly.
In the abdomen, passing forwards through the opening in the right crus of the diaphragm, the oesophagus comes to lie in the oesophageal groove on the posterior surface of the left lobe of the liver, covered by peritoneum on its anterior and left aspects. Behind it is the left crus of the diaphragm. Blood supply is from the inferior thyroid artery, branches of the descending thoracic aorta and the left gastric artery. The veins from the cervical part drain into the inferior thyroid veins, from the thoracic portion into the azygos vein and from the abdominal portion partly into the azygos and partly into the left gastric veins. The lymphatic drainage is from a peri-oesophageal lymph plexus into the posterior mediastinal nodes, which drain both into the supraclavicular nodes and into nodes around the left gastric vessels.
It is not uncommon to be able to palpate hard, fixed supraclavicular nodes in patients with advanced oesophageal cancer. Radiographically, the oesophagus is studied by X-rays taken after a barium swallow, in which it is seen lying in the retrocardiac space just in front of the vertebral column. Anteriorly, the normal oesophagus is indented from above downwards by the three most important structures that cross it, the arch of the aorta, the left bronchus and the left atrium. In portal hypertension these veins distend into large collateral channels, oesophageal varices, which may then rupture with severe haemorrhage probably as a result of peptic ulceration of the overlying mucosa. This is therefore the side of election to approach the oesophagus surgically. Development of the oesophagus The oesophagus develops from the distal part of the primitive fore-gut.
From the floor of the fore-gut also differentiate the larynx and trachea, first as a groove the laryngotracheal groove which then converts into a tube, a bud on each side of which develops and ramifies into the lung. This close relationship between the origins of the oesophagus and trachea accounts for the relatively common malformation in which the upper part of the oesophagus ends blindly while the lower part opens into the lower trachea at the level of T4 oesophageal atresia with tracheooesophageal fistula. Less commonly, the upper part of the oesophagus opens into the trachea, or oesophageal atresia occurs without concomitant fistula into the trachea.
Rarely, there is a tracheo-oesophageal fistula without atresia Fig. The thoracic duct Figs 37, The cisterna chyli lies between the abdominal aorta and right crus of the diaphragm. It drains lymphatics from the abdomen and the lower limbs, then passes upwards through the aortic opening to become the thoracic duct. This ascends behind the oesophagus, inclines to the left of the oesophagus at the level of T5, then runs upwards behind the carotid sheath, descends over the subclavian artery and drains into the commencement of the left brachiocephalic vein see Fig.
The left jugular, subclavian and mediastinal lymph trunks, draining the left side of the head and neck, upper limb and thorax respectively, usually join the thoracic duct, although they may open directly into the adjacent large veins at the root of the neck. The upper oesophagus ends blindly; the lower oesophagus communicates with the trachea at the level of the 4th thoracic vertebra. Jugular Oesophagus Superior vena cava lymph Subclavian trunk Left subclavian vein Left brachiocephalic vein Azygos vein Thoracic duct Cisterna chyli Fig. On the right side, the right subclavian, jugular and mediastinal trunks may open independently into the great veins.
Usually the subclavian and jugular trunks first join into a right lymphatic duct and this may be joined by the mediastinal trunk so that all three then have a common opening into the origin of the right brachiocephalic vein. This usually results in lymphoedema of the legs and scrotum but occasional involvement of the main channels of the trunk and thorax is followed by chylous ascites, chyluria and chylous pleural effusion. If noticed at operation, the injured duct should be ligated; lymph then finds its way into the venous system by anastomosing channels. If the accident is missed, there follows an unpleasant chylous fistula in the neck. Such injuries are followed by a chylothorax. The thoracic sympathetic trunk Fig. It then passes behind the medial arcuate ligament of the diaphragm to continue as the lumbar sympathetic trunk. The thoracic chain bears a ganglion for each spinal nerve; the first frequently joins the inferior cervical ganglion to form the stellate ganglion.
Each ganglion receives a white ramus communicans containing preganglionic fibres from its corresponding spinal nerve and donates back a grey ramus, bearing postganglionic fibres. Common cartoid Aortic arch Sympathetic chain Bronchus Greater splanchnic nerve Phrenic nerve DIAPH RAGM a Thoracic sympathetic ganglion trunk 1st Bronchus B RI Contribution to greater splanchnic nerve Oesophagus and trachea Vagus and phrenic nerves Azygos vein Superior vena cava R. Pulmonary A. Cut edge of pleura Inferior vena cava RAGM DIAPH b Fig. b The right mediastinum. They lie medial to the sympathetic trunk on the bodies of the thoracic vertebra and are quite easily visible through the parietal pleura For their distribution see pages and Clinical features A high spinal anaesthetic will produce temporary hypotension by paralysing the sympathetic vasoconstrictor preganglionic outflow from spinal segment T5 downwards, passing to the abdominal viscera.
On the examination of a chest radiograph The following features should be examined in every radiograph of the chest. Centering and density of film The sternal ends of the two clavicles should be equidistant from the shadow of the vertebral spines. General shape Any abnormalities in the general form of the thorax scoliosis, kyphosis and the barrel chest of emphysema, for example should always be noted before other abnormalities are described. Bony cage The thoracic vertebrae should be examined first, then each of the ribs in turn counting conveniently from their posterior ends and comparing each one with its fellow of the opposite side , and finally clavicles and scapulae.
Unless this procedure is carried out systematically, important diagnostic clues e. the presence of a cervical rib, or notching of the ribs by enlarged anastomotic vessels are liable to be missed. The mediastinum The outline of the mediastinum should be traced systematically. Special note should be made of the size of the heart, of mediastinal shift and of the vessels and nodes at the hilum of the lung. Lung fields Again, systematic examination of the lung fields visible in each intercostal space is necessary if slight differences between the two sides are not to be overlooked. Abnormalities When this scheme has been carefully followed, any abnormalities in the bony cage, the mediastinum or lung fields should now be apparent. They should then be defined anatomically as accurately as possible and checked, where necessary, by reference to a film taken from a different angle.
Radiographic appearance of the heart For the appearance of the heart as seen at fluoroscopy, reference should be made to a standard work in radiology or cardiology. In the present account, only the more important features of the heart and great vessels which can be seen in standard posteroanterior and oblique lateral radiographs of the chest will be described. The heart and great vessels in anteroposterior radiographs Fig. These should be examined as follows. Size and shape of the heart Normally the transverse diameter should not exceed half the total width of the chest, but since it varies widely with bodily build and the position of the heart, these factors must also be assessed. The shape of the cardiac shadow also varies a good deal with the position of the heart, being long and narrow in a vertically disposed heart and broad and rounded in the socalled horizontal heart. The right border of the mediastinal shadow is formed from above downwards by the right brachiocephalic vein, the superior vena cava and the right atrium.
Beneath this there are, successively, the shadows due to the pulmonary trunk or the infundibulum of the right ventricle , the auricle of the left atrium, and the left ventricle. The shadow of the inferior border of the heart blends centrally with that of the diaphragm, but on either side the two shadows are separated by the well-defined cardiophrenic angles. The heart and great vessels in anterior oblique radiographs The left oblique view Fig. The right oblique view Fig. posterior wall forms the upper half of the posterior border of the cardiac shadow. This border can be defined more accurately by giving the patient barium paste to swallow; the outlined oesophagus is indented by an enlarged left atrium. The xiphoid. The costal margin extends from the 7th costal cartilage at the xiphoid to the tip of the 12th rib although the latter is often difficult to feel ; this margin bears a distinct step, which is the tip of the 9th costal cartilage. Identify this tubercle by direct palpation and also by running the fingers along the adductor longus tendon tensed by flexing, abducting and externally rotating the thigh to its origin at the tubercle.
Feel the firm vas deferens between the finger and thumb as it lies within the spermatic cord at the scrotal neck. Trace the vas upwards and note that it passes medially to the pubic tubercle and thence through the external inguinal ring, which can be felt by invaginating the scrotal skin with the fingertip. Vertebral levels Fig. It also corresponds to the level of termination of the spinal cord. This corresponds to the level of the bifurcation of the aorta. It is also a useful landmark in performing a lumbar puncture, since it is well below the level of the termination of the spinal cord, which is approximately at L1 see page In the healthy adult it lies at the junction of L3 and L4 vertebrae.
It is lower in the infant and, naturally, when the abdomen is pendulous. It is higher in late pregnancy. Surface markings Fig. b The surface markings of the liver and aorta. The upper border follows a line passing through the 5th intercostal space on each side. Spleen This underlies the 9th, 10th and 11th ribs posteriorly on the left side commencing 2 in 5 cm from the midline. Pancreas The transpyloric plane defines the level of the neck of the pancreas which overlies the vertebral column. From this landmark, the head can be imagined passing downward and to the right, the body and tail passing upwards and to the left.
Aorta This terminates just to the left of the midline at the level of the iliac crest at L4; a pulsatile swelling below this level may thus be an iliac, but cannot be an aortic, aneurysm. Kidneys The lower pole of the normal right kidney may sometimes be felt in the thin subject on deep inspiration. Anteriorly, the hilum of the kidney lies on the transpyloric plane four finger breadths from the midline. Posteriorly, the upper pole of the kidney lies deep to the 12th rib. The right kidney normally extends about 1 in 2. Using these landmarks, the kidney outlines can be projected on to either the anterior or posterior aspects of the abdomen. In some perfectly normal thin people, especially women, it is possible to palpate the lower pole of the right kidney and the sigmoid colon if loaded with faeces; in most of us, only the aorta is palpable.
If there were, we would presumably be unable to take a deep breath or enjoy a large meal! This, in the lower abdomen, forms a superficial fatty layer of Camper and a deeper fibrous layer of Scarpa. In the perineum it is attached behind to the perineal body and posterior margin of the perineal membrane and, laterally, to the rami of the pubis and ischium. It is because of these attachments that a rupture of the urethral bulb may be followed by extravasation of blood and urine into the scrotum, perineum and penis and then into the lower abdomen deep to the fibrous fascial plane, but not by extravasation downwards into the lower limb, from which the fluid is excluded by the attachment of the fascia to the deep fascia of the upper thigh.
Nerve supply The segmental nerve supply of the abdominal muscles and the overlying skin is derived from T7 to L1. This distribution can be mapped out approximately if it is remembered that the umbilicus is supplied by T10 and the groin and scrotum by L1 via the ilio-inguinal and iliohypogastric nerves— see Fig. The muscles of the anterior abdominal wall These are of considerable practical importance because their anatomy forms the basis of abdominal incisions. The rectus abdominis Fig. At the tip of the xiphoid, at the umbilicus and half-way between, are three constant transverse tendinous intersections; below the umbilicus there is sometimes a fourth. These intersections are seen only on the anterior aspect of the muscle and here they adhere to the anterior rectus sheath. Posteriorly they are not in evidence and, in consequence, the rectus muscle is completely free behind. At each intersection, vessels from the superior epigastric artery and vein pierce the rectus.
The sheath in which the rectus lies is formed, to a large extent, by the aponeurotic expansions of the lateral abdominal muscles Fig. The anterior rectus sheath on the left side has been reflected laterally. Posteriorly lie the posterior part of this split internal oblique aponeurosis and the aponeurosis of transversus abdominis. The posterior wall at this level is made up of the only other structures available — the transversalis fascia, the thickened extraperitoneal fascia of the lower abdominal wall , and peritoneum.
The posterior junction between b and c is marked by the arcuate line of Douglas, which is the lower border of the posterior aponeurotic part of the rectus sheath. At this point the inferior epigastric artery and vein from the external iliac vessels enter the sheath, pass upwards and anastomose with the superior epigastric vessels which are terminal branches of the internal thoracic artery and vein. The rectus sheaths fuse in the midline to form the linea alba stretching from the xiphoid to the pubic symphysis. The lateral muscles of the abdominal wall comprise the external and internal oblique and the transverse muscles. These correspond to the three layers of muscle of the chest wall — external, internal and innermost intercostals, and, like them, have their neurovascular bundles running between the second and third layer.
They are clinically important in making up the rectus sheath and the inguinal canal, and also because they must be divided in making lateral abdominal incisions. Their attachments can be remembered when one bears in mind that they fill the space between the costal margin above, the iliac crest below, and the lumbar muscles covered by lumbar fascia behind. Medially, as already noted, they constitute the rectus sheath and thence blend into the linea alba from xiphoid to pubic crest. The obliquus externus abdominis external oblique arises from the outer surfaces of the lower eight ribs and fans out into the xiphoid, linea alba, the pubic crest, pubic tubercle and the anterior half of the iliac crest.
From the pubic tubercle to the anterior superior iliac spine its lower border forms the aponeurotic inguinal ligament of Poupart. The obliquus internus abdominis internal oblique arises from the lumbar fascia, the anterior two-thirds of the iliac crest and the lateral two-thirds of the inguinal ligament. It is inserted into the lowest six costal cartilages, linea alba and the pubic crest. The transversus abdominis arises from the lowest six costal cartilages interdigitating with the diaphragm , the lumbar fascia, the anterior twothirds of the iliac crest and the lateral one-third of the inguinal ligament; it is inserted into the linea alba and the pubic crest. Note that the external oblique passes downwards and forwards, the internal oblique upwards and forwards and the transversus transversely.
The anatomy of abdominal incisions Incisions to expose the intraperitoneal structures represent a compromise on the part of the operator. On the one hand he requires maximum access; on the other hand he wishes to leave a scar which lies, if possible, in an unobtrusive crease, and which will have done minimal damage to the muscles of the abdominal wall and to their nerve supply. The nerve supply to the lateral abdominal muscles forms a richly communicating network so that cuts across the lines of fibres of these muscles, with division of one or two nerves, produce no clinical ill-effects. The segmental nerve supply to the rectus, however, has little cross-communication and damage to these nerves must, if possible, be avoided. The copious anastomoses between the blood vessels supplying the abdominal muscles make damage to these by operative incisions of no practical importance. Midline incision The midline incision is made through the linea alba. Superiorly, this is a relatively wide fibrous structure, but below the umbilicus it becomes almost hair-line and the surgeon may experience difficulty in finding the exact point of cleavage between the recti at this level.
Being made of fibrous tissue only, it provides an almost bloodless line along which the abdomen can be opened rapidly and, if necessary, from Dan in the North to Beersheba in the South! Paramedian incision The paramedian incision is placed 1 in 2. This incision has the advantage that, on suturing the peritoneum, the rectus slips back into place to cover and protect the peritoneal scar. The adherence of the anterior sheath to the rectus muscle at its tendinous intersections means that the sheath must be dissected off the muscle at each of these sites, and at each of these a segmental vessel requires division. Having done this, the rectus is easily slid laterally from the posterior sheath from which it is quite free. The posterior sheath and the peritoneum form a tough membrane down to half-way between pubis and umbilicus, but it is much thinner and more fatty below this where, as we have seen, it loses its aponeurotic component and is made up of only transversalis fascia and peritoneum.
The inferior epigastric vessels are seen passing under the arcuate line of Douglas in the posterior sheath and usually require division in a low paramedian incision. The rectus receives its nerve supply laterally and the muscle medial to the incision must, in consequence, be deprived of its innervation and undergo atrophy; it is an incision therefore best avoided. Subcostal incision The subcostal Kocher incision is used on the right side in biliary surgery and, on the left, in exposure of the spleen. The skin incision commences at the midline and extends parallel to, and 1 in 2. The anterior rectus sheath is opened, the rectus cut and the posterior sheath with underlying adherent peritoneum incised. The small 8th intercostal nerve branch to the rectus is sacrificed but the larger and more important 9th nerve, in the lateral part of the wound, is preserved. The divided rectus muscle is held by the intersections above and below and retracts very little.
It subsequently heals by fibrous tissue. This incision is valuable in the patient with the wide subcostal angle. Where this angle is narrow, the paramedian incision is usually preferred. The aponeurosis of the external oblique is incised in the line of its fibres obliquely downwards and medially ; the internal oblique and transversus muscles are then split in the line of their fibres, and retracted without their having to be divided. On closing the incision, these muscles snap together again, leaving a virtually undamaged abdominal wall. Transverse and oblique incisions Incisions cutting through the lateral abdominal muscles do not damage their richly anastomosing nerve supply and heal without weakness. They are useful, for example, in exposing the sigmoid colon or the caecum or, by displacing the peritoneum medially, extraperitoneal structures such as the ureter, sympathetic chain and the external iliac vessels. Thoraco-abdominal incisions An upper paramedian or upper oblique abdominal incision can be extended through the 8th or 9th intercostal space, the diaphragm incised and an extensive exposure achieved of both upper abdomen and thorax.
Paracentesis abdominis Intraperitoneal fluid collections can be evacuated via a cannula inserted through the abdominal wall. The coils of gut are not in danger in this procedure because they are mobile and are pushed away by the tip of the trocar. These two landmarks are also used for insertion of cannulae for laparoscopic surgery. The inguinal canal Fig. Questions on the anatomy of this region are probably asked more often than any other in examinations because of its importance in diagnosis and treatment of hernias. The canal is 1. It passes downwards and medially from the internal to the external inguinal rings and lies parallel to and immediately above, the inguinal ligament.
The conjoint tendon represents the fused common insertion of the internal oblique and transversus into the pubic crest and pectineal line. The internal or deep ring represents the point at which the spermatic cord pushes through the transversalis fascia, dragging from it a covering which forms the internal spermatic fascia. This ring is demarcated medially by the inferior epigastric vessels passing upwards from the external iliac artery and vein. The external or superficial ring is a V-shaped defect in the external oblique aponeurosis and lies immediately above and medial to the pubic tubercle. The inguinal canal transmits the spermatic cord and the ilio-inguinal nerve in the male and the round ligament and ilio-inguinal nerve in the female. The spermatic cord comprises Fig. Clinical features An indirect inguinal hernia passes through the internal ring, along the canal and then, if large enough, emerges through the external ring and descends into the scrotum. If reducible, such a hernia can be completely controlled by pressure with the fingertip over the internal ring, which lies 0.
This pulse can be felt at the mid-inguinal point, half-way between the anterior superior iliac spine and the symphysis pubis see Fig. If the hernia protrudes through the external ring, it can be felt to lie above and medial to the pubic tubercle, and is thus differentiated from a femoral hernia emerging from the femoral canal, which lies below and lateral to this landmark see Fig. A direct inguinal hernia pushes its way directly forwards through the posterior wall of the inguinal canal. Since it lies medial to the internal ring, it is not controlled by digital pressure applied immediately above the femoral pulse. Occasionally, a direct hernia becomes large enough to push its way through the external ring and then into the neck of the scrotum. This is so unusual that one can usually assume that a scrotal hernia is an indirect hernia. The only certain way of determining the issue is at operation; the inferior epigastric vessels demarcate the medial edge of the internal ring, therefore an indirect hernia sac will pass lateral and a direct hernia medial to these vessels.
Quite often both a direct and an indirect hernia coexist; they bulge through on each side of the inferior epigastric vessels like the legs of a pair of pantaloons. Peritoneal cavity The endothelial lining of the primitive coelomic cavity of the embryo becomes the thoracic pleura and the abdominal peritoneum. Each is invaginated by ingrowing viscera which thus come to be covered by a serous membrane and to be packed snugly into a serous-lined cavity, the visceral and parietal layer respectively. In the male, the peritoneal cavity is completely closed, but in the female it is perforated by the openings of the uterine tubes which constitute a possible pathway of infection from the exterior. To revise the complicated attachments of the peritoneum, it is best to start at one point and trace this membrane in an imaginary round-trip of the abdominal cavity, aided by Figs 47 and departure is the parietal peritoneum of the anterior abdominal wall below the umbilicus.
At this level the membrane is smooth apart from the shallow ridges formed by the median umbilical fold the obliterated fetal urachus passing from the bladder to the umbilicus , the medial umbilical folds the obliterated umbilical arteries passing to the umbilicus from the internal iliac arteries and the lateral umbilical folds the peritoneum covering the inferior epigastric vessels. A cicatrix can usually be felt and seen at the posterior aspect of the umbilicus, and from this the falciform ligament sweeps upwards and slightly to the right of the midline to the liver. In the free border of this ligament lies the ligamentum teres the obliterated fetal left umbilical vein which passes into the groove between the quadrate lobe and left lobe of the liver.
Elsewhere, the peritoneum sweeps over the inferior aspect of the diaphragm, to be reflected on to the liver leaving a bare area demarcated by the upper and lower coronary ligaments of the liver and on to the right margin of the abdominal oesophagus. After enclosing the liver for further details, see page 95 , the peritoneum descends from the porta hepatis as a double sheet, the lesser omentum, to the lesser curve of the stomach. Here it again splits to enclose this organ, reforms at its greater curve, then loops downwards, then up again to attach to the length of the transverse colon, forming the apron-like greater omentum. The transverse colon, in turn, is enclosed within this peritoneum which then passes upwards and backwards as the transverse mesocolon to the posterior abdominal wall, where it is attached along the anterior aspect of the pancreas.
diaphragm L. pleural cavity T12 b Fig. b The corresponding CT scan through T At the base of the transverse mesocolon, this double peritoneal sheet divides once again; the upper leaf passes upwards over the posterior abdominal wall to reflect on to the liver at the bare area , the lower leaf passes over the lower part of the posterior abdominal wall to cover the pelvic viscera and to link up once again with the peritoneum of the anterior wall. This posterior layer is, however, interrupted by its being reflected along an oblique line running from the duodenojejunal flexure, above and to the left, to the ileocaecal junction, below and to the right, to form the mesentery of the small intestine.
The mesentery of the small intestine, the lesser and greater omenta and mesocolon all carry the vascular supply and lymph drainage of their contained viscera. The lesser sac Fig. wall is formed by the spleen attached by the gastrosplenic and lienorenal ligaments. The right extremity of the sac opens into the main peritoneal cavity via the epiploic foramen or foramen of Winslow Fig. Notice that none of these important boundaries can be incised to release the strangulation; the bowel must be decompressed by a needle to allow its reduction. If the cystic artery is torn during cholecystectomy, haemorrhage can be controlled by this manoeuvre named after James Pringle , which then enables the damaged vessel to be identified and secured.
Intraperitoneal fossae A number of fossae occur within the peritoneal cavity into which loops of bowel may become caught and strangulated. The subphrenic spaces Fig. One or more of these spaces may become filled with pus a subphrenic abscess walled off inferiorly by adhesions. There are five subdivisions of clinical importance. The right and left subphrenic spaces lie between the diaphragm and the liver, separated from each other by the falciform ligament. The right and left subhepatic spaces lie below the liver. The right is the pouch of Morison and is bounded by the posterior abdominal wall behind and by the liver above. It communicates anteriorly with the right subphrenic space around the anterior margin of the right lobe of the liver and below both open into the general peritoneal cavity from which infection may track, for example, from a perforated appendix or a perforated peptic ulcer.
The left subhepatic space is the lesser sac which communicates with the right through the foramen of Winslow. It may fill with fluid as a result of a perforation in the posterior wall of the stomach or from an inflamed or injured pancreas to form a pseudocyst of the pancreas. The right extraperitoneal space lies between the bare area of the liver and the diaphragm. It may become involved in retroperitoneal infections or directly from a liver abscess. A finger is then passed upwards and forwards between liver and diaphragm to open into the abscess cavity. An anteriorly placed collection of pus below the diaphragm can alternatively be drained via an incision placed below and parallel to the costal margin. Nowadays, intra-abdominal fluid collections can often be drained percutaneously under ultrasound or CT control. The gastrointestinal tract The stomach The stomach is roughly J-shaped, although its size and shape vary considerably.
It tends to be high and transverse in the obese short subject and to be elongated in the asthenic individual; even in the same person, its shape depends on whether it is full or empty, on the position of the body and on the phase of respiration. The stomach has two surfaces — the anterior and posterior; two curvatures — the greater and lesser; and two orifices — the cardia and pylorus Fig. The stomach projects to the left, above the level of the cardia, to form the dome-like gastric fundus. Between the cardia and the pylorus lies the body of the stomach leading to a narrow portion, immediately preceding the pylorus, which is termed the pyloric antrum. The junction of the body with the pyloric antrum is marked by a distinct notch on the lesser curvature termed the incisura angularis. The junction of pylorus with duodenum is marked by a constriction externally and also by a constant vein of Mayo which crosses it at this level.
The thickened pyloric sphincter is easily felt and surrounds the lumen of the pyloric canal. The pyloric sphincter is an anatomical structure as well as a physiological mechanism. The cardia, on the other hand, although competent gastric contents do not flow out of your mouth if you stand on your head , is not demarcated by a distinct anatomical sphincter. The exact nature of the cardiac sphincter action is still not fully understood, but the following mechanisms have been suggested, each supported by some experimental and clinical evidence. Relations of the stomach Fig. The lesser omentum is attached along the lesser curvature of the stomach, the greater omentum along the greater curvature. These omenta contain the vascular and lymphatic supply of the stomach. The arterial supply Fig. The corresponding veins drain into the portal system. The lymphatic drainage of the stomach accompanies its blood vessels. The stomach can be divided into three drainage zones Fig.
This extensive lymphatic drainage and the technical impossibility of its complete removal is one of the serious problems in dealing with stomach cancer. Involvement of the nodes along the splenic vessels can be dealt with by removing spleen, gastrosplenic and lienorenal ligaments and the body and tail of the pancreas. Lymph nodes among the gastro-epiploic vessels are removed by excising the greater omentum. However, involvement of the nodes around the aorta and the head of the pancreas may render the growth incurable. The vagal supply to the stomach Fig. The anterior nerve lies close to the stomach wall but the posterior, and larger, nerve is at a little distance from it. The anterior Fig. The posterior vagus gives branches to both the anterior and posterior aspects of the body of the stomach but the bulk of the nerve forms the coeliac branch. This runs along the left gastric artery to the coeliac ganglion for distribution to the intestine, as far as the midtransverse colon, and the pancreas.
The exact means by which the vagal fibres reach the stomach is of considerable practical importance to the surgeon. The gastric divisions of both the anterior and posterior vagi reach the stomach at the cardia and descend along the lesser curvature between the anterior and posterior peritoneal attachments of the lesser omentum the anterior and posterior nerves of Latarjet. The stomach is innervated by terminal branches from the anterior and posterior gastric nerves and it is, therefore, possible to divide those branches which supply the acid-secreting body of the stomach yet preserving the pyloric innervation highly selective vagotomy, see below. The vagus constitutes the motor and secretory nerve supply for the stomach. When divided, in the operation of vagotomy, the neurogenic reflex gastric acid secretion is abolished but the stomach is, at the same time, rendered atonic so that it empties only with difficulty; because of this, total vagotomy must always be accompanied by some sort of drainage procedure, either a pyloroplasty to enlarge the pyloric exit and render the pyloric sphincter incompetent or by a gastrojejunostomy to drain the stomach into the proximal small intestine.
Drainage can be avoided if the nerve of Latarjet is preserved, thus maintaining the innervation and function of the pyloric antrum highly selective vagotomy. Ulceration into the splenic artery — a direct posterior relation—may cause torrential haemorrhage. In these circumstances the middle colic vessels are in danger of damage during mobilization of the stomach for gastrectomy. A plain erect film of the abdomen reveals a bubble of air below the left diaphragm; this is gas in the stomach fundus. After the subject has swallowed radio-opaque contrast fluid, for example barium sulphate, the stomach can be seen and its position, movements and outline studied. The wide variations in the position and shape of the stomach that we have already mentioned have come to light principally as a result of such investigations. By tipping the subject head-down, the opaque meal can be made to impinge against the cardia; incompetence of this sphincter mechanism will be demonstrated by seeing barium regurgitate into the oesophagus.
The mucosa of the air-inflated stomach can be inspected in the living subject through the gastroscope. instrument the whole of the gastric mucosa can be viewed, the duodenum examined, and the common bile duct and the pancreatic duct intubated for retrograde contrast-enhanced radiological study. The duodenum The duodenum curves in a C around the head of the pancreas and is 10 in 25 cm long. At its origin from the pylorus it is completely covered with peritoneum for about 1 in 2. Relations Figs 57, 58 For descriptive purposes, the duodenum is divided into four sections. The first part 2 in 5 cm ascends from the gastroduodenal junction, overlapped by the liver and gall-bladder.
Immediately posterior to it lie the portal vein, common bile duct and gastroduodenal artery which separate it from the inferior vena cava. The second part 3 in 7. It is crossed by the transverse colon and lies on the right kidney and ureter. Half-way along, its posteromedial aspect enters the common opening of the bile duct and main pancreatic duct of Wirsung on to an eminence called the duodenal papilla. This common opening is guarded by the sphincter of Oddi. The subsidiary pancreatic duct of Santorini opens into the duodenum a little above the papilla. The third part 4 in 10 cm runs transversely to the left, crossing the inferior vena cava, the aorta and the third lumbar vertebra. It is itself crossed anteriorly by the root of the mesentery and the superior mesenteric vessels. Its upper border hugs the pancreatic head.
The fourth part 1 in 2. It is surprisingly easy for the surgeon to confuse this with the ileocaecal junction, a mistake which may be disastrous. He confirms the identity of the duodenal termination by the presence of the suspensory ligament of Treitz, which is a well-marked peritoneal fold descending from the right crus of the diaphragm to the duodenal termination, and by visualizing the inferior mesenteric vein which descends from behind the pancreas immediately to the left of the duodenojejunal junction. These vessels both lie in the curve between the duodenum and the head of the pancreas, supplying both structures. Interestingly, their anastomosis represents the site of junction of the fore-gut supplied by the coeliac artery , and the mid-gut supplied by the superior mesenteric artery , at the level of the duodenal papilla see page Moreover, a gallstone may ulcerate from the fundus of the gall-bladder into the duodenum. The gallstone may then impact in the lower ileum as it traverses the gut to produce intestinal obstruction gallstone ileus.
Erosion of the gastroduodenal artery by such an ulcer results in severe haemorrhage. Similarly, the right kidney lies directly behind this part of the duodenum, which may be injured in performing a right nephrectomy. Within a few minutes of swallowing a barium meal, the first part of the duodenum becomes visible as a triangular shadow termed the duodenal cap. Every few seconds the duodenum contracts, emptying this cap, which promptly proceeds to fill again. It is in this region that the great majority of duodenal ulcers occur; an actual ulcer crater may be visualized, filled with barium, or deformity of the cap, produced by scar tissue, may be evident. The rest of the duodenum can also be seen, the shadow being floccular due to the rugose arrangement of the mucosa.
See also page Resection of up to onethird or even half of the small intestine is compatible with a perfectly normal life, and survival has been reported with only 18 in 45 cm of small intestine preserved. The mesentery of the small intestine has a 6 in 15 cm origin from the posterior abdominal wall, which commences at the duodenojejunal junction to the left of the 2nd lumbar vertebra, and passes obliquely downwards to the right sacro-iliac joint; it contains the superior mesenteric vessels, the lymph nodes draining the small gut and autonomic nerve fibres. The upper half of the small intestine is termed the jejunum, the remainder is the ileum. There is no sharp distinction between the two and this division is a conventional one only. The bowel does, however, change its character from above downwards, the following points enabling the surgeon to determine the level of a loop of small intestine at operation.
The ileum is supplied by shorter and more numerous terminal vessels arising from complete series of three, four or even five arcades Fig. The large bowel may vary considerably in length in different subjects; the average is approximately 5 feet 1. The colon but not the appendix, caecum or rectum , bears characteristic fat-filled peritoneal tags called appendices epiploicae scattered over its surface. These are especially numerous in the sigmoid colon. The colon and caecum but not the appendix or rectum are marked by the taeniae coli. These are three flattened bands commencing at the base of the appendix and running the length of the large intestine to end at the rectosigmoid junction. They represent the great bulk of the longitudinal muscle of the large bowel; because the taeniae are about a foot shorter than the gut to which they are attached, the colon becomes condensed into its typical sacculated shape.
These sacculations may be seen in a plain radiograph of the abdomen when the large bowel is distended and appear as incomplete septa projecting into the gas shadow. The radiograph of distended small intestine, in contrast, characteristically has complete transverse lines across the bowel shadow due to the transverse mucosal folds of the valvulae conniventes. Peritoneal attachments The transverse colon and sigmoid are completely peritonealized the former being readily identified by its attachment to the greater omentum. The ascending and descending colon have no mesocolon but adhere directly to the posterior abdominal wall although exceptionally the ascending colon has a mesocolon. The caecum may or may not be completely peritonealized, and the appendix, although usually free within its own mesentery, occasionally lies extraperitoneally behind caecum and ascending colon or adheres to the posterior wall of these structures.
The rectum is extraperitoneal on its posterior aspect in its upper third, posteriorly and laterally in its middle third and completely in its lower third as it sinks below the pelvic peritoneum. The appendix The appendix arises from the posteromedial aspect of the caecum about 1 in 2. In the fetus it is a direct outpouching of the caecum, but differential overgrowth of the lateral caecal wall results in its medial displacement. The position of the appendix is extremely variable—more so than that of any other organ Fig. The appendix is usually quite free in this position although occasionally it lies beneath the peritoneal covering of the caecum. colon and abut against the right kidney or the duodenum; in these cases its distal portion lies extraperitoneally. Less commonly, it passes in front of or behind the terminal ileum, or lies in front of the caecum or in the right paracolic gutter. A long appendix has been known to ulcerate into the duodenum or perforate into the left paracolic gutter.
The mesentery of the appendix, containing the appendicular branch of the ileocolic artery, descends behind the ileum as a triangular fold Fig. Another peritoneal sheet, the ileocaecal fold, passes to the appendix or to the base of the caecum from the front of the ileum. The ileocaecal fold is termed the bloodless fold of Treves although, in fact, it often contains a vessel and, if cut, proves far from bloodless. Since obstruction of the lumen is the usual precipitating cause of acute appendicitis it is not unnatural, therefore, that appendicitis should be uncommon at the two extremes of life.
It runs first in the edge of the appendicular mesentery and then, distally, along the wall of the appendix. Acute infection of the appendix may result in thrombosis of this artery with rapid development of gangrene and subsequent perforation. This is in contrast to acute cholecystitis, where the rich collateral vascular supply from the liver bed ensures the rarity of gangrene of the gall-bladder even if the cystic artery becomes thrombosed. The caecum is delivered into the wound and, if the appendix is not immediately visible, it is located by tracing the taeniae coli along the caecum — they fuse at the base of the appendix. When the caecum is extraperitoneal it may be difficult to bring the appendix up into the incision; this is facilitated by first mobilizing the caecum by incising the almost avascular peritoneum along its lateral and inferior borders. The appendix mesentery, containing the appendicular vessels, is firmly tied and divided, the appendix base tied, the appendix removed and its stump invaginated into the caecum.
The rectum The rectum is 5 in 12 cm in length. It commences anterior to the third segment of the sacrum and ends at the level of the apex of the prostate or at the lower quarter of the vagina, where it leads into the anal canal. The rectum is straight in lower mammals hence its name but is curved in man to fit into the sacral hollow. Moreover, it presents a series of three lateral inflexions, capped by the valves of Houston, projecting left, right and left from above downwards. Relations Figs 62, 63 The main relations of the rectum are important. They must be visualized in carrying out a rectal examination, they provide the key to the local spread of rectal growths and they are important in operative removal of the rectum.
Posteriorly lie sacrum and coccyx and the middle sacral artery, which are separated from it by extraperitoneal connective tissue containing the rectal vessels and lymphatics. The lower sacral nerves, emerging from the anterior sacral foramina, may be involved by growth spreading posteriorly from the rectum, resulting in severe sciatic pain. Anteriorly, the upper two-thirds of the rectum are covered by peritoneum and relate to coils of small intestine which lie in the cul-de-sac of the pouch of Douglas between the rectum and the bladder or the uterus. vesicles in the male, or the vagina in the female. A layer of fascia Denonvilliers separates the rectum from the anterior structures and forms the plane of dissection which must be sought after in excision of the rectum. Laterally, the rectum is supported by the levator ani. The anal canal Fig. cutaneous invagination termed the proctodaeum. Failure of breakdown of the separating membrane results in imperforate anus.
A carcinoma of the upper anal canal is thus an adenocarcinoma, whereas that arising from the lower part is a squamous tumour. The two venous systems communicate and therefore form one of the anastomoses between the portal and systemic circulations. A carcinoma of the rectum which invades the lower anal canal may thus metastasize to the groin nodes. The lower canal is therefore sensitive to the prick of a hypodermic needle, whereas injection of an internal haemorrhoid with sclerosant fluid, by passing a needle through the mucosa of the upper part of the canal, is painless.
The anal sphincter Forming the walls of the anal canal is a rather complicated muscle arrangement which constitutes a powerful sphincter mechanism Fig. At its upper end the external sphincter fuses with the fibres of levator ani. In carrying out a digital rectal examination, the ring of muscle on which the flexed finger rests just over an inch from the anal margin is the anorectal ring. This represents the deep part of the external sphincter where this blends with the internal sphincter and levator ani, and demarcates the junction between anal canal and rectum. The anal canal is related posteriorly to the fibrous tissue between it and the coccyx anococcygeal body , laterally to the ischiorectal fossae containing fat, and anteriorly to the perineal body separating it from the bulb of the urethra in the male or the lower vagina in the female.
Note that the ischiorectal fossa is now often referred to, more accurately, as the ischioanal fossa—it relates to the anal canal rather than the rectum. Do not be deceived by foreign objects placed in the vagina. The commonest are a tampon or a pessary. During parturition, dilatation of the cervical os can be assessed by rectal examination since it can be felt quite easily through the rectal wall.
Home Add Document Sign In Register. Blackwell Publishing - Clinical Anatomy 11th Edition Home Blackwell Publishing - Clinical Anatomy 11th Edition. Download PDF. 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 , without the prior permission of the publisher. 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. 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 clinical 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 applications are indicated throughout the text — they cannot, within the limitations 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. Representative 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.
To Mrs Katherine Ellis go my grateful thanks for invaluable secretarial assistance. I am grateful to the following authors for permission to reproduce illustrations: The late Lord Brock for Figs 20 and 21 from Lung Abscess ; and Professor R. 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. Finally, I wish to express my debt to Martin Sugden and the staff of Blackwell Publishing for their continued and unfailing help. Note from Fig. Since the 1st and 12th ribs are difficult to feel, the ribs should be enumerated from the 2nd costal cartilage, which articulates with the sternum at the angle of Louis.
The spinous processes of all the thoracic vertebrae can be palpated in the midline posteriorly, but it should be remembered that the first spinous process that can be felt is that of C7 the vertebra prominens. The position of the nipple varies considerably in the female, but in the male it usually lies in the 4th intercostal space about 4in 10cm from the midline. The apex beat, which marks the lowest and outermost point at which the cardiac impulse can be palpated, is normally in the 5th intercostal space 3. The trachea is palpable in the suprasternal notch midway between the heads of the two clavicles. In the erect position and in full inspiration the level of bifurcation is at T6. The pleura The cervical pleura can be marked out on the surface by a curved line drawn from the sternoclavicular joint to the junction of the medial and middle thirds of the clavicle; the apex of the pleura is about 1 in 2.
This fact is easily explained by the oblique slope of the first rib. The lines of pleural reflexion pass from behind the sternoclavicular joint on each side to meet in the midline at the 2nd costal cartilage the angle of Louis. On the left side the pleural edge arches laterally at the 4th costal cartilage and descends lateral to the border of the sternum, due, of course, to its lateral displacement by the heart; apart from this, its relationships are those of the right side. The pleura actually descends just below the 12th rib margin at its medial extremity — or even below the edge of the 11th rib if the 12th is unusually short; obviously in this situation the pleura may be opened accidentally in making a loin incision to expose the kidney, perform an adrenalectomy or to drain a subphrenic abscess.
The lungs The surface projection of the lung is somewhat less extensive than that of the parietal pleura as outlined above, and in addition it varies quite considerably with the phase of respiration. The apex of the lung closely follows the line of the cervical pleura and the surface marking of the anterior border of the right lung corresponds to that of the right mediastinal pleura. On the left side, however, the anterior border has a distinct notch the cardiac notch which passes behind the 5th and 6th costal cartilages. The lower border of the lung has an excursion of as much as 2—3 in 5—8cm in the extremes of respiration, but in the neutral position midway between inspiration and expiration it lies along a line which crosses the 6th rib in the midclavicular line, the 8th rib in the midaxillary line, and reaches the 10th rib adjacent to the vertebral column posteriorly.
The oblique fissure, which divides the lung into upper and lower lobes, is indicated on the surface by a line drawn obliquely downwards and outwards from 1in 2. This can be represented approximately by abducting the shoulder to its full extent; the line of the oblique fissure then corresponds to the position of the medial border of the scapula. The surface markings of the transverse fissure separating the middle and upper lobes of the right lung is a line drawn horizontally along the 4th costal cartilage and meeting the oblique fissure where the latter crosses the 5th rib. The heart The outline of the heart can be represented on the surface by the irregular quadrangle bounded by the following four points Fig. The left border of the heart indicated by the curved line joining points 1 and 4 is formed almost entirely by the left ventricle the auricular appendage of the left atrium peeping around this border superiorly , the lower border the horizontal line joining points 3 and 4 corresponds to the right ventricle and the apical part of the left ventricle; the right border marked by the line joining points 2 and 3 is formed by the right atrium see Fig.
A good guide to the size and position of your own heart is given by placing your clenched right fist palmar surface down immediately inferior to the manubriosternal junction. The surface markings of the vessels of the thoracic wall are of importance if these structures are to be avoided in performing aspiration of the chest. The internal thoracic internal mammary vessels run vertically downwards behind the costal cartilages half an inch from the lateral border of the sternum. The intercostal vessels lie immediately below their corresponding ribs the vein above the artery so that it is safe to pass a needle immediately above a rib, dangerous to pass it immediately below see Fig. The thoracic cage The thoracic cage is formed by the vertebral column behind, the ribs and intercostal spaces on either side and the sternum and costal cartilages in front. The ribs The greater part of the thoracic cage is formed by the twelve pairs of ribs. Each typical rib Fig.
The angle demarcates the lateral limit of attachment of the erector spinae muscle. This is flattened from above downwards. It is not only the flattest but also the shortest and most curvaceous of all the ribs. In front of this tubercle, the subclavian vein crosses the rib; behind the tubercle is the subclavian groove where the subclavian artery and lowest trunk of the brachial plexus lie in relation to the bone. It is here that the anaesthetist can infiltrate the plexus with local anaesthetic. Crossing the neck of the first rib from the medial to the lateral side are the sympathetic trunk, the superior intercostal artery from the costocervical trunk and the large branch of the first thoracic nerve to the brachial plexus. The 2nd rib is much less curved than the 1st and about twice as long. The 10th rib has only one articular facet on the head. The 11th and 12th ribs are short, have no tubercles and only a single facet on the head.
The 11th rib has a slight angle and a shallow subcostal groove; the 12th has neither of these features. Clinical features Rib fractures The chest wall of the child is highly elastic and therefore fractures of the rib in children are rare. In adults, the ribs may be fractured by direct violence or indirectly by crushing injuries; in the latter the rib tends to give way at its weakest part in the region of its angle. Not unnaturally, the upper two ribs, which are protected by the clavicle, and the lower two ribs, which are unattached and therefore swing free, are the least commonly injured. With each inspiration this loose flap sucks in, with each expiration it blows out, thus undergoing paradoxical respiratory movement. The associated swinging movements of the mediastinum produce severe shock and this injury calls for urgent treatment by insertion of a chest drain with underwater seal, followed by endotracheal intubation, or tracheostomy, combined with positive pressure respiration.
Coarctation of the aorta see Fig. Together with the communication between the internal thoracic and inferior epigastric arteries, they provide the principal collaterals between the aorta above and below the block. In consequence, the intercostal arteries undergo dilatation and tortuosity and erode the lower borders of the corresponding ribs to give the characteristic irregular notching of the ribs, which is very useful in the radiographic confirmation of this lesion. On the right side the brachial plexus is shown arching over the rib and stretching its lowest trunk. Cervical rib A cervical rib Fig. It is attached to the transverse process of the 7th cervical vertebra and articulates with the 1st thoracic rib or, if short, has a free distal extremity which usually attaches by a fibrous strand to the normal first rib.
Pressure of such a rib on the lowest trunk of the brachial plexus arching over it may produce paraesthesiae along the ulnar border of the forearm and wasting of the small muscles of the hand T1. Less commonly vascular changes, even gangrene, may be caused by pressure of the rib on the overlying subclavian artery. This results in post-stenotic dilatation of the vessel distal to the rib in which a thrombus forms from which emboli are thrown off. The costal cartilages These bars of hyaline cartilage serve to connect the upper seven ribs directly to the side of the sternum and the 8th, 9th and 10th ribs to the cartilage immediately above. The cartilages of the 11th and 12th ribs merely join the tapered extremities of these ribs and end in the abdominal musculature. The sternum This dagger-shaped bone, which forms the anterior part of the thoracic cage, consists of three parts.
The manubrium is roughly triangular in outline and provides articulation for the clavicles and for the first and upper part of the 2nd costal cartilages on either side. It is situated opposite the 3rd and 4th thoracic vertebrae. Opposite the disc between T4 and T5 it articulates at an oblique angle at the manubriosternal joint the angle of Louis , with the body of the sternum placed opposite T5 to T8. Its lateral border is notched to receive part of the 2nd and the 3rd to the 7th costal cartilage. The xiphoid process is the smallest part of the sternum and usually remains cartilaginous well into adult life. The cartilaginous manubriosternal joint and that between the xiphoid and the body of the sternum may also become ossified after the age of Direct violence to the sternum may lead to displacement of the relatively mobile body of the sternum backwards from the relatively fixed manubrium.
A complete vertical split of the whole sternum is one of the standard approaches to the heart and great vessels used in modern cardiac surgery. The intercostal spaces There are slight variations between the different intercostal spaces, but typically each space contains three muscles, comparable to those of the abdominal wall, and an associated neurovascular bundle Fig. Note that a needle passed into the chest immediately above a rib will avoid the neurovascular bundle. The fibres of this sheet cross more than one intercostal space and it may be incomplete. Anteriorly it has a more distinct portion which is fan-like in shape, termed the transversus thoracis or sternocostalis , which spreads upwards from the posterior aspect of the lower sternum to insert onto the inner surfaces of the second to the sixth costal cartilages.
Just as in the abdomen, the nerves and vessels of the thoracic wall lie between the middle and innermost layers of muscles. This neurovascular bundle consists, from above downwards, of vein, artery and nerve, the vein lying in a groove on the undersurface of the corresponding rib remember— v,a,n. The vessels comprise the posterior and anterior intercostals. The posterior intercostal arteries of the lower nine spaces are branches of the thoracic aorta, while the first two are derived from the superior intercostal branch of the costocervical trunk, the only branch of the second part of the subclavian artery. Each runs forward in the subcostal groove to anastomose with the anterior intercostal artery.
Each has a number of branches to adjacent muscles, to the skin and to the spinal cord. The corresponding veins are mostly tributaries of the azygos and hemiazygos veins. The first posterior intercostal vein drains into the brachiocephalic or vertebral vein. On the left side the sites of eruption of a tuberculous cold abscess tracking forwards from a diseased vertebra are shown—these occur at the points of emergence of the cutaneous branches.
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Tracheostomy Tracheostomy may be required for laryngeal obstruction diphtheria, tumours, inhaled foreign bodies , for the evacuation of excessive secretions severe postoperative chest infection in a patient who is too weak to cough adequately , and for long-continued artificial respiration poliomyelitis, severe chest injuries. This, in turn, is reflected around the roots of the great vessels to become continuous with the visceral layer or epicardium. The transversus abdominis arises from the lowest six costal cartilages interdigitating with the diaphragm , the lumbar fascia, the anterior twothirds of the iliac crest and the lateral one-third of the inguinal ligament; it is inserted into the linea alba and the pubic crest. The muscles of the anterior abdominal wall These are of considerable practical importance because their anatomy forms the basis of abdominal incisions. The divided rectus muscle is held by the intersections above and below and retracts very little. pleural cavity T12 b Fig. Since it lies medial to the internal ring, it is not controlled by digital pressure applied immediately above the femoral pulse.
Rarely, there is a tracheo-oesophageal fistula without atresia Fig. A complete vertical split of the whole sternum is one of the standard approaches to the heart and great vessels used in modern cardiac surgery. The fibres of this sheet cross more than one intercostal space and it may be incomplete. From this landmark, the head can be imagined passing downward and to the right, the body and tail passing upwards and to the left. Posteriorly, the upper pole of the kidney lies deep
blackwell publisher free download pdf the 12th rib,
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