Dalley, 10th Edition

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Overview and Basic Concepts

Back

Upper Limb

Thorax

Abdomen

Pelvis and Perineum

Lower Limb

MOORE’S Clinically Oriented Anatomy

TENTH EDITION

ARTHUR F. DALLEY II, PHD, FAAA Professor Emeritus, Department of Cell and Developmental Biology

Former Director, Medical Gross Anatomy Co-Director, Brain, Behavior, and Movement Former Adjunct Professor, Department of Orthopaedic Surgery and Rehabilitation

Vanderbilt University School of Medicine Former Adjunct Professor of Anatomy Belmont University School of Physical Therapy Nashville, Tennessee

ANNE M. R. AGUR, BSC (OT), MSC, PHD, FAAA Professor, Division of Anatomy, Department of Surgery, Faculty of Medicine Division of Physical Medicine and Rehabilitation, Department of Medicine Department of Physical Therapy, Department of Occupational Science & Occupational Therapy Copyright © 2027 Wolters Kluwer. Unauthorized reproduction of the article is prohibited.

Division of Biomedical Communications, Institute of Medical Science Rehabilitation Sciences Institute, Graduate Department of Dentistry University of Toronto Toronto, Ontario, Canada

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Tenth Edition

Ninth edition translations: Japanese, Medical Sciences International, Ltd.

Korean, Bioscience Publishing Co., Ltd. Portuguese, Editora Guanabara Koogan Spanish, Wolters Kluwer Health Spanish Language Program Turkish, Tıbbi Yayınlar Merkezi

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Library of Congress Cataloging-in-Publication Data

Names: Dalley, Arthur F., II author | Agur, A. M. R. author | Moore, Keith L. Clinically oriented anatomy. Title: Moore’s clinically oriented anatomy / Arthur F. Dalley II, PhD, FAAA, Anne M.R. Agur, BSc (OT), MSc, PhD, FAAA. Description: Tenth edition. | Philadelphia : Wolters Kluwer, [2027] | Includes bibliographical references and index. Identifiers: LCCN 2025038019 (print) | LCCN 2025038020 (ebook) | ISBN 9781975241582 paperback | ISBN 9781975241643 epub Subjects: LCSH: Human anatomy | Anatomy, Pathological Classification: LCC QM23.2 .M67 2027 (print) | LCC QM23.2 (ebook) LC record available at https://lccn.loc.gov/2025038019 LC ebook record available at https://lccn.loc.gov/2025038020

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To My Colleague Melissa Who brings friendship, love and joy into my life And to My Family

Tristan, Lana, Elijah, Finley, Sawyer, and Dashiell Denver, Samantha, Olin, Anderson, and Louise Skyler, Sara, Dawson, Willa, and Foster with great appreciation for their support, humor, and patience. • (AFD)

To Enno and Our Family To my husband, Enno, and to my family, Erik, Amy, and Kristina, for their support and encouragement This edition is also dedicated to my brother Peter, and Alexandra, Robyn, Tomas, and Serena. • (AMRA)

To Our Students We hope you will enjoy reading this book, increase your understanding of clinically oriented anatomy, pass your exams, and be excited and well prepared for your careers in patient care, research, and teaching. You will remember some of what you hear, much of what you read, more of what you see, and almost all of what you experience and understand.

To Professors May our book be a helpful resource for you. We appreciate the numerous constructive comments we have received over the years from you. Your remarks have been invaluable to us in improving this edition.

To Anatomical Donors With sincere appreciation to all those who donate their bodies for anatomical study and research, without whom anatomical textbooks and atlases and anatomical study in general would not be possible. Copyright © 2027 Wolters Kluwer. Unauthorized reproduction of the article is prohibited.

Preface

Almost half a century has passed since the rst edition of Clinically Oriented Anatomy appeared on bookstore shelves in 1980. Keith L. Moore, was the founding author of Clini cally Oriented Anatomy a vanguard of Clinically Oriented Anatomy textbooks. The retitling of Clinically Oriented Anatomy as “Moore’s” pays tribute to Keith’s foundational work on the books and the legacy they represent. Although the factual basis of anatomy is remarkable among basic sciences for its longevity and consistency, this book has evolved markedly since its inception. This is a re ection of changes in the clinical application of anatomy, new imaging technologies that reveal living anatomy in new ways, and improvements in graphic and publication tech nology that enable superior demonstration of this informa tion. Efforts continue to make this book even more student friendly, authoritative, and re ective of the diversity of our students and the populations they will serve. The tenth edi tion was thoroughly reviewed by students, anatomists, and clinicians in addition to ourselves for accuracy and relevance and revised with signi cant new changes and updates for this tenth edition. Clinically Oriented Anatomy has been widely acclaimed for the relevance of its clinical correlations. As in previous edi tions, the tenth edition places clinical emphasis on anatomy that is important in physical examination for primary care, interpretation of diagnostic imaging, and understanding the anatomical basis of practice in medical care, rehabilita tion, and allied health sciences. Special attention has been directed toward assisting students in learning the anatomy they will need to know in the 21st century, and to this end, new features have been added and existing features updated. KEY FEATURES

ef ciency. The skeletal base art has been revised for the tenth edition. Efforts continue to ensure that all the anatomy pre sented and covered in the text are also illustrated. The text and illustrations were developed to work together for optimum pedagogical effect, aiding the learning process, and markedly reducing the amount of searching required to nd structures. The great majority of the clinical conditions are supported by photographs and/or color illustrations; multipart illustrations often combine dissections, line art, and medical images; and tables are accompanied by illustrations to aid the student’s understanding of the structures ef ciently described. CLINICAL BLUE BOXES Clinical Blue Boxes have evolved with changes in practice and many of them are supported by photographs and/or dynamic color illustrations to help with understanding the practical value of anatomy. The boxes continue to be reviewed and revised to re ect recent medical advances. Topics in the Clinical Blue Boxes are classi ed by the following icons to indicate the type of clinical information covered: Anatomical variations feature anatomical varia tions that may be encountered in the dissection lab or in practice, emphasizing the clinical importance of awareness of such variations. Life cycle boxes emphasize prenatal developmental factors that affect postnatal anatomy and anatomical phenomena speci cally associated with stages of life— childhood, adolescence, adult, and advanced age. Trauma boxes feature the effects of traumatic events on normal anatomy and the clinical manifes tations and dysfunction resulting from such injuries. Diagnostic procedures discuss the anatomical features and observations that play a role in physical examination. Surgical procedures address such topics as the anatomical basis of surgical procedures, such as the planning of incisions, and the anatomical basis of regional anesthesia. Pathology boxes cover the effects of disease on nor mal anatomy, such as cancer of the breast, and ana tomical structures or principles involved in the con nement or dissemination of disease within the body.

EXTENSIVE ART PROGRAM

Revision of the art program that began with the seventh edi tion continues into the tenth edition. Major revisions over the last three editions have improved accuracy and consistency and giving classical art derived from Grant’s Atlas of Anatomy a fresh, vital, new appearance. The tenth edition includes fur ther updates to gures and labeling to maximize clarity and

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Preface

THE BOTTOM LINE SUMMARIES

terms during their clinical studies. Although not universally adopted or approved, TA2 is available at https://libraries.dal. ca/Fipat.html, which also provides a link to TA2Viewer, a searchable, dynamic web application of TA2 (2019).

Frequent “The Bottom Line” boxes summarize the preceding information, ensuring that primary concepts do not become lost in the many details necessary for thorough understand ing. These summaries provide a convenient means of ongoing review and underscore the “big picture” point of view.

RETAINED AND IMPROVED FEATURES

Students and faculty have told us what they want and expect from Clinically Oriented Anatomy , and we listened: • A comprehensive text enabling students to ll in the blanks, as time allotted for lectures continues to decrease, laboratory guides and curricula become exclusively instructional, and multiauthored lecture notes develop inconsistencies in comprehension, fact, and format • A resource capable of supporting areas of special interest and emphasis within speci c anatomy courses that serves the anatomy needs of students during both the basic science and the clinical phases of their studies • Updated organization of the chapters to match that of Grant’s Atlas of Anatomy and Grant’s Dissector • A thorough introductory chapter (Chapter 1, Overview and Basic Concepts) that covers important systemic in formation and concepts basic to the understanding of the anatomy presented in the subsequent regional chapters. Students from many countries and backgrounds have written to express their views of this book—gratifyingly, most are congratulatory. Health professional students have more diverse backgrounds and experiences than ever before. The introductory chapter includes ef cient summaries of functional systemic anatomy. Student and faculty comments speci cally emphasized the need for a systemic description of the nervous system and the pe ripheral autonomic nervous system (ANS) in particular be presented at the outset of their study. Clinically Oriented Anatomy was the rst anatomy textbook to acknowledge and describe the structure and function of the enteric nervous system and its unique role in the innervation of the digestive tract. • In the tenth edition, a section on Sex and Gender was added to Chapter 1, Overview and Basic Concepts as well as a Clinical Box on Gender Transitioning in Chapter 6, Pelvis and Perineum. • Routine facts (such as muscle attachments, innervations, and actions) presented in tables are organized to demon strate shared qualities and illustrated to demonstrate the provided information. • Illustrated clinical correlations that not only describe but also show anatomy as it is applied clinically • Illustrations that re ect the diversity of both those using the textbook and the patients they will be treating • Illustrations that facilitate orientation. Many orienta tion gures have been added, along with arrows to in dicate the locations of the inset gures (areas shown in

ANATOMY DESCRIBED IN A PRACTICAL, FUNCTIONAL CONTEXT

A more realistic approach to the musculoskeletal system emphasizes the action and use of muscles and muscle groups in daily activities, such as gait and grip. The eccentric con traction of muscles, which accounts for much of their activity, is discussed along with the concentric contraction. This per spective is important to most health professionals.

SURFACE ANATOMY AND MEDICAL IMAGING

Surface anatomy and medical imaging are integrated into the chapter, presented at the time each region is being discussed, clearly demonstrating anatomy’s relationship to physical examination. Surface anatomy and illustrations superimpos ing anatomical structures on surface anatomy photographs are components of each regional chapter. Medical images, focusing on normal anatomy, include plain and contrast radiographic, MRI, CT, and ultrasonography studies, often with correlative line art as well as explanatory text, to help prepare future professionals who need to be familiar with diagnostic images. The terminology generally adheres to Terminologia Anatom ica: International Anatomical Nomenclature (1998), gener ated by the Federative International Program on Anatomical Terminology (FIPAT) and approved by the International Federation of Associations of Anatomists (IFAA). Selected updates proposed for Terminologia Anatomica 2 ( TA2 ) (2019) have been incorporated in the tenth edition. Although the of cial English-equivalent terms are used throughout the book, when new terms are introduced, the Latin form, used in Europe, Asia, and other parts of the world, is often provided. The roots and derivations of terms are provided to help students understand meaning and increase reten tion. Eponyms, although not endorsed by the IFAA, appear in parentheses in this edition—for example, sternal angle (angle of Louis)—to assist students who will hear eponymous TERMINOLOGY

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Preface

COMMITMENT TO EDUCATING STUDENTS

close-up views) and viewing sequences. Labels have been placed to minimize the distance between label and object, with leader lines running the most direct course possible. • Equitable focus on female as well as male anatomy • Boldface type indicates the main entries of anatomical terms, when they are introduced and de ned. In the in dex, the page numbers of these main entries also appear in boldface type, so that the main entries can be easily located. Boldface type is also used to introduce clinical terms in the Clinical Blue Boxes. • Italic type indicates anatomical terms important to the topic and region of study or labeled in an illustration that is being referenced. • Useful content outlines appear at the beginning of every chapter.

This book is written for health science students, keeping in mind those who may not have had a previous acquaintance with anatomy. We have tried to present the material in an interesting way so that it can be easily integrated with what will be taught in more detail in advanced training such as in physical diagnosis, rehabilitation, and surgery. We hope this text will serve two purposes: to educate and to excite. If students develop enthusiasm for clinical anatomy, the goals of this book will have been ful lled.

Arthur F. Dalley II

Anne M. R. Agur

Contents

Preface / vi Acknowledgments / ix List of Clinical Blue Boxes / xvii

Peripheral Nervous System / 49 Somatic Nervous System / 58 Autonomic Nervous System / 58 Medical Imaging Techniques / 67 Conventional Radiography / 67 Computed Tomography / 68 Ultrasonography / 69 Magnetic Resonance Imaging / 69 Nuclear Medicine Imaging / 71

List of Tables / xxii Figure Credits / xxv References and Suggested Reading / xxxiv

OVERVIEW AND BASIC CONCEPTS / 1

BACK / 73

Approaches to Studying Anatomy / 2 Regional Anatomy / 2 Systemic Anatomy / 2 Clinical Anatomy / 2 Sex and Gender / 3 Anatomicomedical Terminology / 3

Overview of Back and Vertebral Column / 74 Vertebrae / 76 Structure and Function of Vertebrae / 77 Regional Characteristics of Vertebrae / 79 Variations in Vertebrae / 89 Vertebral Column / 97 Joints of Vertebral Column / 97 Movements of Vertebral Column / 103 Curvatures of Vertebral Column / 104 Vasculature of Vertebral Column / 105 Nerves of Vertebral Column / 106 Muscles of Back / 117 Surface Anatomy of Back Muscles / 126 Suboccipital and Deep Neck Muscles / 126 Contents of Vertebral Canal / 130 Spinal Cord / 130 Spinal Nerves and Nerve Roots / 132 Extrinsic Back Muscles / 118 Intrinsic Back Muscles / 119

Anatomical Position / 3 Anatomical Planes / 4 Terms of Relationship and Comparison / 5

Terms of Laterality / 7 Terms of Movement / 7 Anatomical Variations / 10 Integumentary System / 11

Fascial System / 15 Skeletal System / 18

Cartilage and Bones / 18 Classi cation of Bones / 19 Bone Markings and Formations / 19 Bone Development / 20 Vasculature and Innervation of Bones / 21 Joints / 24 Muscle Tissue and Muscular System / 28 Types of Muscle (Muscle Tissue) / 28

Spinal Meninges and Cerebrospinal Fluid (CSF) / 132 Vasculature of Spinal Cord and Spinal Nerve Roots / 137

Skeletal Striated Muscle / 28 Cardiac Striated Muscle / 36 Smooth Muscle / 36 Cardiovascular System / 37 Vascular Circuits / 37 Blood Vessels / 37 Lymph Vascular System / 43 Nervous System / 46 Central Nervous System / 47

UPPER LIMB / 142

Overview of Upper Limb / 143 Comparison of Upper and Lower Limbs / 144 Bones of Upper Limb / 145

Clavicle / 145 Scapula / 145 Humerus / 148

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Contents

THORAX / 296

Bones of Forearm / 149 Bones of Hand / 150 Surface Anatomy of Upper Limb Bones / 153 Fascia of Upper Limb / 160 Vessels and Nerves of Upper Limb / 162 Overview of Arterial Supply of Upper Limb / 162 Cutaneous and Motor Innervation of Upper Limb / 166 Overview of Peripheral Nerves of Upper Limb / 170 Pectoral and Scapular Regions / 173 Anterior Axio-Appendicular Muscles / 173 Posterior Axio-Appendicular and Scapulohumeral Muscles / 175 Surface Anatomy of Pectoral, Scapular, and Deltoid Regions / 182 Axilla / 189 Axillary Artery / 191 Axillary Vein / 194 Axillary Lymph Nodes / 194 Brachial Plexus / 195 Arm / 207 Veins of Arm / 212 Nerves of Arm / 213 Cubital Fossa / 215 Surface Anatomy of Arm and Cubital Fossa / 215 Forearm / 221 Compartments of Forearm / 221 Veins of Forearm / 236 Nerves of Forearm / 237 Surface Anatomy of Forearm / 240 Hand / 247 Fascia and Compartments of Palm / 247 Muscles of Hand / 249 Long Flexor Tendons and Tendon Sheaths in Hand / 255 Arteries of Hand / 255 Venous Drainage of Upper Limb / 164 Lymphatic Drainage of Upper Limb / 165 Muscles of Arm / 207 Brachial Artery / 212 Muscles of Forearm / 221 Arteries of Forearm / 234

Overview of Thorax / 297 Thoracic Wall / 297

Skeleton of Thoracic Wall / 299 Thoracic Apertures / 303 Joints of Thoracic Wall / 304 Movements of Thoracic Wall / 306 Surface Anatomy of Skeleton of Thoracic Wall / 306 Muscles of Thoracic Wall / 313 Fascia of Thoracic Wall / 318 Nerves of Thoracic Wall / 319 Vasculature of Thoracic Wall / 321 Breasts / 325 Viscera of Thoracic Cavity / 332 Pleurae, Lungs, and Tracheobronchial Tree / 333 Overview of Mediastinum / 355 Pericardium / 355 Heart / 363 Superior Mediastinum and Great Vessels / 390 Overview: Walls, Cavities, Regions, and Planes / 414 Anterolateral Abdominal Wall / 416 Fascia of Anterolateral Abdominal Wall / 416 Muscles of Anterolateral Abdominal Wall / 417 Surface Anatomy of Anterolateral Abdominal Wall / 423 Neurovasculature of Anterolateral Abdominal Wall / 424 Internal Surface of Anterolateral Abdominal Wall / 432 Inguinal Region / 433 Spermatic Cord, Scrotum, and Testes / 437 Peritoneum and Peritoneal Cavity / 447 Embryology of Peritoneal Cavity / 448 Peritoneal Formations / 449 Subdivisions of Peritoneal Cavity / 451 Abdominal Viscera / 456 Overview of Abdominal Viscera and Digestive Tract / 456 Esophagus / 459 Stomach / 460 5 Posterior Mediastinum / 398 Anterior Mediastinum / 403 ABDOMEN / 412

Veins of Hand / 258 Nerves of Hand / 258 Surface Anatomy of Hand / 262 Sternoclavicular Joint / 270 Acromioclavicular Joint / 272 Glenohumeral Joint / 272 Elbow Joint / 277 Proximal Radioulnar Joint / 280 Distal Radioulnar Joint / 282 Wrist Joint / 285 Intercarpal Joints / 285

Small Intestine / 468 Large Intestine / 476 Spleen / 495 Pancreas / 496 Liver / 500 Biliary Ducts and Gallbladder / 509 Kidneys, Ureters, and Suprarenal Glands / 523 Innervation of Abdominal Viscera / 535 Diaphragm / 541 Vessels and Nerves of Diaphragm / 542 Diaphragmatic Apertures / 543 Actions of Diaphragm / 544

Joints of Upper Limb / 269

Carpometacarpal and Intermetacarpal Joints / 287 Metacarpophalangeal and Interphalangeal Joints / 288

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Posterior Abdominal Wall / 545 Fascia of Posterior Abdominal Wall / 545 Muscles of Posterior Abdominal Wall / 547 Nerves of Posterior Abdominal Wall / 548 Vessels of Posterior Abdominal Wall / 549 Sectional Medical Imaging of Abdomen / 557

Venous Drainage of Lower Limb / 702 Lymphatic Drainage of Lower Limb / 706 Cutaneous Innervation of Lower Limb / 707 Motor Innervation of Lower Limb / 707 Peripheral Nerves of Lower Limb / 707 Posture and Gait / 715 Standing at Ease / 715 Walking: Gait Cycle / 715 Anterior and Medial Regions of Thigh / 717 Organization of Proximal Lower Limb / 717

PELVIS AND PERINEUM / 561

Introduction to Pelvis and Perineum / 562 Pelvic Girdle / 562 Bones and Features of Pelvic Girdle / 562 Orientation of Pelvic Girdle / 566 Pelvic Girdle Sexual Differences / 566 Joints and Ligaments of Pelvic Girdle / 566 Pelvic Cavity / 573 Walls and Floor of Pelvic Cavity / 573 Peritoneum and Peritoneal Cavity of Pelvis / 578 Pelvic Fascia / 580 Neurovascular Structures of Pelvis / 584 Pelvic Arteries / 584 Pelvic Veins / 590 Lymph Nodes of Pelvis / 590 Pelvic Nerves / 591 Pelvic Viscera / 597 Urinary Organs / 597 Rectum / 603 Female Internal Genital Organs / 611 Male Internal Genital Organs / 629 Lymphatic Drainage of Pelvic Viscera / 636 Perineum / 638 Fasciae and Pouches of Urogenital Triangle / 643 Features of Anal Triangle / 645 Female Urogenital Triangle / 654 Male Urogenital Triangle / 661 Sectional Imaging of Pelvis and Perineum/ 671 Magnetic Resonance Imaging / 671

Anterior Thigh Muscles / 718 Medial Thigh Muscles / 721 Neurovascular Structures and Relationships in Anteromedial Thigh / 724 Surface Anatomy of Anterior and Medial Regions of Thigh / 729 Gluteal and Posterior Thigh Regions / 735 Gluteal Region: Buttocks and Hip Region / 735 Muscles of Gluteal Region / 736 Posterior Thigh Region / 742 Neurovascular Structures of Gluteal and Posterior Thigh Regions / 745 Surface Anatomy of Gluteal and Posterior Thigh Regions / 750 Popliteal Fossa and Leg / 756 Popliteal Region / 756 Anterior Compartment of Leg / 760 Lateral Compartment of Leg / 765 Posterior Compartment of Leg / 769 Surface Anatomy of Leg / 776 Foot / 782 Skin and Fascia of Foot / 783 Muscles of Foot / 783 Neurovascular Structures and Relationships in Foot / 787 Surface Anatomy of Ankle and Foot Regions / 795 Joints of Lower Limb / 799

Hip Joint / 799 Knee Joint / 807 Tibio bular Joints / 816

Ankle Joint / 820 Foot Joints / 822 Surface Anatomy of Joints of Knee, Ankle, and Foot / 830

LOWER LIMB / 676

Overview of Lower Limb / 677 Development of Lower Limb / 678 Bones of Lower Limb / 678 Arrangement of Lower Limb Bones / 680 Hip Bone / 680

NECK / 843

Overview / 844 Bones of Neck / 844

Cervical Vertebrae / 844 Hyoid Bone / 846

Femur / 684 Patella / 688 Tibia and Fibula / 688 Bones of Foot / 691 Fascia of Lower Limb / 700 Subcutaneous Tissue / 700 Deep Fascia / 700 Overview of Vessels and Nerves of Lower Limb / 702 Arterial Supply of Lower Limb / 702

Fascia of Neck / 847 Cervical Subcutaneous Tissue and Platysma / 847 Deep Cervical Fascia / 849 Super cial Structures of Neck: Cervical Regions / 851 Sternocleidomastoid Region / 851

Posterior Cervical Region / 854 Lateral Cervical Region / 854

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Anterior Cervical Region / 861 Surface Anatomy of Cervical Regions and Triangles of Neck / 867 Deep Structures of Neck / 874 Prevertebral Muscles / 874 Root of Neck / 874 Viscera of Neck / 880 Endocrine Layer of Cervical Viscera / 880 Respiratory Layer of Cervical Viscera / 883 Alimentary Layer of Cervical Viscera / 894 Surface Anatomy of Endocrine and Respiratory Layers of Cervical Viscera / 901 Lymphatics of Neck / 902

Temporal Region / 1009 Infratemporal Fossa / 1009

Oral Region / 1021 Oral Cavity / 1021 Lips, Cheeks, and Gingivae / 1021

Teeth / 1023 Palate / 1027 Tongue / 1031 Salivary Glands / 1036 Pterygopalatine Fossa / 1044 Pterygopalatine Part of Maxillary Artery / 1044 Maxillary Nerve / 1044 Nose / 1048 External Nose / 1048 Nasal Cavities / 1049 Vasculature and Innervation of Nose / 1052 Paranasal Sinuses / 1053 Ear / 1059

HEAD / 914

Overview of Head / 915 Cranium / 915

Anterior Aspect of Cranium / 920 Lateral Aspect of Cranium / 922 Occipital Aspect of Cranium / 922 Superior Aspect of Cranium / 923 External Surface of Cranial Base / 923 Internal Surface of Cranial Base / 926 Walls of Cranial Cavity / 929 Regions of Head / 930 Face and Scalp / 936

External Ear / 1059 Middle Ear / 1060 Internal Ear / 1067

CRANIAL NERVES / 1075

Overview / 1076 Olfactory Nerve (CN I) / 1083 Optic Nerve (CN II) / 1084

Face / 936 Scalp / 936 Muscles of Face / 937 Nerves of Face and Scalp / 942 Super cial Vasculature of Face and Scalp / 948 Surface Anatomy of Face / 951 Cranial Meninges / 958 Dura Mater / 958 Arachnoid Mater and Pia Mater / 965 Meningeal Spaces / 965 Brain / 971 Parts of Brain / 971 Ventricular System of Brain / 971 Arterial Blood Supply to Brain / 975 Venous Drainage of Brain / 976 Orbits, Eyeball, and Accessory Visual Structures / 982 Orbits / 982 Anterior Accessory Visual Structures / 984 Eyeball / 987 Extraocular Muscles of Orbit / 991 Nerves of Orbit / 997 Vasculature of Orbit / 998 Surface Anatomy of Eye and Lacrimal Apparatus / 1000 Parotid and Temporal Regions, Infratemporal Fossa, and Temporomandibular Joint / 1007 Parotid Region / 1007

Oculomotor Nerve (CN III) / 1086 Trochlear Nerve (CN IV) / 1086 Trigeminal Nerve (CN V) / 1087 Ophthalmic Nerve (CN V 1 ) / 1088 Maxillary Nerve (CN V 2 ) / 1088 Mandibular Nerve (CN V 3 ) / 1088 Abducent Nerve (CN VI) / 1088 Facial Nerve (CN VII) / 1091 Somatic (Branchial) Motor / 1091 Visceral (Parasympathetic) Motor / 1091 Somatic (General) Sensory / 1091 Special Sensory (Taste) / 1091 Vestibulocochlear Nerve (CN VIII) / 1093 Glossopharyngeal Nerve (CN IX) / 1093 Somatic (Branchial) Motor / 1093 Visceral (Parasympathetic) Motor / 1093 Somatic (General) Sensory / 1094 Special Sensory (Taste) / 1095 Visceral Sensory / 1095 Vagus Nerve (CN X) / 1096 Spinal Accessory Nerve (CN XI) / 1097 Hypoglossal Nerve (CN XII) / 1099

INDEX / 1107

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Back 2

OVERVIEW OF BACK AND VERTEBRAL COLUMN / 74 TABLE 2.1. Relationships of Palpable Landmarks of Back to Signi cant Deep Structures / 75 VERTEBRAE / 76 Structure and Function of Vertebrae / 77 Regional Characteristics of Vertebrae / 79 TABLE 2.2. Cervical Vertebrae / 81 TABLE 2.3. Thoracic Vertebrae / 83 TABLE 2.4. Lumbar Vertebrae / 85 Variations in Vertebrae / 89 CLINICAL BOX: Vertebrae / 89 VERTEBRAL COLUMN / 97 Joints of Vertebral Column / 97 Movements of Vertebral Column / 103 Curvatures of Vertebral Column / 104 Vasculature of Vertebral Column / 105 Nerves of Vertebral Column / 106 CLINICAL BOX: Vertebral Column / 108 MUSCLES OF BACK / 117 Extrinsic Back Muscles / 118 Intrinsic Back Muscles / 119 TABLE 2.5. Super cial Layer of Intrinsic Back Muscles / 120 TABLE 2.6. Intermediate Layer of Intrinsic Back Muscles / 121

TABLE 2.7. Deep Layers of Intrinsic Back Muscles / 123 TABLE 2.8. Principal Muscles Producing

Movement of Cervical Intervertebral Joints / 124 TABLE 2.9. Principal Muscles Producing Movements of Thoracic and Lumbar Intervertebral (IV) Joints / 125 Surface Anatomy of Back Muscles / 126 Suboccipital and Deep Neck Muscles / 126 TABLE 2.10. Suboccipital Muscles and Suboccipital Triangle / 127 TABLE 2.11. Principal Muscles Producing Movement of Atlantooccipital Joints / 128 TABLE 2.12. Principal Muscles Producing Movement of Atlantoaxial Joints / 128 TABLE 2.13. Nerves of Posterior Cervical Region, Including Suboccipital Region/Triangles / 129 CLINICAL BOX: Muscles of Back / 129 CONTENTS OF VERTEBRAL CANAL / 130 Spinal Cord / 130 Spinal Nerves and Nerve Roots / 132 TABLE 2.14. Numbering of Spinal Nerves and Vertebrae / 132 Spinal Meninges and Cerebrospinal Fluid (CSF) / 132 TABLE 2.15. Spaces Associated with Spinal Meninges / 135 Vasculature of Spinal Cord and Spinal Nerve Roots / 137 CLINICAL BOX: Contents of Vertebral Canal / 139

CLINICAL BOX KEY

Anatomical Variations

Diagnostic Procedures

Life Cycle

Surgical Procedures

Trauma

Pathology

Overview of Back and Vertebral Column

Spine of scapula

C7 (vertebra prominens) Spinous processes of vertebrae:

Acromion

Trapezius

Greater tubercle of humerus

Teres major

Inferior angle of scapula Spine of scapula

Site of inferior angle of scapula

Posterior median furrow overlying spinous processes of vertebrae

Latissimus dorsi

Level of diaphragm

7th rib

T10

Erector spinae

Palpable features of back Angles of ribs

Dimple overlying posterior superior iliac spine (PSIS)

Iliac crest

Thoracodorsal fascia

Gluteal muscles

Tip of 12th rib

Iliac crest

Back muscles

Superficial extrinsic Intermediate extrinsic

Erector spinae (intermediate intrinsic) Transversospinales (deep intrinsic)

Posterior superior iliac spine

Body of vertebra

(E) Posterior view

Rib

Angle of rib

FIGURE 2.1. Anatomy of back. C. Surface anatomy of back. In lean individuals with well-developed musculature, extrinsic back muscles serving the upper limb are apparent. D. Layered arrangement of extrinsic and intrinsic muscles of back. Intrinsic back muscles lie medial to the angles of the ribs. E. Skeleton of back. A central column of vertebrae and intervertebral discs anked by the posterior portions of ribs comprise the axial skeleton of the back. Features normally palpable are highlighted in green . Although located in the back, scapulae are parts of the superior appendicular skeleton. ( continued )

Serratus posterior inferior

Latissimus dorsi

Thoracic spinous process

Trapezius

(D) Schematic transverse section

TABLE 2.1. RELATIONSHIPS OF PALPABLE LANDMARKS OF BACK TO SIGNIFICANT DEEP STRUCTURES Palpable Landmark Spinous Process Signi cant Deep Structure (Approximations)

Formation of superior vena cava

Spine of scapula

T4–T5 IV disc; transverse thoracic plane (intersects: sternal angle, aortic arch, bifurcation of trachea, arch of azygos vein)

Inferior angle of scapula T7

Level of nipple on anterior thoracic wall

T9–T10

Central tendon of diaphragm; base of lungs

Tips of 12th rib

Inferior end of spinal cord

Iliac crest

Bifurcation of aorta; commonly lumbar puncture performed between laminae of 4th and 5th lumbar vertebrae

Dimple overlying posterior superior iliac spine (PSIS)

Inferior extent of dural sac/subarachnoid space

Chapter 2 ■ Back

Dens of C2

(C1)

Atlas (C1) Axis (C2)

Vertebrae:

C1 C2 C3 C4 C5 C6 C7

(C2)

7 Cervical (C)

T1 T2 T3 T4 T5 T6 T7 T8 T9

12 Thoracic (T)

Spinous process overlapping inferior vertebra

Vertebral canal

Intervertebral foramina

T10 T11 T12

L1 L2 L3 L4 L5

Intervertebral (IV) discs

Parts of vertebral arches

Spinous process Lamina Pedicle

5 Lumbar (L)

Hip bone

S1 S2

Lumbosacral angle

Sacrum (S) (5 segments)

S5 Co1 Co2 Co3 Co4

Coccyx (Co) (4 segments)

(A) Anterior view

(B) Right lateral view

(D) Medial view of bisected column from left with ribs, cranium (skull), and pelvis

FIGURE 2.2. Vertebral column and its ve regions. A and B. Anterior and lateral aspects of vertebral column with isolated vertebra typical of each of three mobile regions. The continuous, weight-bearing column of vertebral bodies and IV discs increases in size as the column descends. Zygapophysial (facet) joints representative of each region are circled. C. Posterior view with vertebral ends of ribs. This represents more fully the skeleton of the back. D. Bisected vertebral column in context of axial skeleton and pelvis, demonstrating vertebral canal. The intervertebral (IV) foramina (also seen in B ) are openings in the lateral wall of the vertebral canal through which spinal nerves exit.

VERTEBRAE

fact that successive vertebrae bear increasing amounts of the body’s weight as the column descends. The vertebrae reach maximum size immediately superior to the sacrum, which transfers the weight to the pelvic girdle at the sac roiliac joints. The vertebral column is exible because it consists of many relatively small bones, called vertebrae (singular = vertebra ), that are separated by resilient IV discs (Fig. 2.2D). The 25 cer vical, thoracic, lumbar, and rst sacral vertebrae also articulate at synovial zygapophysial ( facet ) joints (see Fig. 2.5C), which facilitate and control the vertebral column’s exibility. Although the movement between two adjacent vertebrae is small, in ag gregate, the vertebrae and IV discs uniting them form a re markably exible yet rigid column that protects the spinal cord it surrounds.

The vertebral column in an adult typically consists of 33 vertebrae arranged in ve regions: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal (Fig. 2.2A–D). Signi - cant motion occurs only between the 25 superior verte brae. Of the 9 inferior vertebrae, the 5 sacral vertebrae are fused in adults to form the sacrum , and after approxi mately age 30, the 4 coccygeal vertebrae fuse to form the coccyx . The lumbosacral angle occurs at the junction of the long axes of the lumbar region of the vertebral col umn and sacrum (Fig. 2.2D). The vertebrae gradually be come larger as the column descends to the sacrum and then become progressively smaller toward the apex of the coccyx (Fig. 2.2A–D). The change in size is related to the

Vertebrae

Structure and Function of Vertebrae Vertebrae vary in size and other characteristics from one re gion of the vertebral column to another and to a lesser de gree within each region; however, their basic structure is the same. A typical vertebra (Fig. 2.3) consists of a vertebral body, a vertebral arch, and seven processes. 1 The vertebral body is the more massive, roughly cylin drical, anterior part of the bone that gives strength to the column and supports body weight. The size of the bodies increases as the column descends, most markedly from T4 inferiorly, as each bears progressively greater body weight. The vertebral body consists of vascular, trabecular (spongy, cancellous) bone enclosed by a thin external layer of compact bone (Fig. 2.4). The trabecular bone is a mesh work of mostly tall vertical trabeculae intersecting with short,

Parts:

Muscle attachment and movement Functions:

Spinous process (x1) Transverse processes (x2)

Articular processes (x4)

Restriction of movement Protection of spinal cord Support of body weight

Vertebral arch Vertebral body

Superior view

horizontal trabeculae. The spaces between the trabeculae are occupied by red bone marrow that is among the most actively hematopoietic (blood-forming) tissues of the mature individual. One or more large foramina in the posterior sur face of the vertebral body accommodate basivertebral veins that drain the marrow (see Fig. 2.29). color), a vertebral arch ( red ), and seven processes: three for muscle attachment and leverage ( blue ) and four that participate in synovial joints with adjacent vertebrae ( yellow ). FIGURE 2.3. Functional components of a typical vertebra, represented by 2nd lumbar vertebra. Components include the vertebral body (bone

1 In contemporary usage, the terms vertebral body and centrum and the terms vertebral arch and neural arch are often erroneously used as syn onyms. Technically, however, in each case, the former is a gross anatomy term applied to parts of the adult vertebrae, and the latter is an embryology term referring to parts of a developing vertebra ossifying from primary cen ters. The vertebral body includes the centrum and part of the neural arch; the vertebral arch is thus less extensive than the neural arch, and the centrum is less extensive than the vertebral body (O’Rahilly, 1986; Standring, 2021).

Vertebral canal

Posterior aspect of epiphysial rim

Pedicle

Compact bone Trabecular (spongy) bone Canal for basivertebral vein

Supraspinous ligament

Lamina

Inferior vertebral "end plate"

Spinous process

Zygapophysial joint

Superior vertebral "end plate"

Interspinous ligament

Trabeculae

Anterior longitudinal ligament Posterior longitudinal ligament Intervertebral foramen

Ligamentum flavum

Joint capsule of zygapophysial joint

AF Anulus fibrosus NP Nucleus pulposus Intervertebral (IV) disc

Vertebral arches

Vertebral bodies

Medial view of left halves of two adjacent hemisected vertebrae and associated IV discs

FIGURE 2.4. Internal aspects of vertebral bodies and vertebral canal. The bodies consist largely of trabecular (spongy) bone—with tall, vertical supporting trabeculae linked by short horizontal trabeculae—covered by a relatively thin layer of compact bone. Hyaline cartilage “end plates” cover the superior and inferior surfaces of the bodies, surrounded by smooth bony epiphysial rims. The posterior longitudinal ligament, covering the posterior aspect of the bodies and linking the IV discs, forms the anterior wall of the vertebral canal. Lateral and posterior walls of the vertebral canal are formed by vertebral arches (pedicles and laminae) alternating with IV foramina and ligamenta ava.

Vertebrae

Long, strong transverse processes extend posterolaterally

Transverse process

Nearly vertical articular facets directed primarily posteriorly and anteriorly Circular vertebral foramen, relatively small compared to size of body

Columnar bodies, heart-shaped in superior view

Triangular vertebral foramen

Uncus of body (uncinate process) Rectangular bodies with concave superior and convex inferior surfaces

Bifid spinous process

Oblique, relatively horizontal articular

facets directed primarily superiorly and inferiorly

Foramen transversarium

(B) Superolateral view, thoracic vertebra Spinous process long and sloping; overlaps inferior vertebra Vertebral foramen triangular, intermediate in size

Perforated transverse processes with anterior and posterior tubercles

Costal facets 2 on each side of body 1 on each transverse process

(A) Superolateral view, cervical vertebra

Short, broad, and blunt spinous process

Massive columnar body, kidney-shaped in superior view

Transverse processes long and slender, directed laterally

Nearly vertical articular facets directed primarily medially and laterally

FIGURE 2.6. Comparison of typical presacral vertebrae. As the vertebral column descends, bodies increase in size in relationship to increased weight bearing. The size of the vertebral canal changes in relationship to the diameter of the spinal cord.

Regional Characteristics of Vertebrae Each of the 33 vertebrae is unique; however, most of the vertebrae demonstrate characteristic features identifying them as belonging to one of the ve regions of the vertebral column (e.g., vertebrae having foramina in their transverse processes are cervical vertebrae) (Fig. 2.6). In addition, cer tain individual vertebrae have distinguishing features; the C7 vertebra, for example, has the longest spinous process. It forms a prominence under the skin at the back of the neck, especially when the neck is exed (see Fig. 2.10A). In each region, the articular facets are oriented on the articular processes of the vertebrae in a characteristic di rection that determines the type of movement permitted between the adjacent vertebrae and, in aggregate, for the re gion. For example, the articular facets of thoracic vertebrae are nearly vertical and together de ne an arc centered in the IV disc. This arrangement permits rotation and lateral exion

The spinous and transverse processes provide attachment for deep back muscles and serve as levers, facilitating the muscles that x or change the position of the vertebrae. The articular processes are in apposition with corre sponding processes of vertebrae adjacent (superior and inferior) to them, forming zygapophysial ( facet ) joints (Figs. 2.2B and 2.5C). Through their participation in these joints, these processes determine the types of movement permitted and restricted between the adjacent vertebrae of each region. The articular processes also assist in keeping adjacent vertebrae aligned, particularly preventing one vertebra from slipping anteriorly on the vertebra below. Generally, the ar ticular processes bear weight only temporarily, as when one rises from the exed position, and unilaterally, when the cervical vertebrae are laterally exed to their limit. How ever, the inferior articular processes of the L5 vertebra bear weight even in the erect posture.

Chapter 2 ■ Back

of the vertebral column in this region (see Fig. 2.9). Regional variations in the size and shape of the vertebral canal accom modate the varying thickness of the spinal cord (Fig. 2.2D). CERVICAL VERTEBRAE Cervical vertebrae form the skeleton of the neck (Figs. 2.2 and 2.7). The smallest of the 24 movable vertebrae, the cervical vertebrae are located between the cranium and

thoracic vertebrae. Their smaller size re ects the fact that they bear less weight than do the larger inferior vertebrae. Although the cervical IV discs are thinner than those of infe rior regions, they are relatively thick compared to the size of the vertebral bodies they connect. The relative thickness of the IV discs, the nearly horizontal orientation of the articular facets, and the small amount of surrounding body mass give the cervical region the greatest range and variety of move ment of all the vertebral regions.

Groove for vertebral artery Posterior tubercle

Posterior arch

Tubercle for transverse ligament Superior articular surface (process) Foramen transversarium Transverse process

Lateral mass

Anterior tubercle Facet for dens

Anterior arch

Atlas (C1)

Inferior articular process

Superior lip

Transverse process

Pars interarticularis

Zygapophysial joint

Dens Superior articular facet

Inferior lip

Axis (C2)

Groove for spinal nerve

Anterior tubercle Groove for spinal nerve Posterior tubercle

Inferior articular facet

Transverse process

(B) Lateral view, articulated typical cervical vertebrae

Typical cervical vertebrae

Vertebral foramen

Angles of right mandible

Foramen transversarium

Posterior arch Anterior arch

Spinous process

of atlas (C1)

Dens of C2 Hyoid (H) Transverse process

Uncus of body (uncinate process)

Inferior

Articular process

Spinous process of C7 Zygapophysial (facet) joint Superior articular process Inferior articular process

Superior

Carotid tubercle

Vertebral canal

Vestigial anterior tubercle

FIGURE 2.7. Cervical vertebrae. A. Comparison of cervical vertebrae. C1, C2, and C7 vertebrae are atypical. B. Articulation of cervical vertebrae. The superior and inferior surfaces of the bodies of the cervical vertebrae are reciprocally convex and concave. Combined with the oblique orientation of the articular facets, this facilitates exion and extension as well as lateral exion. C. Alignment of cervical vertebrae. The anterior arch of the atlas lies anterior to the continuous curved line formed by the anterior surfaces of the C2–C7 vertebral bodies. (C) Lateral radiograph (A) Superior views

Chapter 2 ■ Back

Anterior tubercle

Anterior arch

Facet for dens Superior articular surface Transverse ligament of atlas Transverse process Foramen transversarium Groove for vertebral artery Posterior tubercle

Foramen for dens of axis

Lateral mass

Vertebral foramen (for spinal cord)

Posterior arch

(B) Superior view,

atlas (C1 vertebra)

Occipital condyles Foramen magnum

Grooves for attachment of alar ligaments

Dens of axis

Posterior articular facet for transverse ligament of atlas

Superior articular facet Foramen transversarium Transverse process Pars interarticularis

(A) Inferior view, cranial base

Body

X-ray beam

Vertebral foramen (for spinal cord)

Inferior articular process

Occipital condyles

Lamina

Cranium

Lateral mass of atlas (C1) Dens of axis (C2) Body of axis (C2) Lower row of teeth

Spinous process (bifid)

Lateral atlantoaxial joint ( red arrows )

Body

Facet for atlas

Superior articular facet

Anteroposterior radiograph of C1 and C2 (taken through open mouth)

Dens of axis

Transverse process

Lateral mass of atlas (C1) Dens of axis (C2)

Vertebral foramen (for spinal cord)

Inferior articular process Lamina

Body of axis (C2)

C3 vertebra

(E) Anterior view, articulating C1 and C2 vertebra as viewed radiographically

(D) Superior view,

Spinous process (bifid)

axis (C2 vertebra)

FIGURE 2.8. Cranial base and C1 and C2 vertebrae. A. Occipital condyles of cranium. The occipital condyles articulate with the superior articular facets of the atlas (vertebra C1). B. Arches and lateral masses of atlas. The atlas, on which the cranium rests, has neither a spinous process nor a body. It consists of two lateral masses connected by anterior and posterior arches. C and D. Dens (odontoid process) of axis. The tooth-like dens characterizes the axis (vertebra C2) and provides a pivot around which the atlas turns and carries the cranium. It articulates anteriorly with the anterior arch of the atlas (“facet for dens of the axis,” in B ) and posteriorly with the transverse ligament of the atlas (see B ). E. Radiograph and articulated atlas and axis showing the dens projecting superiorly from the body of the axis between the lateral masses of the atlas. Since the atlas and axis lie posterior to the mandible (Fig. 2.7C), anterior radiographs must be taken through the open mouth.

The dens is held in position against the posterior aspect of the anterior arch of the atlas by the transverse ligament of the atlas (Fig. 2.8B). This ligament extends from one lateral mass of the atlas to the other, passing between the dens and spinal cord, forming the posterior wall of the “socket” that

receives the dens. Thus, it prevents posterior (horizontal) displacement of the dens and anterior displacement of the atlas. Either displacement would compromise the portion of the vertebral foramen of C1 that gives passage to the spinal cord. C2 has a large bi d spinous process (Fig. 2.8C, D) that

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