Grant's Dissector

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Dissector

Alan J. Detton

Edition 18

Dissector

Edition 18

Dissector

Edition 18

Alan J. Detton, PhD Associate Professor Department of Pathology and Cell Biology at CUIMC Columbia University Vagelos College of Physicians & Surgeons New York, New York

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Eighteenth Edition

By A. J. Detton: Seventeenth Edition, 2021; Sixteenth Edition, 2017 By P. W. Tank: Fifteenth Edition, 2013; Fourteenth Edition, 2009; Thirteenth Edition, 2005 By E. K. Sauerland: Twelfth Edition, 1999; Eleventh Edition, 1994; Tenth Edition, 1991; Ninth Edition, 1984; Eighth Edition, 1978; Seventh Edition, 1974 By J. C. B. Grant: Sixth Edition, 1967; Fifth Edition, 1959 By J. C. B. Grant and H. A. Cates: Fourth Edition, 1953; Third Edition, 1948; Second Edition, 1945; First Edition, 1940

Copyright © 2021, 2017 Wolters Kluwer. Copyright © 2013, 2009 Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2005, 1999 Lippincott Williams & Wilkins. Copyright © 1994, 1991, 1984, 1978, 1974, 1967, 1959, 1953, 1948, 1945, 1940 Williams & Wilkins.

Seventeenth edition translations: Chinese, Simplified (Beijing Science & Technology Publishing Co., Ltd.) (BSTP) Spanish (Wolters Kluwer)

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Library of Congress Cataloging-in-Publication Data

Names: Detton, Alan J., author. Title: Grant’s dissector / Alan J. Detton. Other titles: Dissector Description: Edition 18. | Philadelphia : Wolters Kluwer, [2025] | Includes bibliographical references and index. Identifiers: LCCN 2023043815 (print) | LCCN 2023043816 (ebook) | ISBN 9781975193669 | ISBN 9781975193683 (epub) | ISBN 9781975193690 Subjects: MESH: Dissection | Laboratory Manual | BISAC: MEDICAL / Anatomy Classification: LCC QM34 (print) | LCC QM34 (ebook) | NLM QS 130 | DDC 611--dc23/eng/20231122 LC record available at https://lccn.loc.gov/2023043815 LC ebook record available at https://lccn.loc.gov/2023043816

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This work is no substitute for individual patient assessment based on health care professionals’ examination of each patient and consid eration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Health care professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any result ing diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and health care professionals should consult a variety of sources. When prescribing medication, health care professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infre quently used, or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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To the incredible women who have taught me so much and continue to bring inspiration to my life.

Thank you for your examples of strength and determination through new beginnings, and for

showing me how compassion, love, and character can always be present no matter the situation.

I am so fortunate to have you in my life and love you all more than I can express.

I also wish to express my sincere gratitude and appreciation to the donors who have given all to the

advancement of education and research without whom this work would not be possible.

Reviewers

Language and Inclusivity Consultant Yasmin Carter, PhD Associate Professor Division of Translational Anatomy, Department of Radiology UMass Chan Medical School Worcester, Massachusetts Clinical Reviewer Alan M. Engler, MD Clinical Assistant Professor Department of Anatomy and Structural Biology Albert Einstein College of Medicine Bronx, New York Faculty Reviewers Abduelmenem Alashkham, PhD, MSc (Distinction), MBBCh Anatomy, School of Biomedical Sciences University of Edinburgh Edinburgh, Scotland, United Kingdom Steven W. Kubalak, PhD Medical University of South Carolina Charleston, South Carolina

Robert Terreberry, PhD Jerry M. Wallace School of Osteopathic Medicine Campbell University Buies Creek, North Carolina Brent J. Thompson, PhD DeBusk College of Osteopathic Medicine Lincoln Memorial University-Knoxville Knoxville, Tennessee Daniel B. Topping, MD College of Medicine University of Florida Gainesville, Florida Christopher T. York Wake Forest University School of Medicine Winston-Salem, North Carolina

Robert W. Zajdel, PhD Upstate Medical University State University of New York Syracuse, New York Jiepei Zhu, MD, PhD Morehouse School of Medicine Atlanta, Georgia

Preface

Grant’s Dissector is intended to provide dissection instruc tions and enough anatomical detail to help students observe and recognize important relationships revealed through human dissection. The eighteenth edition of Grant’s Dissector aims to continue the strong tradition of previous editions as a regional dissection instruction manual with an emphasis on streamlining the content for today’s gross anatomy courses. As curricula are con stantly changing, the modifications described here are intended to increase the adaptability of Grant’s Dissector to a variety of dissection needs while maintaining an ap propriate level of depth. UNIT ORGANIZATION The organizational flow in the eighteenth edition has been maintained for consistency throughout every chap ter. The chapters are subdivided into units, which begin with a clearly labeled title and short summary of the re gion of interest followed by three key aspects to each dis section: an overview, the instructions, and a follow-up. The summary lists of clinical correlations are meant to provide a quick point of reference for students interested in the application of anatomical knowledge in the clini cal setting, a key component to clinical gross anatomy in struction. The list of clinical correlates is found throughout the text at the start of each chapter and has been updated to include figure references from Grant’s Atlas of Anatomy . For the first time, figures have been included within select clinical correlates to highlight anatomical variants or re lationships key to comprehension of the anatomy related to a clinical condition or procedure. Diversity and Inclusion A conscious effort was made in this text to address in clusive language as well as highlighting the difference between sex and gender. Sex and gender are recognized as nonbinary distinctions, and acknowledgment is made that not all individuals may feel represented in the figures Dissection Overview Clinical Correlations

and descriptions in this text. It is hoped that the efforts to portray female representative anatomy first through out this text, most notably in the chapter on pelvis and perineum, alongside references for female and male struc tures are seen as progress toward a more inclusive teach ing and learning environment for all. Skeletal and Surface Anatomy The dissection overview introduces what is to be ac complished during the dissection session and includes step-by-step instructions to guide students through the relevant skeletal anatomy subdivided topically, followed by applicable surface anatomy. Commencing a dissection with the relevant skeletal features is meant to reinforce their anatomical relevance and lay a foundation for the surface anatomy that is then palpable on the cadaver. Similar to a clinical exam, a proper understanding of the skeletal and surface landmarks plays a key role in compre hension of the underlying anatomy during a dissection. All dissection overview and dissection instruction se quences begin with a figure reference for the anatomi cal terms included in the subsequent instructions. The streamlined method of figure reference is meant to fa cilitate student comprehension of the association of mul tiple structures, minimize the amount of back-and-forth figure referencing, and provide a much higher association of all bolded terms to the presented figure. Subcutaneous Tissue and Body Habitus Definitions for skin removal versus skin reflection , as well as full- and partial-skinning techniques are provided in the Introduction Chapter. Additionally, each dissection se quence related to skinning includes updates to the colors used in the figures for required versus optional cut lines for improved clarity. The introduction figure representing the subcutaneous tissue has been updated to include a more detailed representation of the fat and fascial layers deep to the skin. Additionally, a more inclusive dialogue has been added to address varying amounts of subcutane ous tissue as related to body habitus. Dissection Instructions Figure References

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PREFACE

Dissection Follow-up Cadaver Care

cord, breast, diaphragm, and orbit. Cross-sectional images including the pelvis, abdomen, and neck have been up dated to depict similar colors associated with fascial lay ers as seen in Grant’s Atlas of Anatomy . New figures have been added for an alternative method of abdominal dis section with removal of the small intestine in isolation, as well as for clarification of the sequences pertaining to the pharynx, and head reflection or bisection. Addition ally, figures for the external genitalia have been created or updated, including new figures of the female pelvis and perineum, as well as the cross-sectional anatomy of the clitoris. ADDITIONAL RESOURCES References to companion atlas and video material in the eighteenth edition of Grant’s Dissector are now con sistently listed next to the correlating section headings. In the printed text, two primary resources have been highlighted for supplemental instruction: Grant’s Atlas of Anatomy (Atlas) and Grant’s Dissection Videos (Video). References to Atlas Illustrations The student is encouraged to rely on Grant’s Dissector for dissection instruction and to use Grant’s Atlas of Anatomy for additional portrayal of anatomical structures. To fa cilitate figure searching, atlas references now refer to spe cific figure numbers rather than page numbers as seen in previous editions. • Agur AMR, Dalley AF. Grant’s Atlas of Anatomy . 16th ed. Wolters Kluwer; 2025.

Each dissection sequence ends with a Dissection Follow up and includes a numbered list of tasks for the students to perform in the lab following the dissection and re minds students of proper care and cadaver maintenance throughout the entire dissection protocol. The numbered tasks highlight the important features of the dissection and encourage the synthesis of information through re view of the material. The Dissection Follow-up also serves as a reminder of the text in the Introduction Chapter on cadaver care which includes a description of the students’ “first patient” and the responsibility to properly care for the donor’s remains. Muscle Summary Tables The 33 muscle summary tables introduced in the sixteenth edition in the Dissection Follow-up have been maintained and improved for accuracy in the eighteenth edition. The muscle summary tables provide succinct information re lated to muscles names, attachments, actions, and innerva tions of the key muscles identified during each dissection unit. The muscle tables provide a key review opportunity for students while simultaneously making the dissections steps in the instructions more task oriented and approachable.

KEY FEATURES Expansion of Representative Skin Tones

A significant effort has been undertaken in this eigh teenth edition to represent a broad and inclusive range of representative skin tones in patient populations. Figures include a range of skin tone variations throughout each chapter of the text. New Illustrations Significant effort has been made to update the style of many older illustrations in this volume of work including but not limited to those of the vertebral column, spinal

References to Dissection Videos The time stamp references (identified as “VIDEO” in the text) correlate to the companion series of high-definition videos, Grant’s Dissection Videos , paralleling the instruc tions for each region of the body. Each dissection instruc tion protocol of the videos was performed, filmed, and edited by the author, Dr. Alan J. Detton. The dissections were performed on a single female and single male ca daver to replicate the dissection experience encountered by students within the laboratory environment. Copyright © 2025 Wolters Kluwer. Unauthorized reproduction of the article is prohibited.

Acknowledgments

Working on the eighteenth edition of Grant’s Dissector has taught me perhaps more than ever the powerful and unique educational value that dissection offers. It is an incredible privilege to be able to appreciate first-hand the texture and feel of the tissues of the human body and to witness that despite the beauty of anatomical variation, each of us are far more similar than we are different. As I have progressed in my career while writing each edition of this text, I have felt a growing bond to those who also dedicate their time, passion, and energy to providing clar ity in this unique educational modality. I wish to express my continued and expanded grati tude for the significant contributions of the authors in volved in the development of previous editions of Grant’s Dissector . I look back on conversations with Patrick Tank with extreme fondness and hope that my vision for this work has aligned with the potential he would have also seen as efforts are made to make a more inclusive dissec tion companion. I have been fortunate to have so many incredible col leagues and mentors along my somewhat unique career path. I acknowledge I cannot reference you all by name but know that I value our conversations at annual meet ings, committees, and social settings and that I look for ward to continued interactions with each of you. To my incredible colleagues Anne Agur and Arthur (Art) Dalley, you continue to impress me with your dedication to creating educational resources of the highest quality. You have taught me so much about being an educator in all senses of the word, and I feel so honored to continue to

have increased interactions with you in personal and pro fessional capacities. I would like to express my thanks to Yasmin Carter who has helped this work progress in both subtle and direct ways. Yasmin, your passion for inclusion and raising awareness of the beautiful range of all people is truly inspirational. To have worked with you on elements in this text has been a privilege, and I look forward to in creased collaborative efforts in the future. I wish to also express my appreciation for the advice, support, and guid ance I received from Bob Acland while creating the dis section videos. Each time I reflect on how to demonstrate something, or portray a technique to be filmed, I reflect on his timeless advice that “the words must come first.” As always, I am so appreciative for the entire Wolters Kluwer team. Working with you at national and interna tional events has been such a remarkable opportunity for which I am truly appreciative. Crystal Taylor, I value your support so much and hope to continue brainstorming new ideas and projects. Greg Nicholl, I am so glad you were brought in on this project once again and hope you remain involved moving forward. I put you through a lot in this edition, yet you continued to be supportive as you negotiated and delivered so much more than I could have hoped for. I would also like to thank Jennifer Clements and the entire art and editorial teams for the support of changing and incorporating so many figures and updates to a single edition. This has truly been a team effort and your work is recognized and greatly appreciated.

Alan J. Detton

Contents

Preface vii Acknowledgments ix Figure Credits xviii Introduction 1

CHAPTER 2 Upper Limb 29 SKIN AND SUPERFICIAL MUSCLES OF BACK 29 SHOULDER AND POSTERIOR ARM 30 Dissection Overview 30

• SKELETAL ANATOMY 30 • SURFACE ANATOMY 30 Dissection Instructions 31 • SKIN INCISIONS OF POSTERIOR ARM 31 • POSTERIOR SHOULDER 32 • ROTATOR CUFF 33

CHAPTER 1 Back 7 SKIN OF BACK AND SUPERFICIAL SUBOCCIPITAL REGION 7 Dissection Overview 7

• SUPRASCAPULAR ARTERY AND NERVE 33 • POSTERIOR COMPARTMENT OF ARM 33 Dissection Follow-up 34 PECTORAL REGION AND SUBCUTANEOUS TISSUE OF UPPER LIMB 35 Dissection Overview 35

• SKELETAL ANATOMY 8 • SURFACE ANATOMY 11 Dissection Instructions 12

• SKIN INCISIONS OF BACK 12 • SUPERFICIAL SUBOCCIPITAL REGION 13 Dissection Follow-up 14 SUPERFICIAL MUSCLES OF BACK 14

• SKELETAL ANATOMY 35 • SURFACE ANATOMY 36 Dissection Instructions 38 • SKIN INCISIONS OF PECTORAL REGION 38 • BREAST 38 • SUPERFICIAL PECTORAL REGION 39 • SKIN INCISIONS OF ARM AND FOREARM 40 • SUPERFICIAL ARM AND FOREARM 41

Dissection Overview 14 Dissection Instructions 15 • TRAPEZIUS 15 • LATISSIMUS DORSI 15 • RHOMBOID MAJOR AND RHOMBOID MINOR 16 • LEVATOR SCAPULAE 16 Dissection Follow-up 17 INTERMEDIATE AND DEEP MUSCLES OF BACK 17

Dissection Follow-up 42 PECTORAL REGION 42 Dissection Overview 42 Dissection Instructions 42 • PECTORALIS MAJOR 42 • PECTORALIS MINOR AND THORACOACROMIAL ARTERY 43 Dissection Follow-up 44 AXILLA 44

Dissection Overview 17 Dissection Instructions 17

• SERRATUS POSTERIOR SUPERIOR 17 • SERRATUS POSTERIOR INFERIOR 18 • SPLENIUS 18 • ERECTOR SPINAE 18

Dissection Overview 44 Dissection Instructions 44 • AXILLA 44

• SEMISPINALIS CAPITIS 19 • SEMISPINALIS CERVICIS 19 • MULTIFIDUS 20

• AXILLARY ARTERY 45 • BRACHIAL PLEXUS 46 Dissection Follow-up 48 ANTERIOR ARM AND CUBITAL FOSSA 49 Dissection Overview 49 • SKELETAL ANATOMY 50 Dissection Instructions 51 • ANTERIOR COMPARTMENT OF ARM 51 • NEUROVASCULATURE OF ARM 52 • CUBITAL FOSSA 53 Dissection Follow-up 54 Copyright © 2025 Wolters Kluwer. Unauthorized reproduction of the article is prohibited.

Dissection Follow-up 20 SUBOCCIPITAL REGION 21 Dissection Overview 21 • SKELETAL ANATOMY 21 Dissection Instructions 21 • SUBOCCIPITAL MUSCLES 21 • CONTENTS OF SUBOCCIPITAL TRIANGLE 22 Dissection Follow-up 22 VERTEBRAL CANAL, SPINAL CORD, AND MENINGES 23

Dissection Overview 23 Dissection Instructions 24 • LAMINECTOMY 24 • SPINAL MENINGES 25 Dissection Follow-up 27

CONTENTS

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ANTERIOR COMPARTMENT OF FOREARM 55 Dissection Overview 55 • SKELETAL ANATOMY 55 Dissection Instructions 56 • SUPERFICIAL LAYER OF ANTERIOR FOREARM 56 • INTERMEDIATE LAYER OF ANTERIOR FOREARM 56 • NEUROVASCULATURE OF ANTERIOR FOREARM 58 • DEEP LAYER OF ANTERIOR FOREARM 61 Dissection Follow-up 62 PALM OF HAND 62 Dissection Overview 62 • SKELETAL ANATOMY 63 Dissection Instructions 63 • SKIN INCISIONS OF PALM 63

LUNGS 92 Dissection Overview 92 Dissection Instructions 92 • LUNGS IN THORAX 92 • RIGHT LUNG 93 • LEFT LUNG 94 Dissection Follow-up 96 MEDIASTINUM 96 Dissection Overview 96 Dissection Instructions 96

• INFERIOR MEDIASTINUM 96 • HEART IN MEDIASTINUM 97 • REMOVAL OF HEART 98

Dissection Follow-up 99 EXTERNAL FEATURES OF HEART 99 Dissection Overview 99 Dissection Instructions 100 • SURFACE FEATURES AND VALVES OF HEART 100 • CARDIAC VEINS 101 • CORONARY ARTERIES 102 Dissection Follow-up 104 INTERNAL FEATURES OF HEART 104

• SUPERFICIAL PALM 64 • CARPAL TUNNEL 65 • THENAR EMINENCE 67 • HYPOTHENAR EMINENCE 67 • DEEP PALM 68

Dissection Follow-up 69 POSTERIOR FOREARM AND DORSUM OF HAND 70 Dissection Overview 70 Dissection Instructions 71 • DORSUM OF HAND 71 • SUPERFICIAL LAYER OF POSTERIOR FOREARM 71 • DEEP LAYER OF POSTERIOR FOREARM 73 Dissection Follow-up 76 JOINTS OF UPPER LIMB 76

Dissection Overview 104 Dissection Instructions 104 • RIGHT ATRIUM 104 • RIGHT VENTRICLE 105 • LEFT ATRIUM 106 • LEFT VENTRICLE 107 Dissection Follow-up 108 SUPERIOR MEDIASTINUM 108 Dissection Overview 108 Dissection Instructions 108 • SUPERIOR MEDIASTINUM 108 Dissection Follow-up 110 POSTERIOR MEDIASTINUM 110 Dissection Overview 110 Dissection Instructions 111 • POSTERIOR MEDIASTINUM 111 Dissection Follow-up 113

Dissection Overview 76 Dissection Instructions 77

• STERNOCLAVICULAR JOINT 77 • ACROMIOCLAVICULAR JOINT 77 • GLENOHUMERAL JOINT 78

• ELBOW AND PROXIMAL RADIOULNAR JOINTS 79 • INTERMEDIATE AND DISTAL RADIOULNAR JOINTS 81 • METACARPOPHALANGEAL AND INTERPHALANGEAL JOINTS 81 Dissection Follow-up 82

CHAPTER 3 Thorax 83

CHAPTER 4 Abdomen 115 SUBCUTANEOUS TISSUE OF ABDOMEN 116 Dissection Overview 116 • SKELETAL ANATOMY 116 • SURFACE ANATOMY 117 Dissection Instructions 118 • SKIN INCISIONS OF ABDOMEN 118 • SUBCUTANEOUS TISSUE OF ABDOMEN 119 Dissection Follow-up 120 ANTEROLATERAL ABDOMINAL WALL 120 • EXTERNAL OBLIQUE 120 • INTERNAL OBLIQUE 121 • TRANSVERSUS ABDOMINIS 123 • RECTUS ABDOMINIS 123 • EPIGASTRIC VESSELS AND DEEP INGUINAL RING 125 Dissection Follow-up 126 Dissection Overview 120 Dissection Instructions 120

PECTORAL REGION 83 INTERCOSTAL SPACE 84 Dissection Overview 84

• SKELETAL ANATOMY 84 • SURFACE ANATOMY 85 Dissection Instructions 85 • INTERCOSTAL SPACE 85 Dissection Follow-up 87 ANTERIOR THORACIC WALL AND PLEURAL CAVITIES 87 • WINDOW THROUGH THORACIC WALL 87 • REMOVAL OF ANTERIOR THORACIC WALL 88 • ANTERIOR THORACIC WALL 89 • PLEURAL CAVITIES 90 Dissection Follow-up 91 Dissection Overview 87 Dissection Instructions 87

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REFLECTION OF ABDOMINAL WALL 126 Dissection Overview 126 Dissection Instructions 126 • ABDOMINAL QUADRANT REFLECTIONS 126 • ABDOMINAL WALL REFLECTION 127 • ANTERIOR ABDOMINAL WALL 128 Dissection Follow-up 129 PERITONEUM AND PERITONEAL CAVITY 129

DIAPHRAGM 161 Dissection Overview 161 Dissection Instructions 161 • DIAPHRAGM 161 Dissection Follow-up 163

CHAPTER 5 Pelvis and Perineum 165 ANAL TRIANGLE 166 Dissection Overview 166

Dissection Overview 129 Dissection Instructions 130 • ABDOMINAL VISCERA 130 • REFLECTION OF DIAPHRAGM 131 • PERITONEUM 131 Dissection Follow-up 133 FOREGUT DERIVATIVES 133

• SKELETAL ANATOMY 166 • SURFACE ANATOMY 167 Dissection Instructions 168 • SKIN INCISIONS OF GLUTEAL REGION 168 • SUBCUTANEOUS TISSUE OF GLUTEAL REGION 169 • ISCHIOANAL FOSSA 169 Dissection Follow-up 170 FEMALE EXTERNAL GENITALIA, UROGENITAL TRIANGLE, AND PERINEUM 170 Dissection Overview 170 • SKELETAL ANATOMY 171 • SURFACE ANATOMY 172 Dissection Instructions 173 • LABIA MAJORA 173 • SKIN INCISIONS OF FEMALE UROGENITAL TRIANGLE 173 • FEMALE SUPERFICIAL PERINEAL POUCH 174 • CLITORIS 176 • FEMALE DEEP PERINEAL POUCH 176 Dissection Follow-up 177 FEMALE PELVIC CAVITY 177 • SECTIONING OF FEMALE PELVIS 178 • FEMALE INTERNAL GENITALIA 180 Dissection Follow-up 182 FEMALE URINARY BLADDER, RECTUM, AND ANAL CANAL 182 Dissection Overview 182 Dissection Instructions 182 • FEMALE URINARY BLADDER 182 • FEMALE RECTUM AND ANAL CANAL 183 Dissection Follow-up 184 FEMALE INTERNAL ILIAC ARTERY AND SACRAL PLEXUS 184 Dissection Overview 177 Dissection Instructions 177 • FEMALE PELVIC PERITONEUM 177 • BROAD LIGAMENT 178

Dissection Overview 133 Dissection Instructions 134 • STOMACH AND VISCERAL SURFACE OF LIVER 134 • PORTAL TRIAD 135 • CELIAC TRUNK 135 • SPLEEN 136 • LIVER 137 • GALLBLADDER 138 Dissection Follow-up 139 MIDGUT AND HINDGUT DERIVATIVES 139 Dissection Overview 139 Dissection Instructions 140 • MIDGUT DERIVATIVES 140 • SUPERIOR MESENTERIC ARTERY AND VEIN 142 • HINDGUT DERIVATIVES 143 • INFERIOR MESENTERIC ARTERY AND VEIN 144 Dissection Follow-up 144 DUODENUM, PANCREAS, AND HEPATIC PORTAL VEIN 144 Dissection Overview 144 Dissection Instructions 145 • DUODENUM 145 • PANCREAS 145 • HEPATIC PORTAL VEIN 146 Dissection Follow-up 147 REMOVAL OF GASTROINTESTINAL TRACT 147 • OPENING THE STOMACH 148 • OPENING THE SMALL AND LARGE INTESTINES 148 • REMOVAL OF SMALL INTESTINE 149 • REMOVAL OF GASTROINTESTINAL TRACT 151 Dissection Follow-up 152 POSTERIOR ABDOMINAL VISCERA 152 Dissection Overview 152 Dissection Instructions 153 • RETROPERITONEAL VASCULATURE 153 • KIDNEYS 155 • SUPRARENAL GLANDS 156 • ABDOMINAL AORTA AND INFERIOR VENA CAVA 156 Dissection Follow-up 158 POSTERIOR ABDOMINAL WALL 158 Dissection Overview 158 Dissection Instructions 158 • MUSCLES OF POSTERIOR ABDOMINAL WALL 158 • LUMBAR PLEXUS 159 • ABDOMINAL PART OF SYMPATHETIC TRUNK 160 Dissection Follow-up 160 Dissection Overview 147 Dissection Instructions 148

Dissection Overview 184 Dissection Instructions 185 • FEMALE PELVIC BLOOD VESSELS 185 • FEMALE PELVIC NERVES 186 Dissection Follow-up 188 FEMALE PELVIC DIAPHRAGM 188

Dissection Overview 188 Dissection Instructions 188 • FEMALE PELVIC DIAPHRAGM 188 Dissection Follow-up 190 SCROTUM, SPERMATIC CORD, AND TESTIS 190 Dissection Overview 190

• SKELETAL ANATOMY 190 • SURFACE ANATOMY 191

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MEDIAL COMPARTMENT OF THIGH 226 Dissection Overview 226 Dissection Instructions 226 • MEDIAL COMPARTMENT OF THIGH 226 • NEUROVASCULATURE OF MEDIAL THIGH 226 Dissection Follow-up 228 GLUTEAL REGION 228 Dissection Overview 228 • SKELETAL ANATOMY 228 Dissection Instructions 230 • GLUTEUS MAXIMUS 230 • GLUTEUS MEDIUS AND MINIMUS 230 • EXTERNAL ROTATORS OF HIP 231 Dissection Follow-up 232 POSTERIOR COMPARTMENT OF THIGH AND POPLITEAL FOSSA 233 Dissection Overview 233 • SKELETAL ANATOMY 233 Dissection Instructions 234 • POSTERIOR COMPARTMENT OF THIGH 234 • POPLITEAL FOSSA 236 Dissection Follow-up 237 POSTERIOR COMPARTMENT OF LEG 238 Dissection Overview 238 • SKELETAL ANATOMY 239 Dissection Instructions 239 • SUPERFICIAL COMPARTMENT OF POSTERIOR LEG 239 • DEEP COMPARTMENT OF POSTERIOR LEG 239 Dissection Follow-up 242 LATERAL COMPARTMENT OF LEG 243 Dissection Overview 243 Dissection Instructions 243 • LATERAL COMPARTMENT OF LEG 243 Dissection Follow-up 244 ANTERIOR COMPARTMENT OF LEG AND DORSUM OF FOOT 244 Dissection Overview 244 • SKELETAL ANATOMY 244 Dissection Instructions 246 • CRURAL FASCIA 246 • ANTERIOR COMPARTMENT OF LEG 246 • DORSUM OF FOOT 248 Dissection Follow-up 248 SOLE OF FOOT 249 Dissection Overview 249 • SKELETAL ANATOMY 249 Dissection Instructions 250 • SKIN INCISIONS OF SOLE OF FOOT 250 • PLANTAR APONEUROSIS AND CUTANEOUS NERVES 250

Dissection Instructions 192 • SCROTUM 192 • SPERMATIC CORD 192 • TESTIS 193 Dissection Follow-up 194 MALE UROGENITAL TRIANGLE, PENIS, AND PERINEUM 194 Dissection Overview 194 Dissection Instructions 194 • SKIN INCISIONS OF MALE UROGENITAL TRIANGLE 194 • MALE SUPERFICIAL PERINEAL POUCH 195 • PENIS 197

• SPONGY (PENILE) URETHRA 198 • MALE DEEP PERINEAL POUCH 198

Dissection Follow-up 199 MALE PELVIC CAVITY 200 Dissection Overview 200 Dissection Instructions 200

• MALE PELVIC PERITONEUM 200 • SECTIONING OF MALE PELVIS 201 • MALE INTERNAL GENITALIA 202 Dissection Follow-up 204 MALE URINARY BLADDER, RECTUM, AND ANAL CANAL 204 • MALE URINARY BLADDER 204 • MALE RECTUM AND ANAL CANAL 205 Dissection Follow-up 206 MALE INTERNAL ILIAC ARTERY AND SACRAL PLEXUS 206 Dissection Overview 204 Dissection Instructions 204

Dissection Overview 206 Dissection Instructions 207 • MALE PELVIC BLOOD VESSELS 207 • MALE PELVIC NERVES 208 Dissection Follow-up 209 MALE PELVIC DIAPHRAGM 209

Dissection Overview 209 Dissection Instructions 210

• MALE PELVIC DIAPHRAGM 210

Dissection Follow-up 212

CHAPTER 6 Lower Limb 213 SUBCUTANEOUS TISSUE OF LOWER LIMB 213 Dissection Overview 213

• SKELETAL ANATOMY 214 • SURFACE ANATOMY 214 Dissection Instructions 215 • SKIN INCISIONS OF LOWER LIMB 215

• FIRST LAYER OF SOLE OF FOOT 251 • SECOND LAYER OF SOLE OF FOOT 252 • THIRD LAYER OF SOLE OF FOOT 253 • FOURTH LAYER OF SOLE OF FOOT 254 Dissection Follow-up 255 JOINTS OF LOWER LIMB 256

• SUBCUTANEOUS TISSUE OF POSTERIOR LOWER LIMB 216 • SUBCUTANEOUS TISSUE OF ANTERIOR LOWER LIMB 218 Dissection Follow-up 219 ANTERIOR COMPARTMENT OF THIGH 219

Dissection Overview 256 Dissection Instructions 257 • HIP JOINT 257

Dissection Overview 219 Dissection Instructions 220

• SAPHENOUS OPENING 220 • FEMORAL TRIANGLE 221 • ADDUCTOR CANAL AND SARTORIUS 223

• KNEE JOINT POSTERIOR APPROACH 258 • KNEE JOINT ANTERIOR APPROACH 259 • ANKLE JOINT 260 • JOINTS OF INVERSION AND EVERSION 262 Dissection Follow-up 263

• QUADRICEPS FEMORIS 223 • TENSOR OF FASCIA LATA 224

Dissection Follow-up 225

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CHAPTER 7 Neck and Head 265 SUPERFICIAL NECK 266 Dissection Overview 266 • SKELETAL ANATOMY 267 • SURFACE ANATOMY 267 Dissection Instructions 268

• MAXILLARY ARTERY 300 • PTERYGOIDS 300 • TEMPOROMANDIBULAR JOINT 301

Dissection Follow-up 302 INTERIOR OF SKULL 303 Dissection Overview 303 Dissection Instructions 303

• REMOVAL OF CALVARIA 303 • CRANIAL MENINGES 304

• SKIN INCISIONS OF NECK 268 • LATERAL CERVICAL REGION 269 Dissection Follow-up 270 ANTERIOR CERVICAL REGION 271

Dissection Follow-up 306 BRAIN REMOVAL, DURAL INFOLDINGS, AND DURAL VENOUS SINUSES 306 Dissection Overview 306 • SKELETAL ANATOMY 307 Dissection Instructions 308

Dissection Overview 271 Dissection Instructions 271 • SUPERFICIAL ANTERIOR CERVICAL REGION 271 • MUSCULAR TRIANGLE 271 • SUBMANDIBULAR TRIANGLE 272 • SUBMENTAL TRIANGLE 273 • CAROTID TRIANGLE 273 • EXTERNAL CAROTID ARTERY 275 Dissection Follow-up 276 THYROID AND PARATHYROID GLANDS 277 Dissection Overview 277 Dissection Instructions 277 • THYROID AND PARATHYROID GLANDS 277 Dissection Follow-up 278 ROOT OF NECK 279

• REMOVAL OF BRAIN 308 • DURAL INFOLDINGS 309 • DURAL VENOUS SINUSES 309

Dissection Follow-up 309 GROSS ANATOMY OF BRAIN 310 Dissection Overview 310 Dissection Instructions 310 • BRAIN 310 • BLOOD SUPPLY OF BRAIN 310 • CRANIAL NERVES 311 Dissection Follow-up 312 CRANIAL FOSSAE 312 Dissection Overview 312 • SKELETAL ANATOMY 312 Dissection Instructions 314 • ANTERIOR CRANIAL FOSSA 314 • MIDDLE CRANIAL FOSSA 314 • POSTERIOR CRANIAL FOSSA 316 Dissection Follow-up 317 ORBIT 317 Dissection Overview 317

Dissection Overview 279 Dissection Instructions 279 • ROOT OF NECK 279 • SUBCLAVIAN ARTERY 280 Dissection Follow-up 281 FACE 282 Dissection Overview 282 • SKELETAL ANATOMY 282 • SURFACE ANATOMY 285 Dissection Instructions 286

• SKELETAL ANATOMY 318 • SURFACE ANATOMY 319 Dissection Instructions 320 • RIGHT ORBIT FROM SUPERIOR APPROACH 320 • CONTENTS OF ORBIT 320 • EYELID AND LACRIMAL APPARATUS 322 • LEFT ORBIT FROM ANTERIOR APPROACH 323 Dissection Follow-up 325 DISARTICULATION OF HEAD 326 Dissection Overview 326 • SKELETAL ANATOMY 326 Dissection Instructions 327 • RETROPHARYNGEAL SPACE 327 • DISARTICULATION OF HEAD 328 • PREVERTEBRAL AND LATERAL VERTEBRAL REGIONS 328 Dissection Follow-up 329 PHARYNX 329

• SKIN INCISIONS OF FACE 286 • SUBCUTANEOUS TISSUE OF FACE AND FACIAL NERVE 286 • FACIAL ARTERY AND VEIN 288

• MUSCLES AROUND ORBITAL OPENING 288 • MUSCLES AROUND ORAL OPENING 288 • SENSORY NERVES OF FACE 289

Dissection Follow-up 290 PAROTID REGION 291 Dissection Overview 291 • SKELETAL ANATOMY 291 Dissection Instructions 292 • PAROTID REGION 292 Dissection Follow-up 293 SCALP 293

Dissection Overview 293 Dissection Instructions 294 • SCALP 294 Dissection Follow-up 295 TEMPORAL AND INFRATEMPORAL REGIONS 296 Dissection Overview 296 • SKELETAL ANATOMY 296 Dissection Instructions 298 • MASSETER AND REMOVAL OF ZYGOMATIC ARCH 298 • TEMPORAL REGION 298 • INFRATEMPORAL FOSSA 298

Dissection Overview 329 Dissection Instructions 330 • MUSCLES OF PHARYNGEAL WALL 330 • NERVES OF PHARYNX 331 • OPENING OF PHARYNX 332 • BISECTION OF HEAD 333 • INTERNAL ASPECT OF PHARYNX 333 Dissection Follow-up 334

CONTENTS

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NOSE AND NASAL CAVITY 335 Dissection Overview 335

LARYNX 350 Dissection Overview 350 • SKELETAL ANATOMY 350 Dissection Instructions 351 • INTRINSIC MUSCLES OF LARYNX 351 • INTERIOR OF LARYNX 352 Dissection Follow-up 353 EAR 353 Dissection Overview 353

• SKELETAL ANATOMY 335 • SURFACE ANATOMY 336 Dissection Instructions 337 • NASAL SEPTUM 337 • LATERAL WALL OF NASAL CAVITY 337 Dissection Follow-up 339 PALATE AND PTERYGOPALATINE FOSSA 339 Dissection Overview 339 • SKELETAL ANATOMY 340 Dissection Instructions 341 • SOFT PALATE 341 • TONSILLAR BED 343 • PALATINE CANAL AND PTERYGOPALATINE FOSSA 343 Dissection Follow-up 345 ORAL REGION 345 Dissection Overview 345 • SURFACE ANATOMY 345 Dissection Instructions 346 • TONGUE 346 • BISECTION OF TONGUE AND MANDIBLE 347 • SUBLINGUAL REGION 347 Dissection Follow-up 349

• SKELETAL ANATOMY 354 • SURFACE ANATOMY 354 Dissection Instructions 355 • TYMPANIC CAVITY FROM SUPERIOR APPROACH 355 • SECTIONING OF TYMPANIC CAVITY 356 • WALLS OF TYMPANIC CAVITY 357 Dissection Follow-up 358

Index 359

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CHAPTER 1 Back

REFERENCES ATLAS = Grant’s Atlas of Anatomy , 16th ed.,

VIDEO = Grant’s Dissection Videos , video sequence

figure number

number

The vertebral column consists of 33 vertebrae: 7 cervical (C), 12 thoracic (T), 5 lumbar (L), 5 sacral (S), and 4 coccy geal (Co). The vertebrae are numbered within each region from superior to inferior. The upper 24 vertebrae (cervi cal, thoracic, and lumbar) allow flexibility and movement of the vertebral column. The lower vertebrae (sacral and coccygeal) are fused to provide rigid support of the pelvic girdle and to transmit forces to and from the lower limb.

he back is the posterior aspect of the trunk ex tending from the base of the skull to the superior aspect of the gluteal region. The back plays important roles in posture, upper limb stability and movement, and protection of visceral and neurovascular struc tures. The bones of the vertebral column along with the spinal cord and meninges will be studied with the back. T

CLINICAL CORRELATIONS During your dissection protocol, you may encounter anatomical variations, clinical conditions, disease processes, or medical devices in your cadaveric donor. The following select clinical correlations will be described in more detail throughout this chapter. Back 1.1. Excessive Vertebral Curvature (Kyphosis, Lordosis, and Scoliosis), see Thoracic Vertebrae sequence. ATLAS 1.1A, 1.2, 1.6 1.2. Herniated Disc, see Cervical and Lumbar Vertebrae sequence. ATLAS 1.14, 1.16 1.3. Triangles of Back, see Latissimus Dorsi sequence. ATLAS 1.26, 2.33

1.4. Back Pain, Sprains, and Strains, see Erector Spinae sequence. ATLAS 1.14, 1.29, 1.30 1.5. Lumbar Puncture and Epidural Anesthesia, see Laminectomy sequence. ATLAS 1.40, 1.41

SKIN OF BACK AND SUPERFICIAL SUBOCCIPITAL REGION Dissection Overview

The skin of the back, underlying subcutaneous tissue, and deep muscles of the back receive innervation segmentally from the posterior (dorsal) primary rami. Posterior primary rami are unnamed and referred to by their corresponding vertebral levels except for the suboccipital nerve (C1), the greater occipital nerve (C2), and the cluneal nerves in the gluteal region. The order of dissection will be as follows: Skeletal anatomy of the vertebral column and the surface anatomy of the back will be studied. The skin will be either reflected or removed from the back, posterior surface of the neck, and posterior surface of the proximal upper limb. The subcutaneous tissue will either be removed or reflected in a full- or partial-thickness approach. Superficial neurovascular structures in the occipital region will be studied.

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GRANT’S DISSECTOR

Skeletal Anatomy Refer to an articulated skeleton or individual bones and identify the following skeletal features. Posterior Skull and Scapula ATLAS 1.23, 1.36, 2.3 1. Refer to FIGURE 1.1 . 2. On the occipital bone , identify the external occipital protuberance . 3. Identify the superior nuchal line arching laterally from the external occipital protuberance and observe that it runs parallel to the more inferiorly located inferior nuchal line . 4. On the temporal bone , identify the large mastoid process inferolaterally, posterior to the external acoustic meatus . 5. Observe that the scapula is triangular with the superior angle , acromion process, and inferior angle forming the points of the triangle, and the medial (vertebral) border and lateral (axillary) border forming the lower two sides of the triangle. 6. Identify the spine of the scapula , the large ridge along the posterior surface of the scapula. 7. Follow the spine of the scapula laterally and identify the acromion process , the most lateral portion of the bone.

External occipital protuberance

Superior nuchal line

External acoustic meatus

Atlas (C1) Axis (C2)

Mastoid process

Atlas (C1) Axis (C2)

External occipital protuberance

Clavicle

Acromion of scapula

Vertebra prominens (C7)

Cervical curvature

C7 T1

Spine of scapula

Medial (vertebral) border of scapula

Lateral (axillary) border of scapula

Spinous processes of vertebrae

Thoracic curvature

Inferior angle of scapula

Rib

T12

Lumbar curvature

Iliac crest

Sacrum

Ilium

Posterior superior iliac spine

Sacral curvature

Sacrum

Median sacral crest

Acetabulum

Coccyx

Pubis

Ischium

FIGURE 1.1

Skeleton of back. A. Posterior view. B. Lateral view.

CHAPTER 1 BACK

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Thoracic Vertebrae ATLAS 1.12 1. Refer to FIGURE 1.2 . 2. On a thoracic vertebra , identify the large bony mass of the vertebral body anteriorly. 3. Observe that articulation with ribs is a unique char acteristic of thoracic vertebrae. On an articulated skeleton, verify that the head of ribs 1, 10, 11, and 12 articulate with the body of one vertebra while the remaining ribs articulate with the demifacets , the superior and inferior costal facets , of two adjacent vertebrae and the associated intervertebral (IV) disc . 4. Identify the pedicles, the short bony processes arching posteriorly from the vertebral body bilaterally. 5. Identify the superior vertebral notch on the superior aspect of a pedicle and the inferior vertebral notch along the inferior aspect of a pedicle. 6. Identify an inferior vertebral notch of one vertebra and the superior vertebral notch of the vertebra immediately inferior and observe how together they form an IV foramen . Note that a spinal nerve passes

Superior articular facet

Pedicle

Transverse process

Inferior articular facet

Body

Transverse costal facet

T3/T4 intervertebral disc Superior costal facet Inferior costal facet

Spinous process

Inferior vertebral notch

Superior vertebral notch

Intervertebral foramen

Shaft of 5th rib

Head of 5th rib

Spinal n.T5

FIGURE 1.2

Thoracic vertebrae. Lateral view.

through the IV foramen from the vertebral canal where it arose from the spinal cord . 7. Identify the transverse processes and associated transverse costal facets . 8. Observe that the tubercle of a rib articulates with the transverse costal facet of the thoracic vertebra of the same number (i.e., the tubercle of rib 5 articulates with the transverse costal facet of vertebra T5). 9. Identify the superior and inferior articular processes with their associated facets (surfaces) . Observe that in the thoracic region, the articular facets are orientated in the coronal plane, allowing for some rotation and lateral flexion while limiting flexion and extension anteriorly and posteriorly. 10. Identify the spinous process of a thoracic vertebra and observe that it is relatively long and slender, is directed inferiorly and posteriorly, and at lower thoracic levels overlaps the adjacent spinous process of the inferiorly located vertebra. 11. From a superior view, identify the vertebral arch formed by the posterior aspect of the vertebral body, pedicles, transverse processes, laminae , and spinous process to encircle the vertebral foramen . 12. On an articulated skeleton, observe that when individual vertebrae are stacked to form the vertebral column that the vertebral foramina align to form the vertebral canal to protect the spinal cord from the base of the skull to the sacrum. 13. Verify from a lateral perspective that the vertebral column has natural curves, with the thoracic and sacral curva tures being concave anteriorly in a kyphotic orientation, and the cervical and lumbar curvatures concave pos teriorly in a lordotic orientation (see Clinical Correlation 1.1 ). Note that primary curvature relates to the alignment of the vertebral column during development which is maintained in the thoracic and sacral regions, while secondary curvature develops in the cervical and lumbar regions in response to an infant learning to hold up their head or walk, respectively .

CLINICAL CORRELATION 1.1 Excessive Vertebral Curvature (Kyphosis, Lordosis, and Scoliosis) ATLAS 1.1A, 1.2, 1.6

Congenital abnormalities, degenerative diseases, or other pathologic processes such as osteoporosis can lead to excessive vertebral curvature. Kyphosis is an exaggeration of thoracic curvature in the sagittal plane, often caused by degeneration of the anterior aspect of the vertebral bodies. Lordosis is an exaggeration of the lumbar curvature in the sagittal plane, often due to rotation of the hips caused by weakened trunk muscles. Scoliosis is an abnormal amount of lateral curvature of the vertebral column in the coronal plane, often accompanied by rotation of the vertebrae and ribs due to muscular weakness or developmental anomalies.

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