Atlas of clinical gross anatomy 2nd ed k moses, j banks, p nava (saunders, 2013) 1

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Atlas of
CLINICAL GROSS ANATOMY


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Atlas of
CLINICAL GROSS
ANATOMY
Second Edition
Kenneth Prakash Moses, MD
Fellow of the Royal Society of Medicine
Emergency Room Physician
Bear Valley Community Hospital
Big Bear Lake, California


John C. Banks, Jr., PhD
Associate Professor of Anatomy
Department of Pathology and Human Anatomy
Loma Linda University School of Medicine
Loma Linda, California

Pedro B. Nava, PhD
Professor of Anatomy and Vice-Chair
Department of Pathology and Human Anatomy
Loma Linda University School of Medicine
Loma Linda, California

Darrell K. Petersen, MBA
Instructor
Director of Anatomical Services
Biomedical Photographer
Department of Pathology and Human Anatomy

Loma Linda University School of Medicine
Loma Linda, California

Prosections of the Head, Neck, and Trunk
prepared by Martein Moningka
Department of Pathology and Human Anatomy
Loma Linda University School of Medicine
Loma Linda, California


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

ATLAS OF CLINICAL GROSS ANATOMY
Copyright © 2013, 2005, by Saunders, an imprint of Elsevier Inc.
Photographs © 2013 by Darrell K. Petersen.

ISBN: 978-0-323-07779-8

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
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such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our
website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Atlas of clinical gross anatomy / Kenneth P. Moses … [et al.] ; prosections of the head, neck, and trunk
prepared by Martein Moningka.—2nd ed.
   p. ; cm.
  Clinical gross anatomy
  Includes index.
  ISBN 978-0-323-07779-8 (pbk. : alk. paper)
  I.  Moses, Kenneth P.  II.  Title: Clinical gross anatomy.
  [DNLM:  1.  Anatomy—Atlases. QS 17]
  611.0022′2—dc23
2012003930

Content Strategy Director: Madelene Hyde

Senior Content Development Specialist: Andrew Hall
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Linda Van Pelt
Design Direction: Ellen Zanolle

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This book is dedicated to the One who has been there to
assist and guide me throughout the entire process.
K. P. MOSES

To my wife Patricia and daughters Erin and Kirsten, for
allowing me to spend so many hours in my anatomy lab.
J. C. BANKS, JR.

To the many teachers, professors, and mentors who have
had faith in me during my academic career.
P. B. NAVA

To my mother, for all of her love and support;
and to Heather, Jillian, and Megan.
D. K. PETERSEN

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Preface

As we completed the manuscript that was to become the first
edition of Atlas of Clinical Gross Anatomy, released in 2005,
we were pleased with the features of this atlas. We were
able to produce the original intended objectives, such as
outstanding dissections and superb photographs, the general
presentation of the sections from the head down to the foot,
and the consistent organization within each chapter from
superficial structures to deeper structures. These all came
together nicely. The rewards for this endeavor came the next
year with our atlas being awarded the R. R. Hawkins Award
from the Professional and Scholarly Division of the Association
of American Publishers in February 2006, and then winning the
Richard Asher Prize in October 2006, from the Royal Society
of Medicine and the Society of Authors. As exciting as these
accolades were, we readily saw, as an author team and from
comments and suggestions we received (especially from our
students, who found this volume of great help), several ideas
and changes that would greatly improve the usefulness of this
atlas in the classroom as well as in the lab. Utilizing the time
given us and the opportunity to collaborate physically at key
moments over the past couple of years, we accomplished
several notable changes to produce this second edition of Atlas
of Clinical Gross Anatomy.
We feel that the most significant change in the second
edition of our atlas has come in the form of 20 new

dissections. We completely reworked the chapters on the heart
(Chapter 30) and the lungs (Chapter 31). Additionally, the
chapter on the vertebral column (Chapter 26) received three
new and much-needed dissections featuring ligaments of the
vertebral column and the costovertebral joints. The remaining
new dissections were also within Section 3, with Chapter 33
now including a key dissection of the arteries of the celiac
trunk and Chapter 34, the classic presentation of the branches

of the abdominal aorta. Chapters 36 to 38 on the pelvic girdle
and viscera and the perineum were enriched with dissections
of the iliac vessels, the female recto-uterine pouch, and the
male perineal neurovascular structures.
A second significant change in this edition is in the titling
and labeling of all the dissection images. First, each page of
topography and dissection received a more accurate title
within the color bar at the top of each page, giving the reader
a quicker and clearer orientation of the image. The descriptive
legend below each photograph was revisited for greater clarity.
Key structures of each image were bolded for emphasis.
The bolding of key structures helps to illustrate the main
components of each dissection. We also made a few title
changes in the Head and Neck section, which are now more
accurate and all-inclusive.
Finally, another change worth mentioning is the reorganized
sequence of Chapters 32 to 35, placing these chapters in a
more logical progression. In this new edition, we begin with
the anterolateral abdominal wall (Chapter 32) and proceed
through the abdominal organs (Chapters 33 and 34), ending in
Chapter 35 with the posterior abdominal wall.

It will be apparent to the reader that the major changes are
to be found in the Trunk section of this book. We feel very
pleased with the changes we made to improve the quality of
this second edition of Atlas of Clinical Gross Anatomy, and
we hope that this book will be useful in your study of human
anatomy.
Kenneth Prakash Moses
John C. Banks, Jr.
Pedro B. Nava
Darrell K. Petersen

Left to right: Kenneth Prakash Moses, John C. Banks, Jr.,
Pedro B. Nava, Darrell K. Petersen

vii


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Acknowledgments

The idea to write this book came to me while a first-year
medical student. Thank you to each person who encouraged
me to write this book: John, who was my anatomy professor in
college and one of my favorite teachers; Ben, my medical
school gross anatomy professor who is an excellent lecturer
and now a good friend; and Darrell, who is, in my opinion, the
world’s best medical photographer.
Thank you to the Elsevier staff for being such friendly

co-workers on this large task and for being mindful of this
author’s words and opinions. I truly enjoyed the entire process.
Thank you to Kendra Fisher, MD, for all of your assistance in
helping us obtain and also review all of the radiographic
anatomy in this book.
Thank you to my sister, Juanita Moses, MD, who has a great
understanding of practical clinical medicine and an impeccable
attention to detail; she edited the entire manuscript at each of
the three proof stages.
And above all, a special thank you to my mother, Dr. Gnani
Ruth Moses, for raising a son to believe that “all things are
possible.”
K. P. Moses
Thanks must go to everyone who has assisted in the
proofreading and checking of the manuscript.
Grateful thanks to Michigan State University for supplying
the cadavers for the chapters on the upper and lower limbs.
Special thanks go to Kristin Liles, Director of Anatomical
Resources, and Bruce E. Croel, Anatomical Preparation
Technician.
I would also like to thank Andrews University and the
Department of Physical Therapy for the use of their anatomy

lab space, and for the interest and encouragement of its Chairs,
Daryl W. Stuart, EdD, and Wayne L. Perry, PhD.
J. C. Banks, Jr.
I would like to express my appreciation to all of the individuals
within the Division of Anatomy at Loma Linda University who
supported this endeavor. A special thanks to Martein Moningka,
Curator, for his many hours of hard work on numerous detailed

dissections for this atlas. This project would not have been
possible without the strong support from Thomas Smith.
Dawn, thank you for your inspiration and support.
P. B. Nava
I would first like to thank Ken for asking me to be a part of
such a great project. Thanks also to my fellow authors—it has
been a pleasure working with you over the years and I look
forward to many more.
Dave, for being a mentor/instructor in school and, most
important, for being my friend, I owe you many thanks.
I would like to thank Tom for always lending a hand. You
deserve more thanks than you ever receive.
Rachel, you are amazing and very talented. Your words of
encouragement inspire me to always do my best.
Madelene, thanks for your devotion, your vision, and for
continually pushing us forward. You are truly a welcomed asset
to our team.
D. K. Petersen

ix


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Editorial Review Board

Peter Abrahams, MB BS, FRCS(Ed), FRCR
St. George’s University
Grenada

West Indies
Fellow
Girton College
University of Cambridge
Cambridge
Examiner to The Royal College of Surgeons
of Edinburgh
Family Practitioner
London
United Kingdom
Gail Amort-Larson, MScOT
Associate Professor
Department of Occupational Therapy
Faculty of Rehabilitation Medicine
University of Alberta
Edmonton, Alberta, Canada
Judith E. Anderson, PhD
Professor
Department of Human Anatomy and Cell
Sciences
Faculty of Medicine
University of Manitoba
Winnipeg, Manitoba, Canada
Seeniappa Palaniswami Banumathy,
MS, PhD
Director and Professor
Institute of Anatomy
Madurai Medical College
Madurai, India
Raymond L. Bernor, PhD

Professor
Department of Anatomy
Howard University College of Medicine
Washington, DC
Edward T. Bersu, PhD
Professor of Anatomy
Department of Anatomy
University of Wisconsin School of Medicine
and Public Health
Madison, Wisconsin
Homero Felipe Bianchi, MD
Third Chair
Department of Normal Human Anatomy
Faculty of Medicine
University of Buenos Aires
Buenos Aires, Argentina
David L. Bolender, PhD
Associate Professor
Department of Cell Biology, Neurobiology
and Anatomy
Medical College of Wisconsin
Milwaukee, Wisconsin

Dale Buchberger, DC, DACBSP
President
American Chiropractic Board of Sports
Physicians
Auburn, New York
Walter R. Buck, PhD
Dean of Preclinical Education

Professor of Anatomy and Course Director
for Gross Anatomy
Lake Erie College of Osteopathic Medicine
Erie, Pennsylvania
Stephen W. Carmichael, PhD, DSc
Professor and Chair
Department of Anatomy
Mayo Clinic College of Medicine
Rochester, Minnesota
Wayne Carver, PhD
Associate Professor
Department of Cell and Developmental
Biology and Anatomy
University of South Carolina School of
Medicine
Columbia, South Carolina

Julian J. Dwornik, PhD
Professor of Anatomy
Department of Anatomy
Morsani College of Medicine
University of South Florida
Tampa, Florida
Kendra Fisher, MD, FRCP (C)
Assistant Professor of Diagnostic Imaging
Loma Linda University School of Medicine
Staff Physician
Department of Diagnostic Imaging
Loma Linda University Medical Center
Loma Linda, California

Robert T. Gemmell, PhD, DSc
Associate Professor
Department of Anatomy and Developmental
Biology
The University of Queensland
Brisbane St. Lucia, Queensland, Australia
Gene F. Giggleman, DVM
Dean of Academics
Parker College of Chiropractic
Dallas, Texas

David Chorn, MMedSci
Anatomy Teaching Prosector
School of Biomedical Sciences
University of Nottingham Medical School
Queen’s Medical Centre
Nottingham, United Kingdom

Duane E. Haines, PhD
Professor and Chairman
Professor of Neurosurgery
Department of Anatomy
The University of Mississippi Medical Center
Jackson, Mississippi

Patricia Collins, PhD
Associate Professor
Anglo-European College of Chiropractic
Bournemouth, United Kingdom

Jostein Halgunset, MD
Assistant Professor
Institute of Laboratory Medicine
Norwegian University of Science and
Technology
Trondheim, Norway

Cynthia A. Corbett, OD
Director
Vision Center
Redlands, California
Maria H. Czuzak, PhD
Academic Specialist—Anatomical Instructor
Department of Cell Biology and Anatomy
University of Arizona
Tucson, Arizona
Peter H. Dangerfield, MD, ILTM
Director, Year 1
Senior Lecturer
Department of Human Anatomy and Cell
Biology
University of Liverpool
Liverpool, United Kingdom
Jan Drukker, MD, PhD
Emeritus Professor of Anatomy and
Embryology
Department of Anatomy and Embryology
Faculty of Medicine
Maastricht University
Maastricht, The Netherlands

Benedikt Hallgrimsson, PhD
Associate Professor
Department of Cell Biology and Anatomy
University of Calgary
Calgary, Alberta, Canada
Jeremiah T. Herlihy, PhD
Associate Professor
Department of Physiology
University of Texas Health Science Center
San Antonio, Texas
Alan W. Hrycyshyn, MS, PhD
Professor
Division of Clinical Anatomy
University of Western Ontario
London, Ontario, Canada
S. Behnamedin Jameie, PhD
Assistant Professor
Department of Anatomy and Cellular and
Molecular Research Center
School of Medicine
Basic Science Center
Tehran University of Medical Sciences
Tehran, Iran

xi


xii

Editorial Review Board

Elizabeth O. Johnson, PhD
Assistant Professor
Department of Anatomy, Histology and
Embryology
University of Ioannina
Ioannina, Greece
Lars Kayser, MD, PhD
Associate Professor
Department of Medical Anatomy
University of Copenhagen
Copenhagen, Denmark
Lars Klimaschewski, MD, PhD
Professor
Department of Neuroanatomy
Medical University of Innsbruck
Innsbruck, Austria
Rachel Koshi, MB, BS, MS, PhD
Professor of Anatomy
Department of Anatomy
Christian Medical College
Vellore, India
Alfonso Llamas, MD, PhD
Professor of Anatomy and Embryology
Department of Anatomy, Medical School
Universidad Autónoma de Madrid
Madrid, Spain
Grahame J. Louw, DVSc
Professor

Department of Human Biology
Faculty of Health Sciences
University of Cape Town
Cape Town, South Africa
Liliana D. Macchi, PhD
Second Chair
Department of Normal Human Anatomy
Faculty of Medicine
University of Buenos Aires
Buenos Aires, Argentina
Bradford D. Martin, PhD
Associate Professor of Physical Therapy
Department of Physical Therapy
School of Allied Health
Loma Linda University
Loma Linda, California
Martha D. McDaniel, MD
Professor of Anatomy, Surgery and
Community and Family Medicine
Chair
Department of Anatomy
Dartmouth Medical School
Hanover, New Hampshire
Jan H. Meiring, MB, ChB, MpraxMed(Pret)
Professor and Head
Department of Anatomy
University of Pretoria
Pretoria, South Africa
John F. Morris, MB, ChB, MD
Professor

Department of Human Anatomy and Genetics
University of Oxford
Oxford, United Kingdom

Juanita P. Moses, MD, FAAP
Assistant Professor
Department of Pediatrics and Human
Development
Michigan State University College of Human
Medicine
Staff Physician
Department of Pediatrics
Devos Children’s Hospital
Grand Rapids, Michigan
Helen D. Nicholson, MB, ChB, BSc, MD
Professor and Chair
Department of Anatomy and Structural
Biology
University of Otago
Dunedin, New Zealand
Mark Nielsen, MS
Biology Department
University of Utah
Salt Lake City, Utah
Wei-Yi Ong, DDS, PhD
Associate Professor
Department of Anatomy
Faculty of Medicine
National University of Singapore
Singapore

Gustavo H. R. A. Otegui, MD
Department of Anatomy
University of Buenos Aires
Buenos Aires, Argentina
Ann Poznanski, PhD
Associate Professor
Department of Anatomy
Midwestern University
Glendale, Arizona
Matthew A. Pravetz, OFM, PhD
Associate Professor
Department of Cell Biology and Anatomy
New York Medical College
Valhalla, New York
Reinhard Putz, MD, PhD
Professor of Anatomy
Chairman, Institute of Anatomy
Ludwig-Maximilians-Universitat
Munich, Germany
Ameed Raoof, MD, PhD
Lecturer
Division of Anatomy and Department of
Medical Education
University of Michigan Medical School
Ann Arbor, Michigan
James J. Rechtien, DO
Professor
Division of Anatomy and Structural Biology
Department of Radiology
Michigan State University

East Lansing, Michigan
Walter H. Roberts, MD
Professor Emeritus
Department of Pathology and Human
Anatomy
Loma Linda University School of Medicine
Loma Linda, California

Rouel S. Roque, MD
Associate Professor
Department of Cell Biology and Genetics
University of North Texas Health Sciences
Center
Forth Worth, Texas
Lawrence M. Ross, MD, PhD
Adjunct Professor
Department of Neurobiology and Anatomy
The University of Texas Medical School at
Houston
Houston, Texas
Phillip Sambrook, MD, BS, LLB, FRACP
Professor of Rheumatology
University of Sydney
Sydney, Australia
Mark F. Seifert, PhD
Professor of Anatomy and Cell Biology
Indiana University School of Medicine
Indianapolis, Indiana
Sudha Seshayyan, MS
Professor and Head

Department of Anatomy
Stanley Medical College
Chennai, India
Kohei Shiota, MD, PhD
Professor and Chairman
Department of Anatomy and Developmental
Anatomy
Director
Congenital Anomaly Research Center
Kyoto University Graduate School of
Medicine
Kyoto, Japan
Allan R. Sinning, PhD
Associate Professor
Department of Anatomy
The University of Mississippi Medical Center
Jackson, Mississippi
Bernard G. Slavin, PhD
Course Director
Human Gross Anatomy
Keck School of Medicine
University of Southern California
Los Angeles, California
Terence K. Smith, PhD
Professor
Department of Physiology and Cell Biology
University of Nevada School of Medicine
Reno, Nevada
Kwok-Fai So, PhD(MIT)
Professor and Head

Department of Anatomy
Faculty of Medicine
The University of Hong Kong
Hong Kong, China
Susan M. Standring, PhD, DSc
Professor of Experimental Neurobiology
Head
Division of Anatomy, Cell and Human Biology
Guy’s, King’s and St Thomas’ School of
Biomedical Sciences
King’s College
London, United Kingdom



Mark F. Teaford, PhD
Professor of Anatomy
Center for Functional Anatomy and Evolution
Johns Hopkins University School of Medicine
Baltimore, Maryland
Nagaswami S. Vasan, DVM, PhD
Associate Professor
Department of Cell Biology and Molecular
Medicine
New Jersey Medical School
Newark, New Jersey
Ismo Virtanen, MD, PhD
Professor of Anatomy
Anatomy Department
Haartman Institute

University of Helsinki
Helsinki, Finland

Editorial Review Board
Linda Walters, PhD
Professor, Preclinical Education
Midwestern University
Glendale, Arizona
Joanne C. Wilton, PhD
Director of Anatomy
Department of Anatomy
The Medical School, University of
Birmingham
Birmingham, United Kingdom
Susanne Wish-Baratz, PhD
Senior Teacher
Department of Anatomy and Anthropology
Sackler Faculty of Medicine
Tel Aviv University
Tel Aviv, Israel

xiii

David T. Yew, PhD, DSc, DrMed(Habil),
CBiol, FIBiol
Professor and Chairman
Department of Anatomy
The Chinese University of Hong Kong
Hong Kong, China
Henry K. Yip, PhD

Associate Professor
Department of Anatomy
Faculty of Medicine
The University of Hong Kong
Hong Kong, China
N. Sezgie Ylgi, PhD
Professor
Department of Anatomy
Faculty of Medicine
Hacettepe University
Ankara, Turkey


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Specialist Reviewers

ANATOMY
Brad Martin, PhD
Ralph Perrin, PhD
AUDIOLOGY
Heather L. Knutson, MA, CCC-A, FAAA
CARDIOLOGY
Mil Dhond, MD, FACC
Husam Noor, MD
CARDIOTHORACIC SURGERY
Leonard Bailey, MD, FACS
Anees Razzouk, MD, FACS
DENTAL HYGIENE

Jolene N. Bauer, RDH
DENTISTRY
William A. Gitlin, DDS
Carlos Moretta, DDS, RDH
DIETETICS
Arlene Campbell, RD
EMERGENCY MEDICINE
Michael Dillon, MD, FACEP
Greg Goldner, MD, FACEP
Eliot Nipomnick, MD, FACEP
FAMILY PRACTICE
Tricia Scheuneman, MD

GENERAL SURGERY
Nathaniel Matolo, MD, FACS
Hamid Rassai, MD, FACS
Clifton Reeves, MD, FACS
Mark Reeves, MD, FACS
INTERNAL MEDICINE
Sofia Bhoskerrou, MD
Joseph Selvaraj, MD, MPH
NURSING
Robin Hoover, RN, ADN
Pam Ihrig, RN, BSN
Joanna Krupczynski, RN, BSN
Sandy Manning, RN, BSN
Denise K. Petersen, MSN, FNP
OBSTETRICS AND GYNECOLOGY
Tricia Fynewever, MD
Wilbert A. Gonzalez, MD, FACOG

Jeffrey S. Hardesty, MD, FACOG
Kathleen M. Lau, MD, FACOG
Sam Siddighi, MD
OCCUPATIONAL THERAPY
Kristina Brown, OT
OPHTHALMOLOGY
Julio Narvaez, MD, FAAO
Wendell Wong, MD, FAAO
OROMAXILLOFACIAL SURGERY
Allen Herford, MD, DDS, FACS

ORTHOPEDICS
Raja Dhalla, MD, FACS
Christopher Jobe, MD, FACS
Richard Rouhe, MD, FACS
OTORHINOLARYNGOLOGY
George Petti, MD, FACS
Mark Rowe, MD, FACS
PATHOLOGY
Jeff Cao, MD
PHYSICAL MEDICINE AND
REHABILITATION
Jien-sup Kim, MD
PHYSICAL THERAPY
James Ko, PT
PLASTIC AND RECONSTRUCTIVE SURGERY
Subhas Gupta, MD, FACS
Brett Lehocky, MD, FACS
Duncan Miles, MD, FACS
Michael Pickart, MD, FACS

Andrea Ray, MD, FACS
Frank Rogers, MD, FACS
Arvin Taneja, MD, FACS
UROLOGY
H. Roger Hadley, MD, FACS, AUA


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Contents

1 

Introduction to Anatomy  2

SECTION 1  HEAD AND NECK

SECTION 3  TRUNK
25 

Introduction to the Trunk  302

2 

Introduction to the Head and Neck  8

26 

Vertebral Column  306

3 

Skull  12

27 

Suboccipital Region  322

4 

Scalp and Face  26

28 

Back Muscles  334

5 

Parotid, Temporal, and Pterygopalatine
Region  44

29 

Chest Wall and Mediastinum  346

30 

Heart  358

6 

Orbit  60

31 

Lungs  374

7 

Ear  74

32 

Anterolateral Abdominal Wall and Groin  384

8 

Nasal Region  86

33 

Gastrointestinal Tract  398

9 

Oral Region  98

34 

Abdominal Organs  418

10 

Pharynx and Larynx  108

35 

Diaphragm and Posterior Abdominal Wall  432

11 

Submandibular Region  124

36 

Pelvic Girdle  446

12 

Anterior Triangle of the Neck  132

37 

Pelvic Viscera  460

13 

Posterior Triangle of the Neck and Deep
Neck  148

38 

Perineum  478

SECTION 2  UPPER LIMB

SECTION 4  LOWER LIMB

14 

Introduction to the Upper Limb  164

39 

Introduction to the Lower Limb  494

15 

Breast and Pectoral Region  166

40 

Anteromedial Thigh  498

16 

Axilla and Brachial Plexus  178

41 

Hip Joint  512

17 

Scapular Region  192

42 

Gluteal Region and Posterior Thigh  526

18 

Shoulder Complex  204

43 

Knee Joint and Popliteal Fossa  540

19 

Arm  218

44 

Anterolateral Leg  556

20 

Cubital Fossa and Elbow Joint  232

45 

Posterior Leg  568

21 

Anterior Forearm  248

46 

Ankle and Foot Joints  580

22 

Posterior Forearm  258

47 

Foot  594

23 

Wrist and Hand Joints  268

24 

Hand Muscles  282

Index  615

xvii


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Atlas of
CLINICAL GROSS ANATOMY


1 
Introduction to
Anatomy

2

Anatomy is the study of the structure of the body. Like any
other discipline, it has its own language to enable clear and
precise communication. Anatomists base all descriptions of the
body and its structures on the “anatomical position.” In this
position the body is erect, arms at the sides, palms of the
hands facing forward, and feet together. The anatomical
position is used by anatomists and clinicians as a frame of
reference to place anatomy in a three-dimensional context and
to standardize the terms for anatomical structures and their
functions.
Anatomical planes pass through the body in the anatomical
position and are used for reference. The three main descriptive
planes (Fig. 1.1) are

• the median plane—a vertical plane that divides the body
into left and right halves (strictly speaking, this is called
the median sagittal plane)
• sagittal planes—any vertical plane parallel to the median
plane, for example, midway between the median plane
and the shoulder
• the frontal (or coronal) plane—a vertical plane oriented
at 90° to the median plane that divides the body into front
(anterior) and back (posterior) sections
• the horizontal (transverse or axial) plane, which
divides the body into upper (superior) and lower
(inferior) sections and in some situations is referred to as
a “cross section”
Specific terms of description and comparison, based on the
anatomical position, describe how one part of the body relates
to another:
• anterior (ventral)—toward the front of the body
• posterior (dorsal)—toward the back of the body
• superior (cranial)—toward the head
• inferior (caudal)—toward the feet
• medial—toward the midline of the body
• lateral—away from the midline of the body
• proximal—toward the point of origin, root, or
attachment of the structure
• distal—away from the point of origin, root, or attachment
of the structure
• superficial (external)—toward the surface of the body
• deep (internal)—away from the surface of the body
• dorsum—superior surface of the foot and posterior
surface of the hand

• plantar—inferior aspect of the foot
• palmar (volar)—anterior aspect of the hand
There are also terms for movement. Movements take
place at joints, where bone or cartilage articulates. Most
movements occur in pairs, with the movements opposing
each other:
• Flexion decreases the angle between body parts, and
extension increases the angle.
• Adduction is movement toward the median plane of the

body, whereas abduction is movement away from the
median plane.
• Medial rotation turns the anterior surface medially or
inward.
• Lateral rotation turns the anterior surface laterally or
outward.
• Supination is lateral rotation of the forearm, for example,
such that the palm starts the movement facing down and
ends the movement facing up, whereas pronation is
medial rotation of the forearm, for example, such that
the palm starts the movement facing up and ends the
movement facing down.
• Inversion is movement of the foot so that the sole faces
medially, and eversion is movement of the foot so that
the sole faces laterally.

l

Media
ateral

L

Median (sagittal)
plane

Supe
r
(cran ior
ial)

Frontal (coronal)
plane

Horizontal plane

Infe
ri
(cau or
dal)

Prox

imal

Dist

al

Pos

ter

t

Righ

ior

Left

An

ter

ior

FIGURE 1.1  Anatomical planes and orientation.


Body Systems
A body system is a combination of organs with a similar or
related function that work together as a unit. Body systems
work together to maintain the functional integrity of the body
as a whole.

MUSCULOSKELETAL SYSTEM
Skeleton
The human skeleton of 206 bones comprises
• the axial skeleton—the skull, vertebrae, ribs, sternum,

and hyoid bones
• the appendicular skeleton—shoulder girdles with the
upper limbs and hip girdles with the lower limbs

Muscles
Muscle cells contract. Movement is produced when the
contraction occurs in a muscle that is attached to a rigid
structure, such as a bone.
There are three types of muscle that differ in location,
histologic appearance, and how they are controlled (voluntary
versus involuntary control).
• Skeletal muscles are mainly under voluntary—
conscious—control and are the muscles of most interest
in gross anatomy. They are attached at each end—either
to bone or to connective tissue—via tendons and
aponeuroses. They usually span a single joint such that
contraction causes the joint to move in a specific
direction.
• Smooth muscle is found in the digestive, respiratory, and
cardiovascular systems and is under involuntary control. It
helps maintain and change the lumen of the gut, bronchi,
and blood vessels. In the gut, rhythmic contractions of
smooth muscles generate the peristaltic waves that push
food through the gastrointestinal tract.
• Cardiac muscle is present only in the heart and is under
involuntary control. Contractions of cardiac muscle are
the driving force behind the circulation of blood.

Muscle Names
Muscles generally have descriptive names that give an

indication of their shape, number of origins, location, number
of bellies, function, origin, or insertion. Muscles are classified
according to the arrangement of their bundles of muscle fibers
(fasciculi), which affects the degree and type of movement
of an individual muscle. The fiber arrangements may be
• strap-like (parallel)
• fusiform (spindle-like)
• fan shaped

• pennate (feather-like)
• bipennate
• multipennate
• sphincteric (circular)
The attachment of a muscle that moves the least is the origin;
the more mobile attachment is the insertion. In some
instances these roles are reversed.

Connective Tissue
Individual muscle cells are covered by specialized connective
tissue (endomysium). Because each cell is extremely long, the
term fiber is used more often than cell. A bundle of several
fibers (a fascicle) is surrounded by a sheet of connective tissue
(perimysium). In addition, the entire muscle is surrounded
by a sheath of connective tissue (epimysium). These three
levels of connective tissue (also known as investments) are
interconnected and provide a route for nerves and blood
vessels to supply the individual muscle cells. They also transmit
the collective pull of individual muscle cells, fascicles, and
entire muscles to the points of muscle attachment.

Introduction to Anatomy

• Opposition is action whereby the thumb abducts, rotates
medially, and flexes so that it can meet the tip of any
other flexed finger.
• Circumduction is circular movement of the limbs that
combines adduction, abduction, extension, and flexion
(e.g., “swinging the arm around in a circle”).
• Elevation lifts or moves a part superiorly, whereas
depression lowers or moves a part inferiorly.
• Protrusion (protraction) is to move the jaw anteriorly,
and retrusion (retraction) is to move the jaw posteriorly.
Structures may be unilateral or bilateral. The heart is an
example of a unilateral structure: it exists on only one side
of the body. Bilateral structures, such as the vessels of the
arm, are present on both (bi-) sides of the body. Two similar
adjectives—ipsilateral, meaning on the same side of a
structure, and contralateral, meaning on the opposite side—
are often used in anatomical descriptions.

Muscle Groups
Muscles combine in groups to perform complex or powerful
movements. Groups of muscles that initiate a movement
are prime movers; those that oppose the movement are
antagonists. Muscles that contract to support a primary
movement are synergists. Paradoxical muscles are muscles
that relax against the pull of gravity.

NERVOUS SYSTEM
The nervous system, which consists of the brain, spinal cord,

and all peripheral nerves (Fig. 1.2), is the main control center
for the body’s numerous functions; it processes all external and
internal stimuli and responds appropriately. Its main structural
and functional subdivisions are
• the central nervous system (CNS), comprising the
brain, brainstem, and spinal cord
• the peripheral nervous system (PNS), composed of 12
pairs of cranial nerves arising from the brain and 31 pairs
of spinal nerves arising from the spinal cord
• the autonomic division (see later), composed of
elements from both the CNS and PNS
A neuron (nerve cell) comprises a cell body, an axon,
and dendrites. The axon is the long fiber-like part of the
nerve between the cell body and the target organ. In special
circumstances, for example, in the autonomic division
(autonomic part of the PNS, see later) when two neurons
meet, the axon of one neuron meets the dendrites of another
at a junction called the synapse.
Motor nerves (efferent nerves) carry impulses from
the CNS to the PNS and innervate muscles. Sensory nerves
(afferent nerves) receive information from sense receptors
throughout the body and relay it back to the CNS for
processing and interpretation.

Autonomic Division
The autonomic division is subdivided into two parts—the
sympathetic and parasympathetic nervous systems—and
allows the body to respond appropriately to any given set of
circumstances with very little conscious control.
Axons from neurons in the CNS (preganglionic fibers) run

to autonomic ganglia outside the CNS. The preganglionic fiber
from a central neuron synapses with a second neuron within
the ganglion. Nerve fibers (postganglionic fibers) then travel
from this second neuron to the target organ or cell. A ganglion
is therefore a collection of neuron bodies outside the CNS that
acts as a point of transfer for stimulation of neurons. Both the

3


Peripheral
nervous
system

Brain

Cranial nerve

Central
nervous
system

Spinal
cord

Brachial
plexus

Posterior (dorsal)
root

Introduction to Anatomy

Spinal
nerve

Spinal sensory
(dorsal root)
ganglion

Anterior rami
of spinal nerve
Lumbar
plexus
Sympathetic
ganglion

Sacral
plexus

Sympathetic
trunk

which supply blood to the heart itself. The first large branch
from the aorta is the brachiocephalic trunk, which gives rise
to the right common carotid and right subclavian arteries.
These vessels supply blood to the head, neck, and right upper
limb, respectively (Fig. 1.3). The left common carotid and
left subclavian arteries are the next arterial branches and
supply blood to the left side of the head and neck and to the

left upper limb, respectively. After these branches, the aorta
turns inferiorly toward the abdomen. Branches of the
descending thoracic aorta supply the viscera within the thorax
and the chest wall, mediastinum, and diaphragm.
The thoracic aorta pierces the diaphragm at the level of the
thoracic vertebra TXII to become the abdominal aorta. The
abdominal aorta gives rise to three main unpaired arteries:
• the celiac trunk (at vertebral level TXII)
• the superior mesenteric artery (at vertebral level TXII/
LI)
• the inferior mesenteric artery (at vertebral level LIII)
These three arteries supply blood to the abdominal viscera and
are derivatives of the embryonic foregut, midgut, and hindgut,
respectively. The abdominal aorta also supplies blood to the
body wall via paired lumbar segmental arteries. The renal
arteries (at the LI level), suprarenal arteries, and gonadal
arteries (at the LII/LIII vertebral level) are paired arteries that
supply the viscera of the posterior abdominal wall. Inferiorly,
the abdominal aorta divides into the left and right common
iliac arteries at the level of the LIV vertebra. As the common

FIGURE 1.2  Nervous system.

sympathetic and parasympathetic subdivisions of the autonomic
division contain ganglia. Most organs receive input from both
subdivisions of the autonomic division; however, the body wall
does not receive parasympathetic nerve fibers.
Sensory (e.g., pain) fibers from the viscera reach the CNS
via either or both of the autonomic pathways, but there is no
peripheral synapse for visceral sensory nerves. Their cell

bodies are located in either the spinal ganglion (dorsal
root ganglion) or the sensory ganglion of certain cranial nerves.
The sympathetic nervous system sends signals from the CNS
to prepare the body for action—dilating the pupils, increasing
the heart and respiratory rates, and causing sweating,
vasoconstriction, cessation of gastrointestinal movements, and
constriction of urinary and anal sphincter muscles.
Parasympathetic nerve fibers do the opposite—they relax
the body, constrict the pupils, slow the heart rate, promote
salivary secretion, increase peristalsis (gastrointestinal tract
stimulation), and relax the urinary and anal sphincters.

Aortic arch

Right common
carotid artery

Axillary artery

Right subclavian
artery

Pulmonary
trunk

Brachiocephalic
trunk

Celiac trunk

Brachial artery

Renal artery

Radial artery

Abdominal
aorta

Ulnar artery

Inferior
mesenteric
artery

Common iliac
artery

CARDIOVASCULAR SYSTEM
The heart is in the middle mediastinum between the lungs. It
has four chambers that pump blood throughout the body. The
right side of the heart receives deoxygenated blood from the
body and pumps it to the lungs: pulmonary circulation. The
left side receives oxygenated blood from the lungs and sends it
to the body: systemic circulation, with arteries carrying
blood from the heart to tissues and organs and veins returning
blood to the heart.

Arteries

4

The aorta is the largest artery in the body. It carries
oxygenated blood from the left ventricle of the heart to the rest
of the body. Ascending from the heart, the aorta forms an arch
that curves toward the left side of the body and then descends
in the chest toward the abdomen. The first arteries that branch
from the aorta are the relatively small coronary arteries,

Gonadal artery

Deep artery
of the thigh

Femoral artery

Popliteal artery
Anterior tibial
artery
Posterior tibial
artery
Fibular artery

Dorsalis pedis
artery

FIGURE 1.3  Arterial system.


LYMPHATIC SYSTEM

Aortic arch
Brachiocephalic vein

Subclavian vein
Pulmonary arteries

Superior vena cava
Cephalic vein

Pulmonary trunk

Inferior vena cava
Basilic vein

Inferior
mesenteric
vein

Superior
mesenteric
vein

Gonadal
vein

Deep femoral
vein

Great saphenous
vein

Femoral vein

FIGURE 1.4  Venous system.
Right jugular
lymph trunk
Right lymphatic
duct

Cervical lymph
nodes
Thoracic duct

iliac arteries descend into the pelvis, they subdivide into vessels
that supply the pelvis and both lower limbs.

Thoracic duct

Axillary lymph
nodes

Veins

Cisterna chyli

Lymphatics of
mammary gland

Veins transport deoxygenated blood from tissues and organs
back to the heart (Fig. 1.4). Systemic veins direct blood from

the body to the superior and inferior venae cavae, which drain
to the right atrium of the heart. The pulmonary vein, unlike the
rest of the veins, transports oxygenated blood from the lungs to
the left atrium of the heart.
The superior vena cava receives blood from the head and
neck, chest wall, and upper limbs via the internal jugular,
azygos, subclavian, and brachiocephalic veins. The inferior
vena cava receives blood from the pelvis, abdomen, and lower
limbs.
The portal system is a special set of veins that drains blood
from the intestines and supporting organs. Its venous blood is
rich in nutrients absorbed from the digestive tract. The
hepatic portal vein is formed by the union of the splenic
and superior mesenteric veins. Blood flows from the hepatic
portal vein to the liver. From the liver, hepatic veins drain into
the inferior vena cava.

Lumbar lymph
nodes

Pelvic lymph
nodes

Iliac lymph
nodes

Introduction to Anatomy

Hepatic portal
vein

Renal vein

The lymphatic system is composed of a series of lymphatic
vessels and lymph nodes (filters) that transport excess tissue
fluid (lymph) from the tissue spaces to the venous system (Fig.
1.5). Lymphatic vessels also transport nutrient-rich lymph from
the intestines to the blood and play a role in immunity.
Lymph flow through the body is slow. In many areas it is
unidirectional because of the presence of one-way valves in the
vessels. Flow is promoted by the massaging of lymph vessels by
adjacent arteries and—in the limbs—by skeletal muscle and
vessels and by differences in pressure between the abdominal
and thoracic cavities.
Lymphatic vessels begin as blind-ended capillaries within the
tissue spaces. Excess tissue fluid enters these vessels and
becomes a colorless, clear fluid—lymph—which then passes
through a series of lymph nodes as they convey the lymph
toward the venous system:
• The jugular trunks lie beside the internal jugular vein
and receive lymph from each side of the head and neck.
• The subclavian trunks drain the upper limbs and chest.
• The bronchomediastinal trunks drain the organs of the
thorax.
In the abdomen, the thoracic duct drains lymph from the
lower limbs, pelvis, and abdomen. Lymph from the thoracic
duct drains to the junction of the left subclavian and left
internal jugular veins. The thoracic duct receives the left
jugular lymph trunk, the left subclavian lymph trunk, and the
left bronchomediastinal lymph trunks. Essentially, the thoracic

duct drains the lower part of the body, the left upper limb, and
the left side of the head and neck. Lymph from the right upper
limb and the right side of the head and neck drains to the right
jugular lymph trunk via reciprocal vessels, which enter the
venous system at the union of the right internal jugular and
right subclavian veins.

Inguinal lymph
nodes
Lymphatic vessels
of lower limb

FIGURE 1.5  Lymphatic system.

5