Anatomy.a.regional.atlas.of.the.human.body.6th.ed

CLEMENTE

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ANATOMY

CHAPTER 1: Pectoral Region, Axilla, Shoulder, and Upper Limb

Plates 1138

CHAPTER 2: The Thorax

Plates 139218

CHAPTER 3: The Abdomen

Plates 219322

CHAPTER 4: The Pelvis and Perineum

Plates 323370

CHAPTER 5: The Back, Vertebral Column, and Spinal Cord

Plates 371408

CHAPTER 6: The Lower Limb

Plates 409516

CHAPTER 7: The Neck and Head

Plates 517668

CHAPTER 8: Cranial Nerves

Plates 669694

Index

I-1I-24

Acquisitions Editor: Crystal Taylor Marketing Manager: Brian Moody Product Manager: Julie Montalbano Designer: Terry Mallon Compositor: Aptara, Inc. Copyright 2011, 2007, 1997, 1987, 1981, 1975 Lippincott Williams & Wilkins, a Wolters Kluwer business. 351 West Camden Street Baltimore, MD 21201 Printed in China. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at [email protected], or via Web site at lww.com (products and services). 9 8 7 6 5 4 3 2 1 This 6th edition of Anatomy: A Regional Atlas of the Human Body is published by arrangement with Elsevier Germany GmbH, publisher and copyright holder of Sobotta Atlas der Anatomie des Menschen, 22. Auflage, Band 1, Band 2; Mnchen: Elsevier/ Urban & Fischer 2006. The English translation was undertaken by Lippincott Williams & Wilkins. Most of the illustrations in this atlas have been previously published in the following: Clemente, Carmine D. Anatomy: A Regional Atlas of the Human Body, 4th Edition. Baltimore: Williams & Wilkins, 1997. Sobotta, J. Atlas of Human Anatomy, 21st German Edition/13th English Edition, Volumes 1 and 2. Edited by R. Putz and R. Pabst. Munich: Urban & Fischer, 2000; Baltimore: Lippincott Williams & Wilkins, 2001. Sobotta, J. Atlas of Human Anatomy, 11th English Edition, Volume 1. Edited by J. Staubesand. Baltimore, Munich: Urban & Schwarzenberg, 1990. Sobotta, J. Atlas der Anatomie des Menschen, 18. Auflage, Band 2. Edited by H. Ferner. Munich: Urban & Schwarzenberg, 1982. Wicke, L. Atlas of Radiologic Anatomy, 6th English Edition. Edited and translated by A.N. Taylor. Baltimore: Williams & Wilkins, 1998. 530 Walnut Street Philadelphia, PA 19106

Library of Congress Cataloging-in-Publication Data Clemente, Carmine D. Anatomy : a regional atlas of the human body / Carmine D. Clemente. 6th ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-58255-889-9 (alk. paper) 1. Anatomy, Surgical and topographicalAtlases. I. Title. [DNLM: 1. Anatomy, RegionalAtlases. QS 17 C626a 2011] QM531.C57 2011 611dc22 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 2232320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.

2009037389

Preface to the Sixth Edition

It is always reinforcing and rewarding for an author when the publisher of a book requests another edition. I have now had this pleasure five times after the first edition of this atlas was published 34 years ago in 1975. Previous editions, as well as this edition, have benefited greatly by the many suggestions from colleagues and especially students. Students often approach this in a thoughtful subtle manner. First, the student may say how much he or she has learned from the book and give praise to the nature and color of the figures and then point out a mistaken label in one of the figures that may not have caught my eye. Of course, I am always grateful for these suggestions. In this edition, I have added many new figuresfor example, 14 new figures on 5 plates dealing with the brachial plexus. At the same time, a few figures that did not prove to be excellent teaching items have been removed. Perhaps the most important change in the book is the addition of a significant number of X-rays, CT scans, and ultrasound scans. I am most grateful to Edward J. H. Nathanial, M.D., Ph.D., Emeritus Professor at the University of Winnipeg School of Medicine in Canada, for providing at least 15 figures of clinical significance. Several figures also were contributed by Dr. G.L. Colborn, Emeritus Professor from the Medical College of Georgia in Augusta, Georgia. I have also had the pleasure of discussions with Dr. James D. Collins, Professor of Radiologic Sciences here at UCLA. I thank Dr. Constantine Karakousis, Professor of Surgery and Chief of Surgical Oncology at the University of Buffalo in Buffalo, New York, for the use of several of his figures and for comments on the clinical importance of several plates. Certain X-rays from Dr. Lothar Wickes 6th English edition of Atlas of Radiologic Anatomy, edited by Dr. Anna Taylor here at UCLA, were also used. There are more than 200 plates of clinical importance in this atlas, and I have benefited greatly from my discussions and collaboration with Professor Gerald Buckberg, M.D., Professor of Cardiac Surgery here at UCLA, and the late Dr. F. Torrent Guasp

from Madrid, Spain, on the progressive unfolding of cardiac muscle as shown in Plate 186. These studies have given insightful information on the manner by which the heart muscle develops and matures. Most of the figures in this atlas come from the Sobotta atlases, recent editions of which have been published by Professor R. Putz in Munich, Germany, and Professor R. Pabst in Hanover, Germany. My deepest appreciation to these two brilliant anatomists knows no bounds. Their German editions of Sobotta have been recently reproduced as the 14th English Edition in 2006. A number of drawings, some of which were also used in the 5th edition, were made by a former resident artist here at UCLA, Ms. Jill Penkhus. I am most grateful for her artistic creativity. I am most indebted to the editors at Lippincott Williams & Wilkins in Baltimore, and especially to Ms. Crystal Taylor, with whom I have interacted for more than 20 years on several earlier editions of this atlas, and Ms. Julie Montalbano, the Product Manager of this edition. Here at UCLA, I am privileged to have worked with outstanding associates who form the gross anatomy faculty for both the medical and dental school at this university. These include Dr. Shelley Metten, the Chairperson of the Anatomy Division, and Drs. Robert Trelease, Richard Braun, Joseph Miller, Elena Stark, Yau Shi Lin, Jonathan Wisco, Quynh Pham, Guido Zampighi, David Hovda, Anna Taylor, Robin Fisher, Charles Olmstead, Francesco Chiappelli, and Jayc Sedlmayr. Dr. Sedlmayr is now on the faculty of the Louisiana State University School of Medicine in New Orleans. In my 57 years of active teaching here at UCLA, collectively, these anatomists are the finest anatomy colleagues I have ever worked with. Finally, but by no means least, I must say that my wife, Julie, has been a steadfast inspiration to me and my academic life, and I am eternally grateful to her. Carmine D. Clemente Los Angeles, CaliforniaOctober 2009

From the Preface to the Fifth Edition

I continue to observe the use of this atlas in the anatomy classroom and laboratory here at the UCLA Center for the Health Sciences, and many suggestions I have received over the past six years from students and from friends around the world have been incorporated in this edition. Further, students have convinced me that a special section on the cranial nerves would be helpful to them. This has now been included and a series of diagrammatic drawings (patterned after Grant and other authors) along with a number of figures relevant to the cranial nerves have been collected in a group of 29 plates at the end of the Neck and Head section. Most of the new cranial nerve drawings were done by Ms. Jill Penkhus several years ago when she was the resident artist in the Department of Anatomy here. In addition to these, several new pieces of art have been included in this atlas. Among the new illustrations in this edition are modified replacements of the nine remaining illustrations in the 4th edition that originated from the controversial atlas Topographical Human Anatomy by Pernkopf. These new color illustrations were expertly rendered by the medical illustrators at Anatomical Chart Company (ACC) and David Rini. By far, however, my deepest appreciation is extended to Professors R. Putz in Munich and R. Pabst in Hanover, Germany, for their exceedingly creative contributions for the 21st German and 13th English editions of the Sobotta Atlas of Human Anatomy. More than 325 figures in their most recent two-volume set are the principal new drawings on which this edition is based. The other figures are ones that were used in my 4th edition. I am responsible for all the notes that accompany all of the figures, and any mistakes that may be found in these are mine and those

of no one else. I would be most grateful to any student or professor who may have suggestions or who may identify errors, if these were transmitted to me here in Los Angeles. Many new clinically related plates have been added to those in the 4th edition. This atlas now contains more than 150 plates that are of direct clinical importance. These are listed in the front pages of the book and they include surface anatomy, radiographs (many of which come from the outstanding collection of Professor L. Wicke of Vienna), MRIs, CT scans, arteriograms, lymphangiograms, bronchograms, and even a series of arthroscopic images of the knee joint. These have been added because of the increased emphasis on the clinical relevance to the teaching of Anatomy that has become common in medical schools, not only in the United States but in many other countries as well. One plate (#146) is based on the work of Drs. R. Torrent-Guasp of Madrid and Gerald Buckberg of UCLA here in Los Angeles. There are many who have helped to make this atlas possible. Among them are Ms. Betty Sun, Ms. Crystal Taylor, Ms. Kathleen Scogna, and Ms. Cheryl Stringfellow at Lippincott Williams & Wilkins in Baltimore and, of course, many at the Elsevier Corporation, the publishers that acquired the Sobotta collection from Urban & Fischer. I am especially grateful to Dr. Constantine Karakousis, Professor of Surgery and Chief of Surgical Oncology at the University of Buffalo in Buffalo, New York, for his recommendations and comments on the clinical importance of several of the plates. Perhaps most of all, my continuing gratitude goes to Julie, my wife, who has helped me both at the computer and in being considerate for all the time it has taken me to do this manuscript, time that could have been given to some of her interests. Carmine D. Clemente Los Angeles, CaliforniaFebruary 2006

From the Preface to the First Edition

Twenty-five years ago, while a student at the University of Pennsylvania, I marvelled at the clarity, completeness, and boldness of the anatomical illustrations of the original German editions of Professor Johannes Sobottas atlas and their excellent threevolume English counterparts, the recent editions of which were authored by the late Professor Frank H. J. Figge. It is a matter of record that before World War II these atlases were the most popular ones consulted by American medical students. In the United States, with the advent of other anatomical atlases, the shortening of courses of anatomy in the medical schools, and the increase in publishing cost, the excellent but larger editions of the Sobotta atlases have become virtually unknown to a full generation of students. During the past 20 years of teaching Gross Anatomy at the University of California at Los Angeles, I have found only a handful of students who are familiar with the beautiful and still unexcelled Sobotta illustration. This volume introduces several departures from the former Sobotta atlases. It is the first English edition that represents

the Sobotta plates in a regional sequencethe pectoral region and upper extremity, the thorax, the abdomen, the pelvis and perineum, the lower extremity, the back, vertebral column and spinal cord, and finally, the neck and head. This sequence is consistent with that followed in many courses presented in the United States and Canada and one which should be useful to students in other countries. Many have contributed to bringing this Atlas to fruition. I thank Dr. David S. Maxwell, Professor and Vice Chairman for Gross Anatomy and my colleague at UCLA, for his encouragement and suggestions. I also wish to express my appreciation to Caroline Belz and Louise Campbell, who spent many hours proofreading and typing the original text. I especially wish to thank Mary Mansor for constructing the indexa most laborious task. I am grateful to Barbara Robins for her assistance in typing some of the early parts of the manuscript, and above all, to her sister Julie, who is my wife and who makes all of my efforts worthwhile through her encouragement and devotion. Carmine D. Clemente Los Angeles, CaliforniaJanuary 1975

Chapter 5 The Back, Vertebral Column, and Spinal Cord

Contents

CHAPTER 1: Pectoral Region, Axilla, Shoulder, and Upper Limb

Plates

Body Regions 1 Anterior Thorax, Superficial Pectoral Region Including Female Breast 218 Axilla, Deep Pectoral Region 1927 Arteries and Superficial Veins of Upper Limb 2929 Anterior and Posterior Shoulder: Muscles; Neurovascular Structures; Abduction 3033 Upper Limb: Surface Anatomy and Dermatoses 3435 Upper Limb: General; Muscles, Vessels and Nerves 3645 Brachial Plexus 4653 Shoulder, Anterior and Posterior Arm (Brachium): Muscles, Vessels and Nerves (Detailed) 5467 Forearm: General (Superficial) 6869 Forearm: Anterior Aspect, Muscles, Vessels and Nerves 7079 Forearm: Posterior Aspect, Muscles, Vessels and Nerves 8089 Hand: Dorsal Aspect 9093 Hand: Palmar Aspect 94111 Bones and Joints of the Upper Limb 112131 Cross Sections of the Upper Limb 132137 Anatomy of Fingers 9093; 9598; 100105; 107110; 130

CHAPTER 2: The ThoraxSurface Anatomy: Thoracic and Abdominal Wall Anterior Thoracic Wall Thymus, Pleura, Lungs, Trachea, and Bronchi Pericardium and Heart Conduction System of the Heart; Heart Valves Circulation of Blood Posterior and Superior Mediastina Sympathetic Trunks and Vagus Nerves Thoracic Duct and Lymphatic System Frontal Sections and MRIs and Cross Sections of the Chest

Plates139 140149 150165 166187 188191 192195 196205 206209 210211 212218

CHAPTER 3: The AbdomenRegions of the Body, Diagram of the GI System Anterior Abdominal Wall

Plates219 220231

Female Inguinal Region; Autonomic Innervation of Female Genital Organs Male Inguinal Region and Genital Organs Direct and Indirect Inguinal Hernias Abdominal Structures in the Newborn Topographic Views of Thoracic, Abdominal, and Pelvic Organs Development of the Mesenteries Topographic Views of the Abdominal Organs In Situ Stomach: Blood Supply; Surface Projections; X Rays; Lymphatics Duodenum Liver Gallbladder; Bile Duct System; Pancreas; Spleen Small Intestine Large Intestine Posterior Abdominal Wall; Lumbar Nerves Cross Sections of Abdomen

232233 234240 241 242243 244247 248249 250253 254267 268269 270277 278287 288293 294305 306317 318322

CHAPTER 4: The Pelvis and PerineumBones of the Pelvis and Sex Differences; Ligaments of the Pelvis Female Pelvic Organs Placenta; Pregnant Uterus Female Pelvic Vessels; Median Sagittal Section of Female Pelvis Female Perineum: Muscles, Urogenital Diaphragm; Vessels and Nerves; External Genitalia Male Pelvic Organs Male Perineum Rectum Cross Sections and CT Scans: Female and Male Pelvis Male Urogenital Region: Surface Anatomy, Vessels and Nerves Male External Genitalia: Penis (Corpora), Spermatic Cord, Vessels, Nerves, and Cross Sections

Plates323329 330335 336338 339342 343350 351355 355358 359362 363364 365366 367370

CHAPTER 5: The Back, Vertebral Column, and Spinal CordBack: Surface Anatomy; Skeleton; Dermatomes; Cutaneous Nerves; Superficial Muscles Back: Superficial and Intermediate Muscle Layers Back: Intermediate and Deep Muscle Layers; Semispinalis Capitis Muscle; Muscle Charts Upper Back and Suboccipital Triangle Cross Sections Showing Typical Spinal Nerve and Deep Back Muscles Vertebral Column and Vertebrae: Ligaments and Intervertebral Disks Spinal Cord

Plates371373 373374 375381 381385 386 387401 402408

CHAPTER 6: The Lower LimbAnterior and Medial Thigh: Muscles, Vessels, and Nerves Gluteal Region and Posterior Thigh Anterior, Medial and Posterior Nerves of the Lower Limb Popliteal Fossa: Muscles, Vessels and Nerves Anterior and Lateral Compartments of the Leg Dorsum of the Foot

Plates409427 428439 440441 442445 446453 454459

Posterior Compartment of the Leg Plantar Aspect of the Foot Bones and Joints of the Lower Limb Cross Sections and MRIs of the Lower Limb

460469 470477 478509 510516

CHAPTER 7: The Neck and HeadSurface Anatomy of the Head and Neck Triangles of the Neck; Platysma Muscle; Fascias; Nerves and Lymphatics Cervical Plexus of Nerves; Trunks of the Brachial Plexus; Accessory Nerve Arteries and Veins of the Neck; Thyroid Gland; Lymphatics Prevertebral Region; Subclavian and Vertebral Arteries Submental and Submandibular Regions Superficial Muscles of the Face; Facial Nerve Diagram; Muscle Charts Parotid Gland; Muscles of Mastication; Facial Nerve Branches Temporomandibular Joint Internal Carotid Artery; Superficial and Deep Veins of the Head Vessels and Nerves of the Deep Face Bones of the Skull: Adult and Newborn Scalp; Diploic Veins; Radiographs of the Internal Carotid Artery Dura Mater; Dural Sinuses Internal Carotid and Vertebral Arteries to the Brain Base of the Skulls; Bones, Vessels, Nerves; Inferior Surface of the Brain Inferior Surface of the Bony Skull Eye: Anterior View; Bony Socket; Nasolacrimal System Eye: External Structure and Bones of the Nasal Cavity Nose: External Structure and Bones of the Nasal Cavity Paranasal Sinuses Oral Cavity: Anterior View; Lips; Palatine Tonsil and Oropharynx Oral Cavity: Sublingual Region; Palate; Submandibular Gland Floor of the Oral Cavity Tongue Mandibular and Maxillary Teeth Pharynx: Muscles, Arteries and Nerves Larynx External, Middle and Internal Ear

Plates517518 519528 529534 535540 541544 545546 547550 551556 557558 559562 563566 567572 573574 575578 579584 585590 591592 593599 600612 613616 617618 619620 621623 624626 627632 633640 641649 650656 657668

CHAPTER 8: Cranial NervesCranial Nerves: Attachments to the Brain, Foramina; Base of Skull Cranial Nerves I to XII

Plates669670 671694 I-1I-24

Index

Plates of Direct Clinical ImportancePlates 13 Plates 4, 6, 79 Male and Female Surface Anatomy Anatomy of the Female Breast and Lymphatic Channels Plates 10, 1214 Surface Vessels and Nerves of the Anterior Trunk Plates 2224 Arteries, Veins, and Nerves of the Axilla Plates 28, 29 Arteries and Superficial Veins in the Upper Limb Plates 3032, 54, 55 Muscles That Form the Rotator Cuff in the Shoulder Plate 35 Dermatomes of the Upper Limb Plates 36, 37 Vessels and Nerves: Anterior and Posterior Brachium Plates 38, 39 Arteries and Nerves of the Upper Limb; Brachial Arteriogram Plate 41 Variations in the Superficial Veins of the Upper Limb Plate 4653 Brachial Plexus Plate 67 Course of the Radial Nerve Along the Radial Groove Plates 68, 69 Superficial Vessels and Nerves of the Forearm; Cubital Fossa Plates 7779 Median, Ulnar, and Radial Nerves in the Forearm; Brachial Artery Plate 86 Dermatomes on Posterior Aspect of Upper Limb Plates 90, 91 Local Anesthesia of Fingers Plate 99 Synovial Sheathes of the Fingers Plate 115 X-Ray of Should Joint Bones Plates 120, 121 Radiographic Anatomy of the Right Should Joint Bones Plate 123 X-Rays of Elbow Joint: Adult and Child Plate 127 Radiograph of the Wrist and Hand Plate 129 Radiograph of the Right Wrist Plate 131 Radiograph of the Right Hand (Lateral Projection) Plates 132, 133, 135, 136 CT Scans of the Arm, Forearm, and Wrist Plate 139 Surface Anatomy of Anterior Body Wall (Male and Female) Plate 151 Radiograph of the Chest Showing the Heart and Lungs Plates 154156 Surface Projections of the Pleura and Lungs Plate 163 Surface Projection of the Trachea Plate 165 Bronchogram of Bronchial Tree; Bronchoscope of Trachea Plate 168 Radiograph of the Thorax Plate 171 Anterior Wall Projection of Underlying Heart Valves Plate 180 Left Coronary Arteriogram Plate 181 Plate 191 Plate 196 Plate 200 Plate 205 Plates 212, 213, 218 Plate 219 Plate 229 Plates 240, 241 Plate 244 Plate 245 Plates 246, 247 Plate 256 Plate 257 Plate 261 Plate 263 Plate 265 Plate 267 Plate 270 Plate 273 Plate 275 Plate 276 Plate 277 Plate 279 Plate 280 Plate 281 Plate 282 Plate 284 Plate 285 Plate 286 Right Coronary Arteriogram Heart Valves: Projection on Chest Wall and Their Structure Frontal Section of the Thorax and Upper Abdomen Radiograph of Esophagus and View through Esophagoscope Angiogram of the Aortic Arch and Its Branches MRIs and CT of the Chest Surface Anatomy: Regions of the Body; GI System Organs CT Scans of the Body Wall and Abdomen Descent of Testis and Congenital and Direct Inguinal Hernias Surface Projections: Thorax, Abdomen, Male Pelvic Organs Surface Projections: Thorax, Abdomen, Female Pelvic Organs Median and Paramedian Sections of Male Abdomen and Pelvis Celiac Trunk Arteriogram Variations in Blood Supply to the Liver and Stomach Surface Projections and Radiographs of the Stomach X-Ray of the Stomach X-Ray of the Stomach Showing a Small Ulcer X-Rays Showing Gastric and Duodenal Ulcers Surface Projections of the Liver Ultrasound Scans of the Hepatic and Portal Veins CT Scan of Upper Abdomen at Level T10-T11 CT Scan of Abdomen at Level L1 Ultrasound Scans: Upper Abdomen and Tumor Mass in Liver Cholangiogram and X-Ray of Biliary Duct System Ultrasound Scan: Abdomen Showing Parts of the Gallbladder Ultrasound Scans of Gallbladder and Gallstones Surface Projection: Duodenum and Pancreas CT Scan: Abdomen at Level L2 Showing Pancreas, etc. CT Scan Showing a Tumor in the Head of the Pancreas CT Scan: Diffuse Inflammation of the Pancreas (Pancreatitis)

Plate 287 Plate 289 Plate 291 Plate 293 Plate 295 Plate 302 Plate 305 Plate 310 Plate 311 Plate 313 Plates 318322 Plate 325 Plate 330 Plate 332 Plate 334 Plate 337 Plate 338 Plate 339 Plate 340 Plate 344 Plate 353 Plate 356 Plates 363, 364 Plate 371 Plate 372 Plate 391 Plate 398 Plates 400, 401 Plates 402407 Plate 408 Plates 409412 Plates 413415 Plate 422 Plate 428 Plates 434, 435 Plates 440, 441 Plate 444 Plate 446

CT Scan Showing a Hemorrhage within the Spleen Radiograph of the Jejunum, Ileum, Cecum, and Ascending Colon Radiograph of the Small Intestine Superior Mesenteric Arteriogram Inferior Mesenteric Arteriogram Variations in the Location of the Vermiform Appendix Radiograph of the Large Intestine Arteriogram of the Renal Artery Surface Anatomy of the Back Showing Location of the Kidneys Retrograde Pyelogram CT Scans of the Abdomen Radiograph of the Pelvis Uterosalpingogram Variations in the Position of the Uterus in the Pelvis CT Scan of the Female Pelvis X-Ray of the Pregnant Uterus Pregnant Uterus: Fetal Sonograms Variations in the Divisions of the Internal Iliac Artery Arteriogram of the Iliac Arteries in the Female Female External Genitalia Peritoneum over Empty and Full Bladders Radiographs of Male Pelvic Organs CT Scans of the Female and Male Pelvis Surface Anatomy of the Back Cutaneous Nerves and Dermatomes of the Back Radiograph of Odontoid Process and Atlantoaxial Joints Intervertebral Disks Radiograph of the Vertebral Column Spinal Cord Lumbar and Sacral Punctures into the Spinal Column Lower Limb: Surface Anatomy, Cutaneous Nerves, Bones Lower Limb: Arteries, Muscles: Anterior and Posterior Aspects Variations in the Deep Femoral Artery and Circumflex Arteries Surface Vessels and Nerves: Gluteal Region, Posterior Thigh Safe Zones for Intramuscular Injections in Gluteal Region Nerves of the Lower Limb Variations in Branching of Anterior Tibial Fibular Arteries Superficial Veins and Nerves of Anterior and Medial Leg, Foot

Plate 453 Plate 454 Plate 460 Plates 474, 476 Plates 483 Plate 484 Plate 489 Plate 490 Plate 491 Plate 493 Plate 494 Plate 498 Plate 508 Plates 511513 Plate 515 Plates 517, 518 Plate 599 Plate 525 Plate 535 Plates 536538 Plates 548, 553, 554 Plates 557, 558 Plate 560 Plate 571, 572 Plates 573, 574 Plate 582 Plates 583, 584 Plates 588590 Plate 593 Plates 601604 Plate 609 Plates 611, 612 Plate 616 Plates 617, 618 Plates 619622 Plates 625, 626 Plates 633640 Plates 641648 Plates 649656 Plates 657668 Plate 669694

Ankle and Foot Movements Vessels and Nerves of the Dorsal Foot Vessels and Nerves on the Posterior Aspect of the Leg (Calf) Vessels and Nerves on the Plantar Aspect of the Foot Blood Supply and Radiograph of the Hip Joint Radiograph of the Knee Joint Four MRIs of the Knee Joint Arthrogram of the Knee Joint Arthroscopic Images of the Knee Joint Radiographs of the Knee Joint Movements at the Knee Joint X-Ray of the Ankle Joint Radiograph, MRI of Ankle, Subtalar, and Talonavicular Joints CT Scans of the Mid and Distal Thigh and Mid Leg MRI through the Metatarsal Bones of the Foot Surface Anatomy of the Face and Neck Surgical Entry into the Respiratory System Drainage of Lymph of Superficial Lateral Scalp and Face Jugular Veins in the Neck Thyroid Gland Facial Nerve on the Face Temporomandibular Joint Variations in the Maxillary Artery Newborn Skull Scalp, Diploic Veins, Internal Carotid Artery Variations in the Formation of the Circle of Willis Arteriogram of the Internal Carotid and Vertebral Arteries Base of the Skull and Brain: Cranial Nerves and Vessels Eye from Anterior Nerve in the Orbit Horizontal Section of the Eyeball MRI, Vessels and Nerves within the Orbit and Retina Vessels and Nerves in the Nasal Cavity Paranasal Sinuses Oral Cavity Salivary Glands Anatomy of the Dental Arches and Teeth; Their Innervation Pharynx Larynx External, Middle, and Internal Ear Cranial Nerves IXII

Plates Containing Muscle ChartsPectoral Muscle Shoulder Muscles Anterior Brachial Muscles (Flexors) Posterior Brachial Muscles (Extensors) Anterior Forearm Muscles (Flexors) Posterior Forearm Muscles (Extensors) Thenar Muscles of the Hand Hypothenar Muscles of the Hand Dorsal Interosseous Muscles of the Hand Palmar Interosseous Muscles of the Hand Intercostal Muscles Subclavius Muscles Anterior Abdominal Wall Muscles Posterior Abdominal Wall Muscles and the Diaphragm Muscles of the Pelvic Diaphragm and the Urogenital Diaphragm Intermediate and Deep Back Muscles Deep Muscles of the Back (Continued) Muscles of the Suboccipital Region Anterior Muscles of the Hip and Anterior Thigh Muscles Medial, Lateral, and Posterior Thigh Muscles Plates 15, 20 Plates 30, 33 Plates 56, 57 Plate 65 Plates 73, 74 Plates 80, 81, 85, 87 Plates 96, 97 Plate 98 Plate 102 Plate 103 Plate 143 Plate 148 Plates 225227, 230 Plate 314 Plate 346 Plate 379 Plate 380 Plate 385 Plate 426 Plate 427 Muscles of the Gluteal Region Muscles of the Posterior Thigh Muscles of the Anterior and Lateral Compartments of the Leg Muscles of the Dorsum of the Foot Muscles of the Posterior Compartment of the Leg Muscles of the Sole of the Foot Infrahyoid Muscles of the Neck Sternocleidomastoid Muscle Muscles of the Posterior Triangle of the Neck Anterior Vertebral Muscles Muscles of Face and Head: Suprahyoid, Scalp Muscles; Ear, Eyelids Muscles of Face and Head: Muscles of Nose and Mouth Muscles of Mastication Schema of Extraocular Muscles Extrinsic Muscles of the Tongue Muscles of the Palate and Pharynx Muscles of the Larynx (see notes under Figs. 653.1653.4 and Figs. 654.1654.3) Muscles of the Middle Ear Plate 434 Plate 436 Plate 448 Plate 457 Plates 468, 469 Plate 477 Plate 519 Plate 520 Plate 528 Plate 542 Plate 549 Plate 550 Plates 555, 556 Plate 607 Plate 632 Plate 648 Plates 653, 654 Plates 657, 663665

C H A P TE R

1

Pectoral Region, Axilla, Shoulder, and Upper Limb

Plates1 Regions of the Body 2 Surface Anatomy of the Male Body 3 Surface Anatomy of the Female Body 4 Superficial Dissection of the Breast; Milk Line 5 Surface Anatomy of Female Thoracic Wall;Female Breast

23 The Axillary Vein and Its Tributaries 24 The Axillary Artery and Its Branches 25 The Internal ThoracicEpigastric Anastomosis 26 Dissection of Axilla: Superficial Vessels and Nerves 27 Dissection of Axilla: Deep Vessels and Nerves 28 Arterial Supply to the Upper Extremity 29 Superficial Veins of the Upper Extremity 30 Shoulder Region, Anterior Aspect: Muscles 31 Anterior Shoulder Region: Vessels and Nerves;Shoulder Joint Movements

6 Breast: Nipple and Areola (Sagittal Section) 7 Lymph Nodes that Drain the Breast;Lymphangiogram of the Axilla

8 Lymphatic Drainage from Breast; Medial andLateral Mammary Arteries

9 Lateral View of the Female Breast and aDissected Nipple

32 Shoulder Region, Posterior Aspect: Muscles 33 Posterior Shoulder: Vessels and Nerves; Abductionof the Upper Limb

10 Dermatomes; Anterior Thoracic Segmental Nerves 11 Superficial Thoracic and Abdominal Wall Muscles(Lateral View)

34 Surface Anatomy of the Upper Limb 35 Dermatomes of the Upper Limb 36 Superficial Dissection of the Arm (Anterior View) 37 Superficial Dissection of the Arm (Posterior View) 38 Blood Vessels of the Upper Limb 39 Nerves of the Upper Limb 40 Cutaneous (Superficial) Nerves of the Upper Limb 41 Superficial Venous Patterns in the Upper Limb 42 Surface and Skeletal Anatomy of the Upper Limb 43 Muscular Contours of the Upper Limb: Anteriorand Posterior Views

12 Superficial Veins of the Anterior Trunk (Male) 13 Superficial Vessels and Nerves of the AnteriorTrunk (Female)

14 A Typical Segmental Spinal Nerve andIntercostal Artery

15 Superficial Thoracic and Abdominal Wall Muscles 16 Pectoral Region: Superficial Vessels andCutaneous Nerves

17 Pectoral Region: Pectoralis Major and Deltoid Muscles 18 The Pectoralis Major and Minor Muscles 19 The Anterior Surface of the Rib Cage 20 Lateral Thoracic Wall and Superficial Axilla 21 The Pectoral Muscles: Intact and Reflected;Serratus Anterior Muscle

44 Muscles of the Upper Limb: Lateral View 45 Muscles of the Upper Limb: Anterior andPosterior Views

46 The Brachial Plexus and Its Three Cords 47 Brachial Plexus: Roots of Origin andGeneral SchemaChapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

22 Deltopectoral Triangle and the Deep LateralThoracic Muscles

CHAPTER 1


48 Complete Brachial Plexus Diagram 49 Musculocutaneous Nerve: Distribution andSpinal Segments

74 Anterior View of Radius and Ulna: MuscleAttachments; Muscle Chart

75 Fracture of the Radius and the PronatorTeres Muscle

50 Median Nerve: Distribution, Spinal Segments, andMedian Nerve Palsy

76 Anterior Forearm Vessels and Nerves(Superficial Dissection)

51 Ulnar Nerve: Distribution, Spinal Segments, andUlnar Nerve Palsy

77 Anterior Forearm Vessels and Nerves(Intermediate Dissection)

52 Axillary Nerve: Distribution, Spinal Segments, andAxillary Nerve Palsy

78 Anterior Forearm Vessels and Nerves(Deep Dissection)

53 Radial Nerve: Distribution, Spinal Segments, andRadial Nerve Palsy

79 Elbow Region: Vessels and Nerves 80 Superficial Extensor Muscles of Forearm(Posterior View)

54 Anterior Dissection of the Shoulder and Arm:Muscles

55 The Shoulder Muscles: Anterior and PosteriorViews

81 Superficial Extensor Muscles of the Forearm(Lateral View)

56 Muscles of the Anterior Arm (SuperficialDissection)

82 Deep Extensor Muscles of the Forearm 83 Deep Extensor Muscles of the Forearm 84 Supination and Pronation of the Forearm and Hand 85 Extensor Muscles of the Forearm; Muscle Chart 86 Posterior Upper Limb Muscles and Dermatomes(Review)

57 Muscles of the Anterior Arm (Deep Dissection) 58 Brachial Artery and the Median and Ulnar Nervesin the Arm

59 Deep Dissection of the Anterior Arm;Musculocutaneous Nerve

60 Posterior Dissection of Shoulder and Arm: Muscles 61 Shoulder Region: Supraspinatus Muscle and theRotator Cuff Capsule

87 Posterior Attachments of Muscles on the Ulna andRadius; Muscle Chart

88 Nerves and Arteries of the Posterior Forearm(Superficial Dissection)

62 Muscles on the Lateral and Posterior Aspectsof the Arm

89 Nerves and Arteries of the Posterior Forearm(Deep Dissection)

63 Posterior Arm; The Three Heads of theTriceps Muscle

90 Dorsum of the Hand: Veins and Nerves; FingerInjection Site

64 Attachments of Muscles in Upper Limb:Anterior View

91 Dorsum of the Hand: Tendons and InterosseousMuscles; Dermatomes

65 Attachments of Muscles in Upper Limb:Posterior View

92 Dorsal Synovial Tendon Sheaths at the Wrist;Anatomy of a Finger

66 Posterior Arm: Vessels and Nerves(Superficial Dissection)

93 Dorsum of the Hand: Tendons and Arteries(Superficial and Deep Dissections)

67 Arteries and Nerves of the Scapular and PosteriorBrachial Regions

94 Palm of the Hand: Superficial Vessels and Nerves 95 Superficial Dissection of the Palm of the RightHand and Two Fingers

68 Superficial Dissection of the Anterior Forearm 69 Superficial Dissection of the Posterior Forearm 70 Anterior Forearm: Superficial Muscles 71 Anterior Forearm: Pronator Teres and FlexorDigitorum Superficialis

96 Palm of the Hand: Muscles and Tendon Sheaths 97 Thenar and Hypothenar Muscles; CutaneousInnervation of the Palm

98 Palm of the Hand: Muscles and FlexorTendon Insertions

72 Anterior Forearm: Deep Muscles 73 Anterior Muscles of the Forearm; FlexorMuscle Chart

99 Palm of the Hand: Deep Dissection of Musclesand Fingers

CHAPTER 1


100 Muscles of the Deep Palmar Hand Region:Dissection #1

119 Lateral View of Shoulder Joint and Frontal Sectionof the Joint

101 Muscles of the Deep Palmar Hand Region:Dissection #2

120 Radiographic Anatomy of the Right ShoulderJoint I

102 Dorsal Interosseous Muscles in the Deep Hand 103 Palmar Interosseous Muscles in the Deep Hand 104 Lumbrical Muscles; Tendons and Cross Sectionof the Middle Finger

121 Radiographic Anatomy of the Right ShoulderJoint II

122 Bones of the Upper Limb: Radius and Ulna 123 Elbow Joint: Radiographs, Adult and Child 124 Left Elbow Joint (Anterior, Posterior, andSagittal Views)

105 The Carpal Tunnel; More Distal Cross Sectionof the Middle Finger

106 Carpal Tunnel; Superficial Palmar Arterial Arch 107 Palm of the Hand: Nerves and Arteries(Superficial Dissection)

125 Elbow Joint: Bones; Ligaments (Medial View) 126 Radioulnar Joints 127 Radiograph of the Wrist and Hand 128 Bones of the Wrist and Hand (Palmar Aspect) 129 Bones of the Wrist and Hand (Dorsal Aspect) 130 Wrist and Hand: Ligaments and Joints 131 Wrist, Hand, and Fingers: Jointsand Ligaments

108 Palmar Arterial Arches 109 Palmar Arteries and Nerves; Variations in theDeep Palmar Arch

110 Sagittal Section through the Middle Finger(Ulnar View)

111 Radial Side of the Hand: Arteries andSuperficial Nerves

132 Cross Sections of the Upper Limb: Arm 133 Cross Sections of the Lower Third of the Arm 134 Cross Sections of the Upper Limb: Elbow andUpper Forearm

112 Skeleton of the Thorax; Scapula 113 The Humerus 114 Shoulder Joint: Ligaments and Bony Structures 115 X-Ray of the Right Shoulder Joint 116 Acromioclavicular and Shoulder Joints 117 The Right Shoulder Joint (Anterior andPosterior Views)

135 Middle Forearm (Cross Section and MRI) 136 Computerized Tomographs of the Wrist 137 Cross Sections of the Upper Limb: Wristand Hand

118 Glenoid Labrum and Cavity; Clavicular andScapular Ligaments

138 The Thumb, Index Finger, and Fingernails

Regions of the BodyParietal region Frontal region

PLATE 1

Temporal region

Orbital region

Nasal region

Oral region Mental region Palm

Sternocleidomastoid region Infraclavicular region Deltopectoral triangle Deltoid region Sternal region Pectoral region

Anterior neck region Posterior cervical triangle Axillary region Anterior antebrachial (forearm) region

Anterior cubital region Anterior brachial (arm) region Axillary fossa Lateral pectoral region Hypochondriac region

Posterior brachial (arm) region

Epigastric region Umbilical region Lateral abdominal region Inguinal region Hypogastric (pubic) region Trochanteric region Penis

Posterior antebrachial (forearm) region

Anterior antebrachial (forearm) region

Dorsal hand Femoral triangle

Anterior femoral (thigh) region

Anterior knee region

Posterior crural (leg) region

Anterior crural (leg) region Posterior crural (leg) region

Lateral malleolus Dorsal foot

Calcaneal region

FIGURE 1 Regions of the Body: Anterior ViewNOTE: (1) Surface areas are identified by specific names to describe the location of structures and symptoms precisely. (2) Some regions are named after bones (sternal, parietal, infraclavicular, etc.), others for muscles (deltoid, pectoral, sternocleidomastoid), and still others for specialized anatomical structures (umbilical, oral, nasal, etc.). (3) The principal regions of the body include the pectoral region and upper extremity, thorax, abdomen, pelvis and perineum, lower extremity, back and spinal column, and neck and head.

Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 2

Surface Anatomy of the Male Body

FIGURE 2.1 Regions and Longitudinal Lines on the Anterior

Surface of the Male BodyNOTE: (1) The lateral sternal line descends along the lateral border of the sternum. (2) Other lines parallel to this are called parasternal lines. (3) The male nipple lies near the midclavicular line. (4) The anterior axillary line descends from the anterior axillary fold.Arm Anterior axillary line Midclavicular line Lateral sternal line Upper limb Forearm Anterior midline

Hand

Thigh

Lower limb Leg

Foot

Infraclavicular fossa, deltopectoral triangle

FIGURE 2.2 Surface Contours on the Male ThoraxDeltoid muscle

Certain contours on the chest, upper abdomen, and upper limb reveal the shape of underlying muscles.Pectoralis major muscle

Pectoralis major muscle

Biceps brachii muscle

Rectus abdominis muscle Umbilicus


Surface Anatomy of the Female Body

PLATE 3

Head

Neck Suprasternal plane

Sternal angle plane Xiphisternal plane

Thorax

Transpyloric plane Abdomen Subcostal plane Trunk

FIGURE 3.1 Transverse Planes Shown on the Surface of the

Pelvis

Female ThoraxNOTE: (1) The suprasternal plane projects back to the T2 vertebra, the sternal angle to T4, the xiphisternal junction to T9, and the transpyloric plane to L1. (2) The subcostal plane, below the 10th rib anteriorly, projects back to L2.


FIGURE 3.2 Surface Contours on the Lateral Thorax of a Young WomanNOTE the contours of well-developed latissimus dorsi, pectoralis major, teres major, and serratus anterior muscles.

Teres major muscle

Latissimus dorsi muscle

Serratus anterior muscle

Rectus abdominis muscle


PLATE 4

Superficial Dissection of the Breast; Milk LineAnterior layer of pectoral fascia (deep fascia) Deltoid fascia Cephalic vein

Brachial fascia Median nerve Fascia over triceps muscle Axillary sweat glands Axillary fat pad Axillary fascia and lymph nodes Lateral thoracic artery and vein

Fascia over latissimus dorsi muscle

Nipple

Mammary lobes



External oblique muscle

Rectus sheath (anterior layer)

Costal margin

FIGURE 4.1 Anterior Pectoral Region and Female Breast NOTE: (1) The lobular nature of the breast. (2) It extends from the lateral sternal line to the midaxillary line and from the second to the sixth rib. (3) The breast is located in the superficial fascia anterior to the pectoral fascia. (4) Shown are the superficial axillary lymph nodes and the axillary sweat glands.Milk line

Accessory breast

Accessory nipple

FIGURE 4.2 Milk Line and Accessory Nipples and BreastsNOTE: (1) Supernumerary nipples (polythelia) and/or multiple breasts on the same side (polymastia) occur in about 1% of people. (2) These are found along the curved milk line extending from the axillary fossa to the groin. (3) This condition occurs slightly more frequently in males than in females and may easily be handled surgically.Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Milk line

Surface Anatomy of Female Thoracic Wall; Female Breast

PLATE 5

Sternoclavicular joint

Jugular notch Shaft of clavicle (body of clavicle)

Sternal angle

Infrasternal angle (subcostal angle) Costal margin (costal arch)

Umbilicus

Anterior superior iliac spine

FIGURE 5.1 Surface Anatomy of the Anterior Thoracic and Abdominal Walls of a Young FemaleNOTE: Bony structures and the umbilicus are labeled.



Areola Nipple Areolar glands

Nipple Areola


FIGURE 5.2 Female Breast (Anterior View)

FIGURE 5.3 Female Breast (Lateral View)

NOTE: The nipple and areolar glands project from the surface of the pigmented areola. Also observe the muscular contours of the pectoralis major and serratus anterior muscles.


PLATE 6

Breast: Nipple and Areola (Sagittal Section)FIGURE 6.1 Sagittal Section through Mammary Gland of Gravid FemaleNOTE: (1) The radial arrangement of the lobes, separated by connective tissue and fat. (2) In the lactiferous duct system, each of the 15 to 20 lobes has its own duct. (3) The pectoral fascia separates the breast from the pectoralis major muscle. (4) The connective-tissue suspensory ligaments (of Cooper) extend to the pectoral fascia.

Fat body of breast

Lactiferous ducts Pectoral fascia Nipple Lactiferous sinus Suspensory ligaments

Mammary lobes

Mammary lobules

FIGURE 6.2 Right Mammary Gland:

Dissection of the NippleNOTE: (1) A circular piece of skin has been incised from around the nipple. (2) The 15 to 20 lactiferous ducts are arranged radially around the nipple and seen just deep to the skin.

Cut skin margins Nipple

Lactiferous ducts

Cancer of the BreastCancer of the breast usually develops in the epithelial cells that line the ducts of the glandular tissue. Often, the initial clinical sign of breast cancer is a painless lump in the upper lateral quadrant of the organ. This may progress: (1) to invade the connective tissue between the lobules (suspensory ligaments of Cooper) and cause a retraction of the nipple; (2) to grow more deeply and fix the breast to the pectoral fascia overlying the pectoralis major muscle. This causes the breast to be less movable and it tends to elevate when the underlying pectoralis major contracts; (3) to cause a dimpling, a thickening, and a discoloration of the skin over the tumor. The skin then assumes an appearance of an orange peel and hence has been called the peau dorange sign of advanced breast carcinoma. From the local primary tumor site, malignant cells spread by entering lymphatic capillaries and proceed to lymph nodes, where they may multiply to form metastatic secondary tumors. The most frequent routes of early metastatic spread involve the lateral thoracic and axillary lymph nodes as well as nodes that accompany the internal thoracic vessels lateral and parallel to the sternum. Spread of tumor cells also occurs by way of venous capillaries to larger veins and then to more widespread organs.

FIGURE 6.3 Radiograph of Normal

Female BreastLateral mammograph of a 47-year-old woman.


Lymph Nodes that Drain the Breast; Lymphangiogram of the AxillaFIGURE 7.1 Axillary and ParasternalDeep axillary set Lateral axillary nodes Medial (apical) axillary nodes (infraclavicular)

PLATE 7

Nodes and Lymph Channels from the Female BreastNOTE the central and anterior axillary nodes. Also observe the deep lateral and deep medial axillary nodes more superiorly along with the parasternal and deep cervical nodes.

Deltopectoral nodes

Deep cervical nodes (infraclavicular)

Central axillary nodes

Parasternal mammary nodes

Anterior axillary nodes (pectoral nodes) Subareolar plexus

Lymph drainage to the opposite breast and to the rectus abdominus muscle

Supraclavicular lymph nodes

Clavicle

Infraclavicular lymph nodes

Coracoid process

Head of humerus

Infraglenoid tubercle

Axillary lymph nodes

Pectoral lymph nodes

Scapula

FIGURE 7.2 Lymphangiogram of the Pectoral and Axillary Lymph Nodes(From Wicke, 6th ed.)Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 8

Lymphatic Drainage from Breast; Medial and Lateral Mammary Arteries

Deep cervical lymph nodes Supraclavicular lymph nodes Apical axillary lymph nodes

Parasternal lymph nodes

Central axillary lymph nodes

Subscapular (posterior) axillary lymph nodes

Anterior axillary (pectoral) lymph nodes

Inframammary lymph nodes

FIGURE 8.1 Lymphatic Drainage from the Adult Female BreastNOTE: (1) Numerous lymph vessels in the breast communicate in a subareolar plexus deep to and around the nipple. (2) About 85% of the lymph from the breast courses laterally and upward to axillary and infraclavicular nodes. (3) Most of the remaining lymph passes medially to parasternal nodes along the internal thoracic vessels. (4) Some lymph vessels drain downward to upper abdominal nodes and some go to the opposite breast.Pectoralis major muscle Axillary artery Subclavian artery Deltoid muscle Internal thoracic artery Lateral thoracic artery

Lateral mammary branches

Medial mammary branches

FIGURE 8.2 Medial and Lateral Mammary ArteriesNOTE that lateral branches from the lateral thoracic artery and medial perforating branches from the internal thoracic artery supply the breast anteriorly. (From Clementes Anatomy Dissector, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007.)Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Lateral View of the Female Breast and a Dissected Nipple

PLATE 9

Lactiferous sinus Lactiferous ducts Suspensory ligaments

Pectoral fascia (deep fascia)



FIGURE 9.1 Lateral View of the Female Breast in a Reclined ThoraxNOTE: (1) The duct system originating in the mammary gland lobules. The individual ducts course forward through the superficial fascia of the breast to the nipple. (2) The suspensory ligaments (of Cooper) that separate the mammary lobules. These support the breast by attaching to the deep pectoral fascia. In aging, the ligaments loose strength and result in the characteristic sagging breasts of the elderly. (From Clementes Anatomy Dissector, 1st Edition. Baltimore: Lippincott Williams & Wilkins, 2002.)

Areola

Areola

Fat lobule

Nipple

Ampullae of lactiferous ducts

Lactiferous ducts

Mammary lobules

FIGURE 9.2 The Dissected Nipple and Lactiferous Duct SystemNOTE the lactiferous ducts as they commence in the mammary lobules and course forward to open on the surface of the nipple. Also observe how the ducts enlarge into lactiferous sinuses within which milk collects prior to ejection as the infant suckles.


PLATE 10

Dermatomes; Anterior Thoracic Segmental NervesSupraclavicular nerves (C3,4,5) C3 C4 T2 T3 T4 T5 T6 T7 T8 T9 T2 T10 T11 T12 L1 Lateral cutaneous nerves T5 T2

L2

Anterior cutaneous nerves

L3

FIGURE 10.1 Segmental Sensory Innervation of

T12 L1 T10

Anterior Body Wall (Dermatomes)NOTE: C5 to C8 and most of T1 do not supply the body wall, since they supply the upper limb.

L1


Latissimus dorsi muscle Serratus anterior muscle

FIGURE 10.2

Cutaneous Branches of Spinal Nerves

Lateral cutaneous nerves (ant. branches)

NOTE the segmental cutaneous nerves to lateral cutaneous branches in the midaxillary line and anterior cutaneous branches just lateral to the sternum. (From Clementes Anatomy Dissector, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007.)

Lateral cutaneous nerves (post. branches)


FIGURE 10.3 Lateral Cutaneous Branches of Thoracic NervesNOTE that as the lateral cutaneous nerves penetrate the intercostal space, each divides into anterior and posterior cutaneous branches.Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Thoracic and Abdominal Wall Muscles (Lateral View)

PLATE 11

Trapezius muscle Spine of scapula Infraspinatus muscle Teres minor muscle Teres major muscle

Clavicle Pectoralis major muscle, sternocostal head Body of breast, lobes of mammary gland Nipple

Deltoid muscle Serratus anterior muscle Triceps brachii muscle: lateral head, long head Brachialis muscle Biceps brachii Latissimus dorsi muscle Costal margin (costal arch) Pectoralis major muscle, abdominal part

External oblique muscle Umbilicus Thoracolumbar fascia Lumbar triangle Rectus sheath, anterior layer Posterior superior iliac spine Gluteal fascia Anterior superior iliac spine External oblique aponeurosis

Tensor fasciae latae muscle Gluteus maximus muscle Sartorius muscle

FIGURE 11 Muscles of the Lateral Thoracic and Abdominal WallNOTE: (1) The interdigitations of the external oblique muscle with the serratus anterior muscle superiorly and the latissimus dorsal muscle inferiorly. (2) The lumbar triangle. Its boundaries are the external oblique muscle (anteriorly), the latissimus dorsi muscle (posteriorly), and the crest of the ilium (inferiorly). (3) The external oblique muscle ends in a broad and strong aponeurosis medially.


PLATE 12

Superficial Veins of the Anterior Trunk (Male)

Axillary vein

Lateral thoracic vein

Thoracoepigastric vein Thoracoepigastric vein

Paraumbilical veins

Superficial epigastric vein Superficial circumflex iliac vein

Great saphenous vein

FIGURE 12 Anterior Thoracic Wall; Superficial Dissection in the MaleNOTE: (1) The thoracoepigastric veins along both lateral aspects of the thoracic wall; realize that these veins drain superiorly into the lateral thoracic veins, which flow into the axillary veins. (2) The paraumbilical veins. Surrounding the umbilicus, these form an anastomosis between the systemic anterior abdominal wall veins and the intra-abdominal portal vein. (3) Usually surface venous blood flow above the umbilicus drains into vessels that feed into the superior vena cava, while surface veins below the umbilicus drain into the femoral veins and thence into the inferior vena cava. (4) The surface veins can become greatly enlarged if flow through the inferior vena cava is significantly reduced, as in cirrhosis of the liver (From C.D. Clemente. Grays Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)


Superficial Vessels and Nerves of the Anterior Trunk (Female)Supraclavicular nerves (C3, C4)

PLATE 13

Cephalic vein

Intercostobrachial nerve (T2); Lateral mammary artery, vein (from lateral thoracic) Internal thoracic artery, vein Cephalic vein Lateral thoracic artery; thoracoepigastric vein Anterior cutaneous nerves (T1T4)

9 5T5 Superior epigastric artery, vein

8 7External oblique muscle

6

Lateral cutaneous nerves (branches of intercostal nerves T5T12)

T8

8 7 9 9 9 9T 12 T5 Anterior cutaneous nerves (branches of intercostal nerves T5T12)

T 12

10 10

Periumbilical veins

11 11

Medial umbilical ligament

Pyramidalis muscle

Superficial iliac circumflex artery, vein

12 12Inferior epigastric artery, vein IIiohypogastric nerve

Superficial epigastric artery, vein Superficial external pudendal artery, vein Anterior femoral cutaneous nerve

Rectus abdominis muscle IIioinguinal nerve

Great saphenous vein

FIGURE 13 Superficial Vessels and Nerves of the Anterior Trunk: Pectoral Region and Anterior Abdominal WallNOTE: (1) Cutaneous innervation of the trunk: supraclavicular nerves (C3, C4), intercostal nerves (T1T12), and the ilioinguinal and iliohypogastric branches of L1. (2) The intercostal nerves give off lateral and anterior cutaneous branches. (3) Anastomoses between the thoracoepigastric vein above and the superficial iliac circumflex and inferior epigastric veins below. (4) The breast, its innervation (T2T6 intercostal nerves), and its blood supply (internal thoracic artery, lateral thoracic artery, and intercostal arteries). (5) The nipple at the level of T4 and the umbilicus at the level of T10.


PLATE 14

A Typical Segmental Spinal Nerve and Intercostal ArteryLateral branch Medial branch

FIGURE 14.1 A Typical Segmental Spinal Nerve and

Its Branches(From Clementes Anatomy Dissector, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007.)

Dorsal root (sensory) Dorsal root ganglion Dorsal primary ramus Spinal nerve (mixed) Ventral primary ramus Posterior branch Ventral root (motor) Anterior branch Rami communicantes Sympathetic ganglion

Ventral primary ramus Lateral cutaneous branch Lateral branch Anterior cutaneous branch Medial branch

Intercostal vein, artery, and nerve

Spinal cord Posterior primary nerve ramus Internal intercostal membrane Anterior primary nerve ramus External intercostal muscle Innermost intercostal muscle Vertebral body Lateral cutaneous branch of anterior primary nerve ramus Aorta Posterior branch of posterior intercostal artery Posterior intercostal artery

Internal intercostal muscle Posterior cutaneous nerve branch

Lateral cutaneous branch of intercostal artery

Anterior intercostal artery Anterior cutaneous nerve branch

Anterior perforating cutaneous nerve branch

Internal thoracic artery (in cross section)

Perforating cutaneous branch External intercostal membrane Sternum

FIGURE 14.2 A Segmental Thoracic Nerve and Intercostal Artery and Their BranchesNOTE: (1) Segmental intercostal nerves are formed by the junction of dorsal and ventral spinal roots. Distal to this junction, the mixed spinal nerve divides into dorsal and ventral primary rami. The posterior primary ramus courses to the back, while the anterior primary ramus courses between adjacent ribs as an intercostal nerve and gives off lateral and anterior cutaneous branches. (2) Posterior intercostal arteries are derived from the aorta. Each sends a posterior branch to the back. The anterior branch becomes the anterior intercostal artery, and it also gives off lateral and anterior cutaneous branches.Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

Superficial Thoracic and Abdominal Wall MusclesSternocleidomastoid muscle Platysma muscle (cut)

PLATE 15

Pectoralis major muscle Deltoid muscle

Deltopectoral triangle Cephalic vein Deltoid muscle

Brachial fascia Axillary fascia

Deltopectoral triangle



Serratus anterior muscle Costoxiphoid ligaments Latissimus dorsi muscle

Pectoralis major muscle (abdominal portion)


Linea alba

External oblique muscle Rectus sheath (anterior layer)

Umbilicus

Anterior superior iliac spine Superficial fascia

Anterior superior iliac spine

Intercrural fibers

External oblique aponeurosis

Medial crus of superficial inguinal ring Cremaster muscle

Spermatic cord

Reflected inguinal ligament

Fudiform ligament of penis

Suspensory ligament of penis Body of penis

FIGURE 15 Muscles of the Superficial Thoracic and Abdominal Walls

Muscle Pectoralis major

Origin Medial half of clavicle; second to sixth ribs; costal margin of sternum; aponeurosis of external oblique

Insertion Humerus, lateral lip of intertubercular sulcus

Innervation Lateral (C5, C6, C7) and medial (C8, T1) pectoral nerves

Action Adducts and rotates arm medially; sternal part: helps extend humerus; clavicular part: helps flex humerus


PLATE 16

Pectoral Region: Superficial Vessels and Cutaneous Nerves

Intermediate supraclavicular nerves Lateral supraclavicular nerves Medial supraclavicular nerves

Deltoid fascia

Thoracoacromial artery, pectoral branch

Pectoralis major, fascia

Cephalic vein

Anterior cutaneous branches (intercostal nerves)

Brachial fascia Superficial axillary lymph nodes Lateral thoracic artery Thoracoepigastric vein Latissimus dorsi fascia Lateral cutaneous branches (intercostal nerves) Rectus sheath Serratus anterior fascia External oblique fascia

FIGURE 16 Anterior Thoracic Wall; Superficial Dissection in the MaleNOTE: (1) The skin and superficial fascia have been removed, but the cutaneous vessels and nerves have been retained. (2) The cutaneous neurovascular structures penetrate through the deep fascia (pectoral fascia) to get to the superficial fascia and skin. (3) Most cutaneous vessels and nerves are anterior and lateral cutaneous branches of the intercostal nerves and vessels. (4) The deep fascia that covers the pectoralis major muscle and the manner in which it blends inferiorly with the sheath of the rectus abdominus muscle (the rectus sheath) and medially across the sternum with the fascia on the opposite side. (5) The pectoral fascia also has a deep layer that covers the deep surface of the muscle. (6) The supraclavicular nerves are derived from C3 and C4, but overwhelmingly C4. (7) The intercostobrachial nerve (T2) joins the medial brachial cutaneous nerve to supply the skin of the axillary fossa and upper medial arm.


Pectoral Region: Pectoralis Major and Deltoid Muscles

PLATE 17

Platysma muscle Clavipectoral fascia Subcutaneous acromial bursa Supraclavicular nerves

Pectoralis major muscle (clavicular head)

Deltoid muscle

Cephalic vein

Coracobrachialis muscle Anterior cutaneous branch of intercostal nerve (T2) Pectoralis major muscle (sternocostal part)

Anterior axillary lymph nodes (pectoral)

Biceps brachii muscle

4

Anterior cutaneous branch of intercostal nerve (T4)

Medial brachial cutaneous nerve Pectoralis major muscle (abdominal part)

Brachial fascia

5

6Lateral thoracic artery; thoracoepigastric vein Lateral cutaneous branch of intercostal nerve (T4) Lateral cutaneous branch of intercostal nerve (T6) Lateral cutaneous branch of intercostal nerve (T8) Anterior cutaneous branch of intercostal nerve (T6) Anterior sheath, rectus abdominis muscle Anterior cutaneous branch of intercostal nerve (T8)

7

8Fascia over external oblique muscle Fascia over serratus anterior muscle

FIGURE 17 Pectoralis Major and Deltoid Muscles (Anterior View)NOTE: (1) The anterior layer of the pectoral fascia and the deltoid fascia as seen in Figure 16 have been removed. (2) The lateral cutaneous vessels and nerves penetrating through the intercostal spaces in the midaxillary line. (3) The anterior cutaneous vessels and nerves piercing the pectoralis major muscle along the lateral border of the sternum. (4) The clavicular fibers of this muscle course obliquely downward, and laterally, the upper sternocostal fibers are directed nearly horizontally, and the lower sternocostal and abdominal fibers ascend nearly vertically to the humerus. (5) The natural cleft between the clavicular and sternocostal heads. Detaching the clavicular head uncovers some of the vessels and nerves that supply this muscle (see Fig. 22.1). (6) The fourth to the eighth ribs are numbered sequentially.


PLATE 18Acromioclavicular joint Acromion Coracoid process Head of humerus Greater tubercle Crest of greater tubercle Pectoralis major muscle (sternocostal head)

The Pectoralis Major and Minor MusclesClavicle

Pectoralis major muscle (clavicular head)

Jugular notch

FIGURE 18.1 The Pectoralis Major MuscleNOTE: (1) The pectoralis major muscle has fibers that descend from the clavicle and fibers that ascend from the lower sternum and the aponeurosis of the external oblique muscle. Between these are the transverse fibers that cross the chest. (2) This broad mass of muscle fibers inserts onto the lateral lip of the intertubercular sulcus of the humerus. (3) The ascending and lower transverse fibers form a rounded inferior border that becomes the anterior axillary fold. This muscle and the pectoralis minor overlie the nerves of the brachial plexus and the axillary vessels and their branches. (4) The pectoralis major medially rotates and adducts the humerus. In addition, the clavicular fibers assist in flexing the humerus, while the inferior sternal fibers and those attaching to the aponeurosis of the external oblique assist in extending the humerus. (Contributed by Dr. Gene L. Colborn, Medical College of Georgia.)

Manubrium

Body of sternum

Xiphoid process

Acromion Coracoid process Subclavius muscle Clavicle Greater tubercle Lesser tubercle 1 Manubrium

FIGURE 18.2 The Pectoralis Minor MuscleNOTE: (1) The pectoralis minor muscle is often called the key to the axilla; this is because it crosses the axillary artery, dividing it into three parts, medial, deep, and lateral to the pectoralis minor muscle. There is one branch off of the first part of the axillary artery, two branches off of the second part, and three branches off of the third part. (2) Deep to the pectoralis minor muscle, the cords of the brachial plexus are found. These are called the medial, lateral, and posterior cords, and they are located medial, lateral, and posterior to the axillary artery. (3) The pectoralis minor muscle can protract the scapula (i.e., draw it forward) when the insertion on the third, fourth, and fifth ribs is fixed. When the attachment to the coracoid process is fixed, the pectoralis minor can help elevate the ribs, and thus, it becomes an accessory muscle of respiration. (From Clementes Anatomy Dissector, 2nd Edition. Baltimore: Lippincott Williams & Wilkins, 2007.)

2 Humerus 3 Scapula

Sternal angle

Body of sternum

4

Pectoralis minor muscle

5

6 7 8 Xiphoid process


The Anterior Surface of the Rib Cage

PLATE 19

Sternocleidomastoid Trapezius

Deltoid Jugular notch

Clavicular notch

Pectoralis minor Biceps brachii and Coracobrachialis

Sternal angle 1 Glenoid fossa

Manubrium

Triceps brachii Subclavius Subscapularis Pectoralis major Body 3 2

Vertebrosternal or true ribs (17)

Serratus anterior

Pectoralis minor

4

Costal cartilages

5

6

Xiphoid process 7

8

Vertebrochondral or false ribs (810)

9 12 11 10

Vertebral or floating ribs (11 and 12)

FIGURE 19 The Anterior Surface of the Sternum and RibsNOTE: (1) The costal cartilages and the manner in which they articulate with the sternum. (2) The jugular notch (also called the suprasternal notch) along the superior border of the manubrium. (3) Lateral to the manubrium, the clavicle articulates into the clavicular notch, and just below this, the first rib articulates with the lateral surface of the manubrium. (4) Rib 2 articulates with the sternum lateral to the sternal angle (i.e., between the manubrium and body of the sternum). (5) Ribs 4, 5, and 6 articulate on the body of the sternum, and rib 7, joined by the costal margins of ribs 8, 9, and 10, attaches to the junction of the xiphoid process and sternal body (the xiphisternal junction). (6) The origin of the pectoralis major muscle attaches along the medial half of the clavicle and lateral one-third of the manubrium and body of the sternum. (7) The pectoralis minor muscle inserts on the third, fourth, and fifth ribs, and the biceps brachii and coracobrachialis muscles attach just above the glenoid fossa (supraglenoid tubercle), while the triceps arises from the infraglenoid tubercle below the glenoid fossa. (From C.D. Clemente. Grays Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)


PLATE 20

Lateral Thoracic Wall and Superficial Axilla

Coracobrachialis Biceps muscle muscle Median nerve

Deltoid muscle Pectoralis major muscle Musculocutaneous nerve Lateral cord contribution to median nerve Ulnar nerve

Basilic vein

Axillary vein Axillary lymph nodes

Medial antebrachial cutaneous nerve Medial brachial cutaneous nerve Intercostobrachial nerve (T2)

Lateral cutaneous branch of the 3rd intercostal nerve


Pectoralis minor muscle Pectoralis major muscle

Thoracoepigastric vein; lateral thoracic artery Long thoracic nerve

Serratus anterior muscle Lateral cutaneous branch of the 5th intercostal nerve

Lateral cutaneous branch of the 4th intercostal nerve Latissimus dorsi muscle

Pectoralis major muscle (abdominal part)

Lateral cutaneous branch of the 6th intercostal nerve Lateral cutaneous branch of the 8th intercostal nerve

Serratus anterior muscle 9th rib origin

Lateral cutaneous branch of the 10th intercostal nerve


External oblique muscle (part arising from 5th rib) Lateral cutaneous branch of the 6th intercostal nerve Serratus anterior muscle 7th rib origin


FIGURE 20 Lateral Aspect of the Upper Right Thoracic Wall and the Superficial Axillary StructuresMuscle Pectoralis minor Serratus anterior Origin Coracoid process of scapula Fleshy slips from upper nine ribs Insertion Ribs 2 to 5 Medial border of scapula Innervation Medial pectoral nerve (C8, T1) Long thoracic nerve(C5, C6, C7)

Action Protracts scapula; elevates ribsProtracts and rotates scapula; holds scapula close to thoracic wall


The Pectoral Muscles: Intact and Reflected; Serratus Anterior MuscleCoracoid process Serratus anterior muscle (superior part) Deltoid muscle Clavicle Pectoralis major muscle

PLATE 21

Subclavius muscle Pectoralis minor muscle

Coracobrachialis muscle

Subscapularis muscle


Internal intercostal muscle Teres major muscle Serratus anterior muscle Pectoralis major muscle (abdominal part)

FIGURE 21.1 Pectoralis Minor,


Serratus Anterior, and Latissimus Dorsi Muscles, Lateral View (Right)NOTE that the pectoralis major muscle has been reflected, revealing: (1) the pectoralis minor muscle extending from coracoid process to the second to sixth ribs; (2) the serratus anterior, forming the medial wall of the axilla.Pectoralis minor muscle

External intercostal muscle 11th rib



Posterior scalene muscle Acromion Levator scapulae muscle Clavicle Middle scalene muscle Anterior scalene muscle

Deltoid muscle

Biceps brachii (long head) Biceps brachii muscle (short head) Coracobrachialis muscle Teres major muscle Subscapularis muscle

Omohyoid muscle (inferior belly)

ISternocleidomastoid muscle

IISubclavius muscle Internal intercostal muscles External intercostal muscles

Serrratus anterior muscle

IVSerratus anterior muscle


VPectoralis major muscle


VIExternal oblique muscle Rectus abdominis muscle

VII

FIGURE 21.2 The Subscapularis and Serratus Anterior Muscles (Right Lateral View)Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 22

Deltopectoral Triangle and the Deep Lateral Thoracic MusclesPosterior cord Lateral cord Medial cord Clavicle Acromial anastomosis Subclavian artery Acromion Subclavian vein

Deltoid muscle, clavicular part Subclavius muscle Deltoid muscle, acromial part Clavipectoral fascia Cephalic vein Medial pectoral nerves

Thoracoacromial artery, pectoral branches Pectoralis major muscle, clavicular head

Pectoralis major muscle, sternocostal head

FIGURE 22.1 Deltopectoral Triangle (Right)NOTE: (1) The clavicular head of the pectoralis major muscle has been severed and reflected downward. (2) The investing layer of deep fascia covering the deep surface of the pectoralis major muscle and the clavipectoral fascia, which extends between the clavicle and the medial border of the pectoralis minor muscle, are exposed. (3) The cephalic vein pierces the clavipectoral fascia to join the axillary vein. (4) The thoracoacromial artery (from the axillary artery) and the lateral pectoral nerve (from the lateral cord of the brachial plexus) pierce the fascia from below to supply blood to the region and to innervate the pectoralis major muscle.Sternocleidomastoid Pectoralis major, clavicular head Internal intercostal muscles Deltoid Coracobrachialis Brachial plexus, infraclavicular part Biceps brachii, short head Axillary artery Pectoralis major, sternocostal head (Sternalis, var.) Subclavius Axillary vein Pectoralis minor

Pectoralis major

Serratus anterior

Pectoralis minor 2nd5th ribs Latissimus dorsi Serratus anterior Serratus anterior Pectoralis major, abdominal part Pectoralis major, sternocostal head Latissimus dorsi

External oblique

External oblique

FIGURE 22.2 Pectoralis Minor, Serratus Anterior, and Latissimus Dorsi Muscles (Right Lateral View)NOTE that the pectoralis major muscle has been reflected, revealing the pectoralis minor muscle extending from the second to fifth ribs to the coracoid process. Also note that the serratus anterior muscle forms the medial wall of the axilla.Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

The Axillary Vein and Its TributariesPectoralis minor muscle Deltoid muscle Cephalic vein Musculocutaneous nerve Brachial vein Coracobrachialis muscle Axillary artery

PLATE 23

1st rib Pectoralis major muscle Biceps brachii muscle

r illa Ax

ein yv

2nd rib

in ve ilic as B

Ulnar nerve Median nerve Posterior humeral circumflex vein

Pectroalis Pectoralis minor muscle

Subscapular vein Latissimus dorsi muscle

Long thoracic vein Circumflex scapular vein


FIGURE 23.1 The Veins of the Right AxillaNOTE the relationship of the axillary vein to the axillary artery and the nerves in the axilla. (From C.D. Clemente. Grays Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)1. Axillary vein 2. Basilic vein 3. Cephalic vein 4. Lateral border of the scapula 5. Lateral border of the latissimus dorsi 6. Head of humerus 7. Acromion 8. Venous valve 9. Brachial vein

7

6 3

2 4 9FIGURE 23.2 Radiograph of Veins in the Axillary Region

8

1

5

NOTE: (1) The basilic vein [2] becomes the axillary vein [1]. (2) One of the brachial veins [9] also flows into the axillary vein, as does the cephalic vein [3], the junction of which is medial to the field shown here. (3) The venous valves [8] along the course of the axillary vein.Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 24

The Axillary Artery and Its Branches

Subclavian artery Internal thoracic artery

Thyrocervical trunk

Vertebral artery

Common carotid artery

Supreme thoracic artery Thoracoacromial artery Pectoralis minor muscle

CAxillary artery Subscapular artery

LA

V

IC LE

FIGURE 24.1 Branches of the Axillary ArteryNOTE: (1) The subclavian artery becomes the axillary artery distal to the clavicle. (2) Inferior to the teres major, the axillary artery becomes the brachial artery. (3) The pectoralis minor crosses the axillary artery, dividing it into three parts: (a) Medial to the muscle (b) Beneath the muscle (c) Lateral to the muscle (4) From the first part, there is one branch, the supreme thoracic artery. (5) From the second part are derived two branches: (a) Thoracoacromial artery (b) Lateral thoracic artery (6) From the third part come three branches: (a) Subscapular artery (b) Anterior humeral circumflex artery (c) Posterior humeral circumflex artery

1Brachial artery

H

U

M

E

R

U

S

2

3

4Anterior humeral circumflex artery Posterior humeral circumflex artery Circumflex scapular artery Lateral thoracic artery Thoracodorsal artery

5

6

Clavicle Acromial anastomosis Subclavian artery

Deltoid branch Acromial branch Axillary artery Clavicular branch Thoracoacromial artery

FIGURE 24.2 Thoracoacromial

Artery and Its BranchesNOTE that the four branches of the thoracoacromial artery usually are the clavicular, pectoral, acromial, and deltoid.

Pectoral branches


The Internal ThoracicEpigastric AnastomosisScalenus anterior muscle Thyrocervical trunk

PLATE 25

Common carotid artery Subclavian artery Brachiocephalic trunk

Internal thoracic artery

Anterior intercostal arteries

Perforating branches

Superior epigastric artery

Musculophrenic artery

Sheath of rectus abdominis muscle (post. layer)

Transverus abdominis muscle

Inferior epigastric artery

External iliac artery

FIGURE 25 The Internal Thoracic and Epigastric Arterial AnastomosisNOTE: (1) The internal thoracic artery arises from the axillary artery, and in its descent in the chest, it gives off perforating branches segmentally. At the costal margin, the internal thoracic artery terminates by dividing into the musculophrenic and superior epigastric arteries. (2) The inferior epigastric artery arises from the external iliac artery just superior to the inguinal ligament, and it anastomoses with the superior epigastric branch of the internal thoracic artery. (3) This arterial anastomosis forms a major interconnection between the subclavian and external iliac systems and, in effect, between the inferior vena cava and the superior vena cava. (From C.D. Clemente. Grays Anatomy, 30th American Edition. Philadelphia: Lea & Febiger, 1985.)Chapter 1 Pectoral Region, Axilla, Shoulder, and Upper Limb

PLATE 26

Dissection of Axilla: Superficial Vessels and Nerves

Brachial plexus Brachial veins Subscapular vein Axillary vein Thoracoepigastric vein Communicating branch, intercostobrachial nerve

Intercostobrachial nerve (T2)

Lateral thoracic artery, vein

Axillary nerve Teres major muscle Circumflex scapular artery, vein

Pectoralis major muscle Latissimus dorsi muscle Thoracodorsal artery, vein Thoracodorsal nerve Long thoracic nerve


Lateral cutaneous nerves (T4, T5 branches)


Thoracoepigastric vein

FIGURE 26 Axilla: Superficial Vessels and Nerves (Left)NOTE: (1) The boundaries of the axilla are: (a) Anteriorly, the pectoralis major muscle (b) Posteriorly, the subscapularis, teres major, and latissimus dorsi muscles (c) Medially, the serratus anterior muscle covering the second to the sixth ribs (d) Laterally, the bicipital groove of the humerus. (2) The lower part of the serratus anterior muscle arises from the lower ribs as fleshy interdigitations with the external oblique muscle. (3) The serratus anterior is innervated by the long thoracic nerve, and the latissimus dorsi by the thoracodorsal nerve. (4) The axillary vein lies medial to the axillary artery and the brachial plexus. (5) The ascending course of the thoracoepigastric vein and the lateral thoracic vessels.


Dissection of Axilla: Deep Vessels and NervesPhrenic nerve Subclavian artery Clavicle Dorsal scapular artery Axillary vein Axillary artery Brachial plexus Vagus nerve Pectoral Acromial

PLATE 27

Thyrocervical trunk Vertebral artery Common carotid artery

Branches of thoracoacromial artery

Left brachiocephalic vein

Deltoid muscle (cut)

Pectoralis major muscle (cut)

Anterior cutaneous nerves; perforating branches, internal thoracic artery, vein

Pectoralis major muscle (cut)

Axillary artery Axillary vein


Intercostobrachial nerve Thoracodorsal nerve Lateral thoracic artery, vein Thoracodorsal artery, vein Long thoracic nerve

Latissimus dorsi muscle Thoracoepigastric vein External oblique muscle Serratus anterior muscle

FIGURE 27 Axilla (Left): Deep Vessels and NervesNOTE: (1) The subclavian artery becomes the axillary artery distal to the clavicle. (2) The pectoralis minor muscle is capable of elevating the ribs if the coracoid attachment is fixed or of protracting the scapula if the costal attachment is fixed. (3) The axillary artery is surrounded by the three cords of the brachial plexus. (4) The thoracoacromial artery divides into pectoral, acromial, deltoid, and small clavicular branches. (5) The intercostobrachial nerve (T2) pierces the second intercostal space in its course toward the axilla and arm, and it communicates with the medial brachial cutaneous nerve.


PLATE 28

Arterial Supply to the Upper Extremity

Transverse cervical artery Dorsal scapular artery Thoracoacromial artery Subclavian artery Lateral thoracic artery Axillary artery Posterior humeral circumflex artery Anterior humeral circumflex artery Thyrocervical trunk

Brachial artery Subscapular artery

Profunda brachial artery

Superior ulnar collateral artery

Inferior ulnar collateral artery

Ulnar recurrent arteries

Common interosseous artery Radial artery Ulnar artery

Anterior interosseous artery

Deep palmar arch Superficial palmar arch Common palmar digital arteries

Proper palmar digital arteries

FIGURE 28 Arteries of the Upper Limb(Contributed by Dr. Gene L. Colborn, Medical College of Georgia.)


Superficial Veins of the Upper Extremity

PLATE 29

Lateral supraclavicular nerves

Intercostobrachial nerve

Medial brachial cutaneous nerves

Cephalic vein

Medial antebrachial cutaneous nerve Basilic vein Lateral antebrachial cutaneous nerve (continuation of the musculocutaneous nerve) Median cubital vein

Cephalic vein Ulnar nerve

Basilic vein

Radial nerve (superficial branch)

Ulnar nerve

Median nereve

Palmar cutaneous branch (ulnar nerve)

FIGURE 29 The Superficial Veins of the Upper ExtremityNOTE: The cephalic vein laterally commencing on the radial (or thumb) side of the hand and the basilic vein commencing on the ulnar (or little finger) side of the hand. These channels communicate in the antecubital fossa by the median cubital vein. (Contributed by Dr. Gene L. Colborn, Medical College of Georgia.)


PLATE 30

Shoulder Region, Anterior Aspect: MusclesTrapezius muscle Clavicle Subclavius muscle Superior angle of scapula Transverse scapular ligament Acromion Coracoid process Omohyoid muscle Subcoracoid bursa Pectoralis minor muscle Serratus anterior muscle Biceps muscle (short head); coracobrachialis muscle Deltoid muscle

MEDIAL


Supraspinatus muscle

LATERAL


Teres major muscle

Triangular space




Coracobrachialis muscle Tendon of biceps muscle (long head) Brachial plexus

Tendon of latissimus dorsi muscle Triceps muscle (long head) Brachial vessels Biceps muscle (short head) Brachial fascia

Biceps muscle (long head)

FIGURE 30 Muscles of Anterior Aspect of the Shoulder (Left)NOTE: (1) The large triangular mass of the subscapularis muscle occupying the concave subscapular fossa. From this broad origin, its fibers converge toward the humerus, where it inserts on the lesser tubercle. (2) The subscapularis along with the other muscles that constitute the rotator cuff (supraspinatus, infraspinatus, and teres minor) help stabilize the shoulder joint by keeping the head of the humerus in the glenoid fossa. (3) Both the short head of the biceps and the coracobrachialis have a common origin from the coracoid process.

Muscle Subscapularis

Origin Subscapular fossa of the scapula

Insertion Lesser tubercle of humerus

Innervation Upper and lower subscapular nerves (C5, C6) from posterior cord of brachial plexus Thoracodorsal nerve (C6, C7, C8) from posterior cord of brachial plexus Axillary nerve (C5, C6) from posterior cord of brachial plexus

Action Medial rotation of humerus

Latissimus dorsi

Thoracolumbar fascia; spinous processes of lower six thoracic and lumbar vertebrae, and the sacrum Lateral third of clavicle; the acromion; spine of the scapula

Bottom of the intertubercular sulcus of humerus Deltoid tubercle on lateral surface of humerus

Extends, adducts, and medially rotates the humerus Abduction of the humerus; anterior fibers assist in flexion and posterior fibers in extension of humerus

Deltoid


Anterior Shoulder Region: Vessels and Nerves; Shoulder Joint MovementsTransverse scapular ligament

PLATE 31

MEDIAL

Suprascapular nerve Subscapular nerve

Omohyoid muscle Clavicle Suprascapular artery Coracoid process

LATERAL

Posterior cord: brachial plexus Axillary nerve Circumflex scapular artery

Medial cord: brachial plexus

Pectoralis minor muscle Deltoid muscle Axillary artery


Coracobrachialis muscle; biceps muscle (short head) Lateral cord: brachial plexus

Musculocutaneous nerve

Teres major muscle Subscapular artery Thoracodorsal artery Thoracodorsal nerve Latissimus dorsi muscle Radial nerve Medial brachial cutaneous nerve Ulnar nerve Median nerve


Medial antebrachial cutaneous nerve Brachial veins

FIGURE 31.1 Nerves and Vessels of Anterior Aspect of the Shoulder (Left)NOTE: (1) The relationships of the medial, lateral, and posterior cords of the brachial plexus to the axillary artery. (2) The posterior cord and its axillary and radial terminal nerves have been pulled medially from behind the axillary artery in this dissection. (3) The median nerve formed by contributions from the lateral and medial cords. Observe that the median nerve, its two roots of origin and the ulnar and musculocutaneous nerves outline an M formation on the anterior aspect of the axillary artery.

Sagittal axis

Longitudinal axis

Extension Transverse axis Abduction Flexion Adduction

Lateral rotation (external rotation)

Medial rotation (internal rotation)

FIGURE 31.2 Shoulder Joint:



Flexion and ExtensionIn flexion the upper limb is moved anteriorly (forward), while in extension the limb moves posteriorly (backward) in reference to the transverse axis.

Abduction and AdductionIn abduction, the upper limb is moved laterally, or away from the midline of the body, with reference to the sagittal axis. In adduction, the upper limb is moved medially, or toward the midline of the body.

Medial and Lateral RotationMedial rotation at the shoulder joint occurs when the humerus is rotated internally (medially) with reference to the long or longitudinal axis of the bone. In contrast, lateral rotation of the upper limb moves the humerus (arm) externally or laterally.


PLATE 32LATERAL

Shoulder Region, Posterior Aspect: MusclesSpine of scapula Deltoid muscle Acromion Trapezius muscle

MEDIAL

Subdeltoid bursa Teres minor muscle

Levator scapulae muscle

Supraspinatus muscle Surgical neck of humerus Tendon of biceps, long head Quadrangular space Tendon of pectoralis major muscle Infraspinatus muscle

Rhomboideus minor muscle

Deltoid muscle Rhomboideus major muscle Biceps muscle

Triangular space Triceps muscle; long head Brachialis muscle

Teres major muscle

Triceps muscle, lateral head

FIGURE 32 Posterior Scapular Muscles (Left)NOTE: (1) The supraspinatus, infraspinatus, and teres minor muscles all course laterally from the dorsal scapula, and all are considered rotator cuff muscles. (2) These three muscles insert in sequence from above downward on the greater tubercle of the humerus. (3) The long head of the triceps intersects a space between the teres major and teres minor muscles, forming a quadrangular space laterally and a triangular space medially. (4) The posterior humeral circumflex artery and the axillary nerve pass through the quadrangular space. (5) The circumflex scapular branch of the subscapular artery passes through the triangular space. (6) Since the lateral border of the quadrangular space is the surgical neck of the humerus, the axillary nerve and posterior humeral circumflex artery are in danger if the bone is fractured at this site.

Muscle Supraspinatus Infraspinatus Teres major

Origin Supraspinatus fossa of the scapula Infraspinatus fossa of the scapula Lower lateral border and inferior angle of the scapula Upper part of the lateral border of the scapula

Insertion Highest facet of the greater tubercle of humerus Middle part of greater tubercle of humerus Crest of lesser tubercle and medial lip of intertubercular sulcus of humerus

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