Human Anatomy I - All Slides PDF

What is Anatomy  Microscopic Anatomy 4x 40x 1895 1972 1953 CT ultrasonography 1973 1975 radiography...

What is Anatomy  Microscopic Anatomy 4x 40x 1895 1972 1953 CT ultrasonography 1973 1975 radiography MRI endoscopy The difference between life and death may depend on a health care professional’s understanding of the human body  LESSON 1 Introduction  Content  anatomical position, planes, descriptors  terminology of movements  bones: forms, functions, structure, development Joint: classification, structure, movement  Objectives  define common anatomical terms related to body position, body parts and their relationship and movements  acquire the basic terminology necessary for communicating with other healthcare professionals outline the general structure of bone tissue define joint types describe the general features of synovial joints  give examples of synovial joint types  define and give examples of various types of movements  Anatomical terms  Descriptive terms standardized in an international reference guide, Terminologia Anatomica (TA)  These terms, in English and Latin, are used worldwide http://www.unifr.ch/ifaa/Public/EntryPage/ViewSource.html  Eponyms are often used in clinical setting, but are not recommended because they do not provide anatomical context and are not standardized  Bertin’s bone = sphenoidal concha  Bertin’s columns = renal columns  Bertin’s ligament = iliofemoral ligament  Anatomical position  A person standing upright with the:  head, eyes and toes directed anteriorly  arms adjacent to the sides  palms facing forward  lower limbs close together with the feet parallel  Anatomical position  A person standing upright with the:  head, eyes and toes directed anteriorly  arms adjacent to the sides  palms facing forward  lower limbs close together with the feet parallel By Connexions - http://cnx.org, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=29624321 Anatomical planes  Horizontal planes, transverse planes  pass horizontally through the body  lie at right angles to the coronal and sagittal planes  divide the body into superior (upper) and inferior (lower) parts  the most common plane used in CT and MRI (axial planes)  Coronal planes, frontal planes  vertical planes passing through the body from side to side  lie perpendicular to sagittal planes  divide the body into anterior and posterior parts  Sagittal planes  vertical planes passing through the body from the front to the back  lie perpendicular to coronal plane  divide the body into left and right parts  Median plane  sagittal plane that divides the body into left and right halves  Sections  runs lengthwise or  runs at right angle  does not run along parallel to the long axis to the long axis of any anatomical plane of the body part the body part By Connexions - http://cnx.org, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=29624321 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Body planes and terms of relationship Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010.  Terms of position and relationship  Anterior  Medial  in front of another structure  closer to median plane  Posterior  Lateral  behind another structure  further away from median plane  Superior  Proximal  above another structure  closer to the trunk or origin  Inferior  Distal  below another structure  further away from the trunk or origin  Deep  Ipsilateral  further away from body surface  on the same side of the body  Superficial  Controlateral  closer to body surface  on the opposite of the body  Terms of movement  Flexion and extension  movements in the sagittal plane, around a transverse axis  flexion: a reduction in the angle between two body parts, a movement in an anterior direction  extension: a straightening or an increase in the angle between two body parts, a movement in a posterior direction  exceptions: knee joint, ankle joint, thumb movements  Terms of movement  Abduction and adduction  movements in the frontal plane, around a sagittal axis  abduction: movement away from the median plane  adduction: movement towards the median plane  exceptions: movements of digits  Terms of movement  Rotation  movement of part of the body along its long axis  medial rotation (internal rotation): brings the anterior surface of the limb closer to the median plane  lateral rotation (external rotation): brings the anterior surface of the limb away from the median plane  Terms of movement  Pronation and supination  rotational movements of the forearm and hand  pronation: medial rotation of the forearm causing the palm of the hand to face posteriorly  supination: lateral rotation of the forearm causing the palm to face anteriorly  Eversion and inversion  rotational movements of the foot  eversion: movement of the sole of the foot away from the median plane (turning the sole outwards)  inversion: movement of the sole of the foot towards the median plane (turning the sole inwards)  Terms of movement  Movements of thumb Anatomical position and the terminology used to describe various body regions Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010. Subdivisions of the abdomen  Reference lines 4 1 4 1 2 5 2 5 3 4 6 3 6  Abdominal quadrants  Abdominal regions 1) upper right 1) epigastric region 2) upper left 2) umbilical region 3) lower right 3) pubic region 4) lower right 4) hypochondrium 5) lateral region; flank 6) inguinal region; groin  Reference lines  Vertical lines of the thorax 1) anterior axillary line 2) anterior midline 3) sternal line 4) parasternal line 2 4 5) midclavicular line 1 3 5 PROMETHEUS. Atlante di Anatomia  Reference lines  Transverse planes of the trunk 1) transverse thoracic plane 2) transpyloric plane 1 3) subcostal plane 4) supracrestal plane 5) intertubercal plane 6) interspinal plane 2 3 4 5 6 PROMETHEUS. Atlante di Anatomia  Parts of human body By Connexions - http://cnx.org, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=29624317  Regions of upper limb 1 1 2 3 4 1) Deltoid region 2) Anterior region of arm 4a Brachial region 3) Posterior region of arm 5 4) Anterior region of elbow a) cubital fossa Cubital region 6 5) Posterior region of elbow 7 6) Anterior region of forearm Antebrachial region 7) Posterior region of forearm 8) Anterior region of wrist Carpal region 8 9) Posterior region of wrist 9 11 10) Palmar region; Palm 11) Dorsum of the hand Hand region 10 12) Digits of the hand (fingers including thumb) 12 PROMETHEUS. Atlante di Anatomia  Regions of lower limb 1) Gluteal region 2) Anterior region of thigh 1 a) Femoral triangle Femoral region 2a 3) Posterior region of thigh 4) Anterior region of knee 2 3 5) Posterior region of knee Knee region a) Popliteal fossa 6) Anterior region of leg 4 7) Posterior region of leg a) Sural region 5 8) Anterior talocrural (ankle) region Leg region 5a 9) Posterior talocrural (ankle) region a) Lateral retromalleolar region 6 b) Medial retromalleolar region 7 7a 10) Heel region 11) Dorsum of foot 8 12) Sole; Plantar region Foot region 9 13) Digits of foot; Toes 9b 9a 11 10 12  Bones Functions Forms  support for the body  protection for organs  attachment sites for muscles (movement)  storage of minerals (calcium)  hematopoiesis in the bone marrow Martini, Timmons. Anatomia Umana. EdiSES Long bones  Diaphysis  shaft  tube of cortical (compact) bone that surrounds a medullary cavity filled with bone marrow  Metaphysis  widening of bone near the epiphysis  Epiphysis  articular end of bone  composed of spongy bone  Epiphysial plate (growth plate)  site of the growth in length  dissapears in mature skeleton Bone composition Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010  Microscopic bone types  Woven  developing (immature) or pathologic (fracture callus) bone  poorly organized tissue, trabeculae casually-oriented  Lamellar  mature bone  highly organized with stress orientation of trabeculae or lamellae  spongy (trabecular) or compact (cortical) bone Spongy bone Compact bone  Microscopic bone types  Spongy bone  usually forms inside of bones  slender bony plates, called trabeculae, form a bony network  osteocytes lie between the lamellae of matrix in the trabeculae  the spaces between trabeculae contain bone marrow and blood vessels Waugh A, Grant A. Anatomy and Physiology in Health and Illness, 9th ed. Churchill Livingstone 2004  Microscopic bone types  Compact bone  typically forms hard outer shell of bones  lamellae form cylindrical structures called osteons  each osteone has a central canal, known as Haversian canal, that contains a blood vessel  osteocytes occupy small spaces between neighbouring lamellae, called lacunae, and communicate with each other through canaliculi  Bone cells  Osteoprogenitor  Osteoblasts  Osteocytes  Osteoclasts cells  produce bone matrix  90% of bone cells  large, multinucleated  staminal cells that (osteoid)  osteoblasts cells differentiate in  collagen I surrounded by bone  resorb bone osteoblasts  other organic matrix  activity indirectly  reside in periosteum components  maintain and stimulated by PTH; and endosteum  activity stimulated by preserve bone inhibited by calcitonin  active in bone PTH, vit. D, estrogen;  comunicate with and estrogen; formation and fracture inhibited by each other and with  pharmacologically healing glucocorticoids vascular spaces via inhibited by canaliculi bisphosphonates  Osteoclasts Ruffled border  Normal appearance of bone  This is an anteroposterior view of the hip. When viewed in tangent, the cortex can be seen as a white line, varying in thickness in different parts of the bone (white arrows). In the medullary cavity, cancellous bone can be seen to contain an interlacing network of trabeculae (white circle).  Bone formation  Intramembranous ossification  mesenchymal cells of the connective tissue differentiate into osteoblasts, which produce bone  typical of flat bones (e.g. some bones of cranium)  Enchondral ossification  hyalin cartilage forms a template for a future bone  osteoclasts remove the cartilage, osteoblasts make the new bone  typical of long bones Seeley, Stephens, Tate. Anatomy and Physiology. 6th ed. McGraw-Hill 2004 Seeley, Stephens, Tate. Anatomy and Physiology. 6th ed. McGraw-Hill 2004 Seeley, Stephens, Tate. Anatomy and Physiology. 6th ed. McGraw-Hill 2004  Developing bone radiography Adolescent’s wrist Adult’s wrist As the cartilage does not appear As the growth in length ceased, readily on x-ray film, the the cartilage in the epiphyseal epiphyseal plates in the radius plates has become ossified. and ulna seem to separate the diaphysis from epiphysis. Gilsanz V, Ratib O. Hand Bone Age. Springer-Verlag, Berlin Heidelberg 2005  Normal calcium metabolism  Calcium plays critical role in cardiac and skeletal muscle, and nerve function  hypocalcemia causes excessive excitability of the nervous system and leads to muscle tremors, spasms, or tetany (carpopedal spasm, laryngospasm)  hypercalcemia causes depression of the nervous system, emotional disturbances, muscle weakness, sluggish reflexes, cardiac arrest  Calcium serum levels are regulated directly by vitamin D, parathyroid hormone (PTH), and calcitonin Dietery requirement 1,000 mg/day Digestive Absorption Blood Deposition by osteoblasts Bone tract vit. D Calcitonin (weak effect) Ca2+ Hydroxyapatite Excretion 9.2-10.4 mg/dL Resorption by osteoclasts Ca10(PO4)6(OH)2 Kidneys HPO42-/H2PO4- Reabsorption 3.5-4.0 mg/dL Vit. D, PTH, calcitonin vit. D, PTH, calcitonin Fecal loss Urinary loss 350 mg/day 650 mg/day  Vitamin D  Calcitriol is the most active form of vitamin D, produced by the sequential processes in the skin, liver and kidneys UV radiation from sunlight Epidermal keratinocytes cholecalciferol Intestine Food enriched in vit. D 7-dehydrocholesterol vit. D 90% 10% (milk, salmon, eggs) LIVER calcidiol 25(OH)D KIDNEY calcitriol 1,25(OH)2D  Vitamin D increases blood calcium concentration  increases calcium (as well as phosphate and magnesium) absorption in the small intestine  increases calcium and phosphate resorption from bone (by indirectly activating osteoclasts)  increases calcium reabsorption in the kidneys Seeley, Stephens, Tate. Anatomy and Physiology. 6th ed. McGraw-Hill 2004  Osteoporosis  Decrease in bone mass (quantity of bone is reduced), with normal bone mineralization and microstructure  bone mass decreased, mineralization normal  Etiology  endocrine abnormalities (ovaries, parathyroids, adrenal glands, thyroid)  calcium deficiency, malnutrition  chronic liver disease  inactivity, disuse Loss of bone density increases the risk of fractures  vertebral body (axial skeleton predominance), femoral neck, distal radius  Radiographic features  reduced bone density  loss of trabeculae  cortical thinning  fractures vertebral wedge compression fractures  DEXA scan is standard for evaluation  Osteoporosis vertebral wedge compression fractures Anatomy of a fracture due to systemic bone loss https://youtu.be/P5HwYWShBhw Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva. Rickets and osteomalacia  Lack of osteoid mineralization  bone mass can be normal, mineralization decreased  Etiology  vitamin D deficiency  dietary deficiency  gastrointestinal malabsorption  lack of sunlight  liver or kidney disease  Radiographic features  generalized loss of bone density (osteopenia)  loss of corticomedullar differentiation  in rickets  widening of epiphyseal plate  lucent metaphyseal band  bone deformities PA of the wrist and knees of a child with dietery rickets Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva.  in osteomalacia  pseudofractures, mostly in appendicular skeleton AP of the hip of an adult with osteomalacia Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva.  Classification of long bone fractures Incomplete: Greenstick fracture Complete: Oblique fracture Open, transverse fracture Comminuted fracture Auxiliary activity: http://radiologymasterclass.co.uk/tutorials/musculoskeletal/trauma/trauma_x-ray_page1.html  Healing of fracture  Inflammation  Repair  Remodelling  hematoma develops  cells produce soft  soft callus is replaced  Osteoclasts and and supplies (cartilaginous) by immature (voven) osteoblasts transform hematopoietic/ callus that bridges bone by enchondral woven bone into osteoprogenitor cells the bone ends ossification mature (lamellar) bone  Factors that delay healing of fractures  tissue fragments between the ends of bone  deficient blood supply  poor alignment of bone ends  continuous movement of bone ends Seeley, Stephens, Tate. Anatomy and Physiology. 6th ed. McGraw-Hill 2004  Joints  Content  joint classification  joint structure  joint movement  Objectives  define joint types describe the general features of synovial joints  give examples of synovial joint types  define and give examples of various types of movements,  describe the factors that influence range of motion Types of joints  Fibrous joint  the articulating bones are united by fibrous tissue  suture  syndesmosis  Cartilaginous joint  the articulating bones are united by hyaline cartilage or fibrocartilage synchondrosis (primary cartilagineous joint)  Bony union (synostosis)  symphysis (secondary cartilaginous joint) Auricular surface Ileum Ileum Epiphysial Ischium Hip bone Intervertebral disc cartilage Ischium Pubis Pubis Ossified epiphysial cartilage Symphysial surface Sacrum Epiphysis Ossified Pubis epiphysial cartilage Epiphysis Epiphysial cartilage Pubic symphysis Diaphysis Diaphysis Epiphysial cartilage Epiphysis Ossified Epiphysis epiphysial cartilage  SYNOVIAL JOINT (diarthrosis)  the articulating bones are united by a joint capsule  joint capsule is composed of an outer fibrous layer lined by an inner synovial membrane  joint capsule encloses an articular cavity containing synovial fluid  articular surfaces of bones are covered by articular cartilage (hyaline cartilage)  synovial joints are reinforced by ligaments  some synovial joints have articular discs or meniscus (fibrocartilage) Synovial fluid  ultrafiltrate of plasma  composition:  hyaluronic acid, lubricin  glucose, serum proteins  leukocytes  Functions  nutrient and waste transportation to/from articular cartilage  reduction of friction, lubrication  shock absorption, amortization  SYNOVIAL JOINT (diarthrosis)  Articular cartilage  smooth surface covering the ends of articulating bones  avascular (nutrition from synovial fluid), aneural  water up to 80% of weight  chondrocytes produce collagen type II (gives tensile strenght) and proteoglycans (give compressive strenght) Gliding surface Superficial zone (fibers parallel to surface) Collagen fibers Intermediate zone (arcuate fibers) Tidemark (calcification line) Deep zone (fibers perpendicular to surface) Chondrocytes Calcified zone Osteocytes Subcondral bone Blood vessels  SYNOVIAL JOINT (diarthrosis)  Synovial membrane Articular cartilage Fibrous capsule Subintima  areolar connective tissue  contains lymphatics, blood capillaries and nerves Synoviocytes type B  send dendritic processes which form a regular network in the luminal surface of the synovial membrane  produce matrix constituents including hyaluronan, collagens and fibronectin  involved in the pathogenesis of rheumatoid arthritis Synoviocytes type A  can phagocytose actively cell debris and wastes in the joint cavity Articular cartilage  Arthropathy  Inflammatory and/or degenerative joint disease  Painful swollen joint  Some common types:  degenerative joint disease (osteoarthrosis, arthrosis)  rheumatoid arthritis  crystal-induced arthritis  infective arthritis  On radiographic examination:  joint space  articular surface  bone density  bone alignment Osteoarthrosis  Degenerative joint disease  Non-inflammatory localized degeneration of the hyaline cartilage in the synovial joints  Common in weight-bearing joints (vertebral column, hip, knee)  Slow development, over many years to decades  Predisposing factors:  age >55y, female  physical activity (sport, occupation)  trauma, pre-exisiting joint disease or deformity Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010 Osteoarthrosis  On radiographic examination:  eccentric joint space narrowing leading to deformity  osteophyte formation  subchondral sclerosis  subchondral cysts Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva.  Synovial fluid analysis Normal Noninflammatory Inflammatory Septic Hemorrhagic Clarity Transparent Transparent Translucent Opaque Opaque Colour Clear Yellow Yellow Purulent Red Viscosity High High Low Variable Variable WBC/ml 80.000 200-2.000 PMN leukocytes % 75 50-75 Glucose % serum 100 100 75 50 100 Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010  SYNOVIAL JOINT (diarthrosis)  Ligaments  spread between two bones  provide stability to a joint, allowing for physiological range of motion  can be discrete structures or thickenings of the fibrous joint capsule  can be intrinsic (intra- or extracapsular) or extrinsic  typically are made of collagen fibers (some are rich in elastic fibers)  serve as sensory organs in proprioception Coracoclavicular Coraco-acromial ligament ligament Articular cartilage Patellar surface Coracohumeral Lateral collateral ligament Clavicle ligament Medial condyle Posterior cruciate Lateral femoral ligament condyle Lateral meniscus Medial collateral ligament Scapula Medial meniscus Bicipital femoralis Humerus tendon Glenohumeral Anterior cruciate capsule and ligament ligaments Tibia Fibula Transverse  Ligament injuries are called sprains ligament  grade 1: stretching  grade 2: partial tear  grade 3: complete tear of ligament  SYNOVIAL JOINT (diarthrosis) classification according to the shape of articulating facets and the type of movement (1) Plane joint  articular surfaces are flat  movement is limited by tight joint capsule  the opposed articular surfaces slide or glide  uni-axial joint  acromiocalvicular joint, zygapophysial joint Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 (2) Cylindrical joint  the opposed articular surfaces are cylindrical  one is full, the other is hollow or trough-shaped  Pivot joint  Hinge joint  a rounded process of bone fits  a rounded process of bone fits into a sleeve or ring into a trough-shaped concave process  permits rotation  permits flexion and extension uni-axial joint uni-axial joint  median atlanto-axial joint,  elbow joint proximal radio-ulnar joint (3) Condylar joint  the opposed articular surfaces are ellipsoid  one is concave, the other is convex (condyle)  permits flexion and extension, abduction and adduction, and circumduction  bi-axial joint  metacarpophalangeal joints, wrist joint (4) Saddle joint  the opposed articular surfaces are concave in one direction and convex in another and reciprocally fit into each other  permits flexion and extension, abduction and adduction, and circumduction  bi-axial joint  the first carpometacarpal joint, sternoclavicular joint (5) Ball and socket joint  the spheroidal surface of one bone (head) fits into a socket of another  permits flexion and extension, abduction and adduction, lateral and medial rotation, and circumduction  multi-axial joint  hip joint, glenohumeral (shoulder) joint Skull The skull is composed of a number of bones, joined at suture  The skull comprises the neurocranium, which contains the brain and meninges, and the bones of the face (viscerocranium), attached to the anterior aspect of the neurocranium and clothed by soft tissues  The facial bones enclose the orbits, the nose and paranasal air sinuse, and the mouth and pharynx  The mandible articulates with the neurocranium at the temporomandibular joints  The skull is divided into the neurocranium (contains the brain and its meningeal coverings) and the viscerocranium (facial skeleton)  The skull is composed of 22 bones (excluding the middle ear ossicles), with 8 forming the cranium and 14 forming the face  The orbits lie between the calvaria (skull cap) and the facial skeleton and are formed by contributions from 7 different bones  encloses, supports and protects brain and meninges  contains foramina for the transmission of nerves and vessels  forms foundation for the face  contains specialized cavities and openings for sense organs (e.g. nasal, oral) Neurocranium  cranial vault and base of skull  encloses and protect brain  composed of 8 bones  Bones united by interlocking sutures  can be divided  Calvaria-dome-like-roof  Cranial base  Calvaria composed of 4 bones  Frontal bone anteriorly  Occipital bone posteriorly  Two parietal bones laterally  Cranial base formed from  Ethmoid bone  Frontal bone  Sphenoid bone  Parts of occipital and temporal bones  Major sutures of the skull Most bones of the skull are bound by sutures, a type of fibrous joint that fuses with age and becomes immobile  Coronal suture separates frontal and parietal bones  Sagittal suture separates two parietal bones  Lambdoid suture separates parietal and temporal bones from occipital bone  Major sutures of the skull  Squamous suture separates squamous part of temporal bone from parietal bone  Shenosquamous suture separates squamous part of temporal bone from greater wing of the sphenoid  Base of the skull is divided into anterior, middle and posterior cranial fossae Anterior cranial fossa  contains frontal lobe of the brain  is formed by frontal bone anteriorly, ethmoid bone medially, and lesser wing of sphenoid posteriorly  Features:  Frontal crest-midline bony extension of frontal bone  Foramen cecum –foramen at base of frontal crest  Crista galli-midline ridge of bone from ethmoid posterior to foramen cecum  Cribriform plate-Thin, sieve-like plate of bone on either side of crista galli, which transmits olfactory nerves from nasal cavity to olfactory bulbs  Middle cranial fossa  contains temporal lobe, hypothalamus, and pituitary gland  formed by greater wing and body of sphenoid, petrous temporal bone, lesser wing sphenoid  Features:  Sella turcica-central depression in body of sphenoid for pituitary gland  Tuberculum sellae-swelling anterior to sella turcica  Dorsum sella- crest on body of sphenoid posterior to sella turcica  Middle cranial fossa  Features:  Anterior clinoid process- medial projections of lesser wings of sphenoid bone  Posterior clinoid processes- swelling at either end of dorsum sellae  Foramen lacerum (one on each side)- jagged opening closed by plate of cartilage in life, transmits nothing Middle cranial fossa  Contains 4 foramina in a crescent on either side in the body of the sphenoid  Superior orbital fissure  Foramen rotundum  Foramen ovale  Foramen spinosum  Foramina of skull  Numerous holes appear in the cranial floor.  Important structures, especially cranial nerves arising from the brain, pass through the foramen to access the exterior  Posterior cranial fossa  contains cerebellum, pons, and medulla oblongata  composed largely of occipital bone, body of sphenoid, petrous and mastoid parts of temporal bone  Features:  Foramen magnum- transmits spinal cord  Internal occipital crest- divides posterior fossa into two lateral cerebellar fossae  Grooves for transverse and sigmoid dural venous sinuses  Posterior cranial fossa  Features:  Jugular foramen- transmits sigmoid sinus (internal jugular vein) and several cranial nerves  Internal acoustic meatus- anterior and superior to jugular foramen, transmits facial and vestibulocochlear nerves (CN VII and CN VIII)  Hypoglossal canal- anterolateral and superior to foramen magnum, transmits hypoglossal nerve (CN XII) The fetal skull differs from the adult skull:  The facial skeleton is proportionately smaller  Alveolar and mastoid processes are undeveloped  There is a midline suture between the frontal bones: the metopic suture, which usually disappears by 6 years of age  There are two fibrous defects between the skull bones known as fontanelles. The two frontal and parietal bones meet at the anterior fontanelle, which closes by 18–24 months of age, to form the bregma. The two parietal bones and the occipital bone meet at the posterior fontanelle, which closes by approximately 5 months of age to form the lambda.  The temporal fossa lies on the lateral aspect of the skull. It is bounded by the superior temporal line of the temporal bone superiorly, by the frontal process of the zygomatic bone anteriorly and by the zygomatic arch inferiorly  It contents the temporalis muscle, the temporal fascia, the deep temporal nerves and vessels, the auriculotemporal nerve and the superficial temporal artery  The infratemporal fossa lies beneath the base of the skull between the pharynx and the ramus of the mandible  It communicates with the temporal region deep to the zygomatic arch  It contains the medial and lateral pterygoid muscles, branches of the mandibular nerve, the maxillary artery and the pterygoid venous plexus  The pterygopalatine fossa lies between the pterygoid process of the sphenoid bone posteriorly, the palatine bone medially and the maxilla anteriorly  It opens laterally through the pterygomaxillary fissure into the infratemporal fossa  It contains part of the maxillary division of the trigeminal nerve and termination of the maxillary artery, together with accompanying veins and lymphatics The pterygopalatine fossa communicates  with the middle cranial fossa through the foramen rotundum,  with the foramen lacerum through the pterygoid canal,  with the orbit through the inferior orbital fissure,  with the walls of the nasal cavity through the sphenopalatine foramen,  with the palate via the greater and lesser palatine canals  Viscerocranium  Content  bones of the viscerocranium  temporomandibular joint and muscles of mastication  extracranial fossae  Objectives  define the walls, gateways and contents of the temporal, infratemporal and pterygopalatine fossae  describe the walls of the nasal and orbital cavity The viscerocranium is composed of 14 bones:  mandible  vomer  2 inferior nasal conchae  2 maxillary bones  2 nasal bones  2 lacrimal bones  2 zygomatic bones  2 palatine bones  Paired nasal bones form the bridge of the nose  The vomer forms the posteroinferior part of nasal septum  Paired inferior nasal conchae form the lowest processes on the lateral walls of the nasal cavity  Paired lacrimal bones form the small anterior part of the medial walls of the orbits and of the lateral wall of the nasal cavity  The lacrimal fossa is the location of the lacrimal sac  Paired maxillary bones form the upper jaw, floors of the orbits, and parts of the nasal and oral cavity walls  The alveolar process contains the upper teeth  The maxillary hiatus is the opening of the maxillary sinus in the medial wall; the apices of the molar radices are closely related to the maxillary sinus  Three processes: frontal - passes upwards, palatine – medially, and zygomatic - laterally Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Two maxillae unite below the piriform aperture, but their frontal processes, above, remain separated by the nasal bones  An infraorbital foramen opens onto the face  Palatine processes form the anterior part of the hard palate  They articulate with each other and with the horizontal plate of the of the palatine bones  Maxillary sinus sits below each orbit Matshes E et al. Human Osteology and Skeletal Radiology.CRC Press 2005  The mandible forms the lower jaw  A horizontal body connects posteriorly with a vertical ramus on each side, forming an angle at the junction between the two  The superior end of ramus has an anterior coronoid process and posterior condylar process, separated by a mandibular notch  A mental foramen lies on the lateral surface of the anterior part of the body  On the medial side of the body runs the mylohyoid line, which divides a sublingual from a submandibular fossa  A mandibular foramen is located on the inner surface of each ramus Norton NS. Netter’s Head and Neck Anatomy for Dentistry, 2nd ed. Elsevier Saunders 2011  Paired zygomatic bones form the bony prominence of the cheeks and lateral walls of the orbits  The temporal process articulates with the zygomatic process of the temporal bone to form the zygomatic arch Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Paired palatine bones are L-shaped  A horizontal plate forms the posterior part of the hard palate  A vertical perpendicular plate forms part of the lateral wall of the nasal cavity and of the medial wall of the 10 pterygopalatine fossa  An orbital process and a sphenoidal process extend from the free extremity 14 of the perpendicualr plate, while a pyramidal process extends postero- inferiorly from the junction between the perpendicular and horizontal plates 9 15 Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004   The temporomandibular joint is a synovial joint between the head of the mandible and the mandibular fossa on the squamous part of temporal bone  Articular surfaces are lined with fibrous tissue, instead of hyaline cartilage  An articular disc, composed of dense connective tissue, attaches to the capsule and divides the joint cavity into a separate upper compartment, for gliding (translational) movement, and a lower compartment, for hinge (rotational) movement. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010   The lateral (temporomandibular) ligament strengthens the fibrous capsule, while the sphenomandibular and stylomandibular are extrinsic ligaments supporting the joint movements Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Muscles of mastication reside in the parotid region and in the temporal and infratemporal fossae  All muscles of mastication originate on the skull and insert on the mandible  All muscles of mastication are innervated by the mandibular division of the trigeminal nerve (CN V3)  Temporalis muscle  elevates mandible  posterior fibers retract mandible  Lateral pterygoid muscle  protracts mandible and depresses chin  Medial pterygoid muscle  acts with masseter to elevate mandible  contributes to protrusion  Masseter muscle  elevates mandible  contributes to protrusion Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Temporal fossa boundaries  anteriorly, frontal process of the zygomatic bone and zygomatic process of the frontal bone  superiorly and posteriorly, superior temporal line  medially, it overlies the frontal bone, greater wing of the sphenoid, parietal bone, squamous part of the temporal bone  laterally, temporal fascia and zygomatic arch  inferiorly, between the infratemporal crest of the greater wing of the sphenoid and zygomatic arch, it continues with the infratemporal fossa Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Temporal fossa contents  temporalis muscle  middle temporal artery  deep temporal arteries  deep temporal nerves  zygomaticotemporal nerve  Infratemporal fossa boundaries  medially, lateral plate of the pterygoid process and tensor and levator veli palatini muscles  inferiorly, the infratemporal region ends where the medial pterygoid muscle attaches to the inner surface of the mandibular angle  superiorly, infratemporal surface of the greater wing of the sphenoid (with the foramen ovale and spinosum and the petrotympanic fissure)  anteriorly, posterior surface of the maxilla  posteriorly, styloid and mastoid processes laterally, ramus of the mandible Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Infratemporal fossa contents  medial and lateral pterygoid muscles  maxillary artery and its branches Deep head Superficial head of medial pterygoid  Infratemporal fossa contents  pterygoid venous plexus  Infratemporal fossa contents  mandibular division of the trigeminal nerve and its branches  Infratemporal fossa contents  chorda tympani, branch of the facial nerve (CN VII)  Infratemporal fossa contents  lesser petrosal nerve, branch of the glossopharyngeal nerve (CN IX)  otic ganglion Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Ethmoid bone  the perpendicular plate forms part of the bony nasal septum  the crista galli, at the upper end of the perpendicular plate, and the cribriform plate, on each side of the upper end of the perpendicular plate, form the central part of the floor of the anterior cranial fossa  the ethmoidal labyrinth hangs down from the outer edge of the cribriform plate; its lateral wall (orbital plate) is paper-thin (lamina papyracea) and forms the medial wall of the orbit; its medial wall, with the superior and middle conchae, forms the part of the lateral wall of the nasal cavity; from its inferior wall, the uncinate process extends posteroinferiorly across the maxillary hiatus  the ethmoidal bulla is under cover of the middle nasal concha; between the ethmoidal bulla and the uncinate process, the frontonasal duct opens at the infundibulum  Pterygopalatine fossa boundaries  anteriorly, posterior (infratemporal) surface of the maxilla  posterosuperiorly, infratemporal surface of the greater wing of the sphenoid (with the foramen rotundum and pterygoid canal) and pterygoid process  medially, lateral surface of the perpendicular plate of the palatine bone  laterally, the pterygomaxillary fissure forms the communication between the pterygopalatine fossa and the infratemporal fossa  inferiorly, it opens in the oral cavity  Pterygopalatine fossa contents  terminal part of the maxillary artery and its branches  infraorbital vein  Pterygopalatine fossa contents  maxillary division of the trigeminal nerve and its branches  pterygopalatine ganglion and its branches  nerve of pterygoid canal  Pterygopalatine fossa gateways  inferior orbital fissure to the orbit  orbital branches from the pterygopalatine ganglion  zygomatic nerve  infraorbital nerve and artery Foramen rotondum  sphenopalatine foramen to the nasal cavity  nasal nerves  sphenopalatine artery  foramen rotundum to the middle cranial fossa Pterygoid canal  maxillary nerve (CN V2)  pterygoid canal to the middle cranial fossa Palatovaginal canal  nerve and artery of pterygoid canal  palatovaginal canal to the nasopharynx  pharyngeal nerve and artery  palatine canal to the oral cavity  greater and lesser palatine nerves  greater palatine artery  pterygomaxillary fissure to the infratemporal fossa  posterior superior alveolar nerve and artery  nasal nerves  sphenopalatine artery Foramen rotondum middle cranial fossa  maxillary nerve (CN V2)  orbital branches from the pterygopalatine ganglion  zygomatic nerve  infraorbital nerve and artery  posterior superior alveolar nerve and artery Palatovaginal canal nasopharynx  pharyngeal nerve and artery Pterygoid canal middle cranial fossa  nerve and artery of pterygoid canal greater and lesser palatine nerves  greater palatine artery  Nasal cavity boundaries  superiorly (roof), nasal bone, nasal spine of the frontal bone, cribriform plate of the sphenoid bone, anterior surface of the body of the sphenoid, ala of the vomer articulating with the sphenoidal rostrum  inferiorly (floor), palatine process of the maxilla, horizontal plate of the palatine bone  Nasal cavity boundaries  medially, it is divided into two, usually asymmetrical parts, by the septum formed mainly by the septal cartilage, the vomer, and the perpendicular plate of the ethmoid bone  Nasal cavity boundaries  laterally, labirynth and uncinate process of the ethmoid, perpendicular plate of the palatine, medial plate of the pterygoid process of the sphenoid, lacrimal bone, maxilla, inferior concha  Orbital cavity Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Orbital aperture  superiorly, supra-orbital margin of the frontal bone  laterally, zygomatic bone and the zygomatic process of the frontal bone  inferiorly, zygomatic bone and the infra-orbital margin of the maxilla  medially, frontal bone and the anterior lacrimal crest of the orbital process of the maxilla Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Orbit walls  Sphenoid bone  The body contains two sphenoidal sinuses, with their apertures anteriorly  The pituitary fossa indents the upper surface of the body  The lesser wing, on each side, passes laterally, with the optic canal at its origin  the greater wing, on each side, passes laterally below the lesser wing, with the superior orbital fissure between the wings and the foramina rotundum, ovale and spinosum within the greater wing  the pterygoid process, on each side, passes downwards from the body, dividing into the medial and lateral pterygoid plates Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Orbit walls  superior (roof), the orbital part of the frontal bone and the lesser wing of the sphenoid Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Orbit walls  lateral, orbital surfaces of the greater wing of the sphenoid and the zygomatic bone Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Orbit walls  inferior (floor), orbital surface of the maxilla and zygomatic bone, the orbital process of the palatine bone Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004  Orbit walls  medial, the orbital plate of the ethmoid, lacrimal bone, the frontal process of the maxilla Logan et al. McMin’s Color Atlas of Head and Neck Anatomy. 3rd ed. Mosby 2004 Norton NS. Netter’s Head and Neck Anatomy for Dentistry, 2nd ed. Elsevier Saunders 2011  Neck  Content  muscles of neck  fascia of neck  topography of neck region  Objectives  describe the anterior and posterior triangles of the neck with their boundaries and contents  know the subdivisions of the anterior and posterior triangles of the neck  know the fascial layers of the neck and the limits and contents of the compartments they create  know the muscles of neck The neck is surrounded by a A deep cervical fascia superficial fascia invests neck muscles  It lies deep to the dermis and viscera of the skin and invests the platysma muscle  It contains the cutaneous nerves and vessels The deep cervical fascia is divided into three layers:  investing, superficial – surrounds the neck and invests the trapezius and SCM muscles  pretracheal – invests the infrahyoid muscles, thyroid and parathyroid glands, trachea, pharynx and esophagus  prevertebral – invests the prevertebral muscles and vertebral column The investing layer of deep cervical fascia  surrounds the entire neck, beneath the skin and subcutaneous tissue  superior attachments  superior nuchal line, mastoid process, zygomatic arch, inferior border of the mandible, hyoid bone  splits to enclose the SCM and trapezius muscles  encloses parotid gland, thickens to form the stylomandibular ligament, encloses submandibular gland  inferior attachments  spinous process of C7, spine of the scapula, acromion, clavicle, manubrium (suprasternal space with the inferior ends of the anterior jugular veins)  posteriorly, it is continuous with the nuchal ligament Suprasternal space The pretracheal layer of deep cervical fascia  lies only in the anterior neck, from hyoid bone to fibrous pericardium  superior attachments  hyoid bone, thyroid cartilage of the larynx  inferiorly, it fuses with the adventitia of great vessels (aortic arch) and fibrous pericardium  over the hyoid bone, it forms a pulley for the digastric muscle tendon  a thin muscular part encloses infrahyoid muscles (laterally, it encloses the omohyoid muscle)  a visceral part invests the thyroid and parathyroids, trachea, pharynx and esophagus (posteriorly, it forms the buccopharyngeal fascia, covering the buccinator and pharyngeal constrictor muscles and esophagus) The prevertebral layer of deep cervical fascia  lies on C1-T3 vertebrae and associated muscles: deep muscles of the back; anterior, middle and posterior scalene muscles; prevertebral muscles  superior attachment  base of the skull  inferiorly, it blends with the anterior longitudinal ligament at the level of T3 and endothoracic fascia  laterally, it continues as the axillary sheath, around the axillary artery and brachial plexus  anteriorly, it forms the alar fascia (runs in the retropharyngeal space from the cranial base to the level of C7, attached laterally to the carotid sheaths and along the midline to the buccopharyngeal fascia) Alar fascia  suboccipital muscles prevertebral muscles Scalene muscles The retropharyngeal space  potential space between the prevertebral layer of deep fascia and buccopharyngeal fascia  extends from the base of the skull to the posterior mediastinum  permits expansion and movements of the pharynx, esophagus, larynx and trachea during swallowing  infection originating in the pharynx can spread through the retropharyngeal space to the superior and posterior mediastinum Alar fascia Retropharyngeal space Anatomical relationships of the retropharyngeal space  anterior  buccopahryngeal fascia (part of the pretracheal fascia)  pharynx, esophagus  posterior  prevertebral fascia  cervical vertebrae longus capitis and colli muscles  sympathetic trunk (embedded in the preverterbal fascia, anterior to the muscles)  lateral  carotid sheaths (CCA, ICA, IJV, CN X)  deep cervical lymph nodes  superior  skull base  inferior  posterior mediastinum The carotid sheath blends with the three layers of deep cervical fascia  contains the common carotid artery (internal carotid artery), internal jugular vein and vagus nerve, deep cervical lymph nodes  communicates inferiorly with the mediastinum Cervical fascia and compartments  investing fascia (immediately deep to superficial fascia of the body)  muscular compartment  SCM and trapezius muscles  pretracheal fascia (surrounds structures anterior to cervical vertebrae and associated muscles)  visceral compartment  thyroid and parathyroid glands  trachea  esophagus  muscular compartment  infrahyoid muscles  prevertebral fascia (surrounds cervical vertebrae and associated muscles)  vertebral compartment  cervical vertebrae  longus colli and capitis, scalene, splenius capitis, levator scapulae, deep posterior neck muscles  carotid sheaths  vascular compartment  CCA (ICA), IJV, CN X, deep cervical lymph nodes (along IJV) Clinical note The retropharyngeal space and the interfaces between all layers of deep cervical fascia are natural cleavage planes in surgical dissection, but also serve as routes for the spread of infection The SCM muscle divides the neck into regions  Anterior cervical region (anterior cervical triangle)  Sternocleidomastoid region  Lateral cervical region (posterior cervical triangle) Posterior triangle boundaries  anterior, posterior border of SCM  posterior, anterior border of trapezius  inferior, clavicle  lateral (roof), investing layer of the deep cervical fascia Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Posterior triangle boundaries  medial (floor), muscles covered by the prevertebral layer of deep cervical fascia  splenius capitis  levator scapulae  posterior scalene  middle scalene Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Posterior triangle boundaries  anterior - posterior border of SCM  posterior - anterior border of trapezius  inferior - clavicle  lateral (roof) - investing layer of the deep cervical fascia  medial (floor) - muscles covered by the prevertebral layer of deep cervical fascia  splenius capitis  levator scapulae  middle scalene  posterior scalene Posterior triangle contents  nerves  cutaneous branches of cervical plexus  accessory nerve (CN XI)  roots and trunks of brachial plexus  inferior belly of the omohyoid muscle  cervical and suprascapular lymph nodes Posterior triangle contents  vessels  external jugular vein and its tributaries  subclavian artery and vein  transverse cervical artery from thyrocervical trunk of the subclavian a.  suprascapular artery  occipital artery (from external carotid a.) Anterior triangle boundaries  anterior, midline of neck  superior, mandible  posterior, anterior border of SCM Two muscles subdivide the anterior cervical region:  digastric muscle  omohyoid muscle Anterior triangle subdivisions  submandibular triangle  between mandible and anterior and posterior bellies of the digastric muscle  contains submandibular gland and duct, submandibular lymph nodes, hypoglossal nerve, facial artery and vein  submental triangle  between hyoid bone and right and left anterior bellies of the digastric muscles  contains submental lymph nodes, tributaries of anterior jugular vein Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  carotid triangle  bounded by superior belly of the omohyoid, posterior belly of the digastric, anterior border of the SCM  contains carotid sheath with common carotid artery, internal jugular vein, vagus nerve, carotid sinus and body, branches of the external carotid atery  muscular triangle  bounded by anterior border of the SCM, superior belly of the omohyoid, midline of the neck  contains infrahyoid muscles, thyroid and parathyroid glands Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Suprahyoid muscles:  digastric  mylohyoid  geniohyoid  stylohyoid Infrahyoid muscles  omohyoid  sternohyoid  sternothyroid  thyrohyoid  Vertebral column  Content  vertebrae  vertebral joints  muscles of back  Objectives  describe bones of the vertebral column  describe intervertebral joints and movements of the vertebral column  describe the relevant surface anatomy of the back VERTEBRAL COLUMN (SPINE)  33 vertebrae  7 cervical 12 thoracic  5 lumbar  5 sacral (fused)  4 coccygeal (fused)  Vertebrae form a functional column  vertebral column  vertebral canal Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010 VERTEBRAL COLUMN  Spinal physiological curves  cervical lordosis  thoracic kyphosis  lumbar lordosis  sacral kyphosis Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Abnormal curvatures of vertebral column Adam’s forward bending test Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  TYPICAL VERTEBRA  Vertebral body  Vertebral arch  pedicle  lamina  Processes  spinous  transverse  articular Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Cervical vertebrae Typical  C3-C7 vertebrae  body  transverse process  uncus (uncinate process)  foramen transversarium  arch  anterior and posterior tubercles  vertebral foramen large and triangular  articular processes  spinous process  superior articular facets directed  short and bifid superoposteriorly  long in C7 (vertebra prominens)  inferior articular facets directed infero-anteriorly Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010 Cervical vertebrae Atypical  Atlas (C1)  ring shaped  no body or spinous process  2 lateral masses  superior and inferior articular surface  anterior arch  anterior tubercle  facet for dens  posterior arch posterior tubercle  groove for vertebral artery Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010  Axis (C2)  dens  anterior and posterior articular facet Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010  Synovial joints of craniovertebral region  atlanto-occipital joint Superior articular surfaces Occipital condyles Anterior arch Vertebral Foramen foramen magnum Posterior arch  Inferior articular surfaces  Synovial joints of craniovertebral region Anterior arch  median atlanto-axial joint  lateral atlanto-axial joints Facet for dens Posterior arch Atlas: inferior view Anterior articular surface Dens surface Superior articular surface Posterior articular surface Foramen Spinous transversarium process Body Transverse process Arch Inferior articular surface Axis: lateral view Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Synovial joints of craniovertebral region  atlanto-occipital joint  anterior atlanto-occipital membrane  posterior atlanto-occipital membrane  median atlanto-axial joint  alar ligaments  apical ligament of dens  cruciate ligament of atlas  tectorial membrane Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Synovial joints of craniovertebral region  atlanto-occipital joint  anterior atlanto-occipital membrane  posterior atlanto-occipital membrane  median atlanto-axial joint  alar ligaments  apical ligament of dens  cruciate ligament of atlas  tectorial membrane Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Synovial joints of vertebral bodies  uncovertebral joints Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Agur AMR, Dalley II AF. Grant’s Atlas of Anatomy. LWW, 12th ed. 2009 Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva. Thoracic vertebrae  T1-T12 vertebrae  body  heart shaped  costal facets  arch  vertebral foramen small and circular  spinous process  long, slopes postero-inferiorly  transverse process  large and strong  T1-T10 transverse costal facet  articular processes  superior articular facets directed posteriorly and slightly laterally  inferior articular facets directed anteriorly and slightly medially Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Davies AM, Petterson H. The WHO manual of diagnostic imaging. Radiographic anatomy and interpretation of the musculoskeletal system. World Health Organization, Geneva.  While the characteristics of the superior aspect of the vertebra T12 are distinctly thoracic, its inferior aspect has lumbar characteristics, as it articulates with the vertebra L1.  The abrupt transition, allowing primarily rotational movements with vertebra T11 while disallowing rotational movements with the vertebra L1, makes the vertebra T12 especially susceptible to fracture. Lumbar vertebrae  L1-L5 vertebrae  body  massive, kidney-shaped  arch  vertebral foramen triangular, of medium size  spinous process  short and thick, hatchet-shaped  transverse process (costal process)  long and slender  accessory process  articular processes  superior articular facets directed posteromedially  inferior articular facets directed anterolaterally  mammillary process Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010 REGIONAL CHARACTERISTICS OF VERTEBRAE Comparison of typical vertebrae Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  VERTEBRAL JOINTS  Synchondroses of vertebral bodies  intervertebral joints  intervertebral disc Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  INTERVERTEBRAL DISC  anulus fibrosus  nucleus pulposus Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Intervertebral disc herniation CLINICAL CASE (2) Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Thompson JC. Netter’s Concise Orthopeadic Anatomy. Elsevier-Saunders, 2nd ed. 2010  Synovial joints of vertebral arches  zygapophysial joints  in cervical region lie almost in the horizontal plane  in thoracic region lie in the coronal plane  in lumbar region lie almost in the sagittal plane  anterior longitudinal ligament  posterior longitudinal ligament  interspinous ligaments  supraspinous ligament  ligamentum nuchae  ligamenta flava  intertransverse ligaments Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  VERTEBRAL JOINTS Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  Sacrum  base  promontory  ala (wing)  superior articular process  lateral part  auricular surface  sacral tuberosity  pelvic surface  transverse ridges  anterior sacral foramina  dorsal surface  posterior sacral foramina  crests  sacral cornu  sacral canal  sacral hiatus  apex  Coccyx  transverse process  coccygeal cornu Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  SURFACE ANATOMY OF THE BACK  Palpable structures  external occipital protuberance  vertebra prominens  thoracic spinous processes  scapula  iliac crests  sacrum  paraverterbal muscles  MUSCLES OF VERTEBRAL COLUMN  Extrinsic muscles of the back  although located in the back region, most of them are innervated by the anterior rami of spinal nerves  they act mostly on the upper limb  trapezius  lattissimus dorsi  rhomboideus major  rhomboideus minor  serratus posterior superior  serratus posterior inferior Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Intrinsic muscles of the back  they are innervated by the posterior rami of spinal nerves  act to maintain posture and control movements of the vertebral column  superficial layer  spinotrasversales splenius capitis and cervicis  intermediate layer  erector spinae iliocostalis longissimus spinalis Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Intrinsic muscles of the back  deep layer  transversospinales multifidus, semispinalis and rotatores  deep segmental muscles interspinales, intertrasversarii Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  MOVEMENTS OF VERTEBRAL COLUMN Lateral flexion: Flexion: Extension: Rotation: each side 20° AO 10° AO each side 5° AO 0° AA 0° AA 0° AO 0° AA 45° C3-7 30° C3-7 35° AA 30° C3-7 15° C3-7 Lateral flexion: Flexion: Extension: Rotation: each side 35° T 25° T each side 20° T 50° L 35° L 35° T 20° L 5° L  MUSCLES OF VERTEBRAL COLUMN  Extrinsic muscles of the back  although located in the back region, most of them are innervated by the anterior rami of spinal nerves  they act mostly on the upper limb  trapezius  lattissimus dorsi  rhomboideus major  rhomboideus minor  serratus posterior superior  serratus posterior inferior Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Intrinsic muscles of the back  they are innervated by the posterior rami of spinal nerves  act to maintain posture and control movements of the vertebral column  superficial layer  spinotrasversales splenius capitis and cervicis  intermediate layer  erector spinae iliocostalis longissimus spinalis Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Intrinsic muscles of the back  deep layer  transversospinales multifidus, semispinalis and rotatores  deep segmental muscles interspinales, intertrasversarii Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Abdominal wall and groin region  Content  surface anatomy of abdominal wall  anterolateral abdominal wall (fascia, muscles, neurovasculature)  inguinal canal  posterior abdominal wall (fascia, muscles, neurovasculature)  Objectives  describe the skeletal and muscular boundaries of the abdominal cavity  describe the structure of the abdominal wall  discuss the arterial supply, venous drainage and nerve supply of the abdominal wall  describe the boundaries and contents of the inguinal canal  describe the surface anatomy of the abdomen Abdomen and abdominal cavity Surface anatomy  Structure of the anterolateral abdominal wall  Skin  Superficial fascia (subcutaneous tissue)  Muscles  Investing fascia  Parietal abdominal fascia (endo- abdominal fascia)  Extraperitoneal fat  Parietal peritoneum Agur AMR, Dalley II AF. Grant’s Atlas of Anatomy. LWW, 12th ed. 2009  Muscles of the anterolateral abdominal wall  External oblique muscle Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  External oblique muscle  inguinal ligament  Internal oblique muscle Umbilical ring Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Transversus abdominis muscle Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Rectus abdominis muscle V-VII Umbilical ring Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Rectus abdominis muscle  rectus sheath  The rectus sheath is created by fusion of the aponeuroses of the transversus abdominis and abdominal oblique muscles  The inferior edge of the posterior wall of the rectus sheath is called the arcuate line Posterior (internal) view of the anterior abdominal wall Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Agur AMR, Dalley II AF. Grant’s Atlas of Anatomy. LWW, 12th ed. 2009  Inguinal canal  The inguinal canal is an oblique passage through the abdominal wall that allows structures to pass between the abdominopelvic cavity and perineum  Inguinal canal  anterior wall  external oblique aponeurosis  lateral third: internal oblique  posterior wall  transversalis fascia  medial third: conjoint tendon  floor  inguinal ligament  roof  musculo-aponeurotic arcades of internal oblique and transversus abdominis  openings  superficial inguinal ring  palpable immediately superolateral to pubic tubercle  deep inguinal ring  palpable 2-4cm superolateral to pubic tubercle  content  spermatic cord and its coverings  round ligament of the uterus Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010. Muscles of the posterior abdominal wall  Psoas major  Quadratus lumborum  Iliacus Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008 Vasculature of abdominal wall - Arteries  Internal thoracic artery  Musculophrenic artery  Superior epigastric artery  External iliac artery  Inferior epigastric artery  Deep circumflex iliac artery  Abdominal aorta  Intercostal, subcostal and lumbar arteries  Femoral artery  Superficial epigastric artery  Superficial circumflex iliac artery   Internal thoracic artery  Musculophrenic artery  Superior epigastric artery  External iliac artery  Inferior epigastric artery  Deep circumflex iliac artery  Abdominal aorta  Intercostal, subcostal and lumbar arteries  Femoral artery  Superficial epigastric artery  Superficial circumflex iliac artery Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010.  Vasculature of abdominal wall - Veins  Inferior epigastric vein  external iliac vein  Superior epigastric vein  internal thoracic vein  Superficial circumflex iliac  Superficial epigastric  femoral vein Thoraco-epigastric v.  Lateral thoracic vein  axillary vein Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010.  Nerves of abdominal wall  Intercostal nerves T7-T11  Subcostal nerve T12  Lumbar nerves L1-L5  lumbar plexus  iliohypogastric nerve (L1)  ilio-inguinal nerve (L1)  Neurovascular plane of abdominal wall Between the internal oblique and transversus abdominis muscles Abdomen and abdominal cavity Thoracic skeleton  Ribs I-XII  true ribs (I-VII)  false ribs (VIII-XII)  floating ribs (XI, XII)  costal cartilage  Sternum  Thoracic vertebrae T1-T12 Drake. Gray’s Anatomy for Students. Elsevier, 2009. Thoracic cage  Intercostal spaces  Thoracic cavity  Superior thoracic aperture (thoracic inlet)  Costal margin  Infrasternal (subcostal) angle  Inferior thoracic aperture (thoracic outlet) Hansen TJ. Netter’s Clinical Anatomy, 2nd ed. Saunders, 2010 Thoracic cage  protects thoracic and abdominal organs  resists the negative (lower than atmosferic) pressure generated by inspiratory movements  provides attachment for and supports the weight of the upper limb  provides the attachment for many muscles of the upper limbs, abdomen, neck, back and diaphragm Drake. Gray’s Anatomy for Students. Elsevier, 2009. Typical ribs  Head  Neck  Tubercle  Body (shaft)  angle  costal groove Drake. Gray’s Anatomy for Students. Elsevier, 2009. First rib  Scalene tubercle  Groove for subclavian vein  Groove for subclavian artery Drake. Gray’s Anatomy for Students. Elsevier, 2009. Sternum  Manubrium  Body  Sternal angle  Xiphoid process Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Superior thoracic aperture (thoracic inlet) Inferior thoracic aperture (thoracic outlet) First rib and its relations to the thoracic inlet Thoracic outlet syndrome Snell RS. Clinical Anatomy by Regions. LWW, 2012. Joints of thoracic wall  Sternocostal joint  Costochondral joint  Interchondral joint  Costovertebral joints Costovertebral joints Sternocostal joint Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Sternocostal joints  synchondrosis of first rib  synovial joints of ribs II-VII  intra-articular sternocostal ligament  radiate sternocostal ligaments  sternal membrane  Interchondral joints  plane synovial joints between costal cartilages of ribs VI and VII, VII and VIII, VIII and IX, IX and X Hansen JT. Netter’s Clinical Anatomy. 2nd ed. Saunders, 2010. Costovertebral joints Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010  joint of head of rib  radiate ligament of head of rib  intra-articular ligament of head of rib  costotransverse joint  costotransverse ligament  superior costotransverse ligament  lateral costotransverse ligament Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008.  Movements of thoracic wall  at costotransverse joints  ribs I-VII rotate ribs VIII-X glide  pump-handle movement  bucket-handle movement  AP diameter increases  transverse diameter increases Drake. Gray’s Anatomy for Students. Elsevier, 2009. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Structure of the thoracic wall  Skin  Superficial fascia  Muscles  Investing fascia  Endothoracic fascia Drake. Gray’s Anatomy for Students. Elsevier, 2009. Muscles of thoracic wall  Intrinsic  Levatores costarum  Intercostal muscles  Subcostal muscles  Transversus thoracis  Diaphragm Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 2008 Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 2008  Intercostal muscles  External external intercostal membrane  Internal internal intercostal membrane  Innermost Drake. Gray’s Anatomy for Students. Elsevier, 2009. From the outside From the inside 2 External intercostal 3 Fifth intercostal nerve 4 Fifth posterior intercostal artery 5 Fifth posterior intercostal vein 8 Innermost intercostal 9 Internal intercostal 10 Pleura 12 Sixth intercostal nerve Abrahams' and McMinn's Clinical Atlas of Human Anatomy. Elsevier 2020 Diaphragm Drake et al. Gray’s Anatomy for Students. Elsevier  Diaphragm  primary muscle of inspiration 1 lumbar part right crus left crus median arcuate ligament medial arcuate ligament lateral arcuate ligament 2 costal part 3 sternal part Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 2008 Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 2008  Diaphragm  caval opening  T8 inferior vena cava  oesophageal hiatus  T10 oesophagus anterior and posterior vagus trunks oesophageal branches of the left gastric vessels  aortic hiatus  T12 abdominal aorta thoracic duct Ellis H. Clinical Anatomy. Blackwell Publishing, 11th ed. 2006 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. LWW 6th ed. 2010 Gosling. Human Anatomy. Color Atlas and Textbook. Mosby, 5th ed, 2008. Diaphragm innervation  Spinal nerves C3, 4, 5 keep diaphragm alive  Phrenic nerve Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 2008 Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy. Thieme 1st ed. 2008  Vasculature of thoracic wall  Posterior intercostal arteries 1st and 2nd  supreme intercostal artery from costocervical trunk of subclavian artery  3rd-11th  thoracic aorta  Subcostal artery  thoracic aorta  Anterior intercostal arteries  1st-6th  internal thoracic artery  7th-9th  musculophrenic artery Drake. Gray’s Anatomy for Students. Elsevier, 2009.  Superior vena cava  Azygos vein system  Posterior intercostal veins  Internal thoracic veins  Anterior intercostal veins Drake. Gray’s Anatomy for Students. Elsevier, 2009.