Anatomy: A Comprehensive Study Guide PDF

What is anatomy? Anatomy includes those structures that can be seen grossly (without the aid of magnification) and microscopically (with the aid of magnification). Typically, when used by itself, the term anatomy tends to mean gross or macroscopic anatomy---that is, the study of structures that...

What is anatomy? Anatomy includes those structures that can be seen grossly (without the aid of magnification) and microscopically (with the aid of magnification). Typically, when used by itself, the term anatomy tends to mean gross or macroscopic anatomy---that is, the study of structures that can be seen without using a microscopic. Microscopic anatomy, also called histology, is the study of cells and tissues using a microscope. Anatomy forms the basis for the practice of medicine. Anatomy leads the physician toward an understanding of a patient's disease, whether he or she is carrying out a physical examination or using the most advanced imaging techniques. Anatomy is also important for dentists, chiro- practors, physical therapists, and all others involved in any aspect of patient treatment that begins with an analysis of clinical signs. The ability to interpret a clinical observation correctly is therefore the endpoint of a sound anatomical understanding. Observation and visualization are the primary tech- niques a student should use to learn anatomy. Anatomy is much more than just memorization of lists of names. Although the language of anatomy is important, the network of information needed to visualize the position of physical structures in a patient goes far beyond simple memorization. Knowing the names of the various branches of the external carotid artery is not the same as being able to visualize the course of the lingual artery from its origin in the neck to its termination in the tongue. Similarly, understanding the organization of the soft palate, how it is related to the oral and nasal cavities, and how it moves during swallowing is very different from being able to recite the names of its individual muscles and nerves. An under- standing of anatomy requires an understanding of the context in which the terminology can be remembered. 2 How can gross anatomy be studied? The term anatomy is derived from the Greek word temnein, meaning "to cut." Clearly, therefore, the study of anatomy is linked, at its root, to dissection, although dissection of cadavers by students is now augmented, or even in some cases replaced, by viewing prosected (previously dissected) material and plastic models, or using computer teaching modules and other learning aids. Anatomy can be studied following either a regional or a systemic approach. With a regional approach, each region of the body is studied separately and all aspects of that region are studied at the same time. For example, if the thorax is to be studied, all of its structures are examined. This includes the vasculature, the nerves, the bones, the muscles, and all other structures and organs located in the region of the body defined as the thorax. After studying this region, the other regions of the body (i.e., the abdomen, pelvis, lower limb, upper limb, back, head, and neck) are studied in a similar fashion. In contrast, in a systemic approach, each system of the body is studied and followed throughout the entire body. For example, a study of the cardiovascular system looks at the heart and all of the blood vessels in the body. When this is completed, the nervous system (brain, spinal cord, and all the nerves) might be examined in detail. This approach continues for the whole body until every system, including the nervous, skeletal, muscular, gastrointestinal, respiratory, lymphatic, and reproduc- tive systems, has been studied. Each of these approaches has benefits and deficiencies. The regional approach works very well if the anatomy course involves cadaver dissection but falls short when it comes to understanding the continuity of an entire system throughout the body. Similarly, the systemic approach fosters an understanding of an entire system throughout the body, but it is very difficult to coordinate this directly with a cadaver dissection or to acquire suffi- cient detail. Important anatomical terms The anatomical position The anatomical position is the standard reference position of the body used to describe the location of structures (Fig. 1.1). The body is in the anatomical position when standing upright with feet together, hands by the side and face looking forward. The mouth is closed and the facial expres- sion is neutral. The rim of bone under the eyes is in the same horizontal plane as the top of the opening to the ear, and the eyes are open and focused on something in the distance. The palms of the hands face forward with the fingers straight and together and with the pad of the thumb turned 90° to the pads of the fingers. The toes point forward. Anatomical planes Three major groups of planes pass through the body in the anatomical position (Fig. 1.1).What Is Anatomy Important Anatomical Terms 1 *Superior* **Coronal plane** Inferior margin of orbit level with top of external auditory meatus Face looking forward **Sagittal plane** *Anterior Posterior* *Medial* **Transverse, horizontal,** **or axial plane** Hands by sides palms forward *Lateral* Feet together toes forward *Inferior* Fig. 1.1 The anatomical position, planes, and terms of location and orientation. 3The Body Coronal planes are oriented vertically and divide the body into anterior and posterior parts. Sagittal planes also are oriented vertically but are at right angles to the coronal planes and divide the body into right and left parts. The plane that passes through the center of the body dividing it into equal right and left halves is termed the median sagittal plane. Transverse, horizontal, or axial planes divide the body into superior and inferior parts. Terms to describe location Anterior (ventral) and posterior (dorsal), medial and lateral, superior and inferior Three major pairs of terms are used to describe the location of structures relative to the body as a whole or to other structures (Fig. 1.1). Anterior (or ventral) and posterior (or dorsal) describe the position of structures relative to the "front" and "back" of the body. For example, the nose is an anterior (ventral) structure, whereas the vertebral column is a posterior (dorsal) structure. Also, the nose is anterior to the ears and the vertebral column is pos- terior to the sternum. Medial and lateral describe the position of structures relative to the median sagittal plane and the sides of the body. For example, the thumb is lateral to the little finger. The nose is in the median sagittal plane and is medial to the eyes, which are in turn medial to the external ears. Superior and inferior describe structures in reference to the vertical axis of the body. For example, the head is superior to the shoulders and the knee joint is inferior to the hip joint. Proximal and distal, cranial and caudal, and rostral Other terms used to describe positions include proximal and distal, cranial and caudal, and rostral. 4 Proximal and distal are used with reference to being closer to or farther from a structure's origin, particu- larly in the limbs. For example, the hand is distal to the elbow joint. The glenohumeral joint is proximal to the elbow joint. These terms are also used to describe the relative positions of branches along the course of linear structures, such as airways, vessels, and nerves. For example, distal branches occur farther away toward the ends of the system, whereas proximal branches occur closer to and toward the origin of the system. Cranial (toward the head) and caudal (toward the tail) are sometimes used instead of superior and inferior, respectively. Rostral is used, particularly in the head, to describe the position of a structure with reference to the nose. For example, the forebrain is rostral to the hindbrain. Superficial and deep Two other terms used to describe the position of structures in the body are superficial and deep. These terms are used to describe the relative positions of two structures with respect to the surface of the body. For example, the sternum is superficial to the heart, and the stomach is deep to the abdominal wall. Superficial and deep can also be used in a more absolute fashion to define two major regions of the body. The super- ficial region of the body is external to the outer layer of deep fascia. Deep structures are enclosed by this layer. Structures in the superficial region of the body include the skin, superficial fascia, and mammary glands. Deep struc- tures include most skeletal muscles and viscera. Superficial wounds are external to the outer layer of deep fascia, whereas deep wounds penetrate through it.Imaging Diagnostic imaging techniques In 1895 Wilhelm Roentgen used the X-rays from a cathode ray tube to expose a photographic plate and produce the first radiographic exposure of his wife's hand. Over the past 35 years there has been a revolution in body imaging, which has been paralleled by developments in computer technology. Plain radiography X-rays are photons (a type of electromagnetic radiation) and are generated from a complex X-ray tube, which is a type of cathode ray tube (Fig. 1.2). The X-rays are then collimated (i.e., directed through lead-lined shutters to stop them from fanning out) to the appropriate area of the body. As the X-rays pass through the body they are attenuated (reduced in energy) by the tissues. Those X-rays that pass through the tissues interact with the photographic film. In the body: air attenuates X-rays a little; fat attenuates X-rays more than air but less than water; and bone attenuates X-rays the most. These differences in attenuation result in differences in the level of exposure of the film. When the photographic film is developed, bone appears white on the film because this region of the film has been exposed to the least amount of X-rays. Air appears dark on the film because these regions were exposed to the greatest number of X-rays. Modifications to this X-ray technique allow a continu- ous stream of X-rays to be produced from the X-ray tube and collected on an input screen to allow real-time visual- ization of moving anatomical structures, barium studies, angiography, and fluoroscopy (Fig. 1.3). Imaging Diagnostic Imaging Techniques 1 Tungsten targetTungsten filament Focusing cup Glass X-ray tube Cathode Anode X-rays Fig. 1.2 Cathode ray tube for the production of X-rays. Fig. 1.3 Fluoroscopy unit. 5The Body Contrast agents To demonstrate specific structures, such as bowel loops or arteries, it may be necessary to fill these structures with a substance that attenuates X-rays more than bowel loops or arteries do normally. It is, however, extremely important that these substances are nontoxic. Barium sulfate, an insoluble salt, is a nontoxic, relatively high-density agent that is extremely useful in the examination of the gastro- intestinal tract. When a barium sulfate suspension is ingested it attenuates X-rays and can therefore be used to demonstrate the bowel lumen (Fig. 1.4). It is common to add air to the barium sulfate suspension, by either ingest- ing "fizzy" granules or directly instilling air into the body cavity, as in a barium enema. This is known as a double- contrast (air/barium) study. For some patients it is necessary to inject contrast agents directly into arteries or veins. In this case, iodine-based molecules are suitable contrast agents. Iodine is chosen because it has a relatively high atomic mass and so mark- edly attenuates X-rays, but also, importantly, it is naturally excreted via the urinary system. Intra-arterial and intrave- nous contrast agents are extremely safe and are well toler- ated by most patients. Rarely, some patients have an anaphylactic reaction to intra-arterial or intravenous injections, so the necessary precautions must be taken. Intra-arterial and intravenous contrast agents not only help in visualizing the arteries and veins but because they are excreted by the urinary system, can also be used to visualize the kidneys, ureter, and bladder in a process known as intravenous urography. Subtraction angiography During angiography it is often difficult to appreciate the contrast agent in the vessels through the overlying bony structures. To circumvent this, the technique of subtrac- tion angiography has been developed. Simply, one or two images are obtained before the injection of contrast media. These images are inverted (such that a negative is created from the positive image). After injection of the contrast media into the vessels, a further series of images are obtained, demonstrating the passage of the contrast through the arteries into the veins and around the circula- tion. By adding the "negative precontrast image" to the positive postcontrast images, the bones and soft tissues are subtracted to produce a solitary image of contrast only. Before the advent of digital imaging this was a challenge, but now the use of computers has made this technique relatively straightforward and instantaneous (Fig. 1.5). 6 Fig. 1.4 Barium sulfate follow-through. Fig. 1.5 Digital subtraction angiogram.Imaging Diagnostic Imaging Techniques 1 Ultrasound Ultrasonography of the body is widely used for all aspects of medicine. Ultrasound is a very high frequency sound wave (not electromagnetic radiation) generated by piezoelectric materials, such that a series of sound waves is produced. Importantly, the piezoelectric material can also receive the sound waves that bounce back from the internal organs. The sound waves are then interpreted by a powerful computer, and a real-time image is produced on the display panel. Developments in ultrasound technology, including the size of the probes and the frequency range, mean that a broad range of areas can now be scanned. Traditionally ultrasound is used for assessing the abdomen (Fig. 1.6) and the fetus in pregnant women. Ultrasound is also widely used to assess the eyes, neck, soft tissues, and peripheral musculoskeletal system. Probes have been placed on endoscopes, and endoluminal ultra- sound of the esophagus, stomach, and duodenum is now routine. Endocavity ultrasound is carried out most com- monly to assess the genital tract in women using a transvaginal or transrectal route. In men, transrectal ultrasound is the imaging method of choice to assess the prostate in those with suspected prostate hypertrophy or malignancy. Doppler ultrasound Doppler ultrasound enables determination of flow, its direction, and its velocity within a vessel using simple ultrasound techniques. Sound waves bounce off moving structures and are returned. The degree of frequency shift determines whether the object is moving away from or toward the probe and the speed at which it is traveling. Precise measurements of blood flow and blood velocity can therefore be obtained, which in turn can indicate sites of blockage in blood vessels. Computed tomography Computed tomography (CT) was invented in the 1970s by Sir Godfrey Hounsfield, who was awarded the Nobel Prize in Medicine in 1979. Since this inspired invention there have been many generations of CT scanners. A CT scanner obtains a series of images of the body (slices) in the axial plane. The patient lies on a bed, an X-ray tube passes around the body (Fig. 1.7), and a series of images are obtained. A computer carries out a complex mathematical transformation on the multitude of images to produce the final image (Fig. 1.8). Magnetic resonance imaging Nuclear magnetic resonance imaging was first described in 1946 and used to determine the structure of complex Fig. 1.6 Ultrasound examination of the abdomen. Fig. 1.7 Computed tomography scanner. 7The Body molecules. The process of magnetic resonance imaging (MRI) is dependent on the free protons in the hydrogen nuclei in molecules of water (H2O). Because water is present in almost all biological tissues, the hydrogen proton is ideal. The protons within a patient's hydrogen nuclei can be regarded as small bar magnets, which are randomly oriented in space. The patient is placed in a strong magnetic field, which aligns the bar magnets. When a pulse of radio waves is passed through the patient the magnets are deflected, and as they return to their aligned position they emit small radio pulses. The strength and frequency of the emitted pulses and the time it takes for the protons to return to their pre-excited state produce a signal. These signals are analyzed by a powerful computer, and an image is created (Fig. 1.9). By altering the sequence of pulses to which the protons are subjected, different properties of the protons can be assessed. These properties are referred to as the "weight- ing" of the scan. By altering the pulse sequence and the scanning parameters, T1-weighted images (Fig. 1.10A) and T2-weighted images (Fig. 1.10B) can be obtained. These two types of imaging sequences provide differences in image contrast, which accentuate and optimize different tissue characteristics. From the clinical point of view: Most T1-weighted images show dark fluid and bright fat---for example, within the brain the cerebrospinal fluid (CSF) is dark. T2-weighted images demonstrate a bright signal from fluid and an intermediate signal from fat---for example, in the brain the CSF appears white. MRI can also be used to assess flow within vessels and to produce complex angiograms of the peripheral and cerebral circulation. Diffusion-weighted imaging Diffusion-weighted imaging provides information on the degree of Brownian motion of water molecules in various tissues. There is relatively free diffusion in extracellular spaces and more restricted diffusion in intracellular spaces. In tumors and infarcted tissue, there is an increase in intracellular fluid water molecules compared with the extracellular fluid environment resulting in overall increased restricted diffusion, and therefore identification of abnormal from normal tissue. 8 Nuclear medicine imaging Nuclear medicine involves imaging using gamma rays, which are another type of electromagnetic radiation. Fig. 1.8 Computed tomography scan of the abdomen at vertebral level L2. Fig. 1.9 A T2-weighted MR image in the sagittal plane of the pelvic viscera in a woman. The important difference between gamma rays and X-rays is that gamma rays are produced from within the nucleus of an atom when an unstable nucleus decays, whereas X-rays are produced by bombarding an atom with electrons. For an area to be visualized, the patient must receive a gamma ray emitter, which must have a number of proper- ties to be useful, including: a reasonable half-life (e.g., 6 to 24 hours), an easily measurable gamma ray, andImaging Nuclear Medicine Imaging 1 A energy deposition in as low a dose as possible in the patient's tissues. The most commonly used radionuclide (radioisotope) is technetium-99m. This may be injected as a technetium salt or combined with other complex molecules. For example, by combining technetium-99m with methylene diphosphonate (MDP), a radiopharmaceutical is produced. When injected into the body this radiopharmaceutical specifically binds to bone, allowing assessment of the skeleton. Similarly, combining technetium-99m with other compounds permits assessment of other parts of the body, for example the urinary tract and cerebral blood flow. Depending on how the radiopharmaceutical is absorbed, distributed, metabolized, and excreted by the body after injection, images are obtained using a gamma camera (Fig. 1.11). Positron emission tomography Positron emission tomography (PET) is an imaging modality for detecting positron-emitting radionuclides. A positron is an anti-electron, which is a positively charged particle of antimatter. Positrons are emitted from the decay of proton-rich radionuclides. Most of these radionu- clides are made in a cyclotron and have extremely short half-lives. The most commonly used PET radionuclide is fluorode- oxyglucose (FDG) labeled with fluorine-18 (a positron B Fig. 1.10 T1-weighted (A) and T2-weighted (B) MR images of the brain in the coronal plane. Fig. 1.11 A gamma camera. 9The Body emitter). Tissues that are actively metabolizing glucose take up this compound, and the resulting localized high concentration of this molecule compared to background emission is detected as a "hot spot." PET has become an important imaging modality in the detection of cancer and the assessment of its treatment and recurrence. Single photon emission computed tomography Single photon emission computed tomography (SPECT) is an imaging modality for detecting gamma rays emitted from the decay of injected radionuclides such as technetium-99m, iodine-123, or iodine-131. The rays are detected by a 360-degree rotating camera, which allows the construction of 3D images. SPECT can be used to diagnose a wide range of disease conditions such as coronary artery disease and bone fractures. IMAGE INTERPRETATION 10 Imaging is necessary in most clinical specialties to diagnose pathological changes to tissues. It is paramount to appreci- ate what is normal and what is abnormal. An appreciation of how the image is obtained, what the normal variations are, and what technical considerations are necessary to obtain a radiological diagnosis. Without understanding the anatomy of the region imaged, it is impossible to comment on the abnormal. Plain radiography Plain radiographs are undoubtedly the most common form of image obtained in a hospital or local practice. Before interpretation, it is important to know about the imaging technique and the views obtained as standard. In most instances (apart from chest radiography) the X-ray tube is 1 m away from the X-ray film. The object in question, for example a hand or a foot, is placed upon the film. When describing subject placement for radiography, the part closest to the X-ray tube is referred to first and that closest to the film is referred to second. For example, when positioning a patient for an anteroposterior (AP) radio- graph, the more anterior part of the body is closest to the tube and the posterior part is closest to the film. When X-rays are viewed on a viewing box, the right side of the patient is placed to the observer's left; therefore, the observer views the radiograph as though looking at a patient in the anatomical position. Chest radiograph The chest radiograph is one of the most commonly requested plain radiographs. An image is taken with the patient erect and placed posteroanteriorly (PA chest radiograph; that is, with the patient's back closest to the X-ray tube.). Occasionally, when patients are too unwell to stand erect, films are obtained on the bed in an anteroposterior (AP) position. These films are less standardized than PA films, and caution should always be taken when interpret- ing AP radiographs. The plain chest radiograph should always be checked for quality. Film markers should be placed on the appropriate side. (Occasionally patients have dextrocardia, which may be misinterpreted if the film marker is placed inappropriately.) A good-quality chest radiograph will demonstrate the lungs, cardiomediastinal contour, dia- phragm, ribs, and peripheral soft tissues. Abdominal radiograph Plain abdominal radiographs are obtained in the AP supine position. From time to time an erect plain abdominal radiograph is obtained when small bowel obstruction is suspected. Gastrointestinal contrast examinations High-density contrast medium is ingested to opacify the esophagus, stomach, small bowel, and large bowel. As described previously (p. 6), the bowel is insufflated with air (or carbon dioxide) to provide a double-contrast study. In many countries, endoscopy has superseded upper gastro- intestinal imaging, but the mainstay of imaging the large bowel is the double-contrast barium enema. Typically the patient needs to undergo bowel preparation, in which powerful cathartics are used to empty the bowel. At the time of the examination a small tube is placed into the rectum and a barium suspension is run into the large bowel. The patient undergoes a series of twists and turns so that the contrast passes through the entire large bowel. The contrast is emptied and air is passed through the same tube to insufflate the large bowel. A thin layer of barium coats the normal mucosa, allowing mucosal detail to be visualized (see Fig. 1.4). Urological contrast studies Intravenous urography is the standard investigation for assessing the urinary tract. Intravenous contrast medium is injected, and images are obtained as the medium is excreted through the kidneys. A series of films are obtained during this period from immediately after the injection up to approximately 20 minutes later, when the bladder is full of contrast medium. This series of radiographs demonstrates the kidneys, ureters, and bladder and enables assessment of the retro- peritoneum and other structures that may press on the urinary tract.Computed tomography Computed tomography is the preferred terminology rather than computerized tomography, though both terms are used interchangeably by physicians. It is important for the student to understand the presen- tation of images. Most images are acquired in the axial plane and viewed such that the observer looks from below and upward toward the head (from the foot of the bed). By implication: the right side of the patient is on the left side of the image, and the uppermost border of the image is anterior. Many patients are given oral and intravenous contrast media to differentiate bowel loops from other abdominal organs and to assess the vascularity of normal anatomical structures. When intravenous contrast is given, the earlier the images are obtained, the greater the likelihood of arte- rial enhancement. As the time is delayed between injection and image acquisition, a venous phase and an equilibrium phase are also obtained. The great advantage of CT scanning is the ability to extend and compress the gray scale to visualize the bones, soft tissues, and visceral organs. Altering the window set- tings and window centering provides the physician with specific information about these structures. Magnetic resonance imaging There is no doubt that MRI has revolutionized the under- standing and interpretation of the brain and its coverings. Furthermore, it has significantly altered the practice of musculoskeletal medicine and surgery. Images can be obtained in any plane and in most sequences. Typically the images are viewed using the same principles as CT. Intrave- nous contrast agents are also used to further enhance tissue contrast. Typically, MRI contrast agents contain paramag- netic substances (e.g., gadolinium and manganese). Nuclear medicine imaging Most nuclear medicine images are functional studies. Images are usually interpreted directly from a computer, Imaging Safety in Imaging 1 and a series of representative films are obtained for clinical use. SAFETY IN IMAGING Whenever a patient undergoes an X-ray or nuclear medi- cine investigation, a dose of radiation is given (Table 1.1). As a general principle it is expected that the dose given is as low as reasonably possible for a diagnostic image to be obtained. Numerous laws govern the amount of radiation exposure that a patient can undergo for a variety of proce- dures, and these are monitored to prevent any excess or additional dosage. Whenever a radiograph is booked, the clinician ordering the procedure must appreciate its neces- sity and understand the dose given to the patient to ensure that the benefits significantly outweigh the risks. Imaging modalities such as ultrasound and MRI are ideal because they do not impart significant risk to the patient. Moreover, ultrasound imaging is the modality of choice for assessing the fetus. Any imaging device is expensive, and consequently the more complex the imaging technique (e.g., MRI) the more expensive the investigation. Investigations must be carried out judiciously, based on a sound clinical history and examination, for which an understanding of anatomy is vital. Examination Typical effective dose (mSv) Equivalent duration of background exposure Chest radiograph 0.02 3 days Abdomen 1.00 6 months Intravenous urography 2.50 14 months CT scan of head 2.30 1 year CT scan of abdomen 10.00 4.5 years Table 1.1 The approximate dosage of radiation exposure as an order of magnitude and pelvis 11The Body Body systems SKELETAL SYSTEM The skeleton can be divided into two subgroups, the axial skeleton and the appendicular skeleton. The axial skeleton consists of the bones of the skull (cranium), vertebral column, ribs, and sternum, whereas the appendicular skeleton consists of the bones of the upper and lower limbs (Fig. 1.12). The skeletal system consists of cartilage and bone. Cartilage Cartilage is an avascular form of connective tissue consist- ing of extracellular fibers embedded in a matrix that con- tains cells localized in small cavities. The amount and kind of extracellular fibers in the matrix varies depending on the type of cartilage. In heavy weightbearing areas or areas prone to pulling forces, the amount of collagen is greatly increased and the cartilage is almost inextensible. In con- trast, in areas where weightbearing demands and stress are less, cartilage containing elastic fibers and fewer collagen fibers is common. The functions of cartilage are to: support soft tissues, provide a smooth, gliding surface for bone articulations at joints, and enable the development and growth of long bones. There are three types of cartilage: hyaline---most common; matrix contains a moderate amount of collagen fibers (e.g., articular surfaces of bones); elastic---matrix contains collagen fibers along with a large number of elastic fibers (e.g., external ear); fibrocartilage---matrix contains a limited number of cells and ground substance amidst a substantial amount of collagen fibers (e.g., intervertebral discs). Axial skeleton Appendicular skeleton Cartilage is nourished by diffusion and has no blood vessels, lymphatics, or nerves. Fig. 1.12 The axial skeleton and the appendicular skeleton. 12Bone Bone is a calcified, living, connective tissue that forms the majority of the skeleton. It consists of an intercellular calcified matrix, which also contains collagen fibers, and several types of cells within the matrix. Bones function as: supportive structures for the body, protectors of vital organs, reservoirs of calcium and phosphorus, levers on which muscles act to produce movement, and containers for blood-producing cells. There are two types of bone, compact and spongy (tra- becular or cancellous). Compact bone is dense bone that forms the outer shell of all bones and surrounds spongy bone. Spongy bone consists of spicules of bone enclosing cavities containing blood-forming cells (marrow). Classifi- cation of bones is by shape. Long bones are tubular (e.g., humerus in upper limb; femur in lower limb). Short bones are cuboidal (e.g., bones of the wrist and ankle). Flat bones consist of two compact bone plates separated by spongy bone (e.g., skull). Irregular bones are bones with various shapes (e.g., bones of the face). Sesamoid bones are round or oval bones that develop in tendons. In the clinic Accessory and sesamoid bones These are extra bones that are not usually found as part of the normal skeleton, but can exist as a normal variant in many people. They are typically found in multiple locations in the wrist and hands, ankles and feet (Fig. 1.13). These should not be mistaken for fractures on imaging. Sesamoid bones are embedded within tendons, the largest of which is the patella. There are many other sesamoids in the body particularly in tendons of the hands and feet, and most frequently in flexor tendons of the thumb and big toe. Degenerative and inflammatory changes of, as well as mechanical stresses on, the accessory bones and sesamoids can cause pain, which can be treated with physiotherapy and targeted steroid injections, but in some severe cases it may be necessary to surgically remove the bone. Body Systems Skeletal System 1 Os trigonum A Sesamoid bones Os naviculare B Fig. 1.13 Accessory and sesamoid bones. A. Radiograph of the ankle region showing an accessory bone (os trigonum). B. Radiograph of the feet showing numerous sesamoid bones and an accessory bone (os naviculare). 13The Body Bones are vascular and are innervated. Generally, an adjacent artery gives off a nutrient artery, usually one per bone, that directly enters the internal cavity of the bone and supplies the marrow, spongy bone, and inner layers of compact bone. In addition, all bones are covered externally, except in the area of a joint where articular cartilage is present, by a fibrous connective tissue membrane called the periosteum, which has the unique capability of forming new bone. This membrane receives blood vessels whose branches supply the outer layers of compact bone. A bone stripped of its periosteum will not survive. Nerves accompany the In the clinic Determination of skeletal age Throughout life the bones develop in a predictable way to form the skeletally mature adult at the end of puberty. In western countries skeletal maturity tends to occur between the ages of 20 and 25 years. However, this may well vary according to geography and socioeconomic conditions. Skeletal maturity will also be determined by genetic factors and disease states. Up until the age of skeletal maturity, bony growth and development follows a typically predictable ordered state, which can be measured through either ultrasound, plain radiographs, or MRI scanning. Typically, the nondominant (left) hand is radiographed, and the radiograph is compared to a series of standard radiographs. From these images the bone age can be determined (Fig. 1.14). In certain disease states, such as malnutrition and hypothyroidism, bony maturity may be slow. If the skeletal bone age is significantly reduced from the patient's true age, treatment may be required. In the healthy individual the bone age accurately represents the true age of the patient. This is important in determining the true age of the subject. This may also have medicolegal importance. 14 vessels that supply the bone and the periosteum. Most of the nerves passing into the internal cavity with the nutrient artery are vasomotor fibers that regulate blood flow. Bone itself has few sensory nerve fibers. On the other hand, the periosteum is supplied with numerous sensory nerve fibers and is very sensitive to any type of injury. Developmentally, all bones come from mesenchyme by either intramembranous ossification, in which mesenchy- mal models of bones undergo ossification, or endochondral ossification, in which cartilaginous models of bones form from mesenchyme and undergo ossification. A B Carpal bones C D Fig. 1.14 A developmental series of radiographs showing the progressive ossification of carpal (wrist) bones from 3 (A) to 10 \(D) years of age.In the clinic Bone marrow transplants The bone marrow serves an important function. There are two types of bone marrow, red marrow (otherwise known as myeloid tissue) and yellow marrow. Red blood cells, platelets, and most white blood cells arise from within the red marrow. In the yellow marrow a few white cells are made; however, this marrow is dominated by large fat globules (producing its yellow appearance) (Fig. 1.15). From birth most of the body's marrow is red; however, as the subject ages, more red marrow is converted into yellow marrow within the medulla of the long and flat bones. Bone marrow contains two types of stem cells. Hemopoietic stem cells give rise to the white blood cells, red blood cells, and platelets. Mesenchymal stem cells differentiate into structures that form bone, cartilage, and muscle. There are a number of diseases that may involve the bone marrow, including infection and malignancy. In patients who develop a bone marrow malignancy (e.g., leukemia) it may be possible to harvest nonmalignant cells from the patient's bone marrow or cells from another person's bone marrow. The patient's own marrow can be destroyed with chemotherapy or radiation and the new cells infused. This treatment is bone marrow transplantation. Body Systems Skeletal System 1 Red marrow in body of lumbar vertebra Yellow marrow in femoral head Fig. 1.15 T1-weighted image in the coronal plane, demonstrating the relatively high signal intensity returned from the femoral heads and proximal femoral necks, consistent with yellow marrow. In this young patient, the vertebral bodies return an intermediate darker signal that represents red marrow. There is relatively little fat in these vertebrae; hence the lower signal return. 15The Body In the clinic Bone fractures Fractures occur in normal bone because of abnormal load or stress, in which the bone gives way (Fig. 1.16A). Fractures may also occur in bone that is of poor quality (osteoporosis); in such cases a normal stress is placed upon a bone that is not of sufficient quality to withstand this force and subsequently fractures. In children whose bones are still developing, fractures may occur across the growth plate or across the shaft. These shaft fractures typically involve partial cortical disruption, similar to breaking a branch of a young tree; hence they are termed "greenstick" fractures. After a fracture has occurred, the natural response is to heal the fracture. Between the fracture margins a blood clot is formed into which new vessels grow. A jelly-like matrix is formed, and further migration of collagen-producing cells occurs. On this soft tissue framework, calcium hydroxyapatite is produced by osteoblasts and forms insoluble crystals, and then bone matrix is laid down. As more bone is produced, a callus can be demonstrated forming across the fracture site. Treatment of fractures requires a fracture line reduction. If this cannot be maintained in a plaster of Paris cast, it may require internal or external fixation with screws and metal rods (Fig. 1.16B). In the clinic Avascular necrosis Avascular necrosis is cellular death of bone resulting from a temporary or permanent loss of blood supply to that bone. Avascular necrosis may occur in a variety of medical conditions, some of which have an etiology that is less than clear. A typical site for avascular necrosis is a fracture across the femoral neck in an elderly patient. In these patients there is loss of continuity of the cortical medullary blood flow with loss of blood flow deep to the retinacular fibers. This essentially renders the femoral head bloodless; it subsequently undergoes necrosis and collapses (Fig. 1.17). In these patients it is necessary to replace the femoral head with a prosthesis. 16 A B Fig. 1.16 Radiograph, lateral view, showing fracture of the ulna at the elbow joint (A) and repair of this fracture (B) using internal fixation with a plate and multiple screws. Wasting of gluteal muscle Avascular necrosis Bladder Normal left hip Fig. 1.17 Image of the hip joints demonstrating loss of height of the right femoral head with juxta-articular bony sclerosis and subchondral cyst formation secondary to avascular necrosis. There is also significant wasting of the muscles supporting the hip, which is secondary to disuse and pain.In the clinic Epiphyseal fractures As the skeleton develops, there are stages of intense growth typically around the ages of 7 to 10 years and later in puberty. These growth spurts are associated with increased cellular activity around the growth plate between the head and shaft of a bone. This increase in activity renders the growth plates more vulnerable to injuries, which may occur from dislocation across a growth plate or fracture through a growth plate. Occasionally an injury may result in growth plate compression, destroying that region of the growth plate, which may result in asymmetrical growth across that joint region. All fractures across the growth plate must be treated with care and expediency, requiring fracture reduction. Joints The sites where two skeletal elements come together are termed joints. The two general categories of joints (Fig. 1.18) are those in which: the skeletal elements are separated by a cavity (i.e., synovial joints), and there is no cavity and the components are held together by connective tissue (i.e., solid joints). Blood vessels that cross over a joint and nerves that innervate muscles acting on a joint usually contribute articular branches to that joint. Synovial joints Synovial joints are connections between skeletal compo- nents where the elements involved are separated by a narrow articular cavity (Fig. 1.19). In addition to contain- ing an articular cavity, these joints have a number of characteristic features. First, a layer of cartilage, usually hyaline cartilage, covers the articulating surfaces of the skeletal elements. In other words, bony surfaces do not normally contact one another directly. As a consequence, when these joints are viewed in normal radiographs, a wide gap seems to sepa- rate the adjacent bones because the cartilage that covers the articulating surfaces is more transparent to X-rays than bone. A second characteristic feature of synovial joints is the presence of a joint capsule consisting of an inner syno- vial membrane and an outer fibrous membrane. Body Systems Skeletal System 1 A Bone Articular cavity Bone Synovial joint Bone Connective tissue Bone B Solid joint Fig. 1.18 Joints. A. Synovial joint. B. Solid joint. The synovial membrane attaches to the margins of the joint surfaces at the interface between the cartilage and bone and encloses the articular cavity. The synovial membrane is highly vascular and produces synovial fluid, which percolates into the articular cavity and lubricates the articulating surfaces. Closed sacs of synovial membrane also occur outside joints, where they form synovial bursae or tendon sheaths. Bursae often intervene between structures, such as tendons and bone, tendons and joints, or skin and bone, and reduce the friction of one structure moving over the other. Tendon sheaths surround tendons and also reduce friction. The fibrous membrane is formed by dense connective tissue and surrounds and stabilizes the joint. Parts of the fibrous membrane may thicken to form ligaments, which further stabilize the joint. Ligaments outside the capsule usually provide additional reinforcement. Another common but not universal feature of synovial joints is the presence of additional structures within the area enclosed by the capsule or synovial membrane, such as articular discs (usually composed of fibrocartilage), fat pads, and tendons. Articular discs absorb compres- sion forces, adjust to changes in the contours of joint sur- faces during movements, and increase the range of movements that can occur at joints. Fat pads usually occur between the synovial membrane and the capsule and move 17The Body Tendon Sheath Synovial membrane Hyaline cartilage Joint capsule Fibrous membrane Fat pad Articular cavity Articular disc Bone Bone Hyaline cartilage Bone Bone Articular cavity Bursa A B Skin Fibrous membrane Synovial membrane Fig. 1.19 Synovial joints. A. Major features of a synovial joint. B. Accessory structures associated with synovial joints. into and out of regions as joint contours change during movement. Redundant regions of the synovial membrane and fibrous membrane allow for large movements at joints. Descriptions of synovial joints based on shape and movement Synovial joints are described based on shape and movement: based on the shape of their articular surfaces, synovial joints are described as plane (flat), hinge, pivot, bicondylar (two sets of contact points), condylar (ellip- soid), saddle, and ball and socket; based on movement, synovial joints are described as uniaxial (movement in one plane), biaxial (movement in two planes), and multiaxial (movement in three planes). Hinge joints are uniaxial, whereas ball and socket joints are multiaxial. 18Body Systems Skeletal System 1 Specific types of synovial joints (Fig. 1.20) Plane joints---allow sliding or gliding movements when one bone moves across the surface of another (e.g., acromioclavicular joint) Hinge joints---allow movement around one axis that passes transversely through the joint; permit flexion and extension (e.g., elbow \[humero-ulnar\] joint) Pivot joints---allow movement around one axis that passes longitudinally along the shaft of the bone; permit rotation (e.g., atlanto-axial joint) Bicondylar joints---allow movement mostly in one axis with limited rotation around a second axis; formed by two convex condyles that articulate with concave or flat surfaces (e.g., knee joint) Condylar (ellipsoid) joints---allow movement around two axes that are at right angles to each other; permit flexion, extension, abduction, adduction, and circum- duction (limited) (e.g., wrist joint) Saddle joints---allow movement around two axes that are at right angles to each other; the articular surfaces are saddle shaped; permit flexion, extension, abduction, adduction, and circumduction (e.g., carpometacarpal joint of the thumb) Ball and socket joints---allow movement around multiple axes; permit flexion, extension, abduction, B Ulna adduction, circumduction, and rotation (e.g., hip joint) Solid joints Solid joints are connections between skeletal elements where the adjacent surfaces are linked together either by fibrous connective tissue or by cartilage, usually fibro- cartilage (Fig. 1.21). Movements at these joints are more restricted than at synovial joints. Fibrous joints include sutures, gomphoses, and syndesmoses. Sutures occur only in the skull where adjacent bones are linked by a thin layer of connective tissue termed a sutural ligament. Gomphoses occur only between the teeth and adjacent bone. In these joints, short collagen tissue fibers in the periodontal ligament run between the root of the tooth and the bony socket. Syndesmoses are joints in which two adjacent bones are linked by a ligament. Examples are the ligamentum flavum, which connects adjacent vertebral laminae, and an interosseous membrane, which links, for example, the radius and ulna in the forearm. Cartilaginous joints include synchondroses and symphyses. Humerus Radius Synovial membrane Wrist joint Articular disc Radius Olecranon A C Synovial cavity Ulna Odontoid process of axis Cartilage Trapezium Synovial membrane Atlas Metacarpal I Femur D E Synovial membrane F Fig. 1.20 Various types of synovial joints. A. Condylar (wrist). B. Gliding (radio-ulnar). C. Hinge (elbow). D. Ball and socket (hip). E. Saddle (carpometacarpal of thumb). F. Pivot (atlanto-axial). 19The Body **SOLID JOINTS** **Fibrous Cartilaginous** **Sutures** Sutural ligament Skull **Synchondrosis** Head **Gomphosis** Cartilage of growth plate Tooth Long bone Shaft Periodontal ligament Bone **Symphysis** **Syndesmosis** Intervertebral discs Radius Ulna Interosseous membrane Pubic symphysis Fig. 1.21 Solid joints. Synchondroses occur where two ossification centers in a developing bone remain separated by a layer of cartilage, for example, the growth plate that occurs between the head and shaft of developing long bones. These joints allow bone growth and eventually become 20 completely ossified. Symphyses occur where two separate bones are inter- connected by cartilage. Most of these types of joints occur in the midline and include the pubic symphysis between the two pelvic bones, and intervertebral discs between adjacent vertebrae.In the clinic Degenerative joint disease Degenerative joint disease is commonly known as osteoarthritis or osteoarthrosis. The disorder is related to aging but not caused by aging. Typically there are decreases in water and proteoglycan content within the cartilage. The cartilage becomes more fragile and more susceptible to mechanical disruption (Fig. 1.22). As the cartilage wears, the underlying bone becomes fissured and also thickens. Synovial fluid may be forced into small cracks that appear in the bone's surface, which produces large cysts. Furthermore, reactive juxta-articular bony nodules are formed (osteophytes) (Fig. 1.23). As these processes occur, there is slight deformation, which alters the biomechanical forces through the joint. This in turn creates abnormal stresses, which further disrupt the joint. PatellaCartilage loss Femoral condyles Cartilage loss Fig. 1.22 This operative photograph demonstrates the focal areas of cartilage loss in the patella and femoral condyles throughout the knee joint. Body Systems Skeletal System 1 In the United States, osteoarthritis accounts for up to one-quarter of primary health care visits and is regarded as a significant problem. The etiology of osteoarthritis is not clear; however, osteoarthritis can occur secondary to other joint diseases, such as rheumatoid arthritis and infection. Overuse of joints and abnormal strains, such as those experienced by people who play sports, often cause one to be more susceptible to chronic joint osteoarthritis. Various treatments are available, including weight reduction, proper exercise, anti-inflammatory drug treatment, and joint replacement (Fig. 1.24). Osteophytes Loss of joint space Fig. 1.23 This radiograph demonstrates the loss of joint space in the medial compartment and presence of small spiky osteophytic regions at the medial lateral aspect of the joint. 21The Body In the clinic---cont'd Arthroscopy Arthroscopy is a technique of visualizing the inside of a joint using a small telescope placed through a tiny incision in the skin. Arthroscopy can be performed in most joints. However, it is most commonly performed in the knee, shoulder, ankle, and hip joints. Arthroscopy allows the surgeon to view the inside of the joint and its contents. Notably, in the knee, the menisci and the ligaments are easily seen, and it is possible using separate puncture sites and specific instruments to remove the menisci and replace the cruciate ligaments. The advantages of arthroscopy are that it is performed through small incisions, it enables patients to quickly recover and return to normal activity, and it only requires either a light anesthetic or regional anesthesia during the procedure. Fig. 1.24 After knee replacement. This radiograph shows the position of the prosthesis. In the clinic Joint replacement Joint replacement is undertaken for a variety of reasons. These predominantly include degenerative joint disease and joint destruction. Joints that have severely degenerated or lack their normal function are painful. In some patients, the pain may be so severe that it prevents them from leaving the house and undertaking even the smallest of activities without discomfort. Large joints are commonly affected, including the hip, knee, and shoulder. However, with ongoing developments in joint replacement materials and surgical techniques, even small joints of the fingers can be replaced. Typically, both sides of the joint are replaced; in the hip joint the acetabulum will be reamed, and a plastic or metal cup will be introduced. The femoral component will be fitted precisely to the femur and cemented in place (Fig. 1.25). Most patients derive significant benefit from joint replacement and continue to lead an active life afterward. In a minority of patients who have been fitted with a metal acetabular cup and metal femoral component, an aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) may develop, possibly caused by a hypersensitivity response to the release of metal ions in adjacent tissues. These patients often have chronic pain and might need additional surgery to replace these joint replacements with safer models. Artificial femoral head Acetabulum Fig. 1.25 This is a radiograph, anteroposterior view, of the pelvis after a right total hip replacement. There are additional significant degenerative changes in the left hip joint, which will also need to be replaced. 22SKIN AND FASCIAS Skin The skin is the largest organ of the body. It consists of the epidermis and the dermis. The epidermis is the outer cel- lular layer of stratified squamous epithelium, which is avascular and varies in thickness. The dermis is a dense bed of vascular connective tissue. The skin functions as a mechanical and permeability barrier, and as a sensory and thermoregulatory organ. It also can initiate primary immune responses. Fascia Fascia is connective tissue containing varying amounts of fat that separate, support, and interconnect organs and structures, enable movement of one structure relative to another, and allow the transit of vessels and nerves from one area to another. There are two general categories of fascia: superficial and deep. Superficial (subcutaneous) fascia lies just deep to and is attached to the dermis of the skin. It is made up of loose connective tissue usually containing a large amount of fat. The thickness of the superficial fascia (subcutane- ous tissue) varies considerably, both from one area of the body to another and from one individual to another. The superficial fascia allows movement of the skin over deeper areas of the body, acts as a conduit for vessels and nerves coursing to and from the skin, and serves as an energy (fat) reservoir. Deep fascia usually consists of dense, organized connec- tive tissue. The outer layer of deep fascia is attached to the deep surface of the superficial fascia and forms a thin fibrous covering over most of the deeper region of the body. Inward extensions of this fascial layer form intermuscular septa that compartmentalize groups of muscles with similar functions and innervations. Other extensions surround individual muscles and groups of vessels and nerves, forming an investing fascia. Near some joints the deep fascia thickens, forming retinacula. These fascial retinacula hold tendons in place and prevent them from bowing during movements at the joints. Finally, there is a layer of deep fascia separating the membrane lining the abdominal cavity (the parietal peritoneum) from the fascia covering the deep surface of the muscles of the abdominal wall (the transversalis fascia). This layer is referred to as extraperitoneal fascia. A similar layer of fascia in the thorax is termed the endothoracic fascia. Body Systems Muscular System 1 In the clinic The importance of fascias A fascia is a thin band of tissue that surrounds muscles, bones, organs, nerves, and blood vessels and often remains uninterrupted as a 3D structure between tissues. It provides important support for tissues and can provide a boundary between structures. Clinically, fascias are extremely important because they often limit the spread of infection and malignant disease. When infections or malignant diseases cross a fascial plain, a primary surgical clearance may require a far more extensive dissection to render the area free of tumor or infection. A typical example of the clinical importance of a fascial layer would be of that covering the psoas muscle. Infection within an intervertebral body secondary to tuberculosis can pass laterally into the psoas muscle. Pus fills the psoas muscle but is limited from further spread by the psoas fascia, which surrounds the muscle and extends inferiorly into the groin pointing below the inguinal ligament. In the clinic Placement of skin incisions and scarring Surgical skin incisions are ideally placed along or parallel to Langer's lines, which are lines of skin tension that correspond to the orientation of the dermal collagen fibers. They tend to run in the same direction as the underlying muscle fibers and incisions that are made along these lines tend to heal better with less scarring. In contrast, incisions made perpendicular to Langer's lines are more likely to heal with a prominent scar and in some severe cases can lead to raised, firm, hypertrophic, or keloid, scars. MUSCULAR SYSTEM The muscular system is generally regarded as consisting of one type of muscle found in the body---skeletal muscle. However, there are two other types of muscle tissue found in the body, smooth muscle and cardiac muscle, that are important components of other systems. These three types of muscle can be characterized by whether they are con- trolled voluntarily or involuntarily, whether they appear striated (striped) or smooth, and whether they are associ- ated with the body wall (somatic) or with organs and blood vessels (visceral). Skeletal muscle forms the majority of the muscle tissue in the body. It consists of parallel bundles of long, 23The Body multinucleated fibers with transverse stripes, is capable of powerful contractions, and is innervated by somatic and branchial motor nerves. This muscle is used to move bones and other structures, and provides support and gives form to the body. Individual skeletal muscles are often named on the basis of shape (e.g., rhomboid major muscle), attachments (e.g., sternohyoid muscle), function (e.g., flexor pollicis longus muscle), position (e.g., palmar interosseous muscle), or fiber orientation (e.g., external oblique muscle). Cardiac muscle is striated muscle found only in the walls of the heart (myocardium) and in some of the large vessels close to where they join the heart. It consists of a branching network of individual cells linked electri- cally and mechanically to work as a unit. Its contrac- tions are less powerful than those of skeletal muscle and it is resistant to fatigue. Cardiac muscle is innervated by visceral motor nerves. Smooth muscle (absence of stripes) consists of elongated or spindle-shaped fibers capable of slow and sustained contractions. It is found in the walls of blood vessels (tunica media), associated with hair follicles in the skin, located in the eyeball, and found in the walls of various structures associated with the gastrointestinal, respira- tory, genitourinary, and urogenital systems. Smooth muscle is innervated by visceral motor nerves.