Anatomy 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 can...

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. 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 f ingers 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 Superior Coronal plane Inferior margin of orbit level with top of external auditory meatus Face looking forward Hands by sides palms forward Feet together toes forward Sagittal plane Anterior Transverse, horizontal, or axial plane Inferior Posterior Medial Lateral 1 3 Fig. 1.1 The anatomical position, planes, and terms of location and orientation. The 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 f inger. 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. 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 f icial 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. 4 Imaging Diagnostic Imaging Techniques 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 f irst 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 f ilm 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). Tungsten filament Focusing cup Tungsten target 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. 1 5 The 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 6 Fig. 1.4 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). Barium sulfate follow-through. Fig. 1.5 Digital subtraction angiogram. Imaging Diagnostic Imaging Techniques 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 1 7 Fig. 1.6 Ultrasound examination of the abdomen. Fig. 1.7 Computed tomography scanner. 8 The 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 f ield, 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 f luid (CSF) is dark. T2-weighted images demonstrate a bright signal from f luid 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. 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, and Imaging Nuclear Medicine Imaging A B Fig. 1.10 T1-weighted (A) and T2-weighted (B) MR images of the brain in the coronal plane. 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 Fig. 1.11 A gamma camera. 1 9 10 The 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 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 f ilm. 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 f ilms, 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. Imaging Safety in Imaging 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, 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. Table 1.1 The approximate dosage of radiation exposure as an order of magnitude Examination Chest radiograph Abdomen Intravenous urography CT scan of head Typical effective dose (mSv) 0.02 1.00 2.50 2.30 Equivalent duration of background exposure 3 days 6 months 14 months 1 year CT scan of abdomen and pelvis 10.00 4.5 year