Sobotta Atlas vol-1

Vessels and nerves -► T opog ra p hy, back -> Fem ale breast -► Topograp hy, a b dom en and a b d o m in a l w a

Abdominal muscles

M. serratus anterior M . pectoralis m ajor

M. latissim us dorsi M. o bliquus externus abdom inis
M. obliquus externus abdom inis Intersectiones tendineae
V agina m usculi re cti abdom inis,
Mm . intercostales L am ina a n te rio r
Mm . intercostales interni M . rectu s abdom inis
Vagina m usculi recti abdom inis,
Cartilago costalis X Lam ina a n te rio r
M . obliquus e xtern u s abdom inis
M . obliquus internus ab d o m in is Anulus inguinalis superficialis
M. pyram idalis
S pina iliaca anterior superior

Lig. inguinale

Funiculus sperm aticus;
M. crem aster

Fig. 2.92 M iddle layer of th e abdom inal muscles. nial and, like the M . obliquus externus abdom inis, it participates in the
M m . abdominis; ventral view. oblique and transverse muscular abdominal girdle and supports for­
On the right side, th e M. obliquus externus abdom inis is largely re­ ward and side-bending m ovem ents and lateral rotation of the upper
moved. Beneath lies the M . obliquus internus abdom inis. Its aponeu­ torso.
rosis contributes to form ation o f both the superficial (Lamina anterior)
and the deep (Lamina posterior) lamina of the rectus sheath. The M.
obliquus internus abdom inis projects fro m lateral caudal to medial cra­

dissection link

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -» Im a g in g M uscles ->

Abdominal muscles

M m . intercostales M. rectus abdom inis
externi
M. pectoralis m ajor
M m . intercostales M. latissim us dorsi
interni

Cartilagines costales M. obliquus externus
abdom inis
C o s ta e IX; X
Intersectiones tendineae
Vagina m usculi recti
abdom inis, Vagina m usculi recti
abdom inis,
L am ina p o sterio r Lam ina a n te rio r
M . rectu s abdom inis
Linea sem ilunaris
M . obliquus internus
M . transversus abdom inis abdom inis
M . transversus abdom inis
M . obliquus internus
abdom inis Intersectio tendinea

M . obliquus internus M . obliquus internus
abdom inis, abdom inis

A p o n e u ro s is Anulus inguinalis
superficialis,
Linea arcuata Crus m ediale

Vagina m usculi recti Anulus inguinalis
abdom inis, superficialis,
Crus laterale
Lam ina a n te rio r
Fascia transversalis M. pyram idalis

Funiculus sperm aticus M. rectus abdom inis

Fig. 2.93 Deep layer of th e abdom inal muscles. M m . abdominis; aponeurosis radiates into the Linea alba. The M. transversus abdominis
ventral view. is m ainly exerting a con strictive force w h ich results in increased intra­
On th e right abdom inal side th e M. transversus abdom inis is sho w n . In abdominal pressure and supports forced expiration.
addition, th e anterior lamina (Lamina anterior) o f th e rectus sheath (Va­ In its upper section (from sternum to Linea [Zona] arcuata), th e deep
gina m usculi recti abdominis) and the M . rectus abdom inis have been lamina (Lamina posterior) o f the rectus sheath is form ed by the aponeu­
removed. roses of both the M . obliquus internus abdom inis and the M. transver­
The transition from m uscle fibres to the aponeurosis of the M . trans­ sus abdom inis. B elow (from Linea [Zona] arcuata to Os pubis), the La­
versus abdom inis fo rm s a sem ilunar line (Linea sem ilunaris). This apo­ mina posterior only consists o f Fascia transversalis and Peritoneum
neurosis contributes to the major part of the posterior lamina (Lamina parietale.
posterior) o f th e rectus sheath. Caudally o f th e Linea (Zona) arcuata, the
aponeurosis o f th e M . transversus abdom inis participates in th e form a­
tion o f th e Lamina an terior o f th e rectus sheath (-► Fig. 2.96). The

i- Clinical Remarks-----------------------------------------------------------------------------------------------------

A rare SPIGELIAN hernia can occur at the lateral margin of the Surgical scars in th e abdom inal w all can be th e starting point fo r
Linea arcuata bordering on the Linea sem ilunaris. incisional hernias.

dissection link

Vessels and nerves -► T opog ra p hy, back -> Fem ale breast -► Topograp hy, a b dom en and a b d o m in a l w a

Muscle function

Figs. 2.94a to c Directions of m otion of th e trunk. trapezius, and levatores costarum participate in th e dorsal flexion o f the
a side-bending m ovem ents (lateral flexion) o f the trunk spine.
Bending to both sides up to 40° is normal (0740°). Vertebra prom inens c rotation of the trunk
(CVII) and SI serve as reference points w h e n d e term in ing th e angle in Bilateral anterior to posterior rotation o f the tru nk by approxim ately 40°
th e upright and m axim al lateral flexion position. The lateral flexion is is possible. A line con necting th e acrom ion o f th e scapula on both sides
supported by the M m . obliquus externus abdominis, obliquus internus serves as a reference axis. Ipsilateral rotation o f the tru nk is supported
abdominis, quadratus lum borum , iliocostalis, psoas major, longissimus by M m . obliquus internus abdominis, iliocostalis, longissimus, and sple­
and splenius. nius. Rotation o f th e tru n k to th e contralateral side is achieved by the
b Forw ard (flexion) and backward bending o f th e tru n k (extension) in M m . obliquus externus abdominis, semispinalis, m ultifidus, rotatores,
the vertebral joints and levatores costarum.
The range o f m otion is b e tw een approxim ately 100° flexion und 50° The vertebral jo in ts in individual sections o f th e vertebral colum n re­
extension. strict the range o f m ovem ent. As fo r the entire vertebral column, ben­
A straight line b e tw een th e acrom ion o f th e scapula and th e Crista iiiaca ding forw ard (flexion) and backward (extension) o f approxim ately
o f th e fe m u r is used to d e term in e th e se angles. Flexion o f th e tru n k is 1 0 0707 50°, a side-bending (lateral flexion) o f 07 40°, and a torsion (ro­
supported by the M m . rectus abdominis, obliquus externus abdominis, tational m ovem ent) of 4 0 7074 0° are possible; these serve as normal
obliquus internus abdom inis, and psoas major. The M m . iliocostalis, reference values to assess m ovem ent restrictions.
psoas major, longissim us, splenius, spinalis, sem ispinalis, m ultifidus,

Fig. 2.95 O b jective assessm ent of m o v e m e n t restrictions in th e
lum bar section of the vertebral colum n (m ethod by SCHOBER)
and th e thoracic part of th e vertebral colum n (OTT's sign).

i- Clinical Rem arks------------------------------------

M ethod by SCHOBER: To objectify m ovem ent restrictions of the OTT's sign: M o b ility o f th e thoracic spine is de term in ed in the same
lum bar spine, th e patient is asked to stand upright and th e exam iner manner. The origin o f m easure is th e Proc. spinosus o f th e 7th cer­
places his/her right thu m b on the tip of the Crista sacralis mediana vical vertebra (Vertebra prom inens) and is traced 30 cm caudally.
and the index fing er of the same hand on the Proc. spinosus of a W ith maximal flexion, the distance betw een these tw o points usu­
lum bar vertebra about a hand w id th (10 cm) above. W ith maximal ally increases by 8 cm.
flexion, the distance betw een the tw o points usually increases by
5 cm (4-6 cm).

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im a g in g -» M uscles -*•

Abdominal muscles, rectus sheath

M . rectu s abdom inis
A.; Vv. epigastrica(e) superior(es)
M. o bliquus externus abdom inis, Aponeurosis
V agina m usculi recti ab d o m in is, L am ina a n te rio r
M. o b liqu u s internus abdom inis
M . obliquus externus abdom inis

M m . intercostales

M . transversus abdom inis

M. o bliquus externus
abdom inis

M. obliquus internus
abdom inis

M. transversus
abdom inis

Fascia thoracolum balis, Lam ina superficialis Fascia ' A la ossis ilium
M . longissim us thoracis 1 thoracolum balis, M. gluteus medius
Lam ina profunda M. iliacus

Figs. 2.96a to c Structure of th e rectus sheath, Vagina musculi nus abdom inis; the posterior lamina (Lamina posterior) is com posed o f
recti abdominis; cross-section; caudal view. the posterior part of the aponeurosis of the M. obliquus internus abdo­
The M m . rectus abdom inis and pyramidalis are em bedded in a tough minis, the aponeurosis of the M . transversus abdominis as w ell as the
fibrous tub e (Vagina m usculi recti abdom inis) w h ic h is fo rm e d by the Fascia transversalis and th e Peritoneum parietale (a, b).
aponeuroses of the oblique abdominal m uscles (M m . obliquus exter­ In th e lo w e r section, all th re e aponeuroses locate in fro n t o f th e M.
nus abdominis, obliquus internus abdom inis, and transversus abdom i­ rectus abdom inis (c). Here, th e po sterior side o f th e rectus sheath is
nis) as w e ll as th e Fascia transversalis and th e Peritoneum parietale at very thin and com posed exclusively by the Fascia transversalis and the
the inside of the ventral abdominal w all. All aponeuroses radiate into Peritoneum parietale (-» Fig. 2.93).
th e Linea alba. The upper section o f th e rectus sheath is d iffe re n t fro m The um bilicus is a potential w eak spot in the anterior abdominal w all
the low er section.The border betw een both sections is the Linea w h ich is th in n e r in th e region o f th e um bilical pit and th e Papilla um bili­
(Zona) arcuata. calis as com pared to o th e r parts (b).
In th e upper section, th e an terior lamina (Lamina anterior) o f th e rectus
sheath is fo rm e d by th e aponeurosis o f th e M. obliquus externus abdo­ —►T 1 4 -1 6 ,1 8 , 42
minis and the anterior part of the aponeurosis o f the M . obliquus inter-

Vessels and nerves T opog ra p hy, back -► Fem ale breast -► Topograp hy, a b dom en and a b d o m in a l w al

Abdom inal wall, CT

M. rectus abdom inis 2 .9 7 a
Anulus um bilicalis i 2 .9 7 b

I. V Y

M. transversus abdom inis, Aponeurosis
M. o bliquus internus abdom inis, A poneurosis

M. o bliquus externus abdom inis, A poneurosis

M. obliquus externus abdom inis
M. obliquus internus abdom inis
M. transversus abdom inis

M. quadratus ium borum
M . erector spinae

M. transversus abdom inis M. rectus abdom inis M . obliquus internus abdom inis, Aponeurosis;
Linea alba M . transversus abdom inis, Aponeurosis

M. o b liqu u s internus abdom inis M. o bliquus externus abdom inis, Aponeurosis
M. obliquus externus abdom inis

Figs. 2.97a and b Muscles of th e abdom inal w all. The oblique and rectus abdom inal m uscles can be distinguished in CT
M m . abdom inis; com pute d tom ographic (CT) cross-sections. scans. The M . erector spinae and the M . quadratus Ium borum are also
clearly visible.

Clinical Remarks adiposity. The hernial canal is the um bilical ring (Anulus umbilicus).
An om phalocele (congenital um bilical hernia) is a birth d e fe ct result­
U m bilical hernias occur in ne w b orn s and adults. In ne w b orn s the ing in th e persistence o f th e physiological um bilical hernia during the
um bilical papilla has not yet form ed, w hereas in adults the connec­ fetal period.
tive tissue o f the um bilical papilla separates due to an excessive
expansion of the abdominal w all during pregnancy or

91

Trunk surface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im a g in g — M uscles ->

Inside of the ventral abdominal wall

Diaphragm a Lig. fa lcifo rm e
h e p a tis

Diaphragm a

Lig. te re s hepatis

Peritoneum parietale U m bilicus
Linea arcuata M . transversus abdom inis
M. rectus abdom inis
P lica um bilicalis lateralis
Fossa inguinalis latera lis P lica u m bilicalis m edialis
Fossa inguinalis m ed ialis P lica um bilicalis m ed ian a
Fossa supravesicalis

Fig. 2.98 Posterior aspect of th e anterior abdom inal w all; dorsal the rem nants o f the Urachus - the fibrous rem nant o f the allantois
view. On the right side, the fascia and the peritoneum covering the th a t stretches fro m the top o f the urinary bladder to the umbilicus),
diaphragm and the M . transversus abdom inis have been removed. lateral the reo f the Plicae um bilicales m ediales (medial umbilical
On the posterior aspect of the ventral abdominal wall different folds folds; contain the remnants of the Aa. umbilicales), and farthest lateral
(Plicae), p its (Fossae), and ligam ents (Ligam enta) are noticeable. The the Plicae umbilicales laterales (lateral umbilical folds; contain the
Lig. falciform e hepatis (sickle-shaped liver band) extends betw een Vasa epigastrica inferior). The Fossae supravesicales, inguinales
the diaphragm and the liver and inserts in a right angle at the posterior mediales, and inguinales laterales are located betw een the folds. The
aspect o f the ventral abdominal w all. It extends to the um bilicus and Fossa inguinalis lateralis corresponds to the inner inguinal ring
represents the developm ental remnant of the m esentery of the located beneath; the Fossa inguinalis m edialis locates at the same
umbilical vein. The umbilical vein occludes im m ediately after birth and level as the outer inguinal ring.
rem ains visible as a round ligam entous cord (Lig. te res hepatis) at
the free border of the Lig. falciform e hepatis. B elow the um bilicus are -►T 14,15, 19
visible th e Plica um bilicalis m ediana (median um bilical fold; contains

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -► Topograp hy, a b d o m e n and a b d o m in a l w a ll

Diaphragm and posterior abdominal wall

Foram en venae cavae P ars s te rn a lis diaphragm atis
M. transversus abdom inis P a rs c o s ta lis diaphragm atis
O esophagus, Pars abdom inalis
C entrum tendineum Hiatus oesophageus
Hiatus aorticus
P ars c o s ta lis diaphragm atis c o e lia c u s
Pars abdom inalis aortae
P ars lu m b alis diaphragm atis,
Crus dextrum Fascia transversalis
V erte b ra e lu m b a le s III; IV
Lig. arcuatum mediale C rista iliaca
Lig. arcuatum laterale (M . psoas m inor), Tendo
(M. psoas minor) M . psoas m ajor
M . iliacus
M . quadratus lum borum P rom ontorium
M. transversus abdom inis Lacuna vasorum

M . psoas m ajor Vesica urinaria
M . iliacus

Peritoneum parietale
R e ctum

Pecten ossis pubis

Fig. 2.99 D iap hragm , D iap hragm a, and muscles o f th e M . iliacus insert at the Trochanter m inor of the fem ur. The M . psoas
abdom inal w all, M m . abdominis; ventral view. m ajor represents the strongest flexor o f the hip. The M . psoas major
The diaphragm is com posed o f a central tendon plate (Centrum tendi­ can move the upper torso fro m a lying position into an upright sitting
neum) w ith attached m uscles w hich have th e ir origin at the sternum position and participates in the rotation o f the trunk. The M . quadratus
(Pars sternalis), th e ribs (Pars costalis), and th e lum bar region o f the lu m b orum originates fro m th e Labium inte rnum o f th e Crista iliaca and
vertebral colum n (Pars lumbalis). inserts a t th e XII. rib and at the Procc. costales o f the 1st to 4th lum bar
Upon removal of the retroperitoneum , the paravertebral location of the vertebrae. This m uscle is able to depress th e XII. rib and participates in
M m . iliopsoas (composed of a M . psoas m ajor and M . iliacus each), the the forward flexion of the trunk.
M . quadratus lum borum , and, as a variant, the M. psoas m inor are * FALLOPIAN ligam ent or POUPART's ligam ent
shown.
Both th e M . psoas m ajor, originating fro m th e Fossa iliaca, and the —♦ T 15, 16, 19, 42

dissection link

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -» Im a g in g M uscles ->

Diaphragm Proc. xiphoideus
(T r ig o n u m s te r n o c o s ta le ) : A .; V. th o ra c ic a interna,
P a rs s te rn a lis diaphragm atis N. p h re n icu s sinister, R. p h re n ico a b d o m in a lis
Vv. phrenicae inferiores H iatus oesophageus: Oesophagus;
C entrum tendineum Trunci vagales anterior et posterior
F oram en v. ca vae : V. c a v a in fe rio r
N. phrenicus sinister,
N. phrenicus dexter, R. phrenicoabdom inalis
R. p h re n ico a b d o m in a lis
A. phrenica inferior

N. splanchnicus m ajor

P a rs c o s ta lis diaphragm atis Hiatus aorticus: A orta abdom inalis;
Ductus thoracicus
Lig. a rcu a tu m m edianum ; V. h em iazyg o s
H iatus aorticus N. splanchnicus m inor
(Trigonum lu m b o co stale)
P a rs lu m b alis diaphragm atis,
C rus d extrum , (Pars lateralis) M. quadratus Ium borum

Lig. a rcu a tu m m ed iale M . psoas m ajor
Lig. a rc u a tu m latera le Truncus sym pathicus
C o s ta XII

Proc. costalis vertebrae lum balis I
V. azygo s
Pars lum balis diaphragm atis,
Crus d extrum , (Pars medialis)

Fig. 2.100 D iaphragm , Diaphragm a; caudal view . calating Discus intervertebrale. The Crus mediale dextrum form s a loop
The diaphragm com prises the Centrum tendineum and the Partes ster- around the oesophagus (Hiatus oesophageus). The right and left dia­
nales, costales, and lumbales. The Trigonum sternocostale (LARREY's phragm atic crura are connected by a tendinous arch (Hiatus aorticus) at
cleft) is located b e tw e e n th e Pars sternalis and th e Pars costalis, and the level of the vertebral colum n. A t the Hiatus aorticus the aorta enters
the Trigonum lum bocostale (BOCHDALEK's triangle) betw een the the abdominal cavity. The Lig. arcuatum mediale (psoas arcade) dem ar­
Pars costalis and th e Pars lum balis. cates the diaphragm fro m th e M. psoas major, w hereas the Lig. arcua­
The Pars lum balis is divided into a Crus d e xtru m and Crus sinistrum , tum laterale (quadratus arcade) separates the diaphragm from the M.
each o f w h ic h is separated fu rth e r into Crura m ediale, interm edium , quadratus Iumborum.
and laterale. The Crus de xtrum is attached to th e lum bar vertebral
bodies o f L1 to L3 and th e intercalating Disci intervertebrales; th e Crus -► T 19
sinistru m is attached to th e lum bar vertebrae L1 and L2 and th e inter-

V. ca va inferior, Vv. Pars abdom inalis
Pars sternalis diaphragm atis Pars tho ra cica aortae
Pleura parietalis, Pars diaphragm atica
M . latissim us dorsi O esophagus, Pars thoracica
C entrum tendineum
M. serratus anterior Gaster, Pars cardiaca
P e ric a rd iu m
Pars lum balis diaphragm atis,
Hiatus aorticus C rus sinistrum , (Pars lateralis)

Lig. arcuatum m e d ia le *** (Trigonum lu m b o co stale)*
Lig. a rc u a tu m la te ra le **
M . psoas m ajor C o s ta VIII
C o s ta XII
(M. psoas minor)
M. transversus abdom inis
Fig. 2.101 D iaphragm , D iaphragm a, w ith diaphragm atic aper­ Lig. a rcu a tu m m e d ia le ***
tures and muscles of the posterior abdom inal w all; ventral view. Pars lum balis diaphragm atis,
The diaphragm is a double dome-shaped incom plete separation be­ C rus sinistrum , (Pars medialis)
tw e e n th e thoracic and abdom inal cavity (-» Figs. 2.99 und 2.102).
Lig. lum bocostale
M. quadratus Ium borum

* clinical term : BOCHDALEK's triangle
* * quadratus arcade
* * * psoas arcade

—»T 19

dissection link

Vessels and nerves -► T opog ra p hy, back -> Fem ale breast -► Topograp hy, a b dom en and a b d o m in a l w a ll

Diaphragm

D ia p h rag m a , Pars costalis D iaphragm a,
C entrum tendineum
C o s ta VII
C o s ta VIII A .; V. in te rcosta lis;
N. intercostalis (T8)
C o s ta IX

Costa X Fascia transversalis
Peritoneum parietale
M. obliquus externus abdom inis
M. o bliquus internus abdom inis cutaneus fem oris lateralis
M. transversus abdom inis N. fem oralis
C rista iliaca
M . ten so r fasciae latae A. fem oralis
M . iliopsoas V. fem o ra lis
S ym physis pubica

Fig. 2.102 D iaphragm , Diaphragm a, and oblique muscles of the costal spaces during normal breathing. The lateral abdom inal w all is
abdom inal w all. M m . abdominis; frontal section; ventral view. com posed of the oblique m uscles of the abdominal w all (M m . obliquus
The thin and dome-shaped diaphragm is shown. The Partes costales externus abdominis, obliquus internus abdominis, and transversus ab­
originate laterally fro m th e XI. rib and project into th e C entrum tendine- do m inis).
um. The diaphragm atic do m e positions b e tw een th e 5th and 6th inter­

Figs. 2.103a and b Axial (sliding hernia) (a) and para-oesophage-
al hiatal hernia (b); schem atic draw ing. [17]

i- Clinical Rem arks------------------------------------

Diaphragm atic hernias are classified as congenital (Hernia dia- A cquired diaphragm atic hernias are usually sliding hernias o r para-
phragm atica spuria) and acquired (Hernia diaphragm atica vera). If oesophageal hiatal hernias (-» Fig. 2.103). In a hiatal hernia the
th e herniated organs are covered by peritoneum (hernial sac), it is stom ach partially passes through the physiologic slit-shaped open­
called a true hernia. ing of the diaphragm fo r the passage o f the oesophagus (oesopha­
The congenital form usually presents as a gap in the diaphragm geal hiatus). W ith an axial sliding hernia, the cardia is pulled through
through w hich abdominal organs (stomach, intestine, liver, spleen) the diaphragm into th e thorax.
pass into the thorax. Comm only, congenital hernias (usually occur­ There are also m ixed form s. An especially severe fo rm is the upside-
ring at th e physiological w e a k points o f th e diaphragm in th e Trigo- dow n stom ach (thoracic stom ach, large parts o f the stom ach have
num sterno- or lum bocostale [M O RG AG NI's hernia]) have no hernial slipped into the thoracic cavity assuming an upside-down position).
sac.

95

Trunk S urface a n a to m y -► D e ve lo p m e n t -► S keleton -► Im a g in g -► M uscles

Arteries of the ventral wall of the trunk

A. v e rte b ra lis A. carotis communis sinistra
A. subclavia dextra A. axillaris
Truncus brachiocephalicus
R. cla vicu laris
A. thoracica in terna ** R. a cro m ia lis
R. deltoideus A. th o ra c o a c ro m ia lis
Rr. in te rco s ta les a n te rio re s Rete acrom iale
Rr. m a m m arii m e d iales Rr. p e c to ra le s .
Rr. sterna le s A . subscapularis
Rr. p e rfo ra n te s A . th o ra c ic a lateralis
A. tho ra cica superior
A. pericardiacophren ica A. pericardiacophrenica
(Trigonum sternocostale)* A. tho ra c ia interna

Rr. tra c h e a le s e t b ro n ch ia le s
Rr. th y m ic i

A. thoracodorsalis
Rr. m e d iastin a les

A. m usculophrenica

A. epig astrica superior

R. obturatorius A . ep ig as trica inferio r
R. pubicus
A. c irc u m fle xa ilium pro fu n d a
iliaca externa

Fig. 2.104 Arteries of th e ventral w all of th e trunk. Branches of the A. thoracica interna
The ventral w all of the trunk receives arterial blood through branches of
the Aa. subclavia, axillaris, iliaca externa, and fem oralis. The m uscles of • Rr. m ediastinales • Rr. perforantes
the abdominal w all receive blood through segm entally arranged Aa. • Rr. thym ici - Rr. m am m arii m ediales
lumbales derived from the aorta abdominalis (not shown). • Rr. bronchiales
• Rr. tracheales • Rr. intercostales anteriores
* clinical term : LARREY's cleft • A. pericardiacophrenica • A. musculophrenica
* * clinical term : A. m am maria interna • Rr. sternales • A. epigastrica superior

Vessels and nerves -► T opog ra p hy, back -> Fem ale breast Topograp hy, a b dom en and a b d o m in a l w a ll

Arteries of the thoracic wall

R. cutaneus lateralis R. cutaneus medialis
R. dorsalis R. spinalis
A. in terco stalis p o sterio r R. collateralis
Pars; th o ra c ic a a o rta e [A orta th o ra c ic a ]
R. c u ta n eu s lateralis
R. m am m arius lateralis R. in terco stalis a n te rio r

R. m am m arius m edialis
R. p e rfo ra n s

A. th o ra c ic a in te rn a*
Rr. sterna le s

Fig. 2.105 A rteries of th e th oracic w all. Branches of th e Pars thoracicae aortae [Aorta thoracica]
The intercostal arteries create anastom oses betw een the A. thoracica
interna and th e Pars thoracica aortae. Aa. intercostales posteriores - R. collateralis
- R. dorsalis - R. cutaneus lateralis
* clinical term : A. mammaria interna
- R. cutaneus medialis - Rr. m am m arii laterales
- R. cutaneus lateralis
- R. spinalis

r- Clinical Remarks------------------------------------ horizontal bypass circuit: betw een the Aa. thoracicae internae
and A orta thoracica via Rr. intercostales anteriores and Aa. inter­
Stenosis of th e aortic isthm us, a narrowing o f the aorta in the costales posteriores to supply the thoracic and abdominal organs.
aortic arch, results in th e form atio n o f a vertical and a horizontal by­ The enlargem ent of the intercostal arteries leads to the form ation
pass circuit: o f rib usures (erosions) (-» Clinical Remarks p. 47). The bypass
• vertical bypass circuit: betw een the Aa. subclaviae and circuits contribute to the m aintenance of blood supply to parts of
th e body w all and lo w e r extre m itie s (a d iffe ren ce in blood pres­
iliacae externae via the Aa. thoracicae internae, epigastri- sure betw een upper and low er extrem ities is usually still meas­
cae superiores and epigastricae inferiores (w ithin the rectus urable).
sheath) and in the abdominal w all via the Aa. m usculophreni-
cae, epigastricae inferiores, and circum flexae ilium profundae

97

Trunk S urface a n a to m y -► D e ve lo p m e n t -► S keleton -► Im a g in g -► M uscles

Veins of the ventral wall of the trunk

V. s u b c la v ia V. b r a c h io c e p h a lic a s in is tra
Vv. pectorales
V. a x illa ris V. cav a s u p erio r
V. c e p h a lic a V. t h o r a c ic a in t e r n a * *
V. th o ra co a cro m ia lis
V. sca pu la ris V. in te rco sta lis p o s te rio r
V. t h o r a c ic a la te r a lis Rr. p e rfo ra n te s
Rr. p e rfo ra nte s Vv. intercostales
V. th o ra c o d o rsa lis anteriores
s te rn o c o s ta le )*
Plexus venosus
V. th o ra c o e p ig a s tric a V. e p ig a s tr ic a s u p e r io r

Rr. p e rfo ra nte s Vv. paraum bilicales

V. e p ig a s tric a superficialis V. e p ig a s tr ic a in fe r io r
cav a inferio r
c irc u m fle xa ilium s uperficialis
Vv. pudendae externae V. ilia c a c o m m u n is
V. iliaca in terna
V. sa ph en a a c ce sso ria iliaca externa
V. s a p h e n a m a g na
V. fem oralis

Fig. 2.106 Veins of th e ventral w all of th e trunk. * clinical term : LARREY's cleft
The veins of the ventral w all of the trunk, generate a superficial (shown * * clinical te rm : V. m am m aria interna
on the right side of the body) and a deep (left side of the body) system
of anastom oses betw een Vv. cavae superior and inferior.

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Azygos system

V. in te rco sta lis su prem a V. ju g u la ris in terna
V. b ra c h io c e p h a lic a d e xtra s u b c la v ia
V. in te rco sta lis su p e rio r d e xtra
V. b ra c h io c e p h a lic a sin istra
V. ca va
Vv. intercostales I

V. a z y g o s V .,hem iazygos a cc esso ria

V. su b c o s ta lis V. h e m ia z y g o s

V. ca va lum balis a scen d en s
Vv. lum bales — V. s a cra lis m e d ian a
V. ilio lu m b a lis V. iliaca in terna
V. iliaca co m m u n is /. iliaca externa
V. circu m fle xa ilium p ro fu n d a
V. s a cra lis lateralis V. e p ig a s tric a s u p e rficia lis
V. c irc u m fle x a iliu m s u p e rficia lis
V. e p ig a s tric a in fe rio r V. fe m o ra lis sin istra
V. fe m o ra lis d e xtra V. p u d e n d a e xte rn a

Fig. 2.107 A zygos system . com m unis dextra. There are also direct connections o f th e Vv. lumba­
The azygos system drains blood b e tw een th e V. iliaca interna and th e V. les ascendentes w ith th e V. cava inferior. Integrated into th is venous
cava superior. Hidden fro m v ie w by th e V. cava inferior, th e V. lum balis system are the Plexus venosus sacralis and the Plexus venosi vertebra­
ascendens on th e right side connects th e V. azygos w ith th e V. iliaca les externi and interni as w e ll as the Vv. lumbales.

i- Clinical Remarks------------------------------------ • b e tw een V. fem ora lis and V. cava superior via V. circum flexa ilium
superficialis/epigastrica superficialis, V. thoracoepigastrica, V. axil­
V enous congestion o f th e V. cava superior, th e V. cava inferior, or laris, and V. brachiocephalica
Vv. iliacae com m unes results fro m a throm bosis, a mass form ation
and/or an invasion o f tum ours and can lead to the de velopm ent of • b e tw een V. iliaca interna and V. cava superior via Plexus venosus
bypass circulation b e tw e e n th e V. cava superior and V. cava inferior sacralis, Plexus venosi vertebrales externi and interni, V. azygos
(cavocaval anastomoses): and V. hemiazygos
• b e tw e e n V. iliaca externa and V. cava superior via V. epigastrica
• b e tw een Vv. lum bales and V. cava superior via Vv. lum bales as­
inferior, V. epigastrica superior, V. thoracica interna, and V. bra­ cendentes, V. azygos and V. hemiazygos
chiocephalica
Portocaval anastom oses (—> Fig. 6.70, Vol. 2).

99

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging -► M uscles

Arteries and veins of the thoracic wall

A. intercostalis suprem a Truncus costocervicalis
A. subclavia

R. collateralis (A. intercostalis posterior) Pars th o ra c ic a aorta e
A . in terco stalis p o sterio r [A orta thoracica]

A . th o racica in te rn a*

R. perforans anterior

Fig. 2.108 Arteries of th e thoracic w all. [8] R. in terco stalis an terio r
Aorta and A. thoracica interna com m unicate through the Aa. intercosta­
les posteriores and th e Rr. intercostales anteriores. The A. m usculo­ A . m usculophrenica
phrenica, a branch of the A. thoracica interna, runs beneath the costal A. epigastrica superior
arch. These vessels provide blood to the thoracic and abdominal wall.

* clinical term : A. m am maria interna

V. b ra c h io c e p h a lic a d e xtra V. in te rco s ta lis su p erio r sinistra
V. in te r c o s ta lis brachiocephalica sinistra
superior d extra
V. h em ia zyg o s a cce sso ria
V. in te r c o s ta lis p o s te r io r V. t h o r a c ic a in te r n a *
V. a z y g o s R. p e rfo ra n s a n te rio r

V. in te r c o s ta lis a n te r io r V. h em iazyg o s

Fig. 2.109 Veins o f th e thoracic w a ll. [8]
Vv. cavae superior and inferior are connected by the Vv. lumbales, he­
miazygos, and azygos. Additional anastom oses exist betw een the azy-
gos system and th e Vv. thoracicae internae via the Vv. intercostales
posteriores and anteriores. The veins drain the blood of the thoracic
and abdominal wall.

* clinical te rm : V. m am m aria interna

100

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Arteries and veins of the ventral wall of the trunk

A. thoracica interna* M anubrium sterni
A. pericardiacophrenica A. th o racica in te rn a*
V. th o ra c ic a in te r n a * *
Rr. p e rfo ra nte s C o s ta
M. transversus thoracis Rr. in te rco sta le s a n te rio re s
A .; V. m u scu lo p h re n ica
A. thoracica interna*, A .; V. e p ig a s tr ic a s u p e r io r
Rr. in te rco sta le s a n te rio re s Diaphragm a

A. m usculophrenica Fascia transversalis
A. epigastrica superior
A. e p ig as trica inferio r
M. rectus abdom inis V. e p ig a s tric a in ferior
A . iiiaca e xtern a
Vagina m usculi recti abdom inis,
Lam ina posterior

Fig. 2.110 Vessels at th e posterior aspect o f th e ventral w a ll of side o f the body is covered by the M . transversus abdom inis.Upon
the trunk; dorsal view. entering the rectus sheath through the Trigonumsternocostale of the
The epigastric vessels (Vasa epigastrica superior and inferior) run at the diaphragm, th e A. thoracica interna becom es the A. epigastrica superi­
posterior side of the M . transversus abdominis and becom e visible or. The A. epigastrica inferior derives fro m the A. iiiaca externa.
upon rem oval o f th e rectus sheath in th e upper tw o th ird s o f the
abdom inal cavity and upon rem oval o f th e Fascia transversalis in the * clinical term : A. mammaria interna
low er third of the abdominal cavity. The A. thoracica interna on the left * * clinical te rm : V. m am m aria interna

r- Clinical Remarks-----------------------------------------------------------------------------------------------------

The A. thoracica (m ammaria) interna and th e V. saphena magna are th e coronary arteries). Bypass circulation in stenosis o f th e aortic
co m m o n ly used as grafts in coronary bypass surgery fo r revascu- isthm us -» page 97, cavocaval anastom oses -» page 99.
larization o f a heart w ith severe coronary stenosis (narrowing of

101

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging -► M uscles

Lymph vessels

Fig. 2.111 Superficial lym ph vessels and regional lym ph nodes N odi lym phoidei brachiales
of the ventral w all of the trunk. Nodi lym phoidei pectorales
The axillary lym ph nodes (Nodi lym phoidei axillares, including the
Nodi lymphoidei brachiales and pectorales) collect the lymph of the en­
tire upper extrem ity, of large parts of the ventral wall o f the trunk up to
the w atershed at the level of the um bilicus, as w ell as o f th e back up to
th e respective w a te rsh e d (-» Fig. 2.112).
The superficial inguinal lym ph nodes (Nodi lymphoidei inguinales su­
perficiales) consist o f a vertical and horizontal group. They collect the
lymph of the entire low er extrem ity, of the ventral wall of the trunk up
to the w atershed at th e level of the um bilicus, as w ell as of the external
genitalia (including th e penis), the perineal and anal region.
In w o m e n , th e lym ph vessels o f th e Corpus uteri and th e uterotubal
junction that pass through the inguinal canal w ith the Lig. teres uteri
(-» Fig. 2.114) drain th e ir lym ph into th e superficial inguinal lym ph no­
des.
In men, th e lym ph o f th e te s tis is drained to th e para-aortal lym ph
nodes (not shown).

N odi lym phoidei (Tractus
inguinales superficiales horizontalis)

s u p e ro la te ra le s

N odi lym phoidei
inguinales superficiales

superom ediales

N odi lym phoidei 1 (Tractus
in g u in a les su p e rficia le s > ; e rtic a |is)

inferiores J

Fig. 2.112 Superficial lym ph vessels o f th e posterior w a ll of th e
trunk.
A bove the um bilicus, the lym ph is drained into the axillary lym ph nodes,
w hereas be lo w th e um bilicus th e lym ph is drained into th e superficial
inguinal lymph nodes.

102

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Lymph vessels

N odi lym phoidei inguinales superficiales superom ediales

Fig. 2.113 Superficial lym ph vessels and regional lym ph nodes
of the fem ale external genitalia as w ell as the perineal and anal
region; caudal view.
The lym ph of external genitalia, perineum , and anal regions drains into
the superficial inguinal lymph nodes. Initial lym phatic stations are the
Nodi lym phoidei inguinales superficiales superomediales.

N odi lym phoidei aortici laterales N odi lym pho idei
N odi lym phoidei preaortici lu m b a le s sinistri

N odi lym phoidei cavales laterales N odi lym phoidei retroaortici

N odi lym p h o id e i iliaci c o m m u n es

N odi lym pho idei subaortici

N odi lym pho idei iliaci interni

N odi lym pho idei iliaci e xtern i
Lig. te re s uteri

N odi lym phoidei inguinales N odi lym pho idei
superom ediales in g u in a le s
s u p e rfic ia le s
N odi lym phoidei inguinales
inferiores

Fig. 2.114 Superficial and deep lym ph vessels and regional • The second part of lymph from the uterine fundus, corpus, and cer­
lym ph nodes of vagina. Vagina, uterus, Uterus, uterine vix reaches the Nodi lym phoidei iliaci alongside the A. uterina.
(FALLOPIAN) tube. Tuba uterina, and ovary. Ovarium ; ventral view.
• The lym ph o f th e upper tw o th ird s o f th e vagina is drained into the • A third fraction of the uterine lymph from the fundus and corpus
drains alongside the Lig. teres uteri into the Nodi lym phoidei ingui­
pelvic lymph nodes, the low er third drains into the inguinal lymph nales superficiales (highlighted in yellow ).
nodes.
• The lymph from the ovary, the FALLOPIAN tube, and part o f the
uterine fundus and corpus is drained alongside the A. ovarica, lo­
cated in the Lig. suspensorium ovarii, into the Nodi lymphoidei lumbales.

Clinical Remarks------------------------------------ it is im portant to rem em ber that one possible m etastatic route
fro m th e uterus is via th e lym phatic d u cts along th e Lig. teres uteri
Inguinal lym ph nodes are o f clinical significance in inflam m atio n and through the inguinal canal to the inguinal lymph nodes.
m alignant tum ours. Their enlargem ent is a firs t indication o f a patho­
logical process located in th e ir lym ph draining tributary. In w om e n,

103

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging -► M uscles

Innervation of the skin of the back

N. auricularis m agnus, R. posterior
(Plexus cervicalis)

N. o ccipita lis m ino r (Plexus cervicalis)

Nn. supraclaviculares laterales
(Plexus cervicalis)

N. cutaneus brachii lateralis superior
(N. axillaris)

N. cutaneus brachii
poste rio r (N. radialis)
(Rr. cu ta n e i m e d ia le s e t laterales)
(N n. sp in a le s C 4 - L 1 , Rr. p o ste rio re s)

Rr. cu ta n e i laterales
(N n. spinales, Nn. intercostales)

R. cu ta n e u s lateralis
(Plexus lum balis, N. iliohypogastricus)

Nn. clunium superiores (Nn. spinales L 1 -L 3 ,
Rr. p oste rio re s)

Nn. clunium m edii (Nn. spinales
S 1 -S 3 , Rr. p o ste rio re s)

Nn. clunium inferiores
(N. cutaneus fem oris posterior)

N. cutaneus fem oris lateralis (Plexus lum balis)
N. cutaneus fem oris posterior (Plexus lum balis)

Fig. 2.115 Segm ental innervation of th e skin (derm atom es) and neous nerves differ. The dark blue line on the right indicates th e demar­
cutaneous nerves of th e back; dorsal view. cation b e tw e e n th e innervation area o f th e Rr. posteriores (dorsales)
Cutaneous nerves frequently receive nerve fibres fro m m ultiple spinal and Rr. anteriores (ventrales) o f th e spinal nerves.
nerves, thus, the derm atom e and the region of innervation of the cuta­

104

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Vessels and nerves of the back

N. o c c ip ita lis te rtiu s (C3) N. o c c ip ita lis m a jo r (C 2); A .; V. o c c ip ita lis
N. o c c ip ita lis m a jo r (C2) N. auricularis m agnus (Plexus cervicalis)

N. suboccipitalis posterior (C6)
A. vertebralis
posterior (C7)
N. o ccip ita lis m ino r (Plexus cervicalis)
N. auricularis m agnus (Plexus cervicalis) posterior (C8)
p o s te rio r (T1)
M. longissim us capitis N. supraclavicularis lateralis (Plexus cervicalis)
M. levator scapulae M. deltoideus
N. cutaneus brachii lateralis inferior
M . serratus posterior superior
Mm . m ultifidi N. radialis;
A.; (V.) p ro fu n d a b r a c h ii* * *
Nn. th o ra c ic i, Rr. p o ste rio re s,
m ediales et laterales c u ta n e u s
brachii posterior
M . iliocostalis thoracis
M . tric ep s brachii,
M . longissim us thoracis C ap u t longum

N. intercostobrachialis
N . a x illa ris ; A .; V. c ir c u m fle x a
hum eri p o s te rio r**
M . te res m ajor
A .; V. c ir c u m fle x a s c a p u la e *
M . te res m inor
M . infraspinatus

R. p o s te rio r (T12) ■ (Bursa subcutanea spinae iliacae
M. obliquus externus abdom inis posterioris superioris)

C rista iliaca (Bursa subcutanea sacralis)
R. posterior (T12)
Nn. clunium superiores (Bursa subcutanea coccygea)

Fig. 2.116 Vessels and nerves of the back; dorsal view ; superficial • vessels and nerves in th e triceps slit: A. and V. profunda brachii, N.
m uscles and shoulder girdle w ere removed on th e le ft side. radialis (margins: cranial M . teres major, medial Caput longum o f the
• vessels and nerves in the m edial axillary space (triangular axillary M . triceps brachii, lateralhumeral shaft)

space): A. and V. circum flexa scapulae (m argins: cranial M. teres * vessels and nervesinth e triangular axillaryspace
minor, caudal M. teres major, lateral Caput longum of the M . triceps * * vessels and nervesinth e quadrangular axillaryspace
brachii) * * * vessels and nervesinth e triceps slit
• vessels and nerves in th e lateral axillary space (quadrangular axil­
lary space): A. and V. circum flexa hum eri posterior, N. axillaris (mar­
gins: cranial M. teres m inor, caudal M . teres major, medial Caput
longum o f th e M. triceps brachii, lateral humeral shaft)

dissecti on l ink 105

Trunk S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging -► M uscles

Vessels and nerves of the neck

N. o ccip italis m a jo r A . o c c ip ita lis , Rr. o c c ip ita le s
M . sem ispinalis capitis A. occipitalis
A; V. o c c ip ita lis N. o ccip italis m a jo r
V. o c c ip ita lis
A. occipitalis N . o ccip italis m inor
V. a uricu la ris p o s te rio r N . a uricularis m agnus
A . o c c ip ita lis , R. auricularis posterior, R. occipitalis
N . o ccip italis m inor M . splenius capitis
M . longissim us capitis M. sternocleidom astoideus

N. a c c es s o riu s [XI] V. ju g u la ris e x te rn a
M . splenius capitis Rr. c u ta n e i p o s te rio re s
(N n. ce rv ic a le s e t th o ra c ic i, Rr. p oste rio re s)
M. levator scapulae
N. dorsalis scapulae M. trapezius

R. profundus Rr. c u ta n ei p osteriores
(A. transversa coili) (N n. th o ra c ic i, Rr. p o ste rio re s)
M. levator scapulae
Rr. cu ta n e i laterale s p e cto ra le s
V. tra n sve rsa co lli (Nn. thoracici, Nn. intercostales)

M. rhom boideus m inor

M. trapezius

M. rhom boideus m ajor

M. latissim us dorsi

Fig. 2.117 Vessels and nerves of th e occipital region, Regio tius from C3 (not shown) provide cutaneous innervation for the posteri­
occipitalis, posterior neck, Regio cervicalis posterior [(Regio or neck and occipital region (Rr. m ediales o f th e Rr. posteriores [dorsa­
nuchalis)], and upper region of the back; dorsal view. les]). The N. occipitalis m ino r derives fro m th e Plexus cervicalis (Rr.
Up to the scapular line, th e skin o f the back receives segm ental inner­ anteriores [ventrales]) and is part o f th e Punctum nervosum (ERB's
vation by th e Rr. posteriores [dorsales] o f th e spinal nerves (Rr. cutanei nerve point). The course o f th e N. accessorius [XI] in th e neck and
posteriores). The N. occipitalis m ajor fro m C2 and th e N. occipitalis ter- shoulder region is also shown.

106— ► dissection link

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Vessels and nerves of the neck

M. sem ispinalis capitis Protuberantia occipitalis externa
M . epicranius; M. occipitofrontalis,
M . rectu s capitis Venter occipitalis
po sterio r m a jo r N. o ccip italis m a jo r

N. suboccipitalis A. v ertebralis
auricularis posterior
A. occipitalis V. o c c ip ita lis
v e rte b ra lis
M . obliquus
cap itis superior A. occipitalis

A. v ertebralis Atlas, Arcus
M . splenius capitis p o s te rio r
M. longissim us capitis Fascia nuchae
M . obliquus capitis inferio r M . m ultifidus

R. posterior (C 2) cervicalis profunda
M . sem ispinalis capitis V. ce rv ic a lis p ro fu n d a
M. sem ispinalis cervicis
R. posterior (C3)
N. a c c e s s o riu s [XI]
N. dorsalis scapulae

N. a ccesso riu s [X I] M m . rhom boidei m ajor e t m inor

R. s u p e rficia lis
(A. transversa colli)

Fig. 2.118 Vessels and nerves of th e occipital region, Regio o f the neck the short neck m uscles (M m . recti capitis posterior minor
occipitalis, and posterior neck, Regio cervicalis posterior; dorsal and m ajor as w e ll as the M m . obliqui capitis superior and inferior) are
vie w . shown. These m uscles create the margins of the vertebralis triangle
To dem onstrate the deep neurovascular tracts, the M m . trapezius, (Trigonum arteriae vertebralis). Besides arteries and veins, the Nn. oc­
sternocleidom astoideus, splenius capitis, and sem ispinalis capitis w ere cipitalis m ajor and suboccipitalis as w e ll as th e Nn. accessorii [XI] are
detached and partially removed. On both sides of the posterior aspect shown.

dissecti on l ink 107

Trunk S urface a n a to m y -► D e ve lo p m e n t -► S keleton -► Im a g in g -► M uscles

Nerves of the neck and the deep posterior cervical region

N. o ccip italis m a jo r N. o ccip italis tertius
M. sem ispinalis capitis
M. obliquus capitis superior M . rectus capitis posterior m inor
M. rectus capitis posterior major
A. v e rte b ra lis , Pars atlantica Os tem porale, Proc. m astoideus
N. suboccipitalis
N. suboccipitalis Atlas, A rcus posterior
M. obliquus capitis inferior M . o bliquus capitis inferior
v e rte b ra lis , Pars transversaria
R. p o s te rio r (C2) M. rectus capitis posterior major
N. o ccip italis tertiu s

Plexus cervicalis

M m . interspinales cervicis

Fig. 2.119 Nerves of th e posterior neck, Regio cervicalis ally as N. occipitalis tertius into the Lig. nuchae. A scending fro m the
posterior; dorsal view. vertebralis triangle, w h ic h harbours th e A. vertebralis, th e R. posterior
The N . occipitalis m ajor represents th e R. po sterior fro m C2 and pro­ fro m C1 innervates th e sho rt neck m uscles as N. suboccipitalis.
je cts into th e occipital region. The R. po sterior fro m C3 projects crani-

S in us sagittalis Foramen magnum

S inus tra n s ve rsu s N . suboccipitalis
Cisterna cerebellom edullaris Proc. transversus atlantis
Arachnoidea m ater cranialis; A. vertebralis

Cerebellum N. o ccip italis m a jo r
Arachnoidea m ater spinalis N. occip italis tertius
N. spinalis, R. posterior
Dura m ater spinalis Lig. denticulatum
N. spinalis, R. anterior
Arachnoidea m ater spinalis N. spinalis, G anglion sensorium
A. v ertebralis
M. scalenus m edius M edulla spinalis

V erte b ra c e rv ic a lis V,
Proc. transversus
N. cervicalis [C7],

Fila radicularia posteriora

Fig. 2.120 Vessels and nerves of th e deep posterior neck, Regio rem oved to v ie w the Dura m ater w ith opened Sinus sagittalis superior
cervicalis posterior, and content of the vertebral canal; dorsal and Sinus transversus.
view. The ascending part o f the A. vertebralis betw een the cervical verte­
The vertebral canal w a s accessed fro m dorsal and th e occipital bone is brae can be seen.

108— ► dissection link

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Cauda equina and lumbar puncture

Spatium epidurale V erte b ra lu m b a lis II,
Proc. costalis
N. spinalis G anglion sensorium Lig. flavum
nervi spinalis M. quadratus lum borum
Plexus venosus
R. anterior vertebralis internus posterior

R. posterior Dura m ater spinalis

Rr. d o rsa le s (A .; V. lu m b alis) Arachnoidea m ater spinalis
Radices anterior e t posterior Pia m a ter spinalis
Lig. intertransversarium
V. sp in a lis p o s te rio r
Proc. articularis superior
C au d a equina
M. intertransversarius
R. anterior lateralis lum borum
Radix anterior M. intertransversarius
Radix posterior m edialis lum borum

Dura m ater spinalis Lig. iliolum bale

Arachnoidea m ater spinalis Os sacrum , Pars lateralis

Spatium epidurale; Plexus venosus O s sacrum , Proc. articularis superior
vertebralis internus anterior
(Spatium subdurale) Spatium subarachnoideum

Pia m a ter spinalis Fig. 2.121 Vessels and nerves of th e opened vertebral canal of
th e lum bar section of th e vertebral colum n, Regio lumbalis;
dorsal view.

Plexus venosus vertebralis C auda equina
internus p osterior
A rachnoidea m ater spinalis
V erte b ra lu m b a lis III, Dura m ater spinalis
Proc. spinosus Lig. flavum

Lig. interspinale

L am ina a rcu s ve rte b ra e IV

Fig. 2.122 Lum bar puncture. direction of the puncturing needle.

i- Clinical Remarks------------------------------------ (lum bar cistern). The puncture needle is inserted through th e Ligg.
supraspinale and interspinale, the epidural space, the Dura mater,
To obtain cerebrospinal fluid fo r diagnostic purposes or to adm inister and the arachnoid until the needle enters the subarachnoid space
drugs into th e subarachnoid space, a lu m b ar puncture is perform ed ( - Fig. 2.122).
be lo w th e 2nd lum bar vertebra, usually b e tw een th e Proc. spinosus
o f L3/L4 or L4/L5, to prevent spinal cord injuries. A t the sam e level
lies th e Cauda equina; here, th e subarachnoid space is th e w id e s t

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Spinal nerve and Foramen intervertebrale

Truncus sym pathicus, G anglion tru nci sym pathici vertebrae
R. com m unicans M edulla spinalis
R. m ening eus
R adix an terio r
G anglion sensorium nervi
Truncus nervi spin alis ^ Foramen intervertebrale
R. p o sterio r R adix p o sterio r
N . intercostalis Canalis vertebralis
A rcus vertebrae
C o s ta Proc. spinosus
R. lateralis
Mm . dorsi
R. m edialis (R. c u ta n eu s m edialis)

(R. c u ta n eu s lateralis)

Fig. 2.123 Spinal nerve, N. spinalis, in th e thoracic region; tanei m edialis and lateralis). The R. com m unicans is th e connection
caudal view. betw een the spinal nerve and the sym pathetic trunk (Truncus sympa­
The stem o f the spinal nerve is only a fe w m illim eters long (Truncus thicus). The R. m e ningeus o f th e spinal nerve projects back into the
nervi spinalis) and is created by the m erger o f the Radices anterior and vertebral canal and innervates the ligam ents of the vertebral column
posterior. The Truncus divides into th e larger R. anterior (in th e thoracic and th e m eningeal m em branes covering th e spinal cord. The N. inter­
region as N. intercostalis) and th e sm aller R. posterior. The latte r di­ costalis runs along th e underside o f th e rib (not show n) in a ventral di­
vides into a m edial (R. medialis) and lateral (R. lateralis) branch w hich rection, innervates the M m . intercostales externi and interni, and pro­
innervate the autochthonous m uscles of the back (M m . dorsi) and, w ith vides Rr. cutanei lateralis and anterior fo r th e innervation o f th e skin.
th e ir term inal ends, provide cutaneous innervation o f th e back (Rr. cu-

R. m ening eus Truncus nervi spinalis (L3) R adix an terio r Rn a d ix p o s te r io r
R. an terio r
R. com m unicans S p a tiu m
s u b a ra c h n o id e u m

p o sterio r

Lig. fla vu m

Discus intervertebralis,
Anulus fibrosus

Fig. 2.124 Spinal nerve, N. spinalis, in th e lum bar region of th e Fig. 2.125 Spinal nerve, N. spinalis, in th e lum bar region of the
ve rtebral colum n; v ie w fro m th e le ft side. [1] vertebral colum n; sagittal section at the level o f the Foramen
Upon its passage through the Foramen intervertebrale, the spinal nerve intervertebrale; v ie w fro m th e le ft side. [1]
divides into th e Rr. anterior, posterior, m eningeus, and com m unicans. A t the level of the Foramen intervertebrale th e Radices anterior and
posterior have not yet m erged to form the spinal nerve. They are still
surrounded by th e Dura and im m e rsed in cerebrospinal fluid. Show n
are the ventrally located Discus intervertebralis and the dorsally located
Lig. flavum w ith the adjacent zygapophyseal joint.

i- Clinical Remarks-----------------------------------------------------------------------------------------------------

Posterolateral disc herniations, spondylophytes, o r tu m o u rs can lead o f the spinal nerve roots w hich results in deficits o f nerve functions,
to a narrowing of the intervertebral foram ina w ith compression

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Spinal nerve

Discus intervertebralis, A nulus fibrosus

Lig. longitudinale anterius

Lig. longitudinale posterius R. m ening eus

Capsula articularis G anglion tru nci sym pathici
(R. medialis) R. c o m m u n ic a n s albu s
R. c o m m u n ic a n s griseus
Truncus nervi spinalis

R. anterior

(R. lateralis) G anglion sensorium nervi spinalis

R. p o sterio r

Fig. 2.126 Nerves of th e ve rtebral co lum n, C olum na vertebralis; The R. com m unicans albus contains preganglionic sym p athe tic fibres
v ie w fro m th e right side in an oblique angle. from the lateral colum n o f the spinal cord fo r the Truncus sympathicus.
Branches of the spinal nerve are show n w hich project to adjacent struc­ The R. com m unicans griseus contains postganglionic sym p athe tic
tures. These include th e R. m eningeus fo r th e sensory innervation of fibres of the sym pathetic trunk w hich project back to the spinal nerve.
the meningeal m em branes of the spinal cord, sm aller branches derived A utonom ic nerve fibres fro m the sym pathetic tru nk innervate the Disci
fro m th e R. posterior fo r th e Capsula articularis o f th e zygapophyseal intervertebrales and ligam ents of the vertebral column.
joints, and th e Rr. com m unica ntes albus and griseus connecting w ith
the Truncus sympathicus.

Radix posterior

Radix
R. posterior

N. intercostalis

R. cu ta n e u s G anglion sensorium nervi spinalis
Truncus nervi spinalis

R. cu ta n e u s a n te rio r N. in te rc o s ta l is

R. com m unicans
G anglion trunci sym pathici

N n . spinales:
Nn. cervicales
Nn. thoracici
Nn. lum bales
Nn. sacrales
N .coccygeus

Fig. 2.127 S tru ctu re of a spinal nerve, N. spinalis, and spinal cated in the dorsal root ganglion (Ganglion sensorium nervi spinalis) and
cord segm ent, exemplified by tw o thoracic nerves, Nn. thoracici; th e fib re s en ter th e spinal cord via th e dorsal root. Rr. com m unicantes
oblique superior view. connect the spinal cord w ith the chain o f ganglia o f the Truncus sym pa­
Each spinal nerve is com posed o f an an terior ro ot (Radix anterior) and a thicus (Ganglion trunci sympathici). The dorsal branches of th e spinal
posterior root (Radix posterior). The cell bodies (perikarya) o f m otor nerves are arranged in a segm ental order; w ith th e exception o f the
nerve fibres are located in the grey m a tter o f the spinal cord and exit intercostal nerves 2 to 11, th e oth er ventral branches create plexus.
through th e an terior root; th e perikarya o f sensory nerve fibres are lo-

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Blood vessels and nerves of the vertebral canal

Truncus nervi spinalis, R. com m unicans G anglion sensorium nervi spinalis
D u ra m a te r spinalis
T ru n cus nervi sp in a lis, R. N. spinalis, Radix anterior
E p in e u riu m Lig. denticulatum
N. spinalis, Radix posterior
Truncus nervi spinalis, R. posterior P ia m a te r spinalis
G anglion sensorium nervi spinalis
A ra ch n o id e a m a te r spin alis
T ru n cus nervi sp in a lis, R. m e n ing e us

Spatium subarachnoideum
(Spatium subdurale)
Dura m ater spinalis

S p atiu m epid urale; Plexus venosus
verte b ra lis internus p o sterio r

Fig. 2.128 C ontent of th e vertebral canal, Canalis vertebralis; tube and the exiting roots of the spinal nerves are surrounded and pro­
cross-section at th e level o f th e 5th cervical vertebra; cranial view . tected by adipose tissue w ith em bedded venous plexus (Plexus veno­
The spinal cord is surrounded by th e Dura, th e Arachnoidea and th e Pia sus vertebralis internus anterior and posterior) and nourishing blood
m a ter spinalis and im m e rsed in cerebrospinal fluid in th e subarachnoid vessels.
space (Spatium subarachnoideum ). In th e vertebral canal, th is dural See epidural anaesthesia —> page 331, Vol. 3.

Lig. longitudinale posterius Filum term inale
Plexus venosus vertebralis internus anterior C au d a equina
N. spinalis, Radix anterior
Truncus nervi spinalis, R. meningeus G anglion sensorium nervi spinalis

G anglion tru nci sym pathici
T ru n cus nervi sp in a lis, R. co m m u n ica n s
T ru n cus nervi sp in a lis, R. a n te rio r

Truncus nervi spinalis, R. posterior spinalis, Radix posterior
R. lateralis
R. m edialis A rachnoidea m ater spinalis
(Spatium subdurale)
Spatium subarachnoideum Dura m ater spinalis
Pia m a ter spinalis Spatium epidurale
Lig. flavum P eriosteum

Fig. 2.129 C ontent of th e vertebral canal, Canalis vertebralis; collection o f nerve roots is nam ed Cauda equina. Located in be tw een
cross-section at th e level o f th e 3rd lum bar vertebra; cranial view . the nerve fibres and originating from the Conus m edullaris of the spinal
B elow th e 1st/2 nd lum bar vertebra and be fore exiting th e vertebral canal, cord is the thin and thread-like Filum term inale.
nerve roots fro m L2 onw ards, including th e N. coccygeus, run caudally See lum bar puncture —> pages 109 and 331, Vol. 3.
as a loose bundle of fibres surrounded by the dural sac. This entire

112

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Vessels and nerves of the vertebral canal

Dura m ater spinalis A rachnoidea m ater spinalis
N. spinalis, Fila radicularia sp in alis an te rio r, R. radicularis anterior
Proc. articularis superior
Lig. denticulatum Truncus nervi spinalis, R. posterior
T ru n cus nervi sp in a lis, R. a n te rio r
G anglion sensorium nervi spinalis
Spatium subarachnoideum
A rcus vertebrae A rachnoidea m ater spinalis
R. m e n ing e us
Rr. spin ales Plexus venosus v ertebralis
(A. intercostalis posterior) internus a n te rio r

Fovea costalis processus transversi Lig. longitudinale posterius
R. interganglionaris Corpus vertebrae

T ru n cus sym p a th ic u s ; Rr. c o m m u n ic a n te s

Lig. longitudinale anterius

Fig. 2.130 Thoracic region of th e ve rtebral colum n w ith spinal w ith its meninges. It contains the Plexus venosus vertebralis internus
cord. M edulla spinalis, and sym pathetic trunk, Truncus an terior and th e Rr. spinales o f th e A. intercostalis po sterior em bedded
sympathicus; ventral view. in adipose tissue. The A. spinalis an terior runs on to p o f th e spinal cord.
The Spatium epidurale is s ho w n w h ic h surrounds th e vertebral canal

Lig. longitudinale posterius Plexus ven o su s v ertebralis
externus an terio r
(V. b a sive rte bralis)
Plexus venosus v ertebralis

internus a n te rio r

Plexus venosus v ertebralis V. lu m b alis asc en d en s
internus p o sterio r (V. in te rv e rte b ra lis )

Plexus ven o su s v erteb ralis
e xtern u s p o sterio r

Fig. 2.131 Veins of th e ve rtebral canal, Canalis vertebralis; vie w posterior via Vv. intervertebrales. The latter plexus drains th e blood (in
fro m the right side in an oblique dorsal angle. th e lum bar region o f th e vertebral colum n) into th e paravertebral Vv.
The vertebral canal is filled w ith a dense ne tw ork o f veins w hich form lum bales ascendentes (in th e thoracic region o f th e vertebral colum n
the Plexus venosi vertebrates interni anterior and posterior. Lo­ run the Vv. azygos, hemiazygos, and hemiazygos accessoria). These
cated in the Spatium epidurale, this venous plexus covers the m enin­ veins also collect blood from the Plexus venosus vertebralis exter­
ges w hich surround the spinal cord and the Cauda equina. The tw o nus anterior w hich drains the anterior side o f the vertebral bodies and
plexus are connected w ith the Plexus venosus vertebralis externus the intervertebral discs.

113

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Overview and development

«ctoralis m ajor

M. pectoralis m ajor

Papilla m am m aria A reola m am m ae
A reola m am m ae Papilla m am m aria

G landulae areolares

erratus anterior

Fig. 2.132 Breast, M am m a; lateral view. Fig. 2.133 Breast, M a m m a ; ventral view .

Fig. 2.134 M ilk line.
The de velopm ent o f the m am m ary gland initiates in the m ilk line (m am­
m ary ridge), a strip o f thicke ned surface ecto derm fo rm e d in em bryonic
w eek 6 that extends fro m the axillary pit to the inguinal region. W ith the
exception o f the area above the M . pectoralis major, the location fo r the
de velopm ent o f the future breast (Mamma), the rest o f the m ilk line
normally regresses.

i- Clinical Remarks------------------------------------ (possibly due to hormonal disorders), this condition is called gyne­
c o m a stia
The absence of the nipples (athelia) or breasts (amastia, m am ­ Some fem ale breasts are too large (m am m ary hypertrophy),
m ary aplasia) are rare congenital anomalies th a t can occur uni- or w h ich can be associated w ith shoulder and back pain. In such cases,
bilaterally. Supernum erary nipples or breasts are called polythelia a breast reduction surgery is indicated. Too small breasts or the ab­
or polym astia, respectively. This is usually hereditary and can also sence of breasts can necessitate breast augm entation w ith surgical
affect men. insertion of silicone prostheses.
Typically, the rudim entary glandular tissue in male breasts does
not develop furth e r after birth. W hen breast gro w th occurs in men

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Female breast

Fig. 2.135 Breast, M am m a; ventral view. The branched lactiferous ducts term inate in groups o f alveoli (Lobuli).
The breast is com posed o f th e m a m m ary gland (Glandula m ammaria) During pregnancy, the glandular tissue transform s into the lactating
and a fibrous strom a filled w ith adipose tissue. The breast has up to 20 breast.
individual glands (Lobi), each possessing a separate efferen t lactiferous
d u ct opening on to th e m am m ary nipple (Papilla mammaria). * clinical term : COOPER'S ligam ents

Fig. 2.136 Breast, M am m a; sagittal section.
Strong ligam ents (Ligg. suspensoria m am m aria, COOPER'S ligam ents)
derived fro m the Fascia pectoralis o f the M. pectoralis m ajor support
the breast in its normal position.

* clinical term : COOPER'S ligam ents

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Blood supply and lymphatic drainage

N odi lym pho idei
axillares a p icales

Level I *t Level II \ Level III N odi lym pho idei in te rp e c to ra le s *
A.; Vv. thoracica(e) interna(e)
A . thoracoacrom ialis, R. pectoralis
N odi lym pho idei axillares centrales N odi lym pho idei p a ras te rn ale s
Aa.; Vv. m a m m a rial m ediales
N odi lym pho idei axillares h um erales
[la te ra le s ]

N odi lym pho idei
axillares subscapulares

Proc. axillaris
Nodi lym pho idei axillares p e cto rale s

A .; V. th o ra c ic a lateralis
N o d u s lym pho ideus p a ram a m m ariu s

Aa.; Vv. m a m m a rial laterales

N odi lym pho idei p a ram a m m arii

Fig. 2.137 Blood supply of th e fem ale breast, lym phatic drainage from the thoracic and upper abdominal wall. The Truncus subclavius
passages of th e fem ale breast, and location of regional lym ph collects the lym ph o f the axillary lymph nodes and drains it into the
nodes. Ductus lym phaticus dexter and the Ductus thoracicus (not shown)
The approxim ately 40 axillary lymph nodes do not just filte r th e lymph on the right and left side, respectively.
of alm ost the entire upper extrem ity but also collect tw o thirds of the
lymph from the M am m a and the major part of the lymph fluids derived * clinical term : ROTTER's lym ph nodes

i- Clinical Remarks------------------------------------ The parasternal lymph nodes of both sides are interconnected. The
lym ph o f Level I is drained to Level II and via Nodi lym phoidei axilla­
From a clinical topographic and oncosurgical view point, lymph nodes res apicales into Level III, and fro m here into th e Truncus subclavius.
of the fem ale breast are categorized into three levels. The M . pecto­
ralis m ino r acts as a boundary:
• Level I lies lateral to the M . pectoralis minor.
• Level II lies caudal to th e M. pectoralis minor.
• Level III lies m edial to th e M . pectoralis minor.

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Fig. 2.138 Radiograph of th e M am m a (m am m ography) of a Fig. 2.139 Radiograph of a M am m a (m am m ography) of a
47-year-old w om an. 23-year-old w o m a n . [19]
M am m ography is a radiological exam ination used fo r the early diagno­ Normal m am m ary parenchyma shows poorly demarcated w h ite con­
sis o f m am m ary carcinom a, th e m o s t fre q u e n t tu m o u r in w om e n. densations prim arily located beneath th e region of the nipple (M am m il­
la). In young w o m e n , breast tissue can be extre m e ly dense due to
scarcely distributed adipose tissue.

«5%

Fig. 2.140 Frequency o f m a m m a ry carcinom a in relation to th e Fig. 2.141 M am m og rap hy of a m alig nan t breast cancer,
location in percentage.

i- Clinical Rem arks------------------------------------

In Europe, breast cancer m o rtality ranges fro m 1 2 -1 9 % o f all The firs t lym ph node located in the lym ph drainage tributary and
fem ale cancer deaths. Thus, breast cancer is the leading cause to receive lym ph is referred to as sentinel (= th e one th a t keeps
o f cancer deaths in m ost countries o f th e European Union, fo llo w ­ guard) lym ph node w hich is usually also the first lym ph node of
ed by lung and colorectal cancer. In w o m e n , breast cancer is the m e tastatic colonization. The nu m ber o f a ffe cte d lym ph nodes in th e
leading cause o f death b e tw e e n th e age o f 35 and 55 years. In about three hierarchical levels is directly related to the survival rate. Breast
60 % o f all cases th e upper o u te r quadrant o f th e breast is affected cancer o f the medial quadrants can m etastasize via the interconnec­
(-» Fig. 2.140). Breast carcinom a originating m o s tly fro m th e epithe­ ted parasternal lym ph nodes to the contralateral side.
lium o f the Ductus lactiferi (ductal carcinoma) metastasizes m ainly
into the axillary lym ph nodes, less often into retrosternal (paraster­
nal) lym ph nodes.

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Innervation of the skin of the thoracic and abdominal wall

Fig. 2.142 Segm ental sensory innervation of th e ventral thoracic
and abdominal w all (dermatomes).
Skin regions receiving sensory fibres fro m a single spinal nerve are
named derm atom es. The m am m illa is located w ith in derm atom es T4
to T5; th e um bilicus is located in de rm atom e T10.

Diaphragm a (C4)

Oesophagus
(T4.T5)

C o r (T3,T4)

G aster (T8) Fig. 2.143 S egm en tal sensory in nervation of th e thoracic and
abdominal w all.
Hepar; Vesica biliaris On the right side, the spinal nerves responsible fo r th e innervation of
(T8-T11) th e de rm atom es are sho w n (-► Fig. 2.142).
HEAD'S zones represent skin areas w hich refer to distinct viscera as a
Intestinum tenue result of cross-connections betw een the som atic and autonom ic ner­
(T10) vous system in a corresponding spinal cord segm ent. These cross-
connections of the som atic and autonom ic nervous system are due to
Intestinum crassum the segm ented (m etam eric) body structure. HEAD'S zones fo r referred
(T11) pain relate to spe cific inner organs. The HEAD'S zone o f a spe cific or­
gan can stretch across m ultiple derm atom es but has a specific point of
Ren; Testis maximal reflex.
(T 1 0 -L 1 )

Vesica urinaria
(T11-L1)

i- Clinical Remarks------------------------------------ intense burning and localized pain, fo llo w e d th re e to fiv e days later
by exanthema. An irritation o f the corresponding internal organ of a
S hingles (herpes zoster) is th e m o s t com m on infe ction o f the HEAD'S zone (-» Fig. 2.143) can initiate a viscerocutaneous reflex
peripheral nervous system . Herpes zoster leads to an acute neural­ resulting in pain in a specific, m o stly ipsilateral zone (zone o f hy­
gia, w hich is lim ited to the derm atom e o f a specific dorsal root o f a peralgesia). This phenom enon is called referred pain. The pain can
sensory spinal or cranial nerve. An initial infection w ith the varicella som etim es spread to neighbouring segm ents or the affected body
zoster virus caused chickenpox. Shingles are the result of a reactiva­ side (generalization).
tion o f th e dorm ant virus. There is a vesicular exanthem a (form ation
o f blisters), w h ic h is restricted to th e innervation o f a sensory root
ganglion or cranial sensory nerve. Initially, th e patient suffers fro m

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Vessels and nerves of the trunk

Nn. supraclaviculares; V. ce p h a lica
A .; V. ce rv ic a lis s u p e rficia lis
Plexus venosus areolaris A. th o ra c ic a interna*;
Vv. th o ra c ic a e internae
A; V. th o ra c ic a lateralis; Nn. thoracici, Nn. intercostales,
N. thoracicus [T2], N. intercostalis, Rr. cu ta n e i a n te rio re s p e cto ra le s
A .; V. e p ig a s tric a s u p erio r
R. cutaneus lateralis pectoralis M . obliquus externus abdom inis

V. th o ra c o e p ig a s tric a Nn. thoracici, Nn. intercostales,
Rr. cu ta n e i a n te rio re s a b d o m in a le s
Nn. tho ra cici, Nn. intercostales, Anulus um bilicalis
Rr. cu ta n e i laterale s p e cto ra le s
C horda arteriae um bilicalis
Vv. paraum bilicales A.; V. e p ig a s tric a inferio r
Vv. subcutaneae abdom inis
N. iliohypogastricus,
A .; V. c ir c u m fle x a iliu m s u p e r fic ia lis R. cutaneus anterior
N. genitofem oralis, R. fem oralis
N. ilioinguinalis
A .; V. e p ig a s tr ic a s u p e r fic ia lis
A. pudenda externa;

Vv. pudendae externae
N. fe m o ra lis, R. cu ta n e u s a n te rio r

V. s a p h e n a m a g n a

Fig. 2.144 Epifascial and deep vessels as w e ll as nerves o f th e On the left side of the body, the superficial fascia was rem oved to pro­
ventral w all of the trunk of a w om an; ventral view. vide a clear v ie w o f th e m uscles. The rectus sheath is opened, th e M.
On the right side o f the body, the Fasciae deltoidea, pectoralis, thoraci­ rectus abdom inis is cut in the m iddle; its parts are folded up- and do w n­
ca, abdom inis, and lata w ith th e ir epifascial neurovascular structures ward. On the posterior aspect of the M. rectus abdominis the Vasa
and the m am m ary gland are show n. The M am m a receives its blood epigastrica superior and inferior are seen.
supply fro m th e Rr. m am m arii m ediales o f th e A. thoracica interna and
fro m th e Rr. m am m arii laterales o f th e Aa. thoracica lateralis and thora- * clinical term : A. m am maria interna
codorsalis.

dissecti on l ink 119

Trunk S urface a n a to m y -► D e ve lo p m e n t -► S keleton -► Im a g in g -► M uscles

Relief of the inside of the ventral abdominal wall

Lig. falciform e

M. rectus abdom inis

Lig. te re s h ep atis; V. u m b ilica lis

Fossa supravesicalis Linea arcuata
Fossa inguinalis m edialis P lica um bilicalis m ediana
Fossa inguinalis lateralis Plica um bilicalis m edialis
A nulus inguinalis p rofun dus
P lica um bilicalis lateralis

P ro c. vaginalis peritonei Plica vesicalis transversa

A .; V. te s tic u la ris

M. iliacus

A .; V. ilia c a e xte rn a O s ilium

A. um bilicalis A .; V. ilia c a e xte rn a
Am pulla ductus Ureter, Pars pelvica

Fig. 2.145 Ventral abdom inal w all of a new born; inside view. Extending across the Anulus inguinalis profundus, the Proc. vaginalis
The descensus o f the testis into the scrotum is com pleted in a m ature peritonei of the Peritoneum parietale descends slightly into the inguinal
newborn. canal.

Lig. falciform e (hepatis)

Linea arcuata C horda arteriae um bilicalis
Plica um bilicalis

Plica um bilicalis m edialis M. rectus abdom inis

P lica um bilicalis lateralis N. cutaneus fem oris lateralis
A .; V. e p ig a s tric a in fe rio r
M . iliopsoas Lacuna m usculorum
A .; V. fe m o r a lis ----------------- N. fem oralis
Fossa inguinalis lateralis Anulus inguinalis profundus
A rcus iliopectineus
Fossa inguinalis m edialis Lacuna vasorum
Ductus deferens Vasa testicularia
Lig. interfoveolare*
Fossa supravesicalis N. o btu ra to riu s; A .; V. o b tu ra to ria
Ureter Trigonum in gu in a le**

Fig. 2.146 Ventral abdom inal w all; inside view. * clinical term : HESSELBACH's ligam ent
The Fossa inguinalis medialis, Fossa inguinalis lateralis, Lacuna vaso­ * * clinical term : HESSELBACH's triangle
rum, and Lacuna m usculorum are shown. To dem onstrate the neuro­
vascular passage w ays, th e Peritoneum parietale and th e Fascia trans­
versals w ere rem oved on the right side of the body.

120

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a

Inguinal canal

M. M . obliquus
externus abdom inis externus abdom inis

M . obliquus Linea alba
e xtern u s abdom inis,
M. obliquus
A p o n e u ro s is externus abdom inis,
M . obliquus A p o n e u ro s is
in tern u s abdom inis
Lig. inguinale
M . crem aster
Fibrae intercrurales
Lig. reflexum
C r u s "I
Lig. fun d iform e penis latera le A nulus

> inguinalis
C rus superficialis

m ediale J

Funiculus sperm aticu s

Fig. 2.147 Superficial inguinal ring, Anulus inguinalis On the right side of the body, the aponeurosis of the M . obliquus exter­
superficialis; ventral view. nus abdominis w as reflected and provides a clear view on the M . obli­
The Crus m ediale and Crus laterale as part of the aponeurosis o f the quus internus abdominis. M uscle fibres of the M. obliquus internus
M . obliquus externus abdom inis and interconnecting Fibrae intercrura- abdom inis split o ff as M . crem aster and, as a superficial m uscle layer,
les constitute the margins of the superficial inguinal ring. The caudal accompany the Funiculus sperm aticus into the scrotum.
margin is the Lig. reflexum as part o f th e Lig. inguinale.

M . obliquus e xtern u s abdom inis,
A p o n e u ro s is

M. o b liqu u s internus abdom inis

M . transversus abdom inis A nulus inguinalis
N. ilioinguinalis p ro fu n d u s

Fascia transversalis A.; Vv. epigastrica(e)
in ferior(es)

A. d uctus deferentis Fascia transversalis

Fig. 2.148 W alls and co ntent Ductus deferens N. ilioinguinalis
of the inguinal canal, Canalis
inguinalis, right side; ventral Plexus pam piniform is A nulus inguinalis
view . [1] s u p e rfic ia lis
The inguinal canal is confined by N. genitofem oralis,
the aponeurosis of the M . ob­ R. genitalis Lig. reflexum
liquus externus abdom inis in the M. crem aster
front, caudally by th e Lig. inguina­ Lig. inguinale N. genitofem oralis,
le, po steriorly by th e Fascia trans­ R. genitalis
versalis, and cranially by the free Fascia sperm atica externa
margin o f the M . transversus
ab d o m in is.

i- Clinical Rem arks------------------------------------ guinal hernias. The Fossa inguinalis m edialis (HESSELBACH's tri­
angle, -* Fig. 2.146) is th e hernial canal fo r d ire ct inguinal hernias,
The crem asteric reflex is th e contraction o f th e M . cre m aste r and w hereas the Septum fem orale in the Lacuna vasorum is th e hernial
resulting elevation of the testicle on the same side w hen touching canal for fem oral (thigh) hernias.
the inside o f the thigh. It is a physiological extrinsic reflex. The affe­
re nt fibres course in th e R. fem ora lis o f th e N. ge nitofem oralis, the
e ffe re n t fib re s project in th e R. genitalis o f th e N. genitofem oralis.
The Anulus inguinalis profundus is the hernial canal o f indirect in­

dissection link

Rumpf S urface a n a to m y -► D e ve lo p m e n t -► S keleton -► Im a g in g -► M uscles

Inguinal canal

M. obliquus externus abdom inis p arietale
M. o bliquus internus abdom inis
M . tra n s ve rsu s abdom inis N. genitofem oralis, R. fem oralis
A. testicularis; Vv. testiculares
N. genitofem oralis, R. genitalis
A .; V. ilia c a e x te rn a
A .; V. e p ig a s tric a in fe rio r d e xtra
Ductus deferens

Fascia transversalis Vesica urinaria

A nulus inguinalis profundus Tendo conjunctivus*
(Vasa cre m a sterica) M . obliquus externus abdom inis,
Lig. inguinale A p o n e u ro s is
N. ilio in g u in a lis (L1)
A .; V. fem orali:

N. genitofem oralis, R. genitalis

M. crem aster

A nulus inguinalis s uperficialis
Lig. la c u n a re **
Funiculus s perm aticu s

Fig. 2.149 Inguinal canal, Canalis inguinalis, and sperm atic cord. sperm aticus. On its Fascia sperm atica externa, th e N. scrotalis anterior
Funiculus sp erm aticus, rig h t side; ventral view . [10] o f th e N. ilioinguinalis reaches th e an terior part o f th e scro tum . Like the
The approxim ately 4 -6 cm long inguinal canal penetrates the ventral M. transversus abdom inis, the M . obliquus internus abdom inis is po­
abdom inal w all above th e inguinal ligam ent in an oblique angle fro m a sitioned superior to the Funiculus sperm aticus and contributes m uscle
posterior-lateral-cranial to an anterior-medial-caudal direction. The inner fibres (M. cremaster) tha t cover the Funiculus sperm aticus. The M.
opening is the Anulus inguinalis profundus w hich is form ed by the cre m aste r has its o w n fascia (Fascia crem asterica), reaches on to the
P eritoneum and Fascia transversalis as th e po sterior dem arcation and te s tis b e tw e e n Fasciae sperm aticae externa and interna, and plays an
by the M. transversus abdom inis and Lig. inguinale as cranial and cau­ im po rtan t role in regulating th e tem perature fo r spe rm atogenesis to
dal margins, respectively. The outer opening is th e Anulus inguinalis occur.
superficialis w ith the aponeurosis o f the M . obliquus externus abdom i­
nis and th e Lig. inguinale (Lig. reflexum ) being th e an terior and caudal * transversus tendinous arch
margins, respectively. Located in th e inguinal canal is th e Funiculus * * clinical term : GIM BERNAT's ligam ent

122

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Inguinal canal

Peritoneum parietale M . obliquus externus abdom inis
Fascia transversalis
M. o bliquus internus abdom inis
P lica um bilicalis lateralis -------------------- M . tra n sve rsu s a b d o m in is
A.; V. e p ig a s tric a in fe rio r sin istra M . obliquus externus abdom inis, Aponeurosis
A .; V. c irc u m fle x a iliu m p ro fu n d a
Ductus Anulus inguinalis profundus
Lig. um bilicale m ediale N . genitofem oralis, R. genitalis

Lig. um bilicale m edianum
M. rectus abdom inis
M. pyram idalis

Fascia s p erm a tica externa A . testicu laris; Plexus venosus p am pin iform is
M . crem aster
Fascia sperm atica interna
D uctus deferens vaginalis testis, L am ina p arietalis
(C av itas s ero s a scroti)

Caput epididym idis
Tunica vaginalis testis,

L am ina visceralis

Fig. 2.150 C o n ten t o f th e sperm atic cord. Funiculus sperm aticus, The testis is covered by th e serous Lamina visceralis (epiorchium) and
and coverings of testis, left side; ventral view . [10] the Lamina parietalis (periorchium) w hich are separated fro m each
Covered by the Fascia sperm atica externa, the M . crem aster, and the other by a gap, the Cavum serosum scroti. Epiorchium and periorchium
Fascia sperm atica interna, th e sperm atic cord contains th e D uctus de­ are connected at the mesorchium. The other coverings listed from the
ferens, th e A. du ctus deferentis, th e A. testicu laris (a d ire ct branch of inside to th e outside are th e Fascia sperm atica interna, m uscle fib re s of
th e Aorta), th e Plexus pa m pinifo rm is (drains into th e V. testicu laris and th e M . cre m aste r w ith Fascia crem asterica, and th e Fascia sperm atica
fro m the re on th e righ t side into th e V. cava infe rior and on th e le ft side externa. Both te ste s reside in th e scro tum (not show n) w h ich contains
into th e V. renalis), th e R. genitalis o f th e N. ge nitofem oralis, and the the protective dartos fascia (Tunica dartos). M yoepithelial cells in the
V estigium processus vaginalis (obliterated Proc. vaginalis testis w hich Tunica dartos cause th e scro tum to contract, a process involved in tes­
guided the testicular descent from the abdominal cavity into the scro­ ticular therm oregulation and im portant for normal sperm atogenesis to
tum , -» Fig. 2.151). occur.

i- Clinical Remarks------------------------------------ low ed by strangling of the A. testicularis w ith risk of aseptic necrosis
o f the testis.
A ccum ulation o f fluid in th e Cavitas serosa scroti is called hydro­ B a ckflo w o f blood in th e Plexus pa m pinifo rm is is called varicocele,
cele. C ysts in th e Proc. vaginalis te s tis lead to dilation o f th e Fu­ w h ich occurs in 80% o f all cases on th e le ft side (because th e left
niculus sperm aticus and are called funicular hydrocele (Hydrocele V. testicu laris drains into th e le ft V. renalis). Frequent causes are the
funiculi spermatici). ob structio n o f drainage, as in kidney tum ours. V aricoceles can lead
Retention cysts o f the epididym is are called spermatoceles. to infertility.
M alform ation of the m esorchium (attachm ent zone of testis and epi­
didym is) can lead to te stic u lar torsion (com m on in puberty) w ith
strangling of the venous return to the Plexus pam piniform is and fol-

dissecti on l ink 123

2 Trunk surface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging M uscles

Developm ent of the inguinal canal

P erito n eu m p arietale Fascia tran sversalis
Testis
M . transversus abdom inis
M . obliquus internus abdom inis
M. obliquus externus abdom inis

(P roc. vaginalis peritonei)

Fascia sp erm a tica interna
M. crem aster
Fascia sp erm a tica externa

Fig. 2.151 Descensus testis from w eek 7 (post conception) until Peritoneum parietale creates an invagination (Proc. vaginalis peritonei)
birth. tha t stretches from the inguinal canal into th e scrotum and becomes
In th e m ale fe tu s, th e te s te s are relocated during th e fetal period fro m positioned superior to the testis. W ith the exception o f a rem nant on
the abdominal cavity along the Gubernaculum testis and beneath the the testis (Tunica vaginalis testis), the Proc. vaginalis peritonei obliter­
Peritoneum parietale of the dorsal abdominal w all into the scrotum . The ates shortly after birth.

Clinical Remarks Due to elevated tem perature (sperm atogenesis occurs at 35 °C), an
ectopic testis location can result in in fe rtility and an increased risk
The descenut o f the testes into the scrotum is a sign o f foetal ma­ of malignant transform ation.
tu rity at birth. Maldescensus testis occurs in about 3% o f all new ­
borns. The te s tic le can lie in th e abdom inal cavity o r in th e inguinal
canal (testicular retention, cryptorchidism , ectopic testis).

124

Vessels and nerves -► T opog ra p hy, back -► Fem ale breast -> Topograp hy, a b dom en and a b d o m in a l w a ll

Inguinal hernias

Peritoneum parietale Lig. um bilicale m edianum M. rectus abdom inis
Fascia transversalis (C horda urachi) C horda arteriae um bilicalis
M . transversus abdom inis A. epigastrica inferior
M. o bliquus internus abdom inis A. epigastrica inferior
M. o bliquus externus abdom inis Anulus inguinalis
(Fascia superficialis) s u p e rfic ia lis
M. o bliquus externus (P ro c . vaginalis
abdom inis, Aponeurosis p eritonei persistens)

Fascia sperm atica externa S eptum scroti

Fascia c rem asterica; M . c rem a ster 1 Fossa supravesicalis
2 Fossa inguinalis medialis
Fascia sp erm atica interna 3 Fossa inguinalis lateralis

D uctus deferens

Epididym is
(C av itas s ero s a scroti)

Testis

Fig. 2.152 S tru ctu re of th e ventral ab do m in al w a ll and th e is covered by th e Fascia crem asterica. The next deeper layer contains
coverings of the sperm atic cord. Funiculus spermaticus, and the Fascia sperm atica in terna as part o f th e aponeurosis o f th e M.
testis. Testis; schem atic diagram. For didactic reasons, the inguinal transversus abdominis which covers the content o f the Funiculus sper­
canal, th e spe rm atic cord, and th e scro tum are draw n in th e sam e m aticus. W ith th e exception o f a rem nant in th e te sticu la r re­
plane, (according to [1]) gion (Tunica vaginalis te stis w ith Lamina parietalis = periorchium and
The D escensus te s tis causes th e te s tis to lie in a pouch o f th e abdom i­ Lamina visceralis = epiorchium), the Proc. vaginalis peritonei is oblitera­
nal w all w h ic h exte nds into th e scro tum . Therefore, scro tum and sper­ ted and has becom e th e V estigiu m processus vaginalis (a fibrous
m atic cord possess the sam e structure as the abdominal wall. cord; le ft side o f th e image). On th e right side o f th e image, th e Proc.
The Fascia o f th e M . obliquus externus abdom inis continues as Fascia vaginalis te s tis failed to close b u t persists (Proc. vaginalis peritonei per­
sperm atica externa onto the Funiculus sperm aticus. Beneath lies the sistens) and, thus, causes an open connection betw een th e abdominal
M. crem aster w hich splits from the M. obliquus internus abdom inis and cavity and the Cavitas serosa scroti.

Peritoneum parietale A. epigastrica inferior
Fascia transversalis
M . transversus abdom inis M. obliquus
obliquus internus abdom inis externus abdom inis

(Fascia superficialis) Anulus inguinalis
s u p e rfic ia lis
Fascia sperm atica
e x te rn a
Fascia
tra n s v e rs a lis

D uctus deferens D uctus deferens

(P roc. vaginalis p eritonei), Fascia sp erm atica interna
Peritoneum parietale
Fascia crem asterica; 1 Fossa supravesicalis
Fascia sp erm a tica interna M. crem aster 2 Fossa inguinalis m edialis
Fascia crem asterica; M . 3 Fossa inguinalis lateralis
(C avitas s ero s a scroti)
Fascia sperm atica externa

Fig. 2.153 Inguinal hernias; schem atic draw ing. L e ft side o f the w h ich is a w e a k sp o t in th e ventral abdom inal w all. Here, th e po sterior
image: lateral, indirect hernia; right side o f the image: medial, direct abdominal w all consists only o f the Fascia transversalis and the Perito­
hernia, (according to [1]) neum parietale (Paries dorsalis ten uis canalis inguinalis).
Indirect inguinal hernias e n te r th e inguinal canal in th e Fossa inguina­
lis lateralis through the Anulus inguinalis profundus. * intestinal loop in hernial sac
Direct inguinal hernias penetrate through the m uscle-free Trigonum * * peritoneal cavity
inguinale (HESSELBACH's triangle) in th e Fossa inguinalis medialis * * * new ly form ed peritoneal hernial sac

125

2 Trunk Surface ana tom y Topography, abdom en and abdom inal w all

Plexus lumbosacralis

Pars lum balis diaphragm atis, C rus dextrum N . subcostalis
Lig. arcuatum laterale
N . iliohypogastricus
M. q uadratus lum borum N . ilioinguinalis
Plexus lum balis
N . subcostalis
sym pathicus
N . iliohypogastricus N. fem oralis

N. ilioinguinalis Truncus lum bosacralis
M . psoas m ajor
M. obliquus N . genitofem oralis
N. obturatorius
externus abdom inis
M . obliquus Plexus sacralis

internus abdom inis N . cutaneus
M . transversus fe m o ris lateralis
abdom inis
N. cutaneus R. genitalis N. genito-
R. fem oralis fem oralis
fe m o ris lateralis
Lacuna vasorum
N. fem oralis N. obturatorius, R. anterior

N. genitofem oralis, Funiculus sperm aticus
R. fem oralis

N. genitofem oralis,
R. genitalis

N. obturatorius

N. cutaneus
fe m o ris lateralis

N. genitofem oralis,
Rr. fe m o rale s
N . fem oralis,

Rr. c u ta n e i a n te rio re s

N. g en ito fe m o ra lis, Rr.

Fig. 2.154 Posterior abdom inal w all w ith Plexus lumbosacralis; tricu s (T12, L1), ilioinguinalis (L1), ge nitofem oralis (L1, L2) w ith R. fe ­
ventral view. m oralis and R. genitalis, and th e N. cutaneus fe m o ris lateralis (L2, L3).
The Plexus lum bosacralis is com posed o f th e Plexus lum balis (T12, The N. fem oralis (L1-L4) exits the vertebral colum n and, w hen com plet­
L1-L3 [L4]) and th e Plexus sacralis ([L4] L5, S1-S5). The Plexus lum ba­ ing its passage through th e Lacuna m u sculorum , provides Rr. cutanei
lis is im po rtan t fo r th e innervation o f th e w all o f th e trunk. Show n are anteriores fo r th e innervation o f th e skin o f th e thigh. A lso sho w n is the
th e segm ental organization and th e course o f th e Rr. anteriores [ven­ N. obturatorius ([L1] L2-L4) entering th e Canalis obturatorius.
trales] of th e spinal nerves of th e Plexus lum balis w hich innervate
the abdominal muscles, th e inguinal region, and th e thigh. These are —►T 40
fro m cranial to caudal th e Nn. subcostalis (intercostalis XII), iliohypogas­

126—♦ dissection link

Upper Extremity

Surface A n a to m y .............................. 130
D evelopment ..................................... 132
Skeleton .............................................. 134
I m a g in g ................................................ 156
M u s c le s ................................................ 160
T o p o g ra p h y ......................................... 194
Sections .............................................. 239

The Upper Limb -
Grasp the Concept

The upper lim b (M em brum superius) consists of the pectoral girdle table one leaned on one's elbow s. M ore accurately: one leaned on the
(Cingulum m e m bri superioris or pectorale) and th e arm (Pars libera O lecranon o f th e Ulna, a bony process, w h ich is noticeable on th e dor­
m em bri superioris). Both parts m erge in th e shoulder area (Greek: sal side o f the e lb o w jo in t (Articulatio cubiti). Both bony hum ps (Epicon-
"o m o s ", Regio deltoidea) and th e axilla (Fossa axillaris). dylus m edialis and lateralis), palpated m edially and laterally o f the Regio
cubitalis are part o f the Hum erus. These epicondyles serve as th e origin
Shoulder Pectoral Girdle of extensor m uscles to the w rist, w hich are positioned laterally, as op­
posed to th e m edially positioned fle xo r m uscles to th e w ris t. The N.
In con trast to th e pelvic girdle, th e pectoral girdle is not a rigid ring- ulnaris runs in a groove behind the medial epicondyle. Dorsal im pact on
shaped bony structure but is rather very m obile in itself and w ith re­ this nerve can cause painful sensations. In the e lbo w joint, th e hum er­
spe ct to th e trunk. Its stru ctu re con sists ven trally o f th e collarbone (Cla­ us articulates w ith both bones of the forearm and the latter tw o articu­
vicula) and dorsally o f th e shoulder blade (Scapula). The proxim al end of late w ith each other.
the Clavicula articulates w ith the sternum (Articulatio sternoclavicula-
ris). This m edial part o f th e clavicle, w h ic h confines th e Fossa jugularis On the forearm , Antebrachium , the Ulna is palpable along the side of
laterally, is easily visualised and palpated. Tracing th e clavicle laterally th e fifth digit. Bulky m uscles hide th e Radius in its proxim al aspect;
one reaches the acromioclavicular jo in t (Articulatio acromioclavicularis), distally how ever, tow a rds the thum b, its shaft is palpable. During turn­
in w h ic h th e clavicle articulates w ith th e acrom ion, a forw ard-positioned ing m ovem ents o f the forearm and the hand (pronation and supina­
process of the Scapula. During circulating and swinging m otions of the tion), w hich also involve the elbo w joint, the Radius rotates around the
arm, one can feel the m ovem ents o f the pectoral girdle w ith respect to stationary Ulna. Radius and Ulna are joined syndesm otically by the
the trunk. The Scapula, w hich is attached dorsally to the thorax, has no Membrana interossea, but proximally and distally they are connected
further articulations w ith the trunk. Various m uscles o f the thorax, neck, by the form ation o f joints.
and head (M . trapezius) guide th e m o vem en t o f th e Scapula.
The w rist area, Regio carpalis, receives its name fro m the carpal
The Scapula contains th e glenoid cavity o f th e actual shoulder jo in t bones, the Ossa carpi, w hich align in tw o row s at the base o f the hand:
(A rticulatio hum eri). The shoulder jo in t - a ball and socke t jo in t - is very a proximal and a distal row. These bones interlock in a com plicated and
m obile due to its lim p capsule, but also vulnerable to dislocations (luxa­ three-dim ensional puzzle resem bling cypress cones ("ca rp u s"). The
tions). Norm ally num erous muscles, including those of the rotator cuff, tw o joints of the w ris t are identified as articulating joint surfaces of the
sup port th e shoulder joint. The "sho uld er", as it is c o m m only referred Ossa carpi w ith respect to each other, and the proximal ro w of Ossa
to in everyday language, is a transition area o f th e Pars libera and the carpi and the Radius o f the forearm form ing the second joint. The range
Cingulum and is referred to as the Regio deltoidea. The Regio deltoidea o f m otion is largest at th e A rticu la tio radiocarpalis and th e jo in t space is
is nam ed a fte r th e M . deltoideus, w h ic h covers th e shoulder region. located at the "m id riff" of the Regio carpalis. The Ossa carpi are posi­
B elow the shoulder joint, the axilla (Fossa axillaris) is located as a deep tioned m ainly in the palm o f th e hand. The interlocking jo in t o f the
pit, w h ic h opens caudally. The m uscular an terior border o f th e axilla is proxim al and distal ro w o f carpals is called the Articulatio metacarpalis
created by th e M. pectoralis, and the likew ise posterior border o f the and assists in flexion and extension o f th e hand.
axilla is fo rm e d by th e M. latissim us dorsi and th e M. teres m inor. The
hairy axillary skin form s the ro of o f the pit and protects the large axillary The hand (Manus) consists o f th e palm and the digits, w hich protrude
neurovascular stru cture s w h ich , em bedded in adipose tissue, em erge from the metacarpophalangeal joints (Articulationes metacarpophalan-
fro m the upper thoracic aperture and the neck to supply the limb. geales). On th e inside o f th e hand (Palma or Vola manus) tw o larger
m uscle hum ps rise below th e thum b and the fifth digit. These m uscle
Arm hum ps are the thenar and hypothenar, respectively, and function corre­
spondingly. The Ossa carpi are located in th e proxim al area o f th e palm
The Pars libera m e m bri superioris con sists o f th e upper arm (Brachi- below the base of thenar and hypothenar. The remaining larger part of
um), the region of the elbow (Regio cubitalis), the forearm (Antebrachi- th e hand is supported by five long bones, th e m etacarpals (Ossa m eta­
um), the w ris t region (Regio carpalis), and the hand (Manus). carpi). There are no m uscles at the back o f the hand (Dorsum manus).
The Ossa metacarpi are easily palpable below th e tendons o f finger
extensors and the characteristic netw ork o f veins (Rete venosum dor-
sale manus).

On the medial side o f the upper arm , contraction of the M . biceps re­ The fingers or digits (Digiti) are classified as long bones, w hich are also
veals a longitudinal groove, the Sulcus bicipitalis medialis. The pulse of called phalanges. The th u m b (Pollex) con sists o f o n ly tw o phalanges in
th e A. brachialis is palpable in th e sulcus and, w h e n certain pressure is contrast to the other digits (Index, Medius, Anularius and M inim us)
applied, one can feel the shaft of the bone of the upper arm, the Hume­ w h ich all con sist o f th re e phalanges. The exceptional fle xib ility o f the
rus. H ow ever, fo rc e fu l palpations m ay induce unpleasant sensations as thum b, especially th e ability to pose the thu m b opposite to all the other
th e N. ulnaris and N. m edianus run parallel alongside th e A. brachialis. digits (opposition o f the thum b) is a special feature o f the human hand.
The fle xib ility o f th e th u m b originates in th e Os m etacarpi pollicis w hich
The te rm o f th e e lb o w region, Regio cubitalis, originates fro m th e La­ is m ore m obile than the other Ossa metacarpi w ith respect to the car­
tin verb "cu b ita re " (to lie). During antiquity w hen lying dow n at the pals.

128

-C linical Rem arks---------------------------------

The dislocation (luxation) o f th e shoulder jo in t is m ore com m on
than in any o th e r jo in t o f th e body. A lso, th e w e a r o f th e tendons
o f the rotator cuff muscles due to lifting the arm and the en­
tra p m e n t o f attached ten don s under th e acrom ion is a com m on
disease. Depending on lifestyle, sooner or later this disease leads
to im pairm ents. Many hand injuries require surgical reconstitu­
tion to restore the function. Evidence of the significance of the
hand is th e fa c t th a t th e re is a separate specialisation fo r hand
surgeons, w hich accounts fo r the highly com plex anatom y of the
hand. Quite often greatly detailed anatomical topics on this sub­
je c t are fou nd in th e literature w ritte n by and fo r hand surgeons.
Given the outstanding im portance of the grasping function of the
hand, it is conceivable w h y particularly th e nerve lesions o f th e
Nn. medianus, ulnaris, and radialis are im portant to know fo r the
physician. The m o s t com m on injury a ffe cts th e N. ulnaris at th e
elbow ("funny bone"), w hich leads to a typical "claw ed hand"
position o f the fingers. The distal lesion o f the w ris t (carpal tu n ­
nel syndrom e) involves th e N. m edianus and is characterised by
radiating pain and num bness in th e radial fingers. H ow ever, in
the firs t half of the last century the injury to the medial proximal
H um erus (bayonet injury) w as m ore frequent. This injury is asso­
ciated w ith a characteristic "hand o f benediction" position. The
close p ro xim ity to th e bone in th e upper arm region m akes th e N.
radialis particularly prone to injury resulting fro m fractures in this
region. In th is case, failure o f th e ex te n s o r m uscles o f th e fo re ­
arm results in th e so-called w ris t drop. H ow ever, th e extension of
the elbo w is unaffected.

— » Dissection Link
M usculoskeletal system s are dissected in layers (stratigraphically)
fro m superficial to deeper stru cture s. In con trast to th e leg, the arm can
usually be dissected from both sides (ventral and dorsal) w ith o u t
turing over th e body. First, the epifascial veins and cutaneous nerves
w ith in th e subcutaneous adipose tissue are exposed. The V. cephalica
and V. basilica are traced fro m th e w ris ts to th e upper arm . In th e e lbo w
region, these run alongside of the cutaneous nerves o f the forearm .
The cutaneous nerves of the upper arm and forearm are to be exposed
before opening the fascia and displaying individual muscles. The dis­
section of the axillary fossa w ith the nerves of the Plexus brachialis and
the branches o f the A. axillaris requires special skills and is labour-inten-
sive. In th is region only som e o f th e lym ph nodes are displayed. The
coures of individual nerves and blood vessels and their branches are
system atically exposed and traced to achieve a com plete dissection
w hich facilitates understanding of the topography and function of neu­
rovascular pathways. Dissection of the hand should be considered ear­
ly in th e dissection process. Exposure o f th e num erous sm all hand
m uscles and th e branches o f arteries and nerves in th is region is tim e
co n su m in g .

EXAM CHECK LIST

• Bones: apophyses and orig in s, insertions o f m uscles (also the
sm a ll m uscles o f th e hand) • ro ta to r c u ff • jo in ts w ith lig a m e n ts (in
p a rticu la r sh o u ld e r and elbow ) • m uscles and th e ir course,
fu n ctio n , inne rvatio n • Plexus brachialis and its peripheral nerves
includ ing th e ir inne rvatio n and course • nerve lesions and clinical
sym p to m s • arteries and th e ir branches, course and pulses •
course o f veins • lym ph atic drainage including N odi lym phoidei of
the axilla and levels • top ograph y: axilla and hand • carpal tun n e l •
transverse sections: B rachium and A nteb rach iu m • surface
anatom y

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Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Surface anatomy

Regio deltoidea, M. deltoideus

Index P o lle x Thenar
D igitus m edius
M. biceps
b ra c h ii

Plica axillaris anterior

D igitus anularis Antebrachium , E p ic o n d y lu s B ra c h iu m , Regio axillaris, Fossa axillaris
D igitus m inim us m edialis R e g io M. trice p s brachii
H yp o th e n a r Regio antebrachii b ra c h ii
a n te rio r
3.1 a n te rio r

Regio deltoidea, M. deltoideus P ro c. styloideus (R adius)
Dorsum manus
Plica axillaris posterior P o lle x
M. latissim us dorsi Index
M. triceps brachii
D ig itu
3.2 D igitus anul
D igitus minim us
P ro c. styloideus (U lna)

Regio antebrachii
p o s te rio r

Fig. 3.1 and Fig. 3.2 Surface relief of th e arm , righ t side; ventral Clinical Remarks
(-» Fig. 3.1) and dorsal (-» Fig. 3.2) view .
The surface relief o f th e arm is de term in ed by th e m uscles and by
som e o f the skeletal elem ents. The palpable parts o f bones help
w ith orientation during the physical exam.

M uscles -> T o p o g ra p h y -► S ections

Fascias of the arm

3.4

Fig. 3.3 and Fig. 3.4 Fascia of th e upper arm . Fascia brachii, and by a com m on fascia, the fascia of the upper arm and th e forearm ,
fascia of th e fo re arm . Fascia antebrachii, righ t side; ventral w hich resides underneath th e skin. A fte r dissecting all im portant sub­
(-» Fig. 3.3) and dorsal (-» Fig. 3.4) view . cutaneous structures such as the cutaneous nerves and the epifascial
A s sho w n in th e illustration, th e surface relief is de term in ed predom i­ veins, the subcutaneous adipose tissue is rem oved to display the
nantly by the various muscles. The m uscles are covered w ith their ow n fascias.
fascias and bundled to m uscle groups. These group fascias are covered

131

Upper Extremity S urface a n a to m y -» D e ve lo p m e n t -► Skeleton -► Im aging

D e ve lo pm e n t P a d d le -s h a p e d
arm bud

Week 5 Hand plate has form ed
Day 32
Fingers are
Week 5 stum py and
Day 35 webbed

Week 6
Day 44

Week 7 Fingers and toes are
Day 48 long and separated

Week 8 Foot in p lantar flexion,
Day 56 a dducted and supinated

Knee is rotated
c ra n io la te ra lly

Fig. 3.5 D evelop m ent of th e ex tre m ities in w e e k 5 -8 ; schem atic in the prim ordial arms and legs. Beginning in w eek 6, digital rays are
illustration. [20] fo rm in g through program m ed cell death (apoptosis) in th e interposi­
The extre m itie s begin to develop in w e e k 4. The fin-like arm bu d deve­ tioned tissue. The fingers and toes are com pletely separated by the
lops on day 26 - 27, thus tw o days prior to th e developm ent of the leg end of w e e k 8.
bud. A t this point in tim e, the prim ordial extrem ities consist o f a mes­ In contrast to th e arm anlage, th e prim ordial legs rotate laterally during
enchymal core of connective tissue deriving from the m esodermal so- w ee k 8 resulting in the knee to be oriented in a craniolateral position.
m atopleura and o f an encasing surface ectoderm w hich later form s the As a consequence o f this rotation, the extensor m uscles o f the leg are
epiderm al layer o f th e skin (-» Fig. 3.6). E ctoderm o f th e distal edge of in a ventral position, in con trast to th e dorsal position o f th e extensor
the lim b bud (ectoderm al ridge) expresses grow th factors w hich attract m uscles in th e arm . Furtherm ore, at w e e k 8 the fo o t is positioned in
m uscle cell precursors fro m som ites of the m esoderm of th e trunk plan tar flexio n, adduction, and supination. This position is reversed
area. In w e e k 5 - 6 , th e lim b buds display a spatial pa tte rn fo rm atio n until w e e k 11.

Clinical Remarks sion fro m a fo o t position th a t is physiological b e tw een w e e ks 8 and
11 o f gestation.
A congenital clu bfoot is th e m o st com m on m alform a tion o f the
extrem ities. The fo o t is fix e d in plantar flexion and supination. There­
fore, it is assum ed th a t th is d e fo rm ity is caused by th e lack of rever­

132

M uscles -» T o p o g ra p h y -► S ections

Mesenchymal D e ve lo pm e n t
prim ordia o f bones
o f the forearm Ossa carpi
---------- H um erus

loose m esenchym e
condensed mesenchyme
Cartilage
E c to d e rm

Figs. 3.6a to d D evelopm ent of th e cartilaginous precursors of to a specific pattern {-* p. 16). A t w e e k 12, ossification centres are
th e bones of th e upper ex tre m ities in w ee ks 4 -8 ; schem atic present in all bones o f th e upper lim b exce pt fo r th e carpus. O ssifica­
longitudinal sections. [20] tion centres of the carpus only form postnatally betw een 1 and 8
In w e e k 4 th e prim ordial lim bs co n sist o f a connective tissue (m esen­ years of age. As an exception, ossification o f the clavicle proceeds di­
chymal) core and a sheath of surface ectoderm w hich later form s the rectly from the m esenchym e (desmal ossification).
epiderm is o f th e skin. Condensation o f the m esenchym e results in fo r­ O ssification in th e lo w e r e x tre m ity occurs w ith delay. O ssification cen­
m ation o f a cartilaginous skeleton during w ee ks 4 - 6 in th e arm and tre s in th e fe m u r are present already at th e 6th m onth, b u t ossification
w ee ks 6 -8 in th e leg. The cartilaginous skeleton serves as precursor o f th e phalanges occurs only b e tw een th e 5th and 9th m o nth. O ssifica­
fo r the form ation o f bones a t a later point in tim e . This process ad­ tion of the tarsus and the pelvic girdle occurs during the firs t to fourth
vances fro m proxim al to distal. year o f age and up to th e 20,h year o f age, respectively.
W ithin this cartilaginous skeleton prim ary ossification centres begin to Closure of th e epiphyseal plates w ith resulting cessation of the longi­
establish in w eek 7 w hich initiates th e restructuring o f the cartilage into tudinal grow th of the extrem ities takes place betw een years 14 and
bones (endochondral ossification). Ossification progresses according 25, for m ost of the bones before year 21.

Freaxial rim

C7

Postaxial rim

V e n tro a x ia l

LH L4 UbUoIrUdCeIr v

L5

d

Figs. 3.7a to f D evelopm ent of derm atom es in th e extrem ities. initially oriented alm o st longitudinally (a, d) and later during develop­
[20] m e n t in an increasingly oblique direction (-» pp. 197 and 329). A rm s and
Sensory innervation of certain areas of skin derives from one single legs sh o w a ventroaxial border (b, c, e, f) w ith hardly any overlap by
spinal cord se g m e n t (derm atom e). In con trast to th e segm ental orien­ neighbouring derm atom es.
tation o f the derm atom es in the trunk, derm atom es in the lim bs are

Clinical Remarks the ir bones consist partly o f individual ossification centres not yet
connected by bone. Hence, these are not considered fractures.
From the progression of the ossification (bone age), future grow th
and adult height can be predicted in children by radiological exami­
nations. W hen exam ining X-rays of children, one m ust consider that

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3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Skeleton of the upper extrem ity

C in g u lu m
p e c to ra le

Pars libera
m e m b ri

s u p e rio ris

Fig. 3.8 Bones and joints of th e upper extrem ity, M em brum The connecting line betw een the head of Humerus and the head of
superius; right side; ventral view. Ulna depicts the rotation axis fo r the upper arm. The diagonal axis of
Similar to the leg, upper arm and forearm fo rm a lateral open angle of th e forearm is th e axis fo r turning m o ve m e n ts o f th e radius around the
170° w h ic h is divided in half by th e transverse axis o f th e e lb o w joint. Ulna (pronation/supination).

134

M uscles -» T o p o g ra p h y -► S ections

Shoulder girdle

S capular plane

Frontal plane

S c a p u la

A rticulatio acro m io clavicu laris

Clavicula A rticu latio stern oclavicularis
S te rn u m

M edian plane

Fig. 3.9 Shoulder girdle, C ingulum pectorale, righ t side; cranial the skeleton of the trunk through the medial clavicular jo in t (Articulatio
vie w . sternoclavicularis).
The shoulder girdle consists o f th e clavicle (Clavicula) and th e shoul­ The clavicle holds an angle of 60° w ith the median plane and w ith the
der blade (Scapula). Both bones are connected in th e lateral clavicular scapular plane. The shoulder blade is positioned in th e scapular plane
jo in t (A rticulatio acrom ioclavicularis); th e clavicle is also connected to w hich again has an angle o f 60° to th e m edian plane.

.^^25° Figs. 3.10a and b Range of m otion of the shoulder girdle w ith
reference to th e m edial clavicular jo in t, (according to [1 ])
Both clavicular joints are ball and socket joints and both act as a func­
tional unit since the connection of the shoulder girdle to the skeleton of
th e tru n k is exclusively based on th e m edial clavicular joint. In addition
to forw ard and backward m ovem ents (protraction and retraction), a
discrete low ering (depression) and a substantial lifting (elevation) o f the
shoulder is possible. The clavicle is capable o f a 45° rotation around its
fixed sternal end. The m o tions in th e shoulder girdle enable a sub­
stantially increased range o f m o ve m e n t in th e upper extrem ity.

Range of m ovem ent in th e shoulder girdle:
• elevation-depression: 40 °-0°-1 0°
• p rotra ction-retra ction: 25o-0 ° -2 5 °

135

3 Upper Extremity S urface a n a to m y -► D e ve lo p m e n t -► Skeleton -► Im aging

Clavicle

Tuberculum conoideum

Extrem itas acrom ialis Extrem itas sternalis

3.11

Facies articularis acrom ialis Extrem itas sternalis

Extrem itas acrom ialis Facies articularis sternalis
Linea trap e zo id e a Im pressio ligam enti costoclavicularis
Tuberculum conoideum
S ulcus m usculi subclavii
3.12

Fig. 3.11 and Fig. 3.12 Clavicle, Clavicula, righ t side; cranial skeleton, the sternal convexity is oriented ventrally. The inferior side of
(-» Fig. 3.11) and caudal (-» Fig. 3.12) view . this bone shows tw o characteristic apophyses for the attachm ent of
M atching an isolated clavicle to either side o f the body is often not both parts o f th e Lig. coracoclaviculare (-» Fig. 3.28). M edially posi­
easy. It helps to k no w th a t th e Extrem itas sternalis is rather plum p and tioned is the Tuberculum conoideum , lateral the reo f the Linea trap e­
th e Extrem itas acrom ialis is m o re pointed. W hen positioned in the zoidea is located.

136