Clinical Anatomy - Harold Ellis - ebook

Clinical Anatomy ebook

Harold Ellis

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Now in its fourteenth edition, Clinical Anatomy is the definitive text offering medical students, postgraduate trainees and junior doctors the anatomical information they need to succeed in a clinical setting. Professor Harold Ellis and Professor Vishy Mahadevan provide an accessible, comprehensive, and detailed exploration of anatomy, specifically designed for students and trainees at all levels. Revised and updated, the fourteenth edition contains more information about the nervous system as well as medical images, diagrams and photographs that are overlaid with anatomical illustrations, revealing detailed surface anatomy. This edition: * Puts greater emphasis on clinical relevance and contains more content for non-surgical trainees * Offers a variety of illustrative clinical scenario case studies * Contains many more medical images and diagrams such as CT and MRI * Presents expanded information on the nervous system * Includes a companion website that contains digital flashcards of all the illustrations and photographs presented in the book Written for medical students, junior doctors, and those studying for The Royal College of Surgeons examinations, the new edition of Clinical Anatomy continues to be an essential resource for understanding the basics of Clinical Anatomy.

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Table of Contents

Cover

Preface to the Fourteenth Edition

Preface to the First Edition

Part 1: The Thorax

Introduction

Surface anatomy and surface markings

The thoracic cage

The lower respiratory tract

The mediastinum

On the examination of a chest radiograph

Part 2: The Abdomen and Pelvis

Surface anatomy and surface markings

The fasciae and muscles of the abdominal wall

Peritoneal cavity

The gastrointestinal tract

The gastrointestinal adnexae: liver, gall bladder and its ducts, pancreas and spleen

The urinary tract

The male genital organs

The bony and ligamentous pelvis

The muscles of the pelvic floor and perineum

The female genital organs

The posterior abdominal wall

Computed axial tomography

Part 3: The Upper Limb

Surface anatomy and surface markings of the upper limb

The bones and joints of the upper limb

Three important zones of the upper limb: the axilla, the cubital fossa and the carpal tunnel

The arteries of the upper limb

The brachial plexus

The course and distribution of the principal nerves of the upper limb

Compartments of the upper limb

The female breast

The anatomy of upper limb deformities

The spaces of the hand

Part 4: The Lower Limb

Surface anatomy and surface markings of the lower limb

The bones and joints of the lower limb

Three important zones of the lower limb: the femoral triangle, adductor canal and popliteal fossa

The arteries of the lower limb

The veins of the lower limb

The course and distributionof the principal nerves of the lower limb

Compartments of the lower limb

Part 5: The Head and Neck

Surface anatomy of the neck

The thyroid gland

The parathyroid glands (Fig. 192)

The palate

The tongue and floor of the mouth

The pharynx

The larynx

The salivary glands

The major arteries of the head and neck

The veins of the head and neck

The lymph nodes of the neck

The cervical sympathetic trunk

The branchial system and its derivatives

Surface anatomy and surface markings of the head

The scalp

The skull (Figs 222, 223, 224)

The paranasal sinuses (accessory nasal sinuses)

The mandible (Fig. 227)

The vertebral column

Part 6: The Nervous System

Introduction

The brain

The spinal cord

The cranial nerves

The special senses

The autonomic nervous system

Glossary of eponyms

Index

End User License Agreement

List of Tables

Chapter 01

Table 1 The named divisions of the main bronchi

Chapter 02

Table 2 Comparison of male and female pelvis

Table 3 Obstetrical pelvic measurements

Chapter 05

Table 4 Derivatives of the branchial system (note the 5th arch disappears).

Chapter 06

Table 5 Summary of effects of sympathetic and parasympathetic stimulation

List of Illustrations

Chapter 01

Fig. 1 Lateral view of the thorax – its surface markings and vertebral levels. (Note that the angle of Louis (T4/5) demarcates the lower boundary of the superior mediastinum, the upper margin of the heart and the beginning and end of the aortic arch.)

Fig. 2 The surface markings of the lungs and pleura – anterior view.

Fig. 3 The surface markings of the lungs and pleura – posterior view.

Fig. 4 The surface markings of the heart (see text).

Fig. 5 A typical rib.

Fig. 6 Structures crossing the first rib.

Fig. 7 Bilateral cervical ribs. On the right side the brachial plexus is seen arching over the rib and stretching its lowest trunk. The subclavian artery may also be pressed upon by the underlying cervical rib.

Fig. 8 (a) The relationship of an intercostal space. (Note that a needle passed into the chest immediately

above

a rib will avoid the neurovascular bundle.) (b) Steps in the insertion of a chest drain. (i) Local anaesthetic is infiltrated into an intercostal space. (ii) Incision followed by blunt dissection allows access to the pleura. (iii) A finger is passed through the incision to clear the lung away. (iv) A chest tube is passed into the pleural cavity.

Fig. 9 Diagram of a typical spinal nerve and its relationship to the body wall.

Fig. 10 The diaphragm – inferior aspect. The three major orifices, from above downwards, transmit the inferior vena cava, oesophagus and aorta.

Fig. 11 Schematic lateral view of the diaphragm to show the levels at which it is pierced by major structures.

Fig. 12 The development of the diaphragm, showing the four elements contributing to the diaphragm – (1) the septum transversum, (2) the dorsal mesentery of the oesophagus, (3) the body wall and (4) the pleuroperitoneal membrane.

Fig. 13 (a) A sliding hiatus hernia. (b) A rolling hiatus hernia.

Fig. 14 The trachea and its anterior relationships.

Fig. 15 The trachea and main bronchi viewed from the front.

Fig. 16 The cervical part of the trachea and its environs in transverse section (through the 6th cervical vertebra) (viewed from below).

Fig. 17 (a) The thoracic part of the trachea and its environs in transverse section (through the 4th thoracic vertebra) (viewed from below). (b) CT scan (axial view) of the superior mediastinum at a level corresponding to that in (a).

Fig. 18 The lungs, lateral aspects.

Fig. 19 The lungs, anterior aspects.

Fig. 20 The named divisions of the main bronchi.

Fig. 21 (a) The segments of the right lung. (b) The segments of the left lung.

Fig. 22 The subdivisions of the mediastinum.

Fig. 23 The transverse and oblique sinuses of the pericardium. The heart has been removed from the pericardial sac, which is seen in anterior view.

Fig. 24 The heart – (a) anterior and (b) posterior aspects.

Fig. 25 (a) The interior of the right atrium and ventricle. (b) The conducting system of the heart. LA, left atrium; RA, right atrium.

Fig. 26 The interior of the left ventricle. AO, aorta; RV, right ventricle.

Fig. 27 The coronary arteries. (Dotted vessels lie posteriorly.)

Fig. 28 The coronary veins. (Dotted vessels lie posteriorly.)

Fig. 29 The coiling of the primitive heart tube into its definitive form.

Fig. 30 The development of the chambers of the heart. (Note the septum primum and septum secundum that form the interatrial septum, leaving the foramen ovale as a valve‐like opening passing between them.)

Fig. 31 The aortic arches and their derivatives. This diagram explains the relationship of the right recurrent laryngeal nerve to the right subclavian artery and the left nerve to the aortic arch and the ligamentum arteriosum (or to a persistent ductus arteriosus).

Fig. 32 The fetal circulation. The red arrows denote oxygenated blood.

Fig. 33 The tetralogy of Fallot.

Fig. 34 (a) Persistent ductus arteriosus – showing its close relationship to the left recurrent laryngeal nerve. (b) Coarctation of the aorta.

Fig. 35 The oesophagus and its relations.

Fig. 36 The usual form of oesophageal stenosis. The upper oesophagus ends blindly; the lower oesophagus communicates with the trachea at the level of the 4th thoracic vertebra.

Fig. 37 The course of the thoracic duct.

Fig. 38 (a) The left thoracic sympathetic trunk with a display of the left mediastinum. (b) The right thoracic sympathetic trunk with a display of the right mediastinum.

Fig. 39 A tracing of a chest radiograph to show the composition of the right and left borders of the mediastinal shadow.

Chapter 02

Fig. 40 (a) Boundaries, bony landmarks and vertebral levels of the abdomen. (b) The surface markings of the liver and aorta.

Fig. 41 Anterior abdominal wall. The anterior rectus sheath on the left side has been reflected laterally.

Fig. 42 The composition of the rectus sheath shown in transverse section (a) above the costal margin, (b) above the arcuate line and (c) below the arcuate line.

Fig. 43 The right inguinal canal (a) with the external oblique aponeurosis intact and (b) with the external oblique aponeurosis removed.

Fig. 44 Scheme of the spermatic cord and its contents, in transverse section.

Fig. 45 The peritoneal cavity in longitudinal (sagittal) section (female).

Fig. 46 (a) The peritoneal cavity in transverse section (through the foramen of Winslow), seen from below. (b) The corresponding CT scan through T12.

Fig. 47 The foramen of Winslow in transverse section (viewed from above).

Fig. 48 The anatomy of (a) the right and (b) the left subphrenic spaces in sagittal section.

Fig. 49 The stomach and its subdivisions.

Fig. 50 The posterior relations of the stomach; the stomach (indicated by the dashed line) is superimposed upon its bed.

Fig. 51 The arterial supply of the stomach.

Fig. 52 The lymphatic drainage of the stomach.Area I drains along the right and left gastric vessels to the aortic nodes.Area II drains to the subpyloric and thence aortic nodes via lymphatics along the right gastro‐epiploic vessels.Area III drains via lymphatics along the splenic vessels to the suprapancreatic nodes and thence to the aortic nodes.

Fig. 53 The vagal supply to the stomach: (a) anterior vagus; (b) posterior vagus.

Fig. 54 Tracing of a barium meal radiograph of the stomach.

Fig. 55 The relations of the duodenum.

Fig. 56 The duodenum and pancreas dissected to show the pancreatic ducts and their orifices.

Fig. 57 The simple arterial arcades of the jejunum (a) compared with the complex arcades of the ileum (b).

Fig. 58 The positions in which the appendix may lie, together with their approximate incidence.

Fig. 59 The blood supply of the appendix.

Fig. 60 Sagittal section of the rectum and its related viscera in the male.

Fig. 61 Sagittal section of the rectum and its related viscera in the female.

Fig. 62 The sphincters of the anus.

Fig. 63 The anatomy of perianal fistulae and abscesses.

Fig. 64 The superior and inferior mesenteric arteries and their branches.

Fig. 65 The composition of the portal system.

Fig. 66 Lymph nodes of the large intestine.

Fig. 67 Stages in rotation of the bowel. (a) The prolapsed midgut loop, seen in lateral view. (b) The midgut returns to the abdomen. (c) The caecum descends to its definitive position. Note the completion of stomach rotation with the formation of the lesser sac (omental bursa).

Fig. 68 Abnormalities associated with persistence of the vitello‐intestinal tract. (a) Meckel’s diverticulum. (b) Patent vitello‐intestinal duct. (c) Cyst within a fibrous cord passing from the anti‐mesenteric border of the intestine to the umbilicus. (d) Meckel’s diverticulum with a terminal filament passing to the umbilicus.

Fig. 69 The liver and its subdivisions. (a) Anterior aspect. (b) Inferior aspect. (c) The ‘H’.

Fig. 70 The morphological right and left lobes of the liver shown separated by the dotted line: (a) anterior and (b) inferior aspect. Note that the quadrate lobe is morphologically a part of the left lobe while the caudate lobe belongs to both the right and left lobes. (c) The further segmental divisions of the liver.

Fig. 71 (a) Distribution of hepatic arteries. (b) Distribution of hepatic biliary ducts. Note that the quadrate lobe is supplied exclusively by the left hepatic artery and drained by the left hepatic duct. The caudate lobe is supplied by each.

Fig. 72 Liver split open to demonstrate the tributaries of the hepatic vein.

Fig. 73 The gall bladder and its duct system. (The anterior wall of the second part of the duodenum has been removed.)

Fig. 74 The arterial supply of the gall bladder and Calot’s triangle.

Fig. 75 Some variations in biliary anatomy. (a) A long cystic duct joining the hepatic duct low down behind the duodenum. (b) Absence of the cystic duct – the gall bladder opens directly into the common hepatic duct. (c) A double gall bladder, the result of a rare bifid embryonic diverticulum from the hepatic duct. (d) The right hepatic artery crosses

in front

of the common hepatic duct; this occurs in 25% of cases.

Fig. 76 Development of the intestinal adnexae.

Fig. 77 The spleen and its immediate relations.

Fig. 78 The posterior relations of the kidney (viewed from behind).

Fig. 79 The anterior relations of the kidneys.

Fig. 80 Variations in the renal pelvis. (a) The pelvis is buried within the renal parenchyma – pyelolithotomy difficult. (b) The pelvis protrudes generously – pyelolithotomy easy.

Fig. 81 (a) Transverse section (seen from below) demonstrating the fascial compartments of the kidney. (b) CT scan of the same region. Note that CT scans, by convention, are viewed from below, so that the aorta, for example, is seen on the right side. The blood vessels have been enhanced by an intravenous injection of contrast.

Fig. 82 Drawing from an intravenous pyelogram to show the relationship of the ureters to the bony landmarks.

Fig. 83 Development of the pro‐, meso‐ and metanephric systems (after Langman).

Fig. 84 Renal abnormalities. (a) Polycystic kidney. (b) Horseshoe kidney. (c) Pelvic kidney (right) and double ureter (left). (d) Aberrant renal artery and associated hydronephrosis.

Fig. 85 (a) The prostate, seminal vesicles and vasa shown in a posterior view of the bladder. (b) The prostate and urethra in vertical section.

Fig. 86 The surgical anatomy of prostatectomy. (a) The normal prostate in vertical section. (b) Detail of the prostatic urethra. (c) A prostatic adenoma (benign hypertrophy) compresses the normal prostatic tissue into a false capsule.

Fig. 87 Testis and epididymis.

Fig. 88 Transverse section of the testis.

Fig. 89 Types of hydrocele. (a) Vaginal hydrocele, (b) congenital hydrocele, (c) infantile hydrocele, (d) hydrocele of the cord. (The tube at the upper end of each diagram represents the internal inguinal ring. Yellow, hydrocele; brown, vas and epididymis.)

Fig. 90 Lateral view of the os innominatum.

Fig. 91 The sacrum in: (a) posterior and (b) anterior views.

Fig. 92 (a) Male and (b) female pelvis compared.

Fig. 93 The measurements of the female pelvis. (a) The inlet; (b) the outlet. (c) Lateral view to show the diagonal conjugate.

Fig. 94 Pelvic variations and abnormalities – shown as diagrammatic outlines of the pelvic inlet.

Fig. 95 Levator ani – inferior aspect. It forms the ‘diaphragm of the pelvis’.

Fig. 96 The male perineum – on the right side the muscles of the anterior perineum have been dissected away.

Fig. 97 (a) The female perineum – on the right side the muscles of the anterior perineum have been dissected away. (b) Distribution of the pudendal nerve to the female perineum.

Fig. 98 The ischiorectal fossa (more accurately called the ischio‐anal fossa).

Fig. 99 Sagittal section of the uterus and its relations.

Fig. 100 Coronal section of the uterus and vagina. Note the important relationships of the ureter and uterine artery.

Fig. 101 Variations in uterine position and their terminology.

Fig. 102 Lateral view of the uterus (schematic) to show the composition of the broad ligament, the relations of the ureter and uterine artery, and the peritoneal covering of the uterus (pink).

Fig. 103 Lymphatic drainage of the uterus and vagina.

Fig. 104 The Fallopian tube, ovary and broad ligament (viewed from behind).

Fig. 105 The pelvic ligaments seen from above.

Fig. 106 Development of the Fallopian tubes, uterus and vagina from the paramesonephric (Müllerian) ducts and the urogenital sinus (after Hollinshead) (a–c), and formation of the broad ligament (d).

Fig. 107 Psoas sheath and psoas abscess. On the right side is a normal psoas sheath; on the left side it is shown distended with pus, which tracks under the inguinal ligament to present in the groin.

Fig. 108 The abdominal aorta, the inferior vena cava and their main branches.

Fig. 109 The aortic bifurcation and the right internal iliac artery. The internal iliac artery divides into anterior and posterior divisions. The latter gives rise to the superior gluteal artery, whereas the former gives off all the visceral branches. (Although the branches of the internal iliac artery are fairly constant, the arrangement of these branches is variable.) Hatching indicates arteries present only in the female.

Fig. 110 CT scan at the level of the 1st lumbar vertebra. This demonstrates the liver, gall bladder, aorta with the commencement of the superior mesenteric artery, the inferior vena cava, the crura of the diaphragm, the kidneys, the pancreas and the spleen. The splenic vein can be seen as it passes to the splenic hilum posterior to the body of the pancreas. The vena cava lies on the right crus. The vessels have been enhanced by an intravenous injection of contrast.

Fig. 111 CT scan at the level of the 2nd lumbar vertebra demonstrating the kidneys, aorta, inferior vena cava, the liver, renal and superior mesenteric vessels, and the muscles of the abdominal wall. The blood vessels, again, have been enhanced by an intravenous injection of contrast.

Chapter 03

Fig. 112 The relationship of the medial and lateral epicondyles to the olecranon process (a) is disturbed in a dislocation of the elbow (b) but maintained in a supracondylar fracture (c).

Fig. 113 The structures on the anterior aspect of the right wrist.

Fig. 114 The structures on the posterior aspect of the right wrist.

Fig. 115 Section immediately above the wrist joint.

Fig. 116 (a) The cubital fossa with the bicipital aponeurosis in detail. (b) The superficial veins of the upper limb. (Note the bicipital aponeurosis situated between the median cubital vein and brachial artery.) (c) Two common arrangements in the formation of the median cubital vein.

Fig. 117 The left scapula and clavicle (anterior aspect).

Fig. 118 The deformity of a fractured clavicle – downward displacement and adduction of the outer fragment by gravity and muscle spasm, respectively; slight elevation of the inner fragment by the sternocleidomastoid.

Fig. 119 The (a) anterior and (b) posterior views of the right humerus. (c) The humerus with its three major related nerves – axillary, radial and ulnar – all of which are in danger of injury in humeral fractures.

Fig. 120 The right radius and ulna – anterior aspect.

Fig. 121 The important role of pronator teres in radial fractures. (a) In proximal fractures, above the insertion of pronator teres, the distal fragment is pronated. Such a fracture must be splinted in the supinated position. (b) When the fracture is distal to the insertion of pronator teres, the action of this muscle on the proximal fragment is cancelled by the supinator action of biceps. This fracture is, therefore, held reduced in the neutral position, midway between pronation and supination.

Fig. 122 The right carpus, metacarpus and phalanges (anterior aspect).

Fig. 123 Transverse section through the distal carpus (right side viewed from the distal end), showing the attachments of the flexor retinaculum. Note the separate osseofascial compartment for the tendon of flexor carpi radialis. Note also that, at this level, the tendon of flexor carpi ulnaris has ‘disappeared’. It attaches to the pisiform, in the proximal row of carpal bones.

Fig. 124 Blood supply of the scaphoid. (a) Blood vessels enter the bone principally in its distal half. (b) A fracture through the waist of the scaphoid – vessels to the proximal fragment are preserved. (c) A fracture near the proximal pole of the scaphoid – in this case there are no vessels supplying the proximal fragment and aseptic necrosis of bone is therefore inevitable.

Fig. 125 The left shoulder joint (viewed from the lateral aspect) – its ligaments are shown after removal of the humerus.

Fig. 126 The shoulder joint – the same view as in Fig. 125, but now with the addition of the surrounding muscles.

Fig. 127 (a) Supraspinatus and the subacromial–subdeltoid bursa. Note that the supraspinatus tendon lies close against the acromion – if this tendon is inflamed, there is a painful arc of movement as the shoulder is abducted from 60° to 120°, because, in this range, the inflamed tendon impinges against the acromion. (b) Magnetic resonance imaging of the shoulder showing the detailed anatomy revealed by this technique.

Fig. 128 The deformity of shoulder dislocation. The dislocated head of the humerus is held adducted by the shoulder girdle muscles and internally rotated by subscapularis.

Fig. 129 The bony components of the elbow joint (right side; anterior aspect). Note the three sets of articular surfaces.

Fig. 130 The joint capsule of the right elbow – lateral aspect.

Fig. 131 The supination action of biceps (right elbow viewed from the medial side with the ulna removed).

Fig. 132 The wrist, carpal and carpometacarpal joints in section.

Fig. 133 The tendons of a finger. (a) Lateral view. (b) Dorsal (posterior) view.

Fig. 134 Dissection of the right forearm (anterior aspect) to show the principal vessels and nerves. The superficial forearm muscles of the common flexor origin have been removed, apart from pronator teres, which has been partly divided.

Fig. 135 Scheme of the brachial plexus.

Fig. 136 The derivatives of the brachial plexus. The lightly coloured areas show the posterior divisions.

Fig. 137 The segmental cutaneous innervation of the body. (a) Posterior aspect; (b) anterior aspect.

Fig. 138 The distribution of the radial nerve (right upper limb, dorsal aspect).

Fig. 139 Dissection of the right axilla and upper arm to show the course of the major nerves.

Fig. 140 The usual cutaneous distribution (shown in yellow) of the (a) median, (b) ulnar and (c) radial nerves in the hand (considerable variations and overlap occur).

Fig. 141 The principal pathways of lymphatic drainage of the breast. These follow the venous drainage of the breast – to the axilla and to the internal mammary (internal thoracic) chain.

Fig. 142 The lymph nodes of the axilla.

Fig. 143 Deformities of the hand. (a) Radial palsy – wrist drop. (b) Ulnar nerve palsy – ‘main en griffe’ or claw hand. (c) Median nerve palsy – ‘monkey’s hand’. (d) Volkmann’s contracture – another claw hand deformity. The yellow areas represent the usual distribution of anaesthesia.

Fig. 144 The distal pulp space of the finger; note the distribution of the arterial supply to the distal phalanx.

Fig. 145 The synovial sheaths of the flexor tendons of the hand (left) – the radial and ulnar bursae track proximally deep to the flexor retinaculum and provide a potential pathway of infection into the forearm. In many cases, these bursae communicate.

Fig. 146 The mid‐palmar and thenar spaces (left hand): (a) projected onto the surface of the hand and (b) in transverse section (viewed from the proximal aspect).

Chapter 04

Fig. 147 Apparent shortening – one limb may be apparently shorter than the other because of fixed deformity; the legs in this illustration are actually equal in length but the right is

apparently

considerably shorter because of a gross flexion contracture at the hip. Apparent shortening is measured by comparing the distance from the umbilicus to the medial malleolus on each side.

Fig. 148 Measuring real shortening – the patient lies with the pelvis ‘square’ and the legs placed symmetrically. Measurement is made from the anterior superior spine to the medial malleolus on each side.

Fig. 149 (a) Nelaton’s line joins the anterior superior iliac spine to the ischial

tuberosity

– normally this passes above the greater trochanter. (b) Bryant’s triangle – in the supine subject, drop a vertical from each superior spine; compare the perpendicular distance from this line to the greater trochanter on either side. (There is no need to complete the third side of the triangle.)

Fig. 150 The structures passing over the dorsum of the ankle (right ankle, anterior aspect).

Fig. 151 The structures passing behind the medial malleolus (right ankle, medial aspect).

Fig. 152 The surface markings of the femoral artery; the upper two‐thirds of a line joining the mid‐inguinal point (halfway between the anterior superior iliac spine and the symphysis pubis) to the adductor tubercle.

Fig. 153 The relationship of the great (long) saphenous vein to the medial malleolus (right ankle).

Fig. 154 The close relationship of the common peroneal nerve to the neck of the fibula; at this site it may be compressed by a tight bandage or plaster cast (right knee, lateral aspect).

Fig. 155 The surface markings of the sciatic nerve (left gluteal region). Join the midpoint between the ischial tuberosity and posterior superior iliac spine to the midpoint between the ischial tuberosity and the greater trochanter by a curved line; continue this line vertically down the leg – it represents the course of the sciatic nerve.

Fig. 156 The ‘safe area’ for injections in the buttock.

Fig. 157 The anterior aspect of the right femur.

Fig. 158 The posterior aspect of the right femur.

Fig. 159 The sources of blood supply to the femoral head – along the ligamentum teres, through the diaphysis and via the retinacula.

Fig. 160 The head and neck of the femur, showing the terminology of the common fracture sites.

Fig. 161 (a) A pertrochanteric fracture does not damage the retinacular blood supply – aseptic bone necrosis does not occur. (b) A subcapital fracture cuts off most of the retinacular supply to the head – aseptic bone necrosis is common. Note that the blood supply via the ligamentum teres is negligible in adult life.

Fig. 162 The deformities of femoral shaft fractures. (a) Fracture of the proximal shaft – the proximal fragment is flexed by iliacus and psoas and abducted by gluteus medius and minimus. (b) Fracture of the mid‐shaft – flexion of the proximal fragment by iliacus and psoas. (c) Fracture of the distal shaft – the distal fragment is angulated backwards by gastrocnemius; the popliteal artery may be torn in this injury. (In all these fractures overriding of the bone ends is produced by muscle spasm.)

Fig. 163 Factors in the stability of the patella: (a) the medial pull of vastus medialis and (b) the high patellar articular surface of the lateral femoral condyle. These resist the tendency for lateral displacement of the patella, which results from the valgus angulation between the femur and the tibia.

Fig. 164 The tibia and fibula of the right side. (a) Anterior aspect. (b) Posterior aspect.

Fig. 165 (a) The immediate relations of the hip joint (in diagrammatic horizontal section; right hip, viewed from proximal aspect). (b) Scout diagram indicating the level of the section.

Fig. 166 The anterior aspect of the right hip. Note that the psoas tendon and the femoral artery are intimate anterior relations of the joint.

Fig. 167 Dislocation of the hip. If the hip is forced into posterior dislocation while adducted (a), there is no associated fracture of the posterior acetabular lip (b). Dislocation in the abducted position (c) can occur only with a concomitant acetabular fracture (d). (The inset figure indicates the plane of these diagrams.)

Fig. 168 (a) The right knee – anterior view; the knee is flexed and the patella has been turned downwards. (b) The right knee in transverse section.

Fig. 169 The actions of the cruciate ligaments.

Fig. 170 The left ankle. (a) In coronal section (viewed from behind). (b) Medial aspect. (c) Lateral aspect.

Fig. 171 The longitudinal arches of the right foot. (a) Medial view. (b) Lateral view.

Fig. 172 Plantar aspect of the left foot to show the attachments of the important ligaments and long tendons. (The head of the talus is hidden, deep to the spring ligament.)

Fig. 173 The right femoral triangle and its contents.

Fig. 174 The femoral canal and its surrounds (right inguinal region).

Fig. 175 The relationship of an indirect inguinal and a femoral hernia to the pubic tubercle; the inguinal hernia emerges above and medial to the tubercle, the femoral hernia lies below and lateral to it (right inguinal region).

Fig. 176 Cross‐section through the right thigh in the region of the adductor, or subsartorial, canal of Hunter (viewed from the proximal aspect).

Fig. 177 The right popliteal fossa. (a) Superficial dissection. (b) Deep dissection. (c) Floor.

Fig. 178 The relations of the posterior tibial artery as it passes behind the medial malleolus (right ankle region).

Fig. 179 The superficial veins of the left lower limb. (a) Anteromedial. (b) Posterior view.

Fig. 180 Plan of the lumbar plexus (muscular branches have been omitted for clarity).

Fig. 181 Plan of the sacral plexus.

Fig. 182 The sciatic foramina (right side). (a) Contents and related muscles. (b) Boundaries and ligamentous framework.

Fig. 183 Dissection of the sciatic nerve in the thigh and popliteal fossa (right side). Note that gluteus medius has been removed to show the otherwise completely hidden gluteus minimus.

Fig. 184 The segmental cutaneous nerve supply of the skin. (a) Posterior aspect. (b) Anterior aspect.

Fig. 185 Cross‐sectional representation of the compartments of the right leg. EDL, extensor digitorum longus; FDL, flexor digitorum longus; FHL, flexor hallucis longus; LG, lateral head of gastrocnemius; MG, medial head of gastrocnemius; PB, peroneus brevis; PL, peroneus longus; S, soleus; TA, tibialis anterior; TP, tibialis posterior.

Chapter 05

Fig. 186 Structures palpable on the anterior aspect of the neck, together with their corresponding vertebral levels.

Fig. 187 The triangles of the neck.

Fig. 188 (a) Transverse section of the neck through C6, showing the fascial planes and also the contents of the pretracheal fascia (or ‘visceral compartment of the neck’). (b) Computed tomography (CT) scan through the C6 level; compare this with (a).

Fig. 189 The thyroid and its blood vessels.

Fig. 190 The descent of the thyroid, showing possible sites of ectopic thyroid tissue or thyroglossal cysts, and also the course of a thyroglossal fistula. (The arrow shows the further descent of the thyroid that may take place retrosternally into the superior mediastinum.)

Fig. 191 The relationship of the recurrent laryngeal nerve to the thyroid gland and the inferior thyroid artery. (a) The nerve is usually deep to the artery but may be (b) superficial to it or (c) pass through its branches. In these diagrams the lateral lobe of the thyroid is pulled forwards, as it would be in a thyroidectomy.

Fig. 192 The normal sites of the parathyroid glands (posterior aspect).

Fig. 193 Normal and abnormal sites of the parathyroid glands (lateral view).

Fig. 194 The derivatives of the branchial pouches. Note that the inferior parathyroid migrates downwards from the 3rd pouch, whereas the superior parathyroid (4th pouch) remains stationary.

Fig. 195 The ventral aspect of a fetal head showing the three processes, frontonasal, maxillary and mandibular, from which the face, nose and jaws are derived.

Fig. 196 Types of (a) cleft lip and (b) cleft palate.

Fig. 197 Lateral view of the tongue, its extrinsic muscles and its nerves.

Fig. 198 The lymphatic drainage of the tongue. Note two points. (i) The anterior part of the tongue tends to drain to the nodes farthest down the deep cervical chain, whereas the posterior part drains to the upper chain. (ii) The anterior two‐thirds of the tongue drain unilaterally, the posterior one‐third bilaterally.

Fig. 199 Stages in the development of the tongue.

Fig. 200 Coronal section of the floor of the mouth.

Fig. 201 (a) Schematic sagittal section through the head and neck to show the subdivisions of the pharynx. (b) Interior of the pharynx viewed from behind after removing the posterior wall of the pharynx.

Fig. 202 Diagram of the palatine tonsil and its relations – in horizontal section.

Fig. 203 The constrictor muscles of the pharynx.

Fig. 204 A pharyngeal pouch emerging between the two components of the inferior constrictor muscle.

Fig. 205 External view of the larynx. (a) Anterior aspect. (b) Anterolateral aspect (with the thyroid gland removed).

Fig. 206 (a) The internal structure of the larynx – the lamina of the thyroid cartilage has been cut away. (b) The larynx dissected from behind, with cricoid cartilage divided, to show the true and false vocal cords with the sinus of the larynx between. (c) The cartilages and ligaments of the larynx seen from behind (see facing page).

Fig. 207 The larynx as seen at laryngoscopy.

Fig. 208 The parotid and its surrounds in a schematic horizontal section – the facial nerve is the most superficial of the structures traversing the gland. (The line of section is shown in the inset head.)

Fig. 209 The named branches of the facial nerve which traverse the parotid gland. B, buccal; C, cervical; M, mandibular; P, posterior auricular; T, temporal; Z, zygomatic.

Fig. 210 The carotid arteries, their branches and their related nerves.

Fig. 211 The arterial supply of the cerebral cortex. Right cerebral hemisphere. (a) Lateral aspect. (b) Medial aspect.

Fig. 212 The circle of Willis.

Fig. 213 The root of the neck. For clarity, only the vagus nerve is shown on the right and only the phrenic nerve on the left, as this lies on scalenus anterior.

Fig. 214 The venous dural sinuses. (a) Lateral view. (b) Superior view.

Fig. 215 The cavernous sinus – shown in coronal section.

Fig. 216 The usual arrangement of the veins in the neck.

Fig. 217 The great veins of the neck and their tributaries.

Fig. 218 The anatomy of the infraclavicular approach to the subclavian vein. (a) Anterior view. (b) In sagittal section.

Fig. 219 Scheme of the lymph nodes of the head and neck.

Fig. 220 The cervical sympathetic chain.

Fig. 221 The layers of the scalp.

Fig. 222 The skull. (a) Anterior aspect. (b) Lateral aspect.

Fig. 223 The skull. (a) Inferior aspect. (b) Floor of the cranial cavity: the anterior, middle and posterior cranial fossae are colour coded.

Fig. 224 The fetal skull. (a) Anterior aspect. (b) Lateral aspect.

Fig. 225 The lateral wall of the right nasal cavity; the conchae have been partially removed to show structures that drain into the nose.

Fig. 226 (a) The maxillary antrum in coronal section. (Note the inefficient drainage of this antrum and its close inferior relationship to the teeth.) (b) The corresponding computed tomography (CT) scan.

Fig. 227 The mandible. (a) Lateral aspect. (b) Medial aspect.

Fig. 228 A ‘typical’ thoracic vertebra. (a) Lateral aspect. (b) Superior aspect.

Fig. 229 A ‘typical’ cervical vertebra.

Fig. 230 The atlas in superior view.

Fig. 231 The axis in oblique lateral view.

Fig. 232 A lumbar vertebra (superior aspect).

Fig. 233 (a) Longitudinal section through the lumbar vertebrae showing a normal and a prolapsed intervertebral disc. (b) Magnetic resonance imaging (MRI) through a normal lumbar spine and sacrum. Note the excellent anatomical details.

Chapter 06

Fig. 234 (a) The base of the brain showing the cranial nerve roots and their relationships to the circle of Willis. (b) Anterior aspect of the brainstem. (c) Posterior aspect of the brainstem.

Fig. 235 The thalamus and 3rd ventricle in coronal section.

Fig. 236 Localization of function in the cerebral cortex. (a) Lateral aspect. (b) Medial aspect.

Fig. 237 The basal ganglia and internal capsule shown in horizontal section through the cerebrum.

Fig. 238 The long ascending pathways of the dorsal columns (yellow lines) and spinothalamic tracts (red lines).

Fig. 239 The long descending pathway of the pyramidal tract.

Fig. 240 The ventricular system.

Fig. 241 (a) Computed tomography (CT) scan of the skull through the level of the bodies of the lateral ventricles. (b) CT scan cut through the level of the anterior horns of the lateral ventricles.

Fig. 242 Computed tomography (CT) scan cut through the level of the 3rd ventricle.

Fig. 243 Magnetic resonance imaging (MRI) sagittal section of the head. Note the fine details of brain structure which can be visualized by this technique.

Fig. 244 The spinal cord – transverse section through a thoracic segment.

Fig. 245 The location of the important spinal tracts. (The descending tracts are shown on the left, the ascending tracts on the right.)

Fig. 246 The relationship between the spinal cord and the vertebrae in the 3‐month fetus and in the newborn child.

Fig. 247 The range of variation in the termination of the spinal cord in the adult.

Fig. 248 The membranes of the spinal cord.

Fig. 249 (a) The lumbar interlaminar gap when the spine is flexed; this anatomical fact makes lumbar puncture possible. The locations of the spines of L2 and L4 in the extended position are shown cross‐hatched. (b) The anatomy of lumbar puncture.

Fig. 250 The layers of the retina.

Fig. 251 (a) The optic pathway. (b) Scheme of field defects. A–D denote sites of interruption of the visual pathway.

Fig. 252 The cavernous sinus – showing the relations of the IIIrd, IVth, Vth and VIth cranial nerves.

Fig. 253 Plan of the trigeminal nerve and its nuclei in dorsal view.

Fig. 254 Distribution of the trigeminal nerve.

Fig. 255 Areas of the face and scalp supplied by the three divisions of the trigeminal nerve.

Fig. 256 The superior orbital fissure and tendinous ring of origin of the extrinsic orbital muscles, showing the relations of the cranial nerves as they enter the orbit (schematic; left orbit viewed from the front).

Fig. 257 Distribution of the facial nerve within the temporal bone.

Fig. 258 Distribution of the facial nerve: B, buccal; C, cervical; M, mandibular; P, posterior auricular branch; T, temporal; Z, zygomatic.

Fig. 259 The distal course of the hypoglossal nerve.

Fig. 260 The septum of the nose.

Fig. 261 General view of the ear.

Fig. 262 The tympanic membrane as seen through an otoscope.

Fig. 263 Detail of the membranous labyrinth.

Fig. 264 (a) The eyeball in section. (b) Detail of the ciliary region.

Fig. 265 The right fundus oculi as seen through an ophthalmoscope.

Fig. 266 The direction of action of the muscles acting on the eyeball from the primary position (i.e. looking directly forwards).

Fig. 267 Compartments of the orbit.

Fig. 268 The lacrimal gland and its drainage system.

Fig. 269 The essential difference between the cerebrospinal and autonomic outflows: (a) the cerebrospinal system has its lowest efferent nerve cell‐stations within the central nervous system; (b) the autonomic system has its lowest efferent cell‐stations in a peripheral ganglion (here illustrated by a typical sympathetic nerve ganglion). Red, afferent pathway; yellow, efferent pathway.

Fig. 270 The three fates of sympathetic white rami. These may (A) relay in their corresponding ganglion and pass to their corresponding spinal nerve for distribution, (B) ascend or descend in the sympathetic chain and relay in higher or lower ganglia, or (C) pass without synapse to a peripheral ganglion for relay.

Fig. 271 The abdominal sympathetic plexuses.

Fig. 272 The anatomical basis of widespread sympathetic and local parasympathetic response. (a) The widespread distribution of postganglionic fibres from a single sympathetic white ramus. (b) The localized distribution of postganglionic parasympathetic fibres.

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To my wife, Wendy, and my late parents

H. E.

To my wife, Neila, and my late parents

V. M.

Clinical Anatomy

Applied Anatomy for Students and Junior Doctors

HAROLD ELLIS

CBE, MA, DM, MCh, FRCS, FRCP, FRCOG, FACS (Hon)

Clinical Anatomist, Guy’s, King’s and St Thomas’ School of Biomedical Sciences;

Emeritus Professor of Surgery, Charing Cross and Westminster Medical School, London;

Formerly Examiner in Anatomy, Primary FRCS (Eng)

VISHY MAHADEVAN

MBBS, PhD, FRCSEd, FDSRCSEng (Hon), FRCS

Barbers’ Company Professor of Anatomy & Professor of Surgical Anatomy

The Royal College of Surgeons of England

Lincoln’s Inn Fields

London;

Member of the Court of Examiners, RCS England

FOURTEENTH EDITION

This edition first published 2019 © 2019 by John Wiley & Sons Ltd

Edition HistoryHarold Ellis (1960, 1962, 1966, 1969, 1971, 1977, 1977, 1983, 1992, 1992, 2002, 2006); Harold Ellis and Vishy Mahadevan (2010); John Wiley & Sons Ltd (2013).

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Harold Ellis and Vishy Mahadevan to be identified as the authors of this work has been asserted in accordance with law.

Registered OfficesJohn Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USAJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Office9600 Garsington Road, Oxford, OX4 2DQ, UK

For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com.

Wiley also publishes its books in a variety of electronic formats and by print‐on‐demand. Some content that appears in standard print versions of this book may not be available in other formats.

Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

A catalogue record for this book is available from the Library of Congress and the British Library.

ISBN 9781119325536

Cover image: © graphiks‐walid/ShutterstockCover design by Wiley

Preface to the Fourteenth Edition

As a teacher of medical students and surgical trainees, I know that much of clinical examination and diagnosis depends on an adequate knowledge of anatomy. No matter how good the doctors are at communication skills and patient empathy, unless they know what lies beneath their examining fingers or under the bell of their stethoscopes, they will have great difficulty in the interpretation of clinical signs. Understanding and interpreting the exquisite details of modern radiological imaging also requires a good knowledge of the structure of the human body.

This was true over 55 years ago when I wrote the first edition of this book, and is perhaps even more so today, when the content of anatomical knowledge in the medical student’s curriculum has been greatly reduced.

Over these many years, during which time I have taught students and postgraduates in five medical schools, and examined them in eight countries and sixteen universities, my belief in the importance of an adequate knowledge of anatomy as an adjunct to clinical training has been strongly reinforced.

In the preparation of the 12th edition (Golden Jubilee edition) and the subsequent two editions (including this one), I have been fortunate indeed in having been able to recruit Professor Vishy Mahadevan, the Barbers’ Company Professor of Anatomy at the Royal College of Surgeons of England, as co‐author. He is a renowned and revered teacher of surgical trainees as well as being a current examiner in the MRCS and in overseas medical schools. Together, in this new edition, we have carried out a careful revision and updating of the text and diagrams.

We hope that this book will continue to help our students and postgraduate trainees throughout the English‐speaking world.

Harold EllisJuly 2018

Preface to the First Edition

Experience of teaching clinical students at three medical schools has convinced me that there is still an unfortunate hiatus between the anatomy which the student learns in his pre‐clinical years and that which he later encounters in the wards and operating theatres.

This book attempts to bridge this gap. It does so by high‐lighting those features of anatomy which are of clinical importance, in medicine and midwifery as well as in surgery. It presents the facts which a student might reasonably be expected to carry with him during his years on the wards, through final examinations and into his post‐graduate years; it is designed for the clinical student.

Anatomy is a vast subject and therefore, in order to achieve this goal, I have deliberately carried out a rigorous selection of material so as to cover only those of its thousands of facts which I consider form the necessary anatomical scaffolding for the clinician. Wherever possible practical applications are indicated throughout the text – they cannot, within the limitations of a book of this size, be exhaustive, but I hope that they will act as signposts to the student and indicate how many clinical phenomena can be understood and remembered on simple anatomical grounds.

Harold EllisOxford, 1960

Acknowledgements to the Fourteenth Edition

We wish to thank the many students, undergraduates and postgraduates who have taken the trouble to send us constructive suggestions, many of which have been incorporated into this new edition.

Our thanks to Jane Fallows whose skilfully produced illustrations we continue to use in this edition.

CT and MRI scans were provided by Dr Sheila Rankin and Dr Jeremy Rabouhans of the Department of Radiology at Guy’s Hospital, and Professor Adrian Dixon of Cambridge. Our thanks to all three.

Our gratitude to Ruth Swan for her diligent scrutiny and editing of the text in the latter stages of the production of this volume, and for her invaluable editorial advice and help.

We are grateful to the following authors for permission to reproduce illustrations:

The late Lord Brock for

Figs 20

and

21

(from

Lung Abscess

); and

Professor R. G. Harrison for

Figs 12

,

32

and

67

(from

A Textbook of Human Embryology

).

Finally, we wish to express our profound debt and profuse gratitude to Nick Morgan, James Watson, Jennifer Seward, Loan Nguyen and the staff of Wiley Blackwell for their generous and unfailing help, guidance and support.

Harold EllisVishy MahadevanJuly 2018

Acknowledgements to the First Edition

I wish to thank Dr Max Cowan of the Department of Anatomy, Oxford, who has given freely of advice and criticism in the production of this book.

My colleagues – the registrars and house surgeons at the Radcliffe Infirmary – have kindly perused and commented on the text and have given valuable help in proof‐reading.

The majority of the illustrations are by Miss Margaret McLarty and Miss Audrey Arnott; I must thank them sincerely for all their care.

I am grateful to the following authors for permission to reproduce illustrations:

Sir Russell Brock for

Fig. 15

(from

Lung Abscess

); Professor R. G. Harrison for

Figs 10

,

23

,

53

,

67

and

155

(from

A Textbook of Human Embryology

); Professor David Sinclair for

Figs 69

,

92

,

95

,

97

,

100

–1,

105

,

107

,

114

,

126

,

132

,

137

,

139

,

177

and

181

(from

An Introduction to Functional Anatomy

); and Professor Sheila Sherlock for

Fig. 55

(from

Diseases of the Liver and Biliary System

).

The illustrations for an anatomical textbook are inevitably a costly item, yet I was anxious that this book should be within the budget of the students for whom it is primarily intended. It is therefore a pleasure to acknowledge here the generosity of Upjohn of England Ltd in contributing towards the cost of the blocks: their gesture will be widely appreciated.

To my sister, Mrs L. Witte, go my grateful thanks for invaluable secretarial assistance. Finally, I wish to express my debt to Mr Per Saugman and staff at Blackwell Scientific Publications for guiding the hesitant steps of the beginner.

Harold Ellis

About the Companion Website

Clinical Anatomy has its own resources website:

www.ellisclinicalanatomy.co.uk/14edition

with digital flashcards of the images from the book for easy revision.

Part 1The Thorax

Introduction

The clinical anatomy of the thorax, together with the anatomy of radiological and other imaging techniques of the thorax are in daily use in clinical practice. The routine clinical examination of the patient’s chest is little more than an exercise in relating the deep structures of the thorax to the chest wall. Moreover, several commonly undertaken procedures – chest aspiration, insertion of a chest drain or of a subclavian line, placement of a cardiac pacemaker, for example – have their basis, and their safe performance, in sound anatomical knowledge.

Surface anatomy and surface markings

Much of the working life of an experienced clinician is spent in relating the patient’s surface anatomy to underlying deep structures (Fig. 1; see also Figs 11, 22).

Fig. 1 Lateral view of the thorax – its surface markings and vertebral levels. (Note that the angle of Louis (T4/5) demarcates the lower boundary of the superior mediastinum, the upper margin of the heart and the beginning and end of the aortic arch.)

The following bony prominences can usually be palpated in the living subject (corresponding vertebral levels are given in brackets):

superior angle of the scapula (T2);

upper border of the manubrium sterni, the suprasternal notch (T2/3);

spine of the scapula (T3);

sternal angle (of Louis) – the transverse ridge at the manubriosternal junction (T4/5);

inferior angle of the scapula (T8); it also overlies the 7th rib;

xiphisternal joint (T9);

lowest part of the costal margin – 10th rib (the subcostal line passes through L3).

Note from Fig. 1 that the manubrium sterni corresponds to the 3rd and 4th thoracic vertebrae and overlies the aortic arch, and that the body of the sternum corresponds to the 5th–8th vertebrae and neatly overlies the heart.

Since the 1st and 12th ribs are difficult to feel, the ribs should be enumerated from the 2nd costal cartilage, which articulates with the sternum at the angle of Louis.

The spinous processes of all the thoracic vertebrae can be palpated in the midline posteriorly, but it should be remembered that the first spinous process that can be felt is that of C7 (the vertebra prominens).

The position of the nipple varies considerably in the female, but in the male it usually overlies the 4th intercostal space approximately 10 cm (4 in) from the midline. The apex beat, which marks the lowest and outermost point at which the cardiac impulse can be palpated, is normally in the 5th intercostal space 9 cm (3.5 in) from the midline and within the midclavicular line. (This corresponds to just below and medial to the nipple in the male, but it is always preferable to use bony rather than soft‐tissue points of reference.)

The trachea is palpable in the suprasternal notch midway between the heads of the two clavicles.

The trachea (Figs 1, 2)

Fig. 2 The surface markings of the lungs and pleura – anterior view.

The trachea commences in the neck at the level of the lower border of the cricoid cartilage (C6) and runs vertically downwards to end below the level of the sternal angle of Louis (T4/5), just to the right of the midline, by dividing to form the right and left main bronchi. In the erect position and in full inspiration the level of bifurcation is at T6.

The pleura (Figs 2, 3)

Fig. 3 The surface markings of the lungs and pleura – posterior view.

The cervical pleura can be marked out on the surface by a curved line drawn from the sternoclavicular joint to the junction of the medial and middle thirds of the clavicle; the apex of the pleura is approximately 2.5 cm (1 in) above the clavicle. This fact is easily explained by the oblique slope of the first rib. It is important because the pleura can be wounded (with consequent pneumothorax) by a stab wound – and this includes the surgeon’s knife and the anaesthetist’s needle – above the clavicle, or, in an attempted subclavian vein catheterization, below the clavicle. The lines of pleural reflexion pass from behind the sternoclavicular joint on each side to meet in the midline at the 2nd costal cartilage (the angle of Louis). The right