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E-kniha: Regional anatomy - Josef Stingl; Miloš Grim; Rastislav Druga

Regional anatomy

Elektronická kniha: Regional anatomy
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Publikace vznikla jako základní učební text pro zahraniční studenty na lékařských fakultách v České republice. Obsahuje topografickou anatomii lidského těla, které je členěno na ... (celý popis)
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Popis

Publikace vznikla jako základní učební text pro zahraniční studenty na lékařských fakultách v České republice. Obsahuje topografickou anatomii lidského těla, které je členěno na jednotlivé krajiny podle klinických a praktických potřeb. U každé krajiny je vymezen její rozsah, popsán její reliéf a hmatné útvary a uvedena projekce orgánů. Obsah krajiny je popsán po vrstvách ve vztahu k fasciím a osteofasciálním prostorům a s ohledem na chirurgické přístupy. Uvedena je poloha a vzájemné vztahy orgánů, není však popisována jejich anatomická stavba, která je obsahem dílčích částí základních učebnic oboru.

Nedílnou součástí učebnice je barevná obrazová dokumentace malířů Ivana Helekala a Jana Kacvinského, doplněná několika obrazy Stanislava Macháčka a snímky CT a MR z archivu rtg oddělení Nemocnice Na Homolce.

Dílo poskytuje dostatečně ilustrovaný popis regionální anatomie celého těla, který svým rozsahem odpovídá současným požadavkům pregraduálního studia, navíc poskytne základní informace i začínajícímu lékaři.

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Žádná část této tištěné či elektronické knihy nesmí být reprodukována a šířena v papírové,

elektronické či jiné podobě bez předchozího písemného souhlasu nakladatele.

Neoprávněné užití této knihy bude trestně stíháno.

Galén

Na Bělidle 34, 150 00 Praha 5

www.galen.cz

© Galén, 2012


Josef Stingl, Miloš Grim, Rastislav Druga

REGIONAL

ANATOMY

Karolinum

Galén


Přeloženo z českého originálu

Miloš Grim, Rastislav Druga et al. Základy anatomie.

Josef Stingl, Miloš Grim, Rastislav Druga. 5. Anatomie krajin těla. Praha: Galén–Karolinum 2002 a 2008.

Autoři

prof. MUDr. Josef Stingl, CSc. / Anatomický ústav, 3. lékařská fakulta, Univerzita Karlova v Praze

prof. MUDr. Miloš Grim, DrSc. / Anatomický ústav, 1. lékařská fakulta, Univerzita Karlova v Praze

prof. MUDr. Rastislav Druga, DrSc. / Anatomický ústav, 2. lékařská fakulta, Univerzita Karlova v Praze

Recenzenti českého vydání

prof. MUDr. Radomír Čihák, DrSc. / Anatomický ústav, 1. lékařská fakulta, Univerzita Karlova v Praze

prof. MUDr. Pavel Pafk o, DrSc. / III. chirurgická klinika, 1. lékařská fakulta, Univerzita Karlova v Praze, FN v Motole

Ilustrace

Mgr. Jan Kacvinský

akad. mal. Ivan Helekal

Anatomický ústav, 1. lékařská fakulta, Univerzita Karlova v Praze

Stanislav Macháček

Překladatelé do angličtiny

prof. MUDr. David Sedmera, DSc., editor anglického překladu

Mgr. Jana Bednářová

MUDr. Zdeněk Fík

MUDr. Ivo Klepáček, CSc.

MUDr. Ondřej Kodet

Marek Kolár

MUDr. Lukáš Lacina, Ph.D.

MUDr. Veronika Němcová, CSc.

MUDr. Živorad Peševski

Kristýna Špillerová

doc. MUDr. Petr Valášek, Ph.D.

Anatomický ústav, 1. lékařská fakulta, Univerzita Karlova v Praze

Odborná jazyková revize

Natasha Agabalyan / University of Sussex, Brighton, United Kingdom

Knižní vydání / 2012

Nakladatelství Galén, Na Bělidle 34, 150 00 Praha 5

a Univerzita Karlova v Praze, nakladatelství Karolinum, Ovocný trh 3-5, 116 36 Praha 1

Josef Stingl, Miloš Grim, Rastislav Druga

REGIONAL ANATOMY

První vydání v elektronické verzi

Vydalo nakladatelství Galén, Na Bělidle 34, 150 00 Praha 5

Editor nakladatelství PhDr. Lubomír Houdek

Šéfredaktorka nakladatelství PhDr. Soňa Dernerová

Odpovědný redaktor Mgr. Radek Lunga

Sazba Milena Honců, DTP Galén

G 311070

Všechna práva vyhrazena.

Tato publikace ani žádná její část nesmějí být reprodukovány, uchovávány v rešeršním systému

nebo přenášeny jakýmkoli způsobem (včetně mechanického, elektronického, fotografi ckého či jiného záznamu)

bez písemného souhlasu nakladatelství.

© Galén, 2012

ISBN 978-80-7262-931-2 (PDF)

ISBN 978-80-7262-932-9 (PDF pro čtečky)


5

Foreword .................................................................... 7

1 Regions of the head, regiones capitis

1.1 Th e brain case ................................................ 9

1.1.1 Frontal, parietal and temporal region ................9

Vascular and nerve supply to the scalp ........... 10

1.1.2 External surface of the cranial base ................. 11

1.1.3 Internal surface of the cranial base .................. 11

1.2 Superfi cial regions of the face ......................14

1.2.1 Orbital region .................................................... 14

1.2.2 Nasal region ........................................................ 15

1.2.3 Oral region .......................................................... 15

1.2.4 Buccal region ...................................................... 17

1.2.5 Parotideomasseteric region .............................. 19

1.2.6 Mental region ..................................................... 19

1.3 Deep regions of the face ...............................19

1.3.1 Infratemporal region ......................................... 19

1.3.2 Pterygopalatine fossa ......................................... 22

1.3.3 Pterygomandibular space ................................. 22

1.3.4 Parapharyngeal space ........................................ 22

1.3.5 Retropharyngeal space ...................................... 22

1.3.6 Th e orbit .............................................................. 22

Orbital content ................................................... 24

1.3.7 Nasal cavity ......................................................... 26

1.3.8 Oral cavity ........................................................... 27

1.3.9 Tonsilar region ................................................... 29

1.3.10 Sublingual region ............................................... 29

2 Regions of the neck, regiones cervicales

2.1 Anterior triangle of the neck ........................31

2.1.1 Muscular triangle (omotracheal) ..................... 31

2.1.2 Submandibular triangle, digastric triangle ..... 36

2.1.3 Submental triangle ............................................. 39

2.1.4 Carotid triangle .................................................. 39

2.1.5 Sternocleidomastoid region .............................. 41

2.1.6 Scalenovertebral triangle .................................. 42

2.2 Lateral region of the neck .............................42

3 Regions of the trunk, regiones trunci

3.1 Regions of the chest ......................................43

3.1.1 Topography of the thoracic wall ...................... 44

3.1.2 Presternal region ................................................ 45

3.1.3 Pectoral region, clavipectoral triangle ............. 46

3.1.4 Pleural cavities .................................................... 48

Boundaries of the pleura and their projection

on the chest surface ........................................... 49

Boundaries and projection of the lungs

on the chest surface ........................................... 50

Projection of the heart ....................................... 50

3.1.5 Mediastinum....................................................... 52

Superior mediastinum ....................................... 52

Inferior anterior mediastinum ......................... 57

Inferior middle mediastinum ........................... 57

Inferior posterior mediastinum ....................... 57

3.2 Regions of the abdomen ...............................57

3.2.1 Projection of organs onto the anterior

abdominal wall ................................................... 58

3.2.2 Abdominal wall structure ................................. 59

3.2.3 Inguinal region, the groin ................................. 61

3.2.4 Peritoneal cavity ................................................. 62

3.2.4.1 Supramesocolic part of the peritoneal

cavity .................................................................... 62

 Lesser sac ....................................................... 64

 Position and syntopy of the liver ................ 64

 Position and syntopy of the gallbladder

and the biliary ducts ..................................... 65

 Syntopy of the abdominal oesophagus ...... 67

 Position and syntopy of the stomach ......... 67

 Position and syntopy of the spleen ............. 67

 Position and syntopy of the duodenum .... 67

 Position and syntopy of the pancreas ........ 69

3.2.4.2 Inframesocolic part of the peritoneal cavity .... 71

 Right inframesocolic space ......................... 73

 Left inframesocolic space ............................ 73

 Organs in the inframesocolic space ........... 73

3.2.5 Retroperitoneum ................................................ 75

 Th e middle part of the retroperitoneal

space ............................................................... 75

Contents


6 Basic Anatomy

 Th e lateral part of the retroperitoneal

space ............................................................... 75

3.3 Regions of the pelvis .....................................77

3.3.1 Position and syntopy of the urinary bladder .. 77

3.3.2 Position and syntopy of the rectum ................. 78

3.3.3 Topography of the male pelvis ......................... 79

3.3.4 Topography of the female pelvis ...................... 80

3.3.5 Perineal regions .................................................. 81

 Male urogenital region ................................ 82

 Female urogenital region ............................. 83

 Anal region .................................................... 84

 Ischioanal (ischiorectal) fossa ..................... 85

3.4 Regions of the back and nuchal regions ......86

3.4.1 Dorsal regions .................................................... 86

3.4.2 Posterior cervical (nuchal) region ................... 86

3.4.3 Vertebral and sacral region ............................... 90

 Topography of the vertebral canal .............. 90

3.4.4 Lumbar region .................................................... 90

4 Regions of the upper limb,

regiones membri superioris

4.1 Scapular region .............................................93

4.2 Deltoid region ...............................................93

4.3 Th e axilla .......................................................95

4.4 Anterior and posterior region of the arm ....98

4.5 Elbow regions ...............................................99

 Anterior cubital region ................................ 99

 Posterior cubital region ............................. 101

4.6 Regions of forearm .....................................101

 Anterior antebrachial region ..................... 101

 Posterior antebrachial region .................... 102

4.7 Wrist regions ...............................................103

 Anterior carpal region .............................. 103

 Posterior carpal region ............................. 105

4.8 Palmar region .............................................106

4.9 Dorsum of the hand....................................107

4.10 Th e fi ngers...................................................107

5 Regions of lower limb,

regiones membri inferioris

5.1 Gluteal region .............................................109

5.2 Femoral regions ..........................................109

 Anterior femoral region ............................ 110

 Posterior femoral region ............................ 114

5.3 Knee regions ...............................................115

 Anterior knee region .................................. 115

 Posterior knee region (popliteal fossa) .... 116

5.4 Leg regions ..................................................117

 Anterior crural region................................ 117

 Posterior crural region, the calf ................ 118

5.5 Retromalleolar regions ...............................119

 Medial retromalleolar region .................... 119

 Lateral retromalleolar region .................... 119

5.6 Dorsum of the foot .....................................120

5.7 Sole of the foot ............................................121

5.8 Th e toes .......................................................122


7

Th e Czech version of Basic Anatomy, Volume 5,

dedicated to the memory of Prof. Karel Weigner

(1874–1937), chair of the Institute of Anatomy in

Prague and founder of Czech regional and clinical anatomy, is part of a fi ve-volume textbook of

anatomy for fi rst year medical students. Since its

publication, this series has gained a lot of popularity

among students of the systems-based curriculum

for its convenient format, clear fi gures and concise

text. While the main benefi t of the organ systembased teaching method is its clear connection with

microscopic anatomy, physiology and clinicalspecialities, topographic approach needs an integrative

component that puts all the structures together in

a region-oriented way. Th is is the main objective of

this volume covering Topographic Anatomy.

Most English anatomy textbooks are region-based

because of the prevalence of a regionally-oriented

curriculum in the US. One might rightfully ask what

makes this volume stand out in comparison. In fact,

the translation was prompted by repeated prodding

of our English-taught medical students, who wanted

the same textbook their Czech colleagues were using

during the dissections and preparations for the fi nal

examination. While we provided online translation

of some of the most commonly used fi gures, it still

did not satisfy their longing for a full text.

Comparing the external appearance of this book

with that of most frequently used volumes (Gray’s

Anatomy for Students, Moore’s Clinically Oriented

Anatomy or Snell’s Clinical Anatomy), the main

diff erence seems to lie in its size: it is several times

smaller than the other volumes in both thickness

and weight. Th is is due to a deliberate omission of

detailed description of the individual organs which

was already provided in the Systems Anatomy.

Th is book focuses on the relationships between

varied organs as encountered during the dissection

course, making it a useful tool during this highly

enriching, but also stressful time. Th e description

of key anatomical regions is supplemented byamle coloured schematic drawings and oft encomplemented by matched radiographic images. Th e book

follows the dissection of a human body from head

to toe, providing external landmarks and superfi cial

anatomy, as well as detailed descriptions of thestructures. Key points of clinical implications arehighlighted in gray boxes. A lot of emphasis has been put

on cross-sectional anatomy, as it is the way in which

the students will encounter the human body in the

future. Th ree dimensional integration of knowledge

gained during dissection with these imagingmodalities (CT, MRI) is a must for functionalunderstanding of the human body not only for surgery, but also

for other branches of medicine.

We sincerely hope that the English-speakingstudents will fi nd this book as useful as our Czechstudents, and wish all of them success on their path to

become medical doctors.

Prague, December 2011

Milos Grim

(for the authors of the original Czech version)

David Sedmera

(for the team of translators) Foreword



9

1 Regions of the head,

regiones capitis

Th e head can be subdivided into neurocranium (the

calvaria) and splanchnocranium (the face). It isde

fi ned from the neck by a conventional line running

from the external occipital protuberance across the

superior nuchal line towards the external acoustic

meatus and then along the posterior and inferior

border of the lower jaw to the midline in the mental

region. Th e border between the brain case and face

is the line running from the external acoustic meatus

anteriorly along the zygomatic arch and eyebrows

to the glabella. In the depth, these two regions are

separated by the external cranial base.

In the brain case are fi rst described the superfi cial

regions and then the cranial base. In the facial region

of the head are also fi rst found the superfi cial regions

followed by the orbital, nasal and oral cavities

and fi nally infratemporal and pterygo -

palatine fossa and related regions.

1.1 The brain case

Th e skeleton of the brain case is composed of the

cranial vault, the calvaria (the skull cap) and the

basicranium (the cranial base).

1.1.1 Frontal, parietal and

temporal region

Th ese regions (Fig. 1.1) correspond to underlying

bones of the same names. Because the arrangement

of the layers in these regions is similar, they arede

18

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17

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Fig. 1.1 Overview of regions

of the head and neck.

1 – frontal region

2 – parietal region

3 – temporal region

4 – occipital region

5 – parotideomasseteric region

6 – buccal region

7 – lateral cervical region

8 – sternocleidomastoid region

9 – muscular triangle

10 – carotid triangle

11 – submandibular triangle

12 – submental region

13 – mental region

14 – oral region

15 – nasal region

16 – infraorbital region

17 – orbital region

18 – zygomatic region


10 Regions of the head, regiones capitis

scribed together. Th eir base is formed by the cranial

vault, the calvaria, covered by soft tissues – the scalp

(Fig. 1.2).

Th e principal layers are formed by:

 Skin, which is very thick, and normally covered

by hair;

 Subcutaneous connective tissue, with a large

amount of fi brous bundles that connect the deep

layer of the skin with the galea aponeurotica. Th is

arrangement allows only minimal movement of

skin against the galea aponeurotica. In the sub

cutaneous tissue are found thin walled veins that

frequently gape when injured, causing profuse

bleeding;

 Galea aponeurotica, a layer of dense connective

tissue into which diff erent parts of the epicranius

muscle insert: occipitofrontal and temporopa

rietal. It is also sometimes called the epicranial

aponeurosis;

 Loose connective tissue under the galea which

allows large movements of the skin and galea

aponeurotica against the periost. Th is can also

be a site of large hematomas after blunt skin

trauma;

 Periosteum, the fi brous layer covering the bones

of the cranial vault.

567

4

3

2

1

14

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10

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8

In the temporal region, underneath the tempo

roparietal muscle, is the temporalis muscle, covered

by strong temporalis fascia. Th is fascia has two layers

that run from the inner to the outer border of the

zygomatic arch and fuse together superiorly where

the muscle attaches to the superior temporal line.

Between these two layers is a layer of fatty tissue.

Th e periosteum covering the bones of the cra

nial vault is called the pericranium. It can easily be

peeled off the bones in the newborn child, but is

fi rmly adhered in the adult, particularly in areas of

cranial sutures.

Th e wounds that do not penetrate the galeaapone

urotica do not gape greatly; in contrast, the wounds

penetrating into the sub-galear connective tissue

do gape. Separation of the hairy skin together with

the galea is called the scalping injury.

Vascular and nerve supply to the scalp

Th e frontal region is supplied by the branches of the

supraorbital and supratrochlear artery (Fig. 1.5).

Th ere are rich anastomoses positioned laterally to

the branches of the zygomaticoorbital and superfi cial

temporal arteries. Th e temporal region is supplied by

Fig. 1.2 Frontal section showing the soft tissues of the head, the bones of the cranial vault and brain coverings.

1 – falx cerebri, 2 – cerebral cortex, 3 – arachnoid granulations, 4 – superior sagittal sinus, 5 – sagittal suture, 6 – skin,

7 – emissary vein, 8 – pericranium (periost), 9 – outer compact layer, 10 – diploe, 11 – inner compact layer, 12 – dura

mater, 13 – subarachnoid space, 14 – pia mater


the branches of superfi cial temporal artery, which

splits above the auricle into frontal and parietal

branches. Its pulsations can be palpated against the

bone. Underneath the temporalis muscle run the

deep temporal arteries and nerves. Blood supply

of the occipital region is provided by the occipital

artery (Fig. 1.7).

Th e veins of the scalp empty anteriorly into the

veins of the orbit, laterally into the superfi cialtemoral vein and the pterygoid plexus, and from the

occipital region into the external jugular vein.

Lymphatics from the frontal and temporal region

drain into the parotid lymphatic nodes, from the

temporoparietal region into the retroauricular lymph

nodes and from the occipital region into the occipital

lymph nodes.

Motor innervation of the entire epicranius muscle

as well as the muscles of the auricles is provided by

the facial nerve. Th e temporalis muscle is innervated

by the third division of the trigeminal nerve.

Sensory innervation of the skin is providedanteriorly up to the interauricular line by the trigeminal

nerve via the supraorbital, auriculotemporal and

zygomaticotemporal branch of the zygomatic nerve.

Behind the interauricular line, it is provided by the

great auricular and the greater and lesser occipital

nerves (Fig. 1.7).

Th e cranial vault proper, the calvaria, is formed

by the parietal bones, squamous parts of the frontal,

occipital and temporal bones, and greater wings of

the sphenoid bone. It is thinnest in its temporal and

parietal regions, whereas anteriorly and posteriorly

it is more robust. Th e bones of the cranial vault are

composed of the outer and inner compact layers

with a spongy bone called the diploe between them

(Fig. 1.2). Th e venous blood from the diploe drains

through the diploic veins to the dural sinuses.Anteriorly, the frontal bone shows variable pneumatization

by oft en asymmetric frontal sinuses. In the temporal

region run the branches of the middle meningealvessels on the inner aspect of the vault (Fig. 1.3).

Bleeding from torn meningeal vessels causesepidural hematoma.

Th e deepest layer of these regions is the dura

mater of the brain, which adheres to the bones from

the bottom and is stuck to their periost. In between

the dura and the periosteum are the dural venous

sinuses: the superior sagittal sinus, the confl uence

of the sinuses, the transverse sinus, and the occipital

sinus (Figs. 1.2 and 1.4).

1.1.2 External surface of the

cranial base

Th e lower aspect of the cranial base, basis craniiexterna, borders underneath the anterior cranial fossa

with the spaces of the splanchnocranium, the nasal

cavity and the orbit. Underneath the middle cranial

fossa there is in the center the sphenoidal sinus and

lateral to the cartilagineous part of thenasopharyngeal (Eustachian) tube, the pterygopalatine fossa,

the infratemporal fossa and the temporomandibular joint. Underneath the posterior cranial fossa is

the attachment of the pharynx and the middle and

parapharyngeal space. Behind the pharynx lie the

atlantooccipital joint and the attachments of the deep

nuchal muscles.

1.1.3 Internal surface of the

cranial base

Th e upper aspect of the cranial base, basis cranii

interna (Fig. 1.4), is covered with the dura mater and

is subdivided into three cranial fossae: Fig. 1.3 Projection of the anterior and posteriorbranches of the middle meningeal artery (circles) and central and lateral sulcus of the brain. 1 – perpendicular line through the posterior edge of the mastoid process (intercepts line no. 3 in the posterior point of Krönlein), 2 – perpendicular line through the centre of the zygomatic arch (intercepts line no. 3 in the anterior point of Krönlein), 3 – line parallel with the auriculoorbital line passing through the superior rim of the orbit, 4 –auriculoorbital line (so-called Frankfurt horizontal) passing through the inferior rim of the orbit (5) and the upper rim of the external acoustic meatus, 5 – lower rim of the orbit, 6 – entrance of the middle meningeal artery to the skull through the foramen spinosum, 7 – external acoustic meatus, 8 – mastoid process, 9 – projection of the lateral sulcus of the brain (the line of projection splits the angle between lines 3 and 10 in half), 10 – approximate projection of the central sulcus of the brain (line connecting the anterior point of Krönlein with the point of intersection of the vertical line number 1 3 4

12

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9

5 6 7 8

Th e brain case 11


12 Regions of the head, regiones capitis

Fig. 1.4 Interior of the base of the skull, basis cranii interna (blue marks the position of the sinus durae matris, with

the dura mater partially removed). 1 – olfactory bulb, 2 – anterior meningeal artery, branch of the anterior ethmoidal

artery, 3 – olfactory nerves, 4 – anterior cerebral artery, 5 – optic nerve and ophthalmic artery, 6 – lacrimal nerve and

superior ophthalmic vein, 7 – frontal nerve, 8 – trochlear nerve, 9 – abducent nerve, 10 – nasociliary nerve, 11 –oculomo

tor nerve, 12 – middle meningeal artery, 13 – lesser petrosal nerve, 14 – greater petrosal nerve, 15 – posterior cerebral

artery, 16 – anterior inferior cerebellar artery, 17 – posterior inferior cerebellar artery, 18 – vertebral artery, 19 – basilar

artery, 20 – anterior spinal artery, 21 – hypoglossal nerve, 22 – spinal root of the accessory nerve, 23 – glossopharyngeal,

vagus and accessory nerve, 24 – facial nerve and vestibulocochlear nerve, 25 – abducent nerve, 26 – trochlear nerve,

27 – superior cerebellar artery, 28 – oculomotor nerve, 29 – mandibular nerve, 30 – posterior communicating artery,

31 – maxillary nerve, 32 – ophthalmic nerve, 33 – internal carotid artery, 34 – anterior communicating artery

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