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Color Atlas of Surface Anatomy
Copyright© K.M. Backhouse, R.T. Hutchings, 1986 Published by Wolfe Medical Publications Ltd, 1986 Printed by Royal Smeets Offset b.v., Weert, Netherlands Designer: Iain Wolfe All rights reserved. The contents of this book, both photographic and textual, may not be reproduced in any form, by print, photoprint, phototransparency, microfilm, microfiche, or any other means, nor may it be included in any computer retrieval system, without written permission from the publishers. Library of Congress Cataloging-in-Publication Data
Backhouse, Kenneth M. A color atlas of surface anatomy. Includes Index. 1. Anatomy, Surgical and topographical—Atlases. I. Hutchings, R.T. II. Title. [DNLM: 1. Anatomy—atlases. QS 17 B 126c] QM531.B25 1986 611’.9 85-26527 ISBN 0-683-00307-0
Color Atlas of
Surface Anatomy clinical and applied Kenneth M. Backhouse O.B.E., V.R.D., M.B., B.S., M.R.C.S. Reader Emeritus in Applied Anatomy, University of London. Clinical Anatomist, Institute of Laryngology and Otology and the Royal National Throat, Nose and Ear Hospital, London. Lecturer in Anatomy and Orthopaedics, Royal Ballet School, London. Formerly: Reader in Applied Anatomy, Hunterian Professor, Arris and Gale Lecturer and Examiner in Anatomy for Primary F.R.C.S. and F.D.S., Royal College of Surgeons of England.
Ralph T. Hutchings Formerly: Chief Medical Laboratory Scientific Officer, Royal College of Surgeons of England.
Williams & Wilkins Baltimore
Acknowledgements We would like to thank our models for providing the physical substance for this book, and Professor Robert McMinn for kindly allowing us to use some of the subsurface photographs from his ‘Colour Atlas of Human Anatomy’.
Contents Preface 8 The Skin 9 The Appearance of the Skin 10 Deep Attachments of the Skin 11 Stress Lines in Skin 11 Hair 13 Surface Contours 15 Bone and Muscle 16 Insufficiency in Muscles 18 Proportions of the Body 20 Facial Proportions 22 Examination of Bony Points 24 The Nose 30 Temporomandibular Joint 34 Muscles of Mastication 35 The Eye 36 The Extraocular Muscles 40 The External Ear 42 Muscles of Facial Expression 44 Facial Musculature and Speech 48 The Cranial Nerves 50 Blood Vessels of the Face and Head 58 Axial Vascular Flaps in the Face 61 The Salivary Glands 62 The Neck 64 Neck Movement 65 Sternomastoid Muscle 66 The Posterior Triangle 68 The Cervical Nerves 70 The Larynx 74 Submandibular Region 77 Great Vessels of the Neck 78 Central Venous Catheterization 82 Lymphatics of the Head and Neck 83 Shoulder Girdle and Joint 84 Muscles Controlling the Shoulder Girdle 90 Muscles acting over the Shoulder Girdle and Joint 96 Muscles acting over the Shoulder Joint 100 The Axilla 104 Muscles on the Upper Arm 106 Bony Points of the Elbow, Forearm and Wrist 110 Rotation of the Arm 116 Pronation and Supination 118 Movement at the Elbow Joint 119 The Cubital Fossa 120 Movements at the Wrist 123 Muscles on the Front of the Forearm 129 Tendons on the Front of the Wrist 130 Muscles on the Back of the Forearm 132 Tendons on the Back of the Wrist 135
The Hand 136 The Skin of the Hand 138 Hand Functions 144 Development of Grip 153 Movements of the Digits 154 Movement of the Thumb 158 Relative Values of the Digits 160 The Little Finger 163 Muscles Controlling the Digits 164 Nerves of the Arm and Hand 170 The Arteries of the Arm and Hand 181 The Veins of the Arm and Hand 184 The Retinacula and Synovial Sheaths of the Hand 186 The Back 188 Movements of the Back 192 The Thoracic Wall 194 The Breast 196 Blood Supply and Lymph Drainage of the Breast 204 The Sternal Angle 205 The Pleura and Lungs 206 The Heart 212 Other Thoracic Structures 216 The Diaphragm 217 Control of Respiration 219 Anterior Abdominal Wall 222 The Inguinal Region 228 The External Genitalia 232 Nerves of the Thoracic and Abdominal Walls 235 Blood Vessels of the Thoracic and Abdominal Walls 238 Surface Features of the Abdominal Wall 240 The Viscera 244 The Great Vessels of the Abdomen 253 Bony Landmarks Around the Hip 254 Movement at the Hip Joint 256 Bony Points Around the Knee 258 Movement at the Knee 260 Knee Angulation 262 Muscles acting over the Hip Joint 264 Muscles acting over the Hip and Knee Joint 272 Muscles acting over the Knee Joint 276 Bony Features of the Ankle and Foot 278 Movements of the Ankle and Foot 280 Muscles acting over the Knee and Ankle 284 Muscles acting over the Ankle and Foot 286 Retinacula and Synovial Sheaths of the Foot 291 The Nerves of the Leg 292 The Arteries of the Leg 298 The Veins of the Leg 301 Lymphatics of the Leg 303 Index 305
LEVATOR LABII SUPERIORIS ORBICULARIS ORIS DEPRESSOR ANGULI ORIS DEPRESSOR LABII INFERIORS & MENTALIS STERNOMASTOID STERNAL HEAD STERNOMASTOID CLAVICULAR HEAD-— OMOHYOID DELTOID DELTO PECTORAL GROOVE
ORBITAL PARTS OF ORBICULARIS OCULI
ZYGOMATICUS MINOR ZYGOMATICUS MAJOR MASSETER BUCCINATOR TRAPEZIUS STERNOHYOID SCALENUS MEDIUS STERNOTHYROID CLAVICULAR HEAD \ OF PECTORALIS STERNOCOSTAL HEAD / MAJOR
BICEPS LONG HEAD BICEPS SHORT HEAD WITH CORACOBRACHIALIS
SERRATUS ANTERIOR MEDIAL INTERMUSCULAR SEPTUM
FIBROUS INTERSECTIONS OF RECTUS ABDOMINIS BICEPS TENDON EXTERNAL OBLIQUE OF ABDOMEN -
BICIPITAL APONEUROSIS PRONATOR TERES BRACHIORADIALIS FLEXOR CARPI RADIALIS PALMARIS LONGUS
RECTUS ABDOMINIS COVERED BY RECTUS SHEATH ANTERIOR SUPERIOR ILIAC SPINE EXTERNAL OBLIQUE APONEUROSIS PYRAMIDALIS INGUINAL LIGAMENT ILIOPSOAS TENSOR FASCIA LATA
FLEXOR DIGITORUM SUPERFICIALIS FLEXOR CARPI ULNARIS PUBIS ABDUCTOR POLLICIS BREVIS FLEXOR POLLICIS BREVIS THENAR MUSCLES HYPOTHENAR MUSCLES
PECTINEUS ADDUCTOR LONGUS
PATELLA PATELLAR LIGAMENT •
MEDIAL MENISCUS COVERED BY MEDIAL PATELLAR RETINACULUM
PERONEUS LONGUS PERONEUS BREVIS TIBIALIS ANTERIOR GASTROCNEMIUS
SUBCUTANEOUS SURFACE OF TIBIA
EXTENSOR DIGITORUM LONGUS SOLEUS
PERONEUS TERTIUS EXTENSOR HALLUCIS LONGUS -- MEDIAL MALLEOLUS LATERAL MALLEOLUS
SPLENIUS CAPITIS LEVATOR SCAPULI
ACROMIONSPINE OF SCAPULA
INFRASPINATUS TERES MINOR TERES MAJOR TRICEPS LONG HEAD TRICEPS LATERAL HEAD LATISSIMUS DORSI
TRICEPS MEDIAL HEAD
EXTERNAL OBLIQUE OF ABDOMEN OLECRANON
ANCONEUS EXTENSOR CARPI RADIALIS LONGUS
SUBCUTANEOUS BORDER OF ULNA
EXTENSOR CARPI ULNARIS EXTENSOR DIGITORUM
EXTENSOR CARPI RADIALIS BREVIS
ABDUCTOR POLLICIS LONGUS
EXTENSOR POLLICIS BREVIS POSITION OF GREATER TROCHANTER
EXTENSOR POLLICIS LONGUS EXTENSOR RETINACULUM
1ST DORSAL INTEROSSEOUS
ADDUCTOR MAGNUS SEMITENDINOSUS BICEPS FEMORIS (LONG HEAD)
POPLITEAL SURFACE OF FEMUR
GASTROCNEMIUS LATERAL HEAD GASTROCNEMIUS MEDIAL HEAD
PERONEUS LONGUS TENDO CALCANEUS (ACHILLIS)
PERONEUS BREVIS '
FLEVOR DIGITORUM LONGUS
For many medical and dental students, anatomy represents a period of learning facts based essentially on dried bones and cadaveric dissections, which bear little relationship with the living patient or even the dissections of operative surgery. The subject tends to become a chore which has to be tolerated in order to achieve the aim of working with living people. While the medical student does at least have the advantage of examining structures in three dimensions in the dissecting room or anatomy museum, these facilities are often not available to the other professional training groups for whom a knowledge of living anatomy is just as important as to the future doctor, e.g. physical and occupational therapists, nurses and other paramedical groups as well as physical educators, dance teachers etc. The learning of anatomical structure is of little value unless it can be seen essentially as it exists and functions in the normal living person. To be of any value as anything but a morphological exercise, the anatomy must live, move, grow, age and exhibit all the variations evident in the community as well as the changes due to physical training, disease etc. The physician, surgeon, therapist, nurse, physical educator, artist must look at the skin covered individual and visualise what lies and functions beneath that skin. Only in this way can the clinician assess normal function and any variation from that normality be it from injury or disease. Many structures can be seen readily from their surface contours and appearance; bony points, superficial muscles, tendons, veins etc. For deeper structures, their positions need to be known as from the surface and their normality assessed from a knowledge of their functions which can be tested clinically. Thus normal functioning of muscles (and their nervous control) can be tested from a knowledge of their positions and functions in the intact living body and, where pathology is suspected, how to test for that normality or otherwise is vital. It is also important to be able to assess the disability which might ensue from failure of structures. In the physical fields the term kinaesiology has been coined to cover the study of muscle function and this particular aspect of living anatomy has been stressed within the overall functional control of the body. It is fashionable, particularly among some physicians, to claim that they have forgotten most of the anatomy they ever knew and don’t miss it. They dismiss the lifeless morphology in such statements and include their considerable knowledge of living anatomy as an integral part of their medical, clinical expertise. May we therefore offer this book in that light as an introduction to clinical medicine. In examining the form and functioning of the body it has been necessary to limit the field to matters of more general importance and avoid the more specialist examinations. For this reason examination of the orifices of the body has been excluded. With the enormous developments in fibreoptics and other clinical weaponry for endoscopic examinations this has become an enormous field, well beyond the scope of a general book. In producing a basically pictorial book of the surface of the body, it is always tempting to use dramatic lighting techniques and people with highly developed muscles. We have deliberately avoided these approaches. Our aim has been to produce good pictorial representation of the type of person whom the practitioner is likely to meet in everyday practice. It has been a policy to leave many pictures unlabelled to persuade the reader to look and see. Copy pictures have been used to carry labels where considered advisable. Although this book has been designed primarily with medical and paramedical personnel in mind it is hoped that, in view of its strong emphasis in kinaesiology, it will be of value to physical educators, teachers of dance etc. and also useful in life study for artists.
THE SKIN Observation and examination of the body must begin with the skin, or, in the orifices, the mucous membranes. The skin is responsible for much of the health of the body. That health or lack of it is often evident in the appearance of the skin and it is prudent for the clinician to remember this fact. The skin and subcutaneous tissues may do much to camouflage the deeper structures of the body but the clinician needs to be able not only to identify and locate these structures through the skin but also, in certain cases, to test their function and effectiveness. The skin must be closely related to the underlying structures but must move freely in accord with them without in any way restricting their movement. The body must have total skin cover. A major part of a plastic surgeon’s activity is to replace skin after loss, whether by injury or necessary surgical excision, so as to give full protective covering for the body, by means of skin grafts or various forms of flaps. The new skin cover may then need to be manipulated to allow full freedom of mobility with, whenever possible, effective sensory response. The skin contains the receptive components of much of the sensory awareness of the body, i.e. exteroceptive sensibility, and is linked by sensory nerves to the brain, either directly or through the spinal cord. In certain parts of the body this is especially important. The palmar surfaces of the hands for instance receive, under normal circumstances, such remarkably fine sensory stimuli that the resultant tactile awareness can give enormous amounts of infor¬ mation to the brain. The blind man can read braille through his fingers; the correct coin can be chosen from pocket or purse by touch. In fact, from this tactile awareness through the skin, the hands have been described as the eyes that see in the dark and around corners. The character of the skin varies enormously over the body. This difference is particularly obvious at the lips where the relatively thinly keratinised vermilion region changes to much thicker hairy skin; here the shaven bearded area of a male (2).
Beneath the dermal ridges which characterise the finger and palm prints are enormous numbers of touch end-organs, giving the potential of exquisite sensory awareness. Because of the need, a blind person makes much more effective use of this perception than the average sighted person. Note that in the special tactile areas of the body the skin is devoid of hairs. In the shaded area of the photograph the bright dots of sweat are obvious at the openings of the sweat glands.
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