Thieme Dissector Volume 2 E-Book

Vishram Singh

• Herausgeber: Thieme Medical Publishers
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2024

Beschreibung

<p><em>Thieme Dissector, Second Edition</em> is a richly illustrated and detailed three-volume manual for guiding students and teachers in the dissection lab. It is enriched with intricate illustrations of the human anatomy created from the clinician’s perspective. These illustrations and the carefully researched and structured text elucidate the layer-by-layer dissection of each region of the human body in a stepwise manner.</p> <p>The volumes have been created by renowned experts in the field: Dr. Vishram Singh, Dr. G. P. Pal, Dr. S. D. Gangane, and Dr. Sanjoy Sanyal. The text of the volumes flows lucidly through well-defined sections in each chapter. These sections have also been made visually distinct to aid access. The authors have aimed to make the reading of these volumes educative, interesting, and visually engaging.</p> <p>Salient Features of the Second Edition</p> <ul> <li>Updated videos: Provides access to more than 100 new videos on Thieme MedOne to facilitate learning, understanding, and comprehension. These videos enhance the scope of understanding the topic under discussion.</li> <li>Dissection screenshots: Most relevant and duly labelled screenshots from the cadaveric dissection videos are presented at suitable places within the text to provide better insight into the steps of dissection.</li> <li>Radiographs: Includes newly added radiographs to help broaden the gamut of interpretation of the anatomy.</li> <li>New section: A new section on “Vertebral Column” has been added to Volume I for extensive coverage of the back region.</li> </ul> <p>This book includes complimentary access to a digital copy on <a href="https://medone.thieme.com./">https://medone.thieme.com.</a></p><p><strong>Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product.</strong></p>

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Thieme Dissector

Second Edition

Volume II

Abdomen and Lower Limb

ThiemeDissector

Second Edition

Volume IIAbdomen and Lower Limb

Vishram Singh, MBBS, MS, PhD (hc), MICPS, FASI, FIMSA Adjunct Professor Department of Anatomy KMC, Manipal Academy of Higher Education Mangalore, Karnataka, India; Editor-in-Chief

Journal of the Anatomical Society of India; Member, Federative International Committee for Scientific Publications (FICSP) International Federation of Association on Anatomists (IFAA) Geneva, Switzerland

G. P. Pal, MBBS, MS, DSc, FASI, FAMS, FNASc, FASc, Bhatnagar Laureate Director Professor Department of Anatomy Index Medical College; Emeritus Professor MGM Medical College Indore, Madhya Pradesh, India

S. D. Gangane, MBBS, MS, FAIMS Professor and Head Department of Anatomy Terna Medical College Navi Mumbai, Maharashtra, India

Sanjoy Sanyal MBBS, MS, MSc, ADPHA Provost and Dean Professor and Department Chair Anatomical Sciences Richmond Gabriel University College of Medicine St. Vincent and the Grenadines Canada

Based on the work of Michael Schuenke Erik Schulte Udo Schumacher

Illustrations by Markus Voll Karl Wesker

ThiemeDelhi • Stuttgart • New York • Rio de Janeiro

Publishing Director: Ritu Sharma

Senior Development Editor: Dr. Nidhi Srivastava

Director-Editorial Services: Rachna Sinha

Project Manager: Aishwarya Panday

Vice President Sales and Marketing: Arun Kumar Majji

Managing Director & CEO: Ajit Kohli

© 2023. Thieme. All rights reserved.

Thieme Medical and Scientific Publishers Private Limited.

A - 12, Second Floor, Sector - 2, Noida - 201 301,

Uttar Pradesh, India, [phone]

Email: [email protected]

www.thieme.in

Cover design: Thieme Publishing Group

Cover image source: Voll M and Wesker K

Illustrations by Voll M and Wesker K. From: Schuenke M, Schulte E, Schumacher U, THIEME Atlas of Anatomy.

Page make-up by RECTO Graphics, India

Printed in India by Office Now India Pvt Ltd

5 4 3 2 1

ISBN: 978-93-92819-17-9

Also available as an e-book:

eISBN (PDF): 978-93-92819-22-3

eISBN (ePub): 978-93-92819-24-7

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular, our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary, in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released in the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Thieme addresses people of all gender identities equally. We encourage our authors to use gender-neutral or gender-equal expressions wherever the context allows.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

To my students, past and present.

Vishram Singh

To my grandson, Yatharth.

G. P. Pal

To my family and colleagues, for their support;my patients and students, for teaching me to learn from them;the willed body-donors, for their silent altruism to medical science.

Sanjoy Sanyal

Contents

Video Contents

Note from the Authors

About the Authors

Contributors to Volume II

1.Overview of the Bones of the Lower Limb

2.Anterior and Medial Compartments of the Thigh

3.Gluteal Region

4.Posterior Compartment of the Thigh and Popliteal Fossa

5.Anterior and Lateral Compartments of the Leg and Dorsum of the Foot

6.Posterior Compartment of the Leg

7.Sole of the Foot

8.Joints of the Lower Limb

9.Introduction and Overview of the Bones of the Abdomen

10.Anterior Abdominal Wall

11.Male External Genitalia

12.Loin

13.Abdominal Cavity and Peritoneum

14.Abdominal Part of Esophagus, Stomach, Celiac Trunk, and Spleen

15.Duodenum, Pancreas, and Portal Vein

16.Small and Large Intestines

17.Liver and Biliary System

18.Kidney, Ureter, and Suprarenal Gland

19.Diaphragm and Posterior Abdominal Wall

20.Introduction to Pelvis and Perineum

21.Pelvic Viscera

22.Rectum and Anal Canal

23.Uterus, Vagina, and Ovary

24.Pelvic Wall

25.Perineum

26.Joints of the Pelvis

Appendix

Index

Video Contents

Video 2.1

Muscles of anterior compartment of thigh

Video 2.2

Femoral nerve

Video 2.3

Fascia lata

Video 2.4

Adductor brevis

Video 2.5

Femoral triangle and adductor canal

Video 3.1

Gluteal region—Part 1

Video 3.2

Gluteal region—Part 2

Video 3.3

Gluteal muscles

Video 4.1

Hamstring muscles

Video 4.2

Hamstring muscles and sciatic nerve

Video 4.3

Popliteal fossa—Part 1

Video 4.4

Popliteal fossa—Part 2

Video 5.1

Tendons on dorsum of foot

Video 5.2

Anterior compartment of leg

Video 5.3

Anterior lateral aspect of leg and dorsum of foot

Video 6.1

Posterior aspect of leg—Part 1

Video 6.2

Posterior aspect of leg—Part 2

Video 6.3

Posterior aspect of leg—Part 3

Video 7.1

Sole of foot aponeurosis muscle layers and plantar nerves

Video 8.1

Knee—Part 1

Video 8.2

Knee—Part 2

Video 8.3

Ankle joint/Talocrural joint (movements and axis)

Video 8.4

Joints of foot

Video 10.1

Abdominal wall—flat muscles, rectus sheath, and linea alba

Video 10.2

Abdominal wall—rectus muscles, posterior rectus sheath, and vessels

Video 11.1

Spermatic cord and testis

Video 11.2

Testis, epididymis, spermatic cord, ductus deferens, and clinical aspects

Video 11.3

Male genital organs—structural configuration

Video 13.1

Peritoneal cavity—greater sac, lesser sac, and greater omentum

Video 13.2

Peritoneal cavity—Foramen of Winslow

Video 14.1

Overview of abdominal organs

Video 14.2

Abdominal viscera—an overview

Video 15.1

Duodenum: parts, relations, and vasculature

Video 15.2

Pancreas

Video 15.3

Portal vein

Video 16.1

Small intestine and its mesentery

Video 16.2

Superior mesenteric artery and its distribution

Video 16.3

Distribution of Inferior mesenteric artery in hindgut—high-definition clinical demonstration

Video 16.4

Large intestine

Video 17.1

Liver in situ

Video 17.2

Gallbladder and extrahepatic biliary apparatus

Video 18.1

Kidney

Video 18.2

Renal pelvis and ureter

Video 18.3

Locations of Suprarenal glands

Video 19.1

Posterior abdominal wall

Video 19.2

Lumbar plexus

Video 21.1

Urinary bladder: Parts, ligaments, and vessels

Video 21.2

Urinary bladder, UV junction, and trigone

Video 21.3

Bladder neck, trigone, and prostatic urethra

Video 21.4

Pelvic part of ureter, bladder of urinary relations, and trigone of urinary bladder

Video 22.1

Ampulla of ductus deferens, seminal vesicle, rectum, and pelvic vessels

Video 22.2

Ischioanal fossa, Alcock’s canal, and sciatic foramen

Video 23.1

Layers of uterine wall

Video 23.2

Female pelvic organs with endopelvic fascia and pelvic vessels

Video 23.3

Bony pelvis male vs. female: obstetric fractures

Video 24.1

Bony pelvis inlet–outlet and diameters

Video 25.1

Neurovascular structure of male perineum

Note from the Authors

There was a long-felt need of a good dissection manual for first-year undergraduate medical students undertaking the anatomy course. Anatomy is the foundation of all medical subjects, and hence, its thorough knowledge is essential for all students aspiring to become good doctors, especially in surgical fields.

The best modus operandi to learn anatomy is through dissection. Recently, due to information explosion in the medical field, the health sciences curricula have markedly reduced the time allocation for studying and teaching anatomy; yet it is realized by all that the gross structure of the human body, including its three-dimensional conceptualization, must be understood thoroughly before proceeding further to learn medicine.

Therefore, we have made a sincere effort to meet all the needs of the students in creating this three-volume set of dissection manuals. They not only delineate instructions for students to perform perfect dissection but also provide gross anatomy descriptions, supplemented by clinical correlations of gross structures studied during dissection. The textual descriptions are complemented by numerous colored illustrations that will help students recognize significant structures with more precision. To further enhance understanding, the content of the volumes is organized in sections like (a) Learning Objectives, (b) Surface Landmarks, (c) Dissection and Identification, (d) Description of Gross Anatomy, and (e) Clinical Notes. Laced with all these features, we hope that these volumes will be useful not only for medical and dental students but also for teachers of anatomy. The value of these volumes is further enhanced by providing videos at relevant places.

As educators of anatomy, we have tried our best to make these manuals easy for learning. We highly appreciate the contribution of Prof. Poonam Kharb and Mr. D. Krishna Chaitanya in Volume II and Prof. Shabana M. Borate in Volume I. For further improvements, we would sincerely welcome comments and suggestions from all students and teachers.

The second edition of this dissection manual is thoroughly updated with new line diagrams, X-ray pictures, and CT and MRI scans.

All dissection steps are supplemented by dissection videos in all the three volumes for easy understanding of gross and clinical anatomy by the students.

Vishram Singh, MBBS, MS, PhD (hc), MICPS, FASI, FIMSA

The medical curriculum in India requires basic anatomy, along with some other basic subjects, to be taught to students in the first year of the course. This often leads to an information overload for them. For some students, the situation is made even more difficult due to linguistic limitations and late admissions. As a result, there has long been a pressing need for comprehensive teaching resources that create thorough understanding of these courses in a short time span. Specifically for anatomy, one cannot stress enough on the value of a complete and detailed dissection manual that explains basic concepts in a simple and lucid manner, without duplication of facts or unnecessary complexities.

In Volume III, every care has been taken to describe all steps involved in the dissection of the head, neck, and brain in a stepwise manner that is easy to understand for the beginners. Several high-quality illustrations have been used to explain each step. They help show the dissections with a great amount of detailing and clarity. To make the discourse interesting, relevant clinical conditions have also been presented under separate sections called “Clinical Notes.”

Producing a book with hundreds of illustrations is a joint effort by the author and the publisher in a true sense.

I strongly believe that this book will be an invaluable learning resource for students and teachers of anatomy in medical and dental courses.

G. P. Pal, MBBS, MS, DSc, FASI, FAMS, FNASc, FASc, Bhatnagar Laureate

Cadaveric dissection is an integral part of teaching anatomy in medical schools. It offers an unmatched firsthand experience of exploring the structure of organs and their relationship with each other. Thieme Dissector provides a complete account of dissection of human body through a set of three volumes.

The first volume deals with the upper limb and thorax. The introduction of this volume gives general information about preservation of cadaver, instruments required for dissection, and anatomical terms, followed by a discussion on basic tissues of the body. This is followed by 10 chapters on upper limb and 5 chapters on thorax. Each chapter begins with “Learning Objectives,” followed by an introduction to the topic, dissection steps with description of the relevant structures, and clinical notes.

To facilitate understanding of the subject, photographs of actual dissected parts and real dissection videos have been provided. Access to these videos will help and enrich students’ learning process.

My heartfelt gratitude to Dr. Shabana M. Borate, Associate Professor, Department of Anatomy, at Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India, Dr. Sachin Yadav, Assistant Professor at Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India, and Dr. Shilpa Domkundwar, Professor and Head, Department of Radiodiagnosis, Grant Government Medical College and Sir J. J. Group of Hospitals, Mumbai, Maharashtra, India, for their untiring efforts in preparation of this volume. I am grateful to the entire team of Thieme Publishers for their constant support, and special thanks to Dr. Vishram Singh sir, who has been the guiding force for all of us in preparation of the Thieme Dissector.

S. D. Gangane, MBBS, MS, FAIMS

Thieme has taken a positive step by introducing this book for imparting anatomy education to medical students worldwide. The process of depicting videos and pictures of actual cadaver dissections in a textbook is indeed a monumental task. It starts with planning of the region to be dissected. This is followed by meticulous dissection of the region itself, which can take hours if not days. Then comes the process of accurate live narration of the dissection of the region on camera, while the video recording is in progress. The back-breaking task of editing and captioning the video frames and clips follows next, because many anatomical and medical terms used in the narration may otherwise be incomprehensible to the student. Since clinical students like content related to radiology, some videos have radiological images embedded within the frames. The relevant still shots from the dissections are then edited and labeled. Finally, of course, comes the task of publishing the finished product.

There are many digital anatomy tools available to the medical academia, ranging in size and versatility from usage in classrooms and digital labs to those used in individual laptops and tablets. Some have virtual reality–like, immersive three-dimensional, or augmented reality applications. They vary in accuracy, comprehensiveness, and versatility. They are good study tools, which are interactive and interesting to use in teaching and learning anatomy. They show body parts and spatial relationships. They are available offline, accessible anytime, anywhere, and can even show rare pathology. They present consolidated anatomy information to suit users’ learning styles. They do not have the legal, ethical, religious, social, regional, and logistical constraints of human cadaver procurement. These factors are weaning away institutions from the hoary art of cadaver dissection.

However, cadaver dissection is still the gold standard for learning human anatomy and surgery. It is the benchmark for measuring the success of newer learning technologies. Cadavers are medical students’ first “patients.” Digital resources are to be considered as supplements to the armamentarium of learning methods in human anatomy. Digital technologies lack haptic qualities of human tissue, which are essential for a surgeon. Therefore, they can never completely replace cadaver dissection for anatomy students and surgical residents under training. Nobody would want to be treated by surgeons who acquired their entire quantum of expertise in operating on the human body through virtual reality alone, just like nobody would want to be flown by an airline pilot whose only flying experience was in the digital flight simulator.

The author is truly gratified knowing that students have learned the subject of anatomy and mastered the intricacies of the human body by watching Thieme Dissector videos and illustrations.

Sanjoy Sanyal, MBBS, MS, MSc, ADPHA

Note from the Authors

About the Authors

Vishram Singh

Editor-in-Chief and Author, Volume II, Abdomen and Lower Limb)

Vishram Singh, MBBS, MS, PhD (hc), MICPS, FASI, FIMSA, is currently the Adjunct Professor, Department of Anatomy, KMC, Manipal Academy of Higher Education, Mangalore, Karnataka, India; Editor-in-Chief, Journal of the Anatomical Society of India; and Member, Federative International Committee for Scientific Publications (FICSP), International Federation of Association on Anatomists (IFAA), Geneva, Switzerland.

A renowned anatomist, Prof. Singh has taught undergraduate and postgraduate students at several colleges and institutes, such as GSVM Medical College, Kanpur; King George Medical College, Lucknow; All India Institute of Medical Sciences, New Delhi; and Al Arab Medical University, Benghazi, Libya. He has more than 50 years of experience in teaching, research, and clinical practice. He has various bestselling titles to his credit, such as Textbook of Clinical Neuroanatomy, Textbook of Anatomy—three volumes, and Textbook of Clinical Embryology. He has published more than 20 books and more than 100 research articles in reputed national and international journals.

Prof. Singh has received various recognitions and awards for his contributions in the field of gross anatomy, neuroanatomy, and embryology.

He has been elected Vice President of the Anatomical Society of India many times. He is currently Editor-in-Chief, Journal of Anatomical Society of India (JASI).

G. P. Pal

(Author, Volume III, Head, Neck, and Brain)

G. P. Pal, MBBS, MS, DSc, FASI, FAMS, FNASc, FASc, Bhatnagar Laureate, is currently the Director Professor of Anatomy at the Index Medical College; Emeritus Professor at MGM Medical College, Indore, Madhya Pradesh, India. Dr. Pal is an eminent teacher with almost five decades of teaching experience in various medical colleges of India and the United States. He has to his credit numerous publications in journals of international repute. He has received several national awards and honors for his research works, which includes Shakuntala Amir Chand Prize of Indian Council of Medical Research (ICMR), Shanti Swarup Bhatnagar Prize of Council of Scientific and Industrial Research (CSIR), and several gold medals, oration awards, and Lifetime Achievement Award by the Anatomical Society of India. He has been elected Fellow at various leading academies of sciences in India—Anatomical Society of India; National Academy of Medical Sciences (New Delhi), National Academy of Sciences (Allahabad), and Indian Academy of Sciences (Bengaluru). His research work is cited in more than 100 standard medical textbooks throughout the world. Recently, his name featured in the list of top 2% scientists of the world. As per a survey conducted by the Stanford University, USA, in 2020, he is ranked as no. 1 Anatomy Scientist in India and 102 in the world. Dr. Pal has authored many well-received books such as Textbook of Histology, Illustrated Textbook of Neuroanatomy, Medical Genetics, Genetics in Dentistry, General Anatomy, Basics of Medical Genetics, Human Osteology, Genetics for Dental Student, Neuroanatomy for Medical Students, and Thieme Dissector. He has edited 1st South Asian edition of Grant’s Atlas of Anatomy (in press). He has also coauthored Prof. Inderbir Singh’s Human Embryology from the 7th to 9th editions. For more information about the author and his works, Google “Indian Anatomists - Wikipedia” or “Gaya Prasad Pal - Wikipedia.”

S. D. Gangane

(Author, Volume I, Upper Limb and Thorax)

S. D. Gangane, MBBS, MS, FAIMS, is currently serving as Professor and Head, Department of Anatomy at Terna Medical College, Navi Mumbai, Maharashtra, India. He has been Professor and Head, Department of Anatomy and Genetic Division at Grant Medical College, Mumbai and Sir J. J. Group of Hospitals, Mumbai. This is a unique Anatomy Department offering services to patients having genetic disorders. Prof. Gangane has authored a bestselling book titled Human Genetics which has been widely accepted by faculty and both undergraduate and postgraduate students.

Prof. Gangane has over four decades of teaching experience and has been guiding students for MD Anatomy, and MSc and PhD in Applied Biology courses at the Mumbai University. He has also been a guide for the MD Anatomy and PhD Genetics courses at Maharashtra University of Health Sciences (the State Health University). He has published several articles in national and international journals and is also a coauthor of the recently published Textbook of Pathology and Genetics for Nurses. In addition, he has been on the national advisory board and the executive editorial board for a few journals, including Indian Journal of Anatomy and National Journal of Medical Sciences.

Prof. Gangane has also worked as an Officer of Special Duty (OSD) for the Government of Maharashtra under the Directorate of Medical Education and Research. He is a member of the advisory panel for the South Asian region of the international publishing house, Lippincott Williams and Wilkins. He is the founder Trustee of “Sandnya Sanwardhan Sanstha”, an organization that takes care of mentally challenged children by imparting vocational training and enabling them to lead better lives.

Sanjoy Sanyal

(Contributor of Videos, Volumes I, II, and III)

Sanjoy Sanyal, MBBS, MS, MSc, ADPHA, is the Provost and Dean of Richmond Gabriel University College of Medicine, St. Vincent and the Grenadines, Canada. He is also the Professor and Department Chair of Anatomical Sciences in the same university. With medical degrees from India and the United Kingdom, Dr. Sanyal has 39 years of clinical, surgical, and teaching experience as a surgeon, surgical anatomist, neuroscientist, and medical informatician.

A prolific medical and educational researcher, he has published 25 original research papers in peer-reviewed journals and presented 15 papers in many international conferences in 11 countries. He is the recipient of five Outstanding Professor Awards from several different universities and medical schools.

He is a surgical skills instructor to American Medical Students’ Association (AMSA). He is a life-member of Indian Medical Association (IMA), and annual member of American Association for Anatomy (AAA) and American Association of Clinical Anatomists (AACA). He is a provisional patent holder (January 2014) of a computerized medical program from the United States Patent and Trademark Office (USPTO). He is peer reviewer of several medical journals.

Dr. Sanjoy Sanyal is honorary faculty of the Multimedia Educational Resource for Learning and Online Teaching (MERLOT), a program of the California State University (CSU), Long Beach, partnering with educational institutions, professional societies, and industry. He is Gold-level MERLOT contributor, having authored more than 350 learning materials. He is a member of Virtual Speaker’s Bureau (VSB) of MERLOT. He is also the recipient of Innovative Use of MERLOT award.

With an underpinning philosophy of lifelong learning, his motto is to make each succeeding generation better than the previous.

Contributors to Volume II

Poonam Kharb, MSc, PhD

Ex-Professor

Department of Anatomy

Associate Dean

Sharda University

Greater Noida, Delhi NCR, India

D. Krishna Chaitanya Reddy, MSc, Ph.D., FHPE

Assistant Professor

Department of Anatomy

Kamineni Academy of Medical Sciences and Research Center

Hyderabad, Telangana, India

CHAPTER

1

Introduction and an Overview of the Bones of the Lower Limb

© THIEME Atlas of Anatomy

Introduction

The lower limbs are caudal extensions (appendages) from the trunk, specialized for the transmission of the body weight and locomotion. The lower limb extends from hip to the toes. It comprises four major parts or regions: the gluteal, thigh, leg, and foot (Fig. 1.1).

Fig. 1.1 Regions of the lower limb. (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

The Common people’s reference of lower limb as the leg, is in fact the part of lower limb between knee and foot.

Gluteal region: The gluteal region overlies the side and back of the pelvis. The gluteal region comprises a rounded prominent region, the buttock, and a less prominent region, the hip. It extends from the waist down to the gluteal fold, which limits the buttock inferiorly and to the hollow on the lateral side of the hip. Usually, the hip and buttock are not clearly distinguished from each other. The hip is the lateral aspect of region while buttock is rounded bulge behind. The groove between the buttocks is called the natal cleft. The lower part of the sacrum and coccyx can be felt in this groove. Anterior to the gluteal region lies the perineum, in the depth of the cleft, and continues forward between the thighs.

This region contains the hip bone. It comprises three parts, the ilium, ischium, and pubis, which are fused together at the acetabulum where the head of the femur articulates with it. The ilium is the expanded upper part with a crest, the iliac crest, which can be felt in the lower margin of the waist at the level between the L3 and L4 vertebrae. The ischium is the posteroinferior part. It consists of the ischial tuberosity and ramus on which the body rests during the sitting position. The pubis is the anterior part and comprises a body and superior and inferior pubic rami. The body of the pubis articulates with its fellow of the opposite side through a median fibrocartilaginous pad, the pubic symphysis. It may be felt at the lower end of the abdominal wall in the median plane. Draw your finger laterally from the symphysis on the anterosuperior surface of the body of the pubis. The bone felt is the pubic crest which ends in a small, blunt prominence, the pubic tubercle 2.5 cm laterally. In males, it is not easily palpable as it is covered by the spermatic cord.

Thigh region: The thigh region lies between the gluteal, abdominal, and perineal regions proximally and the knee region distally. It contains the femur, which connects the hip and the knee. The femur articulates at the upper end with the hip bone to form the hip joint and at the lower end with the tibia and patella to form the knee joint.

The junction between the trunk and lower limb is abrupt anteromedially. The boundary between abdomen and lower limb, the inguinal ligament extends between anterior superior iliac spine and pubic tubercle. This junction between the two regions is called the inguinal region or groin.

Leg (L. crus) or leg region: The leg region extends from the knee joint to the ankle joint. The leg contains two bones, the tibia and fibula which are united along the length by interosseous membrane. The soft fleshy prominence on the back of the leg is called the calf and is formed by the triceps surae muscle. The lower end of the tibia and fibula form prominences on the medial and lateral sides of the ankle to form the medial and lateral malleoli. The flattened upper surface of the expanded proximal end of the tibia articulates with the lower end of the femur at the knee joint. The proximal end of the fibula articulates with the inferolateral surfaces of the lateral condyle of the tibia and does not take part in the formation of the knee joint.

Foot (L. Pes) or foot region: The foot region is the distal part of the lower limb and extends from the heel to the tips of the toes. It contains the tarsus, metatarsals, and phalanges. Its superior surface is the dorsum of the foot, while its inferior surface is the sole of the foot, which comes in contact with the ground.

An Overview of the Bones of the Lower Limb

A brief account of the bones of the lower limb is necessary before beginning to dissect so that the student studies the surface anatomy and relates it to the appropriate dried bone. The bones of the lower limb include the hip bone, femur, patella, tibia, fibula, and foot bones (Fig. 1.2).

Fig. 1.2 Bones of the lower limb (posterior view). (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

Hip bone (Fig. 1.3): Hip bone is a large, flat bone formed by the fusion of three primary bones, the ilium, ischium, and pubis. At birth, the components are joined with each other by a Y-shaped triradiate hyaline cartilage (Fig. 1.3). By adulthood, they are ossified.

Fig. 1.3 Right hip bone. (a) Lateral view. (b) Medial view. (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020). Figure in the insert shows three primary components of hip bone.

The hip bone looks like a propeller with a large sinuous blade directed upward and a smaller blade directed downward. The upper blade is called the ilium and the lower blade consists of the ischium and pubis. It is perforated by a large aperture, the obturator foramen. The lateral aspect of the hip bone at the junction of the two blades presents a cup-shaped hollow called the acetabulum. Posteriorly, each hip bone articulates with the sacrum at the sacroiliac joint.

Ilium: Ilium’s flattened upper border is called the iliac crest. It runs backward from the anterior superior iliac spine to the posterior superior iliac spine. It can be felt at the lower margin of the waist and below each of these spines are the corresponding inferior spines. The outer surface of the ilium is termed the “gluteal surface,” which provides attachment to the gluteal muscles. The inferior, anterior, and posterior gluteal lines demarcate bony attachments of these muscles. The inner surface of the ilium is smooth and hollowed out to form the iliac fossa. It provides attachment to the iliacus muscle. The articular surface of the ilium articulates with the sacrum at the sacroiliac joints. The iliopectineal line runs anteriorly on the inner surface of the ilium, from the auricular surface to the pubis.

Ischium: Ischium forms the posteroinferior part of the hip bone. It comprises a spine on its posterior part which demarcates the greater sciatic notch (above) from the lesser sciatic notch (below). The ischial tuberosity is a thickening on the lower part of the body of the ischium which bears the body’s weight in the sitting position. The ischial ramus projects forward from the tuberosity to meet with the inferior pubic ramus to form the ischiopubic ramus.

Pubis: Pubis forms the anteromedial part of the hip bone. It comprises a body and superior and inferior pubic rami. It articulates with the pubic bone of the contralateral side by a secondary cartilaginous joint (the symphysis pubis). The superior surface of the body bears the pubic crest and the pubic tubercle. The large obturator foramen is bounded by the pubis, ischium, and their rami.

Femur (Fig. 1.4): The femur is the longest and heaviest bone in the body. It transmits the body weight from the hip bone to the tibia. It presents the following characteristic features:

Fig. 1.4 Right femur. (a) Anterior view. (b) Posterior view. (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

1.Femoral head: It articulates with the acetabulum of the hip bone at the hip joint. It extends from the femoral neck and is rounded and smooth. It forms two-thirds of the sphere and is covered with articular cartilage except for a medially placed depression or pit called the fovea to which the ligamentum teres is attached. This configuration permits a wide range of movement. The head faces medially, upward and forward into the acetabulum.

2.Femoral neck: It forms an angle of 125 degrees with the femoral shaft, the neck shaft angle. This angle is less in females because of the increased width of the pelvis.

3.Femoral shaft: It constitutes the length of the bone. At its upper end, it carries the greater trochanter placed superolaterally and the lesser trochanter placed posteromedially. Anteriorly the rough intertrochanteric line and posteriorly the smooth trochanteric crest demarcate the junction between the shaft and the neck. The linea aspera is the crest seen running longitudinally along the posterior surface of the femur. It splits in the lower portion into the medial and lateral supracondylar lines. The medial supracondylar line terminates at the adductor tubercle.

The lower end of the femur presents the medial and lateral condyles. These condyles bear the articular surfaces for articulation with the tibia at the knee joint. The two condyles are in the same horizontal plane when the femur is in its anatomical position. The lateral condyle is more prominent than the medial condyle, which prevents the lateral displacement of the patella. The condyles are separated posteriorly and inferiorly by a deep intercondylar notch/fossa. Anteriorly, the lower femoral aspect presents a saddle-shaped smooth surface for articulation with the posterior surface of the patella to form the patellofemoral joint.

Tibia (shin bone) (Fig. 1.5): The tibia is the medial bone of the leg. It is the second largest bone of the body and transfers the body weight from the femur to the talus. It presents the following characteristic features:

Fig. 1.5 Tibia and fibula (right side). (a) Anterior view. (b) Posterior view. (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

1.The proximal end of the tibia widens to form the medial and lateral condyles. The flattened upper end of the tibia—tibial plateau—comprises two smooth articular cartilages over the medial and lateral tibial condyles for articulation with the respective femoral condyles. In contrast to the femur, the medial tibial condyle is larger of the two.

2.The intercondylar area is the space between the two articular surfaces on the tibial condyles. It presents two projections, the medial and lateral intercondylar tubercles. Together, these tubercles constitute the intercondylar eminence.

3.The shaft of the tibia is triangular in cross-section. It has anterior, medial, and lateral borders and posterior, lateral, and medial surfaces.

4.The anterior border of the tibia is the most prominent border. At its upper end, there is a tibial tuberosity which is easily identifiable. It provides attachment to the ligamentum patellae.

5.The anterior border and medial surface of the shaft are subcutaneous throughout its length and are often termed as the shin.

6.On the posterior surface of the proximal part of the tibial shaft, there is an oblique line, the soleal line, which provides the tibial origin of soleus. The popliteus muscle is often inserted into the triangular area above the soleal line.

7.The fibula articulates with the tibia superiorly at an articular facet on the posteroinferior aspect of the lateral condyle to form the superior tibiofibular joint.

8.The fibular notch situated laterally on the lower end of the tibia articulates with the fibula to form the inferior tibiofibular joint.

9.The tibia projects inferiorly as the medial malleolus, which constitutes the medial part of the mortise that stabilizes the talus. The medial malleolus is grooved posteriorly for the passage of the tendon of the tibialis posterior muscle.

Fibula (Fig. 1.5): The fibula is the lateral bone of the leg. It is not a part of the knee joint and has no function in weight transmission. The main functions of the fibula are to provide attachment to the muscles and also to participate in the formation of the ankle joint. It presents the following characteristic features:

1.Its upper end is called the head of the fibula, which presents styloid process, a prominence on to which tendon of biceps femoris is inserted.

2.A constriction below the head is called the fibular neck. It separates the head from the fibular shaft. The common peroneal nerve is in close relation, as it winds around the lateral aspect of the neck before it divides into the superficial and deep peroneal nerves.

3.The fibula is triangular in cross-section. It has anterior, medial (interosseous), and posterior borders with anterior, lateral, and posterior surfaces. A vertical ridge, the medial crest, is on the posterior surface which divides into the medial and lateral parts.

4.The lower end of the fibula enlarges and is prolonged inferiorly to form the lateral malleolus. It is the lateral part of the mortise that stabilizes the talus. It bears a smooth triangular articular facet on the medial surface for articulation with the talus. The area above the articular facet is rough to provide attachment to the tibiofibular ligament. The posterior aspect of the malleolus bears a groove for the passage of the tendons of the peroneus longus and brevis muscles. The lateral malleolus projects more downward than the medial malleolus.

Patella (knee cap) (Fig. 1.6):

Fig. 1.6 Patella. (a) Anterior view. (b) Posterior view (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

1.The patella is the largest sesamoid bone in the tendon of the quadriceps femoris. It is triangular in shape and lies in front of the knee joint.

2.The ligamentum patellae, which extends between the apex of the patella and the tibial tuberosity, is the true insertion of the quadriceps femoris.

3.The posterior surface of the patella bears a smooth articular surface, which is covered with the articular cartilage. It is divided into a large lateral facet and a smaller medial facet for articulation with the femoral condyles.

4.The anterior surface of the patella is subcutaneous.

Bones of the foot (Fig. 1.7): The foot bones comprise the following:

Fig. 1.7(a) Bones of the right foot (dorsal view). (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020) (Continued)

Fig. 1.7(Continued) (b) Bones of the right foot (ventral view). (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

1.Tarsal bones.

2.Metatarsals.

3.Phalanges.

Tarsal bones: The tarsal bones are arranged in two rows. The proximal row consists of two large bones (calcaneus and talus) set one above the other.

Calcaneus (Fig. 1.8a): The calcaneus is the largest tarsal bone forming the skeleton of the foot. Its superior surface articulates with the talus to form the subtalar joint. The inferior surface presents the medial and lateral tubercles at the proximal end. The medial surface presents a distinctive shelf-like projection called the sustentaculum tali. The lateral surface presents a peroneal tubercle. The anterior surface presents a facet for articulation with the cuboid. The posterior surface presents a roughened middle part for attachment to the tendo calcaneus.

Fig. 1.8(a) Right talus (dorsal view) and (b) Right calcaneus (dorsal view). (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020)

Talus (Fig. 1.8b): The talus forms a connecting link between the bones of the foot and leg. It presents the head, neck, and body. The body presents facets on its superior, medial, and lateral surfaces for articulation with the tibia, medial malleolus, and lateral malleolus, respectively. There is a groove on the posterior surface for the tendon of the flexor hallucis longus. The head projects distally and articulates with the navicular bone. The neck connecting the body and head presents a groove called the sinus tarsi.

Cuboid (Fig. 1.7): As the name implies, it is cuboid in shape. It articulates proximally with the calcaneus and distally with the fourth and fifth metatarsals. Its undersurface is grooved for the tendon of the peroneus longus.

Navicular (Fig. 1.7): Navicular is boat-shaped. It articulates proximally by the concave facet with the head of the talus and distally with the three cuneiforms. It presents a tuberosity on its medial aspect for attachment to the tibialis posterior.

Cuneiforms (Fig. 1.7): There are three cuneiforms: medial, intermediate, and lateral. They articulate anteriorly with the first, second, and third metatarsals, respectively.

Metatarsals (Fig. 1.7): The metatarsals are five miniature long bones and are numbered 1 to 5 from the medial side. Their proximal ends articulate with the tarsal bones. The distal end (bead) of each metatarsal articulates with the base of the proximal phalanx of the corresponding toe. The first metatarsal is the largest and the inferior surface of its head is grooved for two sesamoid bones.

Phalanges (Fig. 1.7): The phalanges are miniature long bones of the toes. In each toe, there are three phalanges: proximal, middle, and distal, except in the great toe which has only two phalanges (proximal and distal). The proximal end of each phalanx is its base and the distal end is its head. The phalanges articulate with each other at the interphalangeal joints.

CHAPTER

2

Anterior and Medial Compartments of the Thigh

© THIEME Atlas of Anatomy

Learning Objectives

At the end of the dissection, you should be able to identify the following:

▪Cutaneous nerves innervating the skin of the anterior and medial aspects of the thigh.

▪Saphenous opening and the structures passing through it.

▪Great saphenous vein and its tributaries.

▪Muscles of the anterior compartment of the thigh.

▪Femoral triangle: structures forming its boundaries and contents.

▪Femoral sheath and its compartments and contents.

▪Femoral artery and its branches.

▪Femoral vein and its tributaries.

▪Superficial and deep inguinal lymph nodes.

▪Muscles of the medial compartment of the thigh.

▪Obturator nerve and its branches.

▪Structures forming boundaries of the adductor canal and its contents.

Introduction

The thigh extends from the hip joint to the knee joint. The deep fascia of the thigh (fascia lata) encloses the entire thigh like a sleeve/stocking. From the deep aspect of the fascia lata, three fibrous intermuscular septa—lateral, medial, and posterior—pass to the linea aspera of the femur and divide the thigh into three compartments—anterior, medial, and posterior (Fig. 2.1). The anterior (extensor) compartment of the thigh lies between the lateral and medial intermuscular septa, and the medial compartment lies between the medial and posterior septa.

The superficial fascia on the front of the thigh close to inguinal ligament consists of two layers similar to that in the lower part of abdomen. They fuse with each other 1cm interior to inguinal ligament. An oval opening in the deep fascia 3-4 cm inferolateral to public tubercle is called saphenous opening, through which long saphenous vein enters into femoral vein. The superficial fascia on the front of the thigh contains:

Fig. 2.1 Transverse section of the thigh (right, superior view). Figure in the inset shows three compartments of the right thigh. MIMS, medial intermuscular septum; LIMS, lateral intermuscular septum; PIMS, posterior intermuscular septum. (From Schuenke M, Schulte E, Schumacher U. THIEME Atlas of Anatomy. General Anatomy and Musculoskeletal System. Illustrations by Voll M and Wesker K. © Thieme 2020.)

1.Cutaneous nerves: derived from lumbar plexus, viz., femoral branch of genito femoral nerve, lateral cutaneous nerve of thigh, intermediate, lateral cutaneous nerve of thigh, and medial cutaneous nerve of thigh.

2.Cutaneous arteries: from femoral artery.

3.Termination of great saphenous vein: longest superficial vein of lower limb.

4.Superficial inguinal lymph nodes: lies below the inguinal ligament.

5.Some along the ligament and some along the upper part of long saphenous vein.

Surface Landmarks

1.Before starting the dissection, study the surface anatomy of the region. Palpate the bony landmarks and relate them to the respective bones on the articulated skeleton (refer to Fig. 1.1and 1.2).

2.Run your finger along the fold of the groin (inguinal groove), a shallow groove extending from the pubic tubercle to the anterior superior iliac spine. It corresponds to the underlying inguinal ligament that separates the anterior abdominal wall from the front of the thigh. Feel the resilient band (inguinal ligament) in the groove extending between the anterior superior iliac spine and pubic tubercle.

3.Palpate the anterior superior iliac spine at the lateral end of the fold of the groin and observe that it forms the anterior end of the iliac crest of the hip bone.

4.Palpate the pubic tubercle, a small bony projection at the medial end of the fold of the groin. It lies approximately 2.5 cm lateral to the pubic symphysis. The tubercle is less easily felt in males as it is covered by the spermatic cord.

5.Use chalk to mark the midinguinal point and the midpoint of the inguinal ligament along the inguinal groove. The midinguinal point is a point midway between the anterior superior iliac spine and pubic symphysis, whereas the midpoint of the inguinal ligament is midway between the anterior superior iliac spine and pubic tubercle.

6.At the lower end of the thigh, identify the medial and lateral condyles of the femur and tibia. They form large bony masses on the medial and lateral sides of the knee, respectively.

7.Feel the patella, a triangular bone in front of the knee, and try to move it when the knee is extended.

8.Palpate the tibial tuberosity, a bony prominence in front of the upper part of the tibia.

9.Ligamentum patellae is a strong fibrous band that extends between the patella and tibial tuberosity.

Anterior Compartment of the Thigh

Dissection and Identification

1.Make a horizontal incision “A” through the skin from the anterior superior iliac spine to the midline and continue the incision downward lateral to the external genitalia. Make a vertical incision “B” from the lower end of the above incision till the medial condyle of the tibia. Make another horizontal incision “C” from the lower end of the vertical incision passing laterally till the lateral condyle of the tibia (Fig. 2.2).

2.Reflect the skin from the superficial fascia and turn it laterally, taking care not to damage the cutaneous nerves.

3.Strip the superficial fascia from the front and lateral aspects of the thigh by blunt dissection. Find the cutaneous nerves (lateral cutaneous nerve of the thigh, femoral branch of the genitofemoral nerve, intermediate cutaneous nerve of the thigh, and medial cutaneous nerve of the thigh) which pierce the deep fascia at different points (Fig. 2.3) and follow them distally.

4.Find the great saphenous vein in the superficial fascia of the medial part of the anterior surface of the thigh. Trace it downward till the knee and upward where it turns backward through the saphenous opening (hiatus) to enter the femoral vein. Note that this area is 3 to 4 cm inferolateral to the pubic tubercle and is about 3 cm long and 1.5 cm wide. In this area, the deep fascia is thin and perforated (cribriform fascia). Put your finger beside the upper end of the great saphenous vein to feel the sharp thick edge of the deep fascia (falciform margin) which limits the saphenous opening all around except medially (Fig. 2.4).

5.Identify the lower group of the superficial inguinal lymph nodes scattered along the upper part of the great saphenous vein.

6.Observe that at least three small veins enter the great saphenous vein near its termination. Follow these veins along with the superficial branches of the femoral artery, which pierce the cribriform fascia, and accompany them. The superficial epigastric vessels course superiorly to the anterior abdominal wall, the superficial circumflex iliac artery courses laterally below the inguinal ligament, and the superficial external pudendal vessels pass medially to the external genitalia.

7.Use a pair of scissors to cut through the deep fascia to expose the muscles and deeper structures in the upper anterior compartment of the thigh. Expose the sartorius muscle extending from the anterior superior iliac spine to its insertion into the upper part of the medial surface of the tibia. Medially, expose the adductor longus muscle down to the point where it meets the sartorius muscle (Video 2.1).

8.Identify the boundaries of the femoral triangle: superiorly formed by the inguinal ligament, laterally by the sartorius and medially by the medial border of the adductor longus. Clean the structures, that is, the femoral nerve, femoral artery, and femoral vein within the triangle (Fig. 2.5).

9.Follow the great saphenous vein to the femoral vein. Split the femoral sheath lateral and medial to the femoral vein to expose the femoral artery and femoral canal, respectively. Note the two septa of the femoral sheath that separate the three compartments containing the femoral artery, femoral vein, and femoral nerve (lateral to medial) (Fig. 2.5).

10.Put your little finger into the femoral canal and push it upward. Feel the peritoneum which covers the abdominal opening of the canal. Move the tip of your little finger to feel the structures bounding the abdominal opening of the femoral canal. Feel the inguinal ligament anteriorly, the edge of the lacunar ligament medially, and the pecten pubis posteriorly.

11.Find the femoral nerve lateral to the femoral artery in the groove between the muscles and observe that it immediately divides into anterior and posterior divisions from which arise a number of cutaneous and muscular branches. Trace the nerve to the pectineus passing medially posterior to the femoral artery. Follow the other cutaneous and muscular branches till they leave the femoral triangle (Fig. 2.6; Video 2.2).

12.Remove the venae comitantes of the smaller arteries in this region to trace the deep branches of the femoral artery. Retract the femoral artery medially and identify the profunda femoris artery which arises from the posterolateral aspect of the femoral artery. Follow it downward along with the profunda femoris vein till the apex of the femoral triangle. Note that at the apex of the femoral triangle the femoral artery, femoral vein, profunda femoris vein, and profunda femoris artery lie in this order from before backward.

13.Find the lateral and medial circumflex arteries which usually arise from the profunda femoris near its origin. Trace the lateral circumflex artery as it passes laterally among the branches of the femoral nerve and deep to the upper part of the rectus femoris and gives three branches, that is, the ascending, transverse, and descending branches.

14.Strip the fascia from the iliacus and psoas major muscles in the floor of the femoral triangle. Place your finger on the tendon of the psoas major and push it downward and backward to reach its insertion to the lesser trochanter. Trace the medial circumflex artery as it passes backward between the psoas and pectineus muscles. Make a vertical incision in the fascia lata from the iliac crest to the lateral margin of the patella and remove the fascia between this incision and the sartorius. This would expose the underlying quadriceps femoris muscle and tensor fasciae lata (Fig. 2.5; Video 2.3).

15.Use your fingers to separate the sartorius muscle from the underlying fascia in the middle third of the thigh. Cut the sartorius muscle a little above the apex of the femoral triangle and turn the lower part downward to expose the narrow strip of the fascia extending between the vastus medialis and adductor muscles which forms the roof of the adductor canal. Using a pair of scissors, split the fascia to find the contents of the adductor canal, such as the femoral vessels, saphenous nerve, and nerve to the vastus medialis (Fig. 2.6).

16.Note the femoral vein lies posterior to the femoral artery and the femoral vessels leave the adductor canal to enter the popliteal fossa (at the back of the knee) by passing through the opening in the adductor magnus.

17.Observe the bipennate rectus femoris in the middle of the front of the thigh and obliquely running fibers of the vastus lateralis and medialis on either side of the rectus femoris. Retract the rectus femoris laterally or medially to expose the underlying vastus intermedius. Note that the four parts of the quadriceps femoris muscle mentioned above unite to form the quadriceps tendon which is attached to the patella, and the patellar ligament attaches the patella to the tibial tuberosity.

18.Femoral nerve.

Fig. 2.2 Incisions for dissection of the front of the lower limb.