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2015v1.0
Gray’s
Surface Anatomy
and Ultrasound
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S
SURFACE ANATOMY
AND ULTRASOUND
’
Y
A Foundation for Clinical Practice
A
Claire F. Smith
BSc (Hons) PGCE PhD SFHEA FAS FLF
Head of Anatomy
Reader
Brighton and Sussex Medical School
University of Sussex
R Brighton, UK
Andrew Dilley
BSc (Hons) PhD
Deputy Head of Anatomy
Senior Lecturer in Anatomy
Brighton and Sussex Medical School
G
University of Sussex
Brighton, UK
Barry S. Mitchell
BSc (Hons) MSc PhD CBiol FRSB FHEA
Emeritus Professor of Healthcare Sciences
Former Dean Faculty of Health and Life Sciences
De Montfort University
Leicester, UK
Richard L. Drake
PhD FAAA
Director of Anatomy
Professor of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cleveland, OH, USA
For additional online content visit StudentConsult.com
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018
© 2018, Elsevier Limited. All rights reserved.
The right of Claire Smith, Andrew Dilley, Barry Mitchell and Richard Drake to be identified as authors of this
work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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This book and the individual contributions contained in it are protected under copyright by the publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
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It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to
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To the fullest extent of the law, neither the publisher nor the authors, contributors, or editors, assume any
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material herein.
ISBN: 978-0-7020-7018-1
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Content Strategist: Jeremy Bowes
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Project Manager: Joanna Souch
Design: Christian Bilbow
Printed in China Illustrator: Richard Tibbitts (Antbits)
Last digit is the print number: 9 8 7 6 5 4 3 2 1 Marketing Manager: Melissa Darling
Contents
Foreword ..............................................................................................................................................................vii Abdominal regions ...................................................................30
Preface .........................................................................................................................................................................ix Muscles ............................................................................................32
About this book ......................................................................................................................................x Viscera ...............................................................................................34
Expert reviewers .................................................................................................................................xi Ultrasound ..............................................................................................41
Credits .........................................................................................................................................................................xii Anterior abdominal musculature ....................................41
Acknowledgments .....................................................................................................................xiii Gastrointestinal tract ...............................................................42
Dedications ..................................................................................................................................................xiii Liver ....................................................................................................43
Kidney ...............................................................................................46
Spleen ...............................................................................................46
1. Introduction
Pancreas ..........................................................................................47
Conceptual overview ........................................................................2 Vasculature ....................................................................................47
Surface anatomy ..................................................................................2 Video 3.1 B-mode ultrasound image sequence of the jejunum –
Anatomical position and planes ........................................2 transverse view.
Anatomical terms ........................................................................3
Movement........................................................................................3
4. Pelvis and perineum
Fascia ...................................................................................................3
Skin .......................................................................................................4 Conceptual overview ......................................................................51
Skin color ..........................................................................................5 Surface anatomy ...............................................................................51
Dermatomes and myotomes ..............................................6 Bones .................................................................................................51
Natural variation ...........................................................................6 Muscles ............................................................................................51
Palpation and percussion ......................................................7 Viscera ...............................................................................................51
Ultrasound ................................................................................................7 Perineum .........................................................................................56
Ultrasound theory .......................................................................7 Pregnancy ......................................................................................58
Doppler ..............................................................................................8 Ultrasound ..............................................................................................59
Types of transducer ...................................................................9 Male pelvis .....................................................................................59
Imaging planes .............................................................................9 Female pelvis ...............................................................................60
Screen orientation ......................................................................9 Video 4.1 Colour Doppler ultrasound image sequence of the
Ergonomics ...................................................................................10 bladder – mid-sagittal view.
Manipulating the transducer .............................................10
Short-axis and long-axis views..........................................11
5. Back
Image terminology ...................................................................11
Appearance of tissues ............................................................12 Conceptual overview ......................................................................66
Surface anatomy ................................................................................66
Curvatures ......................................................................................66
2. Thorax
Bones .................................................................................................66
Conceptual overview ......................................................................15 Ligaments .......................................................................................67
Surface anatomy ................................................................................15 Joints..................................................................................................69
Bones .................................................................................................15 Muscles ............................................................................................69
Muscles ............................................................................................15 Movements ...................................................................................71
Breast .................................................................................................18 Vertebral canal and spinal nerves ...................................71
Thoracic cavity.............................................................................18 Ultrasound ..............................................................................................77
Ultrasound ..............................................................................................26
Anterior muscles of the thorax and lungs ................26
6. Upper limb
Heart ..................................................................................................26
Video 2.1 Colour Doppler ultrasound image sequence of the Conceptual overview ......................................................................84
heart – apical view. Surface anatomy ................................................................................84
Shoulder ..........................................................................................84
Axilla ...................................................................................................87
3. Abdomen
Arm .....................................................................................................89
Conceptual overview ......................................................................30 Forearm ............................................................................................91
Surface anatomy ................................................................................30 Hand ..................................................................................................98
Bones .................................................................................................30 Neurovascular structures ...................................................103 v
Contents
Ultrasound ...........................................................................................109 Carotid system .........................................................................185
Scalene triangle .......................................................................109 Thyroid gland ............................................................................189
Shoulder region ...............................................................................110 Posterior triangle of neck ..................................................190
Deltoid muscle .........................................................................110 Video 8.1 Colour Doppler ultrasound image sequence of the
Rotator cuff muscles .............................................................110 internal and external carotid arteries (red) and internal jugular
Anterior arm ...............................................................................113 vein (blue) in the neck – short-axis view.
Posterior arm .............................................................................115
Elbow..............................................................................................115 Index .........................................................................................................................................................................191
Anterior forearm ......................................................................118
Posterior forearm ....................................................................121
Hand ...............................................................................................123
Video 6.1 B-mode ultrasound image sequence of the
long flexor tendons immediately proximal to the wrist –
Get the most out of your
long-axis view.
GRAY’S SURFACE ANATOMY
7. Lower limb AND ULTRASOUND
Conceptual overview ...................................................................127
Included in your purchase is a variety of BONUS electronic content, to supple-
Surface anatomy .............................................................................127 ment and enhance the printed book. The authors have carefully selected
Gluteal region ...........................................................................127 additional figures (‘eFigs’), videos and expanded tables conveying additional
Thigh ...............................................................................................127 information to enrich your learning experience. Just look out for this icon
Knee joint ....................................................................................134 throughout the (printed) book – and see the inside front cover for your access
Leg ...................................................................................................136 instructions.
Foot .................................................................................................137
For a richer learning experience and for no extra charge, find a wealth of
Neurovascular structures ...................................................143
enhanced electronic material in the Student Consult eBook that accompanies
Ultrasound ...........................................................................................150
the print content of this book.
Gluteal region ...........................................................................150
Femoral triangle ......................................................................150 After you redeem your code (see inside front cover) at www.studentconsult.
Anterior thigh ...........................................................................152 com, you can use the eBook in the browser and/or download it (in the Inkling
Knee ................................................................................................152 app) to your mobile device to use anywhere, offline (the videos only play
Medial thigh and adductor canal ................................156 when you’re online). The supplementary material is integrated at relevant
Posterior thigh and popliteal fossa .............................156 locations in the enhanced eBook, so you get it right where you need it.
Anterior leg.................................................................................159
Test your understanding with scored quizzes of single best answer Q&As
Posterior leg ...............................................................................160
accompanying each chapter. They’re also all collected together in the ‘Assess-
Lateral leg ....................................................................................162
ments’ chapter, so you can make full use of the self-assessment in one place.
Video 7.1 Colour Doppler ultrasound image sequence of the Test yourself with some of the figures too, using interactive labels. You can
femoral artery and vein in the thigh – long-axis view. zoom in on high-resolution images, as well as watch videos showing live
ultrasound scans as seen in clinical practice. Click through from the ‘Learning
Resources’ chapter to our interactive, animated Surface Anatomy Tool, where
8. Head and neck
you can explore specific parts of areas of the body and make connections
Conceptual overview ...................................................................166 with the common clinical procedures related to them.
Surface anatomy .............................................................................166
As with all enhanced eBooks on Student Consult, there’s the option to add
Head ................................................................................................166
‘Notes’, ‘Highlights’ and ‘Bookmarks’. Select text to easily highlight or make
Neck ................................................................................................175
notes, which you can choose to share among other users. By setting your
Lymph ............................................................................................179 ‘Note’ to ‘Public’, you and your friends can share ideas – and reply to them
Neurovascular ...........................................................................180 (like on Facebook). Anyone who ‘Follows’ you can see your public
Ultrasound ...........................................................................................183 ‘Notes’/’Highlights’, and if you ‘Follow’ them, you can see theirs. To ‘Follow’
Eye ....................................................................................................183 someone, click ‘Find Friends’ near the top of your ‘Library’ page in Student
Parotid gland .............................................................................184 Consult, and enter the email address that they use for their account. Then
you can see their ‘Notes’ in books that you both have.
Submandibular gland ..........................................................184
Floor of the oral cavity ........................................................184
vi
Foreword
Until the final years of the 19th century, vizualising anatomical 1940s, together with his younger brother Friedrich, a
structures deep within the living body non-invasively had physicist, Karl Dussik tried to image the living human brain
seemed an impossible dream: exploring the contents of the with ultrasound, calling the process ‘hyperphonography’.
body remained the exclusive preserve of the anatomist in He interpreted the resulting 2D representations of the
the dissecting room and the surgeon in the operating theatre. intensity attenuation of the waves through the head as
A few sentences in a London newspaper gave notice of a ‘ventriculograms’ that showed the lateral ventricles within
discovery that would change that perspective and that surely the brain. These images were subsequently shown to be
ranks alongside the ability to control pain and infection as artefactual and for a while it seemed as though ultrasound
a game changer in medicine. ‘It is reported from Vienna … was unlikely to play any further role in diagnostic imaging.
Professor Routgen [sic] … has discovered a light which for the The field was re-invigorated in the 1950s when the transmis-
purpose of photography will penetrate wood, flesh, cloth, and sion technique used by Dussik was replaced by the reflection
most other organic substances. The Professor has succeeded technique. Ultrasound continued to evolve from being a ‘..
in photographing … a man’s hand which showed only the medical curiosity to a recognized clinical procedure, capable
bones, the flesh being invisible.’ This news, cabled from the of providing unique diagnostic information’3. Rapid technical
London Standard on 6 January 1896, appears to be the first developments in electronics, piezoelectric materials and
account in English of Wilhelm Röntgen’s momentous dis- processing power over the last 50 years have produced
covery of X-rays in November 1895. The clinical potential ultrasound units generating real-time, dynamic grey scale
of his discovery was quickly appreciated: numerous con- images of anatomy. Karl Dussik’s comments in 1953 on the
temporary accounts reveal that clinical practice altered within potential use of ultrasound in medicine proved prescient
weeks of the news ‘going viral’ …’Never in the history of …However complicated the problems may be the imperative
science has a great discovery received such prompt recognition of these possibilities seems so great as to justify any and all
and has been so quickly utilized in a practical way as the new efforts to overcome the technical difficulties. ’ 4. Unlike expensive
photography which Professor Roentgen gave to the world only hospital-based CT and MRI scanners, the portability and
three weeks ago. Already it has been used successfully by relatively low cost of modern ultrasound units means that
European surgeons in locating bullets and other foreign sub- they can brought to the patient at the bedside, in the clinic,
stances in human hands, arms and legs and in diagnosing on the battlefield and even in orbiting space stations (as
diseases of the bones in various parts of the body..’ 1 part of ADUM, ADvanced Ultrasound in Microgravity, a NASA
During the 20th century, developments in physics, project5). Today, ultrasound is one of the most widely used
electronics and computing continued to exploit X rays and modalities in medical imaging, regarded by the World Health
introduced novel ways of displaying internal anatomy in Organisation as meeting 2/3 of health care imaging needs
real-time. CT scanning, MRI and ultrasound imaging all (WHO 1999). Point of care ultrasound (POCUS) is used as a
revealed levels of anatomical detail acquired non-invasively physical diagnostic tool, to assess, for example, the extent
that had previously been seen only on the pages of atlases of abdominal trauma following injury (focused abdominal
of frozen, sectioned cadavers2. sonography in trauma, FAST) and fetal growth and gestational
age during pregnancy, where transabdominal B-mode
Ultrasound
imaging is regarded as the gold standard protocol. Coloured
In the 1920s and 1930s, ultrasound was used for physical Doppler ultrasound is used to assess blood flow and vascular
therapy, primarily for members of Europe’s soccer teams, pathologies. Non-diagnostic ultrasound imaging to guide
for sterilization of vaccines and for cancer therapy in combina- interventional procedures such as regional nerve blocks,
tion with radiation therapy. Karl Theodor Dussik, a neurologist central venous catheterisation, and cutting-needle and fine
and psychiatrist working in Vienna, is usually credited as needle aspiration biopsies has significantly reduced the risk
the first to apply ultrasound as a potential diagnostic tool of iatrogenic injury and is regarded as the gold standard
and is regarded as the father of ultrasonic diagnosis. In the for these applications. POCUS training is now a mandatory
3Goldberg BB, Gramiak R, Freimanis AK (1993) Early history of diagnostic ultrasound: the
1Standring S (2016) A brief history of topographical anatomy. J. Anat. (2016) 229, role of American radiologists. AJR Am J Roentgenol 160, 189–194.
pp32–62 4See: Classic Papers in Modern Diagnostic Radiology (Thomas AM, Banerjee AK, Busch U
2Braune W (1867–1872) Topographisch-Anatomischer Atlas: Nach Durchschnitten an (eds) Springer 2005
vii
Gefrornen Cadavern. Leipzig: Verlag von Veit & Comp. 5https://science.nasa.gov/science-news/science-at-nasa/2005/16feb_ultrasound
Foreword
component in many postgraduate courses: e.g the Accredita- take account of these variations. In preparing this book, and
tion Council for Graduate Medical Education. in particular in drawing up the instructions in the ‘To do’
surface anatomy lists, the authors have taken these more
Surface anatomy
recent findings into account. In order to escape the censure
It is self-evident that interpreting the images produced by of their teachers, students are advised to use these lists to
any imaging modality, whether using Xrays, fMRI or ultra- practice on themselves, and their willing friends, before they
sound, is predicated upon relating those images accurately lay hands on their first patient …‘Many a student first realizes
to the relevant topographic anatomy. The bones of Frau [the] importance [of surface anatomy] only when brought
Röntgen’s hand that appeared in one of her husband’s X to the bedside or the operating table of his patient, when the
ray films were identifiable because they corresponded with first thing he is faced with is the last and least he has
what was already known about the skeletal anatomy of the considered’6.
hand (no doubt aided by the presence of her wedding ring Diagnostic imaging is an indispensable element of clinical
on her ring finger). Surface anatomy (living anatomy) relates practice. However, learning to interpret the images produced
structures under the skin to palpable surface features such by Xrays, CT, MRI, ultrasound and during endoscopic pro-
as bony protuberances, tendons, muscle bellies or consistent cedures, takes time, a precious commodity that is in short
skin creases. The impression that may be gained from most supply in today’s overcrowded medical curricula, particularly
anatomy text books that surface anatomy is an exact science in the anatomy lab. This book contains a novel combination
is at variance with everyday clinical experience: relating of evidence-based surface anatomy and ultrasound anatomy
surface features to the location of underlying deeper that will help students to reinforce their clinically relevant
structures is significantly influenced by variations in body anatomical knowledge and develop those vital interpretive
mass index, height, gender, age and ethnicity and by dynamic skills.
factors such as posture and respiration. Recent studies in
which surface features have been related to measurements Susan Standring MBE PhD DSc FKC Hon FAS Hon FRCS
based on modern cross sectional images, rather than Emeritus Professor of Anatomy
measurements based on cadaveric or earlier radiographic King’s College London
studies, have called for a re-appraisal of some markings to May 2017
6Whitnall SE. 1933. The Study of Anatomy. Written for the Medical Student. London: Edward
viii
Arnold. p 48
