Last’s Anatomy: Regional and Applied

559 Pages·2011·190.12 MB·English

by  Chummy S. Sinnatamby

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L A
AST’S NATOMY
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CommissioningEditor:TimothyHorne,JeremyBowes
DevelopmentEditor:SallyDavies
ProjectManager:ElouiseBall
DesignDirection:CharlesGray
IllustrationDirection:BruceHogarth
Artworkcolouring:IanRamsden
Newartwork:GillianOliver
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L A
AST’S NATOMY
R e g i o n a l a n d A p p l i e d
Twelfth Edition
Chummy S. Sinnatamby
FRCS
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Formerly:
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Head of Anatomy, Royal College of Surgeons of England
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Member of Court of Examiners, Royal College of Surgeons of England

Examiner in Anatomy, Royal College of Sur-geons in Ireland
Director of Studies in Anatomy, St Cat9ha rine’s College and Hughes Hall, Camrbridge
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External Examiner in Anatomy, Un9iversity of Cambridge s
External Examiner in Anatomyr, Trinity College,&University of Dublins
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Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2011
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Publisher(otherthanasmaybenotedherein).
Firstedition1954
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Secondedition1959
Thirdedition1963
Fourthedition1966 R
Fifthedition1972
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Sixthedition1978
Seventhedition1984

Eighthedition1990 -
Ninthedition1994 r
Tenthedition1999 9 i
Eleventhedition2006 9 s.
Twelfthedition2011
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Preface
to the twelfth edition
Forthefirsttimeinitspublicationhistoryalltheillustrationsintheprevious(eleventh)editionof
Last’s Anatomy appeared in full colour. This development transformed the illustrations and
received very favourable readership response. In the light of such evaluation the publication of a
twelftheditionhasprovidedtheopportunitytoaugmenttheillustrationsinthebookbytheinclu-
sion of new photographs depicting anatomy of clinical, endoscopic and surgical relevance and
additional photographs of prosections. Where necessary the colour, tone, shade and contrast of
existingillustrationshavebeenenhanced.Colourconsistencyforrelatedstructureshasbeenmain-
tainedthroughouttoensureeaseofcross-referencefromoneillustrationtoanother.
Thetexthasbeenwhollyreviewedandrefinementsmadewhererequiredintheinterestsofrele-
vance and readability. The anatomy of surgical approaches has been updated in the light of the
continuingevolutionofsurgicalpractice,advancesinlaparoscopicsurgeryandtheincreasingscope
of minimal access procedures. The limited field of vision provided by these latter techniques
emphasises the need for a reliable knowledge of regional anatomy and structural relationships.
Eponymsincommonclinicalusehavebeenadded.
Curricular reforms and changes to surgical training programmes have resulted in a reduction of
anatomystudytimeandprosectionexperienceformedicalstudents,andindifficultiesencountered
bysurgicaltraineesinincludinganatomydemonstratorshipsintheircareerpathways.Thesedevelop-
mentshavereiteratedthecontinuingneedforaregionallyarranged,clinicallyandsurgicallyrelevant
anatomytextbookappropriateforbothundergraduatestudyandpostgraduateutilisation.Thetwelfth
editionofLast’sAnatomyaimstofulfilthisroleandbeofvaluetomedicalstudents,surgicaltrainees
andpractisingsurgeons.
ChummyS.Sinnatamby
2010
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Preface
to the eleventh edition
Inresponsetoinnumerablerequests,alltheillustrationsintheeleventheditionappearinfullcol-
our.Carehasbeentakeninthechoiceofandconsistencyinuseofcoloursforsimilarstructuresto
facilitateeaseofrecognitionandenhancethereader’sappreciationoftheillustrations asamean-
ingful adjunct to the text. Some of the illustrations in the first edition of R. J. Last’s Anatomy,
RegionalandAppliedwerepartlycolouredastheyappearedinrelationtothetext.Intheseventhedi-
tion several partly coloured illustrations were collectively positioned as plates at the front of the
book, butthese were thenomitted from subsequent editions. Ithas been gratifying tobe able to
restorecolourtoLast’sAnatomyandextenditsapplicationtofullcolourforalltheillustrationsas
they remain integrated with the text. Several new illustrations, including clinical photographs,
radiographs and magnetic resonance images, have been added, depicting normal anatomy and
lesionsthathaveananatomicalbasis.
Thetexthasbeenextensivelyrevisedwithseveraladditionstotheclinicalandappliedaspectsof
anatomyandtextualchangesintheinterestsofclarityandaccuracy.
Iamgratefultothemanyreaders,postgraduateandundergraduate,intheUKandabroad,who
have communicated their appreciation of and comments on the tenth edition. Their input has
encouragedandaidedthepreparationoftheeleventhedition.
ChummyS.Sinnatamby
2005
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Preface
to the tenth edition
In1954,aftersevenyearsofassociationwithpostgraduatestudentsofanatomyattheRoyalCol-
legeofSurgeonsofEngland,R.J.LastpublishedthefirsteditionofAnatomy,RegionalandApplied.
Forty-fiveyearslaterLast’s‘approachtothestudyofanatomy’isstillofvaluetoundergraduateand
postgraduate students of anatomy. The chief assets of Last’s Anatomy were epitomised in its title.
Intheassessmentandtreatmentofpatients’lesions,cliniciansencountertheanatomyofthehuman
bodyonaregionalbasis,andthebookpresentedappliedanatomydataregionallyarranged.When
R.M.H.McMinntookovertheeditorshipin1990heretained‘theflavourofearlierversions’and
addedtotheappliedaspectsofthesubject.
In preparing the tenth edition of Last’s Anatomy, I have maintained the overall structure and
arrangementofthebook.Theentiretext,however,hasundergonecomprehensiverevisiondirected
towards a reduction of its volume and greater clarity. Anatomical detail of no clinical relevance,
phylogenetic discussion and comparative anatomy analogies have been omitted. Within the con-
straintsofconciseness,clinicallycorrelatedtopographicalanatomyrelevanttotheexpandingfron-
tiers of diagnostic and surgical procedures has been included. Surface anatomy pertaining to
physicalexaminationispresented.Histologicalfeaturesanddevelopmentalaspectshavebeenmen-
tionedonlywheretheyaidtheappreciationofthegrossformorfunctionoforgansandtheappear-
anceofthecommonercongenitalanomalies.
In keeping with the extensive textual changes in this edition, the illustrations have also under-
gonemajorrevision.Whileseveralfigureswhichappearedinpreviouseditionsbutdidnotsignifi-
cantlycontributetoorenhancethetext,havebeenremoved,97newillustrationshavebeenadded.
Thelatterincludeoriginalartworkspeciallycommissionedforthisedition,figuresreproducedfrom
Gray’sAnatomy(withthekindpermissionofthepublishers)onaccountoftheiranatomicalaccu-
racyandclarity,andexamplesofcurrentdiagnosticimagingtechniques.
Throughout the preparation of this edition the curricular reforms of undergraduate education
andtherestructuringofsurgicaltraininghavebeenborneinmind.Timeconstraintsandtheinter-
disciplinaryintegrationpertainingtobothhaverestrictedthestudyofanatomy.Nevertheless,ana-
tomical knowledge is required for performing physical examination and diagnostic tests,
interpreting their results and instituting treatment, particularly surgical procedures. In his preface
to the second edition Last stated that: ‘While the text was written chiefly to help students who
arerevisingtheiranatomyforanexamination,itisparticularlygratifyingtofindthatsomanyclin-
iciansandsurgeonshavefoundthebookofvalueintheirpractice.’Itishopedthattheclinically
relevantanatomicalinformationpresentedinthetenthedition,inasconciseaformasitscontent
concedes, will be of use to students preparing for examinations, participants in basic and higher
surgicaltrainingprogrammes,andpractisingsurgeons.
Thirty-sevenyearsagoIpurchasedacopyofthesecondeditionofLast’sAnatomywhilepreparing
fortheprimaryfellowshipexamination,intheoralsectionofwhichIwasexaminedbyProfessor
Lasthimself.LittledidIimaginethenthatitwouldonedaybemyprivilegetopreparethetenth
editionofLast’sAnatomy,therebymaintainingthelinkagebetweentheeditorshipofthispublica-
tionandtheheadshipofanatomyattheRoyalCollegeofSurgeonsofEngland.
ChummyS.Sinnatamby
1998
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Acknowledgements
Appreciative communications from the readership of the eleventh edition of Last’s Anatomy have
inspired the publication of another edition of this textbook of regional and applied anatomy.
Several people have contributed to the production of the twelfth edition. In particular I thank
Timothy Horne, latelyof Churchill Livingstone and ElsevierLimited, for his encouragement, and
SallyDavies,ElouiseBallandBruceHogarthofElsevierLimitedfortheirassistancewiththeprepa-
ration of the manuscript and the colouring of figures. I am grateful to Dr Ruchi Sinnatamby of
Addenbrooke’sHospital,Cambridge,forherhelpwiththeharvestingofnewclinicalillustrations.
Iamgreatlyindebtedtomywife,Selvi,forherpatientsupportatalltimes.
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Contents
CHAPTER 1: Introduction to regional 9. Posterior compartment of the leg...........146
anatomy 10. Sole of the foot...........................................151
1. Tissues and structures.....................................1 11. Ankle and foot joints.................................156
2. Nervous system................................................9 12. Summary of lower limb innervation.....162
3. Embryology.....................................................22 13. Summaryoflowerlimbnerveinjuries.....163
4. Anatomy of the child...................................32 14. Osteology of the lower limb....................164
CHAPTER 2: Upper limb CHAPTER 4: Thorax
1. Pectoral girdle................................................37 1. Body wall.....................................................179
2. Shoulder..........................................................44 2. Thoracic wall and diaphragm..................180
3. Axilla................................................................50 3. Thoracic cavity............................................189
4. Breast................................................................56 4. Superior mediastinum...............................190
5. Anterior compartment of the arm.............58 5. Anterior mediastinum...............................196
6. Posterior compartment of the arm............61 6. Middle mediastinum and heart...............196
7. Anterior compartment of the forearm......64 7. Posterior mediastinum..............................207
8. Posterior compartment of the forearm.....73 8. Pleura............................................................211
9. Wrist and hand..............................................78 9. Lungs.............................................................213
10. Summary of upper limb innervation........91 10. Osteology of the thorax............................217
11. Summary of upper limb nerve injuries....95
12. Osteology of the upper limb......................97 CHAPTER 5: Abdomen
1. Anterior abdominal wall...........................221
CHAPTER 3: Lower limb
2. Abdominal cavity.......................................233
1. Anterior compartment of the thigh........111 3. Peritoneum..................................................234
2. Medial compartment of the thigh..........121 4. Development of the gut............................238
3. Gluteal region and hip joint....................123 5. Vessels and nerves of the gut...................242
4. Posterior compartment of the thigh.......130 6. Gastrointestinal tract..................................247
5. Popliteal fossa and knee joint.................132 7. Liver and biliary tract................................259
6. Anterior compartment of the leg............141 8. Pancreas........................................................267
7. Dorsum of the foot....................................145 9. Spleen...........................................................270
8. Lateral compartment of the leg...............146 10. Posterior abdominal wall.........................272
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