Split by Nengah Tanu Komalyna

CLINICAL ANATOMY
BY SYSTEMS

Richard S. Snell, MD, PhD

CD-ROM
 Preface

Welcome to Clinical Anatomy by Systems by Richard S. logic investigations. The anatomy of Common Medical
Snell, MD, PhD. This CD-ROM is designed for medical Procedures has also been included, and the complications
students doing their clinical rotations, allied health stu- caused by an ignorance of normal anatomy have been
dents, dental students, nurses, and residents. emphasized.
The information provided is in the form of Clinical Examples of clinical cases are given at the end of each
Notes, which are linked to the appropriate chapters of the group of Clinical Notes. Each clinical vignette is followed
main text. This gives students ready access to the basic by multiple choice questions. Answers and explanations for
anatomic and clinical material. Sections on Congenital the problems are given at the end of the section in the CD-
Anomalies are also included. ROM.
The clinical material provides the medical professional *No part of this CD-ROM may be reproduced in any
with the practical application of anatomic facts that he or form or by any means without written permission from the
she will require when examining patients. It will also be of copyright owner.
great assistance when interpreting the findings of techno-

iii
1 Introduction to Clinical
Anatomy
www.mininova.org
oleh I Nengah Tanu Komalyna
 Chapter Outline
Skin 2 Blood Vessels 4
Lines of Cleavage 2 Diseases of Blood Vessels 4
Skin Infections 3 Lymphatic System 5
Sebaceous Cyst 3 Diseases of the Lymphatic System 5
Shock 3 Nervous System 5
Skin Burns 3 Segmental Innervation of Skin 5
Skin Grafting 3 Segmental Innervation of Muscle 5
Fasciae 3 Clinical Modification of the Activities of the
Fasciae and Infection 3 Autonomic Nervous Systems 5

Skeletal Muscle 3 Mucous and Serous Membranes 5

Muscle Attachments 3 Mucous and Serous Membranes and Inflammatory
Disease 5
Muscle Shape and Form 3
Cardiac Muscle 3 Bones 6
Bone Fractures 6
Necrosis of Cardiac Muscle 3
Rickets 7
Joints 4
Epiphyseal Plate Disorders 7
Examination of Joints 4
Clinical Significance of Sex, Race, and
Ligaments 4 Age on Structure 9
Damage to Ligaments 4
Clinical Problem Solving Questions 9
Bursae and Synovial Sheaths 4
Trauma and Infection of Bursae and Synovial Sheaths 4 Answers and Explanations 11

SKIN
Lines of Cleavage
In the dermis, the bundles of collagen fibers are mostly
arranged in parallel rows. A surgical incision through the
skin made along or between these rows causes the mini-
mum of disruption of collagen, and the wound heals with
minimal scar tissue. Conversely, an incision made across
the rows of collagen disrupts and disturbs it, resulting in the
massive production of fresh collagen and the formation of a
broad, ugly scar. The direction of the rows of collagen is
known as the lines of cleavage (Langer’s lines), and they
tend to run longitudinally in the limbs and circumferen-
tially in the neck and trunk (CD Fig. 1-1). CD Figure 1-1 Cleavage lines of the skin.
 Introduction to Clinical Anatomy 3

A general knowledge of the direction of the lines of new circulation within it at the recipient site. The donor site
cleavage greatly assists the surgeon in making incisions that is usually covered with a split-thickness graft. In certain cir-
result in cosmetically acceptable scars. This is particularly cumstances the full-thickness graft is made in the form of a
important in those areas of the body not normally covered pedicle graft, in which a flap of full-thickness skin is turned
by clothing. A salesperson, for example, may lose his or her and stitched in position at the recipient site, leaving the base
job if an operation leaves a hideous facial scar. of the flap with its blood supply intact at the donor site.
Later, when the new blood supply to the graft has been
established, the base of the graft is cut across.
Skin Infections
The nail folds, hair follicles, and sebaceous glands are
common sites for entrance into the underlying tissues of
pathogenic organisms such as Staphylococcus aureus.
FASCIAE
Infection occurring between the nail and the nail fold is
called a paronychia. Infection of the hair follicle and seba- Fasciae and Infection
ceous gland is responsible for the common boil. A carbuncle Knowledge of the arrangement of the deep fasciae often
is a staphylococcal infection of the superficial fascia. It fre- helps explain the path taken by an infection when it spreads
quently occurs in the nape of the neck and usually starts as an from its primary site. In the neck, for example, the various
infection of a hair follicle or a group of hair follicles. fascial planes explain how infection can extend from the
region of the floor of the mouth to the larynx.
Sebaceous Cyst
A sebaceous cyst is caused by obstruction of the mouth of a
sebaceous duct and may be caused by damage from a comb SKELETAL MUSCLE
or by infection. It occurs most frequently on the scalp.

Shock Muscle Attachments

The importance of knowing the main attachments of all
A patient who is in a state of shock is pale and exhibits goose- the major muscles of the body need not be emphasized.
flesh as a result of overactivity of the sympathetic system, Only with such knowledge is it possible to understand the
which causes vasoconstriction of the dermal arterioles and normal and abnormal actions of individual muscles or
contraction of the arrector pili muscles. muscle groups. How can one even attempt to analyze,
for example, the abnormal gait of a patient without this
Skin Burns information?

The depth of a burn determines the method and rate of

healing. A partial-skin-thickness burn heals from the cells of Muscle Shape and Form
the hair follicles, sebaceous glands, and sweat glands as well The general shape and form of muscles should also be
as from the cells at the edge of the burn. A burn that extends noted, since a paralyzed muscle or one that is not used (such
deeper than the sweat glands heals slowly and from the as occurs when a limb is immobilized in a splint) quickly
edges only, and considerable contracture will be caused by atrophies and changes shape. In the case of the limbs, it is
fibrous tissue. To speed up healing and reduce the inci- always worth remembering that a muscle on the opposite
dence of contracture, a deep burn should be grafted. side of the body can be used for comparison.

Skin Grafting
Skin grafting is of two main types: split-thickness grafting
CARDIAC MUSCLE
and full-thickness grafting. In a split-thickness graft the
greater part of the epidermis, including the tips of the der-
mal papillae, are removed from the donor site and placed on
Necrosis of Cardiac Muscle
the recipient site. This leaves at the donor site for repair pur- The cardiac muscle receives its blood supply from
poses the epidermal cells on the sides of the dermal papillae the coronary arteries. A sudden block of one of the large
and the cells of the hair follicles and sweat glands. branches of a coronary artery will inevitably lead to necro-
A full-thickness skin graft includes both the epidermis sis of the cardiac muscle and often to the death of the
and dermis and, to survive, requires rapid establishment of a patient.
4 Chapter 1

clot at the damaged site is invaded by blood vessels and

JOINTS fibroblasts. The fibroblasts lay down new collagen and elas-
tic fibers, which become oriented along the lines of me-
chanical stress.

Examination of Joints
When examining a patient, the clinician should assess
the normal range of movement of all joints. When
the bones of a joint are no longer in their normal
BURSAE AND
anatomic relationship with one another, then the joint is
said to be dislocated. Some joints are particularly suscep-
SYNOVIAL
tible to dislocation because of lack of support by ligaments,
the poor shape of the articular surfaces, or the absence
of adequate muscular support. The shoulder joint, tem-
SHEATHS
poromandibular joint, and acromioclavicular joints are
good examples. Dislocation of the hip is usually congeni- Trauma and Infection of Bursae
tal, being caused by inadequate development of the
socket that normally holds the head of the femur firmly and Synovial Sheaths
in position. Bursae and synovial sheaths are commonly the site of
The presence of cartilaginous discs within joints, espe- traumatic or infectious disease. For example, the extensor
cially weightbearing joints, as in the case of the knee, makes tendon sheaths of the hand may become inflamed after ex-
them particularly susceptible to injury in sports. During cessive or unaccustomed use; an inflammation of the
a rapid movement the disc loses its normal relationship prepatellar bursa may occur as the result of trauma from re-
to the bones and becomes crushed between the weight- peated kneeling on a hard surface.
bearing surfaces.
In certain diseases of the nervous system (e.g., sy-
ringomyelia), the sensation of pain in a joint is lost. This
means that the warning sensations of pain felt when a joint
moves beyond the normal range of movement are not
experienced. This phenomenon results in the destruction of
BLOOD VESSELS
the joint.
Knowledge of the classification of joints is of great value Diseases of Blood Vessels
because, for example, certain diseases affect only certain
Diseases of blood vessels are common. The surface anatomy
types of joints. Gonococcal arthritis affects large synovial
of the main arteries, especially those of the limbs, is dis-
joints such as the ankle, elbow, or wrist, whereas tubercu-
cussed in the appropriate sections of this book. The collat-
lous arthritis also affects synovial joints and may start in the
eral circulation of most large arteries should be understood,
synovial membrane or in the bone.
and a distinction should be made between anatomic end
Remember that more than one joint may receive the
arteries and functional end arteries.
same nerve supply. For example, the hip and knee joints
All large arteries that cross over a joint are liable to be
are both supplied by the obturator nerve. Thus, a patient
kinked during movements of the joint. However, the distal
with disease limited to one of these joints may experience
flow of blood is not interrupted because an adequate anas-
pain in both.
tomosis is usually between branches of the artery that arise
both proximal and distal to the joint. The alternative blood
channels, which dilate under these circumstances, form the
LIGAMENTS collateral circulation. Knowledge of the existence and posi-
tion of such a circulation may be of vital importance should
it be necessary to tie off a large artery that has been damaged
Damage to Ligaments by trauma or disease.
Coronary arteries are functional end arteries, and if
Joint ligaments are very prone to excessive stretching and they become blocked by disease (coronary arterial occlusion
even tearing and rupture. If possible, the apposing damaged is common), the cardiac muscle normally supplied by that
surfaces of the ligament are brought together by positioning artery will receive insufficient blood and undergo necrosis.
and immobilizing the joint. In severe injuries, surgical Blockage of a large coronary artery results in the death of the
approximation of the cut ends may be required. The blood patient.
 Introduction to Clinical Anatomy 5

Learning the segmental innervation of all the muscles

LYMPHATIC of the body is an impossible task. Nevertheless, the segmen-
tal innervation of the following muscles should be known
SYSTEM because they can be tested by eliciting simple muscle
reflexes in the patient (CD Fig. 1-4):

Diseases of the Lymphatic System ■ Biceps brachii tendon reflex: C5 and 6 (flexion of the
elbow joint by tapping the biceps tendon)
The lymphatic system is often de-emphasized by anatomists ■ Triceps tendon reflex: C6, 7, and 8 (extension of the
on the grounds that it is difficult to see on a cadaver. However, elbow joint by tapping the triceps tendon)
it is of vital importance to medical personnel, since lymph ■ Brachioradialis tendon reflex: C5, 6, and 7 (supination
nodes may swell as the result of infection, metastases, or pri- of the radioulnar joints by tapping the insertion of the
mary tumor. For this reason, the lymphatic drainage of all ma- brachioradialis tendon)
jor organs of the body, including the skin, should be known. ■ Abdominal superficial reflexes (contraction of underly-
A patient may complain of a swelling produced by the ing abdominal muscles by stroking the skin): Upper
enlargement of a lymph node. A physician must know the abdominal skin T6–7, middle abdominal skin T8–9, and
areas of the body that drain lymph to a particular node if he lower abdominal skin T10–12
or she is to be able to find the primary site of the disease. Of- ■ Patellar tendon reflex (knee jerk): L2, 3, and 4 (exten-
ten the patient ignores the primary disease, which may be a sion of the knee joint on tapping the patellar tendon)
small, painless cancer of the skin. ■ Achilles tendon reflex (ankle jerk): S1 and S2 (plantar
Conversely, the patient may complain of a painful ulcer flexion of the ankle joint on tapping the Achilles
of the tongue, for example, and the physician must know the tendon)
lymph drainage of the tongue to be able to determine whether
the disease has spread beyond the limits of the tongue. Clinical Modification of the
Activities of the Autonomic
NERVOUS SYSTEM Nervous System
Many drugs and surgical procedures that can modify the
Segmental Innervation of the Skin activity of the autonomic nervous system are available. For
The area of skin supplied by a single spinal nerve, and example, drugs can be administered to lower the blood
therefore a single segment of the spinal cord, is called a pressure by blocking sympathetic nerve endings and causing
dermatome. On the trunk, adjacent dermatomes overlap vasodilatation of peripheral blood vessels. In patients with
considerably; to produce a region of complete anesthesia, at severe arterial disease affecting the main arteries of the lower
least three contiguous spinal nerves must be sectioned. Der- limb, the limb can sometimes be saved by sectioning the
matomal charts for the anterior and posterior surfaces of the sympathetic innervation to the blood vessels. This produces
body are shown in CD Figs. 1-2 and 1-3. a vasodilatation and enables an adequate amount of blood to
In the limbs, arrangement of the dermatomes is more flow through the collateral circulation, thus bypassing the
complicated because of the embryologic changes that take obstruction.
place as the limbs grow out from the body wall.
A physician should have a working knowledge of the
segmental (dermatomal) innervation of skin, because with
the help of a pin or a piece of cotton he or she can determine
MUCOUS AND
whether the sensory function of a particular spinal nerve or
segment of the spinal cord is functioning normally.
SEROUS
Segmental Innervation of Muscle
MEMBRANES
Skeletal muscle also receives a segmental innervation. Most
of these muscles are innervated by two, three, or four spinal
Mucous and Serous Membranes
nerves and therefore by the same number of segments of the
spinal cord. To paralyze a muscle completely, it is thus nec-
and Inflammatory Disease
essary to section several spinal nerves or to destroy several Mucous and serous membranes are common sites for in-
segments of the spinal cord. flammatory disease. For example, rhinitis, or the common
6 Chapter 1

transverse cutaneous nerve of neck

C2
C3 supraclavicular nerves
C4 anterior cutaneous branch of second
intercostal nerve
upper lateral cutaneous nerve of arm
C5
T3 medial cutaneous nerve of arm
T2 T4
C6 lower lateral cutaneous nerve of arm
T5
T6 medial cutaneous nerve of forearm
T1 T7
T8 lateral cutaneous nerve of forearm
T9 lateral cutaneous branch of
T10
T11
subcostal nerve
C8
L1 T12 femoral branch of genitofemoral
C7 nerve
median nerve
ulnar nerve
S3
ilioinguinal nerve
S4
lateral cutaneous nerve of thigh
obturator nerve
L2
medial cutaneous nerve of thigh
L3 intermediate cutaneous nerve of thigh
infrapatellar branch of saphenous nerve
L4 lateral sural cutaneous nerve

L5

saphenous nerve

superficial peroneal nerve

S1
deep peroneal nerve
CD Figure 1-2 Dermatomes and dis-
tribution of cutaneous nerves on the
anterior aspect of the body.

cold, is an inflammation of the nasal mucous membrane, rections taken by the bony fragments depend not only on
and pleurisy is an inflammation of the visceral and parietal the mechanism of injury, but also on the pull of the mus-
layers of the pleura. cles attached to the fragments. Ligamentous attachments
also influence the deformity. In certain situations—for
example, the ileum—fractures result in no deformity be-
BONES cause the inner and outer surfaces of the bone are splinted
by the extensive origins of muscles. In contrast, a fracture
of the neck of the femur produces considerable displace-
Bone Fractures ment. The strong muscles of the thigh pull the distal frag-
ment upward so that the leg is shortened. The very strong
Immediately after a fracture, the patient suffers severe lo- lateral rotators rotate the distal fragment laterally so that
cal pain and is not able to use the injured part. Deformity the foot points laterally.
may be visible if the bone fragments have been displaced Fracture of a bone is accompanied by a considerable
relative to each other. The degree of deformity and the di- hemorrhage of blood between the bone ends and into the
 Introduction to Clinical Anatomy 7

C2
greater occipital nerve
third cervical nerve C3
great auricular nerve
fourth cervical nerve C5
lesser occipital nerve C6
supraclavicular nerve C4
first thoracic nerve T2
T3 C5
posterior cutaneous nerve of arm
T4
T5
medial cutaneous nerve of arm T2
T6
posterior cutaneous nerve of forearm T7
medial cutaneous nerve of forearm T8
T9 T1
lateral cutaneous nerve of forearm T10
T11
lateral cutaneous branch of T12
T12 C7
posterior cutaneous branches of L1
C6
L1, 2, and 3 S5
radial nerve
ulnar nerve S4
C8
posterior cutaneous branches of S3
S1, 2, and 3
L2
branches of posterior cutaneous
S2
nerve of thigh
posterior cutaneous nerve of thigh L3
obturator nerve

lateral cutaneous nerve L5

of calf
sural nerve L4
saphenous nerve

lateral plantar nerve S1

L5 CD Figure 1-3 Dermatomes and distri-
medial plantar nerve bution of cutaneous nerves on the pos-
terior aspect of the body.

surrounding soft tissue. The blood vessels and the fibroblasts bossing of the frontal bones of the skull. Deformities of the
and osteoblasts from the periosteum and endosteum take pelvis may also occur.
part in the repair process.
Epiphyseal Plate Disorders
Rickets Epiphyseal plate disorders affect only children and adoles-
Rickets is a defective mineralization of the cartilage matrix cents. The epiphyseal plate is the part of a growing bone con-
in growing bones. This produces a condition in which the cerned primarily with growth in length. Trauma, infection,
cartilage cells continue to grow, resulting in excess cartilage diet, exercise, and endocrine disorders can disturb the growth
and a widening of the epiphyseal plates. The poorly miner- of the hyaline cartilaginous plate, leading to deformity and loss
alized cartilaginous matrix and the osteoid matrix are soft, of function. In the femur, for example, the proximal epiphysis
and they bend under the stress of bearing weight. The can slip because of mechanical stress or excessive loads. The
resulting deformities include enlarged costochondral junc- length of the limbs can increase excessively because of in-
tions, bowing of the long bones of the lower limbs, and creased vascularity in the region of the epiphyseal plate sec-
8 Chapter 1

C6, 7, and 8

C5 and 6

triceps tendon reflex

biceps brachii tendon reflex L2, 3, and 4

patellar tendon reflex

C5, 6, and 7

brachioradialis
tendon S1 and 2
reflex

Achilles tendon reflex

CD Figure 1-4 Some important tendon reflexes used in medical practice.

 Introduction to Clinical Anatomy 9

ondary to infection or in the presence of tumors. Shortening 2. The liver is relatively much larger in the child than in
of a limb can follow trauma to the epiphyseal plate resulting the adult. In the infant, the lower margin of the liver ex-
from a diminished blood supply to the cartilage. tends inferiorly to a lower level than in the adult. This
is an important consideration when making a diagnosis
of hepatic enlargement.
CLINICAL 3. The urinary bladder in the child cannot be accommo-
SIGNIFICANCE OF dated entirely in the pelvis because of the small size of
the pelvic cavity and thus is found in the lower part of

SEX, RACE, AND the abdominal cavity. As the child grows, the pelvis en-
larges and the bladder sinks down to become a true
pelvic organ.
AGE ON STRUCTURE 4. At birth, all bone marrow is of the red variety. With
advancing age, the red marrow recedes up the
The fact that the structure and function of the human body
bones of the limbs so that in the adult it is largely
change with age may seem obvious, but it is often over-
confined to the bones of the head, thorax, and
looked; a child is just not a small adult. A few examples of
abdomen.
such changes are given here:
1. In the infant, the bones of the skull are more resilient 5. Lymphatic tissues reach their maximum degree of de-
than in the adult, and for this reason fractures of the velopment at puberty and thereafter atrophy, so the vol-
skull are much more common in the adult than in the ume of lymphatic tissue in older persons is considerably
young child. reduced.

Clinical Problem Solving Questions

Read the following case histories/questions and give examination, she has severe right lateral flexion defor-
the best answer for each. mity of the vertebral column.

A 45-year-old patient has a small, firm, mobile tumor 2. The following statement is correct about this case:
on the dorsum of the right foot just proximal to A. The virus of poliomyelitis attacks and always destroys
the base of the big toe and superficial to the bones and the motor anterior horn cells of the spinal cord.
the long extensor tendon but deep to the superficial B. The disease resulted in the paralysis of the muscles
fascia. The patient has a neurofibroma of a digital that normally laterally flex the vertebral column on
nerve. the left side.
C. The muscles on the right side of the vertebral col-
1. The following information concerning the tumor is umn are hyperactive.
correct: D. The right lateral flexion deformity is caused by the
A. It is situated on the lower surface of the foot close to slow degeneration of the sensory nerve fibers origi-
the root of the big toe. nating from the vertebral muscles on the right side.
B. It is attached to the first metatarsal bone.
C. On palpation, it moves more freely from medial to A 20-year-old woman severely sprains her left ankle while
lateral than from proximal to distal. playing tennis. When she tries to move the foot so that
D. It lies deep to the tendon of the extensor hallucis the sole faces medially, she experiences severe pain.
longus muscle.
3. What is the correct anatomic term for the movement of
E. It is attached to the capsule of the metatarsopha-
the foot that produces the pain?
langeal joint of the big toe.
A. Pronation
A 31-year-old woman has a history of poliomyelitis af- B. Inversion
fecting the anterior horn cells of the lower thoracic and C. Supination
lumbar segments of the spinal cord on the left side. On D. Eversion
10 Chapter 1

A 25-year-old man has a deep-seated abscess in the pos- A woman recently took up employment in a factory.
terior part of the neck. She is a machinist, and for 6 hours a day she has to
move a lever repeatedly, which requires that she extend
4. The following statement is correct concerning the
and flex her right wrist joint. At the end of the second
abscess:
week of her employment, she began to experience pain
A. The abscess probably lies superficial to the deep
over the posterior surface of her wrist and noticed a
fascia.
swelling in the area.
B. The deep fascia does not determine the direction of
spread of the abscess. 8. The following statements concerning this patient are
C. The abscess would be incised through a vertical skin correct except which?
incision. A. Extension of the wrist joint is brought about by
D. The lines of cleavage are not important when several muscles that include the extensor digitorum
considering the direction of skin incisions. muscle.
E. The abscess would be incised, if possible, through a B. The wrist joint is diseased.
horizontal skin incision. C. Repeated unaccustomed movements of tendons
A 40-year-old workman received a severe burn on through their synovial sheaths can produce trau-
the anterior aspect of his right forearm. The area of the matic inflammation of the sheaths.
burn exceeded 4 in.2 (10 cm2). The greater part of D. The diagnosis is traumatic tenosynovitis of the long
the burn was superficial and extended only into the tendons of the extensor digitorum muscle.
superficial part of the dermis. A 19-year-old boy was suspected of having leukemia. It
5. In the superficially burned area, the epidermis cells was decided to confirm the diagnosis by performing a
would regenerate from the following sites except which? bone marrow biopsy.
A. The hair follicles 9. The following statements concerning this procedure
B. The sebaceous glands are correct except which?
C. The margins of the burn A. The biopsy was taken from the lower end of the
D. The deepest ends of the sweat glands tibia.
6. In a small area the burn penetrated as far as the superfi- B. Red bone marrow specimens can be obtained from
cial fascia; in this region, the epidermal cells would the sternum or the iliac crests.
regenerate from the following sites except which? C. At birth, the marrow of all bones of the body is red
A. The ends of the sweat glands that lie in the superfi- and hematopoietic.
cial fascia D. The blood-forming activity of bone marrow in
B. The margins of the burn many long bones gradually lessens with age, and
C. The sebaceous glands the red marrow is gradually replaced by yellow
marrow.
In a 63-year-old man, a magnetic resonance imaging
scan of the lower thoracic region of the vertebral col- A 22-year-old woman had a severe infection under the
umn reveals the presence of a tumor pressing on the lateral edge of the nail of her right index finger. On ex-
lumbar segments of the spinal cord. He has a loss of amination, a series of red lines were seen to extend up
sensation in the skin over the anterior surface of the left the back of the hand and around to the front of the fore-
thigh and is unable to extend his left knee joint. Exam- arm and arm, up to the armpit.
ination reveals that the muscles of the front of the left
10. The following statements concerning this patient are
thigh have atrophied and have no tone and that the
probably correct except which?
left knee jerk is absent.
A. Palpation of the right armpit revealed the presence
7. The following statements concerning this patient are of several tender enlarged lymph nodes (lym-
correct except which? phadenitis).
A. The tumor is interrupting the normal function of the B. The red lines were caused by the superficial lym-
efferent motor fibers of the spinal cord on the left side. phatic vessels in the arm, which were red and in-
B. The quadriceps femoris muscles on the front of the flamed (lymphangitis) and could be seen through
left thigh are atrophied. the skin.
C. The loss of skin sensation is confined to the der- C. Lymph from the right arm entered the bloodstream
matomes L1, 2, 3, and 4. through the thoracic duct.
D. The absence of the left knee jerk is because of D. Infected lymph entered the lymphatic capillaries
involvement of the first lumbar spinal segment. from the tissue spaces.
 Introduction to Clinical Anatomy 11

Answers and Explanations

1. C is the correct answer. The tumor is a neurofibroma of neck plays an important role in the direction of spread
a small digital nerve. This fact explains why the tumor of a deep-seated abscess. C. The abscess would only be
is relatively superficial and moves with the digital nerve incised through a vertical incision if a horizontal inci-
more freely from medial to lateral than from proximal sion along a line of cleavage was not possible. A vertical
to distal. A. The tumor is situated on the dorsum or up- incision in the neck would result in an unsightly scar.
per surface of the foot. B. The tumor is mobile and not D. The lines of cleavage (see CD Fig. 1-1) are very im-
attached to the first metatarsal bone. D. The tumor lies portant when considering the direction of skin inci-
superficial to the tendon of the extensor hallucis longus sions. However, cosmetic concerns have to take second
muscle. E. The tumor is mobile and is not attached to place in life-threatening situations.
the capsule of the metatarsophalangeal joint.
5. D is the correct answer. In a superficial burn, the epi-
2. B is the correct answer. The disease infected the ante- dermal cells would regenerate from the hair follicles,
rior horn cells, whose axons supply the muscles that the sebaceous glands, and the margins of the burn.
normally laterally flex the vertebral column on the left
side. A. The virus of poliomyelitis attacks anterior horn 6. C is the correct answer. The sebaceous glands are lo-
cells in the spinal cord. The result may be death of the cated superficially (see text Fig. 1-4) and are destroyed
cells and muscle paralysis or, depending on the severity in deep burns.
of the attack, the nerve cells may recover and the mus- 7. D is the correct answer. The patellar tendon reflex (knee
cle paralysis may also recover. C. The muscles on the jerk) involves L2, 3, and 4 segments of the spinal cord.
right side of the vertebral column are contracting nor-
mally against the paralyzed left-sided vertebral muscles. 8. B is the correct answer. The wrist joint is not diseased
D. The sensory nerves of muscles are unaffected by the in this patient. The swelling on the posterior surface of
polio virus. the wrist region was caused by the excessive production
of fluid in the synovial sheaths of the extensor tendons
3. B is the correct answer. The movement of the foot so secondary to repeated and excessive extensor move-
that the sole comes to face medially is called inversion ments, a condition called traumatic tenosynovitis.
(see text Fig. 1-3). For a full discussion of the move-
ments of inversion and eversion of the foot at the subta- 9. A is the correct answer. In a 19-year-old boy, the bone
lar and transverse joints of the foot, see text. marrow at the lower end of the tibia is yellow. A biopsy
specimen of red marrow in an adult, who is suspected
4. E is the correct answer. The abscess would be incised, of suffering from leukemia, is easily obtained from the
if possible, through a horizontal skin incision along a iliac crests or the sternum.
line of cleavage (see CD Fig. 1-1). A. A deep-seated
abscess in the neck usually lies deep to the superficial 10. C is the correct answer. Lymph from the right upper
fascia and beneath the investing layer of deep cervical limb enters the bloodstream through the right lym-
fascia. B. The arrangement of the deep fascia in the phatic duct.