Applied Anatomy

Head and Neck

Anterior triangle of the neck

Fig 1.0 – Anterior and posterior triangles of the neck. Note the overlying platysma muscle has been removed

Carotid Triangle

Fig 1.1 – Carotid triangle of the neck

Clinical Relevance: Medical Uses of the Carotid Triangle

In the carotid triangle, many of the vessels and nerves are relatively superficial,
and so can be accessed by surgery. The carotid arteries, internal jugular vein,
vagus and hypoglossal nerves are frequent targets of this surgical approach.
The carotid triangle also contains the carotid sinus –  a dilated portion of the
common carotid and internal carotid arteries. It contains specific sensory cells,
called baroreceptors. The baroreceptors detect stretch as a measure of blood
pressure.  The glossopharyngeal nerve feeds this information to the brain, and
this is used to regulate blood pressure.
In some people, the baroreceptors are hypersensitive to stretch. In these
patients, external pressure on the carotid sinus can cause slowing of the heart
rate and a decrease in blood pressure. The brain becomes underperfused, and
syncope results. In such patients, checking the pulse at the carotid triangle is
not advised.

Posterior Triangle of the neck

Clinical Relevance: Severance of the External Jugular Vein
The external jugular vein has a relatively superficial course down the neck,
leaving it vulnerable to damage.
If it is severed, in an injury such as a knife slash, its lumen is held open – this is
due to the thick layer of investing fascia. Air will be drawn into the vein,
producing cyanosis, and can stop blood flow through the right atrium. This is a
medical emergency, managed by the application of pressure to the wound –
stopping the bleeding, and the entry of air.

Bones of the neck

 The cervical Spine

Clinical Relevance: Injuries to the Cervical

Spine
Jefferson Fracture of the Atlas
A vertical fall onto an extended neck e.g. diving into excessively shallow water
can compress the lateral masses of the atlas between the occipital
condyles and the axis. This causes them to be driven apart, fracturing one or
both anterior/posterior arches.
If the fall occurs with enough force, the transverse ligament of the atlas may
also be ruptured.
Since the vertebral foramen is large, it is unlikely that there will be damage to
the spinal cord at the C1 level. However, there may be damage further down
the vertebral column.

Hyperextension (Whiplash) Injury

A rear-end traffic collision or a poorly performed rugby tackle can both result
in the head being whipped back on the shoulders, causing whiplash. In minor
cases, the anterior longitudinal ligament of the spine is damaged which is
acutely painful for the patient.
In more severe cases, fractures can occur to any of the cervical vertebrae as
they are suddenly compressed by rapid deceleration. Again, since the vertebral
foramen is large there is less chance of spinal cord involvement.
The worst-case scenario for these injuries is that dislocation or subluxation of
the cervical vertebrae occurs. This often happens at the C2 level, where the
body of C2 moves anteriorly with respect to C3. Such an injury may well lead to
spinal cord involvement, and therefore q : uadriplegia or death may occur. More
commonly, subluxation occurs at the C6/C7 level (50% of cases).

Hangman’s Fracture
The hangman’s fracture is the name given to a fracture of the pars
interarticularis, which is a bony column between the superior and inferior
articular facets of the axis. Its name originates from the mechanism by which it
is most commonly created, because of the sudden deceleration that occurs in
hanging.
 1.4 – A fracture of the base of the dens.
Such an injury is likely to be lethal, as either the fracture fragments or the force
involved are likely to rupture the spinal cord, causing deep unconsciousness,
respiratory and cardiac failure, and death.

Fracture of the Dens

Fractures of the dens make up around 40% of the fractures of the axis, and are
most commonly caused by traffic collisions and falls. Often these fractures are
unstable and are at high risk of avascular necrosis, due to the isolation of the
distal fragment from any blood supply. As a result, fractures of the dens often
take a long time to heal.

As with any fracture of the vertebral column, there is a slight risk of spinal cord
involvement.

Hyoid Bone
Clinical Relevance: Fracture of the Hyoid Bone
The hyoid is well protected by the mandible and cervical spine, so fractures are
relatively rare.
Hyoid bones fractures are characteristically associated
with strangulation (found in approximately 1/3 of all homicides by
strangulation). It is therefore a significant post-mortem finding.
They can also occur because of trauma, with clinical features of pain on
speaking, odynophagia and dyspnoea.
Palpations
• Hyoid bone - hyoid bone is a ‘U’ shaped structure located in the anterior
neck. It lies at the base of the mandible (approximately C3).
• Thyroid Cartilage-below hyoid bone
• First cricoid ring-
• Occiput
• Inion
• Mastoid-  btwn the mastoid process and the posterior edge of the
mandible
• Spinous processes
• Facet joints
• Sternocleidomastoid
• Lymph node chain
• Carotid pulse
• Thyroid gland
• Parotid gland
• Supraclavicular fossa
• Sternocleidomastoid
• Scalene
• Masseter
• Suprahyoids
• Infrahyoids
• Temporalis
 Lumbar and thoracic
Clinical Relevance: Herniated Intervertebral Disc

Fig 1.2 – Herniation of an intervertebral disc.

The intervertebral disc is a fibrocartilaginous cylinder that lies between
the vertebrae, joining them together. They act to permit the flexibility of
the spine, and act as a shock absorber. In the lumbar and thoracic
regions, they are wedge shaped, supporting the curvature of the spine.
There are two regions in the vertebral disc; the nucleus
pulposus and annulus fibrosus. The annulus fibrosis is tough and
collagenous, surrounding the nucleus pulposus. The nucleus pulposus is
jelly-like, and is located posteriorly.
In a herniation of the intervertebral disc, the nucleus pulposus ruptures,
breaking through the annulus fibrosus. This most commonly occurs in a
posterior, putting pressure on the spinal cord, resulting in a variety of
neurological and muscular symptoms.

Clinical relevance: Spinal Cord Infarction

Spinal cord infarction (also known as a spinal stroke) refers to the death
of nervous tissue, which results from an interruption of the arterial
supply.
Clinical signs of spinal cord infarction include muscle weakness and
paralysis with loss of reflexes. The most common causes of infarction are
vertebral fractures or dislocations, vasculitic disease, atheromatous
disease, or external compression (e.g. abdominal tumours).
95% of spinal cord ischaemic events are to the anterior aspect of the
spinal cord, with the posterior columns preserved. Treatment is by
reversal of any known cause.
 Clinical Relevance: Abnormal Morphology of the Spine

There are several clinical syndromes resulting from an abnormal

curvature of the spine:
Kyphosis: Excessive thoracic curvature, causing a hunchback deformity.

Lordosis: Excessive lumbar curvature, causing a swayback deformity.

Scoliosis: A lateral curvature of the spine, usually of unknown cause.
Cervical Spondylosis: A decrease in the size of the intervertebral
foramina, usually due to degeneration of the joints of the spine. The
smaller size of the intervertebral foramina puts pressure on the exiting
nerves, causing pain.
Spinal cord
Clinical Relevance: Cauda Equina Syndrome
The cauda equina is a bundle of spinal nerves that arise from the distal
end of the spinal cord. They run in the subarachnoid space, before
exiting at their appropriate vertebral level.
Compression of these nerves produces a range of signs and symptoms
collectively termed cauda equina syndrome. There are many causes of
compression, including intervertebral disc prolapse, extrinsic or primary
cord tumours, spinal stenosis, trauma and abscess formation.
Suspected cauda equina patients should be assessed with a full lower
limb neurological assessment. The main signs to assess for are:
 Saddle-area anaesthesia.
  Incontinence / retention of urine or faeces.
 Reduced anal tone.
 Paralysis ± sensory loss.
If sufficient clinical evidence exists, an MRI is required immediately for
diagnosis. Any confirmed case must be sent for surgery within 36 hours
of first presentation of the symptoms for surgical decompression.
Spinal Meninges

Muscles
Clinical Relevance: Testing the Accessory Nerve
The most common cause of accessory nerve damage is iatrogenic (i.e.
due to a medical procedure). Operations such as cervical lymph node
biopsy or cannulation of the internal jugular vein can cause trauma to
the nerve.
To test the accessory nerve, trapezius function can be assessed. This can
be done by asking the patient to shrug his/her shoulders. Other clinical
features of accessory nerve damage include muscle wasting, partial
paralysis of the sternocleidomastoid, and an asymmetrical neckline.
Latissimus Dorsi

Manubriosterna Articulation of the manubrium with the sternum. Sternal angle or angle of Louis.
l Bones separated by a fibrocartilage disc.

Xiphisternal Articulation of the sternum with the Xiphoid process. Also, a synchondrosis joint.

Costovertebral Head of the rib with two adjacent vertebral bodies. Synovial joint.
Ribs 1, 10, 11, and 12 articulate with only one vertebral body
Costotransverse Synovial joint. Costal tubercle of the rib articulating with the transverse process.
Costochondral Articulation of ribs 1 to 10 with the costal cartilage

Chondrosternal Costal cartilage of ribs 1 to 7 with the sternum

Interchondral Costal cartilage of ribs 7 to 10 articulating with each other

Palpations
• ASIS
• Iliac Crest
• PSIS
• Spinous processes
• Ribs
• Sternum
• Xiphoid Process
• erector spinae
• Transversospinalis group
• Splenius capitis
• Suboccipitalis
• Quadratus lumborum
• Abdominals
• Diaphragm
• Intercostals