Surface Anatomy Richard Tunstall, Nehal Shah
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1Surface Anatomy2
3Surface Anatomy
Richard Tunstall BMedSci (Hons) PhD FHEA Head of Clinical Anatomy & Imaging Warwick Medical School University of Warwick Director of Clinical Anatomy West Midlands Surgical Training Centre Coventry, UK Nehal Shah MBBS BSc (Hons) MRCS FRCR Specialist Registrar in Clinical Radiology Leeds Teaching Hospitals Trust Leeds, UK
4© 2012 JP Medical Ltd.
Photographs © 2012 Sam Scott-Hunter.
Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK
Reprinted 2013
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JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India (
Richard Furn
Development Editors:
Paul Mayhew, Alison Whitehouse
Designers Collective Ltd
Sam Scott-Hunter
Indexed, typeset, printed and bound in India.
The ‘preclinical’ years of my undergraduate course (i.e. years 1 and 2) in the mid 1960s were spent in lecture theatres, tutorial rooms and laboratories, and my timetable was filled exclusively with the basic medical sciences. Patients were encountered only very occasionally, in the artificial surroundings of a large lecture theatre. Anatomy was taught in enormous detail, often far beyond the level required of a medical student. Interestingly, surface anatomy was an afterthought, sometimes mentioned in a tutorial, rarely demonstrated on a student or model and hardly ever formally examined.
Modern medical curricula reflect the seismic shift that has occurred in thinking about medical education in the intervening years. Medical students now usually interact with patients from day 1, with basic medical science informing their clinical experiences to varying degrees throughout their course. In such a clinical context, it quickly becomes obvious that a working knowledge of topographical anatomy is essential for safe clinical practice. Using surface anatomy, i.e. knowing where anatomical structures lie under the skin by reference to prominent and consistent bony features, ligaments, tendons, muscle bellies or skin creases, students can learn to visualise and contextualise the topographical anatomy they need to know to examine their patients, interpret diagnostic images and perform basic interventional procedures such as catheter placement safely and effectively. They will also be able to appreciate the safe siting of surgical incisions when they observe in theatres or clinics – knowing where not to cut is every bit as important as knowing what may safely be incised.
For those who think that there is little new to learn in anatomy, it is worth noting that surface anatomy is currently under something of a spotlight. Recent evidence-based surface anatomy studies, in which surface features are related to measurements based on modern cross sectional images, rather than 6those based on cadaveric or early radiographic studies, indicate that we may have to reappraise some markings in the future to take account of variations according to age, body mass, posture, ethnicity or respiration. Richard Tunstall emphasises the need to bear variation in mind whenever surface positioning structures – a key point that reminds us that all patients are different.
This splendid pocket-sized book is packed with clinically relevant material designed to help medical students at all stages of their courses to learn and/or consolidate their knowledge of surface anatomy. Clinical insights add further relevance to the text. Readers should use the book to practise on themselves and on willing friends until they feel confident identifying bony landmarks and arterial pulses; palpating normal structures through intact skin; testing the range of movement of the joints. Sounds like an ideal way to improve communication skills as well as learn anatomy!
Susan Standring DSc FKC Hon FRCS
Emeritus Professor of Anatomy
King's College London
May 2012
A good knowledge of surface anatomy forms an essential part of safe and effective clinical practice for many healthcare specialities. When writing Pocket Tutor Surface Anatomy we took the broad view that surface anatomy includes clinically-relevant anatomy that can be located, related to, easily accessed or viewed via the surface of the body. With this in mind this book includes reference to movements, cutaneous innervation, referred pain, surgical/anaesthetic access and clinical conditions.
Throughout the book surface anatomy has been related to clinical practice, procedures and radiographs in order to provide context and aid understanding. Indeed, it is our view that surface anatomy is key to understanding and interpreting normal anatomy on medical images. Clear descriptions of location, appearance, reference landmarks and relationships are supported by a series of high quality overlaid images and tables. Chapter 1 introduces the principles of surface anatomy and overviews core anatomical terminology, palpation technique, movements and cutaneous innervation. Subsequent chapters (2-8) then review each main anatomical region in turn.
The book will be of benefit to students in anatomical, medical and healthcare disciplines and also to those in clinical practice, for example foundation doctors or surgical trainees. It can be used as a quick reference whilst in the clinic or teaching, but is equally adept at supporting more in-depth learning or revision. We have designed the book to either support current clinical anatomy courses and texts, or to be used as a stand-alone text.
The best way to learn surface anatomy is to get ‘hands-on’ with yourself, colleagues and patients. We hope this book serves as a useful and stimulating introduction.
Richard Tunstall
Nehal Shah
May 20128
9How to learn surface anatomy
Surface anatomy is best learned via the examination and palpation of living subjects, the more the better. Remember also to cross-reference the information in this book with cadaveric specimens, sections and medical imaging. This will enhance your understanding of positions, variability and relationships. When surface positioning structures it is helpful to remember the following:
Thanks to Paul Mayhew and Richard Furn from JP Medical for their invaluable advice and guidance during this project, and to Richard Prime and Pete Wilder from Designers Collective Ltd for turning my anatomical sketches into artwork.