awinml/medqa-textbooks-chunked · Datasets at Hugging Face

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Anatomy_Gray_0	Anatomy_Gray.txt	What is anatomy?
Anatomy_Gray_1	Anatomy_Gray.txt	Anatomy includes those structures that can be seen grossly (without the aid of magnification) and microscopically (with the aid of magnification). Typically, when used by itself, the term anatomy tends to mean gross or macroscopic anatomy—that is, the study of structures that can be seen without using a microscopic. Microscopic anatomy, also called histology, is the study of cells and tissues using a microscope.
Anatomy_Gray_2	Anatomy_Gray.txt	Anatomy forms the basis for the practice of medicine. Anatomy leads the physician toward an understanding of a patient’s disease, whether he or she is carrying out a physical examination or using the most advanced imaging techniques. Anatomy is also important for dentists, chiropractors, physical therapists, and all others involved in any aspect of patient treatment that begins with an analysis of clinical signs. The ability to interpret a clinical observation correctly is therefore the endpoint of a sound anatomical understanding.
Anatomy_Gray_3	Anatomy_Gray.txt	Observation and visualization are the primary techniques a student should use to learn anatomy. Anatomy is much more than just memorization of lists of names. Although the language of anatomy is important, the network of information needed to visualize the position of physical structures in a patient goes far beyond simple memorization. Knowing the names of the various branches of the external carotid artery is not the same as being able to visualize the course of the lingual artery from its origin in the neck to its termination in the tongue. Similarly, understanding the organization of the soft palate, how it is related to the oral and nasal cavities, and how it moves during swallowing is very different from being able to recite the names of its individual muscles and nerves. An understanding of anatomy requires an understanding of the context in which the terminology can be remembered.
Anatomy_Gray_4	Anatomy_Gray.txt	How can gross anatomy be studied?
Anatomy_Gray_5	Anatomy_Gray.txt	The term anatomy is derived from the Greek word temnein, meaning “to cut.” Clearly, therefore, the study of anatomy is linked, at its root, to dissection, although dissection of cadavers by students is now augmented, or even in some cases replaced, by viewing prosected (previously dissected) material and plastic models, or using computer teaching modules and other learning aids.
Anatomy_Gray_6	Anatomy_Gray.txt	Anatomy can be studied following either a regional or a systemic approach.
Anatomy_Gray_7	Anatomy_Gray.txt	With a regional approach, each region of the body is studied separately and all aspects of that region are studied at the same time. For example, if the thorax is to be studied, all of its structures are examined.
Anatomy_Gray_8	Anatomy_Gray.txt	This includes the vasculature, the nerves, the bones, the muscles, and all other structures and organs located in the region of the body defined as the thorax. After studying this region, the other regions of the body (i.e., the abdomen, pelvis, lower limb, upper limb, back, head, and neck) are studied in a similar fashion.
Anatomy_Gray_9	Anatomy_Gray.txt	In contrast, in a systemic approach, each system of the body is studied and followed throughout the entire body. For example, a study of the cardiovascular system looks at the heart and all of the blood vessels in the body. When this is completed, the nervous system (brain, spinal cord, and all the nerves) might be examined in detail. This approach continues for the whole body until every system, including the nervous, skeletal, muscular, gastrointestinal, respiratory, lymphatic, and reproductive systems, has been studied.
Anatomy_Gray_10	Anatomy_Gray.txt	Each of these approaches has benefits and deficiencies. The regional approach works very well if the anatomy course involves cadaver dissection but falls short when it comes to understanding the continuity of an entire system throughout the body. Similarly, the systemic approach fosters an understanding of an entire system throughout the body, but it is very difficult to coordinate this directly with a cadaver dissection or to acquire sufficient detail.
Anatomy_Gray_11	Anatomy_Gray.txt	The anatomical position
Anatomy_Gray_12	Anatomy_Gray.txt	The anatomical position is the standard reference position of the body used to describe the location of structures (Fig. 1.1). The body is in the anatomical position when standing upright with feet together, hands by the side and face looking forward. The mouth is closed and the facial expression is neutral. The rim of bone under the eyes is in the same horizontal plane as the top of the opening to the ear, and the eyes are open and focused on something in the distance. The palms of the hands face forward with the fingers straight and together and with the pad of the thumb turned 90° to the pads of the fingers. The toes point forward.
Anatomy_Gray_13	Anatomy_Gray.txt	Three major groups of planes pass through the body in the anatomical position (Fig. 1.1).
Anatomy_Gray_14	Anatomy_Gray.txt	Coronal planes are oriented vertically and divide the body into anterior and posterior parts.
Anatomy_Gray_15	Anatomy_Gray.txt	Sagittal planes also are oriented vertically but are at right angles to the coronal planes and divide the body into right and left parts. The plane that passes through the center of the body dividing it into equal right and left halves is termed the median sagittal plane.
Anatomy_Gray_16	Anatomy_Gray.txt	Transverse, horizontal, or axial planes divide the body into superior and inferior parts.
Anatomy_Gray_17	Anatomy_Gray.txt	Terms to describe location
Anatomy_Gray_18	Anatomy_Gray.txt	Anterior (ventral) and posterior (dorsal), medial and lateral, superior and inferior
Anatomy_Gray_19	Anatomy_Gray.txt	Three major pairs of terms are used to describe the location of structures relative to the body as a whole or to other structures (Fig. 1.1).
Anatomy_Gray_20	Anatomy_Gray.txt	Anterior (or ventral) and posterior (or dorsal) describe the position of structures relative to the “front” and “back” of the body. For example, the nose is an anterior (ventral) structure, whereas the vertebral column is a posterior (dorsal) structure. Also, the nose is anterior to the ears and the vertebral column is posterior to the sternum.
Anatomy_Gray_21	Anatomy_Gray.txt	Medial and lateral describe the position of structures relative to the median sagittal plane and the sides of the body. For example, the thumb is lateral to the little finger. The nose is in the median sagittal plane and is medial to the eyes, which are in turn medial to the external ears.
Anatomy_Gray_22	Anatomy_Gray.txt	Superior and inferior describe structures in reference to the vertical axis of the body. For example, the head is superior to the shoulders and the knee joint is inferior to the hip joint.
Anatomy_Gray_23	Anatomy_Gray.txt	Proximal and distal, cranial and caudal,
Anatomy_Gray_24	Anatomy_Gray.txt	Other terms used to describe positions include proximal and distal, cranial and caudal, and rostral.
Anatomy_Gray_25	Anatomy_Gray.txt	Proximal and distal are used with reference to being closer to or farther from a structure’s origin, particularly in the limbs. For example, the hand is distal to the elbow joint. The glenohumeral joint is proximal to the elbow joint. These terms are also used to describe the relative positions of branches along the course of linear structures, such as airways, vessels, and nerves. For example, distal branches occur farther away toward the ends of the system, whereas proximal branches occur closer to and toward the origin of the system.
Anatomy_Gray_26	Anatomy_Gray.txt	Cranial (toward the head) and caudal (toward the tail) are sometimes used instead of superior and inferior, respectively.
Anatomy_Gray_27	Anatomy_Gray.txt	Rostral is used, particularly in the head, to describe the position of a structure with reference to the nose. For example, the forebrain is rostral to the hindbrain.
Anatomy_Gray_28	Anatomy_Gray.txt	Two other terms used to describe the position of structures in the body are superficial and deep. These terms are used to describe the relative positions of two structures with respect to the surface of the body. For example, the sternum is superficial to the heart, and the stomach is deep to the abdominal wall.
Anatomy_Gray_29	Anatomy_Gray.txt	Superficial and deep can also be used in a more absolute fashion to define two major regions of the body. The superficial region of the body is external to the outer layer of deep fascia. Deep structures are enclosed by this layer. Structures in the superficial region of the body include the skin, superficial fascia, and mammary glands. Deep structures include most skeletal muscles and viscera. Superficial wounds are external to the outer layer of deep fascia, whereas deep wounds penetrate through it.
Anatomy_Gray_30	Anatomy_Gray.txt	In 1895 Wilhelm Roentgen used the X-rays from a cathode ray tube to expose a photographic plate and produce the first radiographic exposure of his wife’s hand. Over the past 35 years there has been a revolution in body imaging, which has been paralleled by developments in computer technology.
Anatomy_Gray_31	Anatomy_Gray.txt	X-rays are photons (a type of electromagnetic radiation) and are generated from a complex X-ray tube, which is a type of cathode ray tube (Fig. 1.2). The X-rays are then collimated (i.e., directed through lead-lined shutters to stop them from fanning out) to the appropriate area of the body. As the X-rays pass through the body they are attenuated (reduced in energy) by the tissues. Those X-rays that pass through the tissues interact with the photographic film.
Anatomy_Gray_32	Anatomy_Gray.txt	In the body: air attenuates X-rays a little; fat attenuates X-rays more than air but less than bone attenuates X-rays the most.
Anatomy_Gray_33	Anatomy_Gray.txt	These differences in attenuation result in differences in the level of exposure of the film. When the photographic film is developed, bone appears white on the film because this region of the film has been exposed to the least amount of X-rays. Air appears dark on the film because these regions were exposed to the greatest number of X-rays.
Anatomy_Gray_34	Anatomy_Gray.txt	Modifications to this X-ray technique allow a continuous stream of X-rays to be produced from the X-ray tube and collected on an input screen to allow real-time visualization of moving anatomical structures, barium studies, angiography, and fluoroscopy (Fig. 1.3).
Anatomy_Gray_35	Anatomy_Gray.txt	To demonstrate specific structures, such as bowel loops or arteries, it may be necessary to fill these structures with a substance that attenuates X-rays more than bowel loops or arteries do normally. It is, however, extremely important that these substances are nontoxic. Barium sulfate, an insoluble salt, is a nontoxic, relatively high-density agent that is extremely useful in the examination of the gastrointestinal tract. When a barium sulfate suspension is ingested it attenuates X-rays and can therefore be used to demonstrate the bowel lumen (Fig. 1.4). It is common to add air to the barium sulfate suspension, by either ingesting “fizzy” granules or directly instilling air into the body cavity, as in a barium enema. This is known as a double-contrast (air/barium) study.
Anatomy_Gray_36	Anatomy_Gray.txt	For some patients it is necessary to inject contrast agents directly into arteries or veins. In this case, iodine-based molecules are suitable contrast agents. Iodine is chosen because it has a relatively high atomic mass and so markedly attenuates X-rays, but also, importantly, it is naturally excreted via the urinary system. Intra-arterial and intravenous contrast agents are extremely safe and are well tolerated by most patients. Rarely, some patients have an anaphylactic reaction to intra-arterial or intravenous injections, so the necessary precautions must be taken. Intra-arterial and intravenous contrast agents not only help in visualizing the arteries and veins but because they are excreted by the urinary system, can also be used to visualize the kidneys, ureter, and bladder in a process known as intravenous urography.
Anatomy_Gray_37	Anatomy_Gray.txt	During angiography it is often difficult to appreciate the contrast agent in the vessels through the overlying bony structures. To circumvent this, the technique of subtraction angiography has been developed. Simply, one or two images are obtained before the injection of contrast media. These images are inverted (such that a negative is created from the positive image). After injection of the contrast media into the vessels, a further series of images are obtained, demonstrating the passage of the contrast through the arteries into the veins and around the circulation. By adding the “negative precontrast image” to the positive postcontrast images, the bones and soft tissues are subtracted to produce a solitary image of contrast only. Before the advent of digital imaging this was a challenge, but now the use of computers has made this technique relatively straightforward and instantaneous (Fig. 1.5).
Anatomy_Gray_38	Anatomy_Gray.txt	Ultrasonography of the body is widely used for all aspects of medicine.
Anatomy_Gray_39	Anatomy_Gray.txt	Ultrasound is a very high frequency sound wave (not electromagnetic radiation) generated by piezoelectric materials, such that a series of sound waves is produced. Importantly, the piezoelectric material can also receive the sound waves that bounce back from the internal organs. The sound waves are then interpreted by a powerful computer, and a real-time image is produced on the display panel.
Anatomy_Gray_40	Anatomy_Gray.txt	Developments in ultrasound technology, including the size of the probes and the frequency range, mean that a broad range of areas can now be scanned.
Anatomy_Gray_41	Anatomy_Gray.txt	Traditionally ultrasound is used for assessing the abdomen (Fig. 1.6) and the fetus in pregnant women. Ultrasound is also widely used to assess the eyes, neck, soft tissues, and peripheral musculoskeletal system. Probes have been placed on endoscopes, and endoluminal ultrasound of the esophagus, stomach, and duodenum is now routine. Endocavity ultrasound is carried out most commonly to assess the genital tract in women using a transvaginal or transrectal route. In men, transrectal ultrasound is the imaging method of choice to assess the prostate in those with suspected prostate hypertrophy or malignancy.
Anatomy_Gray_42	Anatomy_Gray.txt	Doppler ultrasound enables determination of flow, its direction, and its velocity within a vessel using simple ultrasound techniques. Sound waves bounce off moving structures and are returned. The degree of frequency shift determines whether the object is moving away from or toward the probe and the speed at which it is traveling. Precise measurements of blood flow and blood velocity can therefore be obtained, which in turn can indicate sites of blockage in blood vessels.
Anatomy_Gray_43	Anatomy_Gray.txt	Computed tomography (CT) was invented in the 1970s by Sir Godfrey Hounsfield, who was awarded the Nobel Prize in Medicine in 1979. Since this inspired invention there have been many generations of CT scanners.
Anatomy_Gray_44	Anatomy_Gray.txt	A CT scanner obtains a series of images of the body (slices) in the axial plane. The patient lies on a bed, an X-ray tube passes around the body (Fig. 1.7), and a series of images are obtained. A computer carries out a complex mathematical transformation on the multitude of images to produce the final image (Fig. 1.8).
Anatomy_Gray_45	Anatomy_Gray.txt	Nuclear magnetic resonance imaging was first described in 1946 and used to determine the structure of complex molecules. The process of magnetic resonance imaging (MRI) is dependent on the free protons in the hydrogen nuclei in molecules of water (H2O). Because water is present in almost all biological tissues, the hydrogen proton is ideal. The protons within a patient’s hydrogen nuclei can be regarded as small bar magnets, which are randomly oriented in space. The patient is placed in a strong magnetic field, which aligns the bar magnets. When a pulse of radio waves is passed through the patient the magnets are deflected, and as they return to their aligned position they emit small radio pulses. The strength and frequency of the emitted pulses and the time it takes for the protons to return to their pre-excited state produce a signal. These signals are analyzed by a powerful computer, and an image is created (Fig. 1.9).
Anatomy_Gray_46	Anatomy_Gray.txt	By altering the sequence of pulses to which the protons are subjected, different properties of the protons can be assessed. These properties are referred to as the “weighting” of the scan. By altering the pulse sequence and the scanning parameters, T1-weighted images (Fig. 1.10A) and T2-weighted images (Fig. 1.10B) can be obtained. These two types of imaging sequences provide differences in image contrast, which accentuate and optimize different tissue characteristics.
Anatomy_Gray_47	Anatomy_Gray.txt	From the clinical point of view:
Anatomy_Gray_48	Anatomy_Gray.txt	Most T1-weighted images show dark fluid and bright fat—for example, within the brain the cerebrospinal fluid (CSF) is dark.
Anatomy_Gray_49	Anatomy_Gray.txt	T2-weighted images demonstrate a bright signal from fluid and an intermediate signal from fat—for example, in the brain the CSF appears white.
Anatomy_Gray_50	Anatomy_Gray.txt	MRI can also be used to assess flow within vessels and to produce complex angiograms of the peripheral and cerebral circulation.
Anatomy_Gray_51	Anatomy_Gray.txt	Diffusion-weighted imaging provides information on the degree of Brownian motion of water molecules in various tissues. There is relatively free diffusion in extracellular spaces and more restricted diffusion in intracellular spaces. In tumors and infarcted tissue, there is an increase in intracellular fluid water molecules compared with the extracellular fluid environment resulting in overall increased restricted diffusion, and therefore identification of abnormal from normal tissue.
Anatomy_Gray_52	Anatomy_Gray.txt	Nuclear medicine involves imaging using gamma rays, which are another type of electromagnetic radiation.
Anatomy_Gray_53	Anatomy_Gray.txt	The important difference between gamma rays and
Anatomy_Gray_54	Anatomy_Gray.txt	X-rays is that gamma rays are produced from within the nucleus of an atom when an unstable nucleus decays, whereas X-rays are produced by bombarding an atom with electrons.
Anatomy_Gray_55	Anatomy_Gray.txt	For an area to be visualized, the patient must receive a gamma ray emitter, which must have a number of properties to be useful, including: a reasonable half-life (e.g., 6 to 24 hours), an easily measurable gamma ray, and energy deposition in as low a dose as possible in the patient’s tissues.
Anatomy_Gray_56	Anatomy_Gray.txt	The most commonly used radionuclide (radioisotope) is technetium-99m. This may be injected as a technetium salt or combined with other complex molecules. For example, by combining technetium-99m with methylene diphosphonate (MDP), a radiopharmaceutical is produced. When injected into the body this radiopharmaceutical specifically binds to bone, allowing assessment of the skeleton. Similarly, combining technetium-99m with other compounds permits assessment of other parts of the body, for example the urinary tract and cerebral blood flow.
Anatomy_Gray_57	Anatomy_Gray.txt	Depending on how the radiopharmaceutical is absorbed, distributed, metabolized, and excreted by the body after injection, images are obtained using a gamma camera (Fig. 1.11).
Anatomy_Gray_58	Anatomy_Gray.txt	Positron emission tomography (PET) is an imaging modality for detecting positron-emitting radionuclides. A positron is an anti-electron, which is a positively charged particle of antimatter. Positrons are emitted from the decay of proton-rich radionuclides. Most of these radionuclides are made in a cyclotron and have extremely short half-lives.
Anatomy_Gray_59	Anatomy_Gray.txt	The most commonly used PET radionuclide is fluorodeoxyglucose (FDG) labeled with fluorine-18 (a positron emitter). Tissues that are actively metabolizing glucose take up this compound, and the resulting localized high concentration of this molecule compared to background emission is detected as a “hot spot.”
Anatomy_Gray_60	Anatomy_Gray.txt	PET has become an important imaging modality in the detection of cancer and the assessment of its treatment and recurrence.
Anatomy_Gray_61	Anatomy_Gray.txt	Single photon emission computed tomography (SPECT) is an imaging modality for detecting gamma rays emitted from the decay of injected radionuclides such as technetium-99m, iodine-123, or iodine-131. The rays are detected by a 360-degree rotating camera, which allows the construction of 3D images. SPECT can be used to diagnose a wide range of disease conditions such as coronary artery disease and bone fractures.
Anatomy_Gray_62	Anatomy_Gray.txt	Imaging is necessary in most clinical specialties to diagnose pathological changes to tissues. It is paramount to appreciate what is normal and what is abnormal. An appreciation of how the image is obtained, what the normal variations are, and what technical considerations are necessary to obtain a radiological diagnosis. Without understanding the anatomy of the region imaged, it is impossible to comment on the abnormal.
Anatomy_Gray_63	Anatomy_Gray.txt	Plain radiographs are undoubtedly the most common form of image obtained in a hospital or local practice. Before interpretation, it is important to know about the imaging technique and the views obtained as standard.
Anatomy_Gray_64	Anatomy_Gray.txt	In most instances (apart from chest radiography) the X-ray tube is 1 m away from the X-ray film. The object in question, for example a hand or a foot, is placed upon the film. When describing subject placement for radiography, the part closest to the X-ray tube is referred to first and that closest to the film is referred to second. For example, when positioning a patient for an anteroposterior (AP) radiograph, the more anterior part of the body is closest to the tube and the posterior part is closest to the film.
Anatomy_Gray_65	Anatomy_Gray.txt	When X-rays are viewed on a viewing box, the right side of the patient is placed to the observer’s left; therefore, the observer views the radiograph as though looking at a patient in the anatomical position.
Anatomy_Gray_66	Anatomy_Gray.txt	The chest radiograph is one of the most commonly requested plain radiographs. An image is taken with the patient erect and placed posteroanteriorly (PA chest radiograph; that is, with the patient’s back closest to the X-ray tube.).
Anatomy_Gray_67	Anatomy_Gray.txt	Occasionally, when patients are too unwell to stand erect, films are obtained on the bed in an anteroposterior (AP) position. These films are less standardized than PA films, and caution should always be taken when interpreting AP radiographs.
Anatomy_Gray_68	Anatomy_Gray.txt	The plain chest radiograph should always be checked for quality. Film markers should be placed on the appropriate side. (Occasionally patients have dextrocardia, which may be misinterpreted if the film marker is placed inappropriately.) A good-quality chest radiograph will demonstrate the lungs, cardiomediastinal contour, diaphragm, ribs, and peripheral soft tissues.
Anatomy_Gray_69	Anatomy_Gray.txt	Plain abdominal radiographs are obtained in the AP supine position. From time to time an erect plain abdominal radiograph is obtained when small bowel obstruction is suspected.
Anatomy_Gray_70	Anatomy_Gray.txt	High-density contrast medium is ingested to opacify the esophagus, stomach, small bowel, and large bowel. As described previously (p. 6), the bowel is insufflated with air (or carbon dioxide) to provide a double-contrast study. In many countries, endoscopy has superseded upper gastrointestinal imaging, but the mainstay of imaging the large bowel is the double-contrast barium enema. Typically the patient needs to undergo bowel preparation, in which powerful cathartics are used to empty the bowel. At the time of the examination a small tube is placed into the rectum and a barium suspension is run into the large bowel. The patient undergoes a series of twists and turns so that the contrast passes through the entire large bowel. The contrast is emptied and air is passed through the same tube to insufflate the large bowel. A thin layer of barium coats the normal mucosa, allowing mucosal detail to be visualized (see Fig. 1.4).
Anatomy_Gray_71	Anatomy_Gray.txt	Intravenous urography is the standard investigation for assessing the urinary tract. Intravenous contrast medium is injected, and images are obtained as the medium is excreted through the kidneys. A series of films are obtained during this period from immediately after the injection up to approximately 20 minutes later, when the bladder is full of contrast medium.
Anatomy_Gray_72	Anatomy_Gray.txt	This series of radiographs demonstrates the kidneys, ureters, and bladder and enables assessment of the retroperitoneum and other structures that may press on the urinary tract.
Anatomy_Gray_73	Anatomy_Gray.txt	Computed tomography is the preferred terminology rather than computerized tomography, though both terms are used interchangeably by physicians.
Anatomy_Gray_74	Anatomy_Gray.txt	It is important for the student to understand the presentation of images. Most images are acquired in the axial plane and viewed such that the observer looks from below and upward toward the head (from the foot of the bed). By implication: the right side of the patient is on the left side of the image, and the uppermost border of the image is anterior.
Anatomy_Gray_75	Anatomy_Gray.txt	Many patients are given oral and intravenous contrast media to differentiate bowel loops from other abdominal organs and to assess the vascularity of normal anatomical structures. When intravenous contrast is given, the earlier the images are obtained, the greater the likelihood of arterial enhancement. As the time is delayed between injection and image acquisition, a venous phase and an equilibrium phase are also obtained.
Anatomy_Gray_76	Anatomy_Gray.txt	The great advantage of CT scanning is the ability to extend and compress the gray scale to visualize the bones, soft tissues, and visceral organs. Altering the window settings and window centering provides the physician with specific information about these structures.
Anatomy_Gray_77	Anatomy_Gray.txt	There is no doubt that MRI has revolutionized the understanding and interpretation of the brain and its coverings. Furthermore, it has significantly altered the practice of musculoskeletal medicine and surgery. Images can be obtained in any plane and in most sequences. Typically the images are viewed using the same principles as CT. Intravenous contrast agents are also used to further enhance tissue contrast. Typically, MRI contrast agents contain paramagnetic substances (e.g., gadolinium and manganese).
Anatomy_Gray_78	Anatomy_Gray.txt	Most nuclear medicine images are functional studies. Images are usually interpreted directly from a computer, and a series of representative films are obtained for clinical use.
Anatomy_Gray_79	Anatomy_Gray.txt	Whenever a patient undergoes an X-ray or nuclear medicine investigation, a dose of radiation is given (Table 1.1). As a general principle it is expected that the dose given is as low as reasonably possible for a diagnostic image to be obtained. Numerous laws govern the amount of radiation exposure that a patient can undergo for a variety of procedures, and these are monitored to prevent any excess or additional dosage. Whenever a radiograph is booked, the clinician ordering the procedure must appreciate its necessity and understand the dose given to the patient to ensure that the benefits significantly outweigh the risks.
Anatomy_Gray_80	Anatomy_Gray.txt	Imaging modalities such as ultrasound and MRI are ideal because they do not impart significant risk to the patient. Moreover, ultrasound imaging is the modality of choice for assessing the fetus.
Anatomy_Gray_81	Anatomy_Gray.txt	Any imaging device is expensive, and consequently the more complex the imaging technique (e.g., MRI) the more expensive the investigation. Investigations must be carried out judiciously, based on a sound clinical history and examination, for which an understanding of anatomy is vital.
Anatomy_Gray_82	Anatomy_Gray.txt	The skeleton can be divided into two subgroups, the axial skeleton and the appendicular skeleton. The axial skeleton consists of the bones of the skull (cranium), vertebral column, ribs, and sternum, whereas the appendicular skeleton consists of the bones of the upper and lower limbs (Fig. 1.12).
Anatomy_Gray_83	Anatomy_Gray.txt	The skeletal system consists of cartilage and bone.
Anatomy_Gray_84	Anatomy_Gray.txt	Cartilage is an avascular form of connective tissue consisting of extracellular fibers embedded in a matrix that contains cells localized in small cavities. The amount and kind of extracellular fibers in the matrix varies depending on the type of cartilage. In heavy weightbearing areas or areas prone to pulling forces, the amount of collagen is greatly increased and the cartilage is almost inextensible. In contrast, in areas where weightbearing demands and stress are less, cartilage containing elastic fibers and fewer collagen fibers is common. The functions of cartilage are to: support soft tissues, provide a smooth, gliding surface for bone articulations at joints, and enable the development and growth of long bones.
Anatomy_Gray_85	Anatomy_Gray.txt	There are three types of cartilage: hyaline—most common; matrix contains a moderate amount of collagen fibers (e.g., articular surfaces of bones); elastic—matrix contains collagen fibers along with a large number of elastic fibers (e.g., external ear); fibrocartilage—matrix contains a limited number of cells and ground substance amidst a substantial amount of collagen fibers (e.g., intervertebral discs).
Anatomy_Gray_86	Anatomy_Gray.txt	Cartilage is nourished by diffusion and has no blood vessels, lymphatics, or nerves.
Anatomy_Gray_87	Anatomy_Gray.txt	Bone is a calcified, living, connective tissue that forms the majority of the skeleton. It consists of an intercellular calcified matrix, which also contains collagen fibers, and several types of cells within the matrix. Bones function as: supportive structures for the body, protectors of vital organs, reservoirs of calcium and phosphorus, levers on which muscles act to produce movement, and containers for blood-producing cells.
Anatomy_Gray_88	Anatomy_Gray.txt	There are two types of bone, compact and spongy (trabecular or cancellous). Compact bone is dense bone that forms the outer shell of all bones and surrounds spongy bone. Spongy bone consists of spicules of bone enclosing cavities containing blood-forming cells (marrow). Classification of bones is by shape.
Anatomy_Gray_89	Anatomy_Gray.txt	Long bones are tubular (e.g., humerus in upper limb; femur in lower limb).
Anatomy_Gray_90	Anatomy_Gray.txt	Short bones are cuboidal (e.g., bones of the wrist and ankle).
Anatomy_Gray_91	Anatomy_Gray.txt	Flat bones consist of two compact bone plates separated by spongy bone (e.g., skull).
Anatomy_Gray_92	Anatomy_Gray.txt	Irregular bones are bones with various shapes (e.g., bones of the face).
Anatomy_Gray_93	Anatomy_Gray.txt	Sesamoid bones are round or oval bones that develop in tendons.
Anatomy_Gray_94	Anatomy_Gray.txt	Bones are vascular and are innervated. Generally, an adjacent artery gives off a nutrient artery, usually one per bone, that directly enters the internal cavity of the bone and supplies the marrow, spongy bone, and inner layers of compact bone. In addition, all bones are covered externally, except in the area of a joint where articular cartilage is present, by a fibrous connective tissue membrane called the periosteum, which has the unique capability of forming new bone. This membrane receives blood vessels whose branches supply the outer layers of compact bone. A bone stripped of its periosteum will not survive. Nerves accompany the vessels that supply the bone and the periosteum. Most of the nerves passing into the internal cavity with the nutrient artery are vasomotor fibers that regulate blood flow. Bone itself has few sensory nerve fibers. On the other hand, the periosteum is supplied with numerous sensory nerve fibers and is very sensitive to any type of injury.
Anatomy_Gray_95	Anatomy_Gray.txt	Developmentally, all bones come from mesenchyme by either intramembranous ossification, in which mesenchymal models of bones undergo ossification, or endochondral ossification, in which cartilaginous models of bones form from mesenchyme and undergo ossification.
Anatomy_Gray_96	Anatomy_Gray.txt	The sites where two skeletal elements come together are termed joints. The two general categories of joints (Fig. 1.18) are those in which: the skeletal elements are separated by a cavity (i.e., synovial joints), and there is no cavity and the components are held together by connective tissue (i.e., solid joints).
Anatomy_Gray_97	Anatomy_Gray.txt	Blood vessels that cross over a joint and nerves that innervate muscles acting on a joint usually contribute articular branches to that joint.
Anatomy_Gray_98	Anatomy_Gray.txt	Synovial joints are connections between skeletal components where the elements involved are separated by a narrow articular cavity (Fig. 1.19). In addition to containing an articular cavity, these joints have a number of characteristic features.
Anatomy_Gray_99	Anatomy_Gray.txt	First, a layer of cartilage, usually hyaline cartilage, covers the articulating surfaces of the skeletal elements. In other words, bony surfaces do not normally contact one another directly. As a consequence, when these joints are viewed in normal radiographs, a wide gap seems to separate the adjacent bones because the cartilage that covers the articulating surfaces is more transparent to X-rays than bone.

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What is anatomy?

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Anatomy includes those structures that can be seen grossly (without the aid of magnification) and microscopically (with the aid of magnification). Typically, when used by itself, the term anatomy tends to mean gross or macroscopic anatomy—that is, the study of structures that can be seen without using a microscopic. Microscopic anatomy, also called histology, is the study of cells and tissues using a microscope.

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Anatomy forms the basis for the practice of medicine. Anatomy leads the physician toward an understanding of a patient’s disease, whether he or she is carrying out a physical examination or using the most advanced imaging techniques. Anatomy is also important for dentists, chiropractors, physical therapists, and all others involved in any aspect of patient treatment that begins with an analysis of clinical signs. The ability to interpret a clinical observation correctly is therefore the endpoint of a sound anatomical understanding.

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Observation and visualization are the primary techniques a student should use to learn anatomy. Anatomy is much more than just memorization of lists of names. Although the language of anatomy is important, the network of information needed to visualize the position of physical structures in a patient goes far beyond simple memorization. Knowing the names of the various branches of the external carotid artery is not the same as being able to visualize the course of the lingual artery from its origin in the neck to its termination in the tongue. Similarly, understanding the organization of the soft palate, how it is related to the oral and nasal cavities, and how it moves during swallowing is very different from being able to recite the names of its individual muscles and nerves. An understanding of anatomy requires an understanding of the context in which the terminology can be remembered.

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How can gross anatomy be studied?

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The term anatomy is derived from the Greek word temnein, meaning “to cut.” Clearly, therefore, the study of anatomy is linked, at its root, to dissection, although dissection of cadavers by students is now augmented, or even in some cases replaced, by viewing prosected (previously dissected) material and plastic models, or using computer teaching modules and other learning aids.

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Anatomy can be studied following either a regional or a systemic approach.

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With a regional approach, each region of the body is studied separately and all aspects of that region are studied at the same time. For example, if the thorax is to be studied, all of its structures are examined.

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This includes the vasculature, the nerves, the bones, the muscles, and all other structures and organs located in the region of the body defined as the thorax. After studying this region, the other regions of the body (i.e., the abdomen, pelvis, lower limb, upper limb, back, head, and neck) are studied in a similar fashion.

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In contrast, in a systemic approach, each system of the body is studied and followed throughout the entire body. For example, a study of the cardiovascular system looks at the heart and all of the blood vessels in the body. When this is completed, the nervous system (brain, spinal cord, and all the nerves) might be examined in detail. This approach continues for the whole body until every system, including the nervous, skeletal, muscular, gastrointestinal, respiratory, lymphatic, and reproductive systems, has been studied.

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Each of these approaches has benefits and deficiencies. The regional approach works very well if the anatomy course involves cadaver dissection but falls short when it comes to understanding the continuity of an entire system throughout the body. Similarly, the systemic approach fosters an understanding of an entire system throughout the body, but it is very difficult to coordinate this directly with a cadaver dissection or to acquire sufficient detail.

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The anatomical position

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The anatomical position is the standard reference position of the body used to describe the location of structures (Fig. 1.1). The body is in the anatomical position when standing upright with feet together, hands by the side and face looking forward. The mouth is closed and the facial expression is neutral. The rim of bone under the eyes is in the same horizontal plane as the top of the opening to the ear, and the eyes are open and focused on something in the distance. The palms of the hands face forward with the fingers straight and together and with the pad of the thumb turned 90° to the pads of the fingers. The toes point forward.

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Three major groups of planes pass through the body in the anatomical position (Fig. 1.1).

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Coronal planes are oriented vertically and divide the body into anterior and posterior parts.

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Sagittal planes also are oriented vertically but are at right angles to the coronal planes and divide the body into right and left parts. The plane that passes through the center of the body dividing it into equal right and left halves is termed the median sagittal plane.

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Transverse, horizontal, or axial planes divide the body into superior and inferior parts.

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Terms to describe location

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Anterior (ventral) and posterior (dorsal), medial and lateral, superior and inferior

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Three major pairs of terms are used to describe the location of structures relative to the body as a whole or to other structures (Fig. 1.1).

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Anterior (or ventral) and posterior (or dorsal) describe the position of structures relative to the “front” and “back” of the body. For example, the nose is an anterior (ventral) structure, whereas the vertebral column is a posterior (dorsal) structure. Also, the nose is anterior to the ears and the vertebral column is posterior to the sternum.

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Medial and lateral describe the position of structures relative to the median sagittal plane and the sides of the body. For example, the thumb is lateral to the little finger. The nose is in the median sagittal plane and is medial to the eyes, which are in turn medial to the external ears.

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Superior and inferior describe structures in reference to the vertical axis of the body. For example, the head is superior to the shoulders and the knee joint is inferior to the hip joint.

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Proximal and distal, cranial and caudal,

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Other terms used to describe positions include proximal and distal, cranial and caudal, and rostral.

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Proximal and distal are used with reference to being closer to or farther from a structure’s origin, particularly in the limbs. For example, the hand is distal to the elbow joint. The glenohumeral joint is proximal to the elbow joint. These terms are also used to describe the relative positions of branches along the course of linear structures, such as airways, vessels, and nerves. For example, distal branches occur farther away toward the ends of the system, whereas proximal branches occur closer to and toward the origin of the system.

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Cranial (toward the head) and caudal (toward the tail) are sometimes used instead of superior and inferior, respectively.

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Rostral is used, particularly in the head, to describe the position of a structure with reference to the nose. For example, the forebrain is rostral to the hindbrain.

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Two other terms used to describe the position of structures in the body are superficial and deep. These terms are used to describe the relative positions of two structures with respect to the surface of the body. For example, the sternum is superficial to the heart, and the stomach is deep to the abdominal wall.

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Superficial and deep can also be used in a more absolute fashion to define two major regions of the body. The superficial region of the body is external to the outer layer of deep fascia. Deep structures are enclosed by this layer. Structures in the superficial region of the body include the skin, superficial fascia, and mammary glands. Deep structures include most skeletal muscles and viscera. Superficial wounds are external to the outer layer of deep fascia, whereas deep wounds penetrate through it.

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In 1895 Wilhelm Roentgen used the X-rays from a cathode ray tube to expose a photographic plate and produce the first radiographic exposure of his wife’s hand. Over the past 35 years there has been a revolution in body imaging, which has been paralleled by developments in computer technology.

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X-rays are photons (a type of electromagnetic radiation) and are generated from a complex X-ray tube, which is a type of cathode ray tube (Fig. 1.2). The X-rays are then collimated (i.e., directed through lead-lined shutters to stop them from fanning out) to the appropriate area of the body. As the X-rays pass through the body they are attenuated (reduced in energy) by the tissues. Those X-rays that pass through the tissues interact with the photographic film.

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In the body: air attenuates X-rays a little; fat attenuates X-rays more than air but less than bone attenuates X-rays the most.

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These differences in attenuation result in differences in the level of exposure of the film. When the photographic film is developed, bone appears white on the film because this region of the film has been exposed to the least amount of X-rays. Air appears dark on the film because these regions were exposed to the greatest number of X-rays.

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Modifications to this X-ray technique allow a continuous stream of X-rays to be produced from the X-ray tube and collected on an input screen to allow real-time visualization of moving anatomical structures, barium studies, angiography, and fluoroscopy (Fig. 1.3).

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To demonstrate specific structures, such as bowel loops or arteries, it may be necessary to fill these structures with a substance that attenuates X-rays more than bowel loops or arteries do normally. It is, however, extremely important that these substances are nontoxic. Barium sulfate, an insoluble salt, is a nontoxic, relatively high-density agent that is extremely useful in the examination of the gastrointestinal tract. When a barium sulfate suspension is ingested it attenuates X-rays and can therefore be used to demonstrate the bowel lumen (Fig. 1.4). It is common to add air to the barium sulfate suspension, by either ingesting “fizzy” granules or directly instilling air into the body cavity, as in a barium enema. This is known as a double-contrast (air/barium) study.

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For some patients it is necessary to inject contrast agents directly into arteries or veins. In this case, iodine-based molecules are suitable contrast agents. Iodine is chosen because it has a relatively high atomic mass and so markedly attenuates X-rays, but also, importantly, it is naturally excreted via the urinary system. Intra-arterial and intravenous contrast agents are extremely safe and are well tolerated by most patients. Rarely, some patients have an anaphylactic reaction to intra-arterial or intravenous injections, so the necessary precautions must be taken. Intra-arterial and intravenous contrast agents not only help in visualizing the arteries and veins but because they are excreted by the urinary system, can also be used to visualize the kidneys, ureter, and bladder in a process known as intravenous urography.

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During angiography it is often difficult to appreciate the contrast agent in the vessels through the overlying bony structures. To circumvent this, the technique of subtraction angiography has been developed. Simply, one or two images are obtained before the injection of contrast media. These images are inverted (such that a negative is created from the positive image). After injection of the contrast media into the vessels, a further series of images are obtained, demonstrating the passage of the contrast through the arteries into the veins and around the circulation. By adding the “negative precontrast image” to the positive postcontrast images, the bones and soft tissues are subtracted to produce a solitary image of contrast only. Before the advent of digital imaging this was a challenge, but now the use of computers has made this technique relatively straightforward and instantaneous (Fig. 1.5).

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Ultrasonography of the body is widely used for all aspects of medicine.

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Ultrasound is a very high frequency sound wave (not electromagnetic radiation) generated by piezoelectric materials, such that a series of sound waves is produced. Importantly, the piezoelectric material can also receive the sound waves that bounce back from the internal organs. The sound waves are then interpreted by a powerful computer, and a real-time image is produced on the display panel.

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Developments in ultrasound technology, including the size of the probes and the frequency range, mean that a broad range of areas can now be scanned.

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Traditionally ultrasound is used for assessing the abdomen (Fig. 1.6) and the fetus in pregnant women. Ultrasound is also widely used to assess the eyes, neck, soft tissues, and peripheral musculoskeletal system. Probes have been placed on endoscopes, and endoluminal ultrasound of the esophagus, stomach, and duodenum is now routine. Endocavity ultrasound is carried out most commonly to assess the genital tract in women using a transvaginal or transrectal route. In men, transrectal ultrasound is the imaging method of choice to assess the prostate in those with suspected prostate hypertrophy or malignancy.

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Doppler ultrasound enables determination of flow, its direction, and its velocity within a vessel using simple ultrasound techniques. Sound waves bounce off moving structures and are returned. The degree of frequency shift determines whether the object is moving away from or toward the probe and the speed at which it is traveling. Precise measurements of blood flow and blood velocity can therefore be obtained, which in turn can indicate sites of blockage in blood vessels.

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Computed tomography (CT) was invented in the 1970s by Sir Godfrey Hounsfield, who was awarded the Nobel Prize in Medicine in 1979. Since this inspired invention there have been many generations of CT scanners.

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A CT scanner obtains a series of images of the body (slices) in the axial plane. The patient lies on a bed, an X-ray tube passes around the body (Fig. 1.7), and a series of images are obtained. A computer carries out a complex mathematical transformation on the multitude of images to produce the final image (Fig. 1.8).

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Nuclear magnetic resonance imaging was first described in 1946 and used to determine the structure of complex molecules. The process of magnetic resonance imaging (MRI) is dependent on the free protons in the hydrogen nuclei in molecules of water (H2O). Because water is present in almost all biological tissues, the hydrogen proton is ideal. The protons within a patient’s hydrogen nuclei can be regarded as small bar magnets, which are randomly oriented in space. The patient is placed in a strong magnetic field, which aligns the bar magnets. When a pulse of radio waves is passed through the patient the magnets are deflected, and as they return to their aligned position they emit small radio pulses. The strength and frequency of the emitted pulses and the time it takes for the protons to return to their pre-excited state produce a signal. These signals are analyzed by a powerful computer, and an image is created (Fig. 1.9).

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By altering the sequence of pulses to which the protons are subjected, different properties of the protons can be assessed. These properties are referred to as the “weighting” of the scan. By altering the pulse sequence and the scanning parameters, T1-weighted images (Fig. 1.10A) and T2-weighted images (Fig. 1.10B) can be obtained. These two types of imaging sequences provide differences in image contrast, which accentuate and optimize different tissue characteristics.

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From the clinical point of view:

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Most T1-weighted images show dark fluid and bright fat—for example, within the brain the cerebrospinal fluid (CSF) is dark.

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T2-weighted images demonstrate a bright signal from fluid and an intermediate signal from fat—for example, in the brain the CSF appears white.

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MRI can also be used to assess flow within vessels and to produce complex angiograms of the peripheral and cerebral circulation.

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Diffusion-weighted imaging provides information on the degree of Brownian motion of water molecules in various tissues. There is relatively free diffusion in extracellular spaces and more restricted diffusion in intracellular spaces. In tumors and infarcted tissue, there is an increase in intracellular fluid water molecules compared with the extracellular fluid environment resulting in overall increased restricted diffusion, and therefore identification of abnormal from normal tissue.

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Nuclear medicine involves imaging using gamma rays, which are another type of electromagnetic radiation.

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The important difference between gamma rays and

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X-rays is that gamma rays are produced from within the nucleus of an atom when an unstable nucleus decays, whereas X-rays are produced by bombarding an atom with electrons.

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For an area to be visualized, the patient must receive a gamma ray emitter, which must have a number of properties to be useful, including: a reasonable half-life (e.g., 6 to 24 hours), an easily measurable gamma ray, and energy deposition in as low a dose as possible in the patient’s tissues.

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The most commonly used radionuclide (radioisotope) is technetium-99m. This may be injected as a technetium salt or combined with other complex molecules. For example, by combining technetium-99m with methylene diphosphonate (MDP), a radiopharmaceutical is produced. When injected into the body this radiopharmaceutical specifically binds to bone, allowing assessment of the skeleton. Similarly, combining technetium-99m with other compounds permits assessment of other parts of the body, for example the urinary tract and cerebral blood flow.

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Depending on how the radiopharmaceutical is absorbed, distributed, metabolized, and excreted by the body after injection, images are obtained using a gamma camera (Fig. 1.11).

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Positron emission tomography (PET) is an imaging modality for detecting positron-emitting radionuclides. A positron is an anti-electron, which is a positively charged particle of antimatter. Positrons are emitted from the decay of proton-rich radionuclides. Most of these radionuclides are made in a cyclotron and have extremely short half-lives.

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The most commonly used PET radionuclide is fluorodeoxyglucose (FDG) labeled with fluorine-18 (a positron emitter). Tissues that are actively metabolizing glucose take up this compound, and the resulting localized high concentration of this molecule compared to background emission is detected as a “hot spot.”

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PET has become an important imaging modality in the detection of cancer and the assessment of its treatment and recurrence.

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Single photon emission computed tomography (SPECT) is an imaging modality for detecting gamma rays emitted from the decay of injected radionuclides such as technetium-99m, iodine-123, or iodine-131. The rays are detected by a 360-degree rotating camera, which allows the construction of 3D images. SPECT can be used to diagnose a wide range of disease conditions such as coronary artery disease and bone fractures.

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Imaging is necessary in most clinical specialties to diagnose pathological changes to tissues. It is paramount to appreciate what is normal and what is abnormal. An appreciation of how the image is obtained, what the normal variations are, and what technical considerations are necessary to obtain a radiological diagnosis. Without understanding the anatomy of the region imaged, it is impossible to comment on the abnormal.

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Plain radiographs are undoubtedly the most common form of image obtained in a hospital or local practice. Before interpretation, it is important to know about the imaging technique and the views obtained as standard.

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In most instances (apart from chest radiography) the X-ray tube is 1 m away from the X-ray film. The object in question, for example a hand or a foot, is placed upon the film. When describing subject placement for radiography, the part closest to the X-ray tube is referred to first and that closest to the film is referred to second. For example, when positioning a patient for an anteroposterior (AP) radiograph, the more anterior part of the body is closest to the tube and the posterior part is closest to the film.

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When X-rays are viewed on a viewing box, the right side of the patient is placed to the observer’s left; therefore, the observer views the radiograph as though looking at a patient in the anatomical position.

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The chest radiograph is one of the most commonly requested plain radiographs. An image is taken with the patient erect and placed posteroanteriorly (PA chest radiograph; that is, with the patient’s back closest to the X-ray tube.).

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Occasionally, when patients are too unwell to stand erect, films are obtained on the bed in an anteroposterior (AP) position. These films are less standardized than PA films, and caution should always be taken when interpreting AP radiographs.

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The plain chest radiograph should always be checked for quality. Film markers should be placed on the appropriate side. (Occasionally patients have dextrocardia, which may be misinterpreted if the film marker is placed inappropriately.) A good-quality chest radiograph will demonstrate the lungs, cardiomediastinal contour, diaphragm, ribs, and peripheral soft tissues.

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Plain abdominal radiographs are obtained in the AP supine position. From time to time an erect plain abdominal radiograph is obtained when small bowel obstruction is suspected.

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High-density contrast medium is ingested to opacify the esophagus, stomach, small bowel, and large bowel. As described previously (p. 6), the bowel is insufflated with air (or carbon dioxide) to provide a double-contrast study. In many countries, endoscopy has superseded upper gastrointestinal imaging, but the mainstay of imaging the large bowel is the double-contrast barium enema. Typically the patient needs to undergo bowel preparation, in which powerful cathartics are used to empty the bowel. At the time of the examination a small tube is placed into the rectum and a barium suspension is run into the large bowel. The patient undergoes a series of twists and turns so that the contrast passes through the entire large bowel. The contrast is emptied and air is passed through the same tube to insufflate the large bowel. A thin layer of barium coats the normal mucosa, allowing mucosal detail to be visualized (see Fig. 1.4).

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Intravenous urography is the standard investigation for assessing the urinary tract. Intravenous contrast medium is injected, and images are obtained as the medium is excreted through the kidneys. A series of films are obtained during this period from immediately after the injection up to approximately 20 minutes later, when the bladder is full of contrast medium.

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This series of radiographs demonstrates the kidneys, ureters, and bladder and enables assessment of the retroperitoneum and other structures that may press on the urinary tract.

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Computed tomography is the preferred terminology rather than computerized tomography, though both terms are used interchangeably by physicians.

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It is important for the student to understand the presentation of images. Most images are acquired in the axial plane and viewed such that the observer looks from below and upward toward the head (from the foot of the bed). By implication: the right side of the patient is on the left side of the image, and the uppermost border of the image is anterior.

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Many patients are given oral and intravenous contrast media to differentiate bowel loops from other abdominal organs and to assess the vascularity of normal anatomical structures. When intravenous contrast is given, the earlier the images are obtained, the greater the likelihood of arterial enhancement. As the time is delayed between injection and image acquisition, a venous phase and an equilibrium phase are also obtained.

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The great advantage of CT scanning is the ability to extend and compress the gray scale to visualize the bones, soft tissues, and visceral organs. Altering the window settings and window centering provides the physician with specific information about these structures.

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There is no doubt that MRI has revolutionized the understanding and interpretation of the brain and its coverings. Furthermore, it has significantly altered the practice of musculoskeletal medicine and surgery. Images can be obtained in any plane and in most sequences. Typically the images are viewed using the same principles as CT. Intravenous contrast agents are also used to further enhance tissue contrast. Typically, MRI contrast agents contain paramagnetic substances (e.g., gadolinium and manganese).

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Most nuclear medicine images are functional studies. Images are usually interpreted directly from a computer, and a series of representative films are obtained for clinical use.

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Whenever a patient undergoes an X-ray or nuclear medicine investigation, a dose of radiation is given (Table 1.1). As a general principle it is expected that the dose given is as low as reasonably possible for a diagnostic image to be obtained. Numerous laws govern the amount of radiation exposure that a patient can undergo for a variety of procedures, and these are monitored to prevent any excess or additional dosage. Whenever a radiograph is booked, the clinician ordering the procedure must appreciate its necessity and understand the dose given to the patient to ensure that the benefits significantly outweigh the risks.

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Imaging modalities such as ultrasound and MRI are ideal because they do not impart significant risk to the patient. Moreover, ultrasound imaging is the modality of choice for assessing the fetus.

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Any imaging device is expensive, and consequently the more complex the imaging technique (e.g., MRI) the more expensive the investigation. Investigations must be carried out judiciously, based on a sound clinical history and examination, for which an understanding of anatomy is vital.

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The skeleton can be divided into two subgroups, the axial skeleton and the appendicular skeleton. The axial skeleton consists of the bones of the skull (cranium), vertebral column, ribs, and sternum, whereas the appendicular skeleton consists of the bones of the upper and lower limbs (Fig. 1.12).

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The skeletal system consists of cartilage and bone.

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Cartilage is an avascular form of connective tissue consisting of extracellular fibers embedded in a matrix that contains cells localized in small cavities. The amount and kind of extracellular fibers in the matrix varies depending on the type of cartilage. In heavy weightbearing areas or areas prone to pulling forces, the amount of collagen is greatly increased and the cartilage is almost inextensible. In contrast, in areas where weightbearing demands and stress are less, cartilage containing elastic fibers and fewer collagen fibers is common. The functions of cartilage are to: support soft tissues, provide a smooth, gliding surface for bone articulations at joints, and enable the development and growth of long bones.

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There are three types of cartilage: hyaline—most common; matrix contains a moderate amount of collagen fibers (e.g., articular surfaces of bones); elastic—matrix contains collagen fibers along with a large number of elastic fibers (e.g., external ear); fibrocartilage—matrix contains a limited number of cells and ground substance amidst a substantial amount of collagen fibers (e.g., intervertebral discs).

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Cartilage is nourished by diffusion and has no blood vessels, lymphatics, or nerves.

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Bone is a calcified, living, connective tissue that forms the majority of the skeleton. It consists of an intercellular calcified matrix, which also contains collagen fibers, and several types of cells within the matrix. Bones function as: supportive structures for the body, protectors of vital organs, reservoirs of calcium and phosphorus, levers on which muscles act to produce movement, and containers for blood-producing cells.

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There are two types of bone, compact and spongy (trabecular or cancellous). Compact bone is dense bone that forms the outer shell of all bones and surrounds spongy bone. Spongy bone consists of spicules of bone enclosing cavities containing blood-forming cells (marrow). Classification of bones is by shape.

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Long bones are tubular (e.g., humerus in upper limb; femur in lower limb).

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Short bones are cuboidal (e.g., bones of the wrist and ankle).

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Flat bones consist of two compact bone plates separated by spongy bone (e.g., skull).

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Irregular bones are bones with various shapes (e.g., bones of the face).

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Sesamoid bones are round or oval bones that develop in tendons.

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Bones are vascular and are innervated. Generally, an adjacent artery gives off a nutrient artery, usually one per bone, that directly enters the internal cavity of the bone and supplies the marrow, spongy bone, and inner layers of compact bone. In addition, all bones are covered externally, except in the area of a joint where articular cartilage is present, by a fibrous connective tissue membrane called the periosteum, which has the unique capability of forming new bone. This membrane receives blood vessels whose branches supply the outer layers of compact bone. A bone stripped of its periosteum will not survive. Nerves accompany the vessels that supply the bone and the periosteum. Most of the nerves passing into the internal cavity with the nutrient artery are vasomotor fibers that regulate blood flow. Bone itself has few sensory nerve fibers. On the other hand, the periosteum is supplied with numerous sensory nerve fibers and is very sensitive to any type of injury.

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Developmentally, all bones come from mesenchyme by either intramembranous ossification, in which mesenchymal models of bones undergo ossification, or endochondral ossification, in which cartilaginous models of bones form from mesenchyme and undergo ossification.

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The sites where two skeletal elements come together are termed joints. The two general categories of joints (Fig. 1.18) are those in which: the skeletal elements are separated by a cavity (i.e., synovial joints), and there is no cavity and the components are held together by connective tissue (i.e., solid joints).

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Blood vessels that cross over a joint and nerves that innervate muscles acting on a joint usually contribute articular branches to that joint.

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Synovial joints are connections between skeletal components where the elements involved are separated by a narrow articular cavity (Fig. 1.19). In addition to containing an articular cavity, these joints have a number of characteristic features.

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First, a layer of cartilage, usually hyaline cartilage, covers the articulating surfaces of the skeletal elements. In other words, bony surfaces do not normally contact one another directly. As a consequence, when these joints are viewed in normal radiographs, a wide gap seems to separate the adjacent bones because the cartilage that covers the articulating surfaces is more transparent to X-rays than bone.