I.                 Back I

a.     Sacralization of lumbar vertebrae- fusion of L5 w/ S1

b.     Lumbarization of S1- separate S1 vertebrae

c.      Vulnerability of occipito-atlantoaxial joint- broken dens often drives back into spinal cord and paralysis/death

d.     Spina bifida- posterior arch of vert(s) missing; can be “silent” save tuft of hair over lumbar region (s.b.occulta)

i.     Meningocele- meninges extend out of canal also

ii.     Meningomyelocele- cord extends out also

iii.     Rachischisis- several or all vert lack posterior arch

e.     Rhizotomy- procedure to sever roots of spinal nn;

i.     Dorsal- produces anesthesia if 3+ roots damaged

ii.     Ventral- used to relieve spastic muscles w/ innervation from several roots

f.       Damage to sensory nn

i.     Phantom Pain- irritation to cut stumps of amputated nn localizes pain to missing extremity

ii.     Pain- irritation to nn close to origin; may localize along dermatone

iii.     Radiculopathy- shooting pain that radiates down; assoc. w/ sensory and motor impairment; caused usu by compression or stretching of spinal nn (ex: Sciatica)

iv.     Referred Pain- stimulation of n fibers in one region with localization of pain to another region (w/ dif n) (ex: infarction w/ left arm pain)

II.               Back II

a.     Secondary curvature of spine- devo after birth: cervical curve as baby holds up head; lumbar curve as baby stands and walks

b.     Kyphosis- exaggerated posterior curvature, usu thoracic region; “humpback” usu from osteoporosis

c.      Lordosis- “swayback;” exaggerated anterior curving in lumbar; can be causes by obesity or pot belly; pregnant women get temporarily; fixed with weight loss and/or exercise

d.     Scoliosis- lateral curvature; most common; results from unequal growth of the sides of 1+ verts

i.     Structural- rotation of vert on each other; when bend over @ hip accentuated curvature and elevated scapula

ii.     Functional- compensation for unequal leg length; no vert rotation

e.     Spondylosis- chronic degenerative disease of vert disks and/or bodies; may compress spinal cord, nn, roots; s/t radiculopathies

f.       Vertebral ankylosis- bony fusion w/ calcification and ossification of intervert disks and ligaments; more common to males

g.     Spondylolisthesis- anerior subluxation of lower lumbar verts on sacrum

i.     Spondylolysis- defect in L5 vert where vertebral arch and body separate; anterior fragment and supradjacent L vertebrae displace anteriorly; pain if n roots passing into sacrum compressed

h.     Herniated Intervertebral Disk- nucleosus pulposus protrudes through defect in anulus fibrosus; usu lateral to posterior longitudinal ligament; common at L4/L5 and L5/S1

i.       Hyperextension of Atlantoaxial Joint- may result in rupture of anterior longitudinal ligament and C2/3 disk; separates skull-C2-C3 from rest; likely spinal cord severed

j.       Head first fall- blow to top of head; may split atlas or fracture occipital bone

k.      Broken Neck- fractures and dislocations of cervical verts; can result from sudden forceful flexion, extension, blow to top of head

l.       Severe Cervical Flexion- posterior longitudinal and interspinous ligaments may be torn; spinal cord injury if vert arches/bodies fracture

m.    Spinal Block- anesthesia; inject minute amount of drug into CSF of lumbar cistern to block roots in dural sack; rapid

n.     Epidural anesthesia- inject drugs into epidural space through sacral hiatus; blocks sensation inferior to injection; takes longer and requires more drugs; used for parturition b/c does not affect fetal blood

o.     Laminectomy- surgical exposure of spinal cord by removal of laminae to relieve pressure

p.     Spinal cord transactions- results in loss of all sensation and voluntary movement inferior to lesion

i.     Paraplegia- transaction b/t cervical and lumbar enlargements

ii.     Quadriplegia- transaction superior to C3

q.     Meningiomas- usu slow growing, benign; most common in middle aged to elderly women; common at thoracic spinal cord or foramen magnum; pain, paresthesias, sensory changes; surgical removal

r.       Neurofibromas- arise from dorsal root, grow medially to enlarge intervert foramen; radicular pain; associated with neurofibromatosis (genetic); surgery

s.      Metastases- most neoplasm that compress spinal cord; extradural, malignant; most intradural are benign and slow; most metastatic from carcinomas of breast, lung, prostate, kidney, malignant melanoma

t.       Lumbar Puncture (Spinal Tap)- obtains CSF for diagnostic reasons; lumbar flexion increases interspinous space; insert into lumbar cistern b/t L3/4 or L4/5 into median plane to avoid nerve root damage

u.     Spinal cord ischemia- disruption of blood supplyàweakness or paralysis; may be due to obstructive arterial disease in radicular arteries or surgical ligation of posterior intercostals or lumbar arteries

v.      Metastsis via vertebral venous plexuses- blood return from abdomen and pelvis traverses; route for prostatic or gynecologic tumors to spread to axial skeleton

III.              Imaging

a.     X-rays-

i.     4 tissue densities- black=no density (air); dark grey=low (fat); light grey=medium (soft tissue, h2o); white=high density (bone); densitities only work for similar thicknesses

b.     CT or computed xray tomography- measures xray transmission with more sophisticated technique

i.     Advantages- 20+ grey levels; planar cross-sectional image w/ better depiction of spatial relationships; visualization of certain structures enhaced with contrast media

c.      Problem w/ xray & CT- potential tissue damage; ionization of DNA, cell death or transformation

d.     MRI- protons excited and recovery from excited state monitored; more contrast w/in soft tissue than CT (good for CNS, joints, heart); takes long time to acquire data and sensitive to movement; strong magnetic field dangerous w/ implanted metal devices

e.     Ultrasound reflection- based on differences in conduction velocities b/t tissues (high bone, low air); large change in density reflects sound waves back; tomographic image produced; no ionizing radiation so safe for regnant women and kids; doppler effect can measure rate of blood flow in heart and periph vessels

f.       Scintigraphy- radiotan injected and detected; radiation source coupled to chemicals that collect into specific organs; can use to detect fast growing tumors; ionization can cause tissue damage so isotopes must have short half life

IV.             Upper Extremity I

a.     Clavicle frequently fractured; fracture in middle third results in medial portion lifting up (due to SCM) and the lateral section sliding under

b.     Shoulder separation- damage to coracoclavicular and costoclavicular ligaments

c.      Surgical neck of humerus common site for fractures

d.     Bursitis- results from inflammation of a bursa, a fibrous sac filled with synoviala fluid that prevents friction in joint

e.     Supraspinatus m- initiates abduction; in paralysis may lean to that side or hit arm with hip to initiate abduction

f.       Rotator cuff muscles- (SItS- supraspinatus, infraspinatus, teres minor, subscapularis) source of stability for gelnohumeral joint

V.               Upper Extremity II

a.     Tennis elbow- tendonitis of common extensor tendon at lateral epicondyle

b.     Student’s elbow- bursitis of superficial olecranon brusa from rubbing of elbow

c.      Pulled elbow- usu young children; sudden jerk or pull on pronated forearm tears annular ligament and head of radius slips out of place

d.     Violent upward pull on arm- (falling out of tree) damages Lower trunkof brachial plexus; intrinsic mm of hand (ulnar n) most severely affected;

e.     Neck and should violently separated- (motorcycle fall) upper trunk of brachial plexus damaged; flsion, abduction, lateral rotation impaired; Waiters Tip

f.       Radial N damage- fracture in shaft of humerus near radial groove; weakness of extensors and loss of sensation on posterior side of arm; extension at wrist and mp joints impossibleàWrist drop

g.     Axillary n may damage with fracture to surgical neck of humerus

h.     Neurovascular Compression Syndrome- cervical rib may compress subclavian artery and brachial plexus; results in coldness, numbness and weakness

i.       “Badge” area of shoulder receives sensory enervation from axillary n.

j.       Erb-Duchenne Palsy- “Waiter’s Tip”- most common brachial plexus injury; lesion of upper ROOTS, affects suprascapular n, musculocutaneousn, axillary n; paralyzes all rotator cuff minus subscapularism, biceps, brachialis, coracobrachialis, deltoid; loss of flexors, loss of abduction, rotated b/c subscap unopposed, pronated b/c of loss of biceps

k.      Klumpke’s Palsy- Lower ROOT lesion; affects ulaner and median nn; paralyzes all intrinsic mm of hand; Claw Hand- hyperextension of MP joints and flexion at IP joints

l.       Median N Injury- Thenar mm (minus adductor pollicis) paralyzed; thumb rotates to lie in same plane as digits; patient cannot flex index and middle fingersàHand of Benediction

m.    Ulnar N Injury-

i.     At wrist: intrinsic mm of hand paralyzed, except thenars and first 2 lumbricals; no finger ab/adduction; flexed at IP joints and extended at MP joints being most severein little finger

ii.     At medial eicondyle of humerus: injury common by blows to medial aspect of the elbow

VI.             Upper Extremity III

a.     Carpal Tunnel Syndrome- neurovascular compression of structures deep to flexor retinaculum; impairment of median n and the mm it enervates

b.     Dupuytren’s Contracture- shortening of fibers of palmar aponeurosis; fingers curl into flexion (3^rd and 4^th worst)

c.      Whitlow/Felon- infection of pad of distal phalanx causing pad to swell; often directed deeply into bone

d.     No man’s land- long flexor tendon sheaths b/c surgery difficult and easy to jeopardize vasculature

e.     Common sheath of flexors connects to sheath around small fingeràinfection may spread to forearm; the same is true in the thumb

VII.           Upper Extremity IV

a.     Test integrity of Ulnar N- try to hold paper b/t fingers w/o it being pulled away

b.     Fascial spaces of palm may become infected

VIII.          Radiology of Upper Extremity

a.     Rotator Cuff

i.     Supraspinatis- primary abductor

ii.     Infraspinatis- primary external rotator

iii.     Teres minor- external rotator

iv.     Subscapularis- primary internal rotator

v.     Supraspinatis most frequently injured

vi.     Chronic Injury- can’t lift arm, usu little old ladies; atrophy of cuff (esp supraspinatis); abnormal articulation of humeral head w/ inferior acromion

vii.     Acute- usu athletes; smaller tear of spuraspinatis m from overextension; seen with arthrography (iodinated dye injection) that shows hole which connects capsule and bursa; also seen with MRI (see the defect)

b.     Anterior Shoulder Dislocation (Subcoracoid)- most common; humeral head drops inferiorly and anteriorly

i.     Hill-Sacks Fracture- resultsdeformity from repeated dislocations, notch forms, at risk for more dislocations

ii.     Bankart Fracture- to anterior surface of glenoid fossa, usu soft tissue damage

c.      Posterior Shoulder Dislocation- occurs w/ grand mal seizures, high voltage shock

i.     Trough fracture- opposite of hill-sacks; fracture on anterior humeral head

ii.     Shoulder goes posterior, often missed on films

iii.     Acromioclavicular Separation- injusry to acromioclavicular ligaments and coracoclavicular ligaments with malalignment of acromioclavicular joint; less common

d.     Transverse Farcture of Olecranon- blood in joint causes elevation of anterior fat pad

e.     Monteggia Fracture- fracture of proximal ulna w/ dislocation of radial head due to disruption of annular ligament

f.       Colles’ Fracture- Dinner fork deformity- transverse fracture of distal radius; most common fracture of wrist; req. orthopedic surgery

g.     Lunate dislocation

h.     Dorsal perrilunate dislocation- dorsal dislocation of capitate; lunate remains with normal articulation; due to fall on outstretched hand

i.       Boxer’s fracture- fracture of 5^th metacarpal (little finger); from poor punching technique

j.       Gamekeeper’s Thumb- named for choking game animals; tear of collateral ligament connecting thumb metacarpal with phalanx; allows abnormal abduction of thumb; evulsion fracture (pulls off piece of bone)

IX.             Clinical Correlate of Upper Extermity

a.     Brachial Plexus Surgery- usu for birth injuries, traction injuries (motorcycle or football)

i.     Avulsion- prior to dorsal root acts like spinal cord injury, roots pulled out then not repairable

ii.     Distal to dorsal root ganglion- similar to peripheral nerve injury

b.     Rotator Cuff Surgery- Axillary n at risk when working on deltoid; when rotator cuff mm damaged the work taken over by more powerful mm; to repair split deltoid, follow biceps tendon to supraspinatis tendon

c.      Brachium- use internervous intervals in surgery (split brachialis to get to humerus w/o endangering any nn);

i.     Biceps repair- common in 4yo males; rupture off of radial tuberosity

ii.     Ligament injury- baseball players may destroy medial collateral ligament of inside of elbow; endoscopic surgery of elbow difficult b/c too much stuff to hurt

d.     Wrist- extensor lacerationsàtx longhorn sign when lacerate the common extensors; flexor lacerations- must test each finger individually

e.     Nerves: must repair epineurium, the rest will take care of itself

X.               Neck I

a.     Fascial layers- barrier to fluid flow; hematoma may form as result of trauma or pus as result of infection

b.     Retropharyngeal space- “danger” space- oral region infections (ie abscessed tooth) can track into pericardium and may cause cardiac tamponade

c.      Torticollis- head flexes towards affected side and rotates away; persistent contraction of SCM; infants: prenatal devo of fibrous tumor or damage during birth; adults: neurological origin

d.     Surgery to elements in carotid sheath go through the carotid triangle

e.     Erb’s point- cutaneous nn emerge around middle of posterior border of SCM; can inject anesthesia there or acupuncture;

f.       Trauma to nn in posterior triangle result in loss of function, may be due to knfe or scalpel slip; similar impairment by tumors as base of skull

i.     Spinal Accessory N may be affected and actions of SCM and trap weakened

ii.     Suprascapular n may be damaged by fracture of middle third of clavicle-weakens supra/infraspinatus

g.     Injury to Cervical Plexus- traumatic injury to sensory nn would result in anesthesia of corresponding dermatones;

h.     Reversible Anesthesia during surgery- injected drug along post border of SCM (cervical plexus block); or superior to clavicle (brachial plexus block)

i.       External Jugular Vein- when veinous pressure rises vein visisble along entire course- indication of heart failure, obstruction of SVC, increase in thoracic pressure; easily severed and may allow air to suck in

j.       Subclavian Vein- used to induce catheters for measurement of cardiac pressure of drug delivery; needle insert inferior to clavicle and moved medially along posterior surface of clavicle until penetrate vessel

k.      Thyroid- follicular cells: secrete thyroxin (metabolism); parafollicular cells secrete calcitonin (lower serum Ca levels)

i.     Parathyroid glands- secrete parathyroid hormone that increase serum Ca

ii.     Originates at basae of tongue and descends anterior to hyoid through thyroglossal duct; may not descend (ligual thyroid gland) or may partially remain in duct; do iodine uptake scan b/f surgery to locate all hormone secreting tissue

iii.     Accessory thyroid gland may form on thymus gland

iv.     Enlarged-goiter; may compress underlying structures; surgery or meds

v.     Thyroid Carcinoma- gland enlargement; requires total thyroidectomy; must be careful not to remove the parathyroid

vi.     Convulsive Tetany- occurs w/o parathyroid due to drop in serum Ca

l.       Alternative Airway Procedures-

i.     Controlled Conditions: Tracheostomy- superior to throid isthmus and inferior to cricoid cartilage

ii.     Emergency- Cricothyrotomy- incision through cricothyroid mmb; risks vocal cord damage

XI.             Neck II

a.     Anesthetic to cervicothoracic (stellate) ganglion- may block vascular spasm; negative effect is ipsilateral Horner’s syndrome

b.     Submandibular gland- exocrine; secretes saliva through submandibular duct under the tongue

c.      Root of Neck damage- pneumothorax if injure apex of lung or cupola of pleura

d.     Surgery to root of neck- risks recurrent laryngeal nerve damage; ipsilateral damage causes hoarseness

e.     Injury Zones:

i.     Zone 1- neck inferior to cricoid cartilage

ii.     Zone 2- b/t cricoid cartilage and angle of mandible

iii.     Zone 3-  region superior ot angle of mandible

iv.     Injuries to zones 1 and 3 most serious b/c affect airways

v.     Injuries to zone 2 most common, treated quickly

XII.           Thorax 1

a.     Abdominal viscera (kidneys, spleen, stomach, liver) protected by the ribs

b.     Dermatones overlap- any point covered by at least two spinal nn

c.      Dermatones C5-T1 mainly do upper extremity; nipple @ T4; navel @ T10

d.     Breast Cancer- 1 out of 9 women; 95% derived from ducts and glandular tissue

i.     Tumor on Cooper ligaments- leads to traction on the ligaments and dimpling

ii.     Lymph Drainage- 75%+ drains to axillary nodes; next to parasternal nodes; drainage is possible ini all directions, including collaterally to other breast

e.     Sternum- marros cavity can be accessed via sternal puncture to get the red marrow for diagnostics;

i.     Fractures- common during car accidents; body and manubrium separate at angle and may drive posteriorly and damage aorta; fractures rarely need repair

ii.     Counting ribs- sternal angle articulates 2^nd rib-start counting

f.       Flail Chest- ribs broken in 2+ places; paradoxical movement- chest moves out in expiration and in during inhalation; also happens when sternum breaks from ribs on both sides

g.     Separated rib- disjuncture from costal cartilage; rare in young people

h.     Crush injuries- fracture of rib anterior to angle

i.       Direct Injuries- fracture rib at point(s) of impact

j.       Slipping Rib- costal cartilage from false rib separates and slides over superior costal cartilages

k.      Lung puncture- rib fractures may cause and result in pneumothorax or hemothorax

l.       Cervical ribs- may cause a neurovascular syndrome of brachial plexus and subclavian a; numbness, cold, tingling; aka thoracic outlet syndrome

m.    Lumbar ribs- often mistaken for fractured transverse processes or cause mistake in counting vert level

n.     Middle ribs most often broken; longest

o.     Lateral diameter of chest greatest at rib 8

p.     Thorcocentesis- needle into thorax; insert above superior border of rib (actually into middle of ICS) to avoid van; if done below 7^th ICS careful not to puncture diaphragm

q.     Shingles(Herpes zoster)- viral infection of dorsal root ganglion followed by eruption of vesicles along nn courses; may follow dermatone

r.       Coarctation of Aorta- narrowing distal to left subclavian a; common birth defect; collateral circulation occurs and intercostals aa enlarge and notch the inferior border of ribs

XIII.          Thorax 2

a.     Pyothorax- pus in pleural cavity

b.     Henothorax- blood in pleural cavity

c.      Pleuritis (pleurisy)- inflammation of pleurae; may cause friction and auscultation during breathing; normally very quiet

d.     Pneumothorax- air in pleural cavity; may be spontaneous (nontraumaic) or from penetrating wound that causes a flap to let air in during inspiration but not outàpostive pressure creates emergency

e.     Irritation of central diagphragmatic and mediastinal pleurae- referred pain in lower neck and shoulder

f.       Irritation of peripheral dagphragmatic and costal pleurae- referred to corresponding region of thoracic wall

g.     Oblique fissures- follow 6^th rib and costal cartilage

h.     Horizontal fissure- follows right 4^th rib

i.       Borders of Lung- rib 6 @midclavicular line; vertebral body 10 posteriorly

j.       Carina- landmark on xrays; most distal point of respiratory tree that capable of cough reflex

k.      Lodged objects- right primary bronchus more in line with trachea; most likely location

l.       Resection of bronchopulmonary segement along border of a segement offers least bloody field

m.    Blockage of a segement- segmental atelectasis or collapse

n.     Lymphatic Flow of Lung- important due to high incidence of cancer; bronchogenic carcinoma common; metastisis to brain; supraclavicular nodal enlargement often indicates cancer

XIV.         Thorax 3

a.     Pericarditis- inflammation of pericardial sack; friction rub makes movements audible; pain substernal or referred to left shoulder and arm; may produce large amounts of fluid (pericardial  effusion)

b.     Cardiac Tamponade- effusion builds up and compresses heart, compromises function

c.      Hemopericardium- may result from puncture wounds of heart

d.     Pericardiocentesis- aspiration of fluid from pericardial cavity; insert needle to left of xiphoid process, direct up and backwards at 45 degree angle

e.     Right coronary artery dominant- becomes posterior descending coronary artery in about 70% people

f.       Arteriosclerosis-hardening of the arteries; compromise blood flow to regions of the heart

g.     Atherosclerosis- form of arteriosclerosis from deposits of lipids

h.     Angina Pectoris- classically a pain over the chest and left arm resulting from ischemia to the heart (lack of O2)

i.       Myocardial Infarction- death of a region of heart muscle; severe ischemia

j.       Coronary Bypass- vessel from another region used to bypass a blockage of artery

k.      Angiocardiography- introduction of radio-opaque cmp to visualize pattern of coronary arteries

l.       Auricle-location for surgical entry into heart

m.    Valvular incompetence-regurgiatation or backwards flow of blood; produces a mumur

n.     Valvular Stenosis- narrowing process may result in fusion of valve leaflets of cusps, may be accompanied by arterial enlargement

o.     Probe Patency of Foramen Ovale- common heart defect

p.     Swallow Barium Cmps- to contrast cardiac structures in radiography

q.     Mitral stenosis- left atrium enlarges aand may compres or rdeviate the esophagus and bronchi

r.       Dysphagia- manifestation of left arterial enlargement after heart failure and compress esophagus

s.      ASD (arterial septum defects)- most common with patent foramen ovale; ostium primum defects less common, accompanied often by VSD and or mitral valve abnormalities

t.       Mitral valve is most diseased valve of heart

u.     Left ventricle wall 3x thicker than right

v.      VSD’s present in 50% of all congenital heart defects

w.    Heart valves and sounds

i.     Valves-

1.     Pulmonary- L 3^rd CCàlisten L 2^nd ICS, parasternal line

2.     Aortic- L 3^rd ICSàlisten R 2^nd ICS parasternal line

3.     Mitral- L 4^th CCà listen L 5^th ICS

4.     Tricuspid- R 4^th ICSàlisten 4^th or 5^th ICS parasternal lines

ii.     Sounds-

1.     Lub- closure of tricuspid and mitral valves

2.     Dup- Closure of aortic and pulmonary valves

x.      Cardiac Rhythm- heart has intrinsic rhythm but also conducting system to regulate and control contractions, if system fails heart fibrillates or twithes irregularly; shock defibrillation willnormalize

i.     Cardiac Pacemaker- delivers synchronizing impulse to compensate for damaged conduction system

XV.           Thorax 4

a.     Mediastinoscopy- done to obtain tissue from superios and anterior mediastinal and hilar lymph nodes; bronchogenic carcinoma  metastases here

b.     Dysphagia lusoria- occurs when a retroesophogeal right subclavian artery forms and compresses the esophagus making swallowing difficult

c.      Transposition of Great vessels- devo anomalies; aorta connected to RV and pulmonary artery to LV

d.     Aortic Atresia- ascending aorta reduced in size, ductus arteriosus patent, usu VSD

e.     Dilatation of Aortic root- results in valvular incompetence, often ruptures and aneurysms

f.       Coarctation of Aorta- most common site near ductus or ligamentum arteriosum; can cause notable pulsation in ICS’s and erosion of ribs; narrowing of aorta with increase in size of intercostals aa

g.     Tunica Media of Thoracic Aorta- site of damage in syphilis of aorta; affects aortic valves usu

h.     Any investigation, surgery, injury, disease in superior mediastinum may injure recurrent laryngeal nn

i.       Tracheo-esophageal fistula (TEF)- due to association during devo; atretic esophagus, etc; surgical correction; most often at level of carina

j.       Vertebral Veinous Plexus- azygous veinous system connects and conduit for infection

k.      Thoracic Duct- if lacerated during surgery lymph may escape into pleural cavity (chylothorax); fluid removed by thoracocentesis or duct ligated

l.       Aneurysms of Aorta- can be replaced with Dacron grafts, common in deceleration injuries (car wrecks); usu tear of ligamentum arteriosum

m.    Cystic Medial Necrosis of aorta- breakdown of collagen, elastin, and smooth muscle results in loss of integrity of elastic tissue; precursor to aortic dissection

n.     Aortic Dissection- most common; untreated 33% results in death during first 24 hours

i.     First few cm of aorta; 90% w/in 10 cm of aortic valve; next most common site is distal to L subclavian

ii.     Diseases that weaken wall predispose

iii.     More common in males

iv.     Chest pain; ripping or tearing with abrupt onset

v.     Syncope and altered mental status

vi.     Change in BP; hypertension from catecholamine surge; hypotension from cardiac tamponade or hypovolemia from rupture of dissection

vii.     New diastolic murmur, asymmetrical BP may also indicate

viii.     Other causes: pregnancy, syphilis, crack cocaine

ix.     75% in age 40-70, peak 50-65

o.     Esophageal varices- devo in portal hypertension; subject ot ruture and hemorrhage; usu occur at the gastroesophageal junction

XVI.         Clinical Correlate of thorax

a.     Dextrocardia- occurs w/ abnormal devo looping of heart; apex points right instead of left

b.     Anatomic LV- has tricuspid valve

c.      Anatomic RV- has mitral valve

d.     Sidus rerversus- positioning of anatomical RV on the left and vice versa

e.     Mebranous VSD- LàR shunt; symptoms may present shortly after birth or years later; most common; shortness of breath ad pulmonary hypertension are symptoms; some spontaneous closure

f.       ASD-

i.     inadequate formation of septum primum of septum secundum (foramen ovale or ostium secudum defect) present symptoms later in life;

ii.     inadequate formation of endocardial cushions (lower asd/ ostium primum defect)

iii.     Sinus venosus defect- inadequate incorporation of sinus venosum into primitive atrium; rare

iv.     AV Canal Defect- VSD, single AV valve, and ostium primum defect; ften fatal neonatally

g.     10% Dominant Left Circulation- with small right coronary atery

h.     Sudden cardiac death w/ exercise- increased flux of blood increases pulse pressure and compresses ostium of right coronary artery

i.       most hearts have posterior descending artery deriving from R coronary a

j.       Coronary Artery that give rise to PDA will supply AV conducting system; from the R coronary artery 90% of time

k.      Artery to SA node- 60% from proximal right coronary a; 40% from circumflex artery

l.       Coronary Heart Disease- abnormality of coronary aa leading to impairment of myocardial blood flow

i.     Major cause is arterial atherosclerosis; must be 75% blocked for problems; plaques cause thrombus, acute coronary heart disease and myocardial infarction

m.    Rheumatic heart disease- strep infection can lead to mitral stenosis; fishmouth valve= slit-like opening

n.     Congenital bicuspid artic valve- progressive scarring, calcification leads to aortic stenosis and impairment of circulation

XVII.       Radiology of Thorax

a.     Lungs-

i.     Normally adiolucent

ii.     The only normally visible soft tissue are blood vessels

iii.     Bronchography- contrast material introduced into bronchi

iv.     Patient’s age and degree of inspiration make difference into radiographic appearance

1.     6mo baby has wide mediastinum due to large thymus

2.     6yo child starting to normalize

3.     adult- cardiothoracic ratio under 50% of transverse diameter of chest

v.     mediastinal mass suspected when widening of mediastinum or displacement of normal air containing structures

vi.     Heart valves are not seen unless calcified or artificial; middle valve is aortic, directly posterior is mitral, lowest valve iss tricuspid

b.     Mediastinal Diseases-

i.     Anterior -Thynoma, Teratoma, Terrible lymph nodes, Thyroid

ii.     Middle- lymph nodes aortic aneurysm, Bronchogenic or pericardial cysts

iii.     Posterior- neurogenic tumors of peripheral nn or sympathetic ganglia

c.      Pleura- normally have 2-5 cc’s o pleural fluid

i.     Normally not visible with radiograph, except fissures b/c fissures made of two layers of visceral pleura

ii.     Calcifications in pleural space- may be result of healed TB empyema, remote pyothorax, remote hemothorax, or asbestos in related pleural dsease

Cranial Nerves I

Olfactory Nerve (CN I)

• Progressive loss of the sense of smell in the elderly is usually due to a reduction in the number of receptors in the olfactory epithelium. Loss of smell (anosmia) is usually unilateral and should be tested one naris at a time.
• In severe head injury, the olfactory bulbs can be torn away from the olfactory nerve or the olfactory nerve can be torn within a fractured cribiform plate. This can lead to unilateral or bilateral anosmia.
• Clinical testing for anosmia: one nostril at a time using pungent compounds, e.g., ammonia.

Optic Nerve (CN II)

• Since the retina and optic nerve develop from the optic vesicle, an outgrowth of the brain, the optic nerve is actually a CNS tract rather than a true cranial nerve.
• Disruption of the optic nerve and optic chiasm results in characteristic visual field losses. Disruption of one optic nerve leads to blindness in that eye. Disruption of the optic chiasm, often from tumors of the pituitary gland, leads to loss of the temporal visual fields from both eyes.
• Clinical testing of CN II: Many syndromes present with loss of peripheral visual fields. Others show central field losses. Color vision is also tested.
• Automated visual field testing may be used.

Oculomotor Nerve (CN III)

• Ptosis (dropping) of the upper eyelid is caused by paralysis of the levator palpebrae superioris m.
• Loss of pupillary reflexes is caused by damage to CN III
• Dilatation of the pupil is due to the interruption of the parasympathetic fibers to the iris.
• Loss of accommodation of the lens is due to paralysis of the ciliary m.
• The eyeball is abducted and directed slightly inferiorly due to the unopposed action of the lateral rectus and superior oblique muscles.
• Clinical testing of accommodation includes pupillary constriction, lens relaxation, and binocular convergence.

Trochlear Nerve (CN IV)

• Injury to CN IV and thus paralysis of the superior oblique results in diplopia. This is most severe when gaze is directed inferomedially. Thus patients with CN IV injury have difficulty walking down stairs. To counteract this, they hold their heads up and inclined to the other side.

Trigeminal Nerve (CN V).

• Clinical testing of cutaneous sensation by light stroking of each dermatome and orbital contents.
• Clinical testing of motor functions evaluated by chewing movements and jaw asymmetries.
• See Trigeminal neuralgia (tic douloureux) in Face Lecture

Abducens Nerve (CN VI)

• Injury to the abducens nerve results in medial strabismus (convergent squint) and thus, diplopia.

Facial Nerve (CN VII)

• See Bell’s palsy in Face Lecture. Complete lesions of the facial nerve lead to facial paralysis, loss of taste from the anterior 2/3 of the tongue on one side, and decreased salivation.
• Clinical testing of motor, viscero-motor (salivation and lacrimation and special sensory) taste. Examine facial tone, asymmetries. Test for taste defects on anterior 2/3 of tongue – Test for salivation and tearing.

Cranial Nerves II

Vestibulocochlear Nerve-CN (VIII)

• Lesions of the vestibulocochlear nerve may result in tinnitus (ringing or buzzing in the ears), impairment or loss of hearing, and loss of balance. These symptoms are frequently associated with acoustic neuromas, which are the most common form of intracranial tumor.
• Clinical testing: Major hearing loss or tinnitus. Difficulty in hearing in crowd may indicate unilateral hearing loss.

Glossopharyngeal Nerve-CN (IX)

• Lesions of the glossopharyngeal nerve result in a loss of the gag reflex.
• Glossopharyngeal neuralgia results from a lesion of CN IX. This manifests itself as severe pain beginning in the throat, radiating along the side of the neck, near the anterior part of the auricle, and posterior aspect of the mandible.
• Clinical testing: Gag reflex. Reduced salivation (parotid gland).

Vagus Nerve-CN (X)

• Lesions of the vagus nerve after it leaves the skull are rare. More often injury of its medullary nuclei or injury within the skull leads to palpitation of the heart, tachycardia, slowing of respiration, and sensation of suffocation. Injury outside the skull, although rare, can lead to paralysis of the soft palate (say Ah-) and larynx, hoarseness, and anesthesia of the larynx.

Accessory Nerve-CN (XI)

• Clinical testing: Examine shoulder strength and asymmetry.

Hypoglossal Nerve-CN (XII)

• Unilateral lesion of the hypoglossal nerve results in unilateral paralysis of the tongue and its eventual atrophy.
• Clinical testing: When the tongue is protruded, it will deviate towards the affected side due to the unopposed action of the intact side.

Face and Scalp

Facial Skeleton

• About 8% of adults have the inferior part of the metopic suture unfused. This may be mistaken as a fracture.
• Since the face has no distinct deep fascia and the superficial fascia between the cutaneous attachments of the facial muscles is loose, facial lacerations tend to gape. Consequently, the skin has to be sutured with great care to prevent scarring.
• The looseness of the superficial fascia also enables blood to accumulate in the loose connective tissue following injury leading to “black eye”.

Ophthalmic Nerve (CV V1)

• Herpes zoster ophthalmicus (shingles) is a viral infection of the face supplied by the ophthalmic nerve. As such the cornea is often involved. Spread of infection within the orbit to cranial nerves III, IV, and VI lead to partial paralysis of their associated muscles.

Maxillary Nerve (CN V2)

• Local anesthesia of the middle face is often accomplished by local anesthetic infiltration of the infraorbital nerve in the infraorbital foramen. The foramen can be localized by pressure on the maxilla that causes acute pain. Care must be taken to prevent injection of anesthetic agents into the infraorbital artery or vein.
• Trigeminal neuralgia (tic douloureux) is a condition characterized by sudden attacks of excruciating pain that are initiated by touching one of the skin fields innervated by the trigeminal nerve, often of the maxillary nerve. The causes of trigeminal neuralgia are unknown.

Mandibular Nerve (CN V3)

• None listed in syllabus
• Facial Nerve (CN VII)

• Bell’s palsy refers to paresis (weakness) or paralysis of the facial muscles with no obvious injury. This may occur following inflammation of the facial nerve at the stylomastoid foramen. Patients with Bell’s palsy cannot close their eye on the affected side, whistle or chew correctly. Since the buccinator muscle is weakened, food and saliva drip out of the mouth. Facial distortion occurs due to the unopposed actions of muscles on the opposite side of the face.

Vasculature of the Face

• The danger area of the face describes a region centered on the midline nose and eyes whose venous drainage communicates with the cavernous sinus of the brain. Thus, patients with thrombophlebitis of the facial vein (inflammation with clot formation) may shed clots that enter the cavernous sinus or cranial veins.

Scalp

• The first three layers are referred to as the scalp proper and usually remain together during injury or surgery to the scalp.
• Scalp lacerations bleed profusely due to the extensive anastomotic network of communicating arteries in the scalp. Infections of the scalp are potentially dangerous because scalp emissary veins communicate with the venous sinus system of the cranium.

Cranium

Meninges

• The dura is sometimes called the pachymeninx (Greek for thick membrane). The pia and arachnoid together are referred to as the leptomeninges (Greek for slender membranes). When clinicians refer to piarachitis, leptomeningitis, or meningitis, they are referring to the same syndrome, the inflammation of the pia-arachnoid.
• The dura is loosely attached to the calvarium but firmly attached to the base of the skull. Thus blows to the head can detach the dura from the calvarium, whereas a fracture to the base of the skull usually leads to a tear of the dura and resultant leakage of CSF into the nose, ear, or nasopharynx.

Dural Sinuses

• Because the cavernous sinus envelopes the internal carotid artery in the middle cranial fossa, fractures at the base of the skull that tear the internal carotid may lead to arterial blood rushing into the venous system. This is known as an anteriovenous fistula. In this case, arterial blood is forced into the ophthalmic veins, which causes the eye to bulge (exophthalmos) and the conjunctiva to become engorged (chemosis). The eye will pulse in synchrony with the radial pulse and thus this condition is known as pulsating exophthalmos.
• V₃ innervates majority of dura lining the lateral skull via nervus spinosus
• The posterior fossa (inferior) is innervated by C2 and C3 via CN X and CN XII.
• V₁ innervates midline portions of anterior cranial fossa via branches of anterior ethmoidal nerve. V₁ also innervates tentorium via recurrent meningeal branch.
• V₂ innervates lateral portions of anterior fossa and anterior portions of middle fossa.

Arterial Supply to the Brain

• Stroke or cerebrovascular incident refers to the sudden loss of circulation into a region of the brain, either due to hemorrhage or occlusion. Hemorrhagic stroke follows the rupture of an artery or aneurysm. Thrombotic stroke results from an embolis (Greek for plug) getting trapped in a small artery. Emboli may be blood clots, aggregations of platelets, or gas bubbles. Transient ischemic attacks (TIAs) often result from soft emboli that either disintegrate or slowly pass through small arteries.

Parotid, Temporal, and Infratemporal Fossa I & II

Temporomandibular Joint

• The mandible is relatively easily fractured by strong blows, as might occur during a fall. Because of the U-shape, a blow to one side will frequently produce a second fracture on the contralateral side. The neck of the mandible is particularly vulnerable due to the capsule of the TMJ, which restrains movement of the head. In contrast, fractures of the coronoid process are uncommon. Fractures of the neck of the mandible frequently involve a dislocation of the TMJ as well. Fractures of the body and angle may be accompanied by fractures of teeth.
• A key functional property of the TMJ is its intrinsic mobility. Extreme movement, however, results in dislocation. In particular, when the mandible is depressed, the head is at the peak of the articular tubercle, and has no bony support. Excessive contraction of the lateral pterygoids, such as during a yawn or a large bite, may cause anterior dislocation. Similarly, when the mandible is depressed, a strong blow can easily dislocate the TMJ. Once the head passes anterior to the tubercle, the actions of most muscles of mastication will reinforce the dislocation. Therefore, it may be necessary to administer a muscle relaxant before reduction. Posterior dislocation is uncommon due to the structure of the postglenoid tubercle and the supporting ligaments.
• One common problem is clicking (crepitus) of the TMJ on elevation and depression of the mandible. This appears to be due to abnormalities of the articular disk.
• Problems in TMJ function have been associated with a number of maladies, particularly headaches and toothaches, but insurance companies tend not to reimburse for this treatment strategy.

Arterial Supply

• Problems The pulse of the superficial temporal artery can be palpated as the artery crosses the root of the zygomatic process of the temporal bone, just anterior to the auricle. This pulse is relatively weak compared to the carotid or radial pulses, but is useful when these other sites are inaccessible. For example, an anesthesiologist at the head of an operating table may measure the temporal pulse when the rest of the body is draped.

Venous Drainage

• Anastomoses of the pterygoid venous plexus with the facial vein and cavernous sinus represent an important potential pathway for the spread of infection. Normally, blood from the medial angle of the eye, nose and lips drains down through the facial vein. Veins in the head, including those of the pterygoid venous plexus, do not have valves, however. Infections may therefore reverse the flow of blood into the cavernous sinus, resulting ultimately in meningeal infections.

Parotid Gland

• Like the submandibular gland, the parotid gland secretes saliva into the oral cavity. Fluid is carried to the oral cavity through the parotid duct. The parotid duct opens to the oral cavity at the second upper molar.
• An accessory parotid gland may be present. It lies anteriorly over the masseter muscle, between the parotid duct and zygomatic arch. Its ducts connect directly to the parotid duct.
• The parotid gland is important anatomically because of the large number of important structures that are embedded within it. These include: the external carotoid artery, the maxillary artery (not shown), the retromandibular vein, the facial nerve and the auriculotemporal nerve (not shown).

Nerve Supply

• The pathways described above are significant clinically because they help describe the consequences of interrupted nerve function, due either to anesthesia or injury. For example, the region of tissue to be anesthetized will determine the site of injection. To numb all branches of CN V3 (mandibular nerve), a needle is passed through the mandibular notch to the roof of the infratemporal fossa. To numb the mandibular teeth for a dental procedure, anesthetic is injected at the lingula of the mandible to block the inferior alveolar nerve. If the needle passes too far posteriorly, it may anesthetize branches of CN VII coursing through the parotid gland. The skin and mucous membrane of the lower lip, the gingivae, and the skin of the chin are also anesthetized because the mental nerve innervates them. To block just the mental nerve (e.g. to place a suture in the skin of the chin), anesthetic is injected into the mental foramen. To anesthetize the cheek, injection should be made into the mucosa covering the retromolar fossa, located posterior to the 3^rd mandibular molar.
• Lesions of branches of the trigeminal nerve, through penetrating injury, compression by tumor, etc., will follow a similar pattern. Especially informative is the interruption of autonomic function due to postganglionic parasympathetic fibers carried by branches of CN V.
• Trigeminal neuralgia (tic douloureux) is a sensory disorder in which the patient experiences strong paroxysmal pain in regions innervated by the maxillary and mandibular branches of CN V. It is thought to be due to the presence of an anomalous artery that compresses the root of the nerve. Symptoms can frequently be alleviated by surgically moving the artery.
• Branches of the facial nerve pass through the parotid bed and the gland itself, and are therefore subject to traumatic injury. Injury to the nerve distal to the stylomastoid foramen will paralyze muscles of facial expression, but not autonomic function or special sensation. Injury of CN VII within or anterior to the parotid gland will result in more circumscribed motor deficits.

Orbit

Bony Orbit

• Since the medial wall and floor of the orbit are so thin, a blow to the eye, which causes an increase in pressure within the orbit, may cause a blowout fracture. This often causes the contents of the orbit to sink into the maxillary sinus, often causing double vision.
• Due to the close proximity of the optic nerve to the sphenoid and posterior ethmoid sinuses, tumors within them can erode their thin walls and compress the optic nerve. Tumors in the orbit produce bulging of the eye, exophthalmos.

Eyelids

• In third nerve palsy, the upper eyelid droops (ptosis) and cannot be raised. This is due to damage of the superior subdivision of the oculomotor nerve (CN III) which innervates the levator palpebrae superioris muscle. Damage to the facial nerve (CN VII) results in the inability to close the eyelids due to paralysis of the orbicularis oculi muscle.
• Injury to the facial nerve (e.g. Bell’s palsy) can result in a person unable to blink their eyes. This leaves the cornea lacking the protection of tears. Inflammation of the ciliary glands can lead to red swelling known as a sty on the eyelid.
• Horner’s Syndrome: interruption of the cervical sympathetic trunk results in ptosis due to paralysis of the superior tarsal muscle, constricted pupil, sinking of the eye, redness, dryness, and increase in temperature on the affected side of face.

Testing Extraocular Muscles

• Look superiolaterally to test the action of the superior rectus muscle.
• Look inferolaterally to test the action of the inferior rectus muscle.
• Look superiomedially to test the action of the inferior oblique.
• Look inferomedially to test the action of the superior oblique.
• Look medially to test the action of the medial rectus.
• Look laterally to test the action of the lateral rectus.

Nerves of the Orbit

• If sensory innervation of the cornea is disrupted, the cornea can be injured by foreign matter that goes unnoticed and can abrade the cornea and produce corneal ulcers.

Vasculature of the Orbit

• Cataract:
  • loss of transparency of the lens
• Complete CN III palsy:
  • ptosis, dilated and non-reactive pupil, eyeball is fully abducted and depressed due to unopposed action of lateral rectus and superior oblique.
• Diplopia:
  • Double vision, often due to paralysis of one or more extraocular muscles.
• Horner’s Syndrome:
  • interruption of the cervical sympathetic trunk results in ptosis due to paralysis of the superior tarsal muscle, constricted pupil, sinking of the eye, redness, dryness, and increase in temperature on the affected side of face.
• Proptosis or exophthalmos:
  • bulging of the eye often due to tumors of the orbit.
• Presbyopia:
  • gradual loss of focusing power due to hardening and flattening of lens
• Pupillary light reflex:
  • sensory information from the retina is relayed via CN II to the midbrain (bilateral) to innervate the Edinger-Westphal n; parasympathetic outflow via CN III terminates in the ciliary ganglion which causes the paupillary sphincter to contract. Lesions along this pathway can lead to loss of direct light reflex (same eye) or consensual light reflex (opposite eye).
• Blink reflex:
  • Sensory stimulation of cornea is transmitter via CN V₁. Reflex loop in brainstem initiates motor outflow via the facial nerve (CN VII) to constrict the orbicularis oculi muscle. The lid is then opened via CN III which innervates the levator palpebrae superioris.
• Vestibular-ocular reflex:
  • Rotation of the head (tilt) is signaled via CN VIII. Signals arising in midbrain and cerebellum are relayed to the oculomotor system, to help maintain the vertical alignment of the eye.

Ear

Auricle

• Bleeding within the auricle from trauma may produce an auricular hematoma. If untreated, the hematoma could interrupt blood supply to the auricular cartilage, resulting in fibrosis. This is the cause of “cauliflower ears” that occurs in wrestlers and boxers.
• Trauma from cosmetic procedures that pierce the skin may lead to infection (otitis externa). The auricles of swimmers who do not dry the meatus can also become infected. Pain is felt in the auricle, and is increased by pulling.

Tympanic Membrane

• The external acoustic meatus and tympanic membrane are examined with an otoscope. This instrument is essentially a conically shaped magnifying glass with a light at the end. The external meatus is generally slightly curved. To provide the best access for the otoscope, the auricle is generally pulled posterosuperiorly before insertion.
• The light from the otoscope will reflect in a “cone of light” from the umbo through the anterior inferior quadrant. This reflection is usually called the “light reflex.” Shadows of the ossicles in the middle ear can be seen through the membrane. The manubrium of the malleus (“handle”) is visible particularly at its inferior attachment at the umbo. The long process of incus may also be seen posterior to the handle.
• Perforation of the tympanic membrane may result from middle ear infection, trauma or excessive pressure. The membrane is also pierced to drain the middle ear (myringotomy). Incisions are generally made posteroinferiorly to minimize the risk of injury to the chorda tympani nerve and the ossicles. The inferior half of the membrane is also less vascular than the superior half, minimizing trauma to the membrane. Small perforations of the membrane will heal spontaneously, but larger lesions may require surgical repair.

Boundaries of the Middle Ear

• One of the main causes of earache, especially in children, is otitis media. The middle ear is susceptible to infection through the auditory tube, which opens into the nasopharynx. In children, the auditory tube is short and straight, facilitating the spread of infection. In the otoscope, the sign of otitis media is a bulging red tympanic membrane. Occasionally, the fluid level of accumulated pus is visible. If untreated, hearing may be impaired due to scarring of the ossicles, restricting their ability to conduct sound to the inner ear.
• Middle ear infections can spread into the mastoid antrum and air cells. From there, infections may spread superiorly into the middle cranial fossa through the petrosquamous fissure and infect the bone of the tegmen tympani. Surgical access to the mastoid process is generally through the posterior wall of the external acoustic meatus. A surgical approach to the middle ear is through the mastoid air cells. Care must be taken, however, not to damage CN VII as it traverses the facial canal.

Auditory Tube

• Normally the walls of the tube are closely apposed, and it takes time for air pressure to equalize across the membrane. Consequently, relatively sudden changes in external pressure (such as ascending a mountain in a car, or descent in an airplane) can result in a pressure differential across the tympanic membrane. This results in limited movement of the membrane, difficulty hearing and a sensation that the ears are plugged. To eliminate this sensation, the tube is opened by actions of the tensor and levator palati muscles, which are activated by yawning or swallowing.
• The most common complaint of divers is middle ear barotrauma. Inability to equalize pressure causes painful stress to the tympanic membrane. At deeper depths, the membrane may rupture. Subsequent exposure of the middle ear to cold water can induce dizziness through stimulation of the inner ear.
• The auditory tube is a common pathway for the spread of infection from the nasopharynx to the middle ear, resulting in otitis media. Over time, residual air may be absorbed into the blood vessels of the mucosa lining the tympanic cavity, and a pressure differential may develop. Mucosal inflammation could impede opening of the auditory tube, preventing equalization and impeding hearing.

Nerve Supply to the Inner Ear

• It is important to distinguish between hearing deficits due to injury of inner ear and middle ear structures. The former (called sensorineural hearing loss) is due to a deficit in the cochlear duct or central neural structures. High tone deafness is one form of sensorineural hearing loss that results from persistent exposure to excessively loud sounds (rock musicians commonly suffer this deficit). The deficit is due to degenerative changes in the spiral organ of the cochlear duct. Sensorineural deficits are difficult to repair, although significant advances have been made in development of prosthetic devices that directly stimulate the cochear nerve.
• The latter (called conductive hearing loss) can be remediated more successfully, e.g. by cleaning out earwax or replacing an ossicle.
• Damage to the semicircular canals results in a sensation of vertigo, which is a hallucination of movement such as spinning or swaying. The lack of information from vestibular organs does not by itself produce vertigo. Rather, it is the confused processing of all position information (including visual and kinesthetic sensation) within the brain that produces the symptoms.
• Ménière syndrome can induce both hearing loss and vertigo, as well as tinnitus (persistent buzzing or ringing sensation). This syndrome is caused by blockage of the cochlear aqueduct and the consequent increase in volume of endolymph. The increased pressure affects the ability of maculae, ampulae and the spiral organ to function properly.
• Acoustic neuroma is a slow growing tumor of Schwann cells (i.e. those cells responsible for the “white matter”) that usually occurs at the base of the brain where CN VII and VIII emerge. The tumor generally begins within the vestibular component of CN VIII, although loss of hearing is generally the first sign of tumor growth. Thus, while the vestibular and cochlear components of CN VIII are functionally independent, peripheral lesions to either component will generally involve both.

Pharynx

Boundaries and Divisions of the Pharynx

Nasopharynx

• When the tubal and pharyngeal tonsils are enlarged, they are known as adenoids and may be of sufficient size to obstruct breathing through the nose. Also, because ‘adenoids’ may prevent the opening of the auditory tube, they may affect hearing because of the gradual absorption of air in the middle ear.
• The competency of the auditory tube is often affected by infections that enlarge the tubal and pharyngeal tonsils. Because tonsillar tissues tend to shrink after puberty, it is of most concern in children.
• Pharyngeal recess: Most of nasopharyngeal cancers start in this recess.

Oropharynx

• The nerve and arterial relations of the palatine tonsils are important due to the relative frequency of surgical procedures.
• The palatine tonsils reach their maximum normal size in early childhood. After puberty, they gradually atrophy. The palatine tonsils are common sites of infection, and if they become inflamed, the condition is termed tonsillitis.

Laryngopharynx

• Clinically the piriform recess is important, because it is a common site for the lodging of foreign bodies, such as fish bones.

Tonsillar Ring (Waldeyer’s Ring)

• The upward regions of the pharynx are blessed with an abundance of lymphatic tissue, and distributed in a more-or-less ring-like manner and is thought to be an obstacle for the spread of infection. This is called Waldeyer’s ring, and is the circle of lymphoid tissue that `protects’ the opening of the pharynx. It consists of the pharyngeal tonsils, tubal tonsil, palatine tonsil, and lingual tonsils.

Muscles of the Pharynx

• Infections originating in the paratonsillar region can easily spread into the thorax through the retropharyngeal space. In the worst case, the result would be infection of the pericardial sac, resulting in cardiac tamponade.

Nerve Supply

• The integrity of the pharyngeal portions of IX and X is typically tested by movement of the soft palate and the ‘gag’ reflex.

Muscle Action Innervation Stylopharyngeus Elevate the thyroid cartilage IX Superior constrictor Sequential constriction X, via the pharyngeal plexus Middle constrictor Sequential constriction X, via the pharyngeal plexus Inferior constrictor Sequential constriction X, via the pharyngeal plexus

Larynx

Nerve Supply

Muscle Action Innervation Thyroepiglotticus Close the inlet Recurrent Laryngeal Aryepiglotticus Close the inlet Recurrent Laryngeal Oblique arytenoid Close the inlet Recurrent Laryngeal Thyroarytenoid Relaxation of vocal folds Recurrent Laryngeal Posterior cricoarytenoid Abduction of vocal folds Recurrent Laryngeal Lateral cricoarytenoid Adduction of vocal folds Recurrent Laryngeal Transverse arytenoid Adduction of vocal folds Recurrent Laryngeal Cricothyroid Stretching and tensing of the vocal fold External Branch of Superior Laryngeal Vocalis Regional tensing of the vocal ligament Recurrent Laryngeal

• Occasionally the mucous membrane of the larynx becomes inflamed, and the vocal folds may not function normally. As a consequence, the voice may become hoarse (laryngitis), sometimes with coughing.
• During surgery, one of two unfortunate things can happen. The external branch of the superior laryngeal nerve, which supplies the cricothyroid muscle, may be damaged. In such an event, the cricothyroid muscle cannot stretch the vocal ligament on the affected side. This results in a lack of overall tenseness along the vocal ligament and consequently the patient typically complains of ‘tiredness’ and ‘hoarseness.’
• The second common complication is destruction of the recurrent laryngeal nerve. When unilateral, the quality of the voice is poor because the vocal ligament on the affected side cannot be abducted or adducted. When bilateral, there may be severe respiratory distress that may require a tracheotomy to save the patient.

Nasal Cavity

Skeletal Framework and Boundaries

• Fracturing of the cribiform plate in the anterior cranial fossa may cause CSF to leak into and out of the nasal cavity (CSF rhinorrhea).

Paranasal Sinuses

• An inflammation of the paranasal sinuses is termed sinusitis. Because the mucosa of sinuses is continuous with the mucosa of the nasal cavity, the infection may spread from the nasal cavities to the sinuses. Occasionally, the sinusitis may further spread to the neighbouring structures, such as orbit, cranial cavity, etc.
• The maxillary sinus is the most important one clinically because this is the only one drained poorly by gravity. The reason is that its ostium into the middle meatus lies high up on its medial wall. Consequently, infections do not drain well and take longer to treat. The maxillary molar teeth have a close relationship with the floor of the maxillary sinus. Their roots may project into the sinus, and, thus a sinus infection may come from the infection of a tooth or the oral cavity.

Blood Supply

• While nosebleeds (epistaxis) are common in the region of the vestibule, most serious bleeding typically is from rupture of the sphenopalatine artery just after it enters the nasal cavity. These nosebleeds may be difficult to control.
• Kiesselbach’s area is located in the anterior part of the nasal septum. Here the blood vessels of the nasal cavity anastomose, and it is where most nasal bleeding occurs.

Oral Cavity

Tongue

Muscles of the Tongue

• If the genioglossus muscle is functioning bilaterally, the tongue will protrude only to the midline. The integrity of CN XII can be conveniently tested by asking the patient to stick their tongue out as far as possible. In a hypoglossal nerve paralysis, only the unaffected side operates, and the tongue is projected to the side of the lesioned nerve.

Nerve Supply of the Tongue

• With respect to taste sensation, damage to the lingual nerve can lead to an ipsilateral impairment of taste in the anterior two-thirds of the tongue, but rarely does such a lesion obliterate taste sensation because there are other taste buds on the posterior 1/3 of the tongue which is innervated by CN IX. In any event, when a patient presents with a complaint of a change in taste, always investigate olfaction since much of our appreciation of taste is really tied to our sense of smell.

Salivary Glands

• Mumps is caused by a virus infection (parotiditis). Typically, it develops swellings in one or both of the parotid glands. Mumps is painful because the parotid sheath (tough fascial capsule) limits swelling. The parotid duct may also be infected by the mumps virus, producing redness of the parotid papilla (orifice of the duct. Usually the redness of papilla is an early sign that the disease involves the gland and not a tooth.

Lymphatics

Components of the Lymphatic System

• Sometimes, lymphatic vessels become inflamed due to a bacterial infection. This condition is called lymphangitis. When this happens in the superficial lymphatic vessels, painful reddish streaks may appear beneath the skin. The lymph nodes along this lymphatic vessel usually become greatly enlarged and painful, and this condition is called lymphadenitis.
• Since the lymphatic vessels tend to carry particles away from tissues, these vessels may also transport cancer cells and promote their spread to other sites of the body (metastasis). So knowledge of the regional lymphatic drainage is important in the diagnosis and treatment of metastatic lesions.

Drainage of Specific Structures and Areas

Lymphatic Drainage of Tongue

• The drainage from the tongue deserves special mention because of the frequency with which this structure in involved in cancerous conditions.
• The anterior two-thirds of the tongue typically drain into submental nodes and submandibular nodes, but may also bypass these pericervical nodes to drain directly into the deep cervical nodes.
• The posterior one-third of tongue drains into the deep cervical nodes directly.
• Drainage from the central portions of the tongue may drain bilaterally, and this is especially the case for the tip of the tongue. This fact can make managing the spread of cancer particularly difficult, as essentially the entire neck can be involved.

Lymphatic Drainage of the Teeth

• Maxillary: drain to the buccal nodes
• Mandibular: drain posteriorly through mandibular canal to the deep cervical chain.

Lymphatic Drainage of Nasal Cavity, Sinuses and Nasopharynx

• The anterior part of the nasal cavity drains to submandibular nodes. The posterior nasal cavity, sinuses and nasopharynx drain directly to the deep cervical chain, or indirectly via the parotid nodes and retropharyngeal nodes to the deep cervical chain.

Lymphatic Drainage of Pharynx and Esophagus

• Drainage of the pharynx and esophagus is to the retropharyngeal nodes, paratracheal nodes or directly to the deep cervical chain

Lymphatic Drainage of Larynx and Trachea

• The lymphatics of the larynx above vocal folds drain directly to the deep cervical chain. The larynx below the vocal folds drain to the pretracheal and paratracheal nodes or directly to the deep cervical chain.

Larynx/Clinical Correlates (Head & Neck/Temporal Bone)

• These have no bulleted clinical correlates…but don’t neglect to read them!

SPINA BIFIDA

Failure of formation of posterior arch

Spina bifida occulta – benign except for tuft of hair over lumbar region

Meningocele – if meninges extend out of the canal into the defect

Meningomyelocele – if cord is involved

Rachischisis – several or all vertebrae have no posterior arch

KYPHOSIS

Exaggerated posterior curvature, in thoracic region

A humpback – osteoporosis

LORDOSIS

Exaggerated anterior curvature in lumbar region

A swayback – precipitated by obesity, temporary in pregnant women

SCOLIOSIS

Lateral curvature – results from unequal growth of the 2 sides of 1 or more vertebrae

SACRAL HIATUS

S5  and sometimes S4, lack laminae and spinous process — bony channel that allows hypodermic needles access to the inferior vertebral canal

OSTEOPEROSIS TYPE 1

Postmenopausal women; loss of endogenous estrogen leads to severe decrease in vertebral bone density – dowager’s hump

-        presents as a vertebral compression fracture

-        can be prevented or slowed by hormone replacement therapy

SPONDYLOSIS

-        chronic degenerative disease of intervertebral discs and/or vertebral bodies

-        presents as radiculopathies

SPONDYLITIS (ankylosing spondylitis)

-        bony fusion with calcification and ossification of intervertebral discs and ligaments (males)

SPONDYLOLISTHESIS

-        anterior subluxation of the lower lumbar vertebrae on the sacrum

-        results from defect in the L5 vertebrae – vertebral arch and body are separate bones

-        results in pain if nerve roots passing into sacrum are compressed

HERNIATED VERTEBRAL DISC
– nucleus pulposis protrudes through defect in annulus fibrosis

-        symptom is pain – depends on spinal cord level and compressed neural tissue

OSTEOPHYTES
– by excrescence; bone fragments may compress spinal cord or nerve roots

-        may result from sudden forceful flexion, extension, or a violent blow to the top of the head

-        spinal cord may be severed if there is sever hyperextension resulting in the rupture of the anterior longitudinal ligament and C2/C3 intervertebral disk separates the skull

-        in a hard blow to the crown of the head, force transmitted along vertebral axis may split the axis or fracture the occipital bone

RADICULOPATHY

-        shooting pain that radiates down one/both legs in a dermatomal distribution

-        sensory and motor impairment

-        caused by compression or stretching or spinal nerves/roots

SCIATICA

-        pain resulting from irritation of the sciatic nerve

-        compression or trauma to sciatic nerve

SPINAL CORD TRANSCECTION
– loss of all sensory and voluntary movement inferior to the spinal cord lesion

1.     Paraplegia – paralysis of lower body; transcection between cervical and lumbosacral enlargements

2.     Quadriplegia – paralysis of all 4 limbs; transection superior to C3

METASTASIS via vertebral venous plexuses

-        venous blood returns from pelvis through vertebral venous plexuses – route for cancer cells from prostatic or gynecologic tumors to spread

SPINAL CORD ISCHEMIA
– disruption of blood supply to the spinal cord

-        weakness or paralysis due to muscle denervation

NEOPLASMS

-        compress spinal cord, nerves or root

-        most benign and slow growing

1. MENINGOMAS – slow growing and benign

o   middle aged women; posterior spinal cord affected

o   surgical removal

3.     NEUROFIBROMAS – arise from dorsal root

a.     Enlarge the cervical foramen

b.     Treatment is surgical

4.     Metastases

a.     Carcinomas of breast, lung, prostate or kidney

SPINAL TAP – LUMBAR PUNCTURE

-        obtain CSF

-        needle inserted into lumbar cistern between spinous processes of L3/L4 or L4/L5

STRAIGHT LEG RAISE TEST

-        diagnostic for intervertebral disc disease; low back pain that radiates down the leg

-        elevation of affected leg relieves the pain

-        elevation of opposite leg increases the pain

-        dorsiflexion of foot exacerbates the pain

SCOLIOSIS SCREENING

-        patient bends forward; abnormal curvature is accentuated and scapula elevated on convex side

-        functional scoliosis – compensation for unequal leg length; vertebral rotation disappears with forward flexion

MYELOGRAPHY

-        radiopaque substance that is injected into the dural sac

-        allows visualization of intradural masses

SPINAL BLOCKS

-        spinal anesthesia injected into the CSF of the lumbar cistern

-        blocks the nerve roots in the dural sack

-        requires minute amount of drug solution

EPIDURAL ANASTHESIA

-        anesthetic agent injected into epidural space; has to diffuse though meninges to act on nerve roots and spinal cord

-        blocks all sensation inferior to site of injection

-        requires long time to take effect, much greater volume of drug solution

LAMINECTOMIES

-        surgical exposure of spinal cord by removal of laminae of vertebral arches

-        relieves pressure on neural structures from bony fragments, protruding intervertebral discs, tumors or hemotomas

WINGING OF THE SCAPULA

-        damage to long thoracic nerve, results in paralysis of serratus anterior

-        protrusion of the inferior angle of scapula

-        C 5, 6, 7 keep your wings out of heaven

-        Nerve can be injured by direct trauma or carrying heavy weights on shoulder; inadvertently transected in mastectomy

BURSITIS

-        inflammation of bursa

-        subdeltiod, supraspinatus, infraspinatus, subscapularis bursae

PARALYSIS OF SUPRASPINATUS

-        only muscle to initiate abduction

-        individual may lean to afflicted side or knock the upper extremity laterally with the hip to initiate abduction

LESION OF UPPER ROOTS (C5&6) – ERB-DUCHENNE PALSY – WAITERS TIP

-        nerves affected: suprascapular, musculutaneous, axillary

-        muscles paralyzed – all of rotator cuff except subscapularis, biceps, brachialis, coracobrachialis, deltoid

-        effect – arm hangs limply, medially rotated by unopposed subscapularis, pronated due to loss of biceps, loss of abduction

LESION OF LOWER ROOTS (C8 AND T1) KLUMPKE’S PALSY

-        nerves affected: ulnar and median

-        muscles paralyzed: all intrinsic muscles of hand

-        effect: clawed hand, due to hyperextension of MP joints and flexion of digits by forearm flexors unopposed by interossei

WRIST DROP

-        injuries to radial nerve, extension of hand and MP joints is impossible

-        PIP and DIP extension is normal

APE HAND

-        median nerve injury

-        thumb rotates to lie in the same plane as the fingers

ULNAR CLAW HAND

-        ulnar nerve injury at the wrist

-        fingers are flexed at DIP and PIP joints, extended at MP due to unopposed actions of extensors

-        most pronounced at the little finger – gradually less towards the index finger

TRUE CLAW HAND

-        median and ulnar nerve injury at the wrist

-        all digits are flexed at IP joints, extended at MP joint

-        in addition, the thumb is rotated into the same plane as the fingers

WHITLOW / FELON

-        infection in the pad of the distal phalanx which causes the pad to swell

CARPAL TUNNEL SYNDROME

-        neurovascular compression of structures deep to the flexor retinaculum

-        diagnosed by noting impairment of the median nerve and the muscles it innervates

-        thumb most affected

-        division of retinaculum to release the structures is recommended

DUPUYTRNE’S CONTRACTURE

-        shortening of fibers of the palmar aponeurosis so that fingers curl into flexion with the 3^rd and 4^th usually affected the 1^st and the worst

-        palmaris longus is absent

* Scaphoid most commonly fractured bone of the wrist

Lunate easily dislocated during hyperextension – lunate and triquetrum may fuse

ANTERIOR (SUBCORACOID DISLOCATION OF THE SHOULDER)

-        Hill-Sacks impaction fracture of the posteriorosuperior head

-        Bankart fracture of the anteriorinferior surface of the gleniod fossa

POSTERIOR SHOULDER DISLOCATION

-        Trough fracture – impacted fracture of the anterior humeral head

-        Acromioclavicular separation – injury to the acromioclavicular ligaments and coracoclavicular ligaments with malalignment of the acromioclavicular joint

ROTATOR CUFF TEAR

-        Chronic – atrophy of the rotator cuff with abnormal articulation of the humeral head with the undersurface of the acromion

-        Acute – smaller tear of the suprapsinatus tendon – abnormal communication between the shoulder joint and the subacromial  subdeltiod bursa

ELBOW PATHOLOGY

- Transverse Fracture of the Olecranon = blood in the joint causing  elevation of the anterior fat pat and visualization of the posterior fat pad

-        Mildly depressed fracture of the radial head causing elevation of the anterior fat pad and visualization of the posterior fat pad

-        Monteggia fracture – fracture of the proximal ulna with dislocation of the radial head from the radio-capitellar joint

HAND AND WRIST PATHOLOGY

-        Colle’s Fracture - transverse fracture of the distal radius with or without associated fracture of the distal ulna

-        Lunate Dislocation – volar dislocation of the lunate bone; articulations with all adjacent carpal bones are disrupted

-        Dorsal Perilunate Dislocation – dislocation of capitate bone with the lunate retaining its normal articulation with the distal radius

-        Boxer’s Fracture – transverse or oblique fracture of the distal small finger metacarpal

-        Gamekeeper’s Thumb – tear of the ulnar collateral ligament that connects the thumb metacarpal  with the proximal phalanx

o   Allows abnormal abduction of the proximal phalanx of the thumb

OSTEOARTHRITIS
– hypertrophic spurring a the distal and proximal interphalangeal joints

-        cartilage loss

-        Preservation of bone mineral

-        Heberden node – cutaneous manifestation of hypertrophic spurring at the distal interphalangeal joint

-        Bouchard node – cutaneous manifestation of hypertrophic spurring at the proximal interphalangeal joint

RHEUMATOID ARTHRITIS

-        periarticular arthritis (bone loss)

-        erosions at the margins of the proximal interphalangeal (PIP) and metacarpal phalangeal (MCP) joints

-        cartilage loss

-        ulnar subluxation of the metacarpophalangeal joints

-        symmetric distribution (involves both hands equally)

ELBOW TENDINITIS/TENNIS ELBOW

-        painful musculoskeletal condition that follows repetitive use of the superficial extensor muscles of the forearm

-        pain experienced over lateral epicondyle

EPICONDYLITIS

-        repeated forceful flexion and extension at the wrist strain the common tendon attachment and may produce inflammation of the epicondyle

MALLET FINGER

-        sudden severe tension on a long extensor tendon which may avulse part of its attachment to the phalanx

-        cannot extent distal interphalangeal joint

TENOSYNOVITIS

-        inflammation of the tendon and synovial sheath

-        i.e. puncture from a rusty nail

-        digit swells, movement painful

-        inflammation usually contained to that digit

-        but, if neglected sheath may burst and spread the infection to the common sheath

-        first dorsal compartment synovitis = De Quervain’s disease

-

* Bleeding profuse in the palmar arch when lacerated

* Surgery in hand may require compressing brachial artery and branches proximal to the elbow

RADIAL NERVE PALSY
– IP joint will extend even though the extrinsic extensors are not functioning, causing one

to miss the diagnosis of a radial nerve lesion

BOUTONNIERE DEFORMITY

-        digital imbalance characterized by pip joint flexion and dip joint hyperflexion

-        occurs after loss of continuity in central band of extensor mechanism

SWAN NECK DEFORMITY

-        complex disbalance of the digit where volar structures of the pip joint are stretched either as primary cause of the deformity or as a result of the imbalance

WEBER 2 POINT DISCRIMINATION TEST & WRINKLING TEST
– examinations for sensations in the hand

ALLEN’S TEST

-        assess blood supply to the hand

-        compressing radial and ulnar arteries and then releasing to record capillary refill time

-        normal range is less than 6 seconds

HYPOTHENAR HAMMER SYNDROME

-        trauma to the ulnar artery when hypothenar eminence is used to hammer large objects

-        results in thrombosis

RAYNAUD’S PHENOMENON

-        state of temporary ischemia of the hand triggered by cold temperature or other stimulus and secondary to a particular disease

-        Ray’s  disease event of unknown cause

DISLOCATION OF THE ACROMIOCLAVICULAR JOINT

-        not uncommon in contact sports

-        shoulder separation

-        serious when both the acromioclavicular and coracoclavicular ligaments are torn

-        makes acromion more prominent

AVULSION OF THE MEDIAL EPICONDYLE

-        children

-        results from a fall that causes severe abduction of the extended elbow (abnormal movement of this articulation)

-        traction on the ulnar collateral ligament pulls the medial epicondyle distally

TRACTION INJURY OF THE ULNAR NERVE
– frequent complication of the abduction type of avulsion of the medial epicondyle

-        passes posterior to the medial epicondyle before entering the forearm

POSTERIOR DISLOCATION OF THE ELBOW JOINT

-        when kids fall on their hands with their elbows flexed

-        distal end of humerus is driven through the weak anterior portion of the fibrous capsule as the radius and ulna dislocate posteriorly

PULLED ELBOW

-        incomplete dislocation of the head of the radius

-        when kids lifted by arms with pronated forearm

TRACTION OF COOPER’S LIGAMENTS (in breast)

-        caused by a tumor

-        can lead to dimpling of the skin

* Sternum has a marrow cavity for sternal puncture for aspiration of red marrow

STERNAL FRACTURES
– car accidents

-        body separates at angle of Louis and driven posteriorly – damaging or rupturing aorta or braches

-        painful, but don’t need repair

STERNAL ANGLE

-        marks articulation with 2^nd rib

FLAIL CHEST

-        results from a rib broken in 2 or more places

-        corresponding section of chest wall moves outward in expiration and inwards during inspiration – wrong way!!

-        May also occur if sternum broken from ribs on both sides

-        Hypoxia seen with this is due to bruised lung

CRUSH INJURIES = fracture the rib just anterior to the angle of the rib

DIRECT INJURIES (to the rib = fracture the rib at the points of impact

SLIPPING RIB

-        distal portion of a costal cartilage from a false rib separates from the costal margin and overrides the superior costal cartilages

PNEUMOTHORAX = air in the pleural cavity

HEMOTHORAX = blood in pleural cavity

THORACIC OUTLET SYNDROME

-        cervical ribs compress the brachial plexus and subclavian artery

-        causes coldness, numbness, tingling in upper extremity

-        surgery needed when cervical rib is the cause

* Middle ribs most commonly fractured; longest; most securely attached

THORACOCENTESIS

-        introduction of needle into the thorax

-        above superior border of the rib not to jeopardize the intercostals neurovascular bundle

-        if below 7^th ICS, don’t puncture diaphragm

COARCTATION

-        narrowing of the aorta just distal to the origin of the left subclavian artery

-        common birth defect

-        intercostals arteries will enlarge and produce an erosion or notching of the inferior border of the ribs

SHINGLES/HERPES ZOSTER

-        viral infection of the dorsal root ganglion

-        eruption of vesicles along the course of the nerves – mapping the dermatomes

-        pain precedes vesicles

EMPYEMA

Pyothorax = pus in thorax cavity

Chylorthorax = lymphatic fluid in pleural cavity

PLEURITIS/PLEURISY

-        inflammation of the pleurae

-        causes friction and results in auscultation of pleurae during breathing

• Irritation of the central diaphragmatic and mediastinal pleurae results in Referred Pain in the shoulder and lower neck

HERNIATION/ INADVERTENT PUNCURE

-        can happen at contralateral pleural cavity during surgical procedure

-        left and right parietal pleura contact each other at a minimum of 2 points – retrosternally and in the posterior mediastinum in Truesdale’s Traingle

ENDOTRACHEAL TUBE

-        positioned using the carina

-        most distal point of the respiratory tree capable of the initiation of a cough reflex

FOREIGN BODY LODGING

-        most likely place in the right primary bronchus

• Resection of bronchopulmonary segment along the border of a segment offers the least bloody field

• knowledge of direction of tertiary bronchioles and bronchopulmonary segments important for:

• proper positioning of patient to encourage drainage of lung segments or to predict route of drainage

LYMPHATIC FLOW and CANCER

-        lymph from left inferior lobe may normally cross to the right

-        cancer of a bronchus, or bronchogenic carcinoma ( BC) is common

-        usual site of metastasis is the brain

-        B.C. – sentinel nodes often enlarged

PANCOAST’S SYNDROME

-        caused by bronchogenic carcinoma of the cupola of the lung

-        compresses structures at the thoracic inlet

-        affects sympathetics to the head and compresses major vessels

-        results in paresthesias and paresis of arm and hand

-        wasting, pain and Horner’s Syndrome

-        surgically treatable after preoperative irradiation to the area

SUPERIOR VENA CAVA SYNDROME

-        caused by a right-sided bronchogenic carcinoma in the hilar region

-        compresses and compromises venous return in SVC

-        causes edema and redness of upper chest, neck and face

-        upon elevation, veins of upper extremity do not empty

Landmarks

Adductor Canal – the space in middle third of the thigh between the vastus medialis and adductor muscles, converted into a canal by the overlying sartorius muscle. It gives passage to the femoral vessels and saphenous nerve, ending at the adductor hiatus.

Adductor Hiatus – the aperture in the aponeurotic insertion of the adductor magnus that transmits the femoral artery and vein from the adductor canal to the popliteal space.  The nerve to the vastus medialis and saphenous nerve do not pass through the hiatus.  [NAVEL]

Hesselbach’s Triangle – the triangular area in the lower abdominal wall bounded by the inguinal ligament below, the border of the rectus abdominis medially and the inferior epigastric vessels (lateral umbilical fold) laterally. It is the site of direct inguinal hernia.

Femoral Sheath – the fascia enclosing the femoral vessels, formed by the transversalis fascia anteriorly and the iliac fascia posteriorly; two septa divide the sheath into three compartments, the lateral of which contains the femoral artery and the femoral branch of the genitofemoral nerve, the middle the femoral vein, and the medial is the femoral canal.

Femoral triangle – a triangular space at the upper part of the thigh, bounded by the sartorius and adductor longus muscles and the inguinal ligament, with a floor formed laterally by the iliopsoas muscle and medially by the pectineus muscle; the branches of the femoral nerve are distributed within the femoral triangle; it is bisected by the femoral vessels, which enter the adductor canal at its apex.  Site for femoral hernias.

McBurney’s Point – 1/3 the point between ASIS and Umbilicus

Popliteal Fossa – bounded by semimembranosus, biceps femoris, lateral and medial head of gastrocs

Rectus Sheath – sheath of the rectus abdominis, formed by the aponeuroses of the three anterolateral muscles of the abdominal wall that split to enclose the rectus and fuse medially to form the linea alba; it consists of an anterior lamina and a posterior lamina, the latter being absent below the arcuate line.

Abdominal Cavity

Use the 4 quadrant system, not the 9 system

Trunk Flexors: external oblique, internal oblique, rectus abdominis

Uracus – fibrous remnant of fetal allantois that becomes part of median umbilical fold from apex of bladder to the umbilicus

Transverse incisions through the rectus abdominis provide good access to the viscera and cause the least possible damage to the nerve supply of the muscle

Median abdominal incisions are good because they course rapidly through the linea alba without cutting major vessels or nerves

Gridiron incision in abdominal flank for appendectomies; Subcostal incisions made for gallbladder exposure

Surface incisions should be made in the direction of Langer’s cleavage lines

Deep and superficial inguinal rings do not overlap because of the oblique path of the inguinal canal.

-The ilioinguinal nerve exits the superficial/external ring but doesn’t pass through the deep one

1.     Direct inguinal hernias – gut protrudes through Hasselbach’s triangle; seen in older men

2.     Indirect – a portion of the gut protrudes through the deep inguinal ring and continues through the inguinal canal (75% of all inguinal hernias)

Vasectomy (deferentectomy) – bilateral trans-sectioning and ligation; sperm degenerate in the epididymis and proximal end of the vas deferens

The peritoneal cavity usually exists as a potential space because the organs are packed so closely

Peritoneal cavity is completely closed in men

It communicates with the exterior of body via fallopian tubes, uterus and vagina

Under pathological conditions the peritoneal cavity may be distended with several liters of fluid (ascites)

The greater omentum prevents the visceral peritoneum from adhering to the parietal peritoneum

Gastro-Instestinal

Referred pain from the diaphragm is felt in two different areas:

1.     The shoulder  in irritation of the diaphragmatic pleura and diaphragmatic peritoneum (C5)

2.     The skin over the costal margin of anterior abdominal wall in irritation of perf regions

Diaphragmatic hernias often through the Foramen of Bochdalek in left PL portion

Gastric ulcers may be controlled by a vagotomy or selective vagotomy to remove parasympathetic innervation of the stomach and decrease acid secretion

A chronic ulcer may perforate posteriorly, adhere to the pancreas and cause pancreatitis

Hiatal hernia – stomach herniating through the diaphragm;

Sliding – gastro-esophageal region slides into the chest when the patient lies down/bends over

Rolling – where the fundus and sac of peritoneum rolls into the thorax

The inferior recess of the omental bursa is a potential space – communicates the greater and lesser omentum through the epiploic foramen of Winslow

Congenital pyloric stenosis due to hypertrophy of the pylorus is not an uncommon problem

Celiac Trunk: supplies liver, pancreas, stomach, duodenum and spleen

1.     Left Gastric

2.     Splenic A.: Short Gastric Arteries, L. gastroomenal

3.     Common Hepatic: L/R Hepatic A.; Gastroduodenal → R. gastroomental, Right Gastric

Meckel’s Diverticulum – a persisten vitelline duct

Appendicitis – acute abdominal pain; digital pressure over McBurney’s point, dull para-umbilical pain that develops into severe RLQ pain

Spleen is the most frequently injured organ in the abdomen in blows to the left side

Liver: 30% of blood from hepatic artery, 70% from portal vein

Ø  Liver biopsy is usually from a needle puncture through the right 10^th IC space at midaxillary line

Ø  Liver is often torn by a fractured rib that perforates the diaphragm

Ø  Caudate lobe is palpable, bare area is in the Quadrate lobe

Lymph Drainage of Intestines First 2cm of the duodenum has mesentery and is mobile; the rest is retroperitoneal -Diverticula of the duodenum are common, especially due to the SMA -Often associated with pancreas, GB, liver → inflammations/erosions easily spread amongst them -Lymph will drain into the surpa-pancreatic then celiac nodes → CISTERNA CHYLI -Lymph from Jejunum-Ileum drain into mesenteric nodes → SM Nodes → CISTERNA CHYLI

Retroperitoneum

Diaphragmatic Openings

1.     Caval Hiatus (T8): transmits IVC and right phrenic

2.     Esophageal Hiatus (T10): formed by a sling from the right crus; esophageal vagal nerves, left esphagel gastric artery

3.     Aortic Hiatus (T12): transmits aorta, thoracic duct, azygos vein

During their “ascent” the embryonic kidneys receive their blood supply and venous draininage from successively more superior vessels than inferior vessels

Fat around the kidney is important.  Its absence can cuasee the kidneys to descend inferiorly, possibly mobilizing and constricting the ureters

Kidney stones often stuck on top of ureters at the iliac bifurcation

Hydronephrosis – dilation of the kidney, one possible result of an obstruction due to a lodged stone

Horseshoe kidney – a single kidney fused across midline (most common anomaly)

Greater (T5-T9), Lesser and Least Splancnics from Thoracic Trunk; Pelvic Splancnics from S2-S4

PARA: Vagus and Sacral spinus nerves

Postganglionic PARA fibers arise out of Meissner’s and Auerbach’s plexi within the organs

Renal Cell Carcinoma: Tumor within capsule, invasion of perinephric fat/gerota’s fascia, invasion of regional lymph nodes/IVC, distal metastases

Retroperitoneal Radiography:

1.     Plain films – preliminary study to reveal pathology; KUB is no contrast of kidneys, ureters & bladder

2.     Fluoroscopy – contrast medium swallowed to study GI, can detect lesions projecting into the lumen (polyps or tumors) as well as outpouchings projecting out from the lumen (diverticula)

3.     Angiography – intravenously or intra-arterially; to check for sources of bleeding and neoplasms

4.     CT – usually with barium contrast; used for more definitive evaluation of the solid organs and spaces of abdomen and pelvis

5.     Ultrasound – extremely valuable for studying gallbladder, pancreas, liver and spleen

6.     MRI – no radiation; becoming competitive with CT for Dx of liver, pancreas and pelvis

7.     Nuclear Radiology – good for evaluation of cholecystitis, biliary obstruction, GI bleeding, Meckel’s diverticulum; especially useful if patient is allergic to iodine and thus cannot have an abdomina CT

Lymphatic Drainage Radix of mesentery – may be trapped Left lateral paracolic gutter – phrenicolienal   ligament may limit flow somewhat Lesser sac – may not escape Right lateral paracolic gutter favored in perforated duodenal ulcer Right anterior phrenicohepatic recess of ruptured gallbladder, duodenum Left anterior phrenicohepatic recess for drainage from perforated stomach and spleen Right posterior phrenicohepatic recess from right paracolic gutter Left posterior phrenicohepatic recess from perforated stomach

Pelvis/Perineum

MALE FEMALE False pelvis                             narrow & deep                  wide & shallow Pelvic inlet                              heart-shaped                    transverselyoval Pelvic outlet                            narrow & oblong               roomy & round Ischial tuberosities                  inverted                            everted Pelvic cavity                            narrow & deep                  roomy & shallow Sacrum                                   long, narrow, convex        short, wide, flat Subpubic angle                       angular & acute                round & wide

False Pelvis (pelvis major) is superior to the pelvic inlet

True pelvis (pelvis minor) is the bony canal through which the fetus passes during birth

During pregnancy the vertebropelvic ligaments relax because of the influence of hormones, making freer movements between the inferior part of the vertebral column and the pelvis

Pelvis/Perineum: Continued

During childbirth the levator ani supports the fetal head while the cervix of the uterus is dilating to permit delivery of the fetus; weakening of the levator ani from stretching or tearing during childbirth may cause urinary stress incontinence

The rectum begins at the rectosigmoid junction; is 12-15 cm in the adult

Ø  The superior 1/3 of the rectum is covered by peritoneum anteriorly and laterally

Ø  Middle 1/3 is covered by peritoneum anteriorly only

Ø  Lower 1/3 has no peritoneal covering

In females the cervix of the uterus and the lateral fornices of the vagina take the place of the seminal vesicles and prostate

Cancer of the testis – mets (up spermatic cord)to the lumbar and preaortic nodes

Cancer of the scrotum – mets to the superficial inguinal nodes

Cremasteric reflex – ilioinguinal nerve acting on the skin on medial aspect of superior thigh

Pudendal nerve (ventral rami of S2-S4) innervates all of pelvis/perineum

Internal Iliac – vascularizes the pelvis/perineum

1.     Anterior Division

a.     Obturator artery – lateral wall of the pelvis → will enter obturator canal

b.     Umbilical artery – gives off superior vesical arteries

c.      Inferior vesical artery – posterolateral wall of bladder

d.     Internal pudendal artery – passes through greater sciatic foramen near ischial spine

i.     Perineal artery – gives off muscular branches → transverse perineal and scrotal/labial branches

ii.     Dorsal artery of penis/clitoris

iii.     External pudendal artery – skin & superificial fascial of external genitalia

iv.     Deep dorsal vein

2.     Posterior Division

a.     Iliolumbar – supplies iliacus, posterior abdominal wall

b.     Lateral sacral – lateral border of sacrum

c.      Superior/Inferior gluteal – enters gluteal region via greater sciatic foramen

The superior rectal is a continuation of the IMA

Superficial Perineal Pouch: contains the corpus spongiosum and caverosa, superifical transverse perineal muscle, bulbospongiosus and ischiocavernosus

In males it surrounds the penis and scrotum

In females it is split by the vestibule and confined to each side of labia majora

Urogenital diaphragm = deep perineal pouch

Contains the transverse perineal ligamentl, deep transverse perineal muscle and urethrovaginal sphincter in females and sphincter urethrae in males

External Iliac – will vascularize lower limb

Lower Limb

Terrible triad – medial meniscus, ACL, MCL

Positive Drawer Test – ACL, PCL rupture

Fractures of femoral head and neck

Ø  Often associated with the medial circumflex femoral artery

Ø  Dislocations usually superio-posterior direction; affected limb appears shorter because the dislocated femoral head is more superior than on the normal side

When a person is standing, the venous return of the leg depends largely on muscle contraction of triceps surae

The ankle is most often injured at the anterior talofibular ligament & the calcaneofibular

Potts’ Fracture – forceful eversion of foot that causes a fractured medial malleolus and a spiral fracture of the fibula on the other side

Hammer toe – proximal phalanx of hallicus is permanently dorsiflexed at the MP joint and the middle phalanx is plantarflexed at the IP joint

Flatfeet in adolescents and adults – are caused by fallen medial arches, usally the spring ligament

Anterior tibial artery – becomes the dorsalis pedis artery

Posterior tibial artery is palpated with knee fully flexed, is absent in about 15% of the people

Ø  Passes posterior to the medial malleolus and splits to become the medial and lateral plantar arteries

Ø  Wounds that involve the plantar arterial arch (lateral plantar + deep plantar from dorsalis pedis) result in severe bleeding

Achilles’ Tendon (Calcaneal) – tendons of gastrocs, plantaris + Soleus

Ø  Rupture of the calcaneal tendon usually results in abrupt pain in the posterior aspect of the leg

Ø  Tested in ankle reflex/ankle jerk test

Ø  If the S1 nerve root is cut or compressed, the ankle reflex is virtually absent

Tennis leg – painful calf injury resulting from partial tearing of the medial belly of the gastrocs at or near its musculotendinous junction

Superficial Group: GN, S + P – posterior tibial artery, popliteal artery, fibular artery; all by tibial nerve

Deep Group: Pop, FHL, FDL, T Pos – Tibial nerve, popliteal, posterior tibial and fibular arteries

True ankle joint – synovial; tibial/fibular/talo joint for flexion and extension only

Talor joints – gliding; very little motion

Subtalar joint – inversion/eversion; posterior talocalcaneal & talocalcaneonavicular joints

Gait: center of gravity just anterior to S2 @ 55% body height; requires non-rigid, non-parallel legs, pelvic tilt and rotation, knee flexion at 15%; figure-8 gliding of hip moves 2 in² in the coronal plane.

I.

A.     A whitlow or felon is an infection in the pad of the distal phalanx which causes the pad to swell.  The retinaculae cutis create a closed space, and as a result, the infection is often directed deeply to the bone

B.     Fibers of the interosseous membrane run from the radial side proximally to the unnar side distally.  As a result, they act as a shock absorber by transmitting of energy from the wrist to the radius, from the radius to the ulna and from the ulna to the humerus

C.    Carpal tunnel syndrome is a neurovasculcar compression of structure deep to the flexor retinaculum  and is diagnosed by noting impairment of the median nerve and the muscles it innervates.  The thumb is the most affected.  Division of the retinacullum to release the structure is recommended.

D.    Dupuytrne’s Contracture is a shortening of fibers of the palmar aponeurosis such that the fingers curl into flexion with the third and fourth usually affected the first and worst.  The palmaris longus is frequently absent.

E.     Due to frequency of lacerations around the wrist, it is important to know the order of tendons and neurovascular structure.  It would be embarrassing to reconnect the extensor digitorum tendon proximally to the indicis proprius distally

F.     The scaphoid the most commonly fractured bone of the wrist.  The lunate is easily dislocated during hyperextension.

G.    The long flexor tendon sheaths are known as ‘No mans land’ an area where surgery is difficult and blood supply is easily jeopardized.  Arrangement of the common sheath in the palm and the sheath around the small finger explains why an infection in that finger can spread to the forearm.  The long flexor of the thumb has it own long sheath and infections may also spread from the thumb to the forearm.

H.    The upper roots of the brachial plexus supply the fore proximal muscles; the lower roots supply the more distal, the segmental innervation of the skin does not correlate with the supply of the muscles beneath.

I.       Elbow tendonitis is a painful musculoskeletal condition that may follow repetitive use of the superficial extensor muscles of the forearm.  Pain is experienced over the lat. Epicondyle.

J.      Epicondylitis- repeated forceful flexion and extension at the wrist strain the common tendon attachment and my produce inflammation of the epicondyle.  Pain is usually cause by inflammation of the common extensor attachment of the muscles.

K.     Mattlet finger- this deformity results from the distal interphalangeal joint suddenly being forced into extreme flexion.  This avulves the attachment of the tendon into the base of the distal phalanx.  As a result, the patient cannot extend the distal interphanlangeal joint.

L.     Dupuytren’s contracture- a progressive fibrosis of the palmar aponeurosis, resulting in shortening and thickening of the digital bands.  These shortened bands pull the digits ( esp. 4 and 5) into varying degrees of fixed flexion.  The digits cannot straighten without corrective surgery on the palmar aponeurosis.  The potential fascial spaces of the palm may become infected.  Untreated infection can spread proximally from them through the carpal tunnel into the forearm

M.    Tenosynovitis- inflammation of the tendon and synovial sheath.  The digit swells and movement becomes painful.  Because the tendon of the second, third, and fourth digits nearly always have separate synovial sheaths, the infection is usually confined to the infected digit.  In neglected infection, however, the proximal ends of these sheaths may rupture, allowing the infection to spread to the midpalmar space.  Because the synovial sheaths of the thumb and fisth digit are continuous with the common flexor synovial sheath, tenosynovitis in these digits may spread to the common sheath.

N.    To obtain a bloodless surgical operating field in the hand, the brachial art. and its braches proximal to the elbow must be compressed using a pneumatic tourniqet.  These procedure prevents blood from reaching the arteries of the forearm and hand through the anastomoses around the elbow.

O.    Median nerve

1.     In attempted suicides by wrist slashing, the median nerve is injured.  This results in paralysis off thenar muscles and first two lumbrical.  Opposition of thumb is not possible, and fine control movements o f 2^nd and 3^rd digits impaired.  Also a loss of sensation over thumb and adjacent two and one-half digits.

2.     median nerve in jury in the elbow region- results in loss of flexion ofprox. And dist. Interphangeal joints of 2^nd and 3^rd digits.  Ability to flex the metacarpophalngeal joints of these digits is also affected.

3.     pronator syndrome- caused by entrapment and compression of median nerve in elbow region.  Symptoms include pain and tendernessin proximal aspect of ant. forearm.

4.     severence of recurrent branch of median nerve- lies superficially- can paralyze the thenar muscles

5.     severence of median nerve in forearm or wrist- thumb cannotbe opposed; however abductor pollicis longus and adductor pollicis may imitate opposition

P.     Ulnar nerve

1.     injuries commonly occurs where nerve passes posterior to the nedial epicondyle of the humerus.  Occurs when elbow it’s a hard surface and epicondyle is fractured.  May result in extensive mortor and sensory loss to hand with impaired power of abduction.

2.     upon flexing the wrist joint the hand is drawn to the lateral side by the flexor carpi radialis.  After ulnar nerve injury, patients are likely to have difficulty making a fist because of paralysis of most intrinsic hand muscles.  They cannot flex their fourth and fifth digits at the distal interpahangeal joints.  This results in a ‘clawhand’

3.     compression of the ulnar nerve may occur at the wrist near where it passes between the hood of the hamate and the pisiform.  Result in hypoesthesia in the medial and one-half digits and weakness of intrinsic muscles of hand.

Q.    Radial nerve

1.     in jury in arm or forearm-paralysis of extensor m. of forearm and inability to extend wrist.  Hand is flexed at wrist and lies flaccid, a condition known as wrist-drop.   Digits are also flexed at the metacarpophalangeal joints.

2.     severance of deep branch of radial nerve-inability to extend thumb and metacarpophangeal joints of other digits.  No loss of sensation occurs because the deep branch of radial n. is entirely muscular and articular in distribution.

3.     severance of superficial branch of radial nerve.- loss of sensation on post. Surf.  of forearm, and proximal parts of lat. Three and one-half digits.

Tags: Acromioclavicular, Angiocardiography, Bankart Fracture, Bursitis, Carpal Tunnel Syndrome, Cervical Flexion, Clavicle, Colles, CT, Dorsal, Dysphagia lusoria, Henothorax, Herniated Intervertebral Disk, Hill-Sacks Fracture, Hyperextension of Atlantoaxial, Klumpke's Palsy, Kyphosis, Laminectomy, Lordosis, Lumbarization, Meningiomas, Meningocele, Meningomyelocele, Metastases, Metastsis, Monteggia, MRI, Neurovascular Compression Syndrome, oronary Artery, Paraplegia, perrilunate, Phantom Pain, Pleuritis, Quadriplegia, Rachischisis, Radiculopathy, Rhizotomy, Rotator cuff, Sacralization, Scintigraphyl, scoliosis, spina bifida, Spondylosis, Subscapularis, Supraspinatis, Supraspinatus, Thorcocentesis, Vertebral ankylosis

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