100 Concepts Anatomy

TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information.

Understand first, then memorize and apply

l

l

100 must important GA conceptions

l

l

Dr. Mavrych, MD, PhD, DSc Dr. Bolgova, MD, PhD

Dr. Mavrych, MD, PhD, DSc [email protected]

Dear students, you can use this presentation like a guide during your preparing for GA exams. It does NOT cover all material of the Gross Anatomy course. To complete GA material you should work with ALL professor’s presentations. Good Luck and All the best! Dr. Mavrych


1. Lumbar puncture (tap) and Epidural anesthesia When lumbar puncture is performed, the needle enters the subarachnoid space to extract cerebrospinal fluid (CSF) or to inject anesthetic to epidural space. l The needle is usually adults inserted between L3/L4 or kids L4/L5. Level of horizontal line through upper points of iliac crests. l Remember, the spinal cord may ends as low as L2 in adults and does end at L3 in children and dural sac extends caudally to level of S2. l

Spinal cord ends L2: Conus Medullaris End Dura Sac S2: Cauda Equina w/ Filum terminale


8 cervical SN (above) 12 thoracic SN 5 lumbar SN (below body) 5 Sacral SNs 1 coccygeal SN

l

l

PLL l l

ALL

1

2

5

6* 10*

Conus medullaris Cauda Equina w/ FT

7

dura matter 7 subdural spac subd space 8 Arachnoid matter 9

Dr. Mavrych, MD, PhD, DSc [email protected] Lamina= front smooth of arches Pedicles= attachment of bodies to arches Processes= protuberances and "attachments" (articular=restricts movement, spinous & transverse muscle attachment & movement) facets= attachments of other vertebrae or bones Body=large part where attachment of intervertebral disc (gelatinous nucleus pulposus, peripheral anulus fibrosus)

3. Abnormal curvatures of the spine

2. Herniated IV disc l

3 4

Patients typically have history of back pain that may radiate down to the lower limb. Herniation of disc usually occurs in lumbar ((L4/L5 or L5/S1)) or cervical regions (C5/C6 or C6/C7) of individuals younger than age 50. Herniated lumbar disc usually compreses the nerve root one number below: traversing root (e.g., the herniation L4/L5 will compress L5 root). The pain begins soon after patient lifted some heavy thing. Lower limb reflexes are decreased on the affected side


Anterior longitudinal ligament protects 9-3oclock around vertebral body Posterior longitudinal ligament protects 6oclock vertebral arch herniations are typically posterior laterally (4-5 or 7-8oclock)

Kyphosis is an exaggeration of the thoracic curvature that may occur in elderly persons as a result of osteoporosis (multiply compression fracture of vertebral bodies) or disk degeneration. l Lordosis is an exaggeration of the lumbar curvature that may be temporary and occurs as a result of pregnancy, spondylolisthesis or potbelly. Leg lengths: l Scoliosis is a complex lateral short bone: deviation, or torsion, that is Coxa Vara caused by poliomyelitis, a leglength discrepancy, or hip disease. <100deg Long bone: Coxa Valga Dr. Mavrych, MD, PhD, DSc [email protected] >130deg Degenerative osteoarthritis: Spondylosis: immobility or fusion of vertebral joints Spondylolysis: degeneration of articulating part of vertebrae Spondylolisthesis: forward displacement of vertebrae l


4. Upper limb fractures: Humerus fractures Sites of potential injury to major nerves in fractures of the humerus: 1. Axillary nerve and posterior humeral circumflex artery at the surgical neck. deep 2. Radial nerve and profunda brachii artery at midshaft. Midshaft fracture affect origin of brachialis Posterior between triceps brachii muscle. 3. Brachial artery and median nerve at the supracondylar region. cubital fossa 4. Ulnar nerve at the medial epicondyle. ulnar epicondylar groove posteriorly and medial to olecranon Dr. Mavrych, MD, PhD, DSc [email protected]

Fracture of distal radius: l

Quadrangular Space: teres major, teres minor, long head biceps brachii, humerus

Scaphoid fracture

l

l

Transverse fracture within the distal 2 cm of the radius. Most common fracture of the forearm (after 50). Smith's fracture results from a fall or a blow on the dorsal aspect of the flexed wrist and produces a ventral angulation of the wrist. The distal fragment of the radius is ANTERIORLY displaced. Colles' fracture results from forced extension of the hand, usually as a result of trying to ease a fall by outstretching the upper limb. Distal fragment is displaced DORSALLY - “dinner fork deformity”. Often the ulnar styloid process is avulced (broken off)


Boxer’s fracture

proximal carpal fracture l

Pain occurs primarily on the lateral side of the wrist, especially during wrist extension and abduction l Scaphoid fracture may not show on X-ray films for 2 to 3 weeks, but a deep tenderness will be present in the anatomical snuffbox. l The proximal fragment may undergo avascular necrosis because the blood supply is interrupted. deep radial artery could be compromised l


Mallet or Baseball Finger

Necks of the metacarpal bones are frequently fractured during fistfights. l Typically, fractures of 2d and Boxer's Fracture d 3 metacarpals are seen in professional boxers, and fractures of 5th and sometimes 4th metacarpals are seen in unskilled fighters. l

Occurs as a result of a fall onto the palm when the hand is abducted Extension & abduction of wrist

Brawler's Fracture


5. Rotator cuff muscles – SITS

This deformity results from the DIP joint suddenly being forced into extreme flexion (hyperflexion) when, for example, a baseball is miscaught or a finger is jammed into the base pad. l These actions avulse the attachment of the extensor digitorum tendon to the base of the distal phalanx. As a result, the person cannot extend the DIP joint. The resultant deformity bears some resemblance to a mallet. Forced Flexion of DIP l

Support the shoulder joint by forming a musculotendinous rotator cuff around it l Reinforces joint on all sides except inferiorly, where dislocation is most likely Rotator cuff muscles are: l Supraspinatus Initiate Abduction, Suprasacular n l Infraspinatus Lat rotation, Suprascapcular n l Teres minor Lat rotation, Axillary n l Subscapularis Med. rotation, Upper & Lower l

Right humerus

Subscapular ns




6. Abduction of the upper limb

Subacromial bursitis & Tearing of supraspinatus tendon l

l

l

l

(0°-15°) Abduction of the upper extremity is initiated by the supraspinatus muscle ((suprascapular suprascapular nerve). (15°-110º) Further abduction to the horizontal position is a function of the deltoid muscle ((axillary axillary nerve). (110°-180°) Raising the extremity above the horizontal position requires scapular rotation by action accessory of the trapezius ((accessory nerve CNXI) and serratus anterior ((long long thoracic nerve).


l

Subacromial bursitis (inflammation of the subacromial bursa) is often due to calcific supraspinatus tendinitis, causing a painful arc of abduction. The same symptoms will be in case of inflammation or trauma of the supraspinatus tendon (MRI !torn! tendon)

Dr. Mavrych, MD, PhD, DSc [email protected] Supraspinatus tendon is most commonly ruptured.

7. Three Elbows: Student's elbow (Subcutaneous olecranon bursitis) l

l

The olecranon, to which the triceps tendon attaches distally, is easily palpated. It is separated from the skin by only the olecranon bursa, which allow the mobility of the overlying skin. Repeated excessive pressure and friction may cause this bursa to become inflamed, producing a friction subcutaneous olecranon bursitis.

Tennis elbow (Lateral epicondylitis) l

l 1. 2. 3. 4.

Lateral epicondylitis: repeated forceful flexion and extension of the wrist resulting strain attachment of common extensor tendon and inflammation of periosteum of lateral epicondyle. Pain felt over lateral epicondyle and radiates down posterior aspect of forearm. Pain often felt when opening a door or lifting a glass Origins of following muscles may be affected: Extensor Carpi Radialis Extends and abducts Longus & Brevis the hand Extensor Digitorum Extends fingers and wrist Extensor Digiti Minimi Extensor Carpi Ulnaris Extends and adducts Radial n


Golfer’s elbow (Medial epicondylitis) l

l 1. 2. 3. 4.

the hand


8. Arterial anastomoses around the scapula Medial epicondylitis is inflammation of the common flexor tendon of the wrist where it originates on the medial epicondyle of the humerus. Origins of following muscles may be affected: Pronator Teres Pronates forearm Flexor Carpi Radialis Flexes and abducts wrist (Median n) Palmaris Longus flexes wrist Flexor Carpi Ulnaris flexes and adducts Wrist Ulnar n


l

Blockage of the Subclavian or Axillary artery can be bypassed by anastomoses between branches of the Thyrocervical and Subscapular arteries: l Transverse cervical off thyrocervical trunk l Suprascapular l Subscapular l Circumflex scapular off subscapular

Suprascapular a above the Transverse Superior Scapular Ligament anastamoses with the Circumflex Scapular a from the triangular space (Teres major/minor and long head biceps brachii)



9. Cubital fossa

Anterior Elbow joint

l

1. 2. 3. LATERAL

MEDIAL l 1. 2.

3.

l

10. Carpal Tunnel Syndrome

Contents from lateral to medial: Biceps brachii tendon Brachial artery Median nerve Subcutaneos structures from lateral to medial: Cephalic vein Median cubital vein:: joins cephalic and basilic veins Basilic vein

l

l

l

l l

Sites of venipuncture is usually median cubital vein because: l

l

Overlies bicipital aponeurosis, so deep

structures protected Biceps Brachii m (flex and supinate forearm) l Not accompanied by nerves O: Longhead supraglenoid tubercle, Shorthead coracoid process) I: to Radial TuberosityMD, PhD, DSc [email protected] Dr. Mavrych, Venous blood is darker/purpleish and flows passively Arterial blood is cherry red and has a pulse Cubital Tunnel Syndrome: Compression of ulnar epicondylar groove via tendon of Flexor Carpi Ulnaris, Ulnar n is compressed: Claw hand and weakened adduction of wrist

11. Test of the proximal and distal interphalangeal joints

Dr. Mavrych, MD, PhD, DSc [email protected] ULNAR TUNNEL SYNDROME: Compression at the wrist between pisiform and hook of hamate carpal bones causes hypoesthesia of medial 1.5 fingers and weakened instrinsic ms (Partial Claw hand bc flexors of forearm are unaffected)

12. Lesion of UL nerves Upper Brachial Palsy l

PIP – FDS

Proximal Interphalangeal joint Flexor Digitorum Superficialis Median n l

l

Pins and needles or anesthesia of the lateral 3.5 digits palm sensation is not affected because superficial palmar cutaneous branch passes superficially to carpal tunnel Apehand deformity - absent of OPPOSITION

Recurrent Median n to Thenar ms are affected

l

l

Results from a lesion that reduces the size of the carpal tunnel (fluid retention, infection, dislocation of lunate bone) Median nerve – most sensitive structure in the carpal tunnel and is the most affected Clinical manifestations:

Injury of upper roots and trunk Usually results from excessive increase in the angle between the neck and the shoulder stretching or tearing of the superior parts of the brachial plexus (C5 and C6 roots or superior trunk) May occur as birth injury from forceful pulling on infant's head during difficult delivery

DID DIP - FDP

Distal Interphalangeal Joint DIPS- Flexor Digitorum Profundus Ulnar and Median ns

MCPs- Lumbricals Metacarpal phalangeal joint

Birth injury or Fall causes Superior Trunk Damage: Erb's Palsy



Upper Brachial Palsy

Lower Brachial Palsy (Klumpke paralysis)

(Erb-Duchenne palsy)

Inferior Trunk damage C8-T1 ·

·

·

In all cases, paralysis of the muscles of the shoulder and arm supplied by C5 and C6 spinal nerves (roots) of the upper trunk. Combination lesions of axillary, suprascapular and musculocutaneous nerves with loss of the shoulder mm and anterior arm. As result patient has “waiter’s tip” hand: · adducted shoulder · medially rotated arm Wrist flexed · extended elbow ·

loss of sensation in the lateral aspect of the upper limb

Axillary C5-C6 Musculocutaenous C5-7 Median C6-T1 Dr. Mavrych, MD, PhD, DSc [email protected]

l

l

l

Injury of lower roots and trunk May occur when the upper limb is suddenly pulled superiorly: stretching or tearing of the inferior parts of the brachial plexus (C8 and T1 roots or inferior trunk) E.g., grabbing support during falling from height or as a birth injury, or TOS – thoracic outlet syndrome

hand paralysis (open extended hand), ulnar and Dr. Mavrych, MD, PhD,Full DSc [email protected] median n damage, thumb is extended bc radial n still good


Lower Brachial Palsy (Klumpke paralysis)

Injury to musculocutaneous nerve

Ulnar and Median Nerve Lesions

l

l

l

l

All intrinsic muscles of the hand supplied by the C8 and T1 roots of the lower trunk affected. Combination lesions of ulnar nerve (“claw hand”) ”) and median nerve (“ape hand”) Loss of sensation in the medial aspect of the upper limb and medial 1,5 fingers. May include a Horner syndrome

l

Usually results from lesions of lateral cord

Greatly weakens flexion of elbow (biceps and brachialis muscles) and supination of forearm (biceps muscle) weakened adduction (coracobrachialis m) l May be accompanied by anesthesia over lateral aspect of forearm Lateral musculocutaneous n of forearm l

Median n lesion: Ape hand/benediction with lateral 3 digits are extended, wrist is extended Ulnar n lesion: Claw hand with medial 2 digits extended Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Radial n lesion: Drop Wrist with flexion of the wrist

Cutaneous innervation reality, in case of superficial branch of of the hand Inradial nerve lesion it will be skin deficit

13. Cardiac catheterization

between 1 & 2 digits on the dorsum of the hand ONLY because of nerve overlapping l

l

Dorsum: 1,5-U and 3,5 R

The femoral artery is used for cardiac catheterization It can be cannulated for left cardiac angiography & also for visualizing the coronary arteries – a long, slender catheter is inserted percutaneously and passed up the external iliac artery, common iliac artery, aorta, to the left ventricle of the heart

Palm: 1,5-U and 3,5 M

A catheter can also be passed through a peripheral vein (femoral vein) into IVC, the R atrium, R ventricle, pulm trunk and pulm arteries. Intracardiac pressures, blood Dr. Mavrych, MD, PhD, DSc [email protected] samples, and visualization of great vessels using Xray


14. Injury of the gluteal region Fractures of Femoral Neck l

l

l

l

Avascular necrosis of femoral head

A common fracture in elderly women with osteoporosis is fracture of the femoral neck. Fractures of the femoral neck cause shortness and lateral rotation of the lower limb. Coxa Vara <100deg Fractures of the femoral neck often disrupt the blood supply to the head of the femur. At present time the best way in case of femoral neck fracture is hip replacement.


l

Transcervical fracture disrupts blood supply to the head of the femur via retinacular arteries (from medial circumflex femoral artery) and may cause avascular necrosis of the femoral head if blood supply through the ligament to the head is inadequate.

Fractures of neck and head of femur will disrupt the cruciate anastamosis that includes the medial circumflex femoral a & ascending and transverse lateral circumflex femoral aa with Retinacular branches that anastamose with the acetabular branch of obturator a within Ligamentum Teres Dr. Mavrych, MD, PhD, DSc [email protected]

TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information. congenital dislocations are more common in females > males

Injury to sciatic nerve

Posterior hip dislocations l

l l

Weakened hip extension and knee flexion Footdrop (lack of dorsiflexion) Flail foot (lack of both dorsiflexion and plantar flexion)

Cause of injury: caused by improperly placed gluteal injections but may result from posterior hip dislocation Gluteal injections should be done with palm over & Piriformis syndrome: Trucker's who sit all day piriformis m greater trochanter, pinky on ASIS and middle finger on Dr. Mavrych, MD, PhD, DSc [email protected] compress n, numbness and tingling mid axillary line, thumb point posteriorly, the V between to the affected side. middle and ring finger is site of injection. l

Superior gluteal nerve injury Normal

Right superior gluteal nerve injury

They are most common. A head-on collision that causes the knee to strike the dashboard may dislocate the hip when the femoral head is forced out of the acetabulum. l The joint capsule ruptures inferiorly and posteriorly (fracture of ishium), allowing the femoral head to pass through the tear in the capsule (tearing of ishiofemoral lig.) and over the posterior margin of the acetabulum onto the lateral surface of the ilium, shortening and anterior medial rotating the limb. pubofemoral lig may also tear Posterior dislocations can damage the sciatic n. bc it is weakest Dr. Mavrych, MD, PhD, DSc [email protected] l

Injury to inferior gluteal nerve

possibly also due to Piriformis syndrome The superior gluteal nerve l may be injured during surgery, posterior dislocation of the hip or poliomyelitis. l Paralysis of the gluteus medius and gluteus minimus muscles occurs so that the ability to pull the pelvis up and abduction of the thigh are lost. Trendelenburg sign: l If the superior gluteal nerve on the right side is injured, the left pelvis falls downward when the patient raises the left foot off the ground. l Note that side is contralateral to the nerve injury.

Patient stands and raises L leg, if the L leg drops, it is standing right leg nerve injury Dr. Mavrych, MD, PhD, DSc [email protected] passes through superior piriformis fossa w/ inferior gluteal a & v

l

l

Weakened hip extension (gluteus maximus), most noticeable when climbing stairs or standing from a seated position Cause of injury: posterior hip dislocation, surgery in this region Inferior gluteal n passes through inferior piriformis fossa with the sciatic n, posterior femorial cutaneous n, Superior gluteal a & v, pudendal n, and internal pudendal a & v


tearing off

Injury of obturator nerve Waddleing Gait (lateral leg swing/drag) l

l

l

Affects Obturator externus, Adductor longus, brevis, magnus (paritally), pectineus, gracilis lateral rotation weakness and poor adduction

Difficulty adducting thigh (e.g., crossing legs while sitting) Decreased sensation over upper medial thigh Cause of injury: anterior hip dislocation, radical retropubic prostatectomia passes through obturator canal that is covered by obturator membrane in obturator foramen


15. Avulsion fractures of the hip bone and hamstrings muscles l

Avulsion fractures occur where muscles are attached - ischial tuberosities

Hamstrings muscles: 1. Biceps femoris (long head) 2. Semitendinosus 3. Semimembranosus l Action: extension of hip joint and flexion of knee joint l Nerve supply – Tibial nerve (short head of biceps femoris is supplied by the common fibular nerve)

Dr. Pseudohamstrings: Mavrych, MD, PhD,Adductor DSc [email protected] Magnus (obturator & tibal ns), Biceps femoris ms (tibial & common peroneal ns)


16. Structures under inguinal ligament:

Femoral hernia Inguinal lig.

l l l l l l

From lateral to medial side: Iliopsoas muscle Femoral nerve w/ circumflexes & Femoral arteryperforating br Femoral vein & great saphenous v br Femoral canal Deep inguinal lymph nodes

Femoral Triangle: Superior inguinal ligament, Medially adductor longus m, laterally sartorius m, it lies on top of pectinius m and iliopsoas ms Inguinal lig serves as flexor retinaculum. Psoas m and Femoral n pass from pelvis to anterior thigh, MD, External becomes femoral vessels Dr. Mavrych, PhD,iliac DSc [email protected] The inguinal canal runs perpendicular to the femoral canal

17. Knee joint injuries: Unhappy triad l

l 1. 2. 3.

FN FA FV Sartorius m

A femoral hernia passes below inguinal ligament through the femoral ring into the femoral canal to form a swelling in the upper thigh inferior and lateral to the pubic tubercle l The hernial sac may protrude through the saphenous hiatus into the Adductor magnus m superficial fascia l A femoral hernia occurs more frequently in females and is dangerous because the hernial sac may become strangulated l An aberrant obturator artery is vulnerable during surgical repair l

Loop of bowel gets pulled downward into femoral canal, aberrant obturator a off Dr. Mavrych,external MD, PhD, [email protected] iliacDSc would cross bowel and becomes vulnerable Laceration of the Femoral a can be compensated by the perforating branch of femoral a and the lateral superior genicular a that anastamoses with the descending lateral femoral circumflex a. Femoral v ligation can be compensated via the great saphenous v

Tibial collateral ligament (medial collateral ligament)

Because the lateral side of the knee is struck more often (e.g., in a football tackle), the tibial collateral ligament is the most frequently torn ligament at the knee. The unhappy triad of athletic knee injuries involves: Tibial collateral ligament Medial meniscus Anterior cruciate ligament

l

l

l

MCL, MM, ACL tears


Fibular collateral ligament (lateral collateral ligament) l

l

l

Rounded cord between lateral epicondyle of femur and head of fibula Does NOT blend with joint capsule and does NOT attach to lateral meniscus Limits extension and adduction of leg at knee

Broad flat band extending from medial epicondyle of femur to medial condyle and shaft of tibia Blends with capsule and firmly attaches to medial meniscus Limits extension and abduction of leg at knee


Rupture of the cruciate ligaments l

With rupture of the anterior cruciate ligament, the tibia can be pulled forward excessively on the femur, exhibiting anterior drawer sign.

l

In the less common rupture of the posterior cruciate ligament, the tibia can be pushed backward excessively on the femur, exhibiting posterior drawer sign. drawer sign is movement of the leg in opposition of the femur 5mm




Prepatellar bursa Suprapatellar bursa articularis genu m

Knee jerk reflex

l

Prepatellar bursa: between superficial surface of patella and skin. May become inflamed and swollen (prepatellar bursitis).

Suprapatellar bursa: superior extension of synovial cavity between distal end of femur and quadriceps muscle and tendon. Usual place for intraarticular injections. May become inflamed and swollen (suprapatellar bursitis). Posterior to Rectus femoris m and vastis intermedialis m

l

The patellar reflex is tested by tapping the patellar Rectus femoris m ligament with a reflex hammer to elicit extension at the knee joint. Both afferent and efferent limbs of the reflex arch are in the femoral nerve (L2-L4).

l

Knee jerk reflex: tests spinal nerves L2-L4.

l


18. Ankle joint injuries: Ankle sprains l l

l

l

Sprains are the most common ankle injuries A sprained ankle is nearly always an inversion injury, involving twisting of the weightbearing plantarflexed foot. The lateral ligament (anterior talofibular ligament) is injured because it is much weaker than the medial ligament. In severe sprains, the lateral malleolus of the fibula may be fractured.


Pott’s fracture

l l l

It is fracture-dislocations of the ankle joint Reason - forced eversion (abduction) of the foot The Deltoid ligament avulses the medial malleolus and after that fibula fractures at a higher level

Pott's fracture

Eversion injury is Deltoid ligament at medial malleolus



19. Injures of the leg and foot: Fracture of the fibular neck

Ankle jerk reflex Calcaneous Tendon Reflex

l l

l

l

Achilles tendon reflex is tested by tapping the calcaneal tendon to elicit plantar flexion at the ankle joint. Both afferent and efferent limbs of the reflex arc are carried in the tibial nerve (S1, S2).

l

l

May cause an injury to the common nerve which winds peroneal nerve, laterally around the neck of the fibula. This injury results in paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors and evertors of the foot) and loosing sensation on the dorsum of the foot. Causing foot drop.

Ankle jerk reflex: tests spinal nerves S1-S2. Flexors take over (Plantar flexion)




Rupture of the Achilles tendon and Triceps surae muscle

Plantar Fasciitis (calcaneal spur) l

Avulsion or rupture of the calcaneal (Achilles) tendon disables the triceps sure muscle (gastrocnemius & soleus) so that the patient cannot plantar flex the foot. Triceps surae muscle: l 2 Heads of Gastrocnemius m. l 1 Head - Soleus muscle l Plantaris l small fusiform belly with long thin tendon; l sometimes may become hypertrophy l


l

Plantar fasciitis is the most common hindfoot problem in runners. It causes pain on the plantar surface of the foot and heel. Point tenderness is located at the proximal attachment of the plantar aponeurosis to the medial tubercle of the calcaneus and on the medial surface of this bone.


20. Injury of tibial nerve SOLE OF FOOT TIBAL n BRANCHES l

l l l

In popliteal fossa: loss of plantar flexion of foot (mainly gastrocnernius and soleus muscles) and weakened inversion (tibialis posterior muscle), causing calcaneovalgus. Inability to stand on toes Loss of sensation and paralysis of intrinsic muscles

Popliteal fossa from superficial to of the sole of the foot deep, contains: l Tibial nerve l Popliteal vein Femoral vessels after passing through adductor haitus/ l Popliteal artery Hunter's canal, Sartorius canal, to become popliteal vessels

Popliteal Fossa is bordered by Semitendinosus, Semimembranosus, Biceps Dr. Mavrych, MD, and PhD, DSc [email protected] femoris, quadracepts (gastronemius, plantaris, and soleus ms)

On soil of the foot there are two terminal branches of tibial n: l Medial plantar nerve supplies: 1. Abductor hallucis, 2. Flexor hallucis brevis 3. Flexor digitorum brevis 4. 1st lumbrical muscles l skin of medial 3.5 digits l Lateral plantar nerve supplies: l All intrinsic plantar muscles which are not innervated by medial plantar nerve l skin of lateral 1.5 digits Adductor hallucis (oblique & transverse heads), Quadratus Plantae, Flexor Digiti Dr. Mavrych, MD, PhD, DSc [email protected] minimi, abductor digiti minimi, DABs, PADs, lateral 3 lumbricals

Common Fibular/Common Peroneal n does not pass in popliteal fossa, instead it goes around neck of fibula

21. Breast: Carcinoma of the Breast l

l

Lymphatic drainage of the breast Carcinomas of the breast are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules 1. It enlarges, attaches to suspensory (Cooper‘s) ligaments, and produces shortening of the ligaments, causing depression or dimpling of the overlying skin.

Suspensory/Cooper's lig sround the lobules of mammary glands.

Dr. Mavrych, MD, PhD, DSc [email protected] $$Million dollar space: Retromammary space behind Pect Major or between fat pad and Pect Major for insertion of breast implants

l

l

l

75%

25%

It is important because of its role in the metastasis of cancer cells. Most lymph (> 75%), especially from the lateral breast quadrants, drains to the axillary lymph nodes, initially to the anterior (pectoral) nodes for the most part. Most of the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast.

Lymph from breast->Interpectoral "Rotter's" lymph nodes -> axillary lymph nodes-> Dr. Mavrych, MD, PhD, DSc [email protected] clavicular nodes-> R lymphatic duct or L Thoracic duct -> subclavian vs >brachiocephalic vs -> SVC-> heart Rotter's nodes are a way breast cancer can metastasize by bypassing axillary nodes


Mastectomy

Breast infection l

Radical mastectomy, a more extensive surgical procedure, involves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region. 1. During a radical mastectomy, the long thoracic nerve may be lesioned during ligation of the lateral thoracic artery. A few weeks after surgery, the female may present with a winged scapula and weakness in abduction of the arm above 90° because serratus anterior m. paralysis. 2. The intercostobrachial nerve may also be damaged during mastectomy, resulting in skin deficit of the medial arm. T2 intercostal n branch gives

l

l

l

l

sensation to skin of axilla and medial cutaneous arm


Mastitis is an infection of the tissue of the breast that occurs most frequently during the time of breastfeeding (1 to 3months after the delivery of a baby). This infection causes pain, swelling, redness, and increased temperature of the breast. It can occur when bacteria, often from the baby's mouth, enter a milk duct through a crack in the nipple. It can occur in women who have not recently delivered as well as in women after menopause.


22. Thoracic wall & Diaphragm: Intercostal spaces

Diaphragm: Paralysis of half and ruptures C3, 4, 5 keeps the Diaphragm alive!

Intercostal blood vessels and nerves: l run between the internal intercostal and innermost intercostal muscles in the costal groove l arranged from superior to inferior as vein, artery, nerve

l

l

Paralysis of the half of the Diaphragm may result from injury or operative division of the phrenic nerve of same side It can be detected radiologically.

Paradoxical movement: dome of diaphragm of injured side pushed superiorly by abdominal viscera during inspiration Flail Chest: One or more broken ribs in two separate places instead of descending upon inspiration the broken area will sink in as chest wall moves out upon expiration the broken area will push out as chest wall moves in Dangerous bc lungs can be punctured Dr. Mavrych, MD, PhD, DSc [email protected] l

l

Most vulnerable structures – intercostal nerve and posterior intercostal artery because they are not covering by ribs.

Skin->Fascia->Fat->External Intercostal m \\ //->Internal Intercostals // \\ -> Intercostal VAN-->Innermost Intercostals == -> Fascia -> Parietal Pleura--> Dr. Mavrych, MD, PhD, DSc [email protected] Thoracocentesis: Ribs 9-10 (9th intercostal space), above rib avoid VAN, remove fluid in pleural cavity Pericardiocenetesis: Left 5-6th intercostal space near sternum, Infrasternal (xiphoid) angle up to left shoulder for Cardiac Tamponade due to Pleural effusion

Phrenic nerve

Bochdalek Hernia: common hernia on the posterolateral L side of diaphragm, fatal congenital hernia that causes pulmonary hypoplasia. Morgangi Hernia: rare hernia on anteromedial R side of diaphragm, not fatal bc musculature typically creates spincter Sliding hernia: Stomach slides up through diaphragm bc of short esophagus Rolling/paraesophageal hernia stomach slides up next to esophagus

Diaphragmatic ruptures l

l

l

l

Arises from the anterior branches C3-C5 nerves and lies in front of the anterior scalene muscle. Runs anterior to the root of the lung,, whereas the vagus nerve runs posterior to the root of the lung. Innervates the fibrous pericardium, the mediastinal and diaphragmatic pleurae (sensory innervation), and the diaphragm for motor and its central tendon for sensory.


l

l

l

Diaphragmatic injuries are relatively rare and result from either blunt trauma or penetrating trauma. Presently, 80-90% of blunt diaphragmatic ruptures result from motor vehicle crashes. The majority (80-90%) of blunt diaphragmatic ruptures have occurred on the left side. side Blunt trauma typically produces large radial tears measuring 5-15 cm, most often at the posterolateral aspect of the diaphragm.

I ate 10 eggs at noon! Vessels entering the diaphragm Dr. Mavrych, MD, PhD, DSc [email protected] Inferior vena cava T8 Esophagus T10 Aorta T12

TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information. P-A projection

23. Cardiac hypertrophy Left atrial enlargement (hypertrophy) secondary to mitral valve failure may compress on the esophagus and manifest as dysphagia (difficulty in swallowing). l It may be observed as a filling defect in the esophagus by barium swallow on the lateral thoracic X-Ray mitral valve failure/tenting keeps causes mitral regurgitation into L atrium during systole, pressure dilates the LA as well as Dr. Mavrych, MD, PhD, DSc [email protected] decreases BP causing heart to work harder to pump blood to aorta resulting in hypertrophy

Cardiac Shadow

l

Right border is formed by: 1. SVC, 2. Right atrium Left border is formed by: 1. Aortic arch 2. Pulmonary trunk 3. Left auricle 4. Left ventricle Dr. Mavrych, MD, PhD, DSc [email protected]

24. Auscultation of Heart Valves

Auscultation sites for mitral and aortic murmurs

Right 2 ICS PSL

Left 2 ICS PSL

Left 4 ICS PSL

Left 5 ICS MCL A heart murmur is heard downstream l l

VALVE ANAT. AUSCULTATION SITE Dr. Mavrych, MD, PhD,LOCATION DSc [email protected] •P 3rd CC 2nd LT ICS •A 3rd ICS 2nd RT ICS •M 4th CC cardiac apex (5th Lt ICS MCL) •T 4th ICS Rt inferior most ST (5th RT ICS) • (3344) (2255)

25. Conducting System of the Heart Sinoatrial (SA) node l

l

l

regurgitation Dr. Mavrych, MD, PhD, DSc [email protected] Stenosis Aortic Systole (HOOT Dub) Pulm Systole (HOOT Dub) Tricuspid Diastole (Lub hoot) Mitral Diastole (Lub hoot)

Regurgiation Aortic Diastole (Lub hoot) Pulm Diastole (Lub hoot) Tricuspid Systole (hoot Dub) Mitral Systole (hoot Dub)

26. Blood supply of the Heart: Right coronary artery (RCA)

site where contraction of heart muscle is initiated (pacemaker of the heart) Crista Terminalis separates l situated in the upper part of the sulcus terminalis just near to the opening of pectinate muscles w/ sinus the SVC venarum Atrioventricular (AV) node l the AV node receives impulses from the SA node; situated in the lower part of the atrial septum near coronary sinus Atrioventricular bundle of His l descends from the AV node to the membranous portion of the ventricular septum where it divides into the left and right bundle branches l Right bundle branch – passes down to reach the moderator band - right ventricle Septomarginal trabeculae l left bundle branch – passes down left side of ventricular septum l

from the valve:

stenosis is orthograde direction from valve insufficiency is retrograde direction from valve

It supplies major parts of the right atrium and the right ventricle. It anastomoses with the marginal branch of the left coronary artery posteriorly Branches: 1. Anterior cardiac branches – supplies the right atrium 2. Nodal branch – supplies the (1) SA node, (2) AV node 3. Marginal artery – supplies the right ventricle Small cardiac vein 4. Posterior interventricular artery – supplies (1) diafragmatic (inferior) surface of both ventricles and (2) posterior 1/3 of the IV septum l l

Middle cardiac vein

Purkinje Fibers throughout walls of ventricles stimulate contractile cells Dr. Mavrych, PhD,ofDSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Triangle of Koch: MD, Location AV node in R Atria Valve of coronary sinus (Thebesian) & IVC (Valve of Eustice) meet to form tendon of todaro, which joins the Septal leaflet of Tricuspid valve


Left coronary artery (LCA)

Blood supply of the conducting system

"Widow Maker" Branches: 1. Anterior (descending) interventricular artery – most common place of MI descends in the anterior interventricular sulcus and provides branches to the (1) anterior heard wall, (2) anterior 2/3 of IV septum, (3) bundle of His, and (4) Great cardiac vein apex of the heart. 2. Circumflex artery – winds around the left margin of the heart in the atrioventricular groove to anastomose with the right coronary artery posteriorly; supplies the left atrium and left ventricle


l

SA node – RCA

l

AV node – RCA

l

AV bundle (and moderator band)- LCA mo When l a MI occurs, a coronary bypass graft can be completed using the internal thoracic artery (used to be Great saphenous v)


Great cardiac v, middle cardiac v, small cardiac v, L marginal v drain into Coronary Sinus which empties in Triangle of Koch at RA

27. Congenital cardiac defects: Atrial Septal Defect (ASD)

Ventricular Septal Defect (VSD)

It is less frequent than VSD l Ventricular septal defect (VSD) is the most common l It results from failure to of the congenital heart defects close of the foramen l It may be found in the ovale after birth (failure of membranous part of the the septum primum and ventricular septum and septum secundum to results from failure to fuse of fuse) Patent Foramen Ovale the membranous portion with the muscular portion of the l Postnatally, ASDs result ventricular septum in left-to-right shunting l In this case, present left–to(between right and left right shunt (right ventricular atrium) and are nonhypertrophy (RVH)) and cyanotic conditions. again non-cyanotic. l If it is small, has no l Necessary surgery for large clinical significance & if defects large - necessary surgical Muscular VSD rarest when there is a hole repair in the trabeculated inferior ventricle wall Ostium secundum: MOST common resorption of lower septum primum or incomplete septum secundum (fatal) Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] leaves open foramen ovale Ostium primum: non fusion of septum primum with septum intermedium leaves open foramen primum Hypoplastic L heart syndrome: premature closure of FO leaving underdeveloped L heart l

Patent Ductus Arteriosus (PDA) It results from failure of the ductus arteriosus (a connection between the pulmonary trunk and aorta)) to constrict and close after birth. l Prostaglandin E and low O2 tension sustain patency of the ductus arteriosus in the fetal period. l PDA is common in premature infants and in cases of maternal rubella infection. l Left –to-right shunt increased pressure in pulmonary circulation (pulmonary hypertension) and is non-cyanotic l Treatment: surgical division and ligation imperative. In great danger is left recurrent nerve (wrapping aorta arch). Injure of this nerve results in hoarseness. Ductus arteriosus (fetal lung bypass from pulmonary trunk to aorta) should immediately close post birth by contraction of muscular wall and become lig. arteriosus, L recurrent laryngeal n (CNX) wrapsDSc around it. Increase BP post birth creates increased BP in pulm Dr. Mavrych, MD, PhD, [email protected] circulation, less blood to body slightly decreases O2 l

Aneurysm of the aorta l

Aneurysm of the aortic arch: compresses the left recurrent laryngeal nerve,, leading to coughing, hoarseness, and paralys is of the ipsilateral vocal cord. It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from pressure on the trachea, root of the lung, or phrenic nerve

l

Aneurysm of the thoracic aorta may compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt by palpating the trachea at the sternal notch (T2).

Dr. Mavrych, MD, PhD, DSc [email protected] L Recurrent Laryngeal n innervates Intrinsic Laryngeal ms: Posterior cricoarytenoid (PCA)-abducts vocal cords*, Transverse arytenoid-whisper, Thyroarytenoid-low pitch, vocalis-opera singer


Abdominal aortic aneurysm l

l

l

l

Coarctation of the Aorta

It is a localized dilatation of the aorta. It is typically happened just above of the bifurcation at level of L4 and crossed by 3rd part of duodenum. Pulsations of a large aneurysm can be detected to the left of the midline at the umbilical region. Acute rupture of an abdominal aortic aneurysm is associated with severe pain in the abdomen or back (mortality rate is nearly 90%). Surgeons can repair an aneurysm by opening it and inserting a prosthetic graft.


28. Aspiration of Foreign Bodies & Bronchopulmonary segments

It results from congenital narrowing of the aorta distal to the offshoot of the left subclavian artery. l Cardinal clinical sign: higher blood pressure in the upper limbs compared to the lower limbs. l Coarctation of the aorta results in the intercostal arteries providing collateral circulation between the internal thoracic artery and the thoracic aorta to provide blood supply to the lower parts of the body l Coarctation of the Aorta characteristic X-ray picture: serrated appearance of inferior borders of ribs (rib rib notching) notching Preductal stenosis proximal to ductus arteriosus causes deoxygenated blood w/ lowMD, BP to the DSc body (life threatening) Dr. Mavrych, PhD, [email protected] Postductal stenosis w/ obliterated ductus ateriorsus is more common l

Right lung: 10 bronchopulmonary segments

Aspiration of Foreign Bodies: l Inhalation of FB’s (e.g. pins, parts of teeth, screws, nuts, bolts, toys) into the lower respiratory tract is common, especially in children l More likely to enter the right primary bronchus and pass into the middle or lower lobe bronchi l If the vertical position of the body, the foreign body usually falls into the posterior basal segment of the right inferior lobe. Laying down on back, it will go into posterior superior lobe Dr. Mavrych, MD, PhD, DSc [email protected] Liquids (Mendleson syndrome) will go to BOTH superior segmental bronchus of Lower Lobes (SULL)

Superior lobe: 1. Apical 2. Anterior 3. Posterior Middle lobe: 4. Lateral 5. Medial Inferior lobe: 6. Superior 7. Anterior basal 8. Posterior basal 9. Lateral basal 10. Medial basal

1 3 2 6

10 9

7

29. Lung diseases: Pneumonia l

1 l

2 l

5

3

l

7

4

8

9 6


5

8


Left lung: 9 bronchopulmonary segments Superior lobe: 1. Apicoposterior 2. Anterior 3. Superior lingularsurrounds cardiac notch 4. Inferior lingular Inferior lobe: 5. Superior 6. Anterior basal 7. Posterior basal 8. Lateral basal 9. Medial basal

4

Pneumonia is an inflammation of the lung, caused by an infection or chemical injury to the lungs. Three common causes are bacteria, viruses and fungi. Symptoms: cough, chest pain, fever, and difficulty in breathing. Chest x-rays: areas of opacity (seen as white) of the lung parenchyma and enlargement of bronchomediastinal lymph nodes (mediastinal widening).



Bronchogenic Carcinoma

Bronchogenic carcinoma may lead to: 1

l l

l

l

l

Arises in the mucosa of the large bronchi Produces as persistent, productive cough or hemoptysis spitting blood Early metastasis to thoracic (bronchomediatinal) lymph nodes Hematogenous spread to the brain, bones, lungs,malignant cells suprarenal glands spread through blood A tumor at the apex of the lung (Pancoast ( tumor)) may result in thoracic outlet syndrome

1. Thoracic outlet syndrome ((TOS) TOS) l It can cause pressure on the lower trunk of the brachial plexus C8-T1 and subclavian artery by cervical rib or pancoast tumor. It results in pain down the medial side of the Blue arm forearm and hand and atrophy of the intrinsic hand muscles) 2. Horner syndrome: compression of cervical sympathetic trunk symp l miosis - constriction of the pupil due to paralysis of the dilator pupillae muscle Long ciliary n of CNV1-> SNS br l ptosis - drooping of the eyelid due to paralysis of the superior tarsal muscle pseudoptosis bc NOT CNIII lesion SNS compression to smooth ms l hemianhydrosis - loss of sweating on one side Sweat glands are SNS

2



Qs about Auscultation and penetrated wounds

Bronchogenic carcinoma may lead to: 3. Superior vena cava syndrome, which causes dilation of the head and neck veins, facial swelling, and cyanosis Blue Face & arm 4. Dysphagia as a result of esophageal obstruction 5. Hoarseness as a result of recurrent laryngeal nerve involvement 6. Paralysis of the diaphragm as a result of phrenic nerve involvement

l

l

4

3 6


30. Open pneumothorax & pleura l l

l

It is entry of air into a pleural cavity causing lung collapse. Open pneumothorax – due to stab wounds of the thoracic wall which pierce the parietal pleura so that the pleural cavity is open to the outside air via the lung or through the chest wall. Air moves freely through the wound during inspiration and expiration. During inspiration, air enters the chest wall and the mediastinum will shift toward other side and compress the opposite lung. During expiration, air exits the wound and the mediastinum moves back toward the affected side.

l

To listen to breath sounds of the superior lobes of the right and left lungs, the stethoscope is placed on the superior area of the anterior chest wall (above the 4th rib for the right lung & above 6th for the left one). For breath sounds from the middle lobe of the right lung, the stethoscope is placed on the anterior chest wall between the 4th and 6th ribs For the inferior lobes of both lungs, breath sounds are primarily heard on the posterior chest wall.


Pleura & Pleural Cavity

2

l

1. Cervical pleura may be affected in case of improper subclavian venipuncture.

l

2. Costodiaphragmatic Recess is deepest place in pleural cavity, around the chest wall, there are two rib interspaces separating the inferior limit of parietal pleural reflections from the inferior border of the lungs and visceral pleura: Midclavicular line - between ribs 6-8 Midaxillary line - between ribs 8-10 Paravertebral line between ribs 10-12

1. 2. 3.

Costodiaphragmatic Recess is where fluid is retained during pleural effusion Stab Wounds & Open pneumothorax: Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Straight in air can move in and out with each respiratory cycle, No air trapping (listen to ventilation of wound) At an angle air can move in with inspiration BUT with expiration skin acts as flap and closes trapping air inside collapsing the lung


Nerve supply of the pleura

31. Mediastinum Superior p mediastinum

Parietal Pleura – sensitive to general sensibilities (pain, temperature, touch, and pressure) - somatic sensory innervation: l costal pleura – intercostal nerves block may be used to decrease thoracic pain l mediastinal pleura – phrenic nerve l diaphragmatic pleura – phrenic nerve over the domes and lower 6 intercostal nerves around the periphery

Improperly done sternal puncture may affect structures related to the posterior surface of the manubrium sternum: l In upper part – Left brachiocephalic vein l In lower part – Aortic arch Azygous vein and ascending aortic arches Trachea and Pulmonary artery bifurcations esophagus and thoracic duct change directions (cross over) l

Visceral Pleura – sensitive to stretch but insensitive to general sensibilities; autonomic nerve supply from the pulmonary plexus

Cervicothoracic Stellate Gangion down to T11 and Subcostal sympathetic ganglion comprise the thoracic Ribs 1-2 down to transverse thoracic sympathetic trunk Dr. muscles Mavrych,ofMD, DSc [email protected] PhD,(T2)/Plane DSc [email protected] of ludwig/angle of louis Innervate the PhD, ribs, abdominal wall, pulmonary and cardiac plexus, and esophageal plexus Dr. Mavrych, MD,plane Vagus CNX assists plexus of thorax for vocal cords and swallowing, and gives off recurrent laryngeal and superior external laryngeal to the larynx muscles

Pericardial sinus: behind pulm trunk and aorta place fingers to clamp/ligate great vessels during surgical procedures

Thoracic duct

A Duck between 2 Gooses Thoracic duct between azygos v and esophagus

Constrictions of the esophagus 25cm long/10in Barium swallow allows Xray visualization

l

Function – conveys to the blood all lymph from the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, left side of the head & neck, and left upper limb ((3/4 3/4 of the body)

Tributaries – at the root of the neck l Left jugular lymph trunk l Left subclavian lymph trunk l Left bronchomediastinal lymph trunk


1

There are sites where ingested foreign bodies can lodge or where strictures may develop following ingestion of caustic fluids, common sites of esophageal carcinoma

2

1. C6 - where the pharynx joins the upper end (6" from the 15cm upper incisors) 2. T4-T5 - where the aortic arch and left main bronchus cross 22.5-27.5cm its anterior surface (10" from the upper incisors) 3. T10 - where it passes through the diaphragm into the stomach (16" from the upper 40cm incisors)

3


R lymphatic duct drains 1/4 of body from R jugular lymph trunk, R subclavian lymph trunk, and R bronchomediastinal lymph trunk

32. Anterior abdominal wall l

l

Referred abdominal pain

The liver and gallbladder are in the right upper quadrant; The stomach and spleen are in the left upper quadrant; RH

l

l

The cecum and appendix are in the right lower quadrant; The end of the descending colon and sigmoid colon are in the left lower quadrant.

RL

RI

E

LH

U

LL

H

LI

l

Pain arising out of the foregut derived structures is referred to the epigastric region. region

l

Pain arising out of the midgut derived structures is referred to the umbilical region.

l

Pain arising out of the hindgut derived structures is referred to the hypogastric region.

of abdominal Camper's Fascia, Scarpa's Fascia, Galludets Fascia (superficial Ext oblique), Oblique \\//, (deep ext oblique, superficial int oblique), Dr. Layers Mavrych, MD, PhD, wall: DSc Skin, [email protected] Dr. Mavrych, MD,Ext PhD, DSc m [email protected] Inter Oblique m //\\, (deep int oblique, superficial transversalis ab), Transversalis abdominus m, deep TA fascia, Extraperitoneal fat, parietal peritoneum . Arcuate line is where lateral abdominal ms tendons merge with Rectus abdominus (linea semilunaris), Above arcuate line int oblique superficial fascia is above rectus abdominus (3 layers of fascia), Below arcuate line ALL fascias above rectus abdominis (6 layers) typically inferior to umbilicus


Nerve supply of the anterior abdominal wall l

l

l

33. Herniations Hernia consist of 3 parts:

l

l

Indirect Inguinal Hernia

l

l

l

Important DEEP ARTERIES lie in the neurovascular plane: plane 1. Superior epigastric internal thoracic a 2. Posterior intercostals arteries 3. Lumbar arteries 4. Deep circumflex iliac artery external iliac a 5. Inferior epigastric from femoral a just past femoral ring (inguinal lig)

PortalMD, Caval anastamosis of paraumbilical veins off hepatic portal v with superficial Dr. Mavrych, PhD, DSc [email protected] epigastric veins (Caput Medusae- swiggly veins on belly button)

Transversalis fascia is the FIRST STRUCTURE which is crossed by any abdominal hernia

Hernial sac is a pouch (diverticulum) of peritoneum and has a neck and a body Hernial contents may consist of any structure found in the abdominal cavity (more offen – loops of small intestine and piece of omentum major) Hernial coverings are formed from the layers of the abdominal wall through which the hernial sac passes


l

Important SUPERFICIAL ARTERIES ((supply supply skin) skin are: 1. Superficial epigastric from femoral a 2. Superficial circumflex iliac

Therefore totally 7 nerves: lower 5 intercostals, 1 subcostal and L1 (iliphypogastric and ilioinguinal) nerves supply ilioinguinal the anterior abdominal wall. L1 can be anaesthetized by injecting 1 inch (2.5 cm) superior to the anterior superior iliac spine. All nerves and deep blood vessels lie in the neurovascular plane: between internal oblique and transversus muscles

T5-T11 T12 L1 Dr. Mavrych, MD, PhD, DSc [email protected]

l

Arterial supply of the anterior abdominal wall:

Indirect inguinal hernia is the most common form of hernia and is believed to be congenital in origin (boys 0-3 years). It passes through the deep inguinal ring lateral to the inferior epigastric vessels, inguinal canal, superficial inguinal ring and descend into the scrotum. An indirect inguinal hernia is about 20 times more common in males than in females, and nearly 1/3 are bilateral. It is more common on the right (normally, the right processus vaginalis becomes obliterated after the left; the right testis descends later than the left).

aponerocis of internal oblique fascia and tranversalis fascia

TIE ICE Transversalis Fascia becomes Internal Spermatic Fascia Dr. Mavrych, MD, PhD, DSc [email protected] Internal Oblique m & Fascia becomes Cremasteric m & Fascia External Oblique fascia becomes External Spermatic Fascia Surrounds the Spermatic cord within the inguinal canal: 3 as: cremasteric (inferior epigastric), ductus deferans (internal iliac-inferior vesicle), gonadal a (aorta) 3 ns: genital br (motor genitofemoral), ANS, ilioinguinal 3 others: Pampiniform plexus (IVC and Lrenal), Ductus Deferens, Lymphatics Process Vaginalis/Gubernaculum

Direct Inguinal Hernia l l

l

Direct inguinal hernia composes about 15% of all inguinal hernias. During a direct inguinal hernia, the abdominal contents will protrude through the weak area of the posterior wall of the inguinal canal medial to the inferior epigastric vessels in the inguinal [Hesselbach's] triangle and after that through superficial inguinal ring. It never descends into the scrotum. It is a disease of old men with weak abdominal muscles. Direct inguinal hernias are rare in women, and most are bilateral.

Dr. Mavrych, MD, PhD, DSc Mavrych, PhD, DSc [email protected] [email protected] finger into superficial inguinal ring, if you can feel hernia at TIP Dr. of finger than itMD, is indirect hernia at the lateral inguinal fossa. If you can feel something lateral to finger it is direct hernia pushing towards Hesselbach's triangle (medial inguinal fossa between medial and lateral umbilical folds. The inferior epigastric vessels reside within Lateral umbilical fold (functional), the inferior border is the inguinal lig.


34. Peritoneal structures: Lesser omentum

Epiploic (winslow’s) foramen

Consist of 2 ligaments: l hepatogastric l hepatoduodenal Contents : l Right & Left gastric vessels l Connective and fatty tissue and Portal triad: l Bile duct l Portal vein l Proper hepatic artery

l

Anteriorly: The free border of the hepatoduodenal ligament, containing portal triad (DVA).

l

Posteriorly: IVC

l

Superiorly: Caudate lobe of the liver.

l

Inferiorly: The 1st part of the duodenum.

Site of Pringles Manuver to block blood supply to liver and investigate Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, DSc [email protected] Liver bleeds: block Hepatic Artery Proper, Hepatic Portal MD, Vein,PhD, and Common Bile Duct. Use thumb anterior, and index posterior within Winslow foramen. If R side bleeds: aberrant R Hepatic artery from SMA If L side bleeds: aberrant L Heptatic artery from L Gastric If double bleed accessory arteries come from elsewhere.

Douglas (rectouterine) pouch

Culdocentesis

In women only! l l

l

Rectouterine pouch (pouch of Douglas): deeper point of peritoneal space in vertical position of the female body between the rectum and the cervix of uterus. It is space of the pelvic abscess location.

l

Vesicouterine pouch

Culdocentesis is aspiration of fluid from the cul-de-sac of Douglas (rectouterine pouch) by a needle puncture of the posterior vaginal fornix near the midline between the uterosacral ligaments Because the rectouterine pouch is the lowest portion of the female peritoneal cavity, it can collect inflammatory fluid (pelvic abscess).

Males have a vesicorectal pouch, fluid can accumulate in these peritoneal areas if there is a pelvic abscess. Dr. Mavrych, MD, PhD, DSc [email protected] Dr.kidney Mavrych, Morrison's pouch is where fluid accumulates if the person is lying down (between and MD, liver)PhD, DSc [email protected]

FOREGUT

35. Smart Table FOREGUT

MIDGUT

HINDGUT

Esophagus Transverse colon Duodenum (2nd, 3rd, (distal 1/3) Stomach 4th Descending colon Duodenum (1st and parts) Sigmoid colon 2nd parts) Jejunum Rectum (anal canal Ileum Liver above pectinate line) Cecum (with Pancreas Appendix) Biliary apparatus IMV to splenic v to Ascending colon Gallbladder hepatic portal v to liver 1st part duodenum is Transverse colon to IVC suspended by greater (proximal 2/3) SMV joins splenic v to omentum and hepato form hepatic portal v 2nd part of duodenum is duodenal lig where Spincter of Oddi/ Ampula of Vader/major papilla of the Wirsung major Dr. Mavrych, MD, PhD, DSc [email protected] Pancreatic duct empties along with the common bile duct

MIDGUT

HINDGUT

Artery: CA

Artery: SMA

Artery: IMA

Parasympathetic innervation: vagus nerves, CNX

Parasympathetic innervation: vagus nerves, CNX

Parasympathetic innervation: pelvic splanchnic nerves, S2-S4

Sympathetic innervation: •Preganglionics: greater splanchnic nerves, T5-T9 •Postganglionics: celiac ganglion

Sympathetic innervation: •Preganglionics: lesser splanchnic nerves, T10T11 •Postganglionics: superior mesenteric ganglion

Sympathetic innervation: •Preganglionics: lumbar splanchnic nerves, L1-L2 •Postganglionics: inferior mesenteric ganglion

Sensory Innervation: DRG T5-T9

Sensory Innervation: DRG T10-T11

Sensory Innervation: DRG L1-L2

Referred Pain: Epigastrium

Referred Pain: Umbilical

Referred Pain: Hypogastrium

Dr. Mavrych, DSc [email protected] Retroperitoneal Organs: MD, SAD PhD, PUCKER Suprarenal glands, Aorta, Duodenum (2-3rd), Pancreas, Ureters, Colon, Kidneys, Esophagus, Rectum DPC are secondary retroperitoneal


37. Congenital diaphragmatic hernia

36. Posterior gastric ulcer 1. Posterior gastric ulcer may erode through the posterior wall of the stomach into the Omental bursa (Lesser peritoneal sac) and affect pancreas resulting in referred pain to the back. 2. Erosion of splenic artery is very common in posterior gastric ulcers as well because of the proximity of the artery to this wall.


l

l

This can damage the vagal trunks as they pass through the hiatus and resulting in hyposecretion of gastric juice. Often due to shortened esophagus

l

Colon l

Features of the large intestine:

2. 3. l

Appendices epiploic Sacculations (haustrations) Taeniae coli The taeniae coli meet together at the base of the appendix where they form a complete longitudinal muscle coat for the appendix.


Meckel's diverticulum is a congenital anomaly representing a persistent portion of the vitellointestinal duct. This condition is often asymptomatic but occasionally becomes inflamed if it contains ectopic gastric, pancreatic, or endometrial tissue, which may produce ulceration. Meckel's diverticulum is located on the Ileum about 2 feet (61 cm) before the ileocecal junction and SMA supply it. It occurs in 2% of patients and is about 2 inches (5 cm) long. The diverticulum is clinically important because diverticulitis, liberation, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently mimicking the symptoms of acute appendicitis.

commonly presents at 2yo, 2:1 males to females Dr. Mavrych, MD, PhD, DSc [email protected]

40. Features of the large intestine

1.

It is seen in infants and the mortality rate is high because of left lung hypoplasia.

39. Meckel's diverticulum Outpouch of intestines into rectum

A sliding hiatal hernia which occurs in individuals past middle age is caused by the hernia of cardia of the stomach into the thorax through the esophageal hiatus of the diaphragm. Fundus of stomach through


l


l

l

Hernia of stomach or intestine through a posterolateral defect in diaphragm (foramen of Bochadalek).

Improper fusion of pleuroperitoneal membranes with septum transversarus Most L sided bc liver and R side closes first.

38. Sliding hiatal hernia l

l

l

l

l

l

The ascending colon lies retroperitoneally and lacks a mesentery. It is continuous with the transverse colon at the right (hepatic) flexure (1) of colon. The transverse colon (3) has its own mesentery called the transverse mesocolon (intraperitoneal position). It becomes continuous with the descending colon at the left (splenic) flexure (2) of colon. The sigmoid colon (4) is suspended by the sigmoid mesocolon (intraperitoneal position).

1 3

4

Ascending colon (R colic a, iliocolic a w/ appendicular a-SMA) Transverse colon (Middle colic a, marginal a-SMA) Dr. Mavrych, MD, PhD, DSc [email protected] Descending colon (L colic a-IMA) Sigmoid colon (Sigmoid branches of IMA) Rectum (Superior Rectal a from IMA, Inferior and medial rectal-internal iliac a)


41. Pain of Appendicitis

Mc Burney's point

In appendicitis, first pain is referred around the umbilicus. Visceral pain in the appendix is produced by distention of its lumen or spasm of its muscle. The afferent pain fibers enter the spinal cord at the level of T10 segment, segment and a vague referred pain is felt in the region of the umbilicus.

l

l

Later if parietal peritoneum gets involved, and then the pain is shifted laterally to the Mc Burney’s point. Here the pain is precise, severe, and localized (second pain)

l

l

This point indicates the surface marking of the base of the appendix.

l

It is a point at the junction between the lateral 1/3 and medial 2/3 of a line joining the right anterior superior iliac spine with the umbilicus.

McBurney's point lies 2/3 from umbilicus to ASIS OR 1/3 from ASIS to umbilicus Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected]

42. Volvulus

43. Hirschsprung's Disease l l

l

Because of its extreme mobility, the Jejunum, Ileum and Sigmoid colon sometimes rotates around its mesentery. It results in avascular necrosis corresponding part of interstine. This may correct itself spontaneously, or the rotation may continue until the blood supply of the gut is cut off completely.

l l

l

l


It is a rare congenital abnormality that results in obstruction because the intestines do not work normally. It is commonly found in Down Syndrome children. males>females The inadequate motility is a result of an aganglionic section (congenital absents of postganglionic parasympathetic neurons inside of the intestinal wall) of the intestines resulting in megacolon. In a newborn, the main signs and symptoms are failure to pass a meconium stool within 1-2 days after birth, reluctance to eat, bile-stained (green) vomiting, and abdominal distension. Treatment is removal of the aganglionic portion of the colon.

NCCs did not travel correctly to the colon resulting in lack of Dr. Mavrych, MD, PhD, DSc [email protected] innervation to the large bowel, no parastalic movements results in megacolon

44. Branches of Abdominal aorta and Mesenteric ischemia l

l

l l l

Celiac trunk (CA) originates from the aorta at the lower border of T12 vertebra Superior mesenteric artery originates at the lower border of L1 vertebra Renal arteries originate at approximately L2 vertebra Inferior mesenteric artery originates at L3 vertebra Two terminal branches are common iliac arteries at the level of L4 vertebra

CELIAC ARTERY (TRUNK) l

Origin: T12, just below the aortic opening of the between crura of diaphragm diaphragm.

l

The CA passes above the superior border of the pancreas and then divides into three retroperitoneal branches: Left gastric artery (1) Common hepatic artery (2) Splenic artery (3)

1

3 2 l l l

Ovarian/testicular (gonadal) as arise between L2-3



TRIAL MODE − a valid license will remove this message. See the keywords property of this PDF for more information. 1st off Celiac Trunk

2nd off Celiac Trunk

Left gastric artery

Common hepatic artery

2

The left gastric artery (1) courses upward to the left to reach the lesser curvature of the stomach and may be subject to erosion by a penetrating ulcer of the lesser curvature of the stomach. Branches: l Esophageal branches (2) - to the abdominal part of the esophagus l Gastric branches (3) supply the left side of the lesser curvature of the stomach and make anastomosis with right gastric artery. l

3

1


OFF Common Hepatic a of Celiac Trunk

Proper hepatic artery l

5

4 3

l

1 2 l

l

2 1 l l

The common hepatic artery (1) passes to the right to reach the superior surface of the first part of the duodenum, where it divides into its two terminal branches: Proper hepatic artery (2) Gastroduodenal artery (3)

3


OFF Common Hepatic a of Celiac Trunk

Gastroduodenal artery

Proper hepatic artery (1) gives off right gastric artery (2) and then ascends within the hepatoduodenal ligament of the lesser omentum to reach the porta hepatis, where it divides into the right (4) and left (3) hepatic arteries. The right and left arteries enter the two lobes of the liver,, right hepatic artery gives cystic artery (5) to the gallbladder. Right gastric artery (2) supplies the right side of the lesser curvature of the stomach where it anastomoses the left gastric artery.


l

1

l

2 l

3

Gastroduodenal artery (1) descends posterior to the first part of the duodenum (may be subject to erosion by a penetrating ulcer in this place) and divides into two branches: Right gastroepiploic artery (2) (supplies the right side of the greater curvature of the stomach where it anastomoses the left gastroepiploic) Superior pancreaticoduodenal arteries (3) (supply the head of the pancreas, where they anastomoses the inferior pancreaticoduodenal arteries from the SMA).


3rd off Celiac Trunk

Splenic artery

Ligature of the hepatic artery: l

The hepatic artery may be ligated proximal to the origin of its gastroduodenal branch, a collateral circulation to the liver is established through the left and right gastric arteries, left and right gastroepiploic and gastroduodenal arteries.

l

The right hepatic artery may be mistakenly ligated during holecystectomy in Calot triangle together with the cystic artery, right lobe hepatic necrosis commonly occurs.

Anastamoses of the L gastric, L gastroepiploic, and Lgastroduodenal Dr. Mavrych, MD, PhD, DSc [email protected] arteries with the R side will cause retrograde flow into the proper hepatic artery to supply the liver

l

1

l

l

Splenic artery (1) runs a tortuous horizontal course to the left along the upper border of the pancreas, behind the peritoneum of the posterior wall of the lesser sac, forming a part of the stomach bed. The splenic artery may be subject to erosion by a penetrating ulcer of the posterior wall of the stomach into the lesser sac. sac N.B. The splenic vein runs a more straight course below the artery and behind of the pancreas.



SUPERIOR MESENTERIC ARTERY (midgut)

Splenic artery BRANCHES Splenic (1) a. is retroperitoneal until it reaches the tail of the pancreas, where it enters the 2 splenorenal ligament to enter the hilum of the spleen. 4 Branches: l Branches to the spleen (2) l Branches to the neck, body, and tail of pancreas (3) l Left gastroepiploic (4) artery that supplies the left side of the greater curvature of the stomach where it anastomoses the right gastroepiploic l Short gastric (5) branches that supply fundus of the stomach

7

1

l

5 1 3


6 2 4

3

SMA Branches: l (1) Inferior pancreaticoduodenal arteries l (2)Jejunal and (3) Ileal branches l (4) Ileocolic artery l Ascending branch l Anterior cecal artery l Posterior cecal artery l (5) Appendicular artery l (6) Right colic artery l (7) Middle colic artery

5

Marginal artery anastamoses the iliocolic a, vasa recta-SMA, with the L colic, sigmoid a and vasa recta of the IMA


INFERIOR MESENTERIC ARTERY

Mesenteric ischemia l

1

IMA Branches: l (1) Left colic artery l (2) Sigmoid arteries l (3) Superior rectal artery

l

3

l

l

2


45. Biliary system & gallstones Bile is secreted by the liver cells, stored, and concentrated in the gallbladder and later it is cystic a from R hepatic a delivered to the duodenum. l The gallbladder lies in it’s fossa on the visceral surface of the Calot's Triangle liver right side of quadrate lobe. l It stores and concentrates bile, which enters and leaves it through the cystic duct. l The cystic duct joins the common hepatic (from left and right hepatic) due to form the common bile duct.

Atherosclerosis, which slows the amount blood flowing through arteries, is a frequent cause of chronic mesenteric ischemia. Ischemia occurs when blood cannot flow through arteries as well as it should, and intestines do not receive the necessary oxygen to perform normally. Mesenteric ischemia usually involves SMA and small intestine. Mesenteric ischemia primarily affects organs which locate far away from anastomoses with CA & IMA. Usually blood supply of the Jejunum and Ileum is most compromised. Mesenteric ischemia typically occurs in people older than age 60 with history of smoking and high cholesterol level.


Biliary system

l


l

l

Sphincter of Oddi Ampula of Vader Amp

The common bile duct descends in hepatoduo ligament, the hepatoduodenal ligament, then passes posterior to the first part of the duodenum duo It penetrates the t head of the pancreas where whe it joins the main and they form the pancreatic duct d hepatopancreatic ampulla hepatopancre (sphincter of o Oddi) Oddi), which drains into posteromedial wall the second part of the duodenum at the major duodenal papilla

Tumor in the head of the pancreas can block the duct and cause jaundice Dr. Mavrych, MD, PhD, DSc [email protected] Blockage of the cystic or common bile duct via gall stones can cause gall bladder rupture w/ refered pain to the shoulder (C3-5 phrenic n), and backflow of pancreatic enzymes that digest the pancreas and the spleen via splenic artery branches


Cholelithiasis (gallstones) l

1

4

l

2 l

3

The distal end of the hepatopancreatic ampulla (Bile duct) is the narrowest part of the biliary passages and is the common site for impaction of gallstones. As result of common hepatic (1), bile duct (2), or hepatopancreatic ampulla (3) obstruction patient will have yellow eyes and jaundice Gallstones may also lodge in the cystic duct. A stone lodged in the cystic duct (4) causes biliary colic (intense, spasmodic pain in the gallbladder) but doesn't produce jaundice.

Gall stone the cystic will cause backflow to the gall bladder (burst) Dr. Mavrych, MD,inPhD, DScduct [email protected]

Gallstones l

l

The fundus [1] of the gallbladder is in contact with the transverse colon and thus gallstones erode through the posterior wall of the gallbladder and enter the transverse colon. They are passed naturally to the rectum through the descending colon and sigmoid colon.

2

Gallstones lodged in the body [2] of the gallbladder may ulcerate through the posterior wall of the body of the gallbladder into the duodenum (because the gallbladder body is in contact with the duodenum) and may be held up at the ileocecal junction, producing an intestinal obstruction.

1


BUT NOT jaundice bc Common bile duct is still releasing bile properly to the stomach

47. Portal Hypertension & Portocaval shunts

46. Nerve supply of the liver and gallbladder

l

The liver receives parasympathetic innervation from the vagi nerves (CNX), reaching it through the celiac plexuses around the supplying arteries. The preganglionic fibers synapse on the cells of the uxtramural plexuses in hilum of the liver and shot postganglionic fibers supply organs.

Portal hypertension is a common clinical condition, and for this reason portal-systemic anastomoses should be remembered.

l

Sympathetic fibers of preganglionic neurons T5-T9 segments (IML) come through the sympathetic trunk and form greater splanchnic nerves. They contribute to the celiac plexus, where postganglionic neurons are located. Branches of celiac plexus reach the liver wrapping around the branches of the celiac artery.

l

[1] Extrahepatic portocaval shunt for the treatment of portal hypertension: the splenic vein may be anastomoses to the left renal vein after removing the spleen. [2] Intrahepatic portocaval shunt : between portal vein and hepatic veins

l

Sensory innervation of the liver: by the right phrenic nerve ((C3-C5 (C3-C5). C3-C5). C3-C5 ). Pain may radiate to the right shoulder. shoulder

l

l


Large intestine metastases & Portocaval anastomosis l

l

l l l

Metastases of the Large intestine cancer typically rich the Liver via portal venous system: Rectum IMV - splenic vein - portal vein Liver If there is an obstruction to flow through the portal system (portal hypertension), blood can flow in a retrograde direction and pass through anastomoses to reach the caval system.. Sites for these anastomoses include: (1) esophageal veins (2) paraumbilical veins (3) rectal veins

Dr.

Diverting blood from portal venous system to the systemic venous system by creating a communication between the hepatic portal vein and the IVC. Mavrych, MD, PhD, DSc [email protected] Side to side shunts connecting the portal system to the IVC, End to side connection with separation and connection of end and head of portal caval system to IVC. And typical splenorenal central shunt all allow portion of blood to IVC to decrease flow to liver.

Esophageal anastomosis l

Anastomosis between the tributaries of the left gastric vein (portal vein) and the tributaries of the azygous vein (SVC) in the wall of the lower end of the esophagus.

l

In portal hypertension these veins enlarge in the wall of the esophagus and later burst into the lumen of the esophagus (esophageal varices) resulting in hematemesis (vomiting red blood).

(4) R, L and middle colic vs anastamose with Esophageal branches of the L Gastric v will anastomose with azygous Renal, suprarenal and gonadal vs, No clinical Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] name however represents as varicocele on the abdomen


Rectal anastomosis

Umbilical anastomosis l

l

Anastomosis between the paraumbilical veins (portal vein) and the superior and inferior epigastric veins (SVC and IVC) in anterior abdominal wall around the umbilicus. In portal hypertension, this anastomosis gets enlarged and dilated veins form “caput Medussae” around the umbilicus.

l

l

Anastomosis between the superior rectal vein (inferior mesenteric vein and then portal vein) vein and inferior rectal vein which drains into the internal iliac vein (from IVC system). In portal hypertension (chronic alcoholics) this anastomosis gets dilated resulting in internal hemorrhoids and bleeding per anus from superior rectal vein.

Superior Rectal vein (IMV) anastomoses with middle and inferior rectal vs (internal iliac v &


Dr. Mavrych, PhD,v)DSc internalMD, pudendal [email protected] portal hypertension Rectal varices (Hemorrhoids)

Internal hemorrhoids are painless superior to pectinate line at internal rectal venous plexus. External hemorrhoids are painful due to blockage of external rectal venous plexus, where Nociceptors (pain) are located.

48. Pancreas: Head and uncinate process l

1st part of Duodenum

l

2nd part of duodenum

Cancer of the head of the pancreas

The head of the pancreas rests within the C-shaped area formed by the 1st-3rd parts of duodenum duodenum and is traversed by the common bile duct.

·

·

It includes the uncinate process which is crossed by the superior mesenteric vessels.

·

·

4th part of duodenum

Cancer of the head of the pancreas compresses the bile duct and results in OBSTRUCTIVE TYPE OF JAUNDICE. Pain will be conveyed to sensory neurons T5-T9 dorsal root ganglia via celiac plexus and greater splanchnic nerve. This type of jaundice is NOT usually associated with fever. Hepatitis also causes jaundice but is associated with the fever.

3rd part of duodenum If the cancer blocks the Wirsung duct, it can cause pancreatic enzymes to digest the


Dr. Mavrych, MD, PhD, [email protected] pancreas and theDSc spleen via splenic artery.

Neck of the pancreas

Body of the pancreas

l

3 1

Posterior to the neck of the pancreas is the site of formation of the PORTAL VEIN. VEIN


l

(1)Splenic vein joins with (2) superior mesenteric vein to form (3) portal vein.

The body passes to the left and anterior to the (1) aorta and the (2) left kidney. posterior to the stomach

l

The (3) splenic artery undulates along the superior border of the body of the pancreas with the splenic vein coursing posterior to the body. body

1 3

2 2

l

The splenic artery is tortuous and has branches going down to perforate the pancreas.



Arterial supply of the pancreas

Tail of the pancreas

Head and Duodenum: l

l

l

Dr. Mavrych, MD, PhD, DSc

The tail of the pancreas enters the splenorenal ligament to reach the hilum of the spleen spleen. It is the only part of the pancreas that is intraperitoneal. Tail of the pancreas may be mistakenly removed during spleenectomy (ligation of splenic artery and vein) and resulting in sugar diabetes because it contains a lot endocrine cells.

Endocrine pancreas contains islet of langerhans that secretes insulin (B cells glucose uptake) [email protected] and glucagon (A cells glucose release)

Annular Pancreas l

l

l 1. 2. 3. l

Annular pancreas is caused by malformation during the development of the pancreas, before birth. Occurs when the ventral and dorsal pancreatic buds form a ring around the duodenum,, thereby causing an obstruction of the duodenum and polyhydramnios Symptoms: Feeding intolerance in newborns Fullness after eating Nausea and bile-stained vomiting (Projectile vomiting) Half of cases are not diagnosed until symptoms occur in adulthood.

Polyhyrdaminos (>1500mL) AF in the amnion bc the fetus is unable to recycle Also caused by esophageal atresis. Dr. Mavrych, drink MD, and PhD, [email protected]

Relations of the Spleen and Left Kidney l

l

The spleen follows the contour of 10th rib and extends from the superior pole of the left kidney to just posterior to the midaxillary line. The border between spleen and upper pole of the left kidney is 11th rib.

parietal lateral plate mesoderm


l

l l

3 1 2

(1) Superior pancreaticoduodenal arteries - Off Common Hepatic a of branches of gastroduodenal Celiac trunk artery. (2) Inferior pancreaticoduodenal arteries - branches of SMA This region is important for collateral circulation because there are anastomoses between these branches of the CA and SMA.

Neck, Body, and Tail of the l

pancreas: Pancreatic branches of the (3) Off celiac trunk Splenic artery.


49. Spleen: RUPTURE Rapture of the Spleen l

l

l l

l

Rapture of the spleen may be result of the left 9th and 10th ribs fracture or blunt trauma of the left upper abdomen. The spleen is a peritoneal organ in the upper left quadrant that is deep to the left 9th, 10th, and 11th ribs. The spleen follows the contour of rib 10 (axis of the spleen). When blood collected deep to the diaphragm phrenic nerve irritates and pain may irradiate to left shoulder. When spleen is ruptured, it cannot be sutured therefore removing is required.

Prenatally the spleen is primary source for hematopoiesis, post birth it is site of RBC Dr. Mavrych, MD, PhD, DSc [email protected] sequester, destruction, and filtration, it produces lymphoctyes and immune surveillance, it recycles iron and globin. (Not vital organ) The spleen has gastric, colic, renal, and costal impressions. It contains many lymphatic nodules, red pulp (blood sinuses) and white pulp (germinal centers).

50. Kidney: Dimensions and position l

l

l

During life, kidneys are reddish brown and measure approximately 11-12 cm in length, 5-6 cm in width, and 2.5-3 cm in thickness. thickness They are extending from the level of T12 to the level of L3, the right kidney lying about 2-3 cm lower than the left one. The lateral border of the kidney is convex. Its medial border is convex at both ends but concave in the middle where there is the hilum of the kidney (L1).

Hilum of the kidney contains the renal v (front), renal a (middle), and ureter (back). Kidneys are intermediate mesoderm from Dr. Mavrych, MD, PhD, DSc [email protected] mesonephric duct and metanephric cap.


Anterior relations of the right kidney APICAL Pouch of Morison ANTEROSUPERIOR L2 ANTEROINFERIOR

Anterior relations of the left kidney 1. Right suprarenal gland pyramidal 2. 2nd part of the duodenum 3. Right lobe of the liver 4. Right colic flexure ascending colon to 5. Small intestine transverse colon Short renal v and Long renal a

INFERIOR

Left suprarenal gland semilunar Stomach Spleen Body of pancreas and L1 splenic vessels 5. Descending colon 6. Small intestine Long renal v and short renal a

1. 2. 3. 4.

Suprarenal glands/adrenal glands have 3 sources of bloody supply: Phrenic artery (superior), aorta (mid), and renal artery (inferior)

Dr. Mavrych, MD, PhD, DSc [email protected] APICAL POSTERIOR INFERIOR segments of posterior kideny


Renal (Gerota) fascia

Perinephric abscess Pus around the kidney within the perinephric/renal fascia

l

l

4

l

3

Enclosing the perinephric fat is a membranous condensation of the extraperitoneal fascia the renal fascia (3). The suprarenal glands (4) are also enclosed in this fascial compartment, usually separated from the kidneys by a thin septum. N.B. The renal fascia must be incised in any surgical approach to this organ.

Paranephric fat surrounds the renal fascia and collagen bundles thether the renal vessels and Dr. Mavrych, MD, PhD, DSc [email protected] kidneys in a fixed position even though supine to erect movements (~3cm) occurs during inspiration.

51. Nephrolithiasis l

l

l

l

Renal calculi are solid concretions (crystal aggregations) formed in the kidneys from dissolved urinary minerals. There are several types of kidney stones. The majority are calcium oxalate stones, followed by calcium phosphate stones. Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage (at least 2-3 mm), they can cause obstruction of the ureter (renal colic).

Kidney stones that can form and become located in Dr. Mavrych, MD, PhD, DSc [email protected] the calices of the kidneys, ureters or bladder. Renal colic is abdominal pain that courses down from loin to groin as stone moves anteroinferiorly.

l

l

l

l

Most infections of the perinephric space occur as a result of extension of an ascending urinary tract infection, commonly in association with nephrolithiasis or tuberculosis. Perinephric abscess typically descends down between 2 sheets of the renal fascia along the psoas major muscle. In case if abscess locates behind of the psoas major muscle it descends down and may affect hip joint. If abscess spreads up it’ll reach the diaphragm and irritate phrenic nerve. As result patient will feel pain in shoulder region.

loosely attached renal fascia in anterior and posterior layers can allow extension of abscess Dr. Mavrych, MD, PhD, DSc [email protected]

3 constrictions of ureter: 1

l

l l

l

2

Ureter located on the anterior surface of the Psoas major muscle and has 3 constrictions: 1st constriction is at the pelviureteric junction (level of L1) 2d constriction lies at the level of pelvic brim (level of the sacroiliac joint) 3d constriction appears where ureter lies obliquely in the wall of urinary bladder (level of ischial spine)



Staghorn calculi

52. Suprarenal glands l

l

Renal stone that develops in the renal pelvis and greater calices, calices and in advanced cases has a branching configuration which resembles the antlers of a stag. Staghorn calculi are composed of magnesium ammonium phosphate, which forms in urine that has an abnormally high pH (above 7.2). This high pH usually develops because of recurrent urinary tract infection with microorganisms such as Proteus mirabilis.

l

l

They are endocrine glands having cortex and medulla. The adrenal cortex [1] secretes aldosterone,, corticosteroids and genital hormones.

The chromaffin cells of the adrenal medulla [2] secrete two catecholamines: epinephrine and norepinephrine, which affect smooth muscle, cardiac muscle, and glands in the same way as sympathetic l stimulation. 2 l Sympathetic stimulation or hypersecretion of catecholamines ((tumor tumor of adrenal medulla or sympathetic chain ganglia)) resulting in: episodes of tachycardia, sweating and high blood pressure. Congenital Adrenal Hyperplasia (CAH): Nephroptosis: Drop kidney >3cm when standing, suprarenal glands stay in place within perinephric fat, ureters coil/kink. excessive androgen production bc of cortex Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Ectopic kidneys: abnormal location and formation congenitally. hyperplasia causing virilization of female genitals Horseshoe kidney: inferior poles of kidneys fuse during embryonic development and are inhibited from ascending by IMA Pancake kidney: inferior and superior poles of kidneys fuse into disc shape organ, also inhibited by IMA. Pelvic kidney: failure of ascent of kidneys so they remain in pelvic region still attached to embryological renal vessels off common iliacs. Renal agenesis (absent of kidneys) is common cause of oligohydraminos (<400mL AF) that can lead to pulmonary hyperplasia. Hydronephrosis: extreme dilation of renal pelvis and calices due to obstruction of renal ureters, typically due to accessory renal vessels.

Unpaired tributaries of IVC l

3 2 l

1 4

l

1

53. Varicocele

The right renal (1) vein is much shorter than the left. Both veins lie anterior to the corresponding artery in hilum of kidneys. The long left renal vein (2) is joined by the left suprarenal (3) and left gonadal (4) (testicular or ovarian) veins before it reached IVC.

l

l

l l

Right suprarenal vein and right gonadal vein drain directly to IVC (unpaired IVC tributaries).


It is enlargement of the pampiniform plexus that produces a wormlike scrotal mass and enlargement of the spermatic cord. Varicocele may be reason of low sperm count. Varicocele formation is usually on the left side and may disappear in supine position of the body. Varicocele may indicate kidney disease or may signal a retro peritoneal malignancy obstructing the testicular vein.

Nutcracker Syndrome: L Renal v passed UNDER the SMA ABOVE Aorta. Compression will cause backflow into the Dr. Mavrych, MD, and PhD, DSc [email protected] L gonadal vein to pampiniform plexus. . May be mistaken for Hydrocele (fluid/blood) within tunica vaginalis of the scrotum, but when lying down Hydrocele DOES NOT Disappear!

Pampiniform plexus 54. Hydrocele l

l

l

Each testicular or ovarian vein is formed by coalescence of a pampiniform plexus: plexus the testicular at the deep inguinal ring, the ovarian at the margin of the superior aperture of the pelvis. The veins run accompanied by the corresponding arteries. The left pampiniform plexus enters the left renal vein; the right one enters directly the IVC inferior to the renal vein. That is why varicocely (engorgement of the pampiniform plexus that produces a scrotal mass) is more often located on

the left.


l

l

l

The tunica vaginalis testis or other remnants of the processus vaginalis may form a hydrocele or hematocele. In spermatic cord it is smooth sausage-shaped structure that persists under gentle compression and isn’t disappear in supine position. In the scrotum with transillumination, a hydrocele produces a reddish glow, whereas light will not penetrate other scrotal masses such as a hematocele, solid tumor, or herniated bowel. spermatocele

Testicular torsion is twisting of the testis within the scrotum, it can cause ischemia to the blood vessels Dr. Mavrych, MD, PhD, DSc [email protected] and must be corrected quickly or may lose testis. Cryptochidism: failure of testis to descend by age 6-9mo can cause infertility


55. Hemorrhoids: Venous drainage from rectum l

2

4

l

External hemorrhoids

Above pectinate line: superior rectal vein [1] into portal system [2]. PAINLESS

l

l

Below pectinate line: inferior rectal vein [3] into inferior vena cava [4]. PAINFUL

l

1

1

3

1



56. Perineal pouches: Deep perineal pouch

Internal hemorrhoids

2 2 2

Hemorrhoids are masses that typically protrude from anus during defecation. Hemorrhoids are commonly associated with constipation, extended sitting and straining at the toilet, pregnancy, and disorders that hinder venous return. 1. External hemorrhoids are dilated tributaries of the inferior rectal veins (IRV) BELOW THE PECTINATE LINE and are painful because the mucosa is supplied by somatic afferent fibers of the inferior rectal nerves (from pudendal).

l

2. Internal hemorrhoids are dilated tributaries of the superior rectal veins (SRV) ABOVE THE PECTINATE LINE and are not painful because the mucosa is supplied by visceral afferent fibers.

l

Internal hemorrhoids frequently develop in chronic alcoholics because of liver cirrhosis and portal hypertension syndrome.


Bound inferiorly by perineal membrane and superiorly by pelvic diaphragm. The deep perineal pouch is formed by the fasciae and muscles of the urogenital diaphragm. It contains: 1. Sphincter urethrae muscle 2. Deep transverse perineal muscle 3. Bulbourethral (Cowper) glands (in the male only)) - ducts perforate perineal membrane and enters bulbar urethra. Dorsal neurovascular structures of the glans penis and clitoris Dr. Mavrych, MD, PhD, DSc [email protected]

Bound laterally by Ishiopubic rami

Superficial perineal pouch 1. Ischiocavernosus muscle – related to the Crus of the penis (Male) & Crus of the clitoris (Female) 2. Bulbospongiosus muscle – related to the Bulb of & deep internal pudendal vessels and pudendal n (dorsal VAN) vestibule (Female) & Bulb of the penis (Male)

Urine leaks

Straddle injury or false passage of catheter After a crushing blow or a 3. Superficial transverse perineal muscle – related to the penetrating injury, the spongy Perineal body (both genders) urethra commonly ruptures within the bulb of the penis,, and 1 urine leaks into the superficial perineal pouch. 2 l The superficial perineal fascia keeps urine from passing into the 3 thigh or the anal triangle, but after distending the scrotum and penis, urine can pass over the pubis into the anterior abdominal wall deep to the deep layer of superficial abdominal fascia. Fractures of the pelvic girdle can rupture the intermediate urethra and cause extravasation of urine and blood into deep peritoneal pouch that may Dr. Mavrych, MD, PhD, [email protected] Mavrych, MD, pass PhD,through DSc [email protected] Essential for integrity of theDSc pelvic floor, Damage leads to prolapse of uterus, rectum, and urinaryDr. bladder urogenital hiatus to bladder and prostate. Males: between bulb of penis and anus, Females: between vagina and anus Congenital persistence of allantois into urachus of the umbilicus can cause Episiotamies in mediallateral incisions are made to widen pouch for labor, and to fix prolapses. urine to leak from belly button. l


57. Ischiorectal abscess l

l

2

l

3 1

58. Cystocele (hernia of bladder)

Ischiorectal abscess [1] is an important surgical condition which usually results from spread of an infection through the external sphincter ani into the ischiorectal fossa [2]. Ischiorectal abscess is a surgical emergency which should be immediately drained by a wide cruciate incision through the skin of the base of the fossa to avoid fistula formation. A surgeon should avoid lateral wall of ischiorectal fossa because here located Pudendal (Alcock's) canal [3] with pudendal nerve and internal pudendal artery.

Fistulas are abnormal connections of organs and Dr. Mavrych, MD, PhD,Ischiorectal DSc [email protected] tissues, abscesses can travel to both sidess and spread infection through the fat fad that raps posteriorly around the rectum. Incisions must be made as medial as possible. If Pudental canal is affected there will be no arousal. Abscesses are also prone to supralevator, internsphincteric, or perianal.

59. Paracentesis of Urinary cystotomy of a full bladder, as the Bladder Suprapubic empty bladders lies just at height of pubis

l

l

In extreme cases it can lead to vaginal prolapse


60. Prostate tumors: Prostate cancer l

Sup Suprapubic aspiration: l Urine can be removed from the bladder without penetrating the peritoneum by inserting a needle JUST ABOVE the pubic symphysis. l The needle passes successively through skin, superficial and deep layers of superficial fascia, linea alba, transversalis fascia, extraperitoneal connective tissue, and wall of the bladder.

Loss of bladder support in females by damage to the pelvic floor during childbirth (e.g., laceration of perineal muscles or a lesion of the nerves supply). It can result in protrusion of the bladder onto the anterior vaginal wall and loss of urine when a women strains or coughs.

l

It usually begins in the posterior lobe of the gland, and early stages are often asymptomatic, may be found during digital rectal examination. Full bladder during exam to keep prostate in place Prostatic malignancies tend to metastasize to vertebrae and the brain because the prostatic venous plexus has numerous connections with the vertebral venous plexus via sacral veins. veins

M

Benign hypertrophy of prostate (BHP) is common after middle age in majority of males distorts the prostatic urethra (middle lobe). Malignant tumors are irregular and hard and often found in posterior lobe due to its Dr. Mavrych, MD, PhD, DSc [email protected] proximity to seminal vesicles and lymph. A

P

does not transverse peritoneum


Benign hypertrophy of the prostate (BHP) typically middle lobe l l

l

l

BHP is common in men after middle age. Prostate adenoma (benign hypertrophy) usually involves median lobe. lobe BHP is a common cause of urethral obstruction, leading to nocturia (need to void during the night), dysuria (difficulty and/or pain during urination), and urgency (sudden desire to void). The prostate is examined for enlargement and tumors by DIGITAL RECTAL examination.

Prostatectomy A prostatectomy may be performed through a suprapubic [1] or perineal [2] incision or transurethrally [3]. l Because of damage to nerves in 1 the capsule of the prostate and around the urethra (cavernosus nerves) can cause impotence (erectaile dysfunction) and/or urinary incontinence. l Pelvic splanchnic nerves may be 3 injured in case of intensive dissection of pelvic lymph nodes Transurethral (prostatic cancer ectomy) and as resection of the th result autonomic innervation of prostate = TURP TUR derivate of hindgut may be allows preservation of affected. neurovasculature l

2

Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Posterior lobe is mostly metastatic and spreads via Batson's plexus (male has lower back pain)


61. Male urethra Prostatic 1st part

Membranous 2nd part

It is the widest and the most dilatable part. l It is spindle shaped (middle part is dilated) l Its posterior wall presents the following features: opening of seminal glandscolliculus 1. Seminal 2. Openings of the 2 ejaculatory ductus deferens ducts are seen on each side on the seminal colliculus. 3. Ducts of the prostate gland open into the male urethra l

l

l

l

l

Passes through the urogenital diaphragm to enter the bulb of the penis It is the shortest, NARROWEST and the least dilatable part It is surrounded by the external sphincter urethra Bulbourethral glands lie posterolateral to this part inside of urogenital diaphragm (deep perineal pouch)

Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Seminal vesicles secrete alkaline fructose solution that nourishes and provides energy for the sperm. Prostate gland secretes a milky fluid (20% of semen volume) and plays role in sperm activation. Bulbourethral glands (cowper's glands) secrete mucous solution that neutralizes urine within the urethra.

Spongy 3rd part

2 sphincters of the urethra l l

l

l

Longest part: average 15 cm in length. Passes through the bulb and corpus spongiosum of the penis to open at the external urethral orifice on the tip of the glans penis. There are two dilatations – bulbar fossa (in the beginning) and navicular fossa (in the glans penis) Ducts of the bulbourethral glands open into the floor of the spongy part in its beginning

1. Internal urethral sphincter is made of smooth muscles in the neck of the bladder and has sympathetic innervation

1

2. External urethral sphincter has skeletal muscle fibers and surrounds the membranous part of urethra, supplied by the perineal branch of the pudendal nerve

2

The 1st and 2nd parts of the urethra are urogenital endoderm and the external urethra meatus is ectoderm The ductus deferens is intermediate mesoderm of the remaining mesonephric duct/tubules Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Muscle of the bladder is Detrusor m, the urinary trigone is where the entrance of the 2 ureters and exit of bladder meet. Internal urethral sphincters are involuntary.

63. Pudendal nerve (S2-S4)

62. Ejaculatory duct l

l

l

It is a very narrow duct 2 cm long Formed by union of ductus deferens and duct of seminal vesicle It serve to passage of seminal fluid from ductus deferens to prostatic urethra.

It is PRINCIPAL SOMATIC ((motor motor and sensory) nerve to supply perineum. l Lies against ischial spine as it passes through lesser sciatic foramen to traverse pudendal canal on lateral wall of ischiorectal fossa. Branches: l 1. Inferior rectal nerve l

3

1 2

l

Dr. Mavrych,CREMASTERIC MD, PhD, DSc [email protected] REFLEX: Genitofemoral

Supplies external anal sphincter muscle and skin around anus 2. Perineal nerve l Deep branch is motor nerve to muscles of urogenital triangle. l Superficial branch gives cutaneous posterior scrotal/labial branches. 3. Dorsal nerve of penis or clitoris l Supplies body, prepuce, and glans of penis or clitoris l

l

Dr. Mavrych, PhD, DSc [email protected] nerve L1-2, Genital branch: withinMD, inguinal canal with the cremasteric m and fascia acts as motor division to pull testis up. Femoral branch is the sensory division of the reflex that is stimulated by touch and temperature


Pudendal nerve block To relieve pain for the mother and prepare for an episiotomy, a pudendal nerve block may be administered during early labor. The nerve may be blocked in 2 ways either: 1. by piercing the vaginal wall posterolaterally near the ischial spine or 2. percutaneously along the medial side of the ischial tuberosity. l Note: Pain from uterine contractions is unaffected because pelvic visceral pain is carried by afferent fibers accompanying autonomic nerve fibers. Doctors hand is placed between the baby's head and the pudendal nerve. l


Micturition reflex

64. Nerve supply of pelvic viscera Parasympathetic innervation: l Preganglionic neurons are located in sacral parasympathetic n. (S2-S4) in the spinal cord. l Their processes run into pelvic splanchnic nerves and relay with postganglionic neurons located inside of pelvic organs in the intramural plexus. plexus Sympathetic innervation: l Sympathetic fibers of preganglionic neurons T12-L2 segments (IML) come through the sympathetic trunk and form sacral splanchnic nerves. l They contribute to the inferior hypogastric plexus, plexus where postganglionic neurons are located. Branches of inferior hypogastric plexus reach organs wrapping around the branches of the internal iliac artery. Sensory innervation: l The sensory fibers from S2-S4 dorsal root ganglia move together with parasympathetic and carry pain sensations from the organs.

PNS Pelvic Splanchnic nerves to intramural plexus Sympathetic Trunk to Sacral Splanchnic nerves to inferior hypogastric plexus Dr.SNS Mavrych, MD, PhD, DSc [email protected] Sensory DRG ride with PNS for PAIN

65. Erection and ejaculation l

1

2

3

Facilitating emptying: l Parasympathetic fibers (pelvic splanchnic nn.) stimulate DETRUSOR MUSCLE [1] contraction and involuntary relax internal sphincter [2]. l Somatic motor fibers (pudendal nerve) cause voluntary relaxation of external [3] urethral sphincter. Inhibiting emptying: l Sympathetic fibers (sacral .) inhibit detrusor splanchnic nn.) muscle [1] and stimulate internal sphincter [2].

PNS & Pudendal to pee! SNS to stop! Dr. Mavrych, MD, PhD, DSc [email protected]

l

l

l

Dr. Mavrych, MD, PhD, DSc [email protected] 1. Erection: PNS S2-4 fill blood, Ischiocavernosus m keeps erect, and bulbospongiosus m prevents venous drainage. 2. Emission: SNS move sperm from epididymis and cause gland secretions 3. Ejaculation: SNS Closure of Internal sphincter, contraction of urethral m and bulbospongiosus m 4. Remission: blood leaves

67. Torsion of the spermatic cord

66. Cryptorchism l

l

Afferent fibrous: Dorsal nerve of penis or clitoris from Pudendal nerve (DRG S2-S4) Efferent fibrous: l Erection: Parasympathetic fibers (S2-S4) from the Pelvic splanchnic nerves dilate arteries supplying erectile bodies of the penis, allowing them to fill with blood. Somatic motor (S2-S4) fibrous from the pudendal nerves cause contraction of ischiocavernosus and bulbospongiosus muscles to press the root of the penis and relax external urethral sphincter. l Ejaculation: Sympathetic fibers (L1-L2) from the Inferior hypogastric plexus (Sacral splanchnic nerves) cause contraction of smooth muscle of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers stimulate internal urethral sphincter to prevent semen from entering bladder or urine entering prostatic urethra.

Undescended testes (cryptorchism) when the testes fail to descend into the scrotum. This normally occurs within 3 months after birth. The undescended testes may be found in the abdominal cavity or in the inguinal canal. If neglected, malignant transformation may occur in the undescended testis. N.B. In case of cryptorchism, spermatogenesis is arrested and the spermatogenic tissue is damaged leading to permanent sterility in bilateral cases.


Main components of the spermatic cord: l Ductus deferens l Testicular artery – direct branch of Aorta l Pampiniform plexus to become single testicular vein (right ! IVC, left ! Left renal vein) l

l

Torsion of the spermatic cord produces acute pain with swelling because of twisting of testicular artery that can result in testicular avascular necrosis. Repair requires a high scrotal incision to untwist the cord,, and the testis is sutured to the scrotal septum to prevent recurrence.



68. Lymphatic drainage of the male viscera n

n

n

Testis & epididymis – lumbar lymph nodes Scrotum – superficial inguinal nodes Penis: n n n

n

n

Lymphatic drainage from the female viscera n

n

skin - superficial inguinal nodes glans – deep inguinal nodes body and roots – internal iliac nodes

n

Prostate gland & bladder - internal iliac nodes Anal canal: n n

above pectinate line - internal iliac below pectinate line - superficial inguinal nodes

n

n


Ovary and uterine tubes – to Lumbar lymph nodes Uterus: n lateral angle and teres ligament – Superficial inguinal lymph nodes n fundus and upper part of the body - Lumbar lymph nodes n lower part of the body - External iliac lymph nodes n cervix - External & Internal iliac Vagina: n Superior to hymen - to External & internal iliac n Inferior to hymen - to Superficial inguinal nodes All external genitalia (with exception glans clitoris) - Superficial inguinal lymph nodes Glans clitoris – Deep inguinal


Deep inguinal nodes-> superficial inguinal nodes-> internal & external iliac nodes-> lumbar nodes-> paraaortic nodes-> thoracic duct

69. Arterial supply of the uterus and Hysterectomy 4 2 1 3

Hysterectomy l

The uterus is almost exclusively supplied by the uterine arteries [1] (from internal iliac artery): l Uterine a. crosses pelvic floor in cardinal ligament [2] passessuperior below the l Ureter passes andUterine anterior(bridge to uterine artery[3] artery over water) l Ascending branch [4] of uterine artery comes along lateral wall of uterus within broad ligament.

l

l

Note: During hysterectomy ureter in the greatest risk because of close relations with uterine artery and cervix of the uterus.

Uterine a anastamosis with Ovarian a from aorta on lateral sides of the uterus. Both need to be taken out so that the pt does not bleed out. Dr. Mavrych, MD, PhD, DSc [email protected] . The Uterine a is homologous to the ductus deferens a in males and the Ovarian a is the testicular a in males

70. Parts of the uterine tube oviduct, fallopian tube, ovarian tube... l

Hysterosalpingography

Pierces uterine wall to Cornua open into uterine cavity

of the uterus

4

l

3

Narrowest part of tube just lateral to uterus

2

Ampulla l

l

l


Isthmus l

l

No contraction of bladder and no relaxation of internal sphincter.

Uterine part l

l

Hysterectomy is surgical removing of the uterus and may include removing of the cervix (total) and the vagina (radical). Blood supply to the ovaries is saved in case of partial hysterectomy ovarian suspensory ligament should be left intact because contain ovarian artery (direct branch of abdominal aorta) and vein. In case of total hysterectomy (with cervix) pelvic splanchnic nerves may be affected. That’s resulting in bladder dysfunction because of detrusor urine muscle loose parasympathetic innervation.

Medial continuation of infundibulum comprising about half of uterine tube Usual site of fertilization

1

Infundibulum l

l

Funnel-shaped expansion of lateral end, fringed with fimbriae Overlies ovary and receives oocyte at ovulation

Ampulla is the site of ectopic pregnancy if the fertilized Dr. Mavrych, MD, PhD, [email protected] ovum does notDSc make its way to the fundus of the uterus.

The instillation of viscous iodine through the external os [1] of the uterine cervix allows the lumen of the cervical canal [2],, the uterine cavity [3],, and the different parts of the uterine tubes [4] to be visualized on X-ray.

Can be used to detect uterine tube obstructions or malformations of uterus/ vagina (bicornate uterus)


The Uterine Triad: Fallopian tube, Round lig of uterus (inguinal canal), and ovarian lig come off the fundus of the uterus.


71. Branches of the Internal iliac artery Anterior Division

Posterior Division

1. Obturator

1. Iliolumbar

2. Umbilical

w/ superior vesicle of bladder

3 Inferior gluteal

goes back up

2. Lateral sacral

to medial sacral a

3. Superior gluteal

4. Internal pudendal

Internal iliac artery

between lumosacral trunk & S1

alcock's canal

to medial sacral a obturator canal gluteus maximus maxi urachus

5. Inferior vesical (males) bladder or Vaginal (females)

gluteus med & min

bladder

6. Middle rectal 7. Uterine (females)

coccygeus m

ductus deferens

aberrant or accessory arteries are common in obturator, inferior vesicle



72. Fracture of the anterior cranial fossa l

genitals

Craniosyntosis-FGFR2 gene mt

73. Cranial Malformations

Fracture of the anterior cranial fossa (Cribriform plate of the Ethmoid bone) is suggested by anosmia, periorbital bruising (raccoon eyes), and CSF leakage from the nose (rhinorrhea).

l

l

l


74. Epidural hematoma


Bean Bleed

Skull fracture near pterion often causes epidural hematoma from torn middle meningeal artery (foramen spinosum). spinosum) l Unconsciousness and death are rapid because the bleeding dissects a wide space as it strips the dura from the inner surface of the skull, which puts pressure on the brain. l An epidural hematoma forms a characteristic biconvex pattern on computed tomography images. can push uncus through foramen magnum and compress CNIII causing pupillary dilation (SNS) bc no PNS to constrictor, eye points down and out (CNVI and IV take over), ptosis bc levator palpebrae m Dr. Mavrych, MD, PhD, DSc [email protected] Subdural Hematoma: blood spread over brain, Shaken Baby Syndrome, coup and counter coup injuries, cause bleeding from bridging veins l

[A] Scaphocephaly: premature closure of the sagittal suture, in which the anterior fontanelle is small or absent, results in a long, narrow, wedge-shaped cranium. [C] Oxycephaly: premature closure of the coronal suture results in a high, tower-like cranium. When premature closure of the coronal or the lambdoid suture occurs on one side only, the cranium is twisted and asymmetrical, a condition known as plagiocephaly [B].

76. Infection of the Cavernous sinus Structures which may be affected by cavernous sinus thrombosis: thrombosis 1. Structures that pass through sinus directly: Ø Internal carotid artery (in case of laceration - arteriovenous fistula) Ø Abducens nerve CN VI (in case of lesion - internal squint) 2. Ø Ø Ø Ø

Structures on lateral wall of sinus: Oculomotor nerve (CN III) Trochlear nerve (CN IV) V1 V2

Medial Rectus adduction takes over (cross-eyed) initially, if bleed persists structures will be affected: loss of eye movements and Dr. Mavrych, MD, then PhD,lateral DSc wall [email protected] visual acuity. Loss of sensory to face


77. Pituitary gland tumors and transsphenoidal operation

Dangerous triangle of the face

2 l

l

1 l

The middle third of the face is a "danger area“ because infection there may produce thrombophlebitis of the facial vein that can spread to the cavernous sinus via swelling of v w/ blot ophthalmic veins or clot that goes to brain pterygoid venous plexus.

l

l

Septicemia leads to meningitis and cavernous sinus thrombosis, both of which can cause neurological damage and are lifethreatening. bacterial infection response

3

Facial v (cheeks)-> angular v (lateral nose)-> opthalmic v (super& inferior eye)-> Cavernous sinus (BRAIN)


Hormones of the pituitary gland l

l

Releasing and inhibiting factors from neurosecretory cells of the hypothalamus reach pituitary gland thought special capillary network – hypophyseal portal system and control the production of adenohypophyseal hormones (ACTH, FSH, LH, TSH, prolactin and somatotropin). Hormones of neurohypophysis (ADH and Oxytocin) are secreted in hypothalamus and transported through axons to pituitary gland.

ACTH-> adrenal gland-> cortisol FSH-> follicles of ovaries LH-> ovaries and leydig cells Dr. Mavrych,TSH-> MD, PhD, DSc [email protected] thyroid gland for release of T4&T3 TH Prolactin-> mammary gland Somatotrophin-> GH -> bones and muscles . ADH/Vasopressin to collecting duct and DCT of nephron-> water reabsorption Oxy to uterus for uterine contractions and orgasm

79. Bell's palsy

Can be corrected using CNXI spinal accessory n transplant l

l

l

It is idiopathic unilateral facial paralysis. Terminal branches of CN VII may be injured by parotid cancer or inflammation injury as passes (parotitis) by surgery to through parotid gland remove a parotid tumorw/ retromandibular v foramen).and external carotid a (stylomastois foramen) foramen

Manifestations: l unable to close lips and eyelids on affected side l eye on affected side is not lubricated (dry eye) l unable to whistle, blow a wind instrument, or chew effectively l facial distortion due to contractions of unopposed contralateral facial muscles

Lesion of CNVII at internal acoustic meatus causes no saliva/tears, hyperacoustics (stapedius m), imbalance and distorted hearing (CNVIII) Mavrych, MD,ganglion PhD, DSc [email protected] LesionDr. past geniculate causes hyperacoustics and Bell's Lesion at chorda tympani causes no taste, no saliva from submandibular& sublingual glands Lesion at stylomastoid foramen causes Bells

Pituitary tumors [1] may extend superiorly through opening in the diaphragma sella, producing disturbances in endocrine system. system Superior extension of a tumor may cause visual deficit owing to pressure on the optic chiasm [2], the place where the optic nerve fibers cross. The transsphenoidal operation is the most common operation for a pituitary tumor. The surgical approach for it is through the nose, nasal cavity and sphenoidal sinus [3] [3]. This surgical approach provides the best exposure of the tumor at the lowest risk.


78. Trigeminal nerve

1

Infraorbital foramen

2

l

Skin of face supplied by branches of the three divisions of the [1] TRIGEMINAL NERVE (CN V)

l

Except for a small area over the angle of the mandible which is supplied by the [2] great auricular nerve (C2-C3) – cervical plexus

CNV1: sensory to forehead, sinuses, nose, dilator pupillae (SNS) and sensory Dr. Mavrych, MD, PhD, DSc [email protected] blinking reflex, (VII is motor) CNV2: sensory to cheeks, nose, upper mouth, tears (SNS/PNS) CNV3: sensory to chin, lower mouth, ant 2/3 tongue (taste is VII), ears, scalp, muscles of mastication

80. Epistaxis l

Epistaxis (nosebleed) most often occurs from the anterior nasal septum (Kiesselbach's area), where branches of the sphenopalatine, anterior ethmoidal, greater palatine, and superior labial (from facial) arteries converge.

Dr. Mavrych, MD, PhD, DSc [email protected] Splenopalantine and Greater palantine as are most vulnerable bc they are in Atrium of middle meatus


81. Sinusitis Sphenoiditis

Ethmoiditis l

l

l

Relationships of the sphenoidal sinus are clinically important ; because of potential injury during pituitary surgery and the possible spread of infection. Infection can reach the sinuses through their ostia from the nasal cavity or through their floor from the nasopharynx. Infection may erode the walls to reach the cavernous sinuses, pituitary gland, optic nerves, or optic chiasma


l

l

Infection in the ethmoidal sinuses can erode the medial wall of the orbit, resulting in orbital cellulites that can spread to the cranial cavity. In orbital cavity infection may erode structures related to the medial orbital wall: l Medial rectus muscle l Superior oblique muscle l Nasociliary nerve

No adduction, no down and out rotation of the eye, and constricted pupils w/ lack of corneal reflex (sensory: touch eye and no blink)


Temporal Maxillary Junction

84. Movements at the TMJs

83. Cheeks l

1 2

l

l

3 l

Form the lateral, movable walls of the oral cavity and the zygomatic prominences of the cheeks over the zygomatic bones. Buccinator [1] – principal muscle of the cheek. Buccal pad of fat – encapsulated collection of fat superficial to buccinator. Parotid duct [2] from Parotid gland [3] perforate buccinator and opens in inner surface of the cheek right opposite 2nd upper molar tooth


85. Innervation of the tongue

Lick your wounds

1. Sensory anterior 2/3:: general – lingual n. (V3), taste – chorda tympani (CNVII) 2. Sensory posterior 1/3:: general and taste – glossopharyngeal (CNIX) 3. Motor – hypoglossal (CNXII) Ø A lesion of the chorda tympani – lose of the taste sensation anterior 2/3 of the tongue Ø A lesion of the lingual nerve – lose of both general and taste sensation anterior 2/3 of the tongue bc chorda tympani runs with lingual n Ø A lesion of CN XII (hypoglossal canal) allows the contralateral, unparalyzed genioglossus muscle to pull the protruded tongue toward the paralyzed side (deviation and atrophy of the tongue).

weaker unparalyzed genioglossus m is unable to maintain contraction of Dr. Mavrych, MD, PhD, DSc [email protected] tongue out, the opposite side takes over and pushes tongue to the side of lesion.

Note: In case of mandibular nerve damage mandible (when it is protruded) deviate toward the side of lesion because of Lateral pterygoid weakness.

All 4 muscles of mastication are innervated by V3: 1. Temporalis – elevation & retraction 2. Masseter - Strong elevation 3. Medial closes jaw pterygoid elevation 4. Lateral Only muscle to pterygoid -open jaw/mouth protrusion

Tensor veli palatini m prevents inhale of food and equalizes the air Dr. Mavrych, MD, PhD, DSc [email protected] pressure protect tympanic membrane Tensor tympani dampens the sound from chewing

86. Gag reflex l

l

Touching the posterior part of the pharynx results in muscular contraction of each side of the pharynx - gag reflex: l Afferent limb: CN IX l Efferent limb: CN X Injury to the GLOSSOPHARYNGEAL NERVE (CN IX) will result in a negative gag reflex No longer sensed

Touching the soft palate or posterior pharynx will be sensed via CNIX pharyngeal branch (afferent) and stimulate a response (efferent) through CNX pharyx, larynx, and palate ms to "gag"



87. Palatine tonsils

Tonsillitis l

l

l

l

Receives main blood supply from tonsillar branch of facial artery Drained by lymph vessels mainly to jugulodigastric lymph node, which is body's most frequently enlarged lymph node Nerve supply: tonsillar plexus of nerves formed by branches of CN IX and CN X

l

l

During palatine tonsillectomy, the peritonsillar space facilitates tonsil removal, except after capsular adhesion to the superior constrictor. If the glossopharyngeal nerve CNIX is injured, taste and general sensation from the posterior 1/3 of the tongue are lost. Hemorrhage may occur, usually from the tonsillar branch of the facial artery; if the superior constrictor is penetrated, a high facial artery or tortuous internal carotid artery may be injured.

Found between Faucel Pillars and become highly inflamed during infection Tonsilectomy and adenoectomy can risk the tonsilar a and v. . Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Pharyngeal, Tubal, Palatine, Lingual Tonsils (Waldeyer's ring of lymph tissue)

88. Muscles of Soft Palate

89. Lymph drainage from face structures

CNV3 prevents inhalation of food & equalizes 1. Preauricular (parotid (parotid ) (on front pressure to protect tympanic membrane 1. Tensor veli palatini and of auricle) receive lymph from 2. Levator veli palatini – elevates anteriolateral part of scalp the soft palate during swallowing (including eyelids) to prevent food entering to the 2. Submandibular (in digastric or 1 nasopharynx submandibular ") – from all air 3. Palatoglossus and sinuses, nose and adjacent cheek, upper lip and lateral 4. Palatopharyngeus – depress parts of lower lip. soft palate and pulls walls of pharynx superiorly 3. Submental (in submental ") – 3 2 from the chin, tip of the tongue 5. Uvular muscle – shortens uvula and central part of the lower and pulls it superiorly lip. CNX innervation via pharyngeal branch ALLOWS EFFICIENT SWALLOWING! Lesion to Vagus can be seen as Uvula deviation to opposite of lesion Triangles of neck: Dr. Mavrych, MD, PhD, DSc [email protected] Dr. Mavrych, MD, PhD, DSc [email protected] Carotid: post digastric, omohyoid, SCM contain internal jugular v, common carotid a, and vagus Swallowing has 3 stages: Submandibular/submental: growth of lip can be throat cancer (CNVII, XII) 1. chew to create bolus (CNV3), tongue rise to hard palate (CNX, IX, VII, XII), Muscular: isthmus of thyroid larynx and trachea hyoid elevates, and fauceal pillars up and back Posterior: Trapezius, SCM, clavical contain ext jugular v, and brachial plexus 2. Seal nasopharynx w/ soft palate and epiglottis (CNX) 3. constrictors contract and pull up larynx to push bolus down

90. Blow-out fracture No look down, no sensation to upper mouth and bleeding from branch of external carotid a l A blow-out fracture of the orbital floor typically is not involve the orbital rim and is caused by blunt trauma to the orbital contents (e.g., by a handball). Content of orbital cavity blow-out in maxillary sinus. l Blow-out fractures may damage: 1. Inferior rectus muscle 2. Infraorbital nerve (from maxillary V2) Branches of External Carotid Artery 3. Infraorbital artery Some = Superior Thyroid A. (hemorrhaging). Angry = Ascending Pharyngeal A. Lady = Lingual A. Found = Facial A. Dr.Out Mavrych, MD,A.PhD, DSc [email protected] = Occipital

P = Posterior Auricular A. M = Maxillary A. S = Superficial Temporal A.

91. Muscles of the orbit

Muscle Superior rectus Inferior rectus Medial rectus Lateral rectus Superior oblique Inferior oblique Levator pulpebra superior

Action Elevates and adducts pupil Depresses and adducts pupil Adducts pupil Abducts pupil Depresses and abducts pupil Elevates and abducts pupil Elevates upper eyelid


Innervation CN III CN III CN III CN VI CN IV CN III CN III


92. Strabismus Eyes are not aligned Oculomotor Nerve Palsy (CNIII)

Trochlear Nerve Palsy (CNIV)

Oculomotor Nerve Palsy (external squint) affects most of the extraocular muscles l Manifestations: levator palpebrae superioris is out l ptosis, . l fully dilated pupil, constrictor pupilae (PNS) is out l and eye is fully depressed and abducted (“down and out”) due to unopposed actions of superior oblique and lateral rectus, respectively. Eyes are looking in opposite directions

Lesions of this nerve or its nucleus cause paralysis of the superior oblique and impair the ability to turn the affected eyeball infero-medially (pupil look superio-laterally) The characteristic sign of trochlear nerve injury is diplopia (double vision) when looking down (e.g., when going down stairs)

l

l

l

No cheating muscle (down and out) l The person can compensate for the person will turn head to mimic contraction

diplopia by inclining the head anteriorly and laterally toward the side of the normal eye.

inferior oblique is unopposed so eye looks up and out Dr. Mavrych, MD, PhD, DSc [email protected]

Abducens Nerve Palsy (CNVI)


93. Horner syndrome Sympathetic trunk compression l

l

l

Abducens Nerve Palsy (internal squint). Injury to abducens nerve ® paralysis of lateral rectus ® inability to abduct the affected eye Affected eye is fully adducted by the unopposed action of the medial rectus that is supplied by CN III


94. Otitis Media

Middle ear inflammation

l

l

l

l

Hearing is diminished because of pressure on the eardrum and CNVIII reduced movement of the ossicles. Taste may be altered because the chorda tympani is affected.CNVII Infection spreading posteriorly cause mastoiditis. Infection that spreads to the middle cranial fossa can cause meningitis or temporal lobe abscess, and infection moving through the floor may produce sigmoid sinus thrombosis.


l

Penetrating injury to the neck, Pancoast tumor, or thyroid carcinoma may cause Horner syndrome by interrupting ascending preganglionic sympathetic fibers anywhere between their origin in the T1 segment (IML) of spinal cord and their synapse in the Superior cervical ganglion. It includes the following signs: l Constriction of the pupil (miosis) PNS l Drooping of the superior eyelid sup. tarsal (ptosis), paralysis l Redness and increased temperature of the skin (vasodilation) l Absence of sweating (anhydrosis)

m


Perforation of the Tympanic Membrane May result from otitis media and is one of several causes of middle ear (conduction) deafness l Causes: foreign bodies in external acoustic meatus, excessive pressure (as in diving), trauma l Because chorda tympani directly Pars flaccida relates to the posterior surface of the tympanic membrane it may be damaged and resulting in loss of taste over anterior 2/3 of the tongue Umbo and secretion of the sublingual and refracted cone of light submandibular glands l Minor perforation heal spontaneously; pars tensa large ones require surgical repair l


Anterior inferior incisions based on cone of light for surgery


95. Thyroid and parathyroid glands

Anatomical relations of tthe o e thyroid t y o d gland ga d

Hormones: l The thyroid gland is the body's largest endocrine gland. It produces thyroid hormone (T3 & T4), which controls the rate of metabolism (increase the temperature of the body), and calcitonin, a hormone controlling calcium metabolism (reduce decrease osteoclasts blood calcium Ca2+). l After total thyroidectomy may develop lower temperature of the body and hypercalcemia. l

The hormone produced by the parathyroid glands, parathormone (PTH), controls the metabolism of phosphorus and calcium in the blood (increase Ca2+ level).increase osteoclasts

l

1

l

l

1 l

1

Anterolateral – infrahyoid muscles Posterolateral – COMMON CAROTID ARTERY [1] Medial – larynx, TRACHEA [2], pharynx, esophagus, cricothyroid muscle, recurrent laryngeal nerve [3] Posterior – parathyroid glands [4]

3

Superior thyroid a off external common carotid and inferior thyroid gland off thyrocervical trunk of subclavian Dr. Mavrych, MD, PhD, DSc [email protected] External laryngeal n w/ superior thy a & Recurrent laryngeal n w/ inferior thy a

CS of the neck

Recurrent laryngeal n to laryngeal ms (PCA*) abducts vocal cords Dr. Mavrych, PhD, DSc External MD, laryngeal n to [email protected] cricothyroid for high pitch

Median cervical cyst l

Carotid Sheath

& CNX

Buccopharyngeal membrane RETROPHARYNGEAL SPACE Alar Fascia DANGER ZONE Prevertebral fascia

l

l

Retropharyngeal area allows infection to spread to posterior mediastinum DANGER ZONE allows infection to spread to abdomen


Variation of parathyroid glands position l

l

l

Dr. Mavrych, MD, PhD, DSc

The superior parathyroid glands, more constant in position than the inferior ones. The inferior parathyroid glands are usually near the inferior poles of the thyroid gland, but they may lie in various positions In 1-5% of people, an inferior parathyroid gland is deep in the superior mediastinum inside the thymus because of common embryonic origin.

This makes surgery dangerous bc parathyroid glands are essential for life as Ca2+ is needed for neuronal pathways, bones, muscle [email protected] contractions, etc....

Usually presents as a painless midline mass on the anterior aspect of the neck just below of the hyoid bone and moves during swallowing together with thyroid gland because of relation with pretracheal layer of cervical fascia and infrahyoid muscles of the neck. Remanent of the thyroglossal canal (thyroid gland originally from epithelium of the tongue). Treatment: surgical excision


96. Larynx 3 1 2

Cavity of the Larynx - 2 Folds: l Vestibular folds [1] (false vocal cords) Morgangni ventricle between them l Vocal folds [2] (true vocal cords) Ø

Ø

1 2

Rima vestibuli – gap between the vestibular folds Rima glottidis [3] – gap between the vocal folds anteriorly and vocal processes of the arytenoid cartilages posteriorly is most narrow place in the larynx (it limits size of intubation tube during endotrachial anaesthesia)

Piriform recess at hyoid-> epiglottis is where small sharp objects get stuck Zenker's is outpouch of pharynx at inferior constrictor where food gets caught Dr. Mavrych, MD, PhD,Diverticulum DSc [email protected] in killians triangle and gets infected leading to hallitosis (bad breath)


Muscles of the Larynx

Cricothyrotomy

Transverse arytenoid (whisper), Thyroarytenoid (low pitch), vocalis (opera singer)- ADDUCTORS

Abductors l Posterior cricoarytenoid – abducts vocal folds (the only abductors of the vocal folds) l It is innervated by recurrent laryngeal nerve (CNX vagus). Most intrinsic ms of the larynx Ø Interruption of recurrent laryngeal nerve results in hoarseness because the corresponding vocal fold does not abduct and deviate toward the midline.

Dr. Mavrych, MD,

Superior Laryngeal n gives branches to internal (vocal cords) and external to cricothyroid ms (high pitch) PhD, [email protected] lesionDSc causes weak low pitch voice

98. Retropharyngeal space

l

l

l

A cricothyrotomy is an emergency procedure that relieves an airway obstruction (e.g. swallowed foreign bodies or abnormal tissue growths). A hollow needle is inserted into the midline of the neck, just below the thyroid cartilage (needle cricothyrotomy). More frequently, a small incision is made in the skin over the Cricothyroid membrane, and another one is made through the membrane between the cricoid and thyroid cartilage.. A tube that enables breathing is inserted through the incision.


99. Axillary sheath

Between Buccopharyngeal fascia and Alar fascia of Carotid sheaths l

l

l

It is interval between pharynx fascia) (Bucco-pharyngeal Bucco-pharyn fascia) and prevertebral fascia May provide a passageway of infection from pharynx p to posterior media mediastinum (mediastinitis !90%!mortality! rate).

l

l

Derived from the prevertebral fascia Encloses the subclavian artery and brachial plexus as they emerge in the interval between the scalenus anterior and medius muscles (Interscalenus ( space) Extends into the axilla

DANGER ZONE: Alar Fascia to prevertebral fascia and Dr. Mavrych, MD, PhD, DSc [email protected] infection spreads farther to abdomen

Dr. BRACHIAL Mavrych, MD, PLEXUS PhD, DSc [email protected] BRANCHES:

MARMU, LT, DS, SS, SC, LP, MP, AP, USS, TD, LSS, Mca, Mcf

100. Posterior Triangle of the Neck Clavical, SCM, Trapezius Veins – external jugular vein, subclavian vein. l Arteries – occipital artery. l Nerves – Accessory nerve (XI), trunks of the brachial plexus, branches of cervical plexus, phrenic nerve. l Lymph nodes – superficial cervical nodes along external jugular vein. CN XI (accessory nerve) supply: l Sternocleidomastoid muscle - face looks upward to the opposite side l Trapezius - superior fibers elevate, middle fibers retract, and inferior fibers depress scapula. l

CN XI

External Jugular v, Brachial Plexus


Good Luck! Carotid Triangle of the Neck: Posterior digastric, omohyoid, SCM Contains: Internal jug v, common carotid, CNX


100 Concepts Anatomy

Recommend Documents