3100 - Imaging Flashcards
Manubriosternal joint vertebral level
T4/5
Costochondral joint type
primary cartilaginous
Sternochondral joint type
Synovial plane
Chest deformities (cause)
Barrel chest - increase AP diameter (emphysema) held inspiration position
Scoliosis - (idiopathic or congenital)
Pectus Carinatum - chest bulges out ant (congenital)
Pectus Excavatum - chest bulges in ant (congenital)
Kyphosis - (compression fractures, osteoporosis)
What is chostochondritis (Tietze Syndrome)
inflamed cartilage and costochondral joint from strain or respiratory infection
What is flail chest
Fractured ribs allow movement during breathing
What way do ribs move in inspiration
outwards
Vertebra prominens is
spine of C7
Medial spine of scapula vertebral level
T3
Inferior angle of scapula
T7
Oblique fissure vertebral level and rib
T4 to rib 6
Horizontal fissure vertebral level and rib
T4 to rib 5 (axillary) and 4 (ant)
Cause of Clay-shoveler fracture
Force from trapezius and rhomboids causes avulsion fracture of lower cervical or upper thoracic spinous processes
What is open pneumothorax
puncture > collapses lung > air in and out
What is tension pneumothorax
puncture > air goes in not out > pressure buildup pushes mediastinum away from injury side
Where is a liver biopsy done
7-10th intercostal space mid-axillary line during expiration
What accumulates in costodiaphragmatic recess
Pus, blood, fluid
What/where are triangles of auscultation
Sites of easy auscultation of lungs. b/n traps, lat dorsi and scap, on ribs 6-7
Main muscles of inspiration
Diaphragm and external intercostals
Accessory muscles of inspiration (5)
pecs, scalenes, SCM, muscles that dilate mouth and nostrils, serratus posterior superior
Accessory muscles of expiration (5)
Abdominal muscles (ext and int obliques, transverse abdominis and rectus abdominis) and serratus posterior inferior
External intercostals are replaced by membrane where
Anteriorly
Internal intercostals are replaced by membrane where
Posteriorly
Innermost intercostals have membrane where
Throughout the membrane in segments
Where is main intercostal bundle
In costal groove
Intercostal nerves branch from and give what branches
ventral rami of spinal nerve > intercostal nerve > lateral and anterior cutaneous branches
What is thoracocentesis vs chest drain and what does it pierce
Needle vs tube to remove fluid or air from pleural cavity. Pierces skin, superficial fascia, external, internal, innermost ICMs (maybe membrane) and parietal pleura
Brachial plexus vertebral level
C5-T1
Axillary sheath a) attachments, b) contents and c) function
a) Rib 1 and clavicle. b) contains brachial plexus and axillary artery/vein. c) stabilises axillary vein for subclavian venous catheter and holds local anaesthetic (axillary block)
Dermatome of nipple and umbilicus
nipple - T4, umbilicus - T10
What is an axial line? How does this distinguish between peripheral and spinal nerve lesions?
Border between two dermatomes that don’t have adjacent spinal cord levels. Peripheral nerve lesions cross axial lines, spinal cord lesions do not
Shingles pathophysiology
Herpes Zoster virus enters sensory nerve terminal, travels to dorsal root ganglion via retrograde transport lies dormant. When reactivated travels back down nerve and inflames terminals (red rash)
Horner’s syndrome pathophysiology
Inferior cervical (stellate) ganglion and first (T1) sympathetic ganglion (SG) send fibers to head. Damage to these ganglion (apical lung tumour - squash) or brain causes lack of sympathetic innervation to face. Pupil constriction, ptosis, absence of sweating.
Palmar hyperhidrosis treatment
upper sympathectomy - removal of T2-4 sympathetic ganglion
Thorax blood supply
Posteriorly and laterally: intercostal arteries & veins (from aorta and draining to azygous veins (hemiazygos on left) to SVC
Anteriorly: Internal thoracic artery and vein (from subclavian, into brachiocephalic into SVC)
Breast blood supply
Axillary/subclavian branches: thoracoacromial, lateral thoracic, internal thoracic, intercostal arteries
Veins: lateral thoracic, internal thoracic, axillary, SVC
Breast spans ribs
2-6
What are the lymph nodes that drain breast
Internal thoracic/mammillary (medial), supraclavicular (upwards) and pectoral (in axilla) lymph nodes (upper lat quad)
coronary artery in-situ graft vs coronary artery bypass graft (CABG)
distal portion of internal thoracic artery is moved to other side of blocked coronary artery. Internal thoracic or radial artery is grafted to a part of the heart.
Superficial veins in thorax (if IVC is blocked)
superficial epigastric drains into thoracoepigastric veins drain into lateral thoracic veins into axillary v
SE > TE > LT > A > SVC
Imaging mechanisms that use ionising radiation
X-ray, CT, nuclear medicine
Features of X-ray machine
occurs in a vacuum, lead stops x-rays escaping, oil filled sleeve surrounding tube absorbs heat
Energy from electrons in x-ray generation is converted to 99% what and 1% what
99% heat and 1% high energy photons (x-rays)
How to tell in x-ray if air and fluid are in contact
Forms a straight line between them
Air allows x-rays to pass through so it appears
black
Metal stops x-rays passing through so it appears
white
Types of x-rays
Projection - single plane, cheap
Tomogram (CT) - many planes, $$, detailed images
What chemicals are used to increase contrast in x-ray images
Iodine and barium
Scans involved in nuclear medicine
SPECT and gamma scan
Risks of x-rays
Ionising radiation creates free radicals which cause DNA damage
Units of radiation dose (x-rays)
mSv, Bq, Ci, Gy
Effect of x-rays on rapidly dividing cells (5)
Embryo (death early on, birth defects later)
Spermatogonia (infertility)
Erthyroblasts (anaemia)
Stem cells in epidermis (ulcers, hair loss)
Stem cell in GI (diarrhoea, ulcers)
Effect of x-rays on some non-dividing cells (3)
Ooctyes (infertility, birth defects)
Lymphocytes (infection, cancer)
Lens (cataracts)
How does radiotherapy work?
Cancer cells are rapidly dividing cells therefore are highly sensitive to ionising radiation
What is an ultrasound, how are they generated
High energy sound waves generated by contraction and expansion of piezoelectric crystals in transducer probe when AC current is passed through. Probe detects reflected ultrasounds.
Bone and air are hyperechoic so they appear (ultrasound)
White
Soft tissue is hypoechoic (weakly reflect) appears (US)
Grey
Fluid is anechoic appears (US)
Black
Types of ultrasound
2D (conventional)
3D voxel-rendered
4D (+time dimension)
HD (better resolution)
What reduces the quality of an US image
The depth - more scatter
Generation of magnetic resonance imaging (MRI)
Patient in magnetic field. H+ aligns on field. Radio pulse shifts H+ 90º. Radio pulse off, H+ shift back, radio signal released, detector converts to image
MRI: T1 vs T2 vs FLAIR vs STIR
T1- long relaxation times. Fat is bright, water dark
T2 - short relaxation times. Fat is dark, water is white
FLAIR - fluid of CSF is dark, inflammation is white, fat is dark
STIR - remove fat signal to see blood vessels
What is a diffusion tensor MRI
water already aligned in white matter tracts give recognisable signal - can be individually coloured
How does a functional MRI work
Active brain regions have more blood flow. Oxygenated/deoxygenated Hb give different signals
Ligaments of diaphragm (3) and muscles attached (medial to lateral/internal to external)
Median arcuate created by crura of diaphragm around aorta
Medial arcuate formed by connection of diaphragm to psoas major
Lateral arcuate formed by quadratus lumborum to diaphragm
nerve supply of abdominal muscles
T6-L1 ventral rami
Left crus vertebral level
right crus VL
L1-L2
L1-3 - forms physiological sphincter
Sliding hiatal hernia
portion of stomach slides through esophageal hiatus (where esophagus goes through diaphragm) up esophagus
Paraesophageal hiatal hernia
stomach goes through esophageal hiatus into chest cavity
which hiatal hernia leads to Barrett’s osephagus
sliding hiatal hernia - laxity of lower oesophageal sphincter - gastrooesophageal reflux disease (GORD) - Barrett’s
Inflammation can spread from pelvis to subphrenic space via
right paracolic gutter
Prevertebral and retropharyngeal spaces end at __. DAnger space between them ends at
T6. Diaphragm
Danger space is between
preverterbal and retropharyngeal spaces
Pericardium of heart fuses with
Supplied by __ nerve
central tendon of diaphragm.
Phrenic
Pericarditis and pleurisy are what pain
sharp
Fibrous heart pericardium is supplied by
phrenic nerve
Parietal pleura (lungs) supplied by
intercostal nerve
Mediastinal pleura (centre chest - holds heart) supplied by
phrenic nerve
Heart tamponade
Fibrous pericardium doesn’t stretch
How to stop blood output
transverse pericardial sinus
Right heart hypertrophy indicates
Problem with lungs (pulmonary fibrosis)
Left heart hypertrophy indicates
Problem with systemic system
Heart appears larger in AP or PA view
AP
Left coronary artery branches and supply
Left anterior descending (LAD) (ant interventricular) supplies ant 2/3 interventricular septum
Circumflex supplies SAN in 40% and AVN in 10% cases
Right coronary artery branches and supply
Right coronary supplies SAN 60% and AVN 90%.
marginal artery.
Posterior descending (interventricular) artery: post 1/3 of interventricular septum
Pulmonary veins are above/below pulmonary arteries
below
where are pectinate muscles
atrium
papillary muscle function
in ventricles attach to chordae tendinae, contract to close valves
trabeculae carneae
in ventricles
Right valvular stenosis leads to
Leg oedema
Left valvular stenosis leads to
pulmonary oedema
How can lung carcinoma cause hoarse voice
Lung carcinoma can enlarge lymph nodes, on LHS can compress recurrent laryngeal nerve leading to vocal fold paralysis
which ventricle is thicker
Left
9 regions of abdomen
R hypochondriac, epigastric, L hypochondriac
R lumbar, umbilical, L lumbar
R iliac, hypogastric, L iliac
indirect inguinal hernia
through deep inguinal ring and inguinal canal, lateral to epigastric vessels
Direct inguinal hernia
through abdomen layers, medial to epigastric vessels
sites for herniation
inguinal canal, lumbar triangles
abdominal muscle nerve supply
T6-L1
muscles for trunk rotation
ext obliques and opposite internal oblique
muscles for trunk flexion
retcus abdominis and gravity
muscle for Trunk extension
erector spinae
muscle for Bracing core
transversus abdominis
what is Meralgia paraesthetica
tingling, numbness, burning of lateral thigh from compression of lateral cutaneous nerve (pregnancy, obesity)
arteries in rectus sheath
superior and inferior epigastric
what is caput medusa
veins in umbilical region from portal hypertension
Portal hypertension leads to
left umbilical vein which
can recanalise > caput medusa, oesophageal varices, haemorrhoids
inguinal canal transmits (male v female)
spermatic cord and round lig of uterus
Inguinal canal travels through what abdominal layers (form the walls of canal)
external oblique, internal oblique, transversus abdominis and transversalis fascia
Components of a hernia
Sac (peritoneum), contents (bowel), coverings (abdominal wall)
Coeliac trunk, sup mesenteric, inf mesenteric VL
T12, L1, L3
lesser omentum contains what ligaments
hepatoduodenal and hepatogastric
what is angular incisure
notch in stomach
Order of anatomical features from stomach to intestine (pylorus, duodenal cap, pyloric antrum, duodenum)
Pyloric antrum > pylorus > duodenal cap > duodenum
portal triad
hepatic artery, portal vein, bile duct
portal triad can be compressed at
epiploic foramen
Which kidney is lower
right
Lesser curvature stomach blood supply
Left and right gastric from coeliac trunk and hepatic artery
Coeliac trunk branches into
left gastric, splenic and hepatic
Hepatic artery splits into
Right gastric and gastroduodenal
Greater curvature stomach blood supply
Gastroduodenal and splenic
Stomach blood drainage
Lesser curvature: left and right gastric into portal vein
Greater curvature: gastroepiploic veins into sup mesenteric + splenic into portal vein
oesophageal varicosities are of what anastomoses
Left gastric and azygous
What artery can be embolised for obesity treatment
left gastric > ischaemia of fundus and reduce ghrelin
what arterey is most at risk from duodenal ulcers
gastroduodenal artery
Whipple’s procedure for pancreatic cancer puts what vessels at risk? why
Uncinate process of pancreas is under superior mesenteric vessels. Most of duodenum is removed with head of pancreas. Sup mes vessels at risk
Falciform ligament contains
remnant of left umbilical vein (round ligament/ligamentum teres). Recanalisation causes caput medusae.
what ligament extends from liver to umbilicus
falciform ligament
what ligament surrounds bare area
coronary ligament formed by left and right triangular lig
what ligament contains portal triad
hepatoduodenal
Sites of fluid accumulation near liver
Hepatorenal (liver - kidney) and subphrenic (live to diaphragm)
Blood supply to liver
hepatic artery, portal vein
Liver blood drainage
central vein > hepatic vein > IVC
What structure allows liver to be cut surgically into left and right halves
Middle hepatic vein
Cancers in GI tract can metastasise where
Liver
How to detect splenomegaly
Dull percussion over Traube’s space
Liver failure manifestations
Jaundice (no clearing of bilirubin), brain damage (toxins not cleared) > asterixis (hand flapping)
What structure in rectum marks transition from autonomic to somatic nerves
Dentate line
what suspends duodenojejunal flexure
ligament of Trietz
Volvulus is what and puts what at risk
Twisting of the sml intestine around root of mesentery puts superior mesenteric artery and vein at risk > ischaemia
Jejunal vs ileal mesentery:
Jejunal: long vasa recta, few arcades, less fat
Ileal: short vasa recta, more arcades, more fat
what is Ileal (Meckel’s) Diverticulum
Out-pouching of ileum congenital from remnant of vitelline duct (connects yolk sac to midgut)
What prevents reflux of caecum contents
ileocaecal valve
What is diverticulosis, most common spot
outpouching of gut common with age, sigmoid colon
Blood supply of rectum
upper 1/3: inferior mesenteric branches
Lower 2/3: int iliac
> anastomose
Dentate line marks (embryologically)
where primitive endoderm meets ectoderm
Most common pouch for fluid accumulation
rectouterine
Parasympathetic supply to foregut and midgut
Vagus nerve
Parasympathetic supply to hindgut
S2-4
Orientation of aorta to IVC
aorta is on the left of the IVC
IVC on right
Renal colic gives pain where
in testes/groin
Corpus cavernosum function
erection
Corpus spongiosum function
Prevent urethra from closing during erection (for ejaculation)
what is tunica albuginea
inflexible fascia around penis – tear = bent
What nerve provides sensation for penis (from sacral plexus)
Pudendal nerve
ischiocavernosus function
helps maintain erection
dartos muscle location and innervation
in skin of scrotum, sympathetic T12-L1 via genitofemoral n
Cremaster muscle location and innervation
around spermatic cord - pulls testis up, genitofemoral n (L1, L2)
Veins of penis
pampiniform plexus
What is testicular varicocele
Enlargement of pampiniform plexus
What causes testicular hydrocoele
accumulation of fluid between 2 tunica vaginalis layers
Greater vestibular gland also called
Bartholin’s gland
Lesser vestibular gland is also
Skenes/paraurethral glands
AnteVersion with resepct to
Vagina
anetFlexion with respect to
Fundus of uterus
blood supply of female reproductives
Ovarian art from aorta, branches of internal iliac: internal pudendal, vaginal, uterine.
Innervatiion of vagina
lower 1/5: pudendal
Upper 4/5: T12-L2, S2-4
broad ligament of uterus contains the mesometrium, mesosalpinx, and mesovarium - what are each of these roles
Mesometrium - support uterus, contains blood vessles/nerves for uterus
Mesosalpinx - support fallopian tubes, contains vessels/nerves for tubes
Mesovarium - supports ovaries, contains vessels/nerves for ovaries
What ligament contains ovarian artery, vein and nerve
Suspensory ligament of ovary
round lig of uterus function
maintain anteflexion
cervical ligaments:
pubocervical, transverse (cardinal), uterosacral
Weakness of cervical ligaments leads to
prolapse uterus
Lymphatics: fundus of uterus and round ligament drains to
superficial inguinal lymph nodes
blood supply to M and F reproductive
internal pudendal from int iliac
which viscera can be heard in the triangle of auscultation
apex of lower lobe of lung
Axillary sheath is derived from what fascial layer
prevertebral fascia
Arteries supplying breast are
lateral thoracic, internal thoracic, intercostal arteries and thoracoacromial
Which breast quadrant are most carcinomas found
upper left - pectoral lymph nodes
Why is xray risky
x rays can ionise atoms, breaking chemical bonds and creating free radicals. This can break DNA stands, causing cell
death/cancer/developmental abnormalities
Why are nerves, bone muscle and cartilage relatively resistant to
ionising radiation damage
Because theyre not dividing
4D ultrasound has what added
time
What can cause hiccups
Can be triggered by inflammation of organs near the diaphragm (e.g. liver, kidneys) or
accumulation of pus/fluid around the diaphragm. involves phrenic/vagus nerves
Impaired valve closure leads to
Impaired valve opening leads to
regurgitation
stenosis > back pressure
Irritation of which part of the pleura gives shoulder pain
Diaphragmatic pleura from phrenic n
Which structures are compressed and what are the symptoms of thoracic outlet syndrome?
Brachial plexus, subclavian artery and vein. Pain, numbness, swelling of arm
through diaphragm: IVC, esophagus, aorta
T8, T10, T12
Which bronchus are things more likely to pass into
right main bronchus as it is wider and more vertical
what is atelectasis
collapsed lung from blockage of bronchi
Lub and dub sounds are from
AV valves and semilunar valves
Congenital ventriculoseptal defects are common. Which blood circuit (pulmonary or systemic) becomes congested
hole in septum (sep ventricles) > pulmonary circuit becomes congested because so much blood going through pulmonary
What has the arcuate line got to do with the rectus sheath
Above arcuate line internal oblique splits around rectus abdominis. Below all layers run anteriorly
is proper or common hepatic branch from celiac trunk
celiac > common > proper + gastroduodenal
If a stomach ulcer perforates posteriorly:
(i) Name the peritoneal compartment into which gastric contents would leak.
(ii) Name two arteries that may bleed
i) retroperitoneal space
ii) gastroduodenal and splenic
structures along transpyloric plane (L1)
pylorus of stomach, part 1 duodenum, hilum of kidney,
what separates into supra and infra colic compartments, left and right infracolic
transverse mesocolon, root of mesentery
A ruptured spleen can be associated with left shoulder pain. Why?
bleeding from spleen may irritate phrenic nerve
what nerve innervates external anus
pudendal (branch of sacral plexus)
To where is renal pain referred and to where is ureteric pain referred
renal pain to back and ipsilateral flank. Ureteric to lower abdomen/groin
On which side do most testicular varicocoels occur?
left scrotum, The left testicular vein (gonadal vein) drains into the left renal vein, which can create higher pressure in the left.
Right testis drainage
Right gonadal vein > IVC
What is the most common cause of a reduced urine stream in ageing men
Larger prostate
How does CNS develop (embryology)
sonic hedgehog gene > ectoderm invaginates > neural tube > CNS
Notochord forms
nucleus pulposus of IVD
Closure of neural tube dependant on what vitamins
B9 (folate)
What is spina bifida and types
Incomplete closure of neural tube.
Spina Bifida Occulta - small gap in 1+ vertebral bones (sometimes unnoticed)
Meningocele - meninges protrude through gap in spine
Myelomenigocoele - Spinal cord and coverings bulge
Anencephaly - incomplete skull (rostral end)
What joint do articular processes form in spine
Facet/zygapophysial
What induces the neural tube to form
The notocord
What angle are the facet joints in different regions and movements
Cervical - 45º - flexion, extension, lateral flexion and rotation
Thoracic - 60º - rotation
Lumbar - 90º (parasagittal) - flexion, extension, small rotation
Main features of cervical vertebrae
transverse foramen in transverse process for vertebral artery (C6-C2) and vertebral vein (C1-C7)
bifid spinous process
uncinate processes
Joint articulations for nodding (C1)
superior articular facet with occipital condyles
Features of C1
Lateral masses, ant and post arches, groove for vertebral artery, post and ant tubercle
Lamina is between
Pedicle is between
Lamina - spinous to transverse processes
Pedicle - transverse to body
What joint for ‘yes’
what joint for ‘no’
yes - atlantooccipital (condyloid/ellipsoid)
no - atlantoaxial (pivot j)
what forms atlantoaxial joint
superior articular surface of lateral mass of C2 with inferior articular surface of lateral mass of C1
dens to anterior arch held by transverse ligament
Hangmans fracture
fracture of pars interarticularis at C2 from hyperflexion and hyperextension e.g car crash
Pars interarticularis fracture where verterbra slips forward
spondylolisthesis
where does spinal cord end
L1/L2
Is fractured odontoid process concerning
yes because vertebrae can move ant and post and slice spinal cord
compression of sacral nerve roots in cauda equina (acute cauda equina syndrome) can lead to
saddle anaesthesia, bladder/bowel incompetence, back/leg pain
> not decompressed in 24 hours > permanent
Pain of lateral foot is compression of which spinal nerve
S1
Ligaments of spine
supraspinous, interspinous, ligamentum flavum, posterior longitudinal, anterior longitudinal
What usually prevents a
posterior disc prolapse?
posterior longitudinal ligament
Thickening of which ligament
can cause spinal stenosis?
posterior longitudinal ligament (sometimes flavum)
What ligaments connect spine to skull
Cruciform ligament: superior longitudinal, inferior longitudinal and transverse
Posterior longitudinal lig > tectorial membrane
Deep part of tectorial
Alar ligaments
What type of joint is IVD
secondary cartilaginous
What type of joint is zygapophyseal/facet
synovial
what is scapulohumeral rhythm
scapula moves 1º for every 2 of humerus
where do 80% of clavicle fractures occur
middle
what ligament holds in place biceps long head tendon
transverse humeral ligament
Acromioclavicular fracture involves which ligaments
acromioclavicular and coracoclavicular
Which side of intertubercular groove is pec major insertion
Lateral - under greater tubercle
Innervation of serratus anterior - damage results in
long thoracic - winged scapula
rhomboids action
retraction of scapula
Latissimus dorsi action
adduct, medially rotate and extend arm at GHJ
What is a SLAP lesion
tendon of long head of biceps slips out of groove or tears labrum in overhead activity. e.g. throwing a javelin
What is adhesive capsulitis
‘Frozen shoulder’ - inflammation of shoulder joint capsule
Which direction does humerus commonly dislocate and what structure is commonly at risk
Anteroinferiorly, axillary nerve
Rotator cuff muscle insertions
Subscapularis - lesser tubercle
Supraspinatus, infraspinatus, teres minor - greater tubercle
Rotator cuff muscle actions
Subscapularis - internal rotation
Supraspinatus - early abduction
Infraspinatus and teres minor - external rotation
Rotator cuff tear partial v full
Often involves supraspinatus
Partial - can abduct but not against resistance
Full - 45º abduction from deltoid action
Function of subacromial bursa
reduce friction of supraspinatus tendon in coracoacromial arch
What is painful arc syndrome
Pain from 50-130º abduction
What can be compressed at apex of axilla
Divisions of brachial plexus
What causes enlargement of axillary lymph nodes
Breast cancer, upper limb and breast infections
Why might pt wake up with weakness or paraesthesia of upper limb after axillary clearance
Removal of axilla lymph nodes may affect brachial plexus. May also cause oedema of upper limb
What forms posterior cord of brachial plexus
posterior divisions
what is innervated by dorsal scapula nerve
levator scapulae
thoracodorsal innervates
lat dorsi
suprascapular innervates
supra and infra spinatus
what does musculocutaneous nerve innervate/supply
anterior arm: biceps brachii, coracobrachialis, brachialis
becomes lateral cutaneous of forearm for sensation
What does ulnar nerve innervate
flexor carpi ulnaris, M 1/2 flexor digitorum profundus, intrinsic muscles of hand: palmaris brevis, lumbricals, hypothenar and interossei
What is scalenus anticus syndrome
Brachial plexus and subclavian artery compressed between scalenus anterior and medius
What structures are at risk in a clavicle fratcure
Divisions of brachial plexus, subclavian artery and vein
what is Klumpke’s palsy
Damage to C8/T1 > paralysis of intrinsic hand muscles (lumbricals and interossei). Loss of flexion at MCP and extension at IPJ Median nerve still active for flexor digitorums + radial nerve for extension
> claw hand
What is Erb-Duchenne palsy
Damage to C5/6 (axillary and musculocutaneous) > paralysis of deltoid, biceps, brachialis > arm extended, forearm pronated, wrist flexed ‘waiters tip hand’
Arm compartments and motor innervation
Posterior: radial
Anterior: median, ulnar, musculocutaneous
Action of biceps brachaii
Flexion of elbow and shoulder, forearm supination
Brachialis O, I, action
shaft of humerus to coronoid process of ulnar
elbow flexion
Coracobrachialis O, I, action
coracoid process to shaft of humerus shoulder flexion and adduction
biceps insertions
Long head: supraglenoid tubercle
Short head: coracoid process
> biceps tendon on radial tuberosity
Tricpes insertions
Long head: infraglenoid tubercle
Medial head: medial to spiral groove
Lateral head: lateral to spiral groove
> olecranon
Where is spiral groove and what runs in it
Posterior humerus, radial nerve and profunda brachii artery
Would fracture of mid humerus damage tricep innervation
Radial nerve is damaged but branches to triceps occur early so no loss of innervation
Sensory innervation of anterior and posterior arm/forearm
Anterior: medial and lateral cutaneous
Posterior: superficial radial
Blood supply for anterior and posterior upper arm
Anterior: brachial artery
Posterior: profunda brachii artery
Venous drainage of arm
Cephalic - lateral over biceps > subclavian
Basilic - medial > axillary v > subclavian
What ligament holds radial head in radial notch
annular ligament
Supinator innervation
Radial nerve
Muscles of pronation and innervation
pronator teres and pronator quadratus
median nerve
cubital fossa borders and contents L>M
brachioradialis, pronator teres, condyles of humerus
(TAN): biceps Tendon, brachial Artery, median Nerve
What nerves are affected in a supracondylar fracture
Median, ulnar and radial nerves
what nerve pierces supinator muscle
posterior interosseous nerve from radial
Which nerve can be entrapped at the elbow by flexor carpi ulnaris?
ulnar nerve
Blood supply of forearm
brachial > ulnar and radial > ulnar to ant and post interosseous arteries
Brachial artery obstruction damages which structures
forearm flexors > Volkman’s ischaemic contracture
Brachioradialis O, I, action, innervation
lateral supracondylar ridge to styloid process (radius), elbow flexion + supination, radial nerve
What tendon is pisiform bone inside
flexor carpis ulnaris
Flexor digitorum superficialis and profundus insertions
Superficialis splits at middle phalanx and flexes at proximal PIP joint
Digitorum inserts base of distal flex distal PIP joint
Wrist drop is caused by
damage to radial nerve > superficial extensors of arm impaired
Muscles for supination (innervation)
Brachioradialis (radial n), biceps (musculocutaneous n), supinator (radial n)
Golfers elbow vs tennis elbow
Golf: medial epicondylitis
Tennis: lateral epicondylitis
Colle’s fracture
Fall on outstretched hand can result in fracture of distal radioulnar joint - radius moves dorsally
Contents of carpal tunnel
4 flexor digitorum superficialis tendons.
4 flexor digitorum profundus
1 flexor pollicis longus
Median nerve > compression = thenar atrophy
What is Guyon’s canal
Thickened part of flexor retinaculum contains ulnar nerve > compression = hypothenar atrophy
Snuff box borders and contents
Extensor pollicis longus, extensor pollicus brevis, abductor pollicis longus
radial artery
What is Dupuytren’s contracture
Flexion of 4th and 5th fingers from palmar aponeurosis contraction
Can infections spread from palmar spaces
No they are distinct from each other
Lumbricals origin and insertion, action
Radial side of flexor digitorum profundus to dorsal digital extensor expansion
Flex at MCP, extend at interphalangeal joints (PIP/DIP) > pincer grip italian hand
Can infections spread through synovial sheaths
yes only from thumb or little finger
Blood supply to hand
Ulnar > superifical palmar arch > digital arteries
radial > deep palmar arch
What is Allens test
Compress both ulnar and radial arteries then release one palm should go pink
Which nerves are affected in following:
Claw hand
Wrist drop
Ape hand
Claw - ulnar from interossei and lumbricals
Wrist - radial
Ape - median from thenar atrophy
How do wrist extensors improve a power grip
Wrist extension stretches the finger
flexors, allowing them to generate more
force
> radial nerve injury affects power grip
What muscles insert on coracoid process
pect minor, coracobrachialis, short head of biceps
Three ligaments of hip joint
Iliofemoral
Iliopubic
pubofemoral
Blood supply to head of femur
Artery of ligament of head of femur (branch of obturator)
Retinacular arteries from lateral and medial femoral circumflex from profunda femoris
Gluteus maximus OIAN
posterior gluteal line to iliotibial tract, extension (stepping up), inferior gluteal nerve
gluteus medius and minimus
middle and inferior gluteal lines to greater trochanter, superior gluteal nerve
Medius - abduction
Minimus - int rotation
Trendelenberg gait is from damage to what muscle
Gluteus medius
Where is intragluteal injection
What nerve/vessel may be affected by this
upper lateral quadrant to avoid sciatic nerve.
superior gluteal n + a
Lateral rotators of hip (6)
Insertions
Innervation
Piriformis, superior and inferior gemellus, obturator internus and externus, quadratus femoris
> greater trochanter
> sacral plexus exc obturator externus - lumbar plexus
piriformis passes through
Greater sciatic foramen
sciatic nerve and inferior gluteal nerve below piriformis
Nerves at hip joint - clinical significance
Femoral, obturator, sciatic - cross hip and knee, knee pain may be hip problem vice versa
Why does neck of femur fracture result in externally rotated and shortened leg
Ext rotate: contraction of lat rotators and psoas
Shortened: contraction of m linking hip to femur - hamstrings, adductors, quads
The hip joint ligaments primarily limit which hip movement
leg extension
Overuse of which muscle is associated with trochanteric bursitis?
gluteus maximus
motor innervation and action
ant thigh: quadriceps + pectineus and sartorius
medial thigh: adductors + pectineus
post thigh: Hamstrings (biceps femoris, semitendinosus, semimembranosus)
ant: Femoral nerve - knee extension, hip flexion
med: obturator nerve - adduction at hip
post: sciatic nerve - knee flexion/hip extension
Hamstring part of adductor magnus - sciatic
bicep femoris short head - fibular n
Biceps femoris long head - tibial n
pectineus - femoral (80%), obturator (20%)
Femoral triangle borders and content
femoral sheath contents
femoral canal contents
sartorius, adductor longus, inguinal canal
Femoral nerve, artery, vein, lympathics,
great saphenous pierces fascia lata (roof) > femoral vein
femoral sheath: not nerve
canal: only lymph and fat - femoral hernia occurs here
Is a lump below inguinal canal always a femoral hernia
No, could also be enlargement of saphenous vein (varix) or enlarged lymph node
which muscle of anterior compartment of thigh arises from anterior femur
vastus intermedius
rectus femoris O and I
Reflected head: acetabulum
straight head: AIIS
> via quadriceps tendon to patella to patella tendon to tibial tuberosity
iliopsoas insertion
lesser trochanter
pectineus O I
pectine of pubis to pectineal line on post femur
adductor canal borders and contents
sartorius, adductor longus and vastus medialis. Contains femoral artery and vein, saphenous nerve
anaesthetic into adductor canal blocks which nerve
saphenous
posterior thigh compartment origin and insertion
ischial tuberosity to
biceps: head of fibula
semitendinosus: pes anserinus
semimembranosus: medial condyle of tibia
adductor muscle origin and insertions
ischiopubis to linea aspera
adductor magnus inserts on linea aspera (adductor part) and adductor tubercle on medial femoral condyle (hamstring part)
popliteal fossa contents
sciatic > tibial and common fibular
popliteal artery and vein
which collateral ligament at knee attaches to meniscus
medial
Damage to ACL and PCL causes
difficulty walking upstairs, and downstairs
Which bursa can become inflamed with prolonged kneeling
Prepatellar
Which bursa can become inflamed with repeated standing and kneeling
infrapatellar
What happens if sudden articular pain (e.g cartilage gets squashed in knee joint)
Relax reflex - all leg muscles go weak / locks to prevent further movement
weakness of oblique running vastus medialis can lead to
lateral patella tracking in knee extension
Fracture of neck of fibula >
Damage to common fibular n > deep and superficial fibular nerves affected > ant and lat compartment muscles > foot drop > steppage gate
What structures are at risk if anterior leg compartment increases (anterior compartment syndrome)
Anterior tibial artery, deep fibular nerve. Check sensation between toes 1+2.
Dorsalis pedis pulse affected
Inversion sprain
Can avulse fibularis brevis, tear EDB, damage anterior talofibular ligament
Rupture of Achilles
Can’t stand on tip toes but can plantar flex from tibialis posterior + FHL + FDL.
During repair - sural n at risk
pes planus
Flat foot - from tibialis post, intrinsic foot muscles, stretch of plantar aponeurosis
what causes leg varicosities
Failure of valves in superficial veins (greater saphenous - medial, ant to medial malleolus > femoral v + lesser saphenous - post leg > popliteal v) leads to build up of blood + pressure > distension of vein > varicosities
how does DVT form
What can it lead to
Blood in deep veins is pushed to heart via muscle pump - inactivity leads to blood pooling > DVT > oedema
Clot can embolise and cause pulmonary embolism
Where at foot does plantar/dorsi flexion occur
where does inversion and eversion occur
Ankle joint - hinge - talocrural - talus with fibula and tibia
subtalar (talus - calcaneus) and transverse tarsal joints
tarsal tunnel contents
T - tibialis posterior
D - flexor Digitorum longus
A - post tibial artery
V - post tibial vein
N - tibial nerve > splits into lat and med plantar n
H - flexor Hallucis longus
> sensation to sole of foot
Emergency venous access can be obtained at the ankle. Where at the ankle and to which vein?
Great saphenous, ant to medial malleolus
What gait disorder is associated with damage to the common fibular nerve?
foot drop - steppage gait
adductor hallucis can compress
medial plantar nerve creating medial toe plantar pain
scalp layers
Skin
subCutaneous tissue
Aponeurosis - continuous with supraspinous ligament
Loose areolar tissue
Pericranium
How do infections spread from scalp to meninges/dural venous sinus
via emissary veins
Where does scalp avulsion occur
at loose areolar tissue
Scalp blood supply
External carotid branches (post), internal carotid branches (ant), anastomose A-P and transversely
Scalp pain can be from neuralgia of which nerves
trigeminal > Vc - mandibular branch (at ear) + Va - ophthalmic (ant head)
C2 > occipital (post head)
Why can a blow to side of head cause death
Pterion is weak point where temporal, frontal, parietal bones join - middle meningeal artery passes under here > extradural haematoma (oval shaped)
what can rupture of bridging veins cause e.g in shaken baby
subdural haematoma (banana shaped) (along side edge of skull)
What can a ruptured aneurysm cause
subarachnoid > thunderclap headache (squiggly white line following contours of brain)
What can happen if base of skull is fractured
damage to ant cranial fossa:
periorbital ecchymosis - racoon eyes
CSF rhinorrhea - runny nose
Damage to middle cranial fossa:
CSF ottorhea - fluid in ears
Damage to posterior cranial fossa:
mastoid ecchymosis - bruising at mastoid
frontalis and occipitalis are connected via
epicranial aponeurosis
Foramen ovale transmits
mandibular division of trigeminal n
Foramen spinosum
Middle meningeal artery
forceps in baby delivery can
compression of facial nerve as no mastoid process to protect
damage of SCM > torticollis
Nerves of face
Motor; facial n for facial muscles,
mandibular division of trigeminal for mastication
Sensory: trigeminal and great auricular n (C2,3)
How to examine inner eyelid
eversion of superior tarsal plate (flipping upper eyelid)
Blow out fracture
Fracture of maxilla affects inferior oblique muscle, infraorbital nerve
Extraocular muscles
take origin on common tendinous ring (exp inferior oblique - maxilla)
why do you get a runny nose when crying
lacrimal fluid runs down nasolacrimal duct
Blood supply to nose
Internal and external carotids anastomose at Little’s area/Kiesselbach’s plexus. Following vessels: ant+ post ethmoidal, greater palatine, sphenopalatine, facial
How to treat intractable (chronic) rhinorrhoea
Cut the nerve of the pterygoid canal (vidians nerve) as it provides parasympathetic stimulation of mucus glands
causes of hearing loss
blocked ear canal
damage to ossicles - otosclerosis
damage to hair cells or cochlear nerve - loud sound, aging, drugs, infections
Cause of hyperacusis
Stapedius muscle (supplied by facial n) contracts to reduce ossicle movement)
> paralysis of stapedius - hyperacusis
Also acoustic neuroma lowkey
what causes a depressed eardrum
Blockage of eustachian tube (connects middle ear to nasopharynx) causes -ve pressur in ear, pulls eardrum in
What is an acoustic neuroma
tumour at internal acoustic meatus - schwannoma on vestibular part of vestibulocochlear nerve damages nerve > tinnitus (cochlear part), vertigo (vestibular part) , facial palsy, hyperacusis (if facial nerve also compressed)
Otitis media can cause
middle ear infection >
superior spread - meningitis
medial spread - facial n palsy, vertigo (damage to semicircular canal)
posterior spread - mastoiditis, facial palsy,
why are balance problems (labyrinthitis) often associated with hearing problems
because fluid in semicircular canals and cochlear are connected (utricle, saccule)
Soft palate raised by muscles innervated by
vagus nerve (CNX)
extrinsic tongue muscles supplied by
CN12 - hypoglossal exc palatoglossus (X - vagus)
genioglossus function
protrudes tongue. Affected in a hypoglossal lesion
at dentist what nerves are anesthetised
lingual and inferior alveolar nerves
parotid gland is pierced by
horizontally: facial nerve
vertically: retromandibular vein, superficial temporal artery, great auricular nerve (sensation)
> do not cut vertically
muscles of mastication
supplied by mandibular branch of trigeminal:
masseter
lateral pterygoid - can cause uneven jaw opening
medial pterygoid
temporalis
Which structure is most likely to
block the posterior concha with
allergy/common cold?
inferior concha - covered by mucoperiosteum - erectile tissue + engorgement of vessels
which gland opens into vestibule of mouth:
submandibular
parotid
sublingual
vestibule of mouth is gap between lips and teeth > parotid
Submandibular and lingual into oral cavity
how does branchial cleft cyst form
remnant of pharyngeal cleft - along border of SCM
what is thyroglossal fistula
thyroglossal duct opens in neck
what is torticollis
birth injury > SCM scars and contracts > twisted head
what is at risk in posterior triangle surgery
accessory nerve which lies on levator scapulae
Where to get emergency airway access
through cricothyroid cartilage > trachea
cough from post nasal drip caused by
superior laryngeal nerve
pharyngeal pain can be referred to
ear by CN9 - glossopharyngeal and CN10 - vagus
Cricopharyngeus forms physiological sphincter
in muscle wasting disease > swallowing problems
Name two major pelvic ligaments that prevent forward tipping of the sacrum (sacral nutation)
Sacrotuberous and sacrospinous ligaments
Along which plane do the ASIS and pubis align in the pelvis of an erect individual?
Coronal/frontal
The posterior superior iliac spines are marked by 2 dimples on the back. For which joint are they a surface landmark?
sacroiliac joint
Apart from the testicular artery, which other artery is found in the spermatic cord
cremasteric artery
Which nerve in the spermatic cord is responsible for the pain felt on direct pressure over the spermatic cord?
ilioinguinal nerve
Explain how a tear in the tunica albuginea and subsequent scarring can lead to curvature of the erect penis (Peyronie’s disease).
scarred tunica albuginea is not elastic, does not expand during an erection
Which nerve would be at risk if the posterior portion of deltoid were injected?
axillary
Which anterior thigh muscles can flex the hip as well as extend the knee?
rectus femoris crosses both joints
A football player kicks the ground instead of the ball and immediately gets a pain in the groin.
Which muscle may have avulsed?
Rectus femoris - hip flexion is suddenly stopped
type of joint is tibiofibular
proximal tibio-fibular joint is plane
distal - syndesmosis
