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AC1 > Anatomy > Flashcards

Anatomy Flashcards

1
Q

What is the Allantois?

A

Adult urachus

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2
Q

How can you identify a thyroglossal duct cyst?

A

Move on swallowing and tongue protrusion

Central mass

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3
Q

What is a Pyramidal lobe of the thyroid?

A

Normal variant due to thyroid tissue developing in the thyroglossal duct

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4
Q

What is the White line of Toldt?

A

Lateral reflection of posterior parietal peritoneum of abdomen over the mesentery of ascending and descending colon - avascular region

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5
Q

What are the 3 intercostal muscle layers?

A

External intercostal
Internal intercostal
Inner most intercostal

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6
Q

Where does the main neurovascular bundle lie in the intercostals?

A

In costal groove

Below rib

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7
Q

How do you surgically get access to mediastinal structures? And why?

A

Median sternotomy

Avoids intercostal muscles and neurovascular bundle, internal thoracic artery & vein

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8
Q

What delineates the safe zone for chest tube insertion?

A

Triangle of safety
Axillary folds
Posterior axillary fold: Latissimus dorsi & teres major
Anterior axillary fold: Pectoralis major & minor
Nipple line (4/5th ICS)

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9
Q

What is the access route for Percardiocentesis?

A

Minimally invasive needle insertion into the pericardial cavity Access via the anterior abdominal wall through the diaphragm

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10
Q

What is a risk of pericardiocentesis?

A

Pneumothorax

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11
Q

How do you get fast access to the heart or lungs?

A

Thoracotomy

Incision in 5th intercostal space from mid sternum to posterior axillary fold

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12
Q

Which compartments can be released by a lateral fasciotomy of the thigh?

A

Anterior and posterior compartments

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13
Q

What 2 fasciotomy incisions are performed in the leg?

A

Anterolateral fasciotomy incision: Access to anterior and lateral
compartments
Posteromedial fasciotomy incision: Access to superficial and deep
posterior compartments

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14
Q

What fasciotomy incisions can be performed in the forearm?

A

Dorsal

Volar (anterior)

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15
Q

How do you approach the femur?

A 
Lateral thigh
Skin
Fat
Tensor Fascia Lata
Vastus lateralis
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16
Q

How do you approach the knee joint?

A

Antero medial approach

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17
Q

How do you approach the tibia?

A

Posterolateral approach

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18
Q

How is the ankle joint (e.g. head of talus) accessed?

A

Incision made midway between tibia & fibula heading towards 4th metatarsal base

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19
Q

What superficial nerves are present on the dorsum of the foot?

A

Deep & Superfical Fibular nerve

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20
Q

During an approach to the hip, which direction would you move piriformis?

A

Medially

To preserve the sciatic nerve

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21
Q

Where does the circumflex humeral artery run?

A

Run with axillary nerve, 5cm inferior to acromion

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22
Q

Where does the profunda brachii artery run?

A

With radial nerve along spiral groove within posterior compartment

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23
Q

Where does the axillary artery run?

A

Passes behind mid-clavicle, medial to coracoid process

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24
Q

Where does the cephalic vein run in relation to the shoulder joint?

A

In deltopectoral groove, anterior shoulder

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25
Q

What approach do you take to access the shoulder joint?

A

Anterolateral
Identity acromion and coracoid process
Line down the arm from the coracoid process
Identify cephalic vein which is superficial
Identify coracobrachialis, lateral to this is safe side, medial is “suicide”

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26
Q

What does lymph consist of?

A

Tissue fluid and plasma proteins

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27
Q

What are lymph nodes?

A

Filters with immune function

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28
Q

Describe the structure of a lymph node

A

Afferent lymphatics bring in fluid to Subcapsular sinus
Germinal Centres sit in Cortex with Paracortex surrounding it
High endothelial venules - blood supply
Medullary Cords where fluid collects back together the leaves via efferent lymphatics

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29
Q

Why do lymphatic vessels follow the arterial supply?

A

Lymphatic vessels similar to veins
Thin-walled & most contain valves
Arterial pulsation compresses lymph vessels aiding venous return
Develop with the vascular system

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30
Q

Which parts of the body drain lymph to the left subclavian vein?

A

Most of the body and the left upper lobe of the lung drain into the left subclavian vein via the thoracic duct

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31
Q

Which parts of the body drain to the right lymphatic duct?

A

Right upper limb
Most of lungs (all bar left upper lobe)
Right half of head and face
Right upper part of chest and back

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32
Q

What is an important thing to do when you see lymphangitis?

A

Check the distal part of the affected structure

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33
Q

Where do lymphatic vessels of the skin run?

A

With cutaneous veins to nodes located at the point of the vein passing through deep fascia

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34
Q

What could lymphangitis be confused with?

A

Thrombophlebitis

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35
Q

What drains to superficial inguinal lymph nodes?

A

Perineal region
Penis/clitoris glans
Lower anal/vaginal canal
Anterior labia majora / scrotal skin

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36
Q

What are the 2 groups of the superficial inguinal nodes?

A

Horizontal

Vertical

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37
Q

Where do the deep inguinal nodes run?

A

Sit along femoral vein

Cloquet node sits superiorly: sentinel node from lower limb and perineum

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38
Q

What do the deep inguinal nodes drain and where do they drain to?

A

Receive deep tissues and superficial node

Drain to external inguinal nodes

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39
Q

Where does abdo wall lymph drain to?

A

Axillary and inguinal lymph nodes

Regional split from umbilicus

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40
Q

Where does the umbilicus receive lymph drainage from?

A

Parasternal nodes
Axillary
Inguinal

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41
Q

Describe the route from the iliac vessels up to the left subclavian vein

A

Drain to cisterna chyli
Up thoracic duct
Into subclavian

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42
Q

Name some thoracic lymphatic trunks

A

Internal thoracic nodes: anterior
Intercostal lymph trunks: posterior
Right bronchomediastinal ducts: from anterior up to right lymphatic duct

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43
Q

What are the pre aortic node groups? And what do they drain?

A

Coeliac nodes: foregut
Superior mesenteric nodes: midgut
Inferior mesenteric nodes: hindgut

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44
Q

Where do mesenteric nodes sit and where do they drain to?

A

Sit in the mesentery around arteries supplying the gut tube

Drain to cisterna chyli

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45
Q

Through what structure does the cisterna chyli drain to the thoracic duct?

A

Aortic hiatus

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46
Q

Where is the cisterna chyli located?

A

R side of L1 & 2

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47
Q

What structures are at risk with Lymph node resection around the aorta?

A

Damage to sympathetic nerve plexi

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48
Q

What could be a result of damage after inferior mesenteric node resection in hindgut neoplasm metastasis?

A

Secretory phase of male ejaculation due to sympathetic nerve damage

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49
Q

Where does most of the tracheobronchial tree drain to? And what is the exception?

A

Right lymphatic duct

Left upper lobe drains to the thoracic duct

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50
Q

Describe lymph drainage from the lungs

A

Hilar/bronchopulmonary nodes drain to paratracheal nodes

Drain to bronchomediastinal duct then either to right lymphatic duct or thoracic duct depending on lung area

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51
Q

What symptoms might occur from mediastinal lymphadenopathy?

A

Dysphagia, tracheal compression, left recurrent laryngeal nerve damage: hoarse voice, superior vena cava obstruction

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52
Q

Which structures drain to iliac nodes?

A

Rectum
Anal canal above pectinate line
Uterus, cervix, proximal vagina
Bladder

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53
Q

Where do the ovaries drain to?

A

Para aortic nodes L2

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54
Q

Where does lymph from Scrotal/labial, penile & perineal skin drain to?

A

Superficial inguinal nodes

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55
Q

Where does lymph from the Glans of penis/clitoris drain to?

A

Deep inguinal nodes

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56
Q

Where does the corpus cavernosum lymph drain to?

A

Internal Iliac nodes

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57
Q

Where does lymph from the male urethra drain to?

A

Proximal spongy & membranous: internal iliac nodes

Distal spongy: deep inguinal nodes

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58
Q

Where does lymph from Prostate, seminal vesicles & ductus drain to?

A

Mainly internal iliac nodes

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59
Q

Where does lymph from Distal anal/vaginal canal drain to?

A

Superficial inguinal nodes

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60
Q

What do Axillary nodes drain?

A

Anterior thoracic wall & breast
Posterior thoracic wall
Upper limb

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61
Q

Name the Axillary lymph node groups

A 
Apical
Central
Humeral 
Subscapular (posterior)
Pectoral (anterior)
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62
Q

What lymph node groups can breast tissue drain to?

A 
Anterior & central axillary nodes
Interpectoral (Rotter) nodes
Parasternal (internal thoracic) nodes
Contralateral parasternal nodes
Contralateral breast
Subdiaphragmatic /hepatic nodes
Inguinal lymph nodes
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63
Q

What can result from blockage/removal of lymph drainage route?

A

Lymphoedema

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64
Q

Where does breast skin drain to?

A

Axillary, deep cervical & infraclavicular nodes

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65
Q

Where do infraclavicular lymph nodes sit?

A

Deltopectoral triangle/ infraclavicular fossa

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66
Q

What is another name for the Inferior deep cervical nodes?

A

Jugulo-omohyoid nodes

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67
Q

Describe the direction of drainage of head and neck lymph nodes

A

Superficial to deep and from superior to inferior

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68
Q

What do submental lymph nodes drain?

A

Lower lip, lip of tongue

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69
Q

What do submandibular lymph nodes drain?

A

Lip, lateral body of tongue, nose, face

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70
Q

What do parotid lymph nodes drain? And what is their other name?

A

Temporal scalp & eye

Pre auricular

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71
Q

What do mastoid nodes drain? What is their other name?

A

EAM and pinna

Post auricular

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72
Q

What do occipital nodes drain?

A

Occipital scalp region to vertex

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73
Q

Where do the superficial cervical chain nodes run?

A

Run with EJV

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74
Q

What are the 3 groups of deep cervical nodes and what do they drain?

A

Jugulo-digastric: Tonsil, pharynx, posterior tongue
Deep Cervical Chain: Superficial node groups
Jugulo-omohyoid: Superficial node groups and central tongue

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75
Q

What areas may be affected with a unilateral lymphadenopathy of the right supraclavicular lymph nodes?

A

Intrathoracic structures
Oesophagus
Lung
Mediastinum

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76
Q

What areas may be affected with a unilateral lymphadenopathy of the left supraclavicular lymph nodes? And what other name do they have?

A

Virchow’s node
Stomach
Kidney
Ovary

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77
Q

What can be done to aid examination of supraclavicular lymph nodes?

A

Ask patient to valsalva

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78
Q

What are the constituents of waldeyers ring?

A

Pharyngeal: Adenoid
Tubal
Palatine
Lingual

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79
Q

What could result from a tubal lymphadenopathy which is common in children?

A

Secretory otitis media: glue ear

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80
Q

What is the significance of vascular watershed points from a surgical perspective?

A

Regions of poor healing

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81
Q

What are the superior and inferior boundaries of the neck?

A

Superior: Inferior mandible & base of skull: Pericraniocervical line
Inferior: Manubrium, Clavicle & Acromion–to-spinous process of C7

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82
Q

What are the supra hyoid muscles? what is their nerve supply? And what is their action?

A 
Digastric anterior belly - CN Vc
Mylohyoid - CN Vc
Digastric posterior belly- CN VII
Stylohyoid - CN VII
Elevate the hyoid
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83
Q

What are the infra hyoid muscles? what is their action? And what is their nerve supply?

A 
Thyrohyoid 
Sternothyroid
Omohyoid (superior & inferior bellies)
Sternohyoid
Scalene muscles
Depress hyoid 
Mostly ansa cervicalis (C1-3)
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84
Q

What are the posterior muscles of the neck and what is their nerve supply?

A

Subocciptial muscles = C1 posterior ramus
Levator scapulae = Dorsal scapula nerve and C3 &C4
Intrinsic vertebral column muscles = Posterior rami of spinal nerves

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85
Q

What are the boundaries of the anterior triangle of the neck?

A 
Medial = Midline (Median Sagittal Plane)
Lateral = Sternocleidomastoid (anterior border)
Superior = Inferior margin of mandible
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86
Q

What are the boundaries of the posterior triangle of the neck?

A 
Medial = Sternocleidomastoid (posterior border)
Lateral = Trapezius (anterior border)
Base = Clavicle (middle 1/3rd)
Apex = Mastoid Process
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87
Q

What are the boundaries of the carotid triangle of the neck?

A 
Ant. = Omohyoid (Superior Belly)
Sup. = Digastric (Posterior Belly)
Post. = Sternocleidomastoid
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88
Q

List some contents of the carotid triangle

A

Carotid, thyroid, facial & lingual arteries
Internal jugular & facial veins
CN X, XI, XII, VII (cervical branch)
Superior laryngeal nerve (internal & external branches)
Thyroid gland

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89
Q

What are the boundaries of the submandibular triangle?

A 
Sup. = Inferior border of mandible
Inf. = Digastric (ant. and post. bellies)
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90
Q

What are some key contents of the submandibular triangle?

A 
Submandibular lymph nodes
Submandibular salivary gland
Hypoglossal nerve
Lingual artery
Facial artery & vein
Marginal mandibular branch of CN VII
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91
Q

What are the boundaries of the submental triangle?

A 
Inf. = Hyoid bone
Lat. = Digastric (ant. belly)
Med. = Midline, if halved
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92
Q

What are some key contents of the submental triangle?

A

Submental lymph nodes

Anterior jugular vein tributaries

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93
Q

What 2 triangles can the posterior triangle of the neck be divided into? And what divides it?

A

Omoclavicular/supraclavicular triangle
Occipital triangle
Inferior belly of omohyoid

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94
Q

Name some of the contents of the supraclavicular triangle

A

Subclavian artery & vein & Supraclavicular nodes
Suprascapular nerve – damaged by clavicle #
Anaesthetise brachial plexus here

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95
Q

What is in the lesser supraclavicular fossa and what can this be used for?

A

Internal jugular vein

Central venous access point

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96
Q

What key nerves sit in the posterior triangle?

A

Accessory nerve
Brachial plexus C5-6
Phrenic nerve

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97
Q

How can you identify the location of the brachial plexus in the neck?

A

Can feel groove between scalenus anterior and medius and use it to locate plexus – sits level with cricoid cartilage

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98
Q

What are Trapezius, sternomastoid and the infrahyoid muscles enclosed in?

A

Investing fascia

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99
Q

How many deep layers of fascia are there in the neck?

A

4

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100
Q

What are the deep layers of fascia in the neck?

A 
Pretracheal fascia
Buccopharyngeal fascia (Post. Pretracheal fascia)
Carotid Sheath
Alar fascia 
Prevertebral fascia
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101
Q

In what region does the sympathetic chain sit in the neck?

A

Danger space

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102
Q

Where does the vertebral compartment extend to?

A

From skull base to thoracic vertebrae

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103
Q

Where does the visceral compartment extend to?

A

Extends to fibrous pericardium

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104
Q

How far does the pre tracheal space extends?

A

Extends into superior mediastinum

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105
Q

How far does the retro pharyngeal space extend?

A

Communicates down to superior mediastinum level

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106
Q

How far does the danger space extend?

A

Communicate with posterior mediastinum to diaphragm level

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107
Q

What fascia covers the brachial plexus and where does this mean that infection can spread to?

A

Covered by layer of prevertebral fascia = axillary sheath
Continues with it into upper limb - Infection in vertebral compartment can spread to upper limb via axillary sheath
Plexus block via injection into axillary sheath

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108
Q

How can cervical vertebrae be approached surgically?

A

From an anterior perspective

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109
Q

What do submental lymph nodes drain?

A

Lower lip, lip of tongue

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110
Q

What do submandibular glands drain?

A

Lip, lateral body of tongue, nose, face

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111
Q

What do parotid or pre auricular lymph nodes drain?

A

Temporal scalp & eye

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112
Q

What do mastoid or post auricular lymph nodes drain?

A

EAM and pinna

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113
Q

What do occipital lymph nodes drain?

A

Occipital scalp region to vertex

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114
Q

Where do superficial cervical lymph nodes run?

A

Run with EJV

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115
Q

What do jugulo Digastric lymph nodes drain?

A

Tonsil, pharynx, posterior tongue

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116
Q

What do the deep cervical chain lymph nodes drain?

A

Superficial node groups

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117
Q

What do jugulo omohyoid lymph node groups drain?

A

Superficial node groups and central tongue

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118
Q

What are the 3 deep neck lymph node groups?

A

Jugulo-Digastric
Deep cervical chain
Jugulo-omohyoid

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119
Q

What do supraclavicular lymph nodes drain?

A

Lung & upper GI

120
Q

Where does the carotid bifurcation occur?

A

Normally sits above thyroid cartilage lamina

At C3 in 45-62% of cases, Range C1-C5

121
Q

What does the external carotid supply?

A

Neck & face

122
Q

How can you distinguish the external carotid in the neck?

A

Multiple branches in the neck

123
Q

What does the internal carotid supply?

A

Enters cranium to supply CNS

124
Q

Where can you feel the carotid pulse?

A

In carotid triangle against C6 tubercle

125
Q

Where does the common carotid travel in relation to the larynx and pharynx?

A

Lateral to larynx & pharynx

126
Q

What sits close to the carotid bifurcation?

A

Carotid sinus and body

127
Q

What can external pressure on a hypersensitive carotid sinus lead to?

A

Syncope – not a good place to take a pulse in patients with unexplained syncope or vascular disease

128
Q

What does the carotid sinus sense?

A

Pressure

129
Q

What does the carotid body sense?

A

PO2 but can also sense PCO2

130
Q

What are the branches of the external carotid in the neck?

A

Superior thyroid artery: Runs close to external laryngeal nerve
Occipital artery: Supplies the occipital region. Runs over CNXII
Lingual artery: Mainly supplies the tongue
Maxillary artery: Deep facial tissues, nasal cavity, sinuses

131
Q

What does the vertebral artery supply? And what foramen does it go through to enter cranium?

A

Brainstem, spinal cord & brain

Run through foramen transversarium

132
Q

What does the internal thoracic artery supply?

A

Thoracic wall & breast

133
Q

What does the thyrocervical artery supply?

A

Thyroid & neck tissues

134
Q

Where do the EJV and IJV sit in relation to sternocleidomastoid?

A

IJV sits under sternomastoid

EJV sits above sternomastoid

135
Q

Where does the internal jugular vein run?

A

Runs from jugular foramen to behind sternoclavicular joint
Sits lateral to common carotid artery
IJV Pulsation can be observed and increases with increased right sided venous pressure

136
Q

Where does the external jugular vein run?

A

Runs from angle of mandible to lateral border where SCM meets clavicle
Sits under platysma
Injury can result in venous air embolus, Can be cannulated

137
Q

How can the internal jugular be accessed?

A

Via the lesser supraclavicular fossa

138
Q

Which veins in the neck feed into the anterior branch and then into the internal jugular vein?

A 
Superficial temporal v.
Maxillary v.
Retromandibular v.
Facial v.
Common facial v.
139
Q

Which veins of the neck feed into the posterior branch and then into the external jugular vein?

A

Superficial temporal v.
Maxillary v.
Retromandibular v.
Posterior auricular v.

140
Q

Where does the thyroid begin its development?

A

Thyroid gland begins development on tongue at foramen
caecum
Therefore an epithelial endoderm-derived structure

141
Q

Which pharyngeal arches does the tongue develop from?

A

Arches 1,3 & 4

142
Q

Via what structure does the thyroid descend?

A

Thyroglossal duct

143
Q

Why does the thyroglossal duct move during swallowing?

A

Thyroglossal duct attaches to hyoid bone, therefore duct moves during swallowing and tongue protrusion

144
Q

How can you identify a thyroglossal duct cyst?

A

Can form anywhere along thyroglossal duct in midline neck

Move on swallowing and tongue protrusion

145
Q

How might you distinguish a thyroglossal duct cyst from a thyroid gland enlargement?

A

Thyroid gland and lumps tends to move during swallowing but not always with tongue protrusion

146
Q

What is a pyramidal lobe of the thyroid?

A

Normal variant due to thyroid tissue developing in thyroglossal duct

147
Q

Where does the superior thyroid artery and vein run and what nerve are they close to?

A

From: external carotid
To: Internal jugular vein
artery runs close to the external branch of superior laryngeal nerve

148
Q

Where does the inferior thyroid artery and vein run and which nerve do they run close to?

A

From: Thyrocervical trunk
To: Left brachiocephalic vein
artery runs close to recurrent laryngeal nerve

149
Q

Where does the middle thyroid vein run to?

A

Internal jugular vein

150
Q

Where does the isthmus of the thyroid sit?

A

Over tracheal rings 2-3 at C7

151
Q

Where is the weak spot on the posterior pharynx?

A

Join between inferior constrictor and cricopharyngeus

Diverticula can form here

152
Q

What could result from a bleed into pretracheal fascia?

A

Trachea could be compressed, airway obstruction

153
Q

Where approximately do the parathyroid glands sit?

A

Posterior thyroid
2 at cricoid level
2 at inferior pole of thyroid

154
Q

What can be injured in thyroid surgery leading to vocal fold paralysis?

A

Close relationship of recurrent laryngeal nerve to inferior thyroid arteries means that nerve is at risk of damage

155
Q

What can thyroid gland enlargement result in which may be an emergency?

A

Compress the trachea causing stridor
Cause tracheal deviation
Affect swallowing

156
Q

What may limit superior enlargement of the thyroid gland?

A

Strap muscles covering gland

157
Q

What muscles and cartilage are formed from pharyngeal arch 1, CN V?

A

Mastication muscles, mylohyoid, anterior belly digastric, tensor tympani, tensor veli palatini
Malleus, incus, spine of sphenoid & sphenomandibular ligament
Maxilla, zygoma & mandible

158
Q

What muscles and cartilages are formed from pharyngeal arch 2, CN VII?

A

Facial expression muscles, stapedius, stylohyoid, posterior belly of digastric
Stapes, styloid process, stylohyoid ligament
Lesser horn and upper body of hyoid

159
Q

What muscles and cartilages are formed from pharyngeal arch 3, CN IX?

A

Stylopharyngeus

Greater horn & lower body of hyoid

160
Q

What muscles and cartilages are formed from pharyngeal arch 4, CN X (sup laryngeal)?

A

Pharyngeal muscles, cricothyroid, levator veli palatini

Thyroid & cricoid cartilages

161
Q

What muscles and cartilages are formed from pharyngeal arch 6, CN X (recurrent laryngeal)?

A

Intrinsic laryngeal muscles, pharyngeal muscles, striated muscle of oesophagus
Arytenoid cartilages

162
Q

What does the external acoustic meatus develop from?

A

1st pharyngeal cleft

163
Q

What forms from the 1st pharyngeal pouch?

A

Tympanic cavity & mastoid antrum

Pharyngotympanic tube

164
Q

What does the tympanic membrane develop from?

A

Ectoderm & Endoderm of 1st Pouch & Cleft

165
Q

What does the 2nd pharyngeal pouch develop into?

A

Palatine tonsillar crypts

Mesoderm under endoderm forms the tonsil

166
Q

What does the 3rd pharyngeal pouch develop into?

A

Inferior parathyroid glands & thymus

167
Q

What does the 4th pharyngeal pouch develop into?

A

Superior parathyroid glands & C-Cells of thyroid

168
Q

What is the branchial sinus?

A

Space where pharyngeal arch 2 grows over lower arches

169
Q

How does a branchial fistula form?

A

Branchial sinus should obliterate. If it remains open it can form a
branchial fistula that opens & discharges onto the lower neck

170
Q

Where do branchial cysts usually form?

A

Branchial cysts often form on anterior border of

sternocleidomastoid

171
Q

What nerves exit from the nerve point of the neck? (C2-4 emerge from posterior border of the middle 1/3 of sternocleidomastoid)

A 
Lesser Occipital nerve
Greater Auricular nerve
Transverse Cervical nerve
Spinal Accessory nerve (CN XI)
Supraclavicular nerves
172
Q

How can neck skin be anaesthetised?

What nerve is at risk here?

A

Anaesthetised via a nerve block around nerve point of neck, posterior border, middle 1/3 SCM
Can also anaesthetise phrenic nerve (C3-5)

173
Q

What are the main functions of the cervical plexus?

A

Sensory to neck skin, and motor to strap muscles & diaphragm

174
Q

Where do branches of the brachial plexus appear in the neck from?

A

Between anterior & middle scalenes

175
Q

What are the main branches of the cervical plexus?

A 
Transverse cervical
Ansa cervicalis 
Supraclavicular
Phrenic nerve
Greater auricular
Lesser occipital
176
Q

Where does the hypoglossal nerve run in the neck? When therefore is it at risk of damage?

A

Lateral to carotid vessels & under occipital artery (or its
branch to sternocleidomastoid)
Passes into floor of mouth deep to mylohyoid
Nerve is at risk during carotid artery surgery or node removal

177
Q

What can damage to the hypoglossal nerve result in?

A

Ipsilateral paralysis of tongue

Deviation of tongue towards damaged side on protrusion

178
Q

What is the function of the glossopharyngeal nerve?

A

Sensory supply to the pharynx, tonsil, middle ear, pharyngotympanic tube and posterior 1/3rd of tongue

179
Q

Where does the glossopharyngeal nerve run in the neck?

A

Nerve passes between carotid vessels
Enters pharynx between sup. & mid. constrictors
Note branch to carotid sinus & body

180
Q

What can damage to the glossopharyngeal nerve result in?

A

Difficulty swallowing
Loss of taste on posterior tongue and pharynx
Loss of gag reflex
Increased risk of aspiration

181
Q

Where does the accessory nerve run in the neck?

A

Exits via jugular foramen (in carotid sheath)
Emerges from under SCM 3-10cm below mastoid tip
Passes deep to trapezius 1-10cm above insertion of trapezius into clavicle
Runs through posterior triangle and is at risk during surgery in posterior triangle

182
Q

What can damage to the accessory nerve result in?

A

Weakness of shrugging ipsilateral shoulder
Weakness of turning head to contralateral side
Long term – scoliosis, trapezius wasting and fasciculations

183
Q

What are the nerve roots and function of the accessory nerve?

A

C1-5

Motor supply to SCM and Trapezius

184
Q

What does the Ansa cervicalis supply?

A

Infrahyoid strap muscles of neck & omohyoid

185
Q

What nerve roots form Ansa cervicalis?

A

Superior (C1) & inferior (C2,3) roots

186
Q

Where does the thoracic duct travel as it heads towards the subclavian vein?

A

Passes posterior to IJV and enters SV near to junction with IJV

187
Q

What are the 3 sympathetic chain ganglia in the neck?

A

Superior cervical ganglia (C1-4)
Middle cervical ganglia (C5-6)
Stellate ganglion/cervicothoracic (C7-C8)

188
Q

What are the anterior and posterior relations of the sympathetic chain in the neck?

A

Sympathetic chain sits posterior to the carotid sheath and anterior to the prevertebral fascia

189
Q

What damage results in horners syndrome?

A

Compression/laceration of sympathetic chain above T1

190
Q

What are the symptoms of horners syndrome?

A

Miosis
Anhydrosis
Flushed skin (red & hot)
Partial ptosis

191
Q

Name some causes of horners syndrome?

A

Neck tumours
Lymphadenopathy
Direct injury (trauma/iatrogenic)

192
Q

Describe the anatomy of the lung hilum

A

Right pulmonary artery travels in front of the right main bronchus
Left pulmonary artery winds over top and then behind left main
bronchus
Look like pulmonary artery and veins crossing each other

193
Q

What things should be looked at when analysing a chest X-ray?

A

Is it AP or PA? (scapulae clear of lungs?)
Is it the correct patient?
Is it adequately penetrated and exposed?
Is it rotated?
Compare upper, mid and lower zones
Look at apicies, lateral margin of lungs, hemidiaphragms
Look behind the heart and behind the hemidiaphragms and descending aorta
Asses hila
Look at soft tissue lines. Rt para tracheal, descending aorta
Look at the bones and soft tissue
Count ribs
Look at breasts

194
Q

If you see multiple nodules on a chest X-ray, what might you be looking at?

A 
Metastases
Abscesses, histoplasmosis, hydatid
AVMs (arteriovenous malformations)
Multiple areas of consolidation-rare (Sarcoid, Lymphoma, Eosinophiliic pneumonia, Wegeners, Alveolar cell ca, Pulmonary emboli,PMF, Rradiation pneumonitis)
Rheumatoid, caplans, wegeners
195
Q

What things might you see on a chest X-ray in someone with a tension pneumothorax?

A

Mediastinal shift away
Flattening of hemidiaphragm, increased pressure causes decreased venous return and death/compromise
Supine position look for a deep sulcus sign and very sharp border: costophrenic angle abnormally deepened as air collects laterally

196
Q

What is the cardiothoracic ratio?

A

A+B/C
Where A is from right heart border to midline
B is from left heart border to midline
C is the full width of the chest

197
Q

What things can cause bilateral upper lobe fibrosis?

A 
TB
Radiation
Extrinsic allergic Alveolitis
Ankylosing spondylitis  
Sarcoid
Histiocytosis
198
Q

What is phlebotomy?

A

Sampling of blood usually from superficial veins

199
Q

What is the preferred site for phlebotomy?

A

Upper limb over the cubital fossa

200
Q

Which veins are most commonly used for phlebotomy?

A

Cephalic, basilic or median cubital veins

201
Q

What are the borders of the cubital fossa?

A

Superior – Epicondylar line
Lateral – Brachioradialis
Medial – Pronator teres

202
Q

Give some indications for cannulation

A 
Short term venous access
Intravenous infusion – fluid, blood, drugs
Repeated drug administration
Repeated sampling
Measuring central venous pressure
203
Q

What states need precaution or are contraindicated for cannulation?

A

Fluid overload
Cardiac failure – check for oedema
Renal failure
Skin sepsis or burns

204
Q

List some possible complications of superficial venous cannulation

A 
Venous inflammation
Thrombosis
Thrombophlebitis: Clot & inflammation
Sepsis
Tissue infusion
205
Q

How many days can a superficial venous cannula be left in? After this time what should be used?

A

Up to 3 days use peripheral veins

Longer term use central/Hickman line

206
Q

What are common locations for superficial venous cannulation?

A

Cubital fossa
Dorsal hand
Anatomical snuffbox
Medial ankle (cutdown)

207
Q

Which nerves are at risk during cannulation in the cubital fossa?

A

Medial cutaneous nerve of the forearm

Lateral cutaneous nerve of the forearm

208
Q

Where does the housemans vein run?

A

Passes over anatomical snuffbox roof from the lateral side of the dorsal venous network

209
Q

Which tendons form the boundaries of the anatomical snuffbox?

A

Extensor Pollicis Longus
Extensor Pollicis Brevis
Abductor Pollicis

210
Q

Which nerve runs in close proximity to the housemans vein and is at risk of damage during cannulation?

A

Superficial cutaneous branch of radial nerve

211
Q

Describe the path of the great saphenous vein

A

Anterior to medial malleolus
Along posterior region of medial tibial border
Alongside saphenous cutaneous nerve
4 fingers breadth posterior to patella
Through saphenous opening 3cm inferior and lateral to pubic tubercle

212
Q

Where does the short saphenous vein run?

A

Posterior to lateral malleolus
Ascends midline posterior leg
Alongside sural cutaneous nerve
Into popliteal fossa via crural fascia and into popliteal vein

213
Q

Describe how you would carry out a venous cut down procedure to access the long saphenous vein

A

Identify medial malleolus
Identify great saphenous vein if possible (palpation)
Measure 1-1.5 cm anterior and superior to medial malleolus
Perform a transverse incision of up to 2.5cm from anterior toward posterior border of tibia

214
Q

Where would you cannulate a child?

A 
Cubital fossa
Hand dorsum
External jugular vein
Scalp-especially babies
NOT FEMORAL-hip joint
Venous cutdown – saphenous, basilic
Intraosseous-anterior tibia
215
Q

What are indications for central venous system cannulation?

A 
Need for long-term venous access
Chemotherapeutic drug administration
Total parenteral nutrition
Access to the heart
Peripheral veins inaccessible
Central venous pressure measurement
216
Q

List some possible complications of central venous system cannulation

A 
Catheter occlusion - clot
Air embolus
Haemorrhage
Displacement & tissue infiltration
Infection
217
Q

How is the central venous system accessed?

A

IJV line

Hickman (Subclavian) line

218
Q

Where does the IJV run in the neck?

A

Deep to SCM from a point medial to mandibular ramus to sternoclavicular joint/ sternal end of clavicle
Sits lateral to pulsating common carotid artery

219
Q

Where can the IJV be accessed in the neck?

A

Lesser supraclavicular fossa

Posterior border of sternocleidomastoid

220
Q

How should the position of an inserted IJV central line be checked? What else should be checked?

A

Radiography

Check for pneumothorax

221
Q

Where does the EJV run in the neck?

A

Runs from angle of mandible to lateral border of where SCM meets clavicle
Sits under platysma

222
Q

What can injury to the EJV during central line insertion result in?

A

Venous air embolus

223
Q

What nerves sit in close proximity to the EJV?

A 
Accessory nerve (CN XI)
Cutaneous branches of cervical plexus
224
Q

How is the subclavian vein accessed?

A

Infraclavicular approach
Insertion point is the junction of middle and medial 1/3 of clavicle on the right hand side
Cannula is directed under clavicle and toward to jugular notch of sternum

225
Q

What important structures are at risk of damage during a subclavian vein central line insertion?

A

Phrenic nerve
Vagus nerve
Recurrent laryngeal nerve
Lung apex

226
Q

Dural venous sinuses in the cranium can be accessed in the neonate. Superior sagittal sinus sits deep to which structures via which it can be accessed?

A 
Anterior and posterior fontanelles 
Soft spots (unossified regions) in newborn and young children
227
Q

What vessels does an interosseous infusion access? How does the fluid then reach the central circulation?

A

Medullary cavity venous sinusoids

Absorbed within cancellous bone through nutrient and emissary veins, which drain into the systemic circulation

228
Q

What are indications for arterial cannulation?

A 
Acid base status
Blood gasses
Assessment of respiratory/cardiac/ renal failure
Drug overdose
Diabetic ketoacidosis (DKA)
Lactic acidosis
Cardiac catheterisation
229
Q

What are possible complications of arterial cannulation?

A 
Haematoma
Arterial spasm – ischaemia
Retrograde embolism
Traumatic aneurysm 
Infection / spesis
230
Q

Which arteries are commonly accessed for cannulation?

A

Brachial artery
Radial artery
Femoral artery

231
Q

How is the radial artery accessed for arterial cannulation?

A

Lateral to flexor carpi radialis tendon

232
Q

How is the ulnar artery accessed for arterial cannulation?

A

Lateral to pisiform and flexor carpi ulnaris at wrist

Sitsimmediately lateral to ulnar nerve

233
Q

What structure ensures a consistent blood flow to the tissue of the hand?

A

Palmar anastomoses

234
Q

List some uses for the radial artery

A

Harvested for grafts
Radiocephalic fistula can be used for haemodialysis
Radial artery can be cannulated

235
Q

What test should be done to test the patency of each vessel of the wrist (normally the ulnar) prior to cannulation?

A

Allens test

236
Q

Briefly describe the radial artery cannulation process

A 
Confirm collateral supply using (Allen’s Test)
Use a pre-heparinised syringe
5-10 mins pressure to ensure haemostasis
Keep sample on ice (if possible)
Minimise delay in analysis
237
Q

How can the brachial artery be identified for an arterial stab?

A

Passes medial to biceps tendon and deep to its aponeurosis

238
Q

Which nerve runs in close proximity to the brachial artery?

A

Median nerve runs medially

239
Q

What are the boundaries of the femoral triangle?

A

Inguinal ligament
Sartorius
Adductor Longus

240
Q

Where does the femoral nerve sit in the femoral triangle?

A

1cm lateral to the pulsating femoral artery

241
Q

Where does the femoral artery enter the femoral triangle?

A

Midinguinal point ± 1.5cm (medial to lateral)

242
Q

What can appear at the saphenous opening?

A

Femoral hernia

Varicosities can for on the saphenous vein at the opening

243
Q

What are indications for a lumbar puncture?

A 
CSF composition & pressure
CNS infection (meningitis, encephalitis)
Subarachnoid haemorrhage
Multiple sclerosis
Peripheral neuropathy (Guillian-Barre)
244
Q

What are contraindications to lumbar puncture?

A 
Patient refusal
Raised intracranial pressure – Papilloedema
Intracranial bleed
Cord compression
Coagulopathy 
Spinal fixation surgery  
Skin sepsis - exfoliation
245
Q

What are possible complications of lumbar puncture?

A 
Headache due to depressed brain position (raise foot of bed)
Nerve root pain 
Bloody (traumatic) tap
Brain or cerebellar herniation
Meningitis
Annulus laceration causing backache
CN VI palsy/hearing loss
Transient/persistent paraesthesia/anaesthesia
246
Q

Where is the zone of spinal cord termination?

A

Ranges from middle 1/3rd of T11 to the middle 1/3rd of L3

247
Q

What is the mean level of spinal cord termination?

A

Middle 1/3rd of L1 vertebral body

Corresponds with lower part of interspinous space between T12 and L1 spinous processes

248
Q

Where is the zone of supracristal plane intersection with vertebral column?

A

Ranges from L2-L3 to L4-L5 junction/interspinous space

249
Q

Where is the highest point of iliac crest and supracristal plane (Tuffier’s line)?

A

Intersects vertebral column from L4 to the L4/5 junction

250
Q

Where does the subarachnoid space terminate in the spinal cord?

A

Usually S1 to S2 level

Can range from L5-S1 to S4

251
Q

At what vertebral level is lumbar puncture performed in adults?

A

L3/4 to L5/S1 interspinous gap

252
Q

At what vertebral level is lumbar puncture performed in children?

A

L4/L5 or L5-S1 interspinous gap

253
Q

What is the filum terminale?

A

Continuation of pia mater in the spinal cord after termination of dura and arachnoid

254
Q

What is the cauda equina?

A

Collection of lumbar and sacral spinal nerves

Supplies lower limbs, pelvic floor, urinary and anal sphincters

255
Q

Damage to T11/T12 vertebra will affect which spinal nerves?

A

L1-L5

256
Q

Damage to vertebra L1/2 will affect which spinal nerves?

A

S1-S5

257
Q

What is located in the epidural space?

A

Fat and Veins

258
Q

What angle is the needle inserted at during a lumbar puncture?

A

Anterosuperiorly

15° cephalad orientation

259
Q

Why do you need to monitor O2 sats during lumbar puncture?

A

Compress diaphragm

Respiratory compromise

260
Q

What layers are gone through during a lumbar puncture?

A 
Skin
Supraspinous and interspinous ligaments
Ligamentum flavum
Dura mater 
Arachnoid mater
261
Q

Where is the epidural space located usually?

A

4.5-5.5cm from skin in lumbar region

262
Q

What needle gauges should be used for lumbar puncture procedures?

A

Adult – 18/20 G
Child – 20 G
Neonate – 22G

263
Q

What should you do if a lumbar puncture needle gets blocked?

A

Try rotating it

264
Q

What different analyses can be performed on CSF?

A

Glucose and protein
Microscopy, Culture, Sensitivity
Cytology and cell counts

265
Q

What problems can occur with a lumbar puncture procedure?

A

Dry tap
Traumatic tap
Herniation
Headache

266
Q

Why might a dry tap occur when trying to perform a lumbar puncture?

A

When subarachnoid space is not entered or needle blocks

267
Q

If a lumbar puncture needle passes of course, what may happen?

A

Dry tap

Possible nerve root damage

268
Q

What might cause a lumbar puncture needle to pass off course?

A

Too little vertebral column flexion

Patient not perpendicular to bed

269
Q

Why does a traumatic lumbar puncture tap occur?

A

Internal vertebral venous plexus is pierced

270
Q

What makes a traumatic lumbar puncture tap more likely?

A

Increased number of attempts

Lateral deviation of needle

271
Q

What cancer type could metastasise to Batsons plexus in the extradural space?

A

Prostate

Direct communication with pelvic veins - valveless

272
Q

Why does headache occur after a lumbar puncture?

A

CSF loss results in a depressed brain, which pulls on sensitive meninges
Onset up to 48h post procedure
Accompanied by nausea, vomiting, tinnitus/hearing reduction

273
Q

What factors increase the likelihood of headache post lumbar puncture?

A

Anything which increases CSF loss:
Multiple punctures
Bevel at wrong orientation - increases leakiness
Large needle

274
Q

Which direction should the needle bevel face when performing a lumbar puncture?

A

Opening of bevel should be facing ceiling with patient lying in lateral decubitus position (on side)

275
Q

Why can herniation occur as a result of a lumbar puncture? Why is it more likely with raised intra cranial pressure?

A

Removing CSF decreases pressure in vertebral canal & can result in inferior herniation of neural tissue
Predisposed to by high pressure gradient between cranium and vertebral canal
Pressure gradient causes transtenorial and cerebellar structures to move inferiorly

276
Q

What is epidural anaesthesia used for?

A

Operative
Obstetrics
Orthopaedics
Pain management

277
Q

Describe needle insertion for epidural anaesthesia

A

Almost exactly the same as for lumbar puncture – just stop in the epidural space

278
Q

How can you increased the number of segments anaesthetised during an epidural?

A

Increased volume of anaesthetic inserted

279
Q

To achieve up to a T10 block from an L3-4 injection of epidural anaesthetic, how much should be injected?

A

9-18ml

280
Q

What difference is there between needle insertion in the lumbar region and thoracic region for epidural anaesthesia?

A

Needle needs to be angled more cephalad in thoracic region

281
Q

Where is spinal anaesthesia performed?

A

L3/L4 to L5/S1

282
Q

How can you control the level of spinal anaesthesia?

A

Volume, density and patient position

283
Q

What is a combined spinal epidural? What is it used for?

A

Both a spinal and lumbar epidural are delivered
Used during labour
Ready for operative procedures (e.g. caesarian/episiotomy/ventouse)

284
Q

What is caudal anaesthesia?

A

Injection into sacral epidural space via the sacral hiatus

Anaesthetises sacral spinal nerves: used to anaesthetise birth canal and perineum

285
Q

Where is the sacral hiatus?

A

Inferior apex of an equilateral triangle measure between the posterior superior iliac spines

286
Q

Describe needle insertion for a caudal anaesthesia

A

Introduced at oblique angle then directed cephalad and advanced

287
Q

How long are the ureters and what 3 parts is it made from?

A

25-30 cm long and has three parts:
abdominal ureter: from renal pelvis to pelvic brim
pelvic ureter: from the pelvic brim to the bladder
intravesical or intramural ureter: within the bladder wall

288
Q

Describe where the ureters run in the abdomen

A 
Medial aspect of psoas
Tips L2 – L5 transverse processes
Pelvis – anterior to SI joints 
Down lateral pelvic sidewall
Level ischial spine – turns anterior and medial
Posterolateral wall of bladder
Obliquely through bladder wall
289
Q

What are common sites of obstruction of the ureters?

A

Pelvic-ureteric junction of renal pelvis and the ureter
As ureter enters pelvis and crosses over the common iliac bifurcation
At vesicoureteric junction as ureter obliquely enters bladder wall

290
Q

To perform an ultrasound scan of the uterus, is it better for the bladder to be full or empty?

A

Transabdominal USS: full bladder as pushes uterus into view

Transvaginal USS: empty bladder so it doesn’t block view

291
Q

Describe the blood supply to the female reproductive system

A

Ovaries – aorta (Right V – IVC Left V – L Renal V)
Branches of internal iliac:
Uterus – internal iliac
Fallopian Tubes – ovarian & uterine branches
Cervix – uterine branch
Vagina – internal iliac

292
Q

What are the segments of the Fallopian tube?

A 
Fimbriae 
Infundibulum 
Ampulla
Isthmus
Interstitial
293
Q

What is a hysterosalpingogram?

A

X ray fluoroscopy and contrast used to look at uterus and Fallopian tubes to check for obstruction, usually in women who are struggling to get pregnant

294
Q

What are fibroids? What symptoms might be present?

A

Non cancerous growths which develop in/around the uterus

Can cause heavy periods, abdominal pain/swelling and urinary problems

295
Q

What is the function of puborectalis?

A

Maintain anorectal angle and therefore maintain faecal continence

AC1 (18 decks)

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