Anatomy Flashcards
1
Q
What is the Allantois?
A
Adult urachus
2
Q
How can you identify a thyroglossal duct cyst?
A
Move on swallowing and tongue protrusion
Central mass
3
Q
What is a Pyramidal lobe of the thyroid?
A
Normal variant due to thyroid tissue developing in the thyroglossal duct
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
5
Q
What are the 3 intercostal muscle layers?
A
External intercostal
Internal intercostal
Inner most intercostal
6
Q
Where does the main neurovascular bundle lie in the intercostals?
A
In costal groove
Below rib
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
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)
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
10
Q
What is a risk of pericardiocentesis?
A
Pneumothorax
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
12
Q
Which compartments can be released by a lateral fasciotomy of the thigh?
A
Anterior and posterior compartments
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
14
Q
What fasciotomy incisions can be performed in the forearm?
A
Dorsal
Volar (anterior)
15
Q
How do you approach the femur?
A
Lateral thigh Skin Fat Tensor Fascia Lata Vastus lateralis
16
Q
How do you approach the knee joint?
A
Antero medial approach
17
Q
How do you approach the tibia?
A
Posterolateral approach
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
19
Q
What superficial nerves are present on the dorsum of the foot?
A
Deep & Superfical Fibular nerve
20
Q
During an approach to the hip, which direction would you move piriformis?
A
Medially
To preserve the sciatic nerve
21
Q
Where does the circumflex humeral artery run?
A
Run with axillary nerve, 5cm inferior to acromion
22
Q
Where does the profunda brachii artery run?
A
With radial nerve along spiral groove within posterior compartment
23
Q
Where does the axillary artery run?
A
Passes behind mid-clavicle, medial to coracoid process
24
Q
Where does the cephalic vein run in relation to the shoulder joint?
A
In deltopectoral groove, anterior shoulder
25
What approach do you take to access the shoulder joint?
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"
26
What does lymph consist of?
Tissue fluid and plasma proteins
27
What are lymph nodes?
Filters with immune function
28
Describe the structure of a lymph node
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
29
Why do lymphatic vessels follow the arterial supply?
Lymphatic vessels similar to veins
Thin-walled & most contain valves
Arterial pulsation compresses lymph vessels aiding venous return
Develop with the vascular system
30
Which parts of the body drain lymph to the left subclavian vein?
Most of the body and the left upper lobe of the lung drain into the left subclavian vein via the thoracic duct
31
Which parts of the body drain to the right lymphatic duct?
Right upper limb
Most of lungs (all bar left upper lobe)
Right half of head and face
Right upper part of chest and back
32
What is an important thing to do when you see lymphangitis?
Check the distal part of the affected structure
33
Where do lymphatic vessels of the skin run?
With cutaneous veins to nodes located at the point of the vein passing through deep fascia
34
What could lymphangitis be confused with?
Thrombophlebitis
35
What drains to superficial inguinal lymph nodes?
Perineal region
Penis/clitoris glans
Lower anal/vaginal canal
Anterior labia majora / scrotal skin
36
What are the 2 groups of the superficial inguinal nodes?
Horizontal
| Vertical
37
Where do the deep inguinal nodes run?
Sit along femoral vein
| Cloquet node sits superiorly: sentinel node from lower limb and perineum
38
What do the deep inguinal nodes drain and where do they drain to?
Receive deep tissues and superficial node
| Drain to external inguinal nodes
39
Where does abdo wall lymph drain to?
Axillary and inguinal lymph nodes
| Regional split from umbilicus
40
Where does the umbilicus receive lymph drainage from?
Parasternal nodes
Axillary
Inguinal
41
Describe the route from the iliac vessels up to the left subclavian vein
Drain to cisterna chyli
Up thoracic duct
Into subclavian
42
Name some thoracic lymphatic trunks
Internal thoracic nodes: anterior
Intercostal lymph trunks: posterior
Right bronchomediastinal ducts: from anterior up to right lymphatic duct
43
What are the pre aortic node groups? And what do they drain?
Coeliac nodes: foregut
Superior mesenteric nodes: midgut
Inferior mesenteric nodes: hindgut
44
Where do mesenteric nodes sit and where do they drain to?
Sit in the mesentery around arteries supplying the gut tube
| Drain to cisterna chyli
45
Through what structure does the cisterna chyli drain to the thoracic duct?
Aortic hiatus
46
Where is the cisterna chyli located?
R side of L1 & 2
47
What structures are at risk with Lymph node resection around the aorta?
Damage to sympathetic nerve plexi
48
What could be a result of damage after inferior mesenteric node resection in hindgut neoplasm metastasis?
Secretory phase of male ejaculation due to sympathetic nerve damage
49
Where does most of the tracheobronchial tree drain to? And what is the exception?
Right lymphatic duct
| Left upper lobe drains to the thoracic duct
50
Describe lymph drainage from the lungs
Hilar/bronchopulmonary nodes drain to paratracheal nodes
| Drain to bronchomediastinal duct then either to right lymphatic duct or thoracic duct depending on lung area
51
What symptoms might occur from mediastinal lymphadenopathy?
Dysphagia, tracheal compression, left recurrent laryngeal nerve damage: hoarse voice, superior vena cava obstruction
52
Which structures drain to iliac nodes?
Rectum
Anal canal above pectinate line
Uterus, cervix, proximal vagina
Bladder
53
Where do the ovaries drain to?
Para aortic nodes L2
54
Where does lymph from Scrotal/labial, penile & perineal skin drain to?
Superficial inguinal nodes
55
Where does lymph from the Glans of penis/clitoris drain to?
Deep inguinal nodes
56
Where does the corpus cavernosum lymph drain to?
Internal Iliac nodes
57
Where does lymph from the male urethra drain to?
Proximal spongy & membranous: internal iliac nodes
| Distal spongy: deep inguinal nodes
58
Where does lymph from Prostate, seminal vesicles & ductus drain to?
Mainly internal iliac nodes
59
Where does lymph from Distal anal/vaginal canal drain to?
Superficial inguinal nodes
60
What do Axillary nodes drain?
Anterior thoracic wall & breast
Posterior thoracic wall
Upper limb
61
Name the Axillary lymph node groups
```
Apical
Central
Humeral
Subscapular (posterior)
Pectoral (anterior)
```
62
What lymph node groups can breast tissue drain to?
```
Anterior & central axillary nodes
Interpectoral (Rotter) nodes
Parasternal (internal thoracic) nodes
Contralateral parasternal nodes
Contralateral breast
Subdiaphragmatic /hepatic nodes
Inguinal lymph nodes
```
63
What can result from blockage/removal of lymph drainage route?
Lymphoedema
64
Where does breast skin drain to?
Axillary, deep cervical & infraclavicular nodes
65
Where do infraclavicular lymph nodes sit?
Deltopectoral triangle/ infraclavicular fossa
66
What is another name for the Inferior deep cervical nodes?
Jugulo-omohyoid nodes
67
Describe the direction of drainage of head and neck lymph nodes
Superficial to deep and from superior to inferior
68
What do submental lymph nodes drain?
Lower lip, lip of tongue
69
What do submandibular lymph nodes drain?
Lip, lateral body of tongue, nose, face
70
What do parotid lymph nodes drain? And what is their other name?
Temporal scalp & eye
| Pre auricular
71
What do mastoid nodes drain? What is their other name?
EAM and pinna
| Post auricular
72
What do occipital nodes drain?
Occipital scalp region to vertex
73
Where do the superficial cervical chain nodes run?
Run with EJV
74
What are the 3 groups of deep cervical nodes and what do they drain?
Jugulo-digastric: Tonsil, pharynx, posterior tongue
Deep Cervical Chain: Superficial node groups
Jugulo-omohyoid: Superficial node groups and central tongue
75
What areas may be affected with a unilateral lymphadenopathy of the right supraclavicular lymph nodes?
Intrathoracic structures
Oesophagus
Lung
Mediastinum
76
What areas may be affected with a unilateral lymphadenopathy of the left supraclavicular lymph nodes? And what other name do they have?
Virchow’s node
Stomach
Kidney
Ovary
77
What can be done to aid examination of supraclavicular lymph nodes?
Ask patient to valsalva
78
What are the constituents of waldeyers ring?
Pharyngeal: Adenoid
Tubal
Palatine
Lingual
79
What could result from a tubal lymphadenopathy which is common in children?
Secretory otitis media: glue ear
80
What is the significance of vascular watershed points from a surgical perspective?
Regions of poor healing
81
What are the superior and inferior boundaries of the neck?
Superior: Inferior mandible & base of skull: Pericraniocervical line
Inferior: Manubrium, Clavicle & Acromion–to-spinous process of C7
82
What are the supra hyoid muscles? what is their nerve supply? And what is their action?
```
Digastric anterior belly - CN Vc
Mylohyoid - CN Vc
Digastric posterior belly- CN VII
Stylohyoid - CN VII
Elevate the hyoid
```
83
What are the infra hyoid muscles? what is their action? And what is their nerve supply?
```
Thyrohyoid
Sternothyroid
Omohyoid (superior & inferior bellies)
Sternohyoid
Scalene muscles
Depress hyoid
Mostly ansa cervicalis (C1-3)
```
84
What are the posterior muscles of the neck and what is their nerve supply?
Subocciptial muscles = C1 posterior ramus
Levator scapulae = Dorsal scapula nerve and C3 &C4
Intrinsic vertebral column muscles = Posterior rami of spinal nerves
85
What are the boundaries of the anterior triangle of the neck?
```
Medial = Midline (Median Sagittal Plane)
Lateral = Sternocleidomastoid (anterior border)
Superior = Inferior margin of mandible
```
86
What are the boundaries of the posterior triangle of the neck?
```
Medial = Sternocleidomastoid (posterior border)
Lateral = Trapezius (anterior border)
Base = Clavicle (middle 1/3rd)
Apex = Mastoid Process
```
87
What are the boundaries of the carotid triangle of the neck?
```
Ant. = Omohyoid (Superior Belly)
Sup. = Digastric (Posterior Belly)
Post. = Sternocleidomastoid
```
88
List some contents of the carotid triangle
Carotid, thyroid, facial & lingual arteries
Internal jugular & facial veins
CN X, XI, XII, VII (cervical branch)
Superior laryngeal nerve (internal & external branches)
Thyroid gland
89
What are the boundaries of the submandibular triangle?
```
Sup. = Inferior border of mandible
Inf. = Digastric (ant. and post. bellies)
```
90
What are some key contents of the submandibular triangle?
```
Submandibular lymph nodes
Submandibular salivary gland
Hypoglossal nerve
Lingual artery
Facial artery & vein
Marginal mandibular branch of CN VII
```
91
What are the boundaries of the submental triangle?
```
Inf. = Hyoid bone
Lat. = Digastric (ant. belly)
Med. = Midline, if halved
```
92
What are some key contents of the submental triangle?
Submental lymph nodes
| Anterior jugular vein tributaries
93
What 2 triangles can the posterior triangle of the neck be divided into? And what divides it?
Omoclavicular/supraclavicular triangle
Occipital triangle
Inferior belly of omohyoid
94
Name some of the contents of the supraclavicular triangle
Subclavian artery & vein & Supraclavicular nodes
Suprascapular nerve – damaged by clavicle #
Anaesthetise brachial plexus here
95
What is in the lesser supraclavicular fossa and what can this be used for?
Internal jugular vein
| Central venous access point
96
What key nerves sit in the posterior triangle?
Accessory nerve
Brachial plexus C5-6
Phrenic nerve
97
How can you identify the location of the brachial plexus in the neck?
Can feel groove between scalenus anterior and medius and use it to locate plexus – sits level with cricoid cartilage
98
What are Trapezius, sternomastoid and the infrahyoid muscles enclosed in?
Investing fascia
99
How many deep layers of fascia are there in the neck?
4
100
What are the deep layers of fascia in the neck?
```
Pretracheal fascia
Buccopharyngeal fascia (Post. Pretracheal fascia)
Carotid Sheath
Alar fascia
Prevertebral fascia
```
101
In what region does the sympathetic chain sit in the neck?
Danger space
102
Where does the vertebral compartment extend to?
From skull base to thoracic vertebrae
103
Where does the visceral compartment extend to?
Extends to fibrous pericardium
104
How far does the pre tracheal space extends?
Extends into superior mediastinum
105
How far does the retro pharyngeal space extend?
Communicates down to superior mediastinum level
106
How far does the danger space extend?
Communicate with posterior mediastinum to diaphragm level
107
What fascia covers the brachial plexus and where does this mean that infection can spread to?
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
108
How can cervical vertebrae be approached surgically?
From an anterior perspective
109
What do submental lymph nodes drain?
Lower lip, lip of tongue
110
What do submandibular glands drain?
Lip, lateral body of tongue, nose, face
111
What do parotid or pre auricular lymph nodes drain?
Temporal scalp & eye
112
What do mastoid or post auricular lymph nodes drain?
EAM and pinna
113
What do occipital lymph nodes drain?
Occipital scalp region to vertex
114
Where do superficial cervical lymph nodes run?
Run with EJV
115
What do jugulo Digastric lymph nodes drain?
Tonsil, pharynx, posterior tongue
116
What do the deep cervical chain lymph nodes drain?
Superficial node groups
117
What do jugulo omohyoid lymph node groups drain?
Superficial node groups and central tongue
118
What are the 3 deep neck lymph node groups?
Jugulo-Digastric
Deep cervical chain
Jugulo-omohyoid
119
What do supraclavicular lymph nodes drain?
Lung & upper GI
120
Where does the carotid bifurcation occur?
Normally sits above thyroid cartilage lamina
| At C3 in 45-62% of cases, Range C1-C5
121
What does the external carotid supply?
Neck & face
122
How can you distinguish the external carotid in the neck?
Multiple branches in the neck
123
What does the internal carotid supply?
Enters cranium to supply CNS
124
Where can you feel the carotid pulse?
In carotid triangle against C6 tubercle
125
Where does the common carotid travel in relation to the larynx and pharynx?
Lateral to larynx & pharynx
126
What sits close to the carotid bifurcation?
Carotid sinus and body
127
What can external pressure on a hypersensitive carotid sinus lead to?
Syncope – not a good place to take a pulse in patients with unexplained syncope or vascular disease
128
What does the carotid sinus sense?
Pressure
129
What does the carotid body sense?
PO2 but can also sense PCO2
130
What are the branches of the external carotid in the neck?
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
What does the vertebral artery supply? And what foramen does it go through to enter cranium?
Brainstem, spinal cord & brain
| Run through foramen transversarium
132
What does the internal thoracic artery supply?
Thoracic wall & breast
133
What does the thyrocervical artery supply?
Thyroid & neck tissues
134
Where do the EJV and IJV sit in relation to sternocleidomastoid?
IJV sits under sternomastoid
| EJV sits above sternomastoid
135
Where does the internal jugular vein run?
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
Where does the external jugular vein run?
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
How can the internal jugular be accessed?
Via the lesser supraclavicular fossa
138
Which veins in the neck feed into the anterior branch and then into the internal jugular vein?
```
Superficial temporal v.
Maxillary v.
Retromandibular v.
Facial v.
Common facial v.
```
139
Which veins of the neck feed into the posterior branch and then into the external jugular vein?
Superficial temporal v.
Maxillary v.
Retromandibular v.
Posterior auricular v.
140
Where does the thyroid begin its development?
Thyroid gland begins development on tongue at foramen
caecum
Therefore an epithelial endoderm-derived structure
141
Which pharyngeal arches does the tongue develop from?
Arches 1,3 & 4
142
Via what structure does the thyroid descend?
Thyroglossal duct
143
Why does the thyroglossal duct move during swallowing?
Thyroglossal duct attaches to hyoid bone, therefore duct moves during swallowing and tongue protrusion
144
How can you identify a thyroglossal duct cyst?
Can form anywhere along thyroglossal duct in midline neck
| Move on swallowing and tongue protrusion
145
How might you distinguish a thyroglossal duct cyst from a thyroid gland enlargement?
Thyroid gland and lumps tends to move during swallowing but not always with tongue protrusion
146
What is a pyramidal lobe of the thyroid?
Normal variant due to thyroid tissue developing in thyroglossal duct
147
Where does the superior thyroid artery and vein run and what nerve are they close to?
From: external carotid
To: Internal jugular vein
artery runs close to the external branch of superior laryngeal nerve
148
Where does the inferior thyroid artery and vein run and which nerve do they run close to?
From: Thyrocervical trunk
To: Left brachiocephalic vein
artery runs close to recurrent laryngeal nerve
149
Where does the middle thyroid vein run to?
Internal jugular vein
150
Where does the isthmus of the thyroid sit?
Over tracheal rings 2-3 at C7
151
Where is the weak spot on the posterior pharynx?
Join between inferior constrictor and cricopharyngeus
| Diverticula can form here
152
What could result from a bleed into pretracheal fascia?
Trachea could be compressed, airway obstruction
153
Where approximately do the parathyroid glands sit?
Posterior thyroid
2 at cricoid level
2 at inferior pole of thyroid
154
What can be injured in thyroid surgery leading to vocal fold paralysis?
Close relationship of recurrent laryngeal nerve to inferior thyroid arteries means that nerve is at risk of damage
155
What can thyroid gland enlargement result in which may be an emergency?
Compress the trachea causing stridor
Cause tracheal deviation
Affect swallowing
156
What may limit superior enlargement of the thyroid gland?
Strap muscles covering gland
157
What muscles and cartilage are formed from pharyngeal arch 1, CN V?
Mastication muscles, mylohyoid, anterior belly digastric, tensor tympani, tensor veli palatini
Malleus, incus, spine of sphenoid & sphenomandibular ligament
Maxilla, zygoma & mandible
158
What muscles and cartilages are formed from pharyngeal arch 2, CN VII?
Facial expression muscles, stapedius, stylohyoid, posterior belly of digastric
Stapes, styloid process, stylohyoid ligament
Lesser horn and upper body of hyoid
159
What muscles and cartilages are formed from pharyngeal arch 3, CN IX?
Stylopharyngeus
| Greater horn & lower body of hyoid
160
What muscles and cartilages are formed from pharyngeal arch 4, CN X (sup laryngeal)?
Pharyngeal muscles, cricothyroid, levator veli palatini
| Thyroid & cricoid cartilages
161
What muscles and cartilages are formed from pharyngeal arch 6, CN X (recurrent laryngeal)?
Intrinsic laryngeal muscles, pharyngeal muscles, striated muscle of oesophagus
Arytenoid cartilages
162
What does the external acoustic meatus develop from?
1st pharyngeal cleft
163
What forms from the 1st pharyngeal pouch?
Tympanic cavity & mastoid antrum
| Pharyngotympanic tube
164
What does the tympanic membrane develop from?
Ectoderm & Endoderm of 1st Pouch & Cleft
165
What does the 2nd pharyngeal pouch develop into?
Palatine tonsillar crypts
| Mesoderm under endoderm forms the tonsil
166
What does the 3rd pharyngeal pouch develop into?
Inferior parathyroid glands & thymus
167
What does the 4th pharyngeal pouch develop into?
Superior parathyroid glands & C-Cells of thyroid
168
What is the branchial sinus?
Space where pharyngeal arch 2 grows over lower arches
169
How does a branchial fistula form?
Branchial sinus should obliterate. If it remains open it can form a
branchial fistula that opens & discharges onto the lower neck
170
Where do branchial cysts usually form?
Branchial cysts often form on anterior border of
| sternocleidomastoid
171
What nerves exit from the nerve point of the neck? (C2-4 emerge from posterior border of the middle 1/3 of sternocleidomastoid)
```
Lesser Occipital nerve
Greater Auricular nerve
Transverse Cervical nerve
Spinal Accessory nerve (CN XI)
Supraclavicular nerves
```
172
How can neck skin be anaesthetised?
| What nerve is at risk here?
Anaesthetised via a nerve block around nerve point of neck, posterior border, middle 1/3 SCM
Can also anaesthetise phrenic nerve (C3-5)
173
What are the main functions of the cervical plexus?
Sensory to neck skin, and motor to strap muscles & diaphragm
174
Where do branches of the brachial plexus appear in the neck from?
Between anterior & middle scalenes
175
What are the main branches of the cervical plexus?
```
Transverse cervical
Ansa cervicalis
Supraclavicular
Phrenic nerve
Greater auricular
Lesser occipital
```
176
Where does the hypoglossal nerve run in the neck? When therefore is it at risk of damage?
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
What can damage to the hypoglossal nerve result in?
Ipsilateral paralysis of tongue
| Deviation of tongue towards damaged side on protrusion
178
What is the function of the glossopharyngeal nerve?
Sensory supply to the pharynx, tonsil, middle ear, pharyngotympanic tube and posterior 1/3rd of tongue
179
Where does the glossopharyngeal nerve run in the neck?
Nerve passes between carotid vessels
Enters pharynx between sup. & mid. constrictors
Note branch to carotid sinus & body
180
What can damage to the glossopharyngeal nerve result in?
Difficulty swallowing
Loss of taste on posterior tongue and pharynx
Loss of gag reflex
Increased risk of aspiration
181
Where does the accessory nerve run in the neck?
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
What can damage to the accessory nerve result in?
Weakness of shrugging ipsilateral shoulder
Weakness of turning head to contralateral side
Long term – scoliosis, trapezius wasting and fasciculations
183
What are the nerve roots and function of the accessory nerve?
C1-5
| Motor supply to SCM and Trapezius
184
What does the Ansa cervicalis supply?
Infrahyoid strap muscles of neck & omohyoid
185
What nerve roots form Ansa cervicalis?
Superior (C1) & inferior (C2,3) roots
186
Where does the thoracic duct travel as it heads towards the subclavian vein?
Passes posterior to IJV and enters SV near to junction with IJV
187
What are the 3 sympathetic chain ganglia in the neck?
Superior cervical ganglia (C1-4)
Middle cervical ganglia (C5-6)
Stellate ganglion/cervicothoracic (C7-C8)
188
What are the anterior and posterior relations of the sympathetic chain in the neck?
Sympathetic chain sits posterior to the carotid sheath and anterior to the prevertebral fascia
189
What damage results in horners syndrome?
Compression/laceration of sympathetic chain above T1
190
What are the symptoms of horners syndrome?
Miosis
Anhydrosis
Flushed skin (red & hot)
Partial ptosis
191
Name some causes of horners syndrome?
Neck tumours
Lymphadenopathy
Direct injury (trauma/iatrogenic)
192
Describe the anatomy of the lung hilum
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
What things should be looked at when analysing a chest X-ray?
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
If you see multiple nodules on a chest X-ray, what might you be looking at?
```
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
What things might you see on a chest X-ray in someone with a tension pneumothorax?
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
What is the cardiothoracic ratio?
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
What things can cause bilateral upper lobe fibrosis?
```
TB
Radiation
Extrinsic allergic Alveolitis
Ankylosing spondylitis
Sarcoid
Histiocytosis
```
198
What is phlebotomy?
Sampling of blood usually from superficial veins
199
What is the preferred site for phlebotomy?
Upper limb over the cubital fossa
200
Which veins are most commonly used for phlebotomy?
Cephalic, basilic or median cubital veins
201
What are the borders of the cubital fossa?
Superior – Epicondylar line
Lateral – Brachioradialis
Medial – Pronator teres
202
Give some indications for cannulation
```
Short term venous access
Intravenous infusion – fluid, blood, drugs
Repeated drug administration
Repeated sampling
Measuring central venous pressure
```
203
What states need precaution or are contraindicated for cannulation?
Fluid overload
Cardiac failure – check for oedema
Renal failure
Skin sepsis or burns
204
List some possible complications of superficial venous cannulation
```
Venous inflammation
Thrombosis
Thrombophlebitis: Clot & inflammation
Sepsis
Tissue infusion
```
205
How many days can a superficial venous cannula be left in? After this time what should be used?
Up to 3 days use peripheral veins
| Longer term use central/Hickman line
206
What are common locations for superficial venous cannulation?
Cubital fossa
Dorsal hand
Anatomical snuffbox
Medial ankle (cutdown)
207
Which nerves are at risk during cannulation in the cubital fossa?
Medial cutaneous nerve of the forearm
| Lateral cutaneous nerve of the forearm
208
Where does the housemans vein run?
Passes over anatomical snuffbox roof from the lateral side of the dorsal venous network
209
Which tendons form the boundaries of the anatomical snuffbox?
Extensor Pollicis Longus
Extensor Pollicis Brevis
Abductor Pollicis
210
Which nerve runs in close proximity to the housemans vein and is at risk of damage during cannulation?
Superficial cutaneous branch of radial nerve
211
Describe the path of the great saphenous vein
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
Where does the short saphenous vein run?
Posterior to lateral malleolus
Ascends midline posterior leg
Alongside sural cutaneous nerve
Into popliteal fossa via crural fascia and into popliteal vein
213
Describe how you would carry out a venous cut down procedure to access the long saphenous vein
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
Where would you cannulate a child?
```
Cubital fossa
Hand dorsum
External jugular vein
Scalp-especially babies
NOT FEMORAL-hip joint
Venous cutdown – saphenous, basilic
Intraosseous-anterior tibia
```
215
What are indications for central venous system cannulation?
```
Need for long-term venous access
Chemotherapeutic drug administration
Total parenteral nutrition
Access to the heart
Peripheral veins inaccessible
Central venous pressure measurement
```
216
List some possible complications of central venous system cannulation
```
Catheter occlusion - clot
Air embolus
Haemorrhage
Displacement & tissue infiltration
Infection
```
217
How is the central venous system accessed?
IJV line
| Hickman (Subclavian) line
218
Where does the IJV run in the neck?
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
Where can the IJV be accessed in the neck?
Lesser supraclavicular fossa
| Posterior border of sternocleidomastoid
220
How should the position of an inserted IJV central line be checked? What else should be checked?
Radiography
| Check for pneumothorax
221
Where does the EJV run in the neck?
Runs from angle of mandible to lateral border of where SCM meets clavicle
Sits under platysma
222
What can injury to the EJV during central line insertion result in?
Venous air embolus
223
What nerves sit in close proximity to the EJV?
```
Accessory nerve (CN XI)
Cutaneous branches of cervical plexus
```
224
How is the subclavian vein accessed?
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
What important structures are at risk of damage during a subclavian vein central line insertion?
Phrenic nerve
Vagus nerve
Recurrent laryngeal nerve
Lung apex
226
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?
```
Anterior and posterior fontanelles
Soft spots (unossified regions) in newborn and young children
```
227
What vessels does an interosseous infusion access? How does the fluid then reach the central circulation?
Medullary cavity venous sinusoids
| Absorbed within cancellous bone through nutrient and emissary veins, which drain into the systemic circulation
228
What are indications for arterial cannulation?
```
Acid base status
Blood gasses
Assessment of respiratory/cardiac/ renal failure
Drug overdose
Diabetic ketoacidosis (DKA)
Lactic acidosis
Cardiac catheterisation
```
229
What are possible complications of arterial cannulation?
```
Haematoma
Arterial spasm – ischaemia
Retrograde embolism
Traumatic aneurysm
Infection / spesis
```
230
Which arteries are commonly accessed for cannulation?
Brachial artery
Radial artery
Femoral artery
231
How is the radial artery accessed for arterial cannulation?
Lateral to flexor carpi radialis tendon
232
How is the ulnar artery accessed for arterial cannulation?
Lateral to pisiform and flexor carpi ulnaris at wrist
| Sitsimmediately lateral to ulnar nerve
233
What structure ensures a consistent blood flow to the tissue of the hand?
Palmar anastomoses
234
List some uses for the radial artery
Harvested for grafts
Radiocephalic fistula can be used for haemodialysis
Radial artery can be cannulated
235
What test should be done to test the patency of each vessel of the wrist (normally the ulnar) prior to cannulation?
Allens test
236
Briefly describe the radial artery cannulation process
```
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
How can the brachial artery be identified for an arterial stab?
Passes medial to biceps tendon and deep to its aponeurosis
238
Which nerve runs in close proximity to the brachial artery?
Median nerve runs medially
239
What are the boundaries of the femoral triangle?
Inguinal ligament
Sartorius
Adductor Longus
240
Where does the femoral nerve sit in the femoral triangle?
1cm lateral to the pulsating femoral artery
241
Where does the femoral artery enter the femoral triangle?
Midinguinal point ± 1.5cm (medial to lateral)
242
What can appear at the saphenous opening?
Femoral hernia
| Varicosities can for on the saphenous vein at the opening
243
What are indications for a lumbar puncture?
```
CSF composition & pressure
CNS infection (meningitis, encephalitis)
Subarachnoid haemorrhage
Multiple sclerosis
Peripheral neuropathy (Guillian-Barre)
```
244
What are contraindications to lumbar puncture?
```
Patient refusal
Raised intracranial pressure – Papilloedema
Intracranial bleed
Cord compression
Coagulopathy
Spinal fixation surgery
Skin sepsis - exfoliation
```
245
What are possible complications of lumbar puncture?
```
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
Where is the zone of spinal cord termination?
Ranges from middle 1/3rd of T11 to the middle 1/3rd of L3
247
What is the mean level of spinal cord termination?
Middle 1/3rd of L1 vertebral body
| Corresponds with lower part of interspinous space between T12 and L1 spinous processes
248
Where is the zone of supracristal plane intersection with vertebral column?
Ranges from L2-L3 to L4-L5 junction/interspinous space
249
Where is the highest point of iliac crest and supracristal plane (Tuffier’s line)?
Intersects vertebral column from L4 to the L4/5 junction
250
Where does the subarachnoid space terminate in the spinal cord?
Usually S1 to S2 level
| Can range from L5-S1 to S4
251
At what vertebral level is lumbar puncture performed in adults?
L3/4 to L5/S1 interspinous gap
252
At what vertebral level is lumbar puncture performed in children?
L4/L5 or L5-S1 interspinous gap
253
What is the filum terminale?
Continuation of pia mater in the spinal cord after termination of dura and arachnoid
254
What is the cauda equina?
Collection of lumbar and sacral spinal nerves
| Supplies lower limbs, pelvic floor, urinary and anal sphincters
255
Damage to T11/T12 vertebra will affect which spinal nerves?
L1-L5
256
Damage to vertebra L1/2 will affect which spinal nerves?
S1-S5
257
What is located in the epidural space?
Fat and Veins
258
What angle is the needle inserted at during a lumbar puncture?
Anterosuperiorly
| 15° cephalad orientation
259
Why do you need to monitor O2 sats during lumbar puncture?
Compress diaphragm
| Respiratory compromise
260
What layers are gone through during a lumbar puncture?
```
Skin
Supraspinous and interspinous ligaments
Ligamentum flavum
Dura mater
Arachnoid mater
```
261
Where is the epidural space located usually?
4.5-5.5cm from skin in lumbar region
262
What needle gauges should be used for lumbar puncture procedures?
Adult – 18/20 G
Child – 20 G
Neonate – 22G
263
What should you do if a lumbar puncture needle gets blocked?
Try rotating it
264
What different analyses can be performed on CSF?
Glucose and protein
Microscopy, Culture, Sensitivity
Cytology and cell counts
265
What problems can occur with a lumbar puncture procedure?
Dry tap
Traumatic tap
Herniation
Headache
266
Why might a dry tap occur when trying to perform a lumbar puncture?
When subarachnoid space is not entered or needle blocks
267
If a lumbar puncture needle passes of course, what may happen?
Dry tap
| Possible nerve root damage
268
What might cause a lumbar puncture needle to pass off course?
Too little vertebral column flexion
| Patient not perpendicular to bed
269
Why does a traumatic lumbar puncture tap occur?
Internal vertebral venous plexus is pierced
270
What makes a traumatic lumbar puncture tap more likely?
Increased number of attempts
| Lateral deviation of needle
271
What cancer type could metastasise to Batsons plexus in the extradural space?
Prostate
| Direct communication with pelvic veins - valveless
272
Why does headache occur after a lumbar puncture?
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
What factors increase the likelihood of headache post lumbar puncture?
Anything which increases CSF loss:
Multiple punctures
Bevel at wrong orientation - increases leakiness
Large needle
274
Which direction should the needle bevel face when performing a lumbar puncture?
Opening of bevel should be facing ceiling with patient lying in lateral decubitus position (on side)
275
Why can herniation occur as a result of a lumbar puncture? Why is it more likely with raised intra cranial pressure?
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
What is epidural anaesthesia used for?
Operative
Obstetrics
Orthopaedics
Pain management
277
Describe needle insertion for epidural anaesthesia
Almost exactly the same as for lumbar puncture – just stop in the epidural space
278
How can you increased the number of segments anaesthetised during an epidural?
Increased volume of anaesthetic inserted
279
To achieve up to a T10 block from an L3-4 injection of epidural anaesthetic, how much should be injected?
9-18ml
280
What difference is there between needle insertion in the lumbar region and thoracic region for epidural anaesthesia?
Needle needs to be angled more cephalad in thoracic region
281
Where is spinal anaesthesia performed?
L3/L4 to L5/S1
282
How can you control the level of spinal anaesthesia?
Volume, density and patient position
283
What is a combined spinal epidural? What is it used for?
Both a spinal and lumbar epidural are delivered
Used during labour
Ready for operative procedures (e.g. caesarian/episiotomy/ventouse)
284
What is caudal anaesthesia?
Injection into sacral epidural space via the sacral hiatus
| Anaesthetises sacral spinal nerves: used to anaesthetise birth canal and perineum
285
Where is the sacral hiatus?
Inferior apex of an equilateral triangle measure between the posterior superior iliac spines
286
Describe needle insertion for a caudal anaesthesia
Introduced at oblique angle then directed cephalad and advanced
287
How long are the ureters and what 3 parts is it made from?
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
Describe where the ureters run in the abdomen
```
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
What are common sites of obstruction of the ureters?
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
To perform an ultrasound scan of the uterus, is it better for the bladder to be full or empty?
Transabdominal USS: full bladder as pushes uterus into view
| Transvaginal USS: empty bladder so it doesn't block view
291
Describe the blood supply to the female reproductive system
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
What are the segments of the Fallopian tube?
```
Fimbriae
Infundibulum
Ampulla
Isthmus
Interstitial
```
293
What is a hysterosalpingogram?
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
What are fibroids? What symptoms might be present?
Non cancerous growths which develop in/around the uterus
| Can cause heavy periods, abdominal pain/swelling and urinary problems
295
What is the function of puborectalis?
Maintain anorectal angle and therefore maintain faecal continence
