Anatomy Flashcards
Scalpel system used to put on dissection blades
Swann Morton system
Can the first rib be felt in the living?
No because it is behind the clavicle and the pectoralis major muscle
Where is the sternal angle and what structures can we gauge from it
The sternal angle (also called the Angle of Louis) is between the manubrium of the sternum and the body of the sternum
It is connected to the second costal cartilage of the ribs
Where is the lower coastal margin and what does it seperate
The lower coastal margin seperates the thorax and the abdomen, it is the bony ridge of the bottom of the ribs
Where would the midclavicular line pass through (think of in a male)
It would be half way between the acriomioclaviocular joint and the sternoclavicular joint, going down (through the nipple for men), and passing in between the superior iliac spine and the pubic tubercle
Give 5 lines (running from head to toe) used to describe the body
Midline
Mid-clavicular line
Anterior axillary line (from the anterior axillary fold)
Mid-axillary line
Posterior axillary line (from the posterior axillary fold)
Give the origin, insertion, innervation and function of pectoralis major
Origin = medial half of the clavicle, sternum and 7 costal cartilages Insertion = intertubercular sulcus of the humerus Innervation = medial and lateral pectoral nerves Function = adduction, medial rotation and flexion of the humerus at the shoulder joint
Give the origin, insertion, innervation and function of pectoralis minor
Origin = 3rd, 4th and 5th rib anterior surface Insertion = coracoid process of the scapula Innervation = medial pectoral nerves Function = depresses the tip of the shoulder and protracts the scapula
Give the origin, insertion, innervation and function of serratus anterior muscle
Origin = Ribs 1 to 8 (or 9) Insertion = medial border of the scapula Innervation = long thoracic nerve (C5, C6 and C7) Function = pulls the scapula forwards on the thoracic wall, protraction and rotation of the scapula
Give the origin, insertion, innervation and function of external oblique muscle
Origin = lower surface of ribs 5 to 12 Insertion = aponeurosis ending in midline (linea alba) and lateral ip of iliac crest Innervation = anterior rami to T7 to T12 Function = compresses abdominal contents, turns anterior part of the abdomen to opposite side
Give the origin, insertion, innervation and function of deltoid muscle
Origin = anterior border of the lateral 1/3 of the clavicle, inferior edge of the crest of the spine of the scapula
Insertion = deltoid tuberosity of the humerus
Innervation = axillary nerve (C5, C6)
Function =abductor of the arm (beyond 15 degrees done by supraspinatus)
Where does the cephalic vein lie and what is its clinical significance
In the groove between the deltoid muscle and the pectoralis major muscle, this is the delto-pectoral groove (it is lateral to the pectoralis major muscle)
It is used clinically for vascular access and is the main vein that drains the superficial part of the upper limb
It is also important for inserting wires and catheters into the heart
Give the origin, insertion, innervation and function of the external intercoastal muscle
Origin = inferior margin of rib above Insertion = superior margin of rib below Innervation = intercoastal nerves T1-T11 Function = moves ribs superiorly, most active during inspiration
It becomes the anterior intercoastal membrane when it covers the coastal cartilages, so we can directly see the internal intercoastal muscles
Give the origin, insertion, innervation and function of internal intercoastal muscle
Origin = lateral edge of costal groove of rib above Insertion = superior margin of the rib below deep to insertion of external intercoastal muscle Innervation = intercostal nerves T1 - T11 Function = active during expiration, moves the ribs inferiorly
Where does the neurovascular bundle supplying the chest wall lie
Below each rib, deep to the internal intercoastal muscle
Give the origin, insertion, innervation and function of innermost intercostal muscle
Origin = medial edge of costal groove of rib above Insertion = superior margin of rib below Innervation = intercoastal nerves T1 - T11 Function = acts with the internal intercoastal muscles
How far down does the lungs and the pleura extends (give the rib markings)
Anteriorly = lungs 6th rib, pleura 8th rib
Mid-axillary line = lungs 8th rib, pleura 10th rib
Posteriorly = lungs 10th rib, pleura 12th rib
Explain where the oblique and horizontal fissures are on the lungs
Anteriorly = oblique 4th costal, horizontal 4th costal cartilage Laterally = oblique , horizontal Posteriorly = oblique , horizontal
Where is the only place the lung is connected to the body
The hilium of the lungs
Where are the internal thoracic vessels located? And what is their use and clinical significance
The internal thoracic arteries are located on the deep surface of the anterior wall of the thorax, they come of the subclavian artery and connect to the external iliac artery in the groin
They supply the medial part of the breast
Their clinical significance is that they are not prone to atherosclerosis and lie close to the left anterior descending artery. The left internal thoracic artery (also called the left internal mammary artery LIMA) is used in cardiac bypass
The internal thoracic vessels supply the abdomen wall and the diaphragm as a well
What structures can be found in the hilium of the lungs
2 pulmonary veins
1 pulmonary artery
1 bronchus (has cartilaginous rings)
Bronchial arteries (which supply the trachea, bronchus and bronchial tree)
Lymphatics
Branches of the vagus nerve and sympathetic chain
Give the differences between the right and left lung
The right lung
Has a horizontal fissure and an oblique fissure
Has a little cardiac impression
The left lung Has only an oblique fissure It has an aortic impression It has a big cardiac impression It has a lingula
Describe the lymph drainage of the breast and how this is relevant to breast cancer
Lymph drainage of the breast medial to the nipple passes through the intercostal space and drains into the internal thoracic (mammary) lymph nodes in the thorax
Lymph drainage of the breast lateral to the nipple drain into the lymph nodes in the axilla
How would you find where to listen to the heart valves using a stethoscope
Start at the suprasternal notch (also called sternal notch) and feel down to the sternal angle (also called the Angle of Louis). The sternal angle is connected to the second costal cartilage, from there feel the space under which is the second intercostal space
The pulmonary valve = left sternal margin at 2nd intercostal space
The aortic valve = right sternal margin at 2nd intercostal space
The mitral valve = left midclavicular line at 5th intercostal space
The tricuspid valve = right sternal margin at the 5th intercostal space
How does contraction of the pectoralis major assist with breathing
Pectoralis major, pectoralis minor and the scapula muscles form a ring around the thoracic cavity. When this ring contracts, it reduces thoracic volume and increases thoracic pressure to assist exhalation.
This is only present in disease as exhalation is usually passive
Which bony structures lie subcutaneously in the anterior chest wall
The clavicle and sternum (manubrium, body and xiphisternum) only
The ribs are deep structures
What are the articulations of the clavicle
The sternoclavicular joint - sternum
The acromioclavicular joint - clavicle
What forms the anterior axillary fold
The lower edge of pectoralis major
What lies deep to pectoralis minor muscle
The axilla
The majority of beast tissue is in the upper outer quadrant of the breast. Where does the lymph from this part drain into
The lymph nodes in the axilla
Which costal cartilage connects to the sternum at the sternal angle
The second costal cartilage
Give the boundaries of the axillary fold
Tbc
Which nerves supply the surface of the visceral pleura and which nerves supply the surface of the (pareital) pleura linning the thoracic cavity
Visceral pleura = autonomic nerves
Parietal pleura = somatic nerves
Give the origin, insertion, innervation and function of the diaphragm
Origin = costal margin and the inner surfaces of the lower ribs
Insertion =
Innervation = phrenic nerve arising from C3, C4 and C5 (3rd, 4th and 5th cervical spinal nerves)
Function = contracts to decrease intra-thoracic pressure
Identify the cervical, mediastinal, diaphragmatic and costal parietal pleurae
Identify the costo-mediastinal and costo-diaphragmatic recesses
Tbc
Describe the contracting and non contracting muscles of the daphragm
The diaphragm has a non-contracting central tendon and peripheral muscle fibres
Give the two effects caused by the decrease in pressure in the thoracic cavity caused by the diaphragm cause
If the glottis is open, then air is drawn into the lungs
Blood is drawn from the inferior vena cava into the right atrium
It is the main mechanism of breathing in adults
How is a V/Q scan done and what is it used for
V stands for ventilation
Q sands for perfusion
A ventilation scan and a perfusion scan are done seperately. For the ventilation scan, a radioactive gas is inhaled by the patient and a gamma camera is used to measure the position of radioactivity in the lungs. For a perfusion scan, radioactive technetium is attached to albumen which is injected into the patient, a gamma camera is used to measure the position of radioactivity
The V/Q scan is used to check for blockages in the pulmonary arteries without affecting the bronchi
What is a sign of advanced respiratory distress and why
Intercostal recession, which is the visible sucking in of intercostal muscles during inspiration. It is a particularly important sign in the first six months of life.
It shows that the pressures needed to support breathing overcome the intercostal muscles - they need to create very negative intra-thoracic pressure to breath in so the intercostal muscles get sucked in.
Which nerves carry sensation from the parietal and visceral pleura
Autonomic nerves carry sensation for the visceral pleura (on lung surface so has same nerves as lungs) - the vagus and sympathetic nerves
Somatic nerves carry sensation for the parietal pleura (on chest wall so same nerves as tissue of chest wall) - the spinal nerves, T1 to T12
What is a bronchopulmunary segment
A bronchopulmonary segment has an artery and nerve which run through the center of the segment branching to feed all of it, the vein usually runs on the surface of the the segment.
The ten bronchopulmonary segments in each lung, each segment functions seperately anatomically and functionally which can influence how disease is spread through the lungs
Which structures pass through the hilum of the lung
2 pulmonary veins
1 pulmonary atery
1 bronchus (cartilageous rings inside)
Bronchial arteries (supply trachea, bronchus and bronchial tree)
Lymphatics
Vagus nerve branches and sympathetic chain branches
How does contraction of the diaphragm assist in returning blood to the heart
Contraction of the diaphragm increases thoracic volume and decreases intra-thoracic pressure. It increases intra-abdominal pressure so the net effect is the flow of blood from the abdomen into the chest
What is the sensory and motor nerve supply to the diaphragm
Sensory and motor are both from the phrenic nerve arising from the C3, C4 and C5 (the 3rd, 4th and 5th cervical spinal nerves)
What is a joint
A connection between two or more bones, irrespective of if movement can occur
Examples of a fibrous joints
The sutures of the cranium
The interosseous membrane between the radius and ulna of the forearm
Examples of a cartilaginous joint
Primary cartilaginous joints are joined solely by hyaline cartilage e.g attachments of the ribs to the sternum
Secondary cartilaginous joints are covered with a layer of hyaline cartilage but joined by fibrocartilage e.g the vertebral bodies
Example of a plane joint and movements allowed in this joint
Acromioclavicular joint
Articular surfaces are flat
Joint capsules are tight
Sliding movements in planes of articular surfaces
Example of a hinge joints and movements it allows
Elbow joint
It permits flexion and extension only
Example of a saddle joint and movements it allows
Carpometacarpal joint of the thumb
Articular surface are concave and convex
Permits flexion, extension, abduction, adduction and circumduction
Examples of condyloid joint and movement it allows
Metacarpophalangeal joints of the fingers
Similar to saddle joint in that movement in two axes but one is usually restricted
Permits flexion, extension, abduction, adduction and circumduction
Example of a ball and socket joint and the movement it allows
Hip joint
Spherical and concave articular surfaces
Multiple axes of movement
Permits flexion, extension, abduction, adduction, circumduction and rotation
Example of a pivot joint and the movement it allows
Atlanto-axial joint of cervical spine (the C1 atlas on the C2 axis)
Rotation around a central axis
Describe the knee joint, include the type of joint it is and the bones and ligaments involved
The knee joint is a synovial hinge joint, it is made up of the femur, patella and tibia
The tibia is flat while the femur is condular so they have a meniscus between them
The 4 ligaments in the knee are the;
Lateral collateral ligament - attaches the lateral epicondyle of the femur to the fibula
Medial collateral ligament - attaches the medial epicondyle of the femur to tibial plateau
Both the medial and lateral collateral ligaments lie in the capsule so will bleed into it when torn
Anterior cruciate ligaments - going from the anterior part of the tibial plateau to the posterior aspect of the lateral condyle of the femur (prevents forward movement of the tibia in relation to the femur)
Posterior cruciate ligaments - going from the posterior part of the tibial plateau to the anterior aspect of the medial condyle of the femur (prevents excessive movement of the femur anteriorly
The patella is attached is to the front of the quadriceps tendons to stop them rubbing on the femur and tibia during motion
Give an example of a fusiform type of skeletal muscle
Biceps brachii
Give an example of a parallel type of skeletal muscle
Rectus abdominis
Give an example of a convergent type of skeletal muscle
Pectoralis major
Describe as a fan muscle -parallel fibres but flat
Give an example of a unipennate type of skeletal muscle
Palmar interosseous
Give an example of a bipennate type of skeletal muscle
Rectus femoris
Give an example of a multipennate type of skeletal muscle
Deltoid muscle
Give an example of a circular type of skeletal muscle
Orbicularis oculi
Eye, mouth and anus
Allows closing of aperture
Give the origin, insertion, innervation and function of the sternocleidomastoid muscle
Origin = the manubrium of the sternum, medial 1/3 of the clavicle Insertion = mastoid process Innervation = accessory nerve (cranial nerve 11) supplies motor innervation and branches from anterior rami of C2, C3 and C4 Function = draw head forward, tilt head towards shoulder on the same side, rotating head to face opposite side
Give the origin, insertion, innervation and function of sterno-hyoid muscle
Origin = sternum Insertion = hyoid bone Innervation = anterior rami C1, C2 and C3 through the ansa cervicalis function = depresses hyoid bone after swallowing
Give the origin, insertion, innervation and function of platysma
Origin = skin of the face and mandible
Insertion = skin overlying the cavicle
Innervation =
Function =
What structures border the anterior triangle of the neck
The left sternocleidomastoid muscle, the lower border of the mandible and the midline
The right sternocleidomastoid muscle, the lower border of the mandible and the midline
Give the origin, insertion, innervation and function of geniohyoid
Origin = mental spine on the mandible Insertion = hyoid bone Innervation = branch of anterior ramus of C1 Function = fixed mandible pulls hyoid bone forward while fixed hyoid bone pulls mandible down and in
Give the origin, insertion, innervation and function of omohyoid bone
Origin = superior border of scapula (omo) Insertion = hyoid bone lateral to sternohyoid attachment Innervation = anterior rami of C1, C2 and C3 through the ansa cerviclis Function = depresses and fixes hyoid bone
Lies lateral to the sternohyoid bone
Has two bellies joined by a tendonous part
Give the origin, insertion, innervation and function of sternothyroid
Origin = sternum Insertion = lamina of thyroid cartilage Innervation = anterior rami of C1, C2 and C3 through ansa cervicalis Function = draws larynx (thyroid cartilage) downwards
Give the origin, insertion, innervation and function of thyrohyoid
Origin = lamina of thyroid cartilage Insertion = body of hyoid bone Innervation = anterior rami of C1 Function = depresses hyoid bone, when hyoid bone is fixed it raises the larynx
Give the origin, insertion, innervation and function of the anterior belly of the diagastric muscle
Origin = diagastric fossa on mandible Insertion = attachment of tendon between the two belly of diagastric muscle Innervation = mylohyoid nerve from inferior alveolar branch of mandibular nerve Function = opens mouth by lowering mandible, raises hyoid bone
Give the origin, insertion, innervation and function of posterior belly of diagastric muscle
Origin = mastoid notch on mastoid process on temporal bone
Insertion =
Innervation = facial nerve
Function = pulls hyoid bone up and back
Give the origin, insertion, innervation and function of cricothyroid muscle
Origin = cricoid cartilage Insertion = thyroid cartilage Innervation = external superior laryngeal nerve from the vagus nerve Function = forward and downwards rotation of the thyroid cartilage, stretches and tenses vocal ligament creating forceful speech and tone of voice (it is called the singer's muscle)
What arteries supply the thyroid gland
superior thyroid artery (branch of the external carotid artery)
inferior thyroid artery (branch of the thyrocervical trunk from the subclavian artery)
superior thyroid vein
medial (or middle) thyroid vein
inferior thyroid vein (all veins drain into the internal jugular vein, the external jugular and the brachiocephalic veins)
What does the carotid sheath contain
carotid artery
(Internal) jugular vein
Vagus nerve
Sympathetic chain
Which nerve is close to the inferior thyroid artery and so is at risk of damage during thyroid surgery
The right recurrent laryngeal nerve
Which tracheal rings are crossed by the isthmus of the thyroid
The second and third ring of the trachea
What are the extrinsic laryngeal muscles
They act to move the larynx superiorly and inferiorly and aid swallowing
Comprised of the suprahyoid, infrahyoid muscles and stylopharyngeus muscle
Suprahyoid muscles and the stylopharyngeus muscle elevate the larynx, they are;
- geniohyoid
- diagastric (anterior and posterior)
- mylohyoid
- stylohyoid
The infrahyoid muscle depress the larynx, they are;
- sternohyoid
- omohyoid (superior and inferior belly)
- sternothyroid
- thyrohyoid
What are the intrinsic laryngeal muscles
They act on individual components of the larynx aiding breathing and phonation
They act to change the shape of the rima glottidis and length and tension of the vocal folds
All of them except the cricothyroid muscle are innervated by the inferior laryngeal nerve (from the recurrent laryngeal nerve)
Cricothyroid Thyroarytenoid Posterior cricoarytenoid Lateral cricoarytenoid Transverse and oblique arytenoids
Give the origin, insertion, innervation and function of thyroarytenoid
Origin = thyroid cartilage Insertion = arytenoid cartilage Innervation = inferior laryngeal nerve (from the recurrent laryngeal nerve) Function = relaxes vocal ligament, allowing softer voice
Give the origin, insertion, innervation and function of posterior cricoarytenoid muscle
Origin = posterior surface of the cricoid cartilage Insertion = muscular process of the arytenoid cartilage Innervation = inferior laryngeal nerve from the recurrent laryngeal nerve Function = abducts vocal folds, widen rima glottidis
Give the origin, insertion, innervation and function of lateral cricoarytenoid
Origin = arch of cricoid cartilage Insertion = muscular process of the arytenoid cartilage Innervation = inferior laryngeal nerve from the recurrent laryngeal nerve Function = adducts the vocal folds
Give the origin, insertion, innervation and function of transverse and oblique arytenoids
Origin = one arytenoid cartilage Insertion = the other arytenoid cartilage Innervation = inferior laryngeal nerve from the recurrent laryngeal nerve Function = adducts the arytenoid cartilages, closes the posterior part of the rima glottidis narrowing the laryngeal inlet
A patient may develop hypocalcaemia after thyroid surgery why?
The parathyroid glands may be accidentally or deliberately removed during the thyroid surgery which can cause acute (sudden) hypoparathyroidism
Give the origin, insertion, innervation and function of stylopharyngeus muscle
Origin = styloid process Insertion = pharyngeal wall Innervation = glossopharyngeal nerve Function = elevation of the pharynx
Why does the thyroid gland have such a good blood supply
Iodine is present in low concentration in the blood so the gland needs a high flow of blood to ensure adequate supply of iodine
Give the origin, insertion, innervation and function of the superior constrictor muscle
Origin = medial pterigold plate and the pterygomandibular raphe extends to mandible Insertion = pharyngeal raphe Innervation = vagus nerve Function = constriction of the pharynx
Give the origin, insertion, innervation and function of the middle constrictor muscle
Origin = hyoid bone Insertion = pharyngeal raphe Innervation = vagus nerve Function = constriction of pharynx
Give the origin, insertion, innervation and function of the inferior constrictor muscle
Origin = thyroid cartilage (the thyropharyngeus), the cricoid cartilage (cricopharyngeus) Insertion = pharyngeal raphe Innervation = vagus nerve Function = constriction of pharynx
Which fascia lines the inner aspect of the constrictors and what is this fascia attached to
The fascia is called the pharyngobasilar fascia and it is attached to the pharyngeal tubercle, the auditory (Eustachian) tube and the medial pterygoid plate
Which fascia bridges the gap between the superior constrictor and the base of the skull
The pharyngobasilar fascia
Which cranial nerves form the pharyngeal plexus on the back of the pharynx
Vagus (10) and glossopharyngeal (9) nerve
What is the weakest part of the pharyngeal wall
Killian’s dehiscence - it is basically the line between the diverging fibres of the thyro-pharyngeal part of the inferior constrictor
Where can the stellate ganglion be found
Between the first rib and the transverse process of the seventh cervical vertebrae
What does the internal superior laryngeal nerve do
Give sensory innervation to the larynx above the vocal cords
Where does the superior laryngeal nerve enter the constrictor muscles
Between the middle and inferior constrictor muscles
What does the external superior laryngeal nerve do
Supply motor innervation to the cricothyroid muscle and the crico-pharyngeal part of the inferior constrictor
Which nerve innervates the carotid sinus
The glossopharyngeal nerve
Which nerve gives taste and sensation to the posterior 1/3 of the tongue
The glossopharyngeal nerve
Which nerve gives general sensation to the oropharynx
The glossopharyngeal nerve
Which nerve supplies the middle ear and the eustachian tube
The tympanic branch of the glossopharyngeal muscle
Which nerve supplies the stylopharyngeus muscle
The glossopharyngeal nerve
What does the glossopharyngeal nerve supply
Give sensory and taste to the posterior 1/3 of the tongue
Sensory to the oropharynx
The tympanic branch of the glossopharyngeal nerve supplies the middle ear and the eustachian tube
It supplies the stylopharyngeus muscle
Give the origin, insertion, innervation and function of the stylopharyngeus muscle
Origin = styloid process Insertion = pharyngeal wall Innervation = glossopharyngeal nerve Function = elevation of the pharynx
What is the significance of Killian’s dehiscence
During swallowing the high pressure can cause the mucosa of the pharynx to bulge out through Killian’s dehiscence and create a pouch.
Food can enter this pouch decompose causing bad breath
The food in the pouch can also cause swelling and difficulty swallowing too
What is the relevance of the carotid sinus and its nervous supply
Sensory receptors in the carotid sinus measure blood pressure
High blood pressure presses on the carotid sinus and sends signals to the brain via the glossopharyngeal nerve
The brain sends signals to the heart via the vagus nerve to slow the heart rate
Pressure can be applied to this area in patients with fast heart rates
Why is a stroke in the area of the brain with the glossopharyngeal nerve dangerous
This can lead to damage of the nerve so when the person swallows they can no longer have sensation of fluid passing down into the larynx so fluid enters the lungs and causes infection
Which nerve gives sensory and taste innervation to the anterior 2/3 of the tongue
The lingular nerve from the mandibular branch of the trigeminal nerve gives sensory innervation
The chorda tympani branch of the facial nerve gives taste sensation
What gives motor innervation to the intrinsic muscles of the tongue
The intrinsic muscles of the tongue are those within the tongue itself
The hypoglossal nerve gives motor innervation to the tongue
Which nerve give motor innervation to the extrinsic muscles of the tongue
The extrinsic muscles of the tongue are those outisde the tongue that support it
palatoglossus - vagus nerve
styloglossus - hypoglossal nerve
genioglossus - hypoglossal nerve
hypoglossus - hypoglossal nerve
Which part of the pharynx lie below the lower border of the mandible
The hypopharynx (also called the laryngopharynx)
Which structures lie immediately behind the pharyngeal wall
Loose areolar tissue and the cervical vertebral bodies
Give the borders of the posterior triangle of the neck
Sternocleidomastoid muscle anteriorly
Trapezius posteriorly
Middle 1/3 of the clavicle inferiorly
What muscles are contained in the posterior triangle of the neck
Muscles Levator scapulae Anterior scalene Middle scalene Splenius capitis
What blood vessels cross the posterior triangle
Blood vessels
External jugular vein
Transverse cervical vein
Suprascapular vein
Distal part of the subclavian artery
Which nerves cross the posterior triangle
Nerves Spinal accessory nerve (11) Cutaneous branches of the cervical plexus Trunks of the brachial plexus Supraclavicular nerve Phrenic nerve
Which nerve enters the thyroid between the middle and inferior constrictor muscles
The superior laryngeal nerve
Which muscles comes from the styloid process and enters he gap between the superior and middle constrictor muscles
The stylopharyngeus muscles, it runs alongside the glossopharyngeal nerve
Which ganglion is fused with the first thoracic nerve in the thorax
The inferior cervical sympathetic ganglion, it is called the stellate ganglion
Give the muscles that run in the anterior triangle of the neck
Infrahyoid muscles Sternohyoid omohyoid Thyrohyoid sternothyroid cricothyroid (actually lies under the thyroid gland)
Suprahyoid muscles Geniohyoid Mylohyoid Stylohyoid Digastric (the anterior belly)
Give the main blood vessels run in the anterior triangle of the neck
The common carotid artery
The internal jugular vein
Give the nerves that run in the anterior triangle of the neck
Facial nerve Glossopharyngeal Vagus Accessory Hypoglossal
Give the four different subdivisions of the anterior triangle of the neck and the main structures that run in them
Carotid triangle
- common carotid artery bifurcates
- internal jugular vein
- hypoglossal nerve
- vagus nerve
Submental triangle
-submental lymph nodes draining lymph from the tongue and mouth
Submandibular triangle
- submandibular gland
- facial artery and vein
Muscular triangle
- infrahyoid muscles
- the pharynx
- thyroid gland
- parathyroid gland
Give the function, connection to brain, skull foramen and test for olfactory nerve
Smell
Cerebrum
Cribiform plate
cover each nostril and ask to smell different smells
Give the function, connection to brain, skull foramen and test for the optic nerve
Sight
Cerebrum
Optic Canal
use snellen chart for visual acuity, Ishihara plates for colour vision test, opthalmoscope to see head of optic nerve
Give the function, connection to brain, skull foramen and test for the occulomotor nerve
Eye movements, eyelid opening, pupil constriction (Parasym), accomodation midbrain
Superior Orbital Fissure
deficit in this nerve can cause diplopia (double vision), down and out facing eye as other nerves are unopposed, ptosis (eyelid drooping) and mydriasis (dilated pupils
To test draw an H shape with your finger and ask patient to follow the shape without moving their eye muscles
Give the function, connection to brain, skull foramen and test for the trochlear nerve
Eye movement through the superior Oblique muscle
Midbrain
Superior Orbital fissure
defect in nerve means cannot depress an adducted eye
Give the function, connection to brain, skull foramen and test for the trigeminal nerve
V1 sensation to anterior head face (superior 1/3) including scalp, forehead, cornea and tip of nose
pons
superior orbital fissure
V2 sensation to the face (middle 1/3) including cheek, nose, upper lip, upper teeth and palate
pons
foramen rotundum
V3 (sensation to face (lower 1/3) including lower lip, lower teeth, chin, jaw and anterior 2/3 of the tongue. Motor to muscles of mastication and the tensor tympani muscles in the middle ear
pons
foramen ovale
test motor by placing hands on muscles that contract when we clench the jaw
tests for sensation by putting cotton bud on each area
Give the function, connection to brain, skull foramen and test for the abducens nerve
Eye movement through the lateral Rectus muscle
Midbrain
Superior Orbital Fissure
defect in nerve means cannot abduct the eye
Give the function, connection to brain, skull foramen and test for the facial nerve
Facial movements, salivation (parasym), lacrimation (producing tears, parasym) and sensation from the external ear canal and taste from the anterior 2/3 of the tongue
Pons
internal acoustic meatus and stylomastoid foramen
testing motor ask the patient to make facial expressions against resistance, facial nerve pulsy is one half of the face is rigid
Give the function, connection to brain, skull foramen and test for the vestibulocochlear nerve
balance and hearing
pons
interior acoustic meatus
to test cover one of patients ears and whisper a number into the ear and see if they can hear it or audiometry or tuning fork for sensory neural or conductive hearing loss
Give the function, connection to brain, skull foramen and test for the glossoharyngeal nerve
taste and sensation from posterior 1/3 of the tongue, sensation from pharynx, salivation, parasympathetics from the carotid vessels , Motor to stylopharyngeus muscle in the pharynx
medulla
jugular foramen
Give the function, connection to brain, skull foramen and test for the vagus nerve
parasympathetic to thoracic (heart) and abdominal (bowel) organs and motor to soft palate, motor to pharyngeal laryngeal muscles
medulla
jugular foramen
allows people to swallow, cough and generate voice from larynx so ask them to cough or if their voice has changed
Give the function, connection to brain, skull foramen and test for the accessory nerve
motor to trapezium and sternocleidomastoid muscle C1 to C5
in through foramen magnum and out through jugular foramen
to test ask patient to shrug into your hand while pushing on their shoulders to check even muscle bulk or ask patient to turn their head into your hand to see protrusion of sternocleidomastoid muscle
Give the function, connection to brain, skull foramen and test for the hypoglossal nerve
movements of the tongue
medulla
hypoglossal canal
ask patient to push tongue into their cheek, defective nerve would have a protrusion of the tongue towards the side of the lesion
Where can a subarachnoid haemorrage be found and what are the signs on an xray
bleeding under arachnoid layer of arteries into the brain - on xray it is widespread and fills spaces in brain - bleed on both side and no midline shift - usually caused by aneurysm
Where can a Subdural haematoma/ haemorrage be found and what are the signs on an xray
Space between the dura and the arachnoid is the subdural space - an actual space containing veins (bridging veins) running from arachnoid to dura
Subdural haematoma/ haemorrage is bleeding between the dura and arachnoid - on xray - bleeding is more wide spread - more concave in shape - midline shift to the contralateral side
Where can a extradural haematoma/ haemorrage be found and what are the signs on an xray
Space between the skull and dura is the extradural or epidural space - potential space and does not exist in healthy individuals - contains bloods vessels which can bleed if there is fracture of the skull
Extradural haematoma/ haemorrage is bleeding between the skull and dura - an xray image would show a contained bleed in a lens shape - a midline shift of the brain to the contralateral side
What are the meninges of the brain
Dura mater, arachnoid and pia mater are the meninges
Meninges protect the brain, provide frame work for blood supply, fluid filled space (subarachnoid space)
Dura mater is made up of the periosteal layer (attached to the skull) and meningeal layer (lower down) - gap between these layers is the venous sinuses
Explain the how the intrinsic back muscles are divided
The intrinsic back muscles are divided into the;
- superficial (spinotransversales)
- intermediate (erector spinae)
- deep (transversospinales)
Explain how the superficial (spinotransversales) intrinsic muscle of the back are divided
- splenuis capitis muscle
- splenuis cervicis muscle
Explain how the intermediate (erector spinae) intrinsic muscle of the back are divided
- iliocostalis
- longissimus
- spinalis
Explain how the deep (transversospinales) intrinsic muscle of the back are divided
- semispinalis
- multifidus
- rotatores
What nerve supplies the dorsal surface of the epiglottis for taste
The vagus nerve (ask if it would be the internal superior laryngeal nerve)
Which nerve supplies the parotid gland
The glossopharyngeal nerve
Where does the duct of the parotid gland enter the mouth
Passes over the masseter muscle into the cheek and enter the mouth adjacent to the 2nd upper molar
Give some blood vessels to be aware of close to the submandibular gland
Retromandibular vein
Facial vein
Facial artery
Which part of the submandibular gland contains it’s duct (the deep or superficial aspect) and where does the duct drain into
The deep part contains the duct
The duct empties under the tongue into the floor of the mouth
Which nerve supplies the submandibular nerve
The facial nerve
Where does the facial nerve exit the skull
The stylomastoid foramina
The facial nerve enters the parotid gland and divides into 5 parts, state those 5 parts
Temporal Zygomatic Buccal Mandibular Cervical
Why is the passage of the facial nerve through the parotid gland clinically significant
Diseases f the parotid gland especially maligancies can invade and damage the nerve leading to paralysis of the facial muscles
Damage to this nerve can also lead to corneal abrasions because the nerve cannot blink the eyes to wash out the front of the cornea and prevent it drying out
Damage to this nerve can lead to food leaking out of the corners of the mouth when eating and drinking because it can no longer close the mouth fully when eating and drinking
What type of joint is formed between the inferior horn of the thyroid cartilage and the cricoid cartilage
Synovial joint
What is the clinical significance of the piriform recess (also called piriform fossa) lateral to the posterior margins of the thyroid and cricoid cartilage
Malignant tumours arising in this piriform recess can remain “silent” (no symptoms) until it is locally advanced and this is because it grows to fill the fossa before the symptoms develop
Another name for the false vocal folds is
The superior vestibular fold
Another name for the true vocal folds is
The inferior vestibular folds
What lies between the false and true vocal folds
The laryngeal sinus
What is the sagittal space between the true vocal folds called
The rima glottidis
What muscle forms the vocal folds (ask if it forms both)
The vocalis muscles
Give the origin, insertion, innervation and function of rectus abdominis muscle
Origin = pubic tubercle, pubic symphysis and pubic crest Insertion = xiphoid process, costal cartilages or ribs 5 to 7 Innervation = anterior rami of T7 to T12 (thoracic spinal nerves) Function = compress abdominal contents and tense abdominal wall
Where is the highest point of the diaphragm (also the abdomen)
The 5th intercostal space on both sides
Where is the subcostal plane
The lowest point of the ribs and costal cartilages
Where is the intertubercular plane
Superior to the anterior superior iliac spine at the lateral tubercle halfway up the iliac crest
-it marks the position of the bifurcation of the abdominal aorta
What are the two horizontal lines of the abdomen
- the subcostal plane
- the intertubercular plane
Give the 9 regions the abdomen can be divided into
Centrally - the epigastrium, umbilicus and suprapubic (also called hypogastrium)
Right side - right hypochondrium, right flank and right iliac fossa
Left side - left hypochondrium, left flank and left iliac fossa
Going from back to front - lumbar (back), loin (side) and flank (front)
Give a posterior horizontal line used for abdominal examination
Intercristal plane - between highest point of iliac crest posteriorly, it runs between 4th and 5th lumbar vertebra and is useful in anaesthetic when giving epidurals
Give an additional horizontal line used for abdominal examinations
Transpyloric plane (transpyloric plane of Addissons) - runs from the tip of the 9th costal cartilage, lateral most part of where rectus abdominis muscle attaches to the costal cartilage
How does the position of the umbilicus move when the patient is lying down
Moves laterally
How does the position of the umbilicus change when the patient is stood up
Moves inferiorly
Where is McBurneys point
It is 2/3 way on the line from the umbilicus to the anterior superior iliac spine and lies over the iliac fossa
What lies on McBurney’s point
- where the appendix usually lies
- gives a guide to the position of the caecum during clinical examination of the abdomen
What is the significance of the line between the pubic tubercle and the anterior superior iliac spine
Below this line is the thigh and above it is the abdomen
How many millimeters does the diaphragm have to move to achieve a tidal volume of 500mls
5 or 6 millimeters
How does the midclavicular line relate to the rectus abdominis muscle
It will run almost on the outer edge of the rectus abdominis muscle
What are the aponeurosis of the abdominal muscles made of
Tendon
Give the origin, insertion, innervation and function of the rectus abdominis muscle
Origin = pubic tubercle, pubic symphysis and pubic crest Insertion = xiphoid process, costal cartilages or ribs 5 to 7 Innervation = anterior rami of T7 to T12 (thoracic spinal nerves) Function = compress abdominal contents and tense abdominal wall
Give the 3 abdominal muscles that form aponeurosis and directions they run
- external oblique muscles - downwards and inwards
- internal oblique muscles - 90 degrees to the external oblique muscles - upwards and inwards
- transverse abdominis muscles - horizontally
Which muscles cross the midline of the linea alba
No muscles does
Name the 3 aponeurosis of the abdomen
- external oblique aponeurosis
- internal oblique aponeurosis
- transversus abdominisis aponeurosis
What structure does the aponeurosis surround as a rectus sheath
The rectus abdominis
Where does the external oblique muscle become the external oblique aponeurosis
At the midclavicular line
Describe the structure of the internal oblique aponeurosis in the upper 2/3 of the abdomen and the lower 1/3 of the abdomen
- in the upper 2/3 of the abdomen, the internal oblique aponeurosis splits in two
- half of the internal oblique aponeurosis travels in front of the rectus abdominis
- half of the internal oblique aponeurosis travels behind the rectus abdominis muscle
-in the lower 1/3 of the abdomen, the internal oblique aponeurosis passes totally in front of the rectus abdominis muscle
Describe the structure of the transverse abominis aponeurosis in the upper 2/3 of the abdomen and the lower 1/3 of the abdomen
- in the upper 2/3, it passes totally behind the rectus abdominis muscle to form the rectus sheath
- in the lower 1/3, it passes totally in front of the rectus abdominis
Which thoracic spinal nerve supplies the dermatone of the umbilicus
Thoracic 10 (T10)
Which nerve supplies the dermatone of the non-hair bearing area of the lower abdomen
Thoracic 12 (T12)
Which nerve supplies the dermatones of the hair bearing area over the pubis
Lumbar 1 spinal nerve (L1)
Where do the pain fibres from the bowel take the sensation to
The thalamus
Give the nervous supply to the 3 parts of the gut and where pain can be felt
Foregut - greater splanchnic nerve - T5 to T9 - pain can be felt in the epigastrium
Midgut - lesser splanchnic nerve - T10 to T11 - pain can be felt in the periumbilical area
Hindgut - least splanchnic nerve - T12 - pain can be felt in the suprapubic area
How is a six pack formed
- rectus abdominis has tendonous intersections
- when the muscle is exercised, it hypertrophies and will bulge
- the tendon will not bulge giving the appearance of a six pack
Which parts of the rectus abdominis is connected to the rectus sheath
The muscle is not connected to the sheath but the tendon is firmly attached to the rectus sheath
What is the artery running on the deep surface of the rectus abdominis muscle
- the lower end of the artery is called the inferior epigastric artery and joins the external iliac artery
- the upper end of the artery is called the superior epigastric artery and it connected to the internal mammary arteries
What is a hernia
Weakness of the muscle wall that has allowed bowel (or other organs) to protrude out of the abdomen
What is the relationship between the external oblique muscle and the inguinal ligament
The lower part of the external oblique muscle is totally aponeurotic and is attached laterally to the anterior superior iliac spine and medially to the pubic tubercle and that is the inguinal ligament
What lies above the inguinal ligament
The inguinal canal which in males transmits all structures to and from the testis
What forms the spermatic cord
Rule of 3s
3 coverings - external spermatic fascia, cremesteric muscle and internal spermatic fascia
3 arteries - testicular artery, cremesteric artery and the artery of the vas
3 veins - testicular veins, cresmesteric vein and the vein from the vas
3 nerves - genital branch of the genitofemoral nerve (nerve to the cremester muscle), inguinal branch of the ileoinguinal nerve (supplies sensation to the anterior 1/3 of the scrotum) and sympathetic nerves to the vas and testis
3 structures - vas deferens, lymphatics and processus vaginalis (connects peritoneal sac around testis to the peritoneal sac in abdomen)
What is a symptom
What the patient tells you is happening to them
What is a sign
What the doctor finds by doing an examination
What is the mid-inguinal point
-midway between the pubic symphysis and anterior superior iliac spine
What structure lies on the transpyloric plane
- the gall bladder
- pancreas
- pylorus of the stomach
- duodeno-jejunal flexure
In thin recumbent patients (basically the people with least variation) where would the umbilicus lie
L3 vertebra
What does the intertubercular plane mark
-the position of the bifurcation of the abdominal aorta
When skin is damaged, where would the pain be felt
Exactly where the damage is occuring
Where would pain arising from internal organs be felt
- poor localised
- diffuse sensation can be felt different from where the organ is
The peritoneum covering the inside of the abdominal walls has the same sensory nerve supply as the skin overlying the same area of abdominal wall. If a diseased process involves the abdominal wall such as an inflamed appendix, where would the pain be felt?
Precisely directly over the appendix
Which diseases can irritate the diaphragm and cause pain
- cholecystitis (inflammation if the gall bladder)
- pain can be felt in the shoulder through C3,4 and 5
What is the sensory innervation of the kidney
- via the sympathetic plexus which accompanies the renal artery(T10, 11 and 12)
- the same sympathetic plexus supplies the gonads
Where can kidney pain be felt
- reffered along the cutaneous nerves of T10, 11 and 12 most commonly T12
- often described as pain radiating from loin to groin
- can also be felt in the gonadal area
Where can gonadal pain be felt
- sensory innervation via sympathetic plexus which accompanies the renal artery (T10, 11 and 12)
- most commonly T12
- can be felt in the loin
What does the iliohypogastric nerve do and where is it
- close to the pubic symphysis
- it originates from the anterior ramus of the L1 nerve root of the Lumbar plexus
- it gives sensory innervation to the posterolateral gluteal skin in the pubic region
- it gives motor innervation to the internal oblique muscle and the transverse abdominis
Describe the typical history of pain for appendicitis (inflammation of the appendix)
- a vague central pain at first but after a few hours or days it becomes a sharp pain in the right iliac fossa
- pain from appendix is relayed through the lesser splanchnic nerve via the sympathetic nervous system so dull pain in the umbilicus area
- inflammation soon extends to the surface of appendix and rubs the inside of the abdominal wall so pain is now relayed by cutaneous nerves so sharp pain is felt directly over the appendix
What is aortic aneurysm and where can it be felt
- an abnormal swelling of aorta which can burst and lead to sudden death
- it can be felt only from the epigastrium to the umbilicus because the intertubercular plane is where the abdominal aorta bifurcates
What is shingles and what is it activated
- an infection of the sensory nerve cell bodies by the Herpes Zoster virus
- it lays dormant in the sensory dorsal root ganglia and can activate when the patient is ill
What are the symptoms of the Herpes Zoster Virus
- the virus reproduces and travels down the sensory nerve fibres to the skin
- it produces an itchy rash with small fluid filled blisters (vesicles)
- these fluid blisters are full of viruses and when a patient scratches, the virus is released to infect others
- if the virus is in the T10 spinal nerve, the rash will form a ribbon from the T10 vertebra at the back to the umbilicus at the front (T10 dermatomes)
What is the afferent nerve of the cough reflex
The internal superior laryngeal nerve
Damage to the glossopharyngeal nerve causes
Loss of sensation to the back of the pharynx affects sensory control of swallowing so larynx remains partially open during swallowing so fluid may enter the lungs and cause infections
-it is common in patients with brain stem stroke
Damage of the vagus nerve
- loss of sensation to the inside of the larynx and affects sensory control of swallowing so the larynx remains open during swallowing so fluid may pass into the lungs causing infection
- it is common in patients with brain stem stroke
Which structure stops liquid refluxing into the back of the nose during swallowing
The soft palate
Which nerve carries sensation from below the vocal cords
The recurrent laryngeal nerve
Describe the histology of the mucus of the trachea
Psuedostratified ciliated columnar epithelium with goblet cells
Which nerve travels through the parotid gland
The facial nerve
Where do the parotid and submandibular gland ducts enter the mouth
Parotid - passes over the masseter muscle enter the cheek adjacent to the second upper premolar
Submandibular -under the tongue into the floor of the mouth
Where can a tracheostomy and cricothyrotomy be performed
Cricothyrotomy - in the cricothyroid membrane (short term)
Tracheostomy - usually in hospital by seperating isthmus of thyroid and assessing trachea directly (long term)
What nerves supply the intrinsic muscle of the tongue
Hypoglossal nerve (12)
What is the function of the extrinsic laryngeal muscles
-they move the larynx up and down the neck and support its central position which is important for swallowing
What is the only complete cartilage around the airways
The cricoid cartilage
Where are the parathyroid glands and how many are there
- they are on the posterior surface of the thyroid gland
- there are four
Describe the journey of ligamentum teres
- Deep surface of the right upper quadrant
- runs from the back of the umbilicus into the liver and join the left branch of the portal vein
- remnant of the umbilical vein carrying blood from the placenta to the feotus
- attached to the anterior surface of the abdominal wall with a double layer of peritoneum, this peritoneum attachment (falciform ligament) runs from the umbilicus to where the inferior vena cava passes through the diaphragm in an upwards direction
What attaches the ligamentum teres to the anterior abdominal wall
The faciform ligament
What is ligamentum teres attached to
The free edge of the faciform ligament (which is attached to the anterior abdominal wall)
In the abdomen, what is the midline structure going from the bladder to the umbilicus and what is it’s function
- the remnant of the urachus
- allows urine to flow from the foetus to the mother
In the abdomen, what are the lateral structure running from the internal iliac artery to the umbilicus and what did they do
- the medial umbilical ligaments
- remnants of the umbilical arteries
- they take blood from the foetus to the placenta (mother)
- they extend from the superior vesical artery to the umbilicus (which are the blood supply of the superior aspect of the bladder)
In the abdomen, which structures are an important landmark for surgery on hernias (both open and laproscopic) and why?
- the inferior epigastric vessels
- they are an important landmark for hernia surgeries because the deep inguinal ring is just lateral to the inferior epigastric vessels
- the inferior epigastric vessels are just lateral to medial umibilical ligaments
In a male, what would you expect to find in the deep inguinal ring
-testicular artery and vein entering and leaving the testis and vas deferens
In a male, where would you expect to observe the testicular artery and testicular vein leaving and entering the testis and vas deferens
-the deep inguinal ring
In the abdomen, what does the falciform ligament divide
-the right and left lobe of the liver
Where can the gall bladder be found
-on the inferior surface of the right lobe of the liver
Give all the lobes of the liver
- right
- left
- caudate (upper)
- quadrate (lower)
What is Glisson’s capsule and what is it innervated by
- It is the fibrous covering of the liver
- it is innervated by the lower intercostal nerves
- distension of the capsule results in a sharp, well localised pain
Where does the anterior aspect of the liver lymphatic vessels drain into
-the hepatic lymph nodes in lesser omentum and drain into colic lymph nodes which in turn drain into the cisterna chyli
Where does the posterior aspect of the liver lymphatic vessels drain into
-into the phrenic and posterior mediastinal nodes which join the right and lymphatic and thoracic ducts
Where is the venous drainage for the liver
- through hepatic veins
- the central veins of the hepatic lobule form collecting veins which combine to form hepatic veins
- these hepatic veins open into the inferior vena cava
Explain these blood supply to the liver: hepatic artery proper, hepatic portal vein and hepatic veins
hepatic artery proper (25%) - supplies the non-parenchymal structures of the liver with arterial blood, comes from the coeliac trunk
hepatic portal vein (75%) - supplies the liver with partially deoxygenated blood carrying nutrients absorbed from the small intestine - this is the DOMINANT blood supply to the liver parenchyma, allows the liver to detoxify the blood
Hepatic veins - central veins from hepatic lobule form collecting veins which then combine to form hepatic veins which open into the vena cava
hepatic veins
Where is the porta hepatis and what
- it is a transverse fissure that seperates the caudate and quadrate lobes of the liver
- it where all vessels (portal vein and hepatic artery), nerves (vagus) and ducts enter and leave the liver with the exception of the hepatic veins
Give all the lobes of the gall bladder
- the fundus
- the body
- the neck
Where can the stomach be found in relation to the liver
-immediately under the left lobe of the liver
What gives sensory innervation below the true vocal cords
-the recurrent laryngeal nerve
What is the greater omentum
-mesentry that connects the foregut to the posterior aspect of the abdominal cavity
What does the greater omentum attach to
- the greater curve of the stomach
- lies over the top of the transverse colon
- the transverse colon
- the spleen
Where does the stomach join the duodenum
-the pyloric sphincter
Describe the journey of the duodenum
- emerges from the retroperitoneum
- passes behind the transverse colon and greater omentum
Where does the small bowel mesentry start and stop
Starts where the duodenum ends
Stops where the large bowel starts
What is mesentry
- carries all the blood vessel, nerves and lymphatics required for the function of the bowel
- absorption of nutrients
Where does the small bowel end
- in the right iliac fossa
- joins the caecum
Give the blood supply to the small and large bowel
Coeliac trunk - from the lower 1/3 of the oesophagus to the duodenum above proximal to the major duodenal papilla
Superior mesenteric artery - from the major duodenal papilla to the proximal 2/3 of the transverse colon
Inferior mesenteric artery - from the distal 1/3 of the transverse colon to the rectum
Give the nerve supply to the small and large bowel
Greater splanchnic nerve - foregut - from lower 1/3 of the oesophagus to the major duodenal papilla
Lesser splanchnic nerve - midgut - from the major duodenal papilla to the proximal 2/3 of the transverse colon
Least splanchnic nerve - hindgut - the distal 1/3 of the transverse colon to the rectum
Which epithelium line the abdominal cavity
- simple squamous epithelium (called peritoneum or serosa)
- where it covers the abdominal wall it is parietal peritoneum
- where it covers the bowel and mesentry it is visceral peritoneum
What is the nervous supply to the parietal peritoneum
Dermatones - pain is felt in the skin directly where affected
What is the nervous supply to the visceral peritoneum
-splanchnic nerves - pain is felt in the rough region e.g foregut is epigastrium, midgut is periumbilicus and hindgut is suprapubic area
How do the cells of the serosa allow viscera to slide freely on its surface
-the cells of the serosa (visceral peritoneum) trap a layer of mucus between the microvilli allowing viscera (bowel and mesentry) to slide freely
Give conditions that can affect the peritoneal cavity highlighting it’s clinical signifiance
- fluid exudates and pus collect in the recesses within the peritoneal cavity
- tumours can spread through the peritoneal cavity
- can become distended by fluid which is ascites
What are structures firmly attached to the posterior aspect of the abdominal wall referred to as
-retroperitoneal
Which structures attaches the left lobe of the liver to the diaphragm
-the left triangular ligament
Which part of the liver cannot be palpated trans-abdorminally
-the entire left lobe of the liver is above the costal margins and cannot be palpated transabdominally
If the patient is slim, when can a right lobe of the liver be palpable
-on deep inhalation just below the costal margin
What structure attaches the lesser curvature of the stomach to the liver
-the lesser omentum
What structures does the lesser omentum attach
- the lesser curvature of the stomach to the liver
- also attaches the first 1cm of the duodenum
What makes up the portal triad and where do they lies
- the portal vein
- the hepatic artery
- bile duct
- they all run in the free edge of the lesser omentum
Where can the portal triad be palpated
-in the epiploic foramen (Foramen of Winslow)
Where is the epiploic foramen
-behind the free edge of the lesser omentum
Why can spleen not be palpated
-it is well above the costal margin
What attaches the spleen to the posterior abdominal wall
-the greater omentum
Where is the lesser sac
-directly behind the stomach
What is lesser sac and how can it be assessed from the greater sac
- it is peritoneal space
- the only way to the lesser sac from the greater sac is through the epiploic foramen
Where do bacteria and infection of the abdominal cavity usually gravitate to when a person is laying down supine or standing up
- when laying supine - behind the right lobe of the liver
- when standing upright - in the pelvis
- tumours are usually spread throughout the cavity
How does the peritoneum contribute to peritoneal dialysis
- the peritoneum is semi-permeable so small molecules can pass freely in and out of the peritoneal cavity
- the large molecules (proteins) cannot pass through the peritoneum
- in patients with renal failure, it is possible to draw waste products from the blood into the peritoneal cavity and then drain the cavity
Give the abdominal contents that are fixed retroperitoneal
- kidneys
- ascending colon
- descending colon
Give the abdominal contents that have a mesentry
- first 1cm of the duodenum
- jejenum
- ileum
- transverse colon
- sigmoid colon
- appendix
How does pain differ for mobile abdominal contents compared to fixed ones
- mobile contents like the ileum and appendix will move with breathing and body movements so in disease (when inflammed) will cause pain with breathing and movements
- fixed contents like the kidneys do not move so will not cause pain
What does supine mean
-lying flat on your back
What embryological structure forms the ligamentum teres
-the umbilical vein, returning blood from the placenta to the liver
Where does the base of the appendix lie (surface marking and internally)
-McBurnies point
-2/3 of the way from the umbilicus to the anterior superior iliac
spine
What structures form the portal triad
- hepatic portal vein
- hepatic artery
- bile duct
What is the greater and lesser omentum
- sheets of tissue covered on both surfaces with peritoneum and containing fat, blood vessels, lymphatics and nerves
- the greater omentum attaches to the greater curvature of the stomach and the posterior abdominal wall
- the lesser omentum attaches the lesser curvature of the stomach to the liver
- the lesser omentum also contains the portal triad entering the porta hepatis
Describe the location of the small bowel in the abdomen-p
-positioned centrally and is often separated from the anterior abdominal wall by the greater omentum
Give the 6 ligaments of the liver and what they do
Falciform ligament - attaches the anterior surface of the liver to the anterior abdominal wall, divided the left and right lobe anatomically, free edge contains the ligamentum teres
Coronary ligaments (anterior and posterior folds) - attaches the surface of the liver to the inferior surface of the diaphragm, demarcates the bare area of the liver, anterior and posterior fold unit to form the triangular ligaments on the right and left lobe of the liver
Triangular ligaments (left and right) - left attaches the left lobe of the liver to the diaphragm and right attaches the right lobe of the liver to the diaphragm
Lesser omentum - attaches liver to the lesser curvature of the stomach and first 1cm of the duodenum, consists of the hepatoduodenal ligament (extends from the duodenum to the liver) and the hepatogastric ligament (extends from the stomach to the liver), the hepatoduodenal ligament surrounds the portal triad
What is the gastric bed
- behind the stomach is the lesser sac
- behind the lesser sac the pancreas, splenic artery and part of the duodenum
Where do tumours of the stomach spread to
- tumours of the stomach are relatively common
- may spread to the lymphatics to the nodes surrounding the coeliac axis or via veins to the liver
Where is classed as the foregut
- lower 1/3 of the oesophagus to
- the 2nd part of the duodenum
- liver
- part of the pancrease
Venous drainage of the foregut
-venous bloods drains into the portal vein to the liver
Give sympathetic and parasympathetic nerve of the foregut
Sympathetic - greater splanchnic nerve (T5-T9)
Parasympathetic - vagal trunks (cranial nerve 10)
Give the 5 bodies of the lesser sac
- greater omentum
- lesser omentum
- caudate lobe of the liver
- pancreas inferiorly
- diaphragm superiorly
How is a barium meal examination of the stomach taken
- patient asked not to eat for 12 hours so the stomach is empty (they can take clear fluids)
- given barium sulphate which is not absorbed into the body but coats the lining of the stomach
- barium sulphate absorbs x-rays so it shows white on the image
- they are given a fizzy drink which dilates the stomach with gas
Give the branches of the coeliac trunk
Celiac trunk
- common hepatic artery
- left gastric artery
- splenic artery
Then
Left gastric artery
-oesophageal branches
Common hepatic artery
- proper hepatic artery
- gastroduodenal
Splenic artery
- left gastroepiploic artery
- short gastric arteries (supply fundus of the stomach)
- pancreatic branches (supply body and tail of pancreas)
Then
Proper hepatic artery
- right gastric artery
- right and left hepatic artery
Gastroduodenal artery
- right gastroepiploic artery
- superior pancreaticoduodenal artery
Then
Right hepatic artery
-the cystic artery
In the disease of the liver (e.g Cirrhosis) the portal venous channels in the liver becomes progressively smaller until they are insufficient for the blood to flow. What occurs with the venous flow form the bowel
- venous blood from the bowel will then flow up the veins of the oesophagus and into the superior vena cava (a porto-systemic shunt)
- the veins in the oesophagus distend to form the oesophageal varices (these are varicose veins of the oesophagus which bleed easily)
What s is pyloric stenosis and why is it relevant for children in the first 6 weeks of life
- in the first 6 weeks of life some children over develop the pyloric sphincter and the stomach cannot empty into the duodenum
- after feeding, when the stomach contracts, food is forced out of the mouth (projectile vomiting)
- because the child is not getting any nutrition they are always hungry and eager to feed
Give a common site of peptic ulcers
- posterior wall of the first part of the duodenum
- if the ulcer erodes through the duodenal wall it may erode into the gastroduodenal artery and cause very brisk bleeding
At what vertebral level does the oesophagus pass through the diaphragm
T10
Which structures pass through the diaphragm alongside the oesophagus
- the vagal trunks
- inferior oesophageal artery
- inferior oesophageal vein
Name the part of the stomach
- cardia
- fundus
- body
- anthrum (from incisura)
- pylorus (area around pyloric spinchter)
From where does the stomach receive its nervous supply
Parasympathetic -vagal trunks
Sympathetic - greater splanchnic nerve T5-T9
What structure attaches the stomach to the liver
-lesser omentum
What structure lies in front of the stomach
- left lobe of the stomach
- anterior abdominal wall
Which structures lie behind the stomach
- lesser sac
- behind the lesser sac is the pancreas and diaphragm
What is the porto-systemic anastamoses
- vein which joins to the hepatic portal system (so can carry blood to the liver) to the systemic system
- can take blood from the bowel and bypass the liver to return the blood to the heart
Name the 4 different parts of the duodenum
- superior (at L1) - most common site of duodenal ulcers, the 1st cm is attached to lesser omentum
- descending (L1-L3) - starts at the major duodenal papilla which is the opening from the ampulla of Vater
- inferior (L3) - crosses over the inferior vena cava and aorta
- ascending (L3-L2) - ends at the duodenojejunal flexure which has the suspensory muscle of the duodenum which widens the angle of the flexure and aids movement of chyme into jejunum
Which compartments does the greater omentum divide the abdomen into
- supracolic compartment
- infracolic compartment
What does the small bowel mesentry divide the abdomen into and the significance of this
- right infracolic cmpartment
- left infracolic compartment
-disease in the left compartment will find it difficult to spread to the right because the mesentry is in the way
Where is the oesophageal hiatus
T1O
What shape is the stomach
J shape
Give the 5 arteries that supply the stomach (including the two arcades on the stomach)
2 in the lesser omentum (arcade 1) - the right and left gastric arteries
2 in the greater omentum (arcade 2) - the right and left gastroepiploic arteries
1 - the short gastric arteries from the splenic artery
What is the blood supply to the lower 1/3 of the oesophagus
- the left gastric artery
- left gastric vein
Give the blood supply to the pancreas
TBC
How is the fundus of the stomach distinguished
-it lies above the line at the level of the gastro-oesophageal junction
Where does the lowest part of the oesophagus lie in
-the abdominal cavity
What is the incisura and what does it indicate
-a notch that marks where the body of the stomach ends and the anthrum/pylorus starts
Which part of the stomach do the short gastric arteries supply
-the fundus of the stomach
What are rugae
- folds of the mucosa of the stomach
- does not contain any muscle from the stomach wall
Give the layers of the abdominal wall from skin to parietal peritoneum
- skin
- fatty layer (camper’s)
- membranous layer (scarpa’s)
- external oblique muscle
- internal oblique muscle
- tranversus abdominis
- transversalis fascia
- extraperitoneal fascia
- parietal peritoneum
Give the 5 arteries that supply the stomach and their origin
- right gastric artery (proper hepatic artery)
- left gastric artery (coeliac trunk)
- right gastroepiploic artery (gastroduodenal artery)
- left gastroepiploic artery (splenic artery)
- short gastric arteries (splenic artery)
What is the median arcuate ligament and its clinical significance
- it anchors the diaphragm and forms the aortic hiatus
- it can lie anterior to the coeliac trunk and cause coeliac trunk compression syndrome
- coeliac trunk compression syndrome is usually treated by division of the median arcuate ligament
Which artery is usually affected by peptic ulcers that erode the stomach and duodenum
-the gastroduodenal artery
What are the risk factors for splenic artery aneurysm and how do they normally present
Risk factors
- female
- multiple pregnancies
- portal hypertension
- pancreatitis
- pancreatic pseudocyst
Usually present with
-epigastric pain
What are the branches of the superior mesenteric arteries
Superior mesenteric artery
- inferior pancreaticoduodenal artery
- jejunal arteries (small number of arterial arcades and long vasa recta)
- ileal arteries (more arterial arcades and short vasa recta)
- ileocolic artery (supplies ascending colon, appendix, caecum and ileum)
- right colic artery (supplies ascending colon)
- middle colic artery (supplies the transverse colon)
Give structures that form the midgut
- 3rd part of duodenum (after the major duodenal papilla)
- to the proximal 2/3 of the transverse colon
What level does the superior mesenteric artery arise from the abdominal aorta
-L1
What level does the coeliac trunk arise from the abdominal aorta
-T12 at the aortic hiatus of the diaphragm
What are the first branches of the abdominal aorta
-the paired inferior phrenic arteries
What level does the inferior mesenteric artery arise from the abdominal aorta
- L3
- it is a retroperitoneal structure
Give structures that form the hindgut
- from the distal 1/3 of the transverse colon
- to the upper 1/3 of the anal canal
- includes the splenic flexure, descending colon and sigmoid colon
Give the branches of the inferior mesenteric artery
Inferior mesenteric artery
- the left colic artery
- sigmoid artery
- superior rectal artery
Then
Left colic artery
- ascending branch (supplies distal 1/3 of the transverse colon and upper part of descending colon)
- descending branch (supplies lower part of descending colon)
Superior rectal artery
-at S3 vertebral level, it divides into two terminal branches supplying the walls of the rectum
What is a left hemicolectomy
-surgical resection (removal) of the descending colon
Give the two anastamoses of the inferior mesenteric artery with the superior mesenteric artery
- marginal artery (also called the marginal artery of drummond) - joining of the left colic artery with the middle colic artery to form the continuous arch of arteries along the colon
- arc of riolan - joining of middle colic artery and left colic artery (basically smaller arch under the marginal artery of drummond)
What is the blood supply to the middle 1/3 of the oesophagus
- branches of the descending thoracic aorta (arteries)
- azygous vein
What is the blood supply to the upper 1/3 of the oesophagus
- inferior thyroid artery
- inferior thyroid veins
What is the duodenal-jejunal flexure
-the junction between the duodenum and the jejunum
What is everything above ad below the ileocecal valve (ileo-cecal orifice) referred to
- above the ileocaecal valve is ascending colon
- below the ileocaecal valve is ceacum
What are the folds in the caecum and large intestines called
-haustrations (also called haustral folds or haustra)
What is a volvulus and which part of the intestines are usually involved in it
- a volvulus is when the intestines become twisted
- the jejunum and ileum are usually become herniated or twisted
What is the difference between a barium meal and barium enema
- a barium meal is taken orally
- a barium enema is put through the anal canal
How do carcinomas of the colon and rectum spread
-directly through the blood stream through the portal circulation to the liver but also through the lymph vessels to regional lymph nodes
What is Meckel’s diverticulum and what is its significance
- usually found about 2 feet from the end of the ileum
- is usually about 2 inches long
- it is an embryological remnant of an attachment of the midgut loop to the yolk sac
-histologically it can contain gastric mucosa and is a site for peptic ulcers and causes abdominal pain
Which part of the colon is most commonly affected by volvulus and what usually happens
- the sigmoid colon
- the mesentery may twist around on itself and cause blockage of draining vein
- can cause increase in capillary hydrostatic pressure
- leading to fluid leakage and eventual death of the tissue
Which veins drains blood from the colon and where does it flow
-inferior mesenteric vein drains into the splenic vein which forms the portal vein and passes into the liver
Where does lymph from the small bowel drain
-into the cisterna chyli and to the thoracic duct
Which foodstuffs are absorbed through the lymphatic system
Lipids
What 4 anatomical features ensure the small bowel has a high surface area for absorption of nutrients
- length
- mucosal folds (plicae circularis)
- villi
- microvilli
Where is the junction between the midgut and the hindgut
-2/3 of the way along the transverse colon
How do you distinguish a loop of large intestine from that of small intestine
Small bowel
- predominantly centrally located
- smooth walled cylindrical tube
Large bowel
- located around the sides
- has taenia coli
- has epiploic appendages (appendices epiploicia)
What part of the gut is supplies by the sacral nerves 2, 3 and 4
-the hindgut
How to differentiate between jejunum and ileum
Jejunum
- one long arcade
- long vasa recti
- many plicae circularis
- less fat in mesentery
Ileum
- multiple arcades (one on top of the other)
- short vasa recti
- not many plicae circularis
- more fat in the mesentery
Give the nervous supply of the gall bladder
- the vagus nerve
- sympathetic nerves from T5 to T9
Where would pain from the gall bladder be initially felt
-the epigastrium
What is the portal triad
- the hepatic artery
- the portal vein
- the bile duct
What does the cystic artery do
-provide blood supply for the gall bladder
What is a cushing’s ulcer?
-also called kissing ulcers
Tbc
Where is the liver divided functionally and into how many lobes
- down the gall bladder
- along the inferior vena cava
- can be functionally divided into 2
How many segments can each lobe be divided into
4 in the left lobe
4 in the right lobe
Where is the bare area of the liver and why is it bare
- on the right lobe of the liver
- has no peritoneum covering it
- bordered by the anterior coronary ligament and posterior coronary ligament
Where is the anatomical left and right lobe of the liver divided
-by the falciform ligament
Embryologically, where does the liver originate and develop in
- originated from the forgut
- develops in the ventral mesentry
In adults, what does the ventral mesentry become
- the lesser omentum
- ligaments that hold the liver close to the right dome of the diaphragm
What conditions can cause an enlarged liver
- congestive heart failure
- cirrhosis
- tumours
- viral infections (hepatitis)
Through which blood vessel does the liver receive all venous blood from the bowel
-the (hepatic) portal vein
Which valve is present in the cystic duct
-the spiral valve
Which organ has a honeycomb appearance to its mucosa
-the gall bladder
Which ducts join to form the common bile duct
- the hepatic duct (from the liver)
- the cystic duct (from the gall bladder)
How does an ultrasound work
- sound waves (ultrasonic sound) emitted from contact of probe on skin
- any surface or change of density of body tissues will reflect some of the sound back to the probe
- time taken for sound wave to be received is the distance of the reflecting surface to the probe
- a picture is created and displayed on the screen
What is biliary colic and what causes it
- pain when gall bladder squeezes against gall stones when contracting
- the gall stones are caused by an imbalance of the chemicals that form bile
How can the neurological disease, hepatic encephalopathy develop
- opathy = disease
- encephalo = of the inside of the head
- hepatic = due to the liver
- short chain proteins (3 or more amino acids) are toxic to the brain because they act as neurotransmitters
- the liver usually converts these proteins from the portal vein into safer molecules
- however in liver failure, a porto-systemic shunt forms and bypasses the liver
- so these proteins can travel to the brain
Which artery is the cystic artery a branch of
- usually the right hepatic artery
- but can be the left hepatic artery or hepatic artery
Which structures can be found in the porta hepatis macroscopically and microscopically
- macroscopically - portal vein, right and left heptic artery, right and left hepatic duct
- microscopically - lymphatics, branches of the vagus and greater splanchnic nerves
What structure degenerates to form the ligamentum venosum
-ductus arteriosus which is an embryological bypass for the liver which exists before the liver has fully formed
Where is the bare area of the liver
-under the central tendon of the right side of the diaphragm
What is the surface marking of the fundus of the gall bladder
- tip of the ninth costal cartilage where the midclavicular line crosses the costal margin
- the most lateral attachment of the rectus abdominis onto the costal margin
Which nerve may relay pain from diseases of the gall bladder and for each nerve where will the patient feel it
- inflammed gallbladder -T5 to T9 - greater splanchnic nerve - epigastrium
- rubs on diaphragm - C3, 4 and 5 - phrenic nerve - shoulder tip (literally over deltoid)
- rubs on skin - directly over that skin
Where do the hepatic veins drain into
-directly into the vena cava
- there are 3 hepatic veins
- the right hepatic vein
- the intermediate hepatic vein
- the left hepatic vein
Give the 5 different parts of the pancreas
- head
- neck
- body
- tail
- uncinate process
Does the pancreas have a capsule
No
The venous drainage of the spleen and where it runs
Tbc
Where is the superior mesenteric vein found, what structures join into it and what does it drain
Tbc
Where is the splenic vein found, what structures join into it and what does it drain
Tbc
What forms the (hepatic) portal vein
Tbc
Are the bile duct and pancreatic duct separate? And why
- yes they are completely separate
- this means pancreatic secretion cannot reflux from the pancreatic duct into the bile duct and bile cannot reflux from the bile duct to the pancreatic duct
Which structures do the common hepatic artery supply
- liver
- gall bladder
- stomach
- duodenum
- pancreas
Which structures do the splenic artery supply
- pancreas
- stomach
- spleen
Describe the journey of the superior mesenteric artery and vein and what is the significance of these vessels
- the superior mesenteric artery and vein pass between the head and uncinate process of the pancreas
- they pass anterior to the third part of the duodenum to enter the small bowel mesentery
- the superior mesenteric vein emerges superior to the neck of the pancreas as the hepatic portal vein
- these vessels mark the axis of rotation of the mid gut during foetal development
Which vessels mark the axis of rotation of the midgut during foetal development
-the superior mesenteric artery and vein
Where does the aorta enter the diaphragm
- T12
- behind the crus of the diaphragm
What are the borders of the spleen
Tbc
How can pancreatitis and jaundice develop
Development of jaundice
- small gall stones can pass through the cystic duct into the common bile duct and block it because it cannot pass through the sphincter of Oddi
- this leads to the build up of pigments in the blood causing jaundice
- it can lead to liver failure
Development of pancreatitis
- blockage of the pancreas can cause high pressure in the duct so digestive enzymes leak out of the duct and start digesting the pancreas
- it is fatal in 10% of cases
What is a cyst and what is a pseudocyst, what causes a psuedocyst
A cyst is a fluid filled structure with an epithelial lining
A pseudocyst is a cyst with a mesothelial lining
- a pseudocyst can be caused by the pancreas leaking fluid into the lesser sac
- pseudocysts can compress the stomach and cause difficulty eating
What is the clinical significance of a carcinoma of the head of the pancreas and is it treatable
- carcinoma of the head of the pancreas can invade the bile duct or pancreatic duct and cause the same issues as gall stones
- carcinoma of the head of the pancreas can grow around the portal vein stopping blood flow from the bowel to the liver
- currently it is untreatable
Can the spleen be palpated during abdominal examination
-normally no, it would need to be quite enlarged or displaced by a mass to be palpable
What structures might a tumour of the head of the pancreas involve
- hepatic portal vein
- bile duct
- pancreatic duct
What structures join to form the common bile duct and what is its course
- common hepatic duct
- cystic duct
-the common bile duct runs in the free edge of the lesser omentum and behind the first part of the duodenum onto the posterior aspect of the pancreas where it enters the pancreas to run alongside the pancreatic duct before opening into the duodenum
Where is the sphincter of Oddi
-on the medial wall of the duodenum between the second and third part of it
Which artery lies behind the first part of the duodenum
-the gastroduodenal artery
What lies between the pancreas and stomach
-the lesser sac
How many pancreatic ducts are there and what is the embryological significance
- two
- one from the ventral pancreatic duct and one from the dorsal pancreatic duct
What is the hard palate made from
-the bone of the maxilla
Which nerve supplies general sensation to the anterior 2/3 of the tongue
-the mandibular branch of the trigeminal nerve
Which nerve supplies taste sensation to the anterior 2/3 of the tongue
-the corda tympani branch of the facial nerve
Give the origin, insertion, innervation and function of palatoglossus muscle
Origin = palatine bone
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of palatopharyngeus muscle
Origin =
Insertion =
Innervation =
Function =
What bones lie behind the hard palate and soft palate
- the maxilla bone forms the hard palate
- palatine bone forms the soft palate
What artery is deep to the tonsils and what is it clinical significance
- facial artery
- at risk of bleeding in patients who are having their tonsils removed
In which fossa does the pituitary gland sit in
-the pituitary fossa
What is the nasal septum made of
- the anterior part of the nasal septum is cartilage
- the posterior part of the nasal septum is bone (vomer, part of maxilla and palatine bone inferiorly, ethmoid plate superiorly)
Where is the division on the face between the area supplied by the opthalmic and maxillary divisions of the trigeminal nerve
-a line from the junction between the upper lip and the nose and through the sphenoid sinus
What can be found in the sphenoethmoidal recess
-the sensory fibres for olfaction (smell)
Describe the journey of the eustachian tube
- passes into the petrous part of the temporal bone
- creates a middles ear cavity
What separates the middle ear from the external auditory meatus
-the tympanic membrane (the eardrum)
What does the eustachian tube do
-equalises pressure on either side of the tympanic membrane
What is the function of the eustachian tube
To equalise the air pressure either side of the tympanic membrane
Why is the maxillary sinus more prone to infection
The opening of the maxillary nasal cavity is at the top of the sinus so it does not drain easily
What is the nerve supply to the anterior 2/3 of the tongue
General sensation - mandibular branch of the trigeminal nerve (5)
Taste sensation - chorda tympanic branch of the facial nerve (7)
Motor - hypoglossal nerve (12)
Where do the ducts of the submandibular salivary glands open into the mouth
-below the tongue
Why may disease in the maxillary sinus cause numbness of the cheek
The infraorbital nerve (inferior orbital nerve) which supplies sensation to the cheek runs along the roof of the maxillary sinus
What are the attachments of the muscles of the tongue
The hyoid bone
What structure stops reflux of liquid into the nose during swallowing
The soft palate
Give 2 ways the eustachian tube can get blocked
- when you have a cold and are producing a lot of mucus
- adenoid tonsils in children which are persistently infected get large enough to block the opening of the eustachian tube
- goblet cells in the middle ear continue to produce mucus which fills the cavity causing glue ear
- the middle ear wont vibrate normally so the child becomes deaf
What is a grommet
- this is a tube in an artificial hole made in the tympanic membrane so the hole doesnt heal
- it bypasses the diseased eustachian tube and allows air from the middle ear to the external acoustic meatus
In which bone is the cribiform plate on
-the ethmoid bone
Where are the olfactory nerves located
-the sphenoethmoidal recess
Which meatus do the frontal, maxilliary and anterior ethmoidal sinuses drain into
-the middle meatus
Where do the posterior ethmoidal sinus drain into
-the superior meatus
What is the haitus semilunaris
-U shaped prominence near where the anterior ethmoid and frontal sinus drain into
Which nerve supplies the mucoperiosteum on the upper and lower surface of maxillary bone
- the greater palatine nerve
- the lesser palatine nerve
- they originate from the maxillary nerve and travel in two tunnels on the posterior aspect of the maxillary sinus
- be confident with where the sphenopalatine ganglion is
How many ethmoidal sinuses are above the maxillary sinus
8 ethmoidal sinuses
-in 2 rows of 4
Which nerve runs in the roof of the maxillary sinus, what does it supply and what is its clinical significance
- the infraorbital nerve (inferior orbital nerve), branch of the maxillary nerve
- it supplies the cheek
- comes out on the cheek under the orbit so a hard punch or cricket ball to the orbit could damage the nerve and cause numbness of the cheek
Give 2 deep features that a hard punch or cricket ball to the orbit can cause
- damage to the infraorbital nerve (inferior orbital nerve) branch of the maxillary nerve causing numbness to the cheek
- the inferior rectus muscle can attach to the fracture so when the superior rectus muscle of the eye tries to pull the eye up, it cannot because the inferior rectus muscle is stuck on the fracture
What are the borders of the oral cavity
- anteriorly the lips
- laterally the cheeks
- superiorly the palate
- inferiorly the tongue
What are the attachments of the tongue
- posterior ramus of the mandible
- the hyoid bone
What are some general sensations of the tongue
- touch
- vibration
- hot
- cold
Which muscle does the palatine tonsil sit on
-the superior constrictor of the pharynx
What are the palatine and adenoid tonsils and what do they
- they are a consolidation of lymphoid tissue
- they sample organisms that may try to enter the body through the mouth or nose
How many teeth does the mouth contain
-32 teeth
- 2 incisors anteriorly
- 1 canine
- 2 premolars
- 3 molars
Each quarter of the mouth
What forms the palate
- anterior 2/3 is bone, palatine processes of the mandible bone and the horizontal plates of the palatine bone
- posterior 1/3 is muscle
What muscles form the soft palate
- tensor palatine
- levator palatine
- musculus uvuli
- palatoglossus
- palatopharyngeus
What does the soft palate do
-elevates during swallowing to stop reflux of food into the nasopharynx and during the phonation to allow the production of explosive consonants
Contraction of which muscles open the eustachian tube
- tensor palatine
- levator palatine
How is drainage of the maxillary sinus different to that of the other sinus and what is the clinical significance
- the maxillary sinus has drainage at the top of the sinus while the others drain from the bottom of the cavity
- less efficient drainage of mucous so increased incidence of maxillary sinusitis
- if the patient lies on their side with the affected maxillary sinus uppermost then drainage will occur and aid recovery
What are children with a cleft palate at risk of
- they may not have function in the soft palate muscles to open the eustachian tube during swallowing
- so they may be at risk of recurrent middle ear infections and conductive deafness
What are children with persistently enlarged tonsils due to repeated throat infections at risk of and how is it treated
- blocked eustachian tube
- they are at risk of repeated middle ear infections and conductive deafness
- a grommet -which is a tiny plastic tube through the tympanic membrane directly into the middle ear cavity which creates an artificial passage into the middle ear to bypass the diseased eustachian tube
Which muscles are responsible for abduction of the shoulder
- initiation by supraspinatus
- assisted by deltoid
- rotation of the scapula by trapezius
Describe the movements of the scapula and humerus during abduction of the shoulder
- supraspinatus initiates abduction
- after 10 to 15 degrees it is assisted by the deltoid muscle
- as the arm rises, the humerus externally rotates to keep the articular surfaces in contact
- at full abduction (upper limb vertically over the head), the humerus has externally rotated by 90 degrees and the scapula is rotated so that the glenoid points upwards by 60 degrees
- for every 2 degrees of abduction at the glenohumeral joint, the scapula rotates by 1 degree over the thoracic wall
Which nerve supplies the trapezius
-the spinal root of the accessory nerve (cranial nerve 11)
Which nerve is damaged by a posterior dislocation of the shoulder and what sensory and motor loss is experienced
- the axillary nerve
- sensory loss in the skin over the insertion of deltoid muscle
- motor loss of deltoid (paralysis)
What structures stabilise the shoulder joint
-the rotator cuff muscles which are suprspinatus, infraspinatus, teres minor and subscapularis
Which bony parts of the shoulder girdle lie subcutaneously and can be palpated easily
- manubrium of the sternum
- clavicle
- acromion of the scapula
- spine of the scapula
Will Saturday night palsy result in weakness of triceps
No
- because saturday night palsy is a loss of function of the radial nerve as it runs along the midshaft of the humerus in the spiral groove
- although the posterior compartment of the arm which is formed by triceps is supplied by the radial nerve, the branches leave the nerve before the spiral groove
Explain what causes frozen shoulder and how would a patient describe it
- the tendon of supraspinatus travels through a gap between the humerus and acromion
- if the tendon becomes inflamed it can causes pain as the swollen part passes through the gap
- the patient would usually be able to lift their arm short distance pain free but then as the swollen part passes through the gap, it is painful to raise the arm
- but once the swollen part is through the gap then raising the arm is pain free again
- the patient will usually describe this as a painful arc and this is called the frozen shoulder
Explain what causes axillary nerve palsy and what symptoms would manifest
- the axillary nerve runs against the neck of the humerus and can be damaged with posterior dislocation of the shoulder and fracture of the neck of the humerus
- damage to the axillary nerve will cause paralysis of the deltoid and a patch of numb skin on the lateral arm
Explain what causes radial nerve palsy (Saturday Night Palsy) and symptoms will it show
- the radial nerve runs in the spiral grove directly against the humerus and it can be easily damaged by a fracture of the humerus or by direct pressure
- it is called Saturday night palsy because usually when someone arrives home drunk they are too tired to go upstairs to bed and sleep on the sofa with their arm hooked over the back of the sofa
- this leads to direct pressure on the radial nerve and they awake with radial nerve palsy
Explain pain in the funny bone (also called ulnar nerve palsy)
- the ulnar nerve passes behind the medial epicondyle of the humerus
- it leads to severe pain and pins and needles in the skin supplied by the ulnar nerve
Give the origin, insertion, innervation and function of the trapezius muscle
Origin = external occipital protuberance and spinous processes of C7 to T12 Insertion = superior aspect of the spine of the scapula, lateral 1/3 of the clavicle, acromion Innervation = spinal root of the accessory nerve (Cranial nerve 10) Function = rotation of the scapula during abduction of the shoulder joint
Give the origin, insertion, innervation and function of the latissimus dorsi muscle
Origin = iliac crest, spinous process of T7 to L5 and sacrum, ribs 10 to 12 Insertion = intertubercular sulcus of the humerus Innervation = thoracodorsal nerve C6, 7 and C8 Function = extends, adducts and medially rotates the humerus e.g pulling the arm downwards like when you are ringing a church bell or pulling a rope on an old fashioned sailing ship
What are the 3 borders of the scapula
- superior border
- inferolateral border
- medial boder
Give the origin, insertion, innervation and function of the supraspinatus muscle
Origin =
Insertion =
Innervation =
Function =
Give the origin, insertion, innervation and function of the infraspinatus muscle
Origin =
Insertion =
Innervation =
Function =
How many muscles are attached to the inferolateral border of the scapula and what are they called
- 2 muscles
- teres major
- teres minor
Describe the journey of the teres major
-most medial part of the border passes anterior to the tendon of the long head of triceps to insert anteriorly on the humerus
Give the origin, insertion, innervation and function of the teres major muscle
Origin = inferior angle of the scapula Insertion = anterior surface of the humerus Innervation = lower subscapular nerve C5, C6 and C7 Function = medial rotation and extension of the arm at the glenohumeral joint
Give the origin, insertion, innervation and function of the teres minor muscle
Origin =
Insertion =
Innervation =
Function =
Describe the journey of teres minor muscle
- from the inferolateral border of the scapula
- runs posterior to the long head of the triceps to insert on the greater tuberosity
Which muscle runs in front of the long head of triceps to insert on the greater tuberosity
-teres major
Which vessels pass through the quadrilateral space created by the humerus, long head of triceps, teres major and teres minor
- axillary nerve
- posterior circumflex humeral blood vessels
Which nerve is at risk of damage by dislocation of the shoulder or fracture of the surgical neck of the humerus
- axillary nerve
- causes paralysis of the deltoid
- causes numb patch of skin on the lateral arm (loss of sensation)
What movements do the mid, lower and upper fibres of the trapezius muscle do when they contract
-the mid portion of the trapezius muscle have horizontal fibres which pull the shoulder blade back towards the spine (this is retraction of the scapula)
- the lowermost fibres of the trapezius is attached to the most superior aspect of the scapula
- the uppermost fibres of the trapezius is attached to the most lateral part of the scapula (the acromion)
-when the fibres of the lowermost and uppermost parts of the trapezius contract simultaneously they rotate the scapula and rotate the glenoid so it is facing upwards which helps with abduction of the arm
What is the glenoid
- the articular surface on the scapula of the humerus
- in the anatomical position it faces laterally
How many muscles are attached to the medial border of the scapula and what are they called
3
- rhomboid major
- rhomboid minor
- levator scapulae
Give the origin, insertion, innervation and function of the rhomboid major muscle
Origin = spinous processes of T2 to T5 Insertion = medial border of the scapula Innervation = dorsal scapula nerve C4 and C5 Function = retracts (adducts) and elevates the scapula
Give the origin, insertion, innervation and function of the rhomboid minor muscle
Origin = spinous processes of C7 to T1, and lower portion of ligamentum nuchae Insertion = medial border of the scapula Innervation = dorsal scapula nerve C4 and C5 Function = retracts (adducts) and elevates the scapula
How do rhomboid major and rhomboid minor move the scapula
-they retract the scapula but will derotate the scapula when the arm is coming down to the side
Give the origin, insertion, innervation and function of the levator scapulae superioris muscle
Origin = tranverse processes of the C1 to C4 Insertion = medial border of the scapula Innervation = C3 to C4, dorsal scapular nerve (C4 and C5) Function = elevates the scapula
Which procedures can put the thoracodorsal nerve and the long thoracic nerve at risk
- radiotherapy to the axilla
- malignant disease of the axilla
- surgery on the axilla
Which nerves are put at risk by malignant disease of the axilla, surgery or radiotherapy of the axilla
- the long thoracic nerve f the roots of the brachial plexus C5, 6 and 7
- the thoracodorsal nerve of the posterior cord of the brachial plexus
Which muscles are antagonists to serratus anterior and why
- trapezius
- rhomboid major
- rhomboid minor
- they retract the scapula
- serratus anterior protracts the scapula
Where does the long thoracic nerve arise from
- the roots of the brachial plexus
- C5, 6 and 7
What does damage to the long thoracic nerve cause
- paralyses of serratus anterior
- when the patient tries to pull their shoulders forward, the medial border of the scapula comes up and away from the thoracic wall (this is winging of the scapula)
Give the 4 rotator cuff muscles
- supraspinatus
- infraspinatus
- teres minor
- subscapularis
Which muscle passes under the acromion to insert on the most superior part of the greater tuberosity
-supraspinatus
What are the 3 muscles that insert on the greater tuberosity and form the posterior superior part of the rotator cuff
- supraspinatus
- infraspinatus
- teres minor
Give the origin, insertion, innervation and function of the subscapularis muscle
Origin = medial 2/3 of subscapular fossa Insertion = lesser tubercle of humerus Innervation = upper and lower subscapular nerves C5, C6 and C7 Function = rotator cuff muscle, medial rotation of the arm at the glenohumeral joint
Which muscle internally rotates the shaft of the humerus
-teres major (inserts anteriorly on the humerus)
Which muscles will externally rotate the shaft of the humerus
-teres minor (insert on the posterior aspect of the humerus)
How many origins and insertions does the triceps muscle have and state them
3 origins
1 insertion
- the long head of the triceps originates from the infraglenoid tubercle of the scapula
- the lateral head of the triceps originates from the posterior aspect of the upper 1/3 of the humerus
- the medial head of the triceps originates from the medial aspect below the spiral groove
-they all insert on the olecranon of the ulnar
Which nerve runs at the elbow level just posterior to the medial epicondyle of the humerus
-ulnar nerve
What does the ulna nerve do
- supply sensation to the medial 1 and 1/2 digits of the hand
- flexor carpi ulnaris
- medial 1/2 of flexor digitorum profundus
Which nerve runs in the spiral groove of the humerus
-the radial nerve
What is the pectoral girdle (shoulder girdle)
-consists of the scapula, clavicle, all muscles attached to these and the lattisimus dorsi muscle
In medial rotation of the shoulder joint, which way does the lesser tubercle rotate
-inwards e.g to scratch the lower part of your back you extend and medially rotate the shoulder joint
In lateral rotation of the shoulder joint, which way does the lesser tubercle rotate
-outwards e.g when combing the back of your hair, the shoulder is abducted and laterally rotates
Give two superficial back muscles
- the trapezius
- latissimus dorsi
Which nerve supplies the flexor muscles of the arm
-musclocutaneous nerve
Which nerve supplies the extensor muscles of the arm and forearm
-radial nerve
What does the median nerve supply
- all muscles of the forearm except
- flexor carpi ulnaris
- medial 1/2 of flexor digitorum profundus
What muscles does the ulnar nerve supply in the forearm
- flexor carpi ulnaris
- medial 1/2 of flexor digitorum profundus
Describe the brachial plexus
Rugby Teams Drink Cold Beer
R for Roots (C5 -T1)
T for Trunks (Upper, Middle and Lower)
D for Divisions (Anterior, Medial and Posterior)
C for Cords (Lateral, Medial and Posterior)
B for Branches (musculocutaneous, median, radian, axillary, ulnar)
Give the origin, insertion, innervation and function of the subclavius muscle
Origin = first rib at junction between rib and costal cartilage Insertion = groove on inferior surface of middle 1/3 of clavicle Innervation = C5 and C6 Function = pulls the tip of the shoulder down, pulls clavicle medially to stabilise sternoclavicular joint
Why is the axilla a clinically important area
-a common site for spread of malignancy
Which vein does the cephalic vein in the deltopectoral groove join to
-the axillary vein
Where does the brachial plexus arise
Cervical nerves 5, 6, 7 and 8 and T1
-arise through the intervertebral foramina posterior to scalenus anterior
Give the origin, insertion, innervation and function of the scalenus anterior muscle
Origin =
Insertion =
Innervation =
Function =
Which nerve runs on the surface of scalenus anterior
-the phrenic nerve (which give motor and sensory innervation to the diaphragm)
Between which two muscles do the roots of the brachial plexus arise?
Between scalenus anterior and scalenus medius
Where is the lower part of the brachial plexus located
-the anterior axillary fold which is formed by the lower border of pectoralis major
Which structures arise between the scalenus anterior and scalenus medius muscles in the neck
- the brachial plexus
- the subclavian artery
Where do the subclavian artery and vein become the axillary artery and vein
-at the outer border of the first rib
Where do the axillary artery and vein change their name to the brachial artery and paired brachial veins
-anterior axillary fold
What does the posterior cord of the brachial plexus give rise to
- the radial nerve
- axillary nerve
- upper and lower subscapular nerve
- thoracodorsal nerve
What does the lateral cord of the brachial plexus give rise to
- musculocutaneous nerve
- lateral part of the medial nerve
What does the medial cord of the brachial plexus give rise to
- ulnar nerve
- medial part of the median nerve
Which nerves form the M shape of the lower part of the brachial plexus below the inferior border of the pectoralis minor muscle, going laterally to medial
- musculocutaneous
- median nerve
- ulnar nerve
Where does the cephalic vein in the arm lie
- in the groove between the posterior and anterior compartment
- on the lateral side of the arm
- the basilic vein lies on the medial side of the arm
Describe the divisions of the subclavian vein
- subclavian vein
- axillary vein
- cephalic and brachial vein
- brachial vein then becomes the basilic vein
Between which two muscles does the musculocutaneous nerve lie in the arm
- the biceps muscle
- the brachialis muscle
Give the origin, insertion, innervation and function of the biceps brachii muscle
Origin of the long head = supraglenoid tubercle of the scapula (superior aspect of the glenoid fossa)
Origin of the short head = coracoid process
Insertion = tuberosity on the radius (the bicipital aponeurosis inserts on the deep fascia of the forearm)
Innervation =
Function = flex the elbow joint, supinator of the forearm
Give the origin, insertion, innervation and function of the brachialis muscle
Origin = lower half of the shaft of the humerus Insertion = tuberosity (coracoid process) of the ulnar Innervation = musculocutaneous nerve C5, C6 Function = flexor of the forearm at the elbow joint
Which muscles does the musculocutaneous nerve supply
- biceps
- brachialis
- coracobrachialis
Where does the cutaneous part of the musculocutaneous nerve run into skin and what does it supply
- runs into skin at the level of the elbow
- supplies the lateral part of the forearm
-above elbow musculocutaneous is motor and below elbow it is sensory
Give the origin, insertion, innervation and function of the coracobrachialis muscle
Origin = apex of coracoid process
Insertion = midshaft of the humerus
Innervation =musculocutaneous nerve C5, C6 and C7
Function = Flexor of the arm at the glenohumeral joint
Lies under the short head of biceps
Which muscle can you find in the bicipital groove
-the long head of biceps
Why is the antecubital fossa an important area
The main site for blood sampling
- lies in front of the elbow joint
- contains the bicipital aponeurosis (from the biceps) and biceps tendon which insert on radius
What forms the antecubital fossa
- brachoradialis (forms lateral part of antecubital fossa)
- pronator teres (forms medial border, it is from the medial epicondyle)
Which vessels pass through the antecubital fossa
- musculocutaneous nerve (the sensory part) on the lateral side
- the median nerve on the medial side (between bicipital aponeurosis and tendon)
- brachial artery and vein on the medial side (between bicipital aponeurosis and tendon)
Where does the ulnar travel in relation to the arm to the forearm
-behind the epicondyle on the medial side
Where does the radial nerve travel in relationto the arm to the forearm
- in the groove between the brachoradialis and the brachialis
- lateral on the antecubital fossa (also called cubital fossa)
What does the axilla contain
- fat and lymph nodes
- axillary artery (major artery supplying the upper limb)
- axillary vein (major veinous drainage of the arm)
- brachial plexus - nervous plexus supplying the limb
What is the axillary sheath and what does it cover
- a continuation of the fascial sheath that covers the muscles in the posterior triangle of the neck (the prevertebral fascia)
- the axillary sheath covers the axillary artery, axillary vein and lower parts of the brachial plexus
On which muscle does the posterior cord of the brachial plexus lie
-the subscapularis muscle
Give the origin, insertion, innervation and function of the subscapularis muscle
Origin = media 2/3 of the subscapular fossa Insertion = lesser tubercle of the humerus Innervation = upper and lower subscapular nerves C5, C6 and C7 Function = rotator cuff muscle, medial rotation of the arm at the glenohumeral joint
The axillary artery is divided into 3 parts and has one branch above the pectoralis minor muscle, 2 behind and 3 below. Name them
HoTeL SPA
(Highest) superior thoracic artery Thoracoacromial artery Lateral thoracic artery Subscapular artery Posterior circumflex humeral artery Anterior circumflex humeral artery
Which artery supplies serratus anterior muscle
-lateral thoracic artery
What is the glenoid labrum and where is it located
- a fibrocartilage
- the margin of the glenoid
Which structures run under the bicipital aponeurosis of the antecubital fossa
- the median nerve
- the brachia artery
- the median cubital vein (from the basilic vein)
What does the musculocutaneous nerve supply
- all muscles of the anterior compartment of the arm (coracobrachialis, biceps and brachialis)
- continues as the lateral cutaneous nerve of the forearm which supplies sensation to the lateral forearm skin
Explain what Erb’s palsy is? And what is its other name
- also called the waiters tip palsy
- it is where one or two upper roots of the brachial plexus are damaged C5 C6
- causes motor paralysis
- external rotators of the shoulder are paralysed
- humerus becomes internally rotated
- extensors of the wrist are paralysed
- wrist is held flexed
- very rare
Explain what klumpke palsy is?
- where one or two lower roots of the brachial plexus are damaged
- all small muscles of the hand are paralysed
- if C8 is damaged the some forearm muscles will be paralysed
Explain what Hormer’s syndrome is
- damage to the T1 nerve
- T1 carries sympathetic nerves
- causes drooping eyelid (ptosis), lack of face sweat (anhidrosis), constricted pupil (miosis)
How does blood reach the right axillary artery from the left ventricle? (Name the arteries through which it passes)
- aorta
- brachiocephalic trunk/artery
- right subclavian vein
- right axillary vein
Outline the arrangement of the cords of the brachial plexus around the second part of the axillary artery.
- the second part of the axillary artery is behind the pectoralis minor muscle
- laterial, medial and posterior
Which muscles form the rotator cuff and where are they inserted
Supraspinatus - superior facet on the greater tuberosity of the humerus
Infraspinatus - middle facet on the greater tuberosity of the humerus
Teres minor - inferior facet on the greater tuberosity of the humerus
Subscapularis - lesser tuberosity of the humerus
Describe the various lymphs node groups in the axilla and their clinical signficance
Anterior (pectoral) nodes - under the pectoralis major
Lateral (Humeral) nodes - between the pectoralis major and latissimus dorsi close to the humerus
Posterior - lying against teres major at the back of the axilla
Central - inferior to the neurovascular bundle deep to the pectoralis minor
Apical - adjacent to the outer border of the first rib
Where does the brachial artery and median nerve pass into the forearm
-medial to the biceps aponeurosis
What is pronation and which muscles perform this movement
- pronation is positioning the radius and ulna crossing each other
- the hand faces backwards in the anatomical position or downwards with elbow flexed
- pronator teres (in any position of the elbow)
- pronator quadratus (in any position of the elbow)
What is supination and which muscles perform these movements
- supination is positioning the radius and ulna parallel to each other
- the hands faces forward in the anatomical position or upwards if the elbowed are flexed
- the supinator (elbows in any position)
- biceps (with elbows flexed)
What parts of the body drain lymph directly to the axillary lymph nodes?
Ipsilateral upper limb and body wall above the umbilicus
What structures lie along the medial border of the biceps in the middle of the arm
- median nerve
- ulnar nerve
- medial cutaneous nerve of the forearm
- brachial artery
- basilar vein
Give the origin, insertion, innervation and function of the deltoid muscle
Origin =inferior aspect of the spine of the scapula
Insertion = mid shaft of the humerus
Innervation = axillary nerve
Function = abduction of the shoulder
Give the origin, insertion, innervation and function of the trapezius muscle
Origin = occiput of the skull, spinous processes of the cervical and thoracic vertebra
Insertion =superior aspect of the scapula
Innervation = spinal portion of the accessory nerve
Function =
What structures form the quadrilateral space on the posterior aspect of the arm
- humerus
- teres minor
- teres major
- long head of triceps
Which vessel lies in the same tissue plane as the brachial plexus
- the subclavian artery
- the brachial plexus and subclavian artery lie between scalenus anterior and scalenus medius
