Anatomy III Final Review Flashcards
45 y/o man came to his PA c/o px and weakness in his right shoulder. Px began after FOOSH 6 months ago. He recalled having some minor shoulder tenderness but no other specific sx. He is otherwise well. PE of shoulder – there was marked wasting of the muscles in the supraspinous and infraspinous fossae. The pt found initiation of abduction difficult and there was a weakness of lateral rotation of the humerus. Which muscles are most likely involved in his current condition?
Supraspinatus and infraspinatus
45 y/o man came to his PA c/o px and weakness in his right shoulder. Px began after FOOSH 6 months ago. He recalled having some minor shoulder tenderness but no other specific sx. He is otherwise well. PE of shoulder – there was marked wasting of the muscles in the supraspinous and infraspinous fossae. The pt found initiation of abduction difficult and there was a weakness of lateral rotation of the humerus. Which nerve is most likely involved in his current condition?
Suprascapular nerve (C5-C6)
From superior trunk of brachial plexus. Typical site for compression of nerve is the suprascapular notch (foramen) on the superior margin of the scapula. Minor injury damaged the fibrocartilaginous glenoid labrum, which allowed a cyst to form and pass along the superior border of the scapula to the foramen, where it compressed the nerve.
57 y/o women underwent right mastectomy for breast CA. Surgical note reported that all of the breast tissue had been removed, including the axillary process. In addition, the surgeon had dissected all LN w/in the axilla w/ their surrounding fat. She made an uneventful recovery. @ 1st f/u, pt’s husband told surgeon that she had now developed a “spike” on her back. On exam, the spike was the inferior angle of the scapular, which appeared to be sticking out posteriorly. Raising the arms accentuated the finding. Which of the following is the most likely explanation for her clinical finding?
A. Damage to axillary nerve
B. Lymphedema secondary to lack of sufficient drainage
C. Post-op wound infx
D. Damage to long thoracic nerve.
E. Damage to rotator cuff muscles.
Damage to long thoracic nerve.
“Winged scapula.” LTN arises from C5-C7 and is susceptible to stretch injuries + direct trauma. During surgery on axilla, LTN can be damaged as it passes down lateral thoracic wall on external surface of the serratus anterior, just deep to the skin + SQ fascia. If transected, unlikely that the pt will improve. Medial winging = dysfunction of LTN. Lateral winging = deficits in CN XI, trapezius muscle, dorsal scapular nerve (C5), or rhomboid muscles
30 y/o man is stabbed in the arm. No evidence of vascular injury, but he cannot flex his three radial digits. Which of the following has been injured?
A. Flexor pollicis long + flexor digitus medius
B. Radial nerve
C. Median nerve
D. Thenar + digital nerves at the wrist
E. Ulnar nerve
Median nerve.
A surgeon wished to carry out a complex procedure on a pt’s wrist and asked the anesthesiologist whether the whole arm could be numbed while the pt was awake. Anesthesiologist injected 10 mL of local anesthetic into the axilla, and the surgeon proceeded w/ the operation while the awake pt did not feel a thing. Where was the anesthetic most likely placed?
A. Into the axillary sheath
B. Into the axillary artery
C. Into the posterior cord of the brachial plexus
D. Into the inferior trunk of the brachial plexus
E. Into the brachiocephalic vein
Into the axillary sheath.
Axillary sheath contains the axillary artery, axillary vein + the brachial plexus. By injecting the anesthetic into the space enclosed by the sheath, all nerves of the brachial plexus are paralyzed. It would be almost impossible to anesthetize the wrist in the forearm bc local anesthetic would have to be placed accurately around the ulnar, median + radial nerves; also, all of the cutaneous branches of the forearm would have to be anesthetized individually. Potential complications: direct needle spike of the branches of the brachial plexus, damage to the axillary artery and inadvertent arterial injection of the local anesthetic.
25 y/o woman was involved in a MVA and thrown from her motorcycle. When she was admitted to the ED, she was experiencing px + dyspnea. RAD exam revealed fx of 1st rib. Which best explains her dyspnea: A. Rupture of anterior mediastinum B. PE from DVT C. COPD D. Left PTX E. Flash pulmonary edema
Left pneumothorax.
Many important structures are near the left 1st rib: apex of the left lung, left subclavian artery, left subclavian vein + left IJ junction, brachial plexus. Damage to any of the above could be critical. Different than all other ribs bc deeply located + well-protected. Very rarely, it can cause a Horner’s syndrome (miosis [pupillary constriction], ptosis + anhidrosis [inability to sweat])
35 y/o woman comes to office c/o tingling + numbness in fingertips of first, second + third digits. Sx provoked by arm extension. Which nerve is the most likely source of her symptoms?
Median nerve.
35 y/o woman comes to office c/o tingling + numbness in fingertips of first, second + third digits. Sx provoked by arm extension. Which of the following locations is most likely the source of the nerve compression? A. Carpal tunnel B. Ulnar tunnel C. Axilla D. Mid-humerus E. Olecranon bursa
Carpal tunnel.
Median nerve is formed from the lateral + medial cords of the brachial plexus anterior to the axillary artery + passes into the arm anterior to the brachial artery. At the level of the elbow joint, it sits medial to the brachial artery, both of which are medial to the biceps tendon. In the forearm, it courses through the anterior compartment and passes deep to the flexor retinaculum. There is a SF branch that supplies sensory innervation to the thenar eminence. This superificial branch is proximal to the flexor retinaculum, so it should not be involved in true carpal tunnel syndrome.
In order regarding hip:
- Ligament that acts in all movements
- Strongest ligament
- Weakest ligament
- Limits extension + abduction
- Cups the acetabulum to form a socket for femoral head
- Artery to femoral head runs in ligament
- Capsular: Ligament that acts in all movements
- Iliofemoral: Strongest ligament
- Ischiofemoral: Weakest ligament
- Pubofemoral: Limits extension + abduction
- Transverse acetabular: Cups the acetabulum to form a socket for femoral head
- Ligament of head of femur: Artery to femoral head runs in ligament
Most common sites for compartment syndrome in UE + LE and causes:
Anterior compartments.
UE: volar compartment of forearm from ulnar, radial or supracondylar fracture.
LE: proximal tibia fx
Muscles of anterior compartment of lower leg.
NV supply?
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius.
Innervated by deep peroneal nerve.
Supply/ drainage from anterior tibial artery + vein.
Muscles of deep posterior compartment of lower leg.
NV supply?
Posterior tibialis
Flexor hallucis longus
Flexor digitorum longus
Popliteus
Neurovascular:
Tibial nerve
Posterior tibial artery + vein
Peroneal artery + vein
Problem with the following nerves will create what impairment?
- Radial
- Ulnar
- Median
- Axillary
- Peroneal
- Radial – wrist drop
- Ulnar – claw hand
- Median – Pope’s blessing
- Axillary – deltoid paralysis
- Peroneal – foot drop
25 y/o woman presents to ED c/o redness + pain in right foot up to the level of the mid-calf. She reports her right leg has been swollen for 15 years, but her left leg has been normal.
On PE: temp is 102.2. Left leg normal. Right leg is not tender but is swollen from her inguinal ligament down and she has an obvious cellulitis of her foot. What is the most likely underlying etiology of her condition?
A. Popliteal entrapment syndrome
B. Acute arterial insufficiency
C. Primary lymphedema
D. Deep venous thrombosis
Primary lymphedema.
She is at high risk of developing cellulitis bc of unilateral primary lymphedema. Hypoplasia of the lymphatic system of the LE accounts for >90% of pt w/ primary lymphedema. The inadequacy accounts for the repeated episodes of cellulitis. Swelling is not seen w/ acute arterial insufficiency or w/ popliteal entrapment syndrome. DVT will result in tenderness + likely swelling but is generally not a predisposing factor for cellulitis of the foot.
A long-distance runner is examined by her PA after c/o pain along the anteromedial aspect of her left leg, extending from just below the knee to just above the ankle. She has been running on a hard surface and notices that the px is especially acute as she pushes off from the ground w/ the affected limb. Which of the following muscles is most likely affected? A. Extensor digitorum longus B. Fibularis longus C. Gastrocnemius D. Popliteus E. Tibialis posterior
Tibialis posterior.
Leg muscles are encased in a strong and tight crural fascia. Overuse of these muscles can lead to swelling + px or damage to the muscles in this compartment. The muscle most often affected by pushing off the ground is the tibialis posterior muscle during plantarflexion at the ankle
Shin splint pain location and primary cause?
Pain along the inner distal 2/3 of the tibial shaft. Common in athletes. Primary cause: repetitive pulling of the tibialis posterior tendon as one pushes off the foot during running. Stress on the muscle occurs at its attachment to the tibia + interosseous membrane. Chronic conditions can produce periostitis and bone remodeling or can lead to stress fractures. Pain usually begins as soreness after running that worsens and then occurs while walking or climbing stairs.
23 y/o male presents to his PCP a few days after being stabbed in the right buttock. PE reveals that he is unable to rise from a seated position w/o use of his arms, as well as weakness in climbing stairs. What muscle and nerve was most likely affected?
Gluteus maximus muscle + inferior gluteal nerves.
The most powerful extensor of the hip, is innervated by the inferior gluteal nerves (L5-S2). Muscle is used esp in climbing stairs or rising from sitting position. Main actions: extends flexed thigh, assists in lateral rotation, abducts thigh
Nerve supply to quads, iliacus + sartorius
Femoral nerve
Nerve supply to adductor longus + brevis, gracilis, obturator externus
Obturator nerve
Nerve supply to gluteus medius + minimus, TFL
Superior gluteal nerve
Nerve supply to gluteus maximus
Inferior gluteal nerve
Nerve supply to posterior thigh compartment + all muscles below the knee
Sciatic nerve
An obese 48 y/o woman presents w/ a painful lump in her proximal thigh just medial to the femoral vessels. Exam reveals herniation of some abdominal viscera, which passes under the inguinal ligament. Through which of the following openings has this hernia passed through to enter her thigh? A. Deep inguinal ring B. Femoral ring C. Fossa ovalis D. Obturator canal E. SF inguinal ring
Femoral ring.
This is a femoral hernia which gains access to the anterior thigh via the femoral ring which is the abdominal opening in the femoral canal. The incidence of strangulation is high; thus, all femoral hernias should be repaired, and incarcerated femoral hernias should have the hernia sac contents examined for viability.
A football player receives a blow to the lateral aspect of his weight-bearing leg and immediately feels his knee give way. Under extreme px, he is carried from the field + immediately examined by the team physician, who is able to move the player’s right tibia forward excessively compared to the uninjured leg. Which ligament is injured?
ACL.
This is a +anterior drawer sign: excessive movement of the tibia forward on a fixed femur. The ACL limits hyperextension. The PCL is shorter + stronger.
An 11 y/o jumps from a tree house 15’ above the grand + lands on his feet before rolling forward, immediately feeling extreme pain in his right ankle. Which tarsal bone is most likely fractured?
Calcaneus.
The calcaneus is a rather soft (cancellous) bone compared to the denser talus, and falls from a great height that include landing on the feet will result in the talus being driven down into the calcaneus, causing an intra-articular fracture.
A 1st year PA student is asked to demonstrate the location of the DP pulse. What landmark would be a reliable guide for finding this artery?
Lateral to the extensor hallucis longus tendon.
It points the big toe upward. DP pulse can be palpated by pressing it against the underlying navicular or intermediate cuneiform bone.
22 y/o runner presents to ED after accidentally running into a pothole. Has acute swelling around lateral aspect of ankle. Plain AP + lat films reveal no evidence of any bone injury. Dx'd w/ ankle sprain, given crutches + analgesics and told to rest. Over ensuing weeks, swelling + edema w/in soft tissue of ankle decreased and she began to run again; however, she noted that the ankle kept "giving way." She went on to an ortho surgeon for further eval. PE revealed +anterior drawer test of ankle joint. Which is the most likely cause of her sx: A. Stress fx of calcaneus B. Calcaneofibular ligament tear C. Anterior talofibular ligament tear D. Posterior talofibular ligament tear E. Tear of medial ligament of ankle.
Anterior talofibular ligament tear.
MC injured ligament in ankle sprains. Typically when running on a hard surface, the final phase of push-involve involves supination of the foot. If foot caught in a pothole or divot, this supinating maneuver continues + inverts the ankle joint in plantarflexion. This puts significant strain on lateral ligament complex and, given the appropriate circumstances, disruption of ligament structures occurs from anterior to posterior. 1st: anterior talofibular, then calcaneofibular ligament and then posterior talofibular ligament. Any +anterior drawer test of ankle suggests an injury to the anterior talofibular ligament.
A 36yo man with DMT1 presents to the ER with severe right leg pain. He states that he was ambulating fine with a friend down a NYC street while looking at building architecture, until he stepped in a pothole. He felt a “pop” and his knee give out and then had significant difficulty ambulating once his friend helped him out of the hole. PE reveals moderate swelling of the right knee without any erythema. The knee is very tender to palpation and he experiences pain with any movement of the knee. Which of the following is the most likely diagnosis? A. Proximal tibial fracture B. Ruptured Baker's cyst C. Complete dislocation of the knee D. Popliteal compartment syndrome E. Lateral meniscal tear.
Complete dislocation of knee.
Knee dislocation is a sprain (tear) of multiple ligaments, typically 3 or 4 major ligaments (both cruciates + one collateral). Often, one or more “pops” are heard/ felt at time of injury. The individual is unable to continue activity after the injury, and there often is swelling w/in 6 hours. Rarely, there can be injury to nerves.
Arthrocentesis Analysis: Color: Yellow Clarity: Clear WCC: 700 PMN: 15% Crystals: None Bacteria: None Which of the following is the most likely dx: A. OA B. Gout C. RA D. Septic Arthritis
OA
Arthrocentesis Analysis: Color: Yellow to milky Clarity: Cloudy WCC: 20000 PMN: 70% Crystals: Urate Bacteria: None Which of the following is the most likely dx: A. OA B. Gout C. RA D. Septic Arthritis
Gout
Arthrocentesis Analysis: Color: Yellow to green Clarity: Cloudy WCC: 20000 PMN: 70% Crystals: None Bacteria: None Which of the following is the most likely dx: A. OA B. Gout C. RA D. Septic Arthritis
RA
