Anatomy PTMRC 3 Flashcards
Surface markings of the heart?
Superior border = third rib right sternal edge to second rib left sternal edge
Inferior border = apex horizontally across to right sternal edge at 6th rib
What forms the right heart border on CXR?
Right atrium
What forms the left heart border on CXR?
Left ventricle and part of left auricle
What chambers make up the anterior surface of the heart?
Right atrium and right ventricle
What chambers make up the posterior surface of the heart?
Left atrium mostly
Surface markings of pleura?
Apex = 3cm above middle of clavicle
Anteriorly to sternum then vetrically down to level of 4th rib
Right pleura goes to 6th rib before going to MCL at 8th rib
Left pleura goes down to 6th rib at MCL
Then travel to midaxillary line at 10th CC and travel along 12th rib
Surface markings of lungs?
Apex = 3cm above middle of clavicle
Anteriorly to sternum, vertically down to level of 4th rib
Right goes to 6th rib before going down to 8th rib MCL
Left goes down to 6th rib at MCL
Then go down to 12th CC and travel along 12th rib
Surface marking of oblique fissures of lung?
Third thoracic spinous process to 6th costochondral junction
Surface marking of right horitzontal fissure?
From oblique fissure in mid axillary line to 4th costal cartilage on right
What level does the trachea divide?
Sternal angle - between T5 and T7
What level does the aorta divide?
L4 - level of umbilicus
Boundaries of submandibular triangle?
Anterior belly of digastric
Posterior belly of digastric
Lower border of body of mandible
What nerve supplies anterior belly of digastric?
Trigeminal nerve V3 - mylohyoid nerve, a branch of the inferior alveolar nerve
Which pharyngeal arch gives rise to mylohyoid and anterior belly of digastric?
First arch
Which pharyngeal arch gives rise to posterior belly of digastric?
Second arch - facial nerve
Which nerve innervates first pharyngeal arch structures?
Trigeminal
What innervates anterior and posterior belly of digastric?
Ant = trigem via V3 mylohyoid nerve from inf alveolar Post = facial
Relationship between submandibular gland and mylohyoid/digastric?
Gland is superior to the digastric and hooks around mylohyoid so there are deep and larger superficial portions
What muscle does the submandibular gland hook around?
Mylohyoid
Where does the submandibular duct run?
Wharton’s duct - from gland deep runs deep to mylohyoid and superficial to hypoglossus, running superoanteriorly to open either side of the lingual frenulum. 5cm long
What nerves are closely related to the submandibular duct?
Lingual - from V3
Hypoglossal
What muscle does the lingual artery lie deep to?
Hypoglossus
What muscle does tongue protrusion?
Genioglossus
Sensorimotor innervation to tongue?
Sensory - Anterior 2/3 is doubly innervated by lingual (general sensory) and facial (chorda tympani - special sensory)
Posterior 1/3 is gloosopharyngeal for both
Motor - all muscles hypoglossal nerve except palatoglossus, which is pharyngeal branch of vagus nerve
What is the only muscle of the tongue not innervated by the hypoglossal nerve?
Palatoglossus - pharyngeal branch of vagus
3 nerves at risk during surgery to submandibular gland?
Lingual
Hypoglossal
Marginal mandibular branch of facial
How do you avoid the marginal mandibular branch of the facial nerve during submandibular gland surgery?
Incision 2.5cm inferior to mandible and then left skin flap superiorly
What type of gland is the submandibular gland?
Mixed serous and mucinous
PNS innervation of submandibular gland?
Chorda tympani, which unifies with lingual branch of mandibular
Which muscle separates subclavian artery from vein? Which is more anterior?
Anterior scalene - vein is more anterior
Describe how to insert a subclavian line?
Infraclavicular approach. Supine, aseptic technique, head to opposite side
US guidance ideally. Insert needle and syringe 1cm below junction between middle and medial 1/3 of clavicle
Aim medially and posteriorly towards suprasternal notch
Advance whilst withdrawing until get flash, then use seldinger to feed catheter in the vein
Which layers would you pass through when inserting a subclavian central line?
Skin Platysma Fascia Pectoralis major Subclavius SCV
Where should the catheter tip lie in a subclavian line?
SVC above pericardial reflection
What would you do if aspirated air during subclavian line insertion? Where would you try again?
Assume pleural breach - check for pneumothorax
Try on same side to avoid bilateral pneumothorax
4 structures at risk during subclavian line insertion?
Subclavian artery - haemothorax
Pleura - pneumothorax
Phrenic nerve - posterior to subclavian vein
If on left - thoracic duct leading to chylothorax
Where is the intercostal neurovascular bundle? What is its organisation?
Between innermost and internal intercostal muscles
In inferior notch of rib
From superior to inferior - Vein Artery Nerve
Nerve supply to pleura?
Parietal = intercostal and phrenic nerve Visceral = pulmonary plexus - autonomic from branches of vagus and symp trunk
What separates inferior from superior mediastinum?
Horizontal line drawn from angle of Louis posteriorly
What level is the sternal angle?
T4/5
From anterior to posterior what is in the superior mediastinum?
Thymus Great veins Great arteries Trachea Oesophagus
What does the thymus do?
Specialised immune organ which ensures self-T cells are eliminated and immune system doesn’t attack itself
What are the features of a typical rib?
Head with 2 articular demifacets
Tubercle for articulation with transverse process
Subcostal groove containing intercostal NV bundle
Which ribs are atypical in terms of facets/tubercles and why?
First - in horizontal plane, single facet and tubercle - scalene tubercle on inner border
Ribs 10-12 - only have 1 facet
Ribs 11 and 12 have no tubercle
What muscles do the breasts overlie?
Pec major medially
Serratus anterior laterally
Blood supply to breast?
Lateral thoracic artery
Internal thoracic
Posterior intercostals
Thoraco-acromial
What muscle is responsible for ptosis e.g. in Horner’s?
Superior tarsal
Structures passing through the foramen magnum?
Medulla Vertebral and ant/post spinal arteries Spinal roots of accessory nerve Tectorial membrane Apical ligament of dens
What passes through the jugular foramen?
IJV
CN9, 10 and 11 (cranial portion)
What passes through the carotid canal?
ICA
Sympathetic nerves
Intracranial course of the facial nerve?
Arises at pontomedullary junction between CN6 and CN8
Large motor and small sensory root
Traverses post fossa, through IAM (in petrous temporal bone)
Enters facial canal
Exits facial canal via stylomastoid foramen, just posterior to styloid process of temporal bone
What 3 branches does the facial nerve give off in the facial canal?
Chorda tympani
Nerve to stapedius
Greater petrosal nerve - PNS to mucous/lacrimal glands
What and where is the geniculate ganglion?
Collection of facial nerve cell bodies in the facial canal
Contents of superior orbital fissure?
Ophthalmic vein
Lacrimal and middle meningeal communicating arteries
Lacrimal, frontal, nasociliary (V1) and trochlear, oculomotor and abducens nerves
What goes through the foramen ovale?
Accessory meningeal artery
V3 of trigem
Lesser petrosal nerve
Where do the greater and lesser petrosal nerves come from and go?
Greater = from geniculate ganglion of CN7, given off in petrous bone facial canal to innervate lacrimal and mucous glands (PNS) Lesser = from CN9, goes through foramen ovale to innervate parotid (PNS) via otic ganglion
What goes through foramen spinosum?
MMA
Meningeal branch of mandibular nerve
What goes through foramen cecum?
Vein to superior sagittal sinus
What goes through the IAM?
CN7, 8 and labyrinthine artery
What goes through the foramen rotundum?
V2 of trigem - maxillary nerve
What are the 3 arches of the foot?
Medial and lateral longitudinal
Anterior transverse
Components of medial arch of foot?
Bones - calcaneum, talus, navicular, all 3 cuneiforms and medial 3 metatarsals
Ligments - interosseus and spring
Muscles - Flexor hallucis longus, digitorum longus and breiv
Tibilais anterior and posterior
Bones of the lateral arch of foot?
Calcaneus, cuboid, lateral metatarsals
Components of lateral arch of foot?
Bones - calcaneus, cuboid and lateral metatarsals
Ligaments - long and short plantar
Muscles- peroneus longus, flexor digitorum longus nad brevis to 4/5 digits
What forms the fibrous tunnel for passage of the peroneus longus tendon?
Long plantar ligmanet and cuboid
Components of anterior transverse arch of foot?
Bases of all 5 metatarsals
Interosseus ligaments
Peroneus longus muscle
Muscle layers of the sole of the foot from deep to superficial?
Plantar and dorsal interossei, and tendons of peroneus longus/tibilalis posterior
Flexor hallucis brevis, adductor hiatus, flexor digiti minimi
Quadratus plantae and lumbricals, tendons of FDL and FHL
Abductor hallucis, abductor digiti minimi, flexor digitorum brevis
Where is the plantar fascia in relation to the layers of muscles in the foot?
Superficial
Where does the deep plantar arch sit between?
Deepest and second-deepest layers
Where do the medial and lateral plantar arteries and nerves run between?
Quadratus plantae/lumbricals layer and abductor hallucis/digiti minimi and FDB layers (superficial and second)
What arteries form the plantar arch?
Lateral plantar branch of posterior tibial artery, and deep plantar branch of dorsalis pedis
What forms the inferior surface of the heart?
Right and left ventricles
How many layers of pericardium are there?
Fibrous, and serous (parietal and visceral)
Which layer of pericardium attaches to the central tendon of the diaphragm and roots of great vessels?
Fibrous outer layer
What runs in the anterior interventricular sulcus of the heart?
Great cardiac vein and Left anterior descending artery
Describe blood supply on surface of heart?
Left and right coronary arteries filled from aortic sinuses
Left runs in AV sulcus and gives off LAD to ant IV sulcus before continuing as circumflex artery
Right gives off posterior interventricular artery which runs in PIV sulcus
Marginal branches from each which cross corresponding ventricle
How many aortic sinuses are there and what comes from them?
3 - anterior, lelft posterior and right posterior
Left from left posterior
Right from anterior
None from right posterior
Which aortic sinus doesn’t yield a vessel?
Right posterior
Where is the sinoatrial node found and what is it supplied by?
Sits in crista terminalis of right atrium
Supplied by RCA in 60% and LCA in 40%
Where does the coronary sinus open into?
Inferior part of right atrium between IVC and tricuspid valve
Which 5 veins drain into the coronary sinus?
Great, middle and small cardiac veins
Olbique vein
Posterior vein
Describe the venous drainage of the heart?
2/3 via coronary sinus into right atrium
1/3 into each chamber via venae cordis minimae, also 3-4 anterior cardiac veins directly into the right atrium
Where is the corronary sinus found?
Along posterior surface of heart between left ventricle and left atrium
3 muscles that flex elbow?
Brachioradialis
Biceps brachii
Brachialis
Boundaries of the antecubital fossa?
Medial = pronator teres Lateral = brachioradialis Superior = line between epicondyles of humerus Floor = brachialis and supinator Roof = fascia and bicipital aponeurosis
Contents of the ACF from medial to lateral?
Median nerve
Brachial artery
Biceps tendon
Also median cubital vein
2 nerves at risk of damage in supracondylar humerus fractures?
Median nerve
Ulnar as it passes behind medial epicondyle
What are the muscular layers of the forearm?
Mobile Wad of Henry - brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis
Anterior - superficial and deep
Posterior - superficial and deep
Msucles of the mobile Wad of Henry in forearm?
Brachioradialis and ext carpi radialis long and brevis
Muscles of the anterior compartment of the forearm?
Superficial = pronator teres, palmaris longus, flexor carpi radialis / ulnaris and flexor digitorum superficialis Deep = flexor pollicis longus, flexor digitorum profundus and pronator quadratus
Muscles of the posterior compartment of the forearm?
Superficial = extensor digitorum communis, extensor carpi ulnaris and extensor digiti minimi Deep = abductor policis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis and supinator
Describe how to do fasciotomy of forearm?
Two-incision fasciotomy:
Volar e.g. along ulnar border
Dorsal e.g. from lateral epicondyle of humerus to mid-wrist
What is the path of the ulnar nerve in the forearm?
Emerges from ulnar tunnel just behind medial epicondyle of distal humerus
Passes between the 2 heads of flexor carpi ulnaris to enter anterior compartment of forearm and run alongside ulna
Joins ulnar artery to pass deep to FCU before travelling through canal of Guyon at wrist
What travels through the canal of Guyon?
Ulnar nerve
Ulnar artery
Tendon of FCU
What are the 3 forearm branches of the ulnar nerve?
Dorsal and palmar cutaneous, and muscular
What does the muscular branch of the ulnar nerve innervate?
Ulnar half of FDP and whole of FCU
Which compartment of the forearm does the ulnar nerve run in?
Anterior compartment
Nerve supply to the forearm?
Posterior compartment = radial nerve
Anterior (flexor) compartment = median nerve except flexor carpi ulnaris and ulnar half of FDP (ulnar)
Common sites for venepuncture in the arm?
Median cubital vein - in ACF
Cephalic vein origin - at wrist
Boundaries of the inguinal canal?
Floor = inguinal ligament - lacunar ligament medial third, iliopubic tract lateral third
Ant wall = external oblique aponeurosis
Roof = int oblique and transversus abdominis
Post wall = transversalis fascia - conjoint ligament medial
What is the conjoint tendon? Where is it?
Lower part of transversus abdominis and internal oblique aponeurosis as they insert at pectineal line and pubic crest
Posteromedially in inguinal canal
Nerve supply to external oblique muscles?
Lower 6 intercostal nerves and subcostal nerve on each side
What are the 3 coverings of the spermatic cord?
External spermatic fascia - from external oblique
Cremasteric muscle and fascia from internal oblique/transversus abdominis
Internal spermatic fascia - transversalis fascia
Contents of spermatic cord?
3 arteries - to vas, cremasteric, testicular
3 nerves - gen branch genfem, ilioinguinal (next to), autonomic nerves
3 others - vas, lymphatics and pampiniform plexus
Nerve supply to testes? Clinical relevance?
T10 sympathetic nerve
So ball pain can refer to umbilicus, or ureteric colic can refer to balls
Lymph drainage of the testes and scrotum?
Testes themselves = para-aortic
Scrotum = inguinal LNs
This is why you don’t biopsy possible Ca
Boundaries of Hasselbach’s triangle? Clinical relevance?
Lateral aspect of rectus sheath medially
Inguinal ligament inferiorly
Inferior epigastric vessels superolaterally
Site of weakness in abdominal wall which can be a site for direct inguinal hernias
Distinguishing between direct and indirect inguinal hernia?
Press over deep ring - should stop indirect from coming out
In reality related to position of hernia sac - lateral to inferior epigastrics = indirect, medial to sac = direct
Which nerves can be damaged in an inguinal hernia repair? How may this present?
Ilioinguinal nerve - upper and medial thigh, anterior scrotum and base of penis
Iliohypogastric nerve - skin above pubis
Genital branch of genitofemoral nerve - cremaster and sensory innervation to scrotum
Where do femoral herniae emerge?
From femoral ring and slide into femoral canal
What is the femoral canal?
Contains space for femoral vein expansion and lymphatics (Cloquet node)
What does Cloquet’s node drain and where is it?
In femoral canal - drains anterior abdominal wall below umbilicus, perineum and lower limb
Boundaries of the femoral ring?
Anteriorly = inguinal ligament Posteriorly = pectineal ligament Medially = lacunar ligament Laterally = fibrous septum on medial side of femoral vein
Most common hernia in elderly females?
Still inguinal, although femoral more comon in females than males
Why are femoral hernias usually repaired?
High incidence of strangulation - due to tight sharp edged lacunar ligament medially in femoral ring
Boundaries of the femoral triangle?
Superiorly = inguinal ligaemnt Medially = adductor longus Laterally = sartorius Floor = pectineus and adductor longus medially, iliopsoas laterally Roof = fascia lata
What does the femoral sheath enclose?
Femoral artery, vein and canal - not nerve
Muscle attaching to ASIS?
Sartorius
What is Hunter’s canal?
The subsartorial/adductor canal
Runs from base of femoral triangle to popliteal fossa
Boundaries of Hunter’s canal?
Vastus medialis anterolaterally
Roof = sartorius
Posteriorly = adductor longus and magnus
What does Hunter’s canal contain?
Femoral artery and vein
Saphenous nerve
Nerve to vastus medialis
Surface marking for adductor hiatus? What is it and what goes through it?
Gap in adductor magnus muscle where it inserts onto femur - end of Hunter’s canal
2/3 along line beween ASIS and adductor tubercle of femur
Allows passage of femoral artery and vein from anterior to posterior thigh
What is the difference between the mid-inguinal point and the midpoint of the inguinal ligament?
Mid-inguinal point is a marker for femoral artery palpation - between ASIS and pubic symphysis
Mid point of inguinal lig is between ASIS and tubercle and is the surface marker for the deep inguinal ring
Where may bruits be auscultated in SFA disease?
Adductor hiatus
