Anatomy PTMRC 4 Flashcards
Describe the makeup of the hip joint capsule?
Anteriorly arises from intertrochanteric line
Posteriorly originates from 1.5cm above the intertrochanteric crest
Ligamentum teres in the middle joining to the head of femur
What are the 3 ligaments of the hip joint and which is strongest?
Iliofemoral - strongest (Y ligament) - taut when standing so maintains upright posture
Pubofemoral
Ischiofemoral
Blood supply to head of femur?
Medial and lateral circumflex femoral arteries - from profunda femoris
Minor contributions from sup and inf gluteal arteries, artery of ligamentum teres
Muscle attaching to lesser trochanter?
Iliopsoas
Where does psoas major originate and what does it do?
2 parts deep and superficial
Deep from transverse processes L1-4
Superficial from T12-L4 bodies and discs
Flex and externally rotate hip
Where does the iliotibial tract go from and to and what does it do? What muscles are related?
From iliac crest - anterolateral iliac tubercle
To lateral tibial condyle (of Gerdy)
Tensor fascia lata keeps taught - keeps extension stable, important in walking and running
Also gluteus maximus
Where does gluteus maximus insert? Nerve supply?
Gluteal tuberosity of femur
Iliotibial tract
Inferior gluteal nerve - L5-S2
Action of gluteus maximus?
Hip extender and external rotator
Nerve supply of tensor fascia lata?
Superior gluteal nerve
2 muscles inserting on greater trochanter of humerus? Their roles?
Gluteus medius and minimus
Hip abduction when standing, when walking prevents pelvic drop
Where may the superior gluteal nerve be damaged during surgery and what may this cause?
Passes 5cm superior to greater trochanter - may be damaged during hip surgery which would cause Trendelenburg / hip drop
Roots and surface marking/route of sciatic nerve?
L4-S3
Exits pelvis via greater sciatic foramen below piriformis
Surface marking is a curved line between 1/2 PSIS to ischial tuberosity, and 1/2 ischial tuberosity to greater trochanter
Things exiting greater sciatic foramen above piriformis?
Superior gluteal nerve, artery and vein
Things exiting greater sciatic foramen below piriformis?
Inferior gluteal artery and vein Sciatic nerve Pudendal nerve Inferior gluteal nerve Posterior femoral cutaneous nerve Nerve to quadratus femoris Nerve to obturator internus
Things exiting lesser sciatic foramen?
Internal pudendal artery and vein Pudendal nerve (re-enters pelvis) Obturator internus tendon and nerve
What separates the greater and lesser sciatic foramen?
Sacrospinous ligament - from sacrum to ischial spine
Borders of greater sciatic foramen?
Superior - Anterior sacroiliac ligament
Posteromedial - sacrotuberous ligament
Anterolateral - Greater sciatic notch of ilium
Inferior - sacrospinous ligament and ischial spine
Borders of lesser sciatic foramen?
Superior - sacrospinous ligament and ischial spine
Anterior - ischial spine, lesser sciatic notch and ischial tuberosity
Posterior - sacrotuberous ligament
What variations may occur in the sciatic nerve exiting the pelvis?
May split and go above and below piriformis
Or all above
However usually goes below
Why may swelling occur in ACL injury? What investigations should be done?
Haemarthrosis
Do XR to rule out bony injury, then MRI to visualise ligaments
Where does the ACL attach and go? 2 tests for it?
Hands in pockets!
Proximally is lateral and posterior on lateral wall of intercondylar notch of femur
Distally is anteromedial between the tibial spines
Anterior drawer and Lachman’s test
Nerve at risk during blow to lateral knee? Risk?
Common peroneal nerve as wraps round fibula
If completely damaged could have decreased function of anterior and lateral compartments - foot drop and sensory loss
Which artery runs between the superficial and deep peroneal nerves?
Anterior tibial artery
3 structures at risk during anteromedially approach to knee surgery?
Saphenous nerve
Geniculate arteries
Great saphenous vein
3 main arteries that supply the knee via anastomotic mesh?
Popliteal
Femoral
Crural
5 branches of the popliteal artery that supply knee?
Medial and lateral superior geniculates
Medial and lateral inferior geniculates
Middle genicular - supplies ACL + PCL
Which artery supplies the ACL and PCL?
Middle genicular - from popliteal
What attaches to the tibial tuberosity?
Patellar tendon
What movements to the quadriceps do?
Extend knee
Also flex hips
Vastus medialis stabilises knee during gait
Nerve and roots of quadriceps muscles?
Femoral nerve - anterior divisions of L2-4
What do the posterior divisions of L2-4 form?
Obturator nerve
Where do semimembranosus and semitendinosus both originate and how can you tell the difference?
Both come from ischial tuberosity
Difference is that member is medial, has membranous insertion extending into aponeurosis
vs tendon that has large tendon
Contents of popliteal fossa from deep to superficial?
Popliteal artery Short saphenous vein Popliteal vein Common peroneal nerve Tibial nerve Lymph nodes
Boundaries of popliteal fossa?
Superiorly - medially = semimemrabnosus and semitendinosus, laterally = biceps femoris
Inferiorly = medial and lateral heads of gastrocnemius
Roof = skin and fascia
Floor = Posterior aspect of knee joint, femur and popliteus
Which nerve splits from tibial nerve to run superficially to gastrocnmius?
Sural
Which area do the popliteal LNs drain?
Area drained by short saphenous vein
Nerve of hamstrings and nerve roots for knee flexion?
Sciatic nerve
L5-S2
What is the pes anserinus, what is it formed by and where is it?
Tendinous joining of 3 muscles inserting into anteromedial aspect of proximal tibia
Sartorius, gracilis and semitendinosus from anterior to posterior - Say Grace before Tea
What is the terrible triad of knee injuries?
ACL, MCL and medial meniscus
Because ACL is weakest cruciate ligament, and MCL and medial meniscus are closely related and relatively immobile
Which of the knee ligaments are intra vs extracapsular?
Collaterals are extracapsular
Crurciates are intra
By what age have the cranial sutures usually ossified?
18-24 months
The pterion is at the junction of what 4 bones?
Frontal
Temporal
Parietal
Sphenoid
The part of the foramen lacerum not occluded by cartilage is traversed by what?
ICA
Artery and nerve of pterygoid canal
What are the bounds of the middle cranial fossa?
Anterior = posterior margin of lesser wing of sphenoid, anterior clinoid process and anterior margin of chiasmatic groove Posterior = crest of petrous temporal bone, dorsum sellae. Laterally by greater wing of sphenoid and squamous temporal bone
5 branches of the ICA? Which is the earliest?
Ophthalmic artery - as soon as exits cavernous sinus
ACA, MCA, PComm and anterior choroidal
Where are the cavernous sinuses and what do they drain?
Either side of sella turcica
Drain superficial middle cerebral, superior and inferior ophthalmic veins and sphenoparietal sinuses
What do the cavernous sinuses drain into?
Joined by intercavernous sinuses before draining in to the superior and inferior petrosal sinuses
What does the cavernous sinus itself contain? What about its walls?
ICA and related sympathetic plexus, venous blood and CN6
Lateral wall contains from superior to inferior CN3, 4 and 5(ophthalmic and maxillary branches)
Which sinus does the cavernous sinus sit just lateral to?
Sphenoidal sinus
Mechanisms of cavernous sinus thrombosis? How may it spread? What does it cause?
Infections of facial areas drained by facial and ophthalmic veins
No valves in draining veins
Intercavernous sinuses so can spread bilaterally
Causes painful proptosis and eye swelling, CN 3/4/5/6 palsies and loss of vision
How many vertebrae are there?
C7 T12 L5 S5 (fused) Co3 (fused)
How many pairs of spinal nerves are there?
31 - C8, T12, L5, S5, Co1
What are the parts of intervertebral disc? What types of collagen are they made up? Where is herniation msot likely to occur and why?
Inner nucleus pulposus - type 2 collagen
Outer annulus fibrosus - type 1 collagen
Usually herniate posterolaterally through weakened annulus as the posterior longitudinal ligament reinforces the back
What kind of joint are intervertebral joints?
Secondary cartilagenous - with intervening fibrocartilage discs
2 examples of secondary cartilagenous joints?
Intervertebral discs
Pubic symphisis
Blood supply to spinal cord?
Anterior and 2x posterior spinal arteries
Anterior supplies anterior to post grey columns
Post supply posterior grey columns
Segmental supply by radicular arteries from cervical, intercostal and lumbar arteries - biggest is artery of adamkiewicz which comes from aorta left side usually T8-L1
Which bits of spinal cord supply pain and temp?
Anterior and lateral spinothalamic tracts
What is anterior spinal cord syndrome?
Due to interruption of anterior spinal artery blood supply
Ischaemia and loss of function of corticospinal tracts and spinothalamic tracts with lower extremity worse than upper
What are the 2 parts of the dorsal columns?
Medial fasciculus gracilis (lower limb)
Lateral fasciculus cuneatus (upper limb)
How can the oblique fissure of lung surface marking be approximate clinically?
Fully abduct shoulder - medial border of scapula lines up with oblique fissure
Vertebral level of suprasternal notch?
T2/3
Vertebral level of sternal angle of Louis?
T4/5
Vertebral level of xiphisternum?
T9
Where does the trachea begin? What is it just below?
C6 - lower border of cricoid cartilage
What level is the carina?
L4/5 - sternal angle
Describe the bronchopulmonary segment set up of the lungs?
Each BP segment ias supplied by a segmental bronchus, artery, vein and lymph so functionally independent
Left lung has 2 lobes and 9/10 BP segments (5 in each)
Right lung has 3 lobes and 10 segments (3/2/5)
Blood supply to lungs?
Bronchial arteries (descending aorta) supply bronchi, lung roots and visceral pleura Pulmonary arteries provide deoxygenated blood
What comprises a lung hilum?
Bronchial artery and vein Main bronchus Pulmonary artery and vein Lymph Autonomic nerves
What goes through the diaphgram caval opening?
IVC, some branches of right phrenic nerve
What goes through the diaphragm oesophageal hiatus?
Oesophagus Vagal nerves (ant and post trunks)
What goes through the aortic hiatus of diaphragm?
aorta
Azygos vein
thoracic duct
What goes throug hteh left crus of the diaphgram?
hemiazyogs vein
left splanchnic nerve
What goes through the right crus of diaphragm?
right splanchnic nerves
Where does the sympathetic trunk traverse the diaphgram?
In a posterior aperture behind the diaphragm which under median lumbocostal arches
What does the posterior mediastinum contain?
Descending aorta and branches Azygos vein Thoracic duct Oesophagus Sympathetic trunks
What branches of the descending aorta are there in the posterior mediastinum?
Posterior intercostal arteries
Bronchial arteries
Oesophageal arteries
Superior phrenic arteries
What forms the SVC?
Right and left brachiocephalic veins
What forms the azygos vein?
Right lumbar vein and right subcostal vein
Where does the azygos vein go?
Originates below diaphragm on right side and ascends next to vertebral column in posterior thorax
Ascends through aortic hiatus
Empties into SVC
What are the tributaries of the azygos vein? What are they formed by?
Hemiazygos - from left lumbar and left subcostal vein (+mediastinal/oesophageal tributaries), ascends and joins at T8
Accessory hemiazygos - - from 4th-8th intercostal veins, descends and joins at T7
What does the azygos vein drain?
Posterior wall of thorax and upper lumbar region
Mediastinal viscera
What is the role of the azygos vein clinicaly?
In vena cava obstruction, can provide collateral to compensate - may dilate over time if subacute
What is the course of the sympathetic trunk?
Exits skull through carotid canal
Passes anterior to first rib before forming plexus on ICA
Travels down through thorax just lateral to vertebral bodies, behind the median arcuate ligaemtn of diaphragm
Goes all the way down to coccyx
What are the features of the sympathetic trunjkk?
Sympathetic ganglion at each spinal level
First ganglion joins with inferior cervical ganglion to form stellate gnalgion
What are the splanchnic nerves and hwhere do they come from?
Greater, lesser and least splanchnic nerves - come from thoracic sympathetic ganglia
What lies anterior to the sympathetic trunk on the left side?
Thoracic duct
Where does the thoraccic duct run?
From 12 on anterior and left of vertebra to base of neck
What forms the thoracic duct and what is this called?
Confluence of left and right lumbar lymph trunks and left and right intestinal lymph tracts - cisterna chyli
Where does the thoracic duct open into?
Junction between left subclavian and left internal jugular vein
What does the thoracic duct not drain? What do they drain into?
Right side of head and neck Right upper limb Right lung Right breast Into right lymphatic duct
During which critical care procedure may the thoracic duct be damaged?
Subclavian line insertion
Branches of the subclavian artery?
VIT C D Vertebral Internal thoracic Thyrocervical trunk Costocervical trunk Dorsal scapular artery
What is the subclavian steal syndrome?
Subclavian artery stenosis proximal to the vertebral artery origin
So during exertion there is steal from the vertebrobasilar system to supply the arm
can cause arm ischaemic type symptoms, as well as vertigo blurred vision tinnitus fainting and ataxia
What level does the common carotid bifurcate?
C4
What is thoracic outlet syndrome and what causes it?
Compression of the brachial plexus, subclavian artery and or subclavian vein causing neurovascular symptoms
Can be due to cervical rib, or trauma or sports e.g. overhead athletes e.g. tennis
What muscles attach to the first rib?
Anterior, middle scalenes
Serratus anterior
What attaches to the scalene tubercle of the first rib? What is in front and behind?
Anterior scalene
SubclavVein is anterior
Artery and brachial plexus are posterior
Describe the blood supply to the intercostal spaces?
2 small anterior intercostal arteries - from internal thoracic/mammary for first 6 spaces, then from musculophrenic artery for remainder
1 large posterior intercostal artery - from subclaivna via costocervical trunk for first 2 spaces, then descending aorta for remainder
What are the 3 parts of the subclavian artery split by?
Scalenus anterior - medial to gives off vertebral, internal thoracic and thyrocervical trunk
Behind serratus gives off costocervical trunk
Lateral to serratus gives off dorsal scapular artery
Surface markings for the parotid gland?
Runs from tragus forward and parallel to zygomatic arch, overlying psoterior border of masseter
Then curves back and round angle of mandible
Then runs back up ramus of mandible , over mastoid process and curves forward around inferior part of auricle of ear
What is the parotid duct called and where does it open?
Stensons duct
Pierces buccinator opposite second upper molar
Blood supply and venous drainage of parotid?
Blood supply = transverse facial artery, from ECA
Drainage = EJV + IJV via tributaries
What innervates the parotid gland?
PNS fibres from glossopharnyngeal nerve carried with auriculotemporal nerve (which comes from the lesser petrosal nerve synapsing in the otic ganglion)
From superficial to deep what passe through teh parotid gland?
Facial nerve and branches
Retromandibular vein
ECA
Which branches of the ECA are given off in the parotid gland?
Maxillary and superficial temporal
Which are the two main tributaries of the retromandibular vein?
Maxillary veins
Superficial temporal vein
What muscle does the zygomatic branch of the facial nerve innervate?
Orbicularis oculi
What is Frey’s syndrome?
Gustatory sweating that occurs due to auriculotemporal PNS nerve fibres reinervating sweat glands in the face following surgery
What is at risk during surgery to the parotid gland?
Terminal branches of facial nerve
Greater auricular nerve
Retromandibular vein
ECA
Blood supply and lymph drainage of oesophagus?
Blood = superior 1/3 from inf thyroid arteries, middle direct from aorta, inf 1/3 from left gastric and inferior phrenic arteries Lymph = middle 1/3 = superior and posterior mediastinal nodes, lower 1/3 = left gastric and coeilac nodes. upper 1/3 has lymph channels so can go anywhere
What veins are involved in oesophageal portosystemic anastomoses?
Porto = oesophageal branch of left gastric vein Systemic = oesophageal branch of azygos vein
What veins are involved in rectal portosystemic anastomoses?
Porto = superior rectal vein Systemic = middle and inferior rectal veins
What features maintain the gastro-esophageal junction and prevents reflux?
Acute angle of His as oesophagus goes into stomach through diaphragm
Phreno-oesophageal ligament which encircles junction
Muscosal folds at GEJ
Also when intraabdo pressure rises wall of oesopahgus is compressed
Why is a sliding hiatus hernia a risk for reflux?
Lower oesophageal sphincter prolapses up into thorax and so loses the high-pressure zone which usually prevents reflux
What is metaplasia?
Pre-malignant but reversible transformation of one differentiated cell type to another differentiated cell type e.g. Barrett’s oesopahagus
Where are the 4 physiological narrowings of the oesophagus?
At cricopharyngeus sphincter 15cm from incisors
Cervical C5/6 - from cricoid cartilage
Thoracic T4/5 from aortic arch
Abdominal from oesopahgeal hiatus at T10
What is the narrowest part of the oesophagus?
At cricopharyngeus sphincter, 15cm from incisors
Where does the oesophagus originate?
C6 - inferior border of cricoid cartilage
Coarse of the oesophagus?
Originates at C6 just below cricoid cartilage
Descends through superior then posterior mediastinum
Posterior to trachea, anterior to vertebral bodies of T1-T10
Enters abdomen at T10 then joins cardiac orifice of stomach at T11
What is achalasia and what causes it?
Narrowing of sphincter due to uncoordinated contraction of smooth muscle and non-relaxation of sphincter due to loss of myenteric plexus
‘Bird beak appearance on barium swallow’
