Anatomy PTMRCS Flashcards
What organs are normally palpable in the abdomen?
Aorta +/- lower pole right kidney
What is the surface marking for the neck of the pancreas?
Transpyloric plane - L1 - halfway between jugular notch of manubrium and upper border of symphysis pubis
What is the surface marking for the liver?
Nipple line superiorly, right 10th rib inferiorly, left 5th ICS MCL
What is the surface marking for the gallbladder?
9th c.c, MCL
What is the surface marking for the spleen?
Ribs 9-11 on left side posteriorly
Name the branches of the abdominal aorta descending?
Inferior phrenic arteries - T12 Coeliac trunk - L1 Suprarenal arteries/middle adrenal - L1 SMA - L1 Renal arteries - L1/2 Gonadal arteries - L2 Four paired lumbar arteries from L1-4 IMA - L3 Bifurcates at L4 to common iliacs and median sacral artery at L4
What is the surface marking of the abdominal aorta?
T12 2 finger breadths above transpyloric plane in midline
Runs down to L4 in midline
What is anterior to the aorta at L1?
Neck of pancreas and SMA
What is in the midline of the transpyloric plane? Back to front
L1 vertebra and conus Aorta SMA Neck of pancreas SMV Pylorus
What is laterally at the transpyloric plane?
Kidney hila Spleen hilum Renal vein D2 and DJ flexure Portal vein origin Fundus of GB 9th c.c.
What is the epiploic foramen of Winslow? What are its boundaries? Clinical significance in terms of pathology?
Boundary between greater and lesser sacs of peritoneum
Above is caudate lobe, below is D1
Anterior is lesser omentum with CBD/portal vein/CHA in free edge
Posterior is IVC
Lesser sac is site for potential internal herniation of bowel
What is Pringle’s manoeuvre?
Clamp hepatoduodenal ligament (containing portal vein and CHA) to control major liver bleeding during laparotomy
FISH of functions of the spleen?
Filtration of encapsulated organs and blood cells
Immunological function
Storage of platelets
Haematopoiesis (fetus)
Organs at risk during splenectomy?
Pancreas (tail) - in relation to hilum Left diaphragm Splenic flexure Left kidney/suprarenal gland Stomach
2 ligaments of the spleen? Where do they attach and what do they contain?
Gastrosplenic - short gastrics and left gastro-epiploics
Lienorenal - splenic vessels and tail of pancreas
5 sites of porto-systemic anastamoses?
Oesophagus - lower end Umbilicus Upper anal canal/lower rectum Retroperitoneum Bare area of liver
What is the oesophageal anastomoses between in portosystemic shunts?
Left gastric/portal
Azygous/hemiazygos veins
Common sites of abdominal collections?
Right subhepatic space - hepatorenal pouch of Rutherford Morrison Pelvis Between bowel loops Right and left subphrenic spaces Right and left paracolic gutters
What is the surface marking for the superior pole of the kidney?
12th rib posteriorly
What is the surface marking for dorsalis pedis?
Between first 2 metatarsal bones proximally just lateral to tendon of EHL
Dorsalis pedis is a continuation of?
Anterior tibial artery
What passes posteriorly to the malleolus? Tom Dick And Very Naughty Harry
From anterior to posterior Tibialis posterior tendon flexor Digitorum longus tendon Posterior tibial Artery Posterior tibial Vein Tibial nerve flexor Hallucis longus tendon
What muscles make up the achilles tendon? What compartment is this?
Gastrocnemius
Soleus
Plantaris
Superficial posterior compartment
What nerve supplies the muscles of the superficial posterior compartment of the leg?
Tibial nerve
What nerve supplies the muscles of the deep posterior compartment of the leg?
Tibial nerve
What muscles are in the deep posterior compartment of the leg?
Flexor hallucis longus
Flexor digitorum longus
Tibialis posterior
Popliteus
What innervates the muscles of the anterior compartment of the leg?
Deep peroneal nerve
What innervates the muscles of the lateral compartment of the leg?
Superficial peroneal nerve
Which peroneus muscle is not like the others?
Peroneus tertius - in anterior compartment rather than lateral
Where does peroneus longus originate from and insert?
Head of fibula to medial cuneiform/base of first metatarsal
Where does peroneus brevis originate from and insert?
Lower 2/3 of lateral surface of fibula medial to peroneus longus, to base of fifth metatarsal
Where does peroneus tertius originate from and insert?
Lower 1/3 of anterior surface of fibular / lower interosseus membrane to base of fifth metatarsal, under extensor retinaculum
Where would you test sensation for S1?
Lateral aspect of foot
Where would you test sensation for L4?
Medial malleolus
Where would you test sensation for deep peroneal nerve?
First web interspace
Where would you test sensation for superficial peroneal nerve?
Dorsum of foot (not first web interspace)
Where would you test sensation for sural nerve?
Lateral border of foot, similar to S1
What movements does EHL do?
Extension of big toe
Also foot dorsiflexion and inversion of foot
What vessels are deep to EHL in leg? Which nerve?
Anterior tibial artery and vein
Deep peroneal nerve
Nerve roots for knee reflex?
L3/4
Nerve roots for ankle reflex?
S1/2
Nerve roots for biceps reflex?
C5/6
Nerve roots for triceps reflex?
C7/8
Between what bones does ankle dorsiflexion occur?
Tibia/fibula and talus
Muscles that dorsiflex foot?
Anterior compartment: Tibialis anterior EHL EDL Peroneus tertius
Muscles that plantarflex foot?
Gastrocnemius
Soleus
Plantaris
Flexor hallucis longus, flexor digitorum longus and tibialis posterior (whole deep compartment except popliteus)
Why can people with achilles tendon rupture still plantarflex?
Superficial posterior compartment insert into achilles tendon but deep posterior compartment except popliteus also plantarflex
What muscles contracting together cause eversion of ankle?
Peroneus longus and brevis
What muscles contracting together cause inversion of ankle?
Tibialis anterior and posterior
At what joint do ankle inversion and eversion occur?
Subtalar
What sensorimotor loss occurs with damage to superficial peroneal nerve?
Loss of sensation to dorsum of foot except first dorsal webspace
Weak ankle eversion
Outline the ligaments supporting the ankle joint?
Deltoid ligament - medial, with strong deep part and weak superficial part
Anterior and posterior talofibular ligaments, and calcaneofibular ligament - lateral
Syndesmosis - normal alignment of distul tib-fib joint
What forms the syndesmosis of the ankle?
Anterior and posterior tibio-fibular ligaments
Interosseus ligament
Inferior transverse ligament
Where would you test saphenous nerve sensation?
Medial aspect of foot
Where would you test tibial nerve sensation?
Posterior sole of foot
Difference between right and left vertebral arteries?
Left often larger
What are the 4 parts of the vertebral artery?
From origin running in front of C7 and sympathetic trunk
Foraminal part from C6-C2
Part crossing C1 transverse foramen
Passes through dura and anterior to medulla
What are the branches of the subclavian artery? VIT C D. Which parts? What does it turn into and where?
1st part - vertebral, internal thoracic, thyrocervical trunk
2nd part - costocervical trunk
3rd part - dorsal scapular
Becomes axillary artery at lateral border of 1st rib
Describe anatomical route of vertebral artery?
Arises from subclavian artery at C7
Enters transverse process at C6 and ascends through to C1
After exiting C1 it traverses posterior arch before entering foramen magnum and forming basilar at base of medulla
Branches of the basilar artery?
AICA
Pontine branches
Superior cerebellar artery
Posterior cerebral artery
How may a basilar tip aneurysm present?
With rupture - SAH
Bitemporal hemianopia due to compression of optic chiasm
Where is the thyroid gland? Where does it attach and by what?
Located below thyroid cartilage with thyroid isthmus below cricoid cartilage
Attached to 2nd and 4th tracheal rings by Berry’s ligament, invested in pretracheal fascia
Why does the thyroid move on swallowing?
Attached to tracheal rings by Berry’s ligament
How are thyroglossal cysts formed?
During development the thyroid descends from tongue base through thyroglossal duct
When duct fails to regress, TG cyst can form
What should you also remove during removal of thyroglossal cyst to prevent recurrence?
Middle 1/3 of hyoid bone
Describe how to do needle cricothyroidotomy?
14G needle with syringe half filled with sterile water, asepsis where possible
Extend neck if able
Palpate cricothyroid recess between thyroid notch and cricoid cartilage
Needle into midline through cricothyroid membrane aiming caudally and continually aspirate watching for air bubbles
Then attach to O2
What does thyrohyoid do? What innervates it?
Depresses hyoid and elevates larynx
C1 - ansa cervicalis
Blood supply to thyroid?
Superior thyroid artery from ECA
Inferior thyroid artery from thyrocervical trunk from SCA
+/- thyroid ima from brachiocephalic trunk
Venous drainage of thyroid?
Superior thyroid vein to IJV
Middle thyroid vein to IJV
Inferior thyroid vein to brachiocephalic vein
Hoarse voice post thyroidectomy? Cause and mechanism? Semon’s law?
Recurrent laryngeal nerve damage - causes paralysis of vocal cords - if progressive then abductor paralysis then adductor paralysis
In bilateral RLN palsies, airway compromise as cords paralysed in midline requiring emergency e.g. tracheostomy
Why are recurrent laryngeal nerves at risk during thyroid surgery?
Run close to inferior thyroid artery
Which muscle of the larynx is not innervated by the recurrent laryngeal nerve?
Cricothyroid
What is cricothyroid muscle innervated by?
External laryngeal nerve
What are the muscles of the pharynx innervated by? What is the exception?
Pharyngeal plexus CN9, CN10 and symp
Exception is stylopharyngeus - CN9
What is the innervation of the tongue? What is the exception?
CN12
Exception is palatoglossus - pharyngeal plexus
What is the innervation of muscles of mastication? What is the exception?
Trigeminal nerve - mandibular branch
Exception is buccinator - facial nerve
Which vessel runs close to the external laryngeal nerve?
Superior thyroid artery
How may external laryngeal nerve palsy present? Why?
Inability to hit high notes / monotonous voice
Innervates cricothyroid which tenses vocal cords to increase pitch
Sensory supply to the larynx?
Above vocal folds - internal laryngeal nerve (from superior laryngeal nerve)
Below vocal folds - recurrent laryngeal nerve
What does the recurrent laryngeal nerve innervate? Sensory?
All intrinsic muscles of larynx except cricothyroid
Sensation below vocal folds
What vertebral levels are the hyoid bone, thyroid cartilage and cricoid cartilage?
C3. C4 and C6
What pharyngeal arches do the hyoid, thyroid cartilage and cricoid cartilage derive from?
C3, C4 and C6
What muscles open the vocal cords?
Posterior cricoarytenoids - by externally rotating arytenoids
What muscles close the vocal cords?
Lateral cricoarytenoids
What are the 4 strap muscles and what do they do?
Sternothyroid, sternohyoid, thyrohyoid and omohyoid
Depress hyoid bone and larynx during swallowing and speaking
What innervates the strap muscles? What is the exception?
Ansa cervicalis
Except thyrohyoid - C1
Where does the ansa cervicalis sit?
Superficial to internal jugular vein in carotid sheath
Where do the parathyroids derive embryologically?
Superior from 4th branchial arch
Inferior from 3rd branchial arch
Why is the position of the inferior thyroids variable?
Derive from 3rd branchial arch same as thymus
Sometimes drawn down into mediastinum with thymus
Bloods supply to parathyroids?
Inferior thyroid artery - to all 4
What are the carpal bones?
Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezius, capitate, hamate
What are the boundaries of the carpal tunnel? Attachments?
Floor = carpal bones
Roof = flexor retinaculum
Proximal surface marking = distal skin crease of wrist
Attachments are tubercle of scaphoid and piriform proximally, and trapezium/hook of hamate distally
What are the contents of the carpal tunnel?
Median nerve
Flexor digitorum superficialis and profundus tendons
Flexor pollicis longus tendon
What runs through the canal of Guyon?
Ulnar artery
Ulnar nerve
Which muscle runs within its own compartment from forearm to wrist? Where abouts?
Flexor carpi radialis - runs between superficial and deep flexor retinaculum
What are the boundaries of the anatomical snuffbox?
Abductor pollicis longus and extensor polilcis brevis laterally
Extensor pollicis longus medially
Proximally = styloid process of radius
Base = bones - base of 1st metacarpal, trapezium, scaphoid
Roof = fascia and skin
Contents of anatomical snuffbox?
Radial artery and terminal branches Cephalic vein (origin)
Where does the cephalic vein originate from?
Anatomical snuffbox
Nerve supply to intrinsic muscles of hand? How to test?
1/2 LOAF = median (lateral 2 lumbricals, opponens policis, abductor policis brevis, flexor policis brevis - test by thumb abduction
Rest are ulnar - test by abducting fingers (dorsal interossei)
What is the first muscle to waste in ulnar nerve injury?
1st dorsal interosseus
What do the interossei muscles do?
Palmar adduct fingers
Dorsal abduct fingers
What do the lumbrical muscles do?
Aid in flexion of MCPJs with extension of IPJs
What are the insertions and actions of flexor digitorum profundus/superficialis?
FDP - inserts onto distal phalanx and flexes DIPJ
FDS - inserts onto middle phalanx and flexes PIPJ
What mechanisms prevent bow-stringing of the flexor tendons?
Pulleys consisting of fascial thickening - proximally the flexor retinaculum, distally 5 annular pulleys and 3 cruciate pulleys
How many compartments of the extensor retinaculum are there?
6: EPB and APL ECRL and ECRB EPL Extensor indicis proprius and extensor digitorum communis EDM ECU
What layers make up the deep cervical fascia?
4 layers from deep to superficial Carotid sheath Prevertebral fascia Pretracheal fascia Investing layer of deep cervical fascia
What are the contents of the pretracheal fascia?
Thyroid gland
Trachea
Oesophagus
At what level does the common carotid artery bifurcate? What is the surface marking?
C4 - superior thyroid notch
What are the contents of the carotid sheath?
Common carotid artery
Vagus nerves
IJV
Lymph nodes
What nerve chain runs in the wall of the carotid sheath?
Ansa cervicalis
Branches of the external carotid artery
Superior thyroid artery Ascending pharyngeal Lingual Facial Occipital Posterior auricular Maxillary Superficial temporal
Muscles in the prevertebral fascia?
Scalenus anterior, medius, posterior
Levator scapulae
Splenius capitus
Boundaries of the posterior triangle of the neck?
Posterior edge SCM Upper border clavicle (middle third) Anterior border trapezius Roof = investing layer deep cervical fascia Floor = prevertebral fascia
Contents of the posterior triangle of the neck?
Omohyoid muscle
Vessels - subclavian artery, transverse cervical, suprascapular, occipital arteries. Transverse cervical, suprascapular, EJV veins
Nerves - spinal root of accessory nerves, phrenic and roots + trunks of brachial plexus
Lymph nodes
Surface marking of spinal branch of accessory nerve? Why is this important?
Important as at risk of injury during dissection of posterior neck
Surface marking is 1/3 way down SCM to 1/3 way up anterior border of trapezius
What muscles does the spinal accessory nerve innervate? Testing?
Trapezius - shrug shoulders
SCM - rotating head to contralateral side
Rotator cuff muscles, nerve supply and actions at shoulder?
Supraspinatus, infraspinatus, subscapularis and teres minor
Supraspinatus = supraspacular nerve, abduction
Infraspinatus = suprascapular nerve, external rotation
Teres minor = axillary nerve, external rotation
Subscapularis = upper and lower subscapular nerve, internal rotation
What joins the coracoid process to the clavicle? What are its component parts?
Coracoclavicular ligament
Conoid ligament and trapezoid ligament
Under which ligament does the supraspinatus muscle commonly get impinged?
Coracoacromial ligament
What ligament is excised during subacromial decompression? What is this used to treat?
Coracoacromial ligament
Used to treat supraspinatus impingment
What structure runs through the bicipital groove?
Long head of biceps brachii
What is the fibrocartilage collar attached to the glenoid fossa called?
Glenoid labrum
What type of joint is the sternoclaviclar joint?
Atypical synovial joint containing fibrocartilagenous disc
Structurally is saddle, functionally is ball and socket
What are the proximal and distal boundaries of the axillary artery?
Proximal = lateral border of first rib Distally = inferior border of teres major
What are the branches of the axillary artery? What are the divisions? Screw The Lawyer Save A Patient
1st part proximal to pec minor = superior thoracic artery
2nd part behind pec minor = thoracoacromial trunk and lateral thoracic trunk
3rd part distal to pec minor = subscapular artery, anterior and posterior circumflex
Boundaries of the quadrangular space? What passes through it?
Medial = long head of triceps
Lateral = medial border of humerus
Superior = inferior border of teres minor
Inferior = superior border of teres major
Contains axillary nerve and posterior circumflex humeral artery and vein
What passes through the triangular interval vs the triangular space in the shoulder?
Interval = radial nerve and profunda brachii Space = circumflex scapular artery and vein
Where does the long head of triceps originate?
Infraglenoid tubercle of scapula
Origin of medial and lateral heads of triceps?
Lateral = posterior surface of humerus just superior to radial groove Medial = posterior surface of humerus just inferior to radial groove
Insertion of triceps?
Onto olecranon process of ulna
Blood supply to triceps?
Branches of deep brachial artery
Where does the long head of biceps originate?
Supraglenoid tubercle of scapula
Where does the short head of biceps originate?
Coracoid process of scapula
Where does the biceps muscle insert?
Radial tuberosity and biciptal aponeurosis
Arterial supply to biceps?
Brachial artery
What is main movement of biceps? Secondary one?
Supinator of forearm
Also flexes elbow
What nerve is at risk during anterior dislocation of the shoulder? What movement will be restricted?
Axillary
Abduction restricted
Where does the axillary nerve arise from?
Posterior cord of brachial plexus - C5-6
What muscles does axillary nerve innervate?
Teres minor
Deltoid
What nerve supples the rhomboid muscles and where does it come from?
Dorsal scapular nerve - from C5 root of brachial plexus
What does serratus anterior do on the scapula?
Laterally rotates and protracts the scapula
Nerve to serratus anterior and nerve root?
Long thoracic nerve of bell - C5, 6, 7
What muscles attach to the greater tuberosity of humerus?
Supraspinatus, infarspinatus and teres minor
Where does subscapularis attach?
Lesser tuberosity of humerus
Where on the humerus is the spiral groove?
Posterolateral
What runs in the spiral groove of the humerus? What would injury here cause?
Radial nerve
Injury would cause wrist drop and loss of sensation of 1st dorsal webspace
What is the only thenar muscle affected in an ulnar injury?
Adductor pollicis
What lies in the bicipital (intertubercular) groove of the humerus?
Long head of biceps
What is the only structure that passes through the shoulder joint?
Long head of biceps
What is lady between 2 majors of attachments of muscles on humerus?
Pec major laterally
Teres major medially
Latissimus dorsi superiorly and between
What nerve can be damaged in fractures of the surgical neck of the humerus?
Axillary nerve as it wraps around
2 pathologies that may physically damage axillary nerve?
Anterior dislocation of shoulder joint
Fracture of surgical neck of humerus
What would the limitation on shoulder abduction be in axillary nerve damage?
Restricted beyond 30 degrees
Describe the muscles involved in full abduction of the shoulder?
First 15-20 degrees is supraspinatus
Up to 90 degrees is deltoid
Beyond 90 is rotation of scapula
What is the difference between the surgical and anatomical neck of humerus? Which is more commonly fractured?
Anatomical - fusion of growth plate (epiphyseal plate) at proximal junction of articular surface
Surgical - distal to anatomical neck
Surgical significantly more likely to fracture
What 3 muscles are innervated by the musculocutaneous nerve? Where do these originate?
Biceps brachii - long head supraglenoid tubercle, short head coracoid process
Brachialis - humerus, lower half of anterior surface
Coracobrachialis - coracoid process
What is the sensory supply of musculocutaneous nerve?
As lateral cutaneous nerve of forearm - volar surface of radial half of forearm
What 3 muscles are attached to the coracoid process?
Short head of bicepps
Corachobrachialis
Pectoralis minor
Where does the biceps tendon insert?
Radial tuberosity
Bicipital aponeurosis to antebrachial fascia
Wrist extension is what myotome?
C6
C5/6 paralysis would cause what?
Erb’s palsy - waiters tip - shoulder adducted and medially rotated, wrist flexed, forearm extended
Numbness on radial edge of arm
What is Klumpke’s paralysis and what would it cause?
C7/8/T1 paralysis - causes flexed elbow, claw hand, paralysis of intrisic muscles, sensory loss
What is the classical cause of Klumpke paralysis and what syndrome may it be associated with?
Forced traction on abducted arm
Can cause Horner’s syndrome
