Anatomy PTMRCS 2 Flashcards
What arteries supply the transverse colon?
Middle colic artery to 2/3
Left colic artery distally
What is the major anastomotic artery between the SMA and IMA?
Marginal artery of Drummond - in mesentery
What arteries are most commonly implicated in diverticular bleeds?
Sigmoid branches of IMA
Where does the inferior mesenteric vein drain?
Splenic vein
What forms the portal vein?
SMV and splenic vein
What positions can the appendix lie in?
Retrocaecal
Pelvic
Subcaecal
Anterior or posterior to terminal ileum
Blood supply to rectum?
Superior rectal artery from IMA
Middle rectal artery from internal iliac
Inferior rectal artery from internal pudendal
Describe nerve supply to rectum?
PNS = S2 3 4, causes bowel contraction and relaxation of internal sphincter
Symp from superior hypogastric plexus and lumbar splanchnic nerves = painful stimuli, contract internal sphincter
Is rectum retroperitoneal?
Yes - upper 1/3 has peritoneum over front and sides, middle 1/3 just over front and bottom 1/3 below peritoneal reflection
What are the 5 branches of the SMA?
Inferior pancreaticoduodenal artery Jejunal and ileal arteries Ileocolic artery Right colic artery Middle colic artery
What are the bones of the orbit?
Frontal bone Lacrimal bone Ethmoidal bone Zygoma Maxillary bone Sphenoid Palatine
Structures passing through superior orbital fissure?
CN 3, 4, 6
Superior ophthalmic vein
Ophthalmic nerve - lacrimal, frontal and nasociliary branches (branch of CN5)
Structures passing through inferior orbital fissure?
Inferior ophthalmic vein
Maxillary nerve infraorbital and zygomatic branches
Branches of pterygopalatine ganglion
Structures passing through the optic canal?
Optic nerve
Ophthalmic artery and associated sympathetic fibres
Nerve supply to lacrimal gland?
PNS - pterygopalatine ganglion
SNS - superior cervical plexus and deep petrosal nerve
Sensation - lacrimal branch of ophthalmic nerve
7 extrinsic muscles of the eyeball?
Superior and inferior, medial and lateral rectus
Inferior oblique and superior oblique
Levator palpebrae superioris
Innervation of superior and inferior oblique muscles?
Sup oblique = trochlear
Inf oblique = oculomotor
Nerve supply to levator palpebrae superioris?
Dual innervation from CN3 and sympathetic ganglion
What are the features of Horner’s syndrome?
Miosis
Ipsilateral anhidrosis
Ptosis
Enophthalmos
Where do the ophthalmic veins drain?
Cavernous sinus
4 clinical features of orbital blowout fractures?
Enophthalmos
Diplopia
Infraorbital numbness due to infraorbital nerve compression
Orbital emphysema
3 signs of inferior orbital blowout fracture on XR?
Orbital emphysema
Tear drop sign - fat into sinus
Blood in sinus
Layers go through in lumbar puncture?
Skin Subcutaenous tissue Supraspinous ligament Interspinous ligament Ligamentum flavum Epidural space w venous plexus Dura Subdural space Arachnoid
Blood supply to spinal cord?
1 anterior and 2 posterior spinal arteries
Anterior from vertebrals
Posteriors from PICAs
Segmental supply from radicular arteries at each level - Artery of Adamkiewicz is largest
What is the Artery of Adamkiewicz and where does it arise?
Largest segemental radicular artery, arises from left T8-L1 area
Fascial layers of neck for an ACDF? What do they contain?
Superficial fascia - platysma, fat
Investing deep fascia - trapezius and SCM
Carotid sheaths - common carotid, IJV, vagus
Pretracheal fascia - thyroid gland, trachea, oesophagus, strap/infrahyoid muscles
Prevertebral fascia - vertebral column and associated muscles
Within which fascial layer does post-op haematoma occur in ACDF, thyroidectomy etc.?
Pretracheal
What are the surface markings for the liver anteriorly?
Superior - 5th ICS right, 4th ICS left
Lateral - 5th ICS right, 8-10th rib
Oblique - line between the 2
Which lobe do the quadrate and caudate arise from?
Right
What is the surface marking for the gallbladder?
Angle between 9th costal cartilage and lateral border of rectus
What are the 3 functions of the gallbladder?
Storage of bile
Concentrating bile
Addition of mucus to bile
How much bile does the gallbladder hold?
50ml
Blood supply to the gallbladder?
Cystic artery, from right hepatic artery from hepatic artery proper
Also collaterals from liver bed
What are the branches of the biliary tree?
Intralobular ducts Intrahepatic ducts Right and left hepatic ducts Common hepatic duct Cystic duct CBD
What is Calot’s triangle? What is it’s clinical significance?
Cystic duct
Inferior border of liver
Common hepatic duct
Contains cystic artery and LNs, important to isolate and ligate cystic artery during lap chole
What is Courvoisier’s Law? Why is it true?
Palpable gallbladder and painless obstructive jaundice unlikely to be gallstones - ?Cancer
Because chronic gallstones cause fibrosed, contracted gallbladder rather than enlargement, or CBD stone causes pain
What are Kehr’s and Boas’ sign?
Kehrs - shoulder tip pain in acute cholecystitis
Boas - area of hyperaesthesia just below right scapula in acute cholecystitis
3 signs associated with acute cholecystitis?
Murphys
Kehrs
Boas
Surface anatomy of breast?
2nd to 6th rib
Sternum to mid axillary line
Deep muscular relations of the breast?
Pectoralis major (2/3) Serratus anterior (1/3)
3 major constituents of breast tissue?
Fat
Glandular tissue
Fibrous tissue
How many lobules are there within the breast?
15-20, each drained by a lactiferous duct
What are Cooper’s ligaments? Clinical signifiance?
Suspensory ligaments of breast
Fibrous tissue from pectoral fascia to subcutaneous tissue separating lobules of the breast
Malignant infiltration causes puckering/induration - p’eau d’orange
Arterial blood supply to breast?
Internal thoracic/mammary artery - from SCA
Lateral thoracic - from axillary 2
Thoraco-acromial - from axillary 2
Intercostal arteries
Lymph drainage of breast?
Axillary lymph nodes - 3 levels with respect to pectoralis minor
Parasternal LNs - along internal thoracics
Posterior intercostal LNs
Sensory nerve supply to breast?
Anterior and lateral cutaneous branches of 4th-6th intercostal nerves
What level do the renal veins join the IVC?
L1
What crosses the ureter anteriorly on each side of the abdomen?
Gonadal vessels
On right - right colic and ileocolic vessels
On left– left colic vessels
What is the blood supply to the ureter?
Upper = renal artery branches Middle = from common iliac and gonadal arteries Lower = common iliac and internal iliac - uterine and superior vesicular arteries
Anterior relations of right kidney?
Right lobe of liver Gallbladder Adrenal D2 Hepatic flexure Small intestine
Where does the IVC originate and from what?
L5 - from common iliac veins
What lies anterior to the IVC at its origin?
Right common iliac artery
Anatomical relationship of IVC to aorta?
Proximally - to right and anterior
Distally - to right and posterior
What are the retroperitoneal structures?
IVC Aorta and para-aortic nodes Kidneys and adrenals Duodenum except 1st part Ureters Splenic and hepatic flexures Ascending and descending colon Rectum, bladder, vagina Pancreas
Name the parts of the stomach?
Cardia Fundus Body Pylorus Antrum Also greater + lesser curvatures with incisura on lesser
Which part of the duodenum does the CBD enter?
D2 - posteromedial wall
Differences between jejunum and ileum?
Jej is slightly wider diameter, thicker walls, longer vasa recta with fewer arcades, also thinner mesentery
Large vs small bowel on radiograph?
Large has haustra, wider, more peipheral
Small has valvulae conniventes, thinner, more central
What are the parts of the pancreas?
Head Neck Body Uncinate process Tail
Blood supply to pancreas?
Pancreatic branches of splenic artery
Superior (coeliac, via gastroduodenal) and inferior (SMA) pancreaticoduodenal arteries to head
What are the 3 main divisions of the coeliac axis?
Splenic artery
Common hepatic
Left gastric
Blood supply to lesser curve of stomach?
Left and right gastric arteries
Blood supply to greater curve of stomach?
Right (from gastroduodenal) and left (from splenic) gastroepiploic arteries
What arteries can be eroded into by ulcers in the duodenum?
Posterior bit of D1/2 = gastroduodenal
D3/4 = pancreaticoduodenal
How may Meckel’s diverticulum present?
Acute inflammation - appendicitis mimic GI bleed Perforation Hernia - Littre's hernia Intussusception Obstruction
Layers of adrenal gland?
Cortex - GFR (glomerulosa - aldosterone, fasciculata - glucocortiocids, reticularis - androgens)
Medulla - catecholamines
Which way does the patella usually dislocate? Why?
Laterally - as knee normally held in valgus
Which muscles attach onto the linea aspera?
Adductors (magnus, longus, brevis)
Pectineus
Short head of biceps femoris
Vastus medialis and lateralis
Innervation and function of tibialis anterior?
Deep peroneal nerve
Dorsiflexion and inversion
Muscles in anterior compartment of leg?
Tibialis anterior
EHL
EDL
Peroneus tertius
Muscles in lateral compartment of leg?
Peroneus longus and brevis
Muscles in deep posterior compartment of leg?
Popliteus
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Muscles in superficial posterior compartment of leg?
Plantaris
Gastrocnemius
Soleus
What separates the anterior and posterior compartments of leg?
Interosseus membrane
What separates the anterior and lateral compartments of leg?
Anterior fascial septum
What separates the lateral and posterior compartments of leg?
Posterior fascial septum
What separates the deep and superficial posterior compartments of leg?
Deep transverse fascial septum
How would you perform a lower limb fasciotomy?
4 compartment decompression
2cm anterior to fibula anteriolateral incision to decompress ant/lat compartments, from tibial tuberosity to ankle
Posteromedial incision from tuberosity to 5cm above medial malleolus
Divide underlying fascia and debride any necrotic tissue
3 muscles attaching to medial cuneiform bone? Think ankle inversion
Peroneus longus
Tibialis anterior and posterior
Describe arterial supply to lower leg? On angiogram where are they?
Popliteal artery divides into anterior tibial artery and tibioperoneal trunk just under arch of soleus below knee
Anterior tibial is most lateral
Tibioperoneal trunk divides into peroneal and posterior tibial
Peroneal is middle of the 3 arteries on angio and supplies lateral compartment
Posterior tibial is most medial and supplies posterior compartments
What nerve does the small saphenous vein run with up the leg and what does it drain into?
Sural nerve in posterior compartment
Drains into popliteal vein
Where does the vas deferens run and what is its function?
Runs from epididymis in scrotum, up through inguinal canal, down into ejaculatory ducts
Carries sperm which are released under sympathetic stimulation via peristalsis of tube into urethra, mixed with seminiferous fluid and secretions
At what angle do the ureters enter the bladder?
Posterior aspect of bladder through trigone, at an oblique angle
What stops reflux of urine into the ureters from the bladder?
Ureters pass through detrusor in bladder wall
So when detrusor contracts it brings wall down and closes ureters
What vessel is near a common site for kidney stone impaction?
Common iliac - at pelvic brim
What is the most common type of bladder cancer worldwide and in the UK? Why difference?
UK = TCC = related to smoking, dyes etc Worldwide = SCC = schistosoma haematobium causing squamous metaplasia
Initial investigation of visible painless haematuria?
CT urogram and flexible cystoscopy
Initial investigation of invisible painless haematuria (microscopic)?
US renal tract and flexible cystoscopy
If findings on flexible cystoscopy are suspicious for cancer what is undertaken next?
Rigid cystoscopy and biopsy under GA
Or TURBT
Blood supply to bladder?
From internal iliac
Superior, middle and inferior iliacs
Nerve supply to bladder?
Efferent parasymp from S2-4 (pelvic splanchnic, inferior hypogastric plexus) to bladder wall and inhibitory fibres to internal sphincter - pee
Efferent symp from hypogastric plexus inhibits detrusor and stimulates internal sphincter - no pee
Voluntary control of urination?
Pudendal nerve - S234 - external sphincter
What are the 5 parts of the brachial plexus and where are they?
Roots - from intervertebral foraminae in neck between anterior and medial scalene muscles
Trunks - base of posterior triangle of neck, over first rib behind 3rd part of subclavian artery
Divisions - posterior to middle 1/3 of clavicle
Cords - related to 2nd part axillary artery in axilla
Branches - related to 3rd part of axillary artery in axilla
Long thoracic nerve of bell innervates? Roots? What does it do?
Serratus anterior - C5-7 - lifts and rotates scapula
Nerve root medial cutaneous nerve of forearm?
C8
Nerve root medial cutaneous nerve of arm?
T1
Which cord of brachial plexus gives rise to the thoracordorsal nerve? Muscle supply?
Posterior cord - C6-8
Latissimus dorsi
Innervation of pectoralis major? Where do they come from?
Medial (C5/6) and lateral (C7/8/T1) pectoral nerves, from medial and lateral cords respectively
Innervation of pectoralis minor?
Medial pectoral nerve
What is a Kulmpke’s palsy? How does it look?
Paralysis of lower trunk (C8/T1) of brachial plexus often related to birth trauma e.g. shoulder dystocia
Claw hand due to loss of intrinsic muscles of hand - flexed IP joints, hyperextended MCP joints
May also cause Horner’s
What is Erb’s palsy? How does it look?
Paralysis of upper trunk (C5/6) of plexus often related to acquired trauma e.g. motorcycle RTAs
Weak shoulder abductors, elbow flexors so arm is adducted and internally rotated with extended and pronated forearm
Boundaries of the quadrangular space?
Superiorly = teres minor Inferiorly = teres major Laterally = humerus Medially = long head of triceps
Boundaries of triangular space?
Superiorly = teres minor Inferiorly = teres major Laterally = long head of triceps
What goes through the quadrangular space?
Axillary nerve
Posterior circumflex humeral artery
Branches of the axillary artery?
3 parts and 6 branches - STLSAP
Superior thoracic
Thoracoacromial and Lateral thoracic
Subscapular, Anterior and Posterior circumflex humerals
Mid shaft humeral fracture will damage which nerve?
Radial - as it goes through spiral groove of humerus
What would damage to the radial nerve at mid shaft humerus cause?
Wrist drop and sensation loss in first webspace
Elbow extension preserved
Which 2 forearm muscles are supplied by the ulnar nerve?
Flexor carpi ulnaris and ulnar half of FDP
What does damage to ulnar nerve at the wrist cause? Why?
Sensory loss of medial 1 1/2 fingers
Motor weakness of intrinsic hand muscles leading to clawing of 4th and 5th digits
Worse clawing than if proximal, as FDP is spared
Where does the flexor retinaculum attach?
Carpal bones - proximally to pisiform and tubercle of scaphoid, distally to hook of hamate and trapezium
Contents of the carpal tunnel?
Median nerve
4x FDP tendons
4xFDS tendons
FPL tendon
What happens to sensation of thenar eminence in carpal tunnel?
Preserved, because palmar cutaneous branch of median nerve is given off before it enters and passes superficial to flexor retinaculum
What nerve innervates levator scapula and the rhomboids?
Dorsal scapular
What does the suprascapular nerve innervate?
Supraspinatus and infraspinatus
What is subscapularis innervated by?
Upper and lower subscapular nerves
