Blue Boxes Flashcards

1
Q

Rib fractures (1st, middle, lower)

A

1st rib is rarely fractured, when it is, brachial plexus injuries and subclavian impingments can occur
Middle ribs - most common, weakest just anterior to angle
Lower ribs- may tear diaphragm

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2
Q

Flail chest

A

multiple rib fractures

paradoxical movements with respiration

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3
Q

thoracotomy is the surgical opening of

A

Anteriorly - thoracic chest - H shaped cut through perichondrium
5th-7th intercostal spaces, posterolaterally (abduct patients arm, lateral recumbent) - pneumonectomy

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4
Q

supernumarary ribs

A

normally 12 ribs each side, some people have
Cervical ribs (.5-2%)
Lumbar ribs
Failure of 12th pair to form

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5
Q

protective function and aging of costal cartilages

A

prevents fracturing from blows (although injury still occurs)
costal cartilages brittle in old folks

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6
Q

ossified xiphoid process occurs at what age

A

partially ossifices in early 40s

complaints of hard lump in pit of stomach

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7
Q

sternal fractures

A

rare- usually comminuted (multiple)
displacement of fragments uncommon due to fascia
eldery - sternal angle where manubriosternal joint is fused
primary concern is heart/lung injury

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8
Q

median sternotomy is used in what procedures

A

split in median plane and retracted
coronary artery bypass
tumors in superior lobe of lung

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9
Q

sternal biopsy done by

A

bone marrow needle biopsy

evaluate for metastatic cancer, blood dyscrasias

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10
Q

sternal anomolies

A

normal development involves fusion of bilateral vertical condensation of sternal band/bars (precartilaginous tissue)
partial clefts - can be repaired by direct apposition/fixation
complete cleft may result in ectopia cordis
perforation (sternal foramen) - not clinically significant, shows up in xrays
pectus excavatum/pectus cavinatum
perforated xiphoid process in elderly
anteriorly protruding xiphoid process in neonates does not require correction

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11
Q

Thoracic outlet syndrome

A

arteries and T1 spinal nerves emerge from thorax

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12
Q

dislocation of ribs

A

common in body-contact sports
dislocation of sternocostal joint
dislocation of interchondral joint occurs unilaterally at ribs 8,9,10 and trauma may affect underlying structures

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13
Q

separation of ribs

A

dislocation of costochondral junction
3rd-10th ribs usually tears pericondrium and periosteum
overrides rib above causing pain

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14
Q

paralysis of diaphragm

A

phrenic nerve damage will affect one half (each dome has separate nerve supply)
if this has occured, paradoxical movement of affected dome will be noted

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15
Q

dyspnea

A

individuals with respiratory problems/heart failure will have difficulty breathing (dyspnea)
will utilize their accessory respiratory muscles to assist in expansion of thoracic cavity
lean on knees/arms of a chair to fix pectoral girdle

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16
Q

extrapleural intrathoracic surgical access

A

loose, thin endothoracic fascia
separation from costal parietal pleura lining the thoracic wall allows intrathoracic access to extrapleural structures (lymph nodes) without opening and contaminating pleural cavity around lungs)

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17
Q

herpes zoster infection of spinal cord

A

causes classic dermatomally distributed skin lesion known as shingles
described as painful af
virus invades ganglion, producing sharp burning pain in dermatome supplied by involved nerve - skin becomes red and vesicular eruptions occur

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18
Q

intercostal nerve block

A

local anesthesia produced by injected anesthetic agent around intercostal nerves between paravertebral line and are of required anesthesia

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19
Q

changes in breasts

A

branching of lactiferous ducts occurs during menstrual periods and pregnancy
colostrum (premilk) may be secreted during third trimester, rich in protein, immune agents and growth factor for intestines
multiparous women - breasts become large and pendulous
elderly - small because decrease in fat and atrophy of glandular tissue

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20
Q

breast quandrants

A

superiomedial
Superiolateral
inferolateral
inferomedial

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21
Q

carcinoma of the breast

A
typically adenocarcinomas (glandular cancer) arising from epithelial cells of lactiferous ducts 
lymphedema (caused by interference with lymphatic drainage by cancer) may cause 
Peau d'orange sign 
fingertip size dimples (from shortening of supsensory ligaments) 
retraciton of nipples 

breast cancer typically spreads by lymphatic vessels (most of which goes to axillary LN)

if breast elevates when pectoral muscle contracts, cancer has advanced enough to invade retromammary space (overlying pectoral fascia)

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22
Q

mammography

A

radiographic examination of the breasts
carcinoma appears as large, jagged density
skin thickening in area over tumor

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23
Q

surgical incisions of breast

A

typically done at inferior quadrants - less vascular structures
inferior cutaneous crease best aesthetic results, crease may hide incisions
areolar incisions are made radially to either side of nipple or circumferentially

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24
Q

simple masectomy

A

breast is removed down to retromammary space

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25
radical masectomy
removal of breast, pectoral muscles, fat, fascia, as many LN as possible in axilla and pectoral regions
26
polymastia
supernumary breasts usually mistaken for nevus until color change during pregnancy, may lactate can appear anywhere down milk line (from axilla to groin)
27
polythelia
accessory nipple
28
breast cancer in men
Accounts for 1.5% of BC metastasizes to bone, pleura, lung, liver, skin, pectoral fascia visible/palpable subareolar mass or secretion from nipple may indicate malignant tumor frequently goes undetected until metastasis has occured
29
gynecomastia
breast hypertrophy in males after puberty rare, may be age/drug related (diethylstilbesterol for prostate cancer) may result from imbalance between estrogenic and androgenic hormones or from a change in metabolism of sex hormones by liver (therefore, gynecomastia may indicate suprarenal/testicular cancers) 40% of klinefelters experience gynecomastia
30
injuries of cervical pleura and apex of lung | IGNORE UNTIL CP
lungs and pleural scs may be injured in wounds to the base of the neck (cervical pleura and apex of lung project through opening of first ribs) results in pneumothorax (air in pleural cavity) especially vulnerable in children as cervical pleura reaches higher levels
31
Injury to other parts of pleurae | IGNORE UNTIL CP
pleura descend past costal margin in three areas right part of infrasternal angle right and left costovertebral angles pneumothorax may occur from an incision in these areas
32
pulmonary collapse | IGNORE UNTIL CP
atelectasis - primary - lung does not inflate at brith secondary - collapse of inflated lung distension of lungs can be disrupted by a penetrating wound, causing the lungs normal elasticity to pull it free from the pleural cavity (also due to air filling negative pressure of pleural cavity and disrupting surface tension forces of pleural fluid) pleural sacs do not communicate, so one lung may collapse without concomitant collapse of the second lung
33
Pneumothorax,hydrothorax, hemothorax | IGNORE UNTIL CP
pneumothorax - entry of air into the pleural cavity from penetrating wound of parietal pleura, rupture of pulmonary lesions, fractured ribs Hydrothorax - significant amount of fluid in pleural cavity Hemothorax - blood in the pleural cavity (commonly due to injury to major intercostal/internal thoracic vessel)
34
Thoracentesis procedure and use | IGNORE UNTIL CP
insertion of hypodermic needle through an intercostal space into pleural cavity to obtain sample of fluid/remove blood or pus must avoid intercostal nerve and vessles by inserting superior to rib (typically 9th intercostal space) angled upward
35
insertion of chest tube | IGNORE UNTIL CP
used to remove fluid/air/pus/ from pleural cavity incision made at 5th or 6th intercostal space and tube is inserted, connected to special pump removal of air allows reinflation of collapsed lung failure to remove fluid may cause fibrosis to occur (requires lung decortication) to fix
36
Pleurectomy and Pleurodesis | IGNORE UNTIL CP
pleurectomy - obliteration of the pleural cavity (by surgery but disease can do it too) does not produce any functional problems Pleurodesis - coating of irritating agent to parietal and visceral layers of pleura to induce adhesion to prevent spontaneous secondary alectasis
37
thoracoscopy | IGNORE UNTIL CP
examine pleural cavity with thorascope | can take biopsies and disrupt adhesions/ remove plaques
38
how is the clavicle different from other long bones?
more varied than most other long bones | thicker in manual laborers
39
Fracture of clavicle
especially common in children - often caused by FOOSH transmitting force up arm (greenstick facture in younger children = bone is broken but does not separate) sternocleidomastoid elevates medial fragment trapezius is unable to hold up lateral fragment because weight of upper limb, patients will carry limb in opposite arm
40
Ossification of clavicle
clavicle is first long bone to ossify (via intramembranous ossification in middle) ends of clavicle later pass through a cartilaginous phase (endochondral ossification) and these are the last epiphyses of long bones to fuse sometimes fusion between ossficiations centers fails to occur, creating bony defect between lateral and medial thirds of clavicle - if unsure radiograph bilaterally
41
fracture of scapula
usually result of severe trauma (vehicular accidents) require little treatment because scapula is covered on both sides by muscles most fractures invovle protruding subcutaneous acromion
42
fractures of humerus (just read)
most injuries of proximal end fracture surgical neck of humerus - common in eldery due to osteoporosis (axillary n involvement) humeral fractures can often present as impacted fractures, where one fragment is driven into the spongy bone of another *patient may have some use of arm avulsion fractures of the greater tubercle usually result form falls on the acromion - muscles tend to pull limb into medial rotation transverse fracture results from trauma - deltoid muscle will carry the proximal fragment laterally spiral fractures of humeral shaft may result from a FOOSH (radial n involvement if radial groove is damaged) intercondylar fracture results from falling on flexed elbow - olecranon separates medial and lateral parts of condyle of humerus (median n for distal end injuries an d ulnar n for medial epicondyle injuries) Fractures usually heal well, humerus is surrounded by muscle and has a well developed periosteum
43
fractures of radius and ulna
typically these bones fracture together if one bone is fractured, typically the nearest joint will be dislocated Fracture of the distal end of the radius is common in adults over 50
44
colle sfracture
complete transverse fracture of the distal 2cm of radius - common FOOSH injury ulnar styloid process often avulsed causing dinner fork deforming (hand has the soft curve of a fork) fracture may extend through epiphyseal plate in children and may misalign during healing
45
Fracture of scaphoid
most frequently fractured carpal bone - fall on palm when hand is abducted often misdiagnosed as severely sprained wrist avascular necrosis of proximal fragment of scaphoid may occur (bone death) could produce degenerative joint disease of wrist
46
Fracture of hamate
may result in non-union due to traction of attached muscles ulnar nerve near hook may be damaged - grip strength will be decreased ulnar a may also be damaged
47
fracture of metacarpals
metacarpals are closely bound and have good blood supply - tend to heal well boxers fracture - fracture of the 5th metacarpal (closed and abducted fist) will cause head of bone to rotate over distal end of shaft producing flexion deformity
48
fracture of phalanges
common in distal phalanges - because of close relationship of phalangeal fractures to flexor tendons, the bone fragments must be carefully realigned to restore normal function
49
absence of pectoral muscles
usually sternocostal part is uncommon but no disability occurs as a result anterior axillary fold will be absent In poland syndrome - both pectoralis major and minor are absent, breast hypoplasia and absence of two to four rib segments are also seen
50
paralysis of serratus anterior
injury to long thoracic n causes medial border of scapula to move laterally and posteriorly away from thoracic wall gives scapula the appearance of a wing arm cannot be abducted above horizontal position because serratus anterior is needed to rotate glenoid cavity upward
51
triangle of auscultation borders and use
superior border of latissimus dorsi medial border of scapula inferolateral border of trapezius used to listen to lungs
52
injury to spinal accessory n
marked ipsilateral weakness when shoulders are elevated against resistance
53
injury of thoracodorsal n
supplies the latisimmus dorsi passes inferiorly along posterior wall of axilla if damaged, patient will be unable to raise trunk with upper limbs or use an axillary crutch because the lat forms a muscular sling between the arm and trunk
54
injury to dorsal scapular n
supplies the rhomboids - if damaged, scapula on affected side will be further from midline than unaffected side
55
injury to axillary n
causes deltoid to atrophy axillary n is usually injured during fracture of surgical neck of humerus shoulder will appear flattened loss of sensation over lateral side of proximal part of arm (supplied by the superior lateral brachial cutaneous n, a branch of the axillary)
56
fracture-dislocation of proximal humeral epiphysis
caused by direct injury to shoulder of child/adolescent may produce this fracture as the joint capsule is stronger than the epiphyseal plate if severe enough, shaft of humerus is displaced but humeral head retains its normal relationship in glenoid cavity
57
Rotator cuff injuries
injury or disease may affect rotator cuff and produce instability in the glenohumeral joint may be trauma to one of SITS muscles - supraspinatus tendon is most commopnly ruptured degenerative tendonitis of the rotator cuff is common in older people
58
arterial anastomoses around scapula
dorsal scapular, suprascapular and subscapular arteries contribute to arterial anastomoses around the scapula direction of blood flow in the subscapular a is reversed when if the axillary a is ligated/has undergone stenosis, enabling blood to reach third part of axillary a the subscapular a receives anastomoses from the suprascapular, dorsal scapular and intercostal aa slow occlusion of axillary often enables sufficient blood collateral circulation (whereas sudden occlusion will not)
59
compression of the axillary a
compression of the third part of the axillary a against the humerus may be necessary when profuse bleeding occurs additionally, compression can be done at the origin of the axillary a by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid muscle
60
aneurysm of axillary a
first part of axillary a may enlarge and compress the trunks of the brachial plexus, causing pain and anesthesia in the areas of the skin common in pitchers and quarterbacks
61
injuries to axillary v
wounds in the axilla often involve axillary v due to its exposed position when arm is abducted, vein overlaps axillary artery anteriorly air emboli may form making this injury dangerous
62
role of axillary v in subclavian vein puncture
subclavian vein punctures involve placing a catheter through the axillary vein as it crosses the first rib here, axillary v is superficial (anterior and inferior) to axillary artery branches of brachial plexus begin to surround artery at this point (aka dont nick it)
63
enlargement of axillary LN
infection in the upper limb can cause axillary nodes to enlarge and become tender and inflamed (lymphangitis) humeral group usually first lymphangitis is characterized by the development of warm, red, tender streaks in skin infections in pectoral region also enlarge axillary LN enlargement of apical nodes may obstruct cephalic vein superior to the pectoralis minor
64
dissection of axillary LN
excision and analysis of axillary LN are often necessary for staging and determining appropriate treatment for cancer lymphatic drainage of the upper limb may be impeded after removal of axillary nodes (lymphedema) during axillary node dissection, two nerves are at risk of injury 1) long thoracic nerve and 2) thoracodorsal n
65
Variations in brachial plexus
Prefixed brachial plexus - contributions are made from C4-C8 (instead of C5-T1) - trunk of plexus may be compressed by the 1st rib Postfixed brachial plexus - C6-T2
66
brachial plexus injuries
injuries to brachial plexus affect movements and cutaneous sensations in upper limb injuries to superior part of the brachial plexus usually results from an excessive increase in the angle between the neck and shoulder - makes limb hang by side stuck in medial rotation - Erb-Duchenne palsy
67
acute brachial plexus neuritis
neuro disorder that is characterized by sudden onset of severe pain around shoulder, usually at night followed by muscle weakness and sometimes atrophy
68
compression of cords of the brachial plexus
may result from prolonged hyperabduction of the arm while working overhead n compressed between coracoid process of scapula and pectoralis minor tendon can cause ischemia of upper limb and distension of the superficial limbs
69
Klumpke paralysis
injuries to the inferior parts of the brachial plexus - occur when upper limb is suddenly pulled superiorly, like when a babys arm is pulled during delivery can result in claw hand
70
brachial plexus block
injection of anesthetic into or around axillary sheath blocks impulses of peripheral nerves all deep structures of upper limb, skin distal to middle arm
71
bicipital myotactic reflex
biceps reflex routinely examined by placing thumb on biceps tendon and tapping examiners nail bed - produces involuntary contraction of the biceps positive response confirms the integrity of musculocutaneous n and C5, C6 spinal cord segments Excessive, diminished, or prolonged (hung) responses may indicate CNS/PNS nervous system disease or metabolic disorders
72
Biceps tendinitis
tendon of long head of biceps brachii is enclosed in synovial sheath that moves in the intertubercular sulcus inflammation of the tendon is usually the result of repetitive microtrauma common in throwing sports
73
Dislocation of Tendon of long head of biceps brachii
tendon of the long head of the biceps can be partially or completely dislocated from the intertubercular sulcus dislocation may occur in youths during traumatic separation of the proximal epiphysis of the humerus or older pople with history of tendinitis usually a popping/catching sensation is felt during arm rotation
74
rupture of tendon of long head of biceps brachii
usually results from wear and tear of inflamed tendon as it moves back and forth in the intertubercular sulcus rupture involves tendon being torn from its attachment at the supraglenoid tubercle of scapula associated with a snap/pop popeye deformity results - muscle belly forms a ball near center of distal part forceful flexion of the arm against excessive resistance or prolonged tendonitis from repetitive overhead motions
75
interruption of blood flow in brachial a
brachial a can be compressed medial to humerus near middle of arm because cubital anastomeses, brachial a may be clamped distal to deep brachial a without producing tissue damage because ulnar/radial a will still receive sufficient bloodflow through this anastomoses however sudden occlusion/laceration will result in ischemia of elbow/forearm within hours and produce a flexion deformity
76
Fracture of humeral shaft
midhumeral fracture may injure radial n in radial groove of shaft supra-epicondylar fracture (distal) may be displaced over the proximal fragment by brachialis and triceps and damage any of the nerves/vasculature in this area
77
Injury to musculocutaneous n
although protected in axilla, if the musculocutaneous n is lacerated the coracobrachialis, biceps, and brachialis will be paralyzed weak flexion at shoulder flexion of elbow and supination of forearm severely weakened (but not lost) weak flexion and supination can still occur through brachioradialis and supinator (radial n innervated)
78
Injury to radial n in arm
injury superior to branches to triceps will result in paralysis of triceps, brachioradialis, supinator, and extensor muscles of wrist and fingers injury in radial groove results in weakened triceps and paralysis of muscles of posterior compartment of forearm - wrist drop syndrome
79
venipuncture in cubital fossa
cubital fossa is common site for sampling and transfusion of blood and intravenous injections median cubital vein lies on top of deep fascia of bicipital aponeurosis, protecting the brachial a and median n cardiac caths for sampling great vessels and chambers of the heart/coronary angiography are also accessibly by the median cubital vein
80
variation in the veins in cubital fossa
median antebrachial vein divides into median basilic vein and median cephalic vein in 20% of the population either the median cubital vein or median basilic vein will cross superficial to the brachial a so both will be suitable for drawing blood
81
elbow tendonitis or lateral epicondylitis
elbow tendonitis follows repetitive use of superficial extensor muscles of forearm felt over lateral epicondyle and radiates down posterior surface of the forearm
82
mallet or baseball finger
sudden severe tension on long extensor tendon may avulse part of its attachment to the phalanx results from DIP joints being forcefully flexed (hyperflexed) as a result, person cannot extend DIP joint which looks like a mallet
83
Fracture of olecranon
fall on elbow combined with contraction of triceps brachii fracture olecranon is pulled away by active and tonic contractions of triceps avulsion fracture - pinning is usually required, healing is slow and cast must be worn for a long time
84
Synovial cyst of wrist
nonpainful cyst containing mucinous fluid may appear on dorsum of hand due to mucoid degeneration usually close to and communicate with synovial sheaths on dorsum of hand cystic swelling of common flexor synovial sheath on anterior aspect of wrist can enlarge enough to produce compression of the median n by narrowing the carpal tunnel
85
high division of brachial a
sometimes, brachial a will divide more proximally | ulnar/radial a begin in superior and middle part of arm and median n passes between them
86
superficial ulnar a
in 3% of the population, ulnar a descends superiorly to flexor muscles, can be felt/be visible do not mistake for a vein and puncture/inject drugs