Clinical correlates exam 1 Flashcards
Laminectomy
a surgery to enlarge spinal canal by removing spinous processes and their corresponding lamina; used to remove pressure on spinal cord and nerves that may cause pain, numbness, etc.
Hangman’s fracture
Fracture of both pedicles at C2 caused by hyperextension of neck.
Lumbar spinal stenosis
narrowing of vertebral foramen, compressing spinal roots. This causes pain and numbness in lower back to legs and make walking difficult. Implications: sometimes treated with decompressive laminectomy.
Intervertebral disc herniation
Typically occurs at lumbar levels (L4-L5 or L5-S1); Disk slips occur posteriorly due to narrow size of posterior longitudinal ligament; occurs when nucleus pulposis protrudes into or through the annulus fibrosis into the vertebral canal and compresses the spinal cord or nerve roots
Triangle of auscultation
Allows lung sounds to be heard clearly because no muscle intervenes between skin and rib cage; bounded by the trapezius, latissimus dorsi and medial edge of the scapula
Lumbar spinal puncture
Spinal puncture (spinal tap) – needle inserted between two vertebrae and into subarachnoid space to remove CSF; can help diagnose infections (meningitis, CNS infections, MS) and detect bleeding and hemorrhaging or cancer of brain or spinal cord. Inject anesthetic or chemotherapy. Introduce dye. Needle must penetrate through skin, fat, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater, subdural space, and arachnoid mater to reach the subarachnoid space.
Whiplash:
Overextension of anterior longitudinal ligament
Spondylolysis and the “Scotty dog” phenomenon?
● Spondylolysis: when fractures of the interarticular parts of the vertebral laminae “Pars Interarticularis” cause displacement/dislocation of the vertebrae; common at L5 vertebra
● Scotty dog – normal appearance of lumbar spine as viewed by oblique radiography. The transverse process is the nose, the pedicle forms the eye, the inferior articular facet forms the front leg, the superior articular facet forms the ear, and the pars interarticularis forms the neck of the dog. When spondylolysis occurs, a break will be visible on the “neck” of the scotty dog.
Spondylolisthesis:
caused by spondylolysis in which vertebrae becomes weakened and a vertebra will slip anteriorly from the other vertebrae where they are no longer aligned. Common at L4/L5
Lumbar triangle of Petit:
Site for hernias of retroperitoneal contents through posterior abdominal wall; bordered by the latissimus dorsi, external obliques, and iliac crest
Vertebral artery atherosclerosis
plaques cause its narrowing and occlusion; the tortuous course of the vertebral artery causes the patients with atherosclerosis may become dizzy and experience other symptoms of brainstem ischemia when the neck is rotated or when chiropractic manipulation is conducted.
Lordosis:
excessive lumbar inward curvature “lowerdosis”
Kyphosis
excessive thoracic outward curvature
Scoliosis
lateral curvature of vertebral column
Crush fracture:
crushing of vertebral body
Lumbar spinal puncture
withdraw CSF from subarachnoid space; done by inserting needle between L4 and L5 vertebral levels (found by tracing iliac crest medially). This penetrates the supraspinous, interspinous ligaments, and ligamentum flavum. “pop “ is the needle penetrating the dura mater.
Caudal epidural:
anesthesia administered into lowest portion of epidural space by penetrating sacrococcygeal ligament which covers the sacral hiatus. Sacral cornua used as bony landmark to administer
Winged scapula”:
serratus anterior (powerful protractor) paralyzed due to damage of long thoracic nerve (from spinal nerve roots C5/C6/C7), causes inability to hold scapula in place and it retracts/looks like a wing
Quadrangular space:
Box of PCANs” contains the Posterior Humeral Circumflex Artery and the Axillary Nerve
Clavicular fractures: Why is the medial clavicular fragment often elevated after a clavicle fracture? Why does shoulder drop occur with a clavicular fracture?
The clavicle is commonly fractured by indirect force transmitted from an outstretched arm to the shoulder during a fall or a blow to the forearm while outstretched. Since the weakest part of the clavicle is at the junction of its middle and lateral thirds, a fracture results in the elevation of the medial clavicular fragment by the upward pull of the sternocleidomastoid muscle (SCM). The trapezius is now unable to hold up the lateral fragment given the weight of the upper limb, so the shoulder drops. Can result in pulmonary embolism (blood clots in subclavian vein), brachial artery embolism (blood clots in subclavian artery), or damage to inferior trunk of brachial plexus.
Lymph node removal:
: two nerves at risk- long thoracic nerve and thoracodorsal nerve. Breast cancer: excision and pathological analysis of axillary lymph nodes is often necessary. Because axillary lymph nodes are arranged and receive lymph (and cancer cells) in a specific order, removing and excising lymph nodes in that order is important in determining how far the cancer has metastasized.
Dermatome
a strip of skin innervated by one spinal cord level
C2 dermatome
Top and back of skull
C3 dermatome
Upper neck (turtleneck)
C4 dermatome
lower neck (collar of shirt)
T4 dermatome
Nipple
t7 dermatome
xiphoid
t10 dermatome
umbilicus/appendix
L4 dermatome
knee
Cutaneous innervation:
a strip of skin that is innervated by one peripheral nerve; may or may not include more than one spinal cord level
Upper limb stenosis
anastomoses provide alternate routes to supply blood
Subclavian Vein puncture
catheter placed into subclavian vein by puncturing axillary vein and advancing it medially. Axillary vein is inferior and anterior to axillary artery, the target for central lines.
Fracture of the surgical neck of the humerus:
posterior humeral circumflex artery are affected and axillary nerve (innervates deltoid and teres minor). Therefore abduction and lateral rotation are impaired.
Fracture of humeral shaft:
damages radial nerve inside radial groove and deep brachial artery/profunda brachii
Spiral fracture of humerus:
result of a fall on the outstretched hand. Impairs radial n. and deep brachial artery.
Fracture of distal humerus:
damage of median nerve
Fracture at radial groove:
damage of radial nerve and deep brachial vein (profunda brachii)
Transverse fracture of humeral shaft:
MARMU nerves can be damaged; results from a direct blow to the arm
Avulsion of greater tubercle of humerus:
SIT muscles of rotator cuff all attach here (subscalularis, lesser tubercle of humerus
Intercondylar fracture
olecranon of elbow is driven into humerus, separating humerus
Supracondylar fracture:
fracture directly superior to epicondyles. Compresses median nerve and brachial artery.
Lymphangitis
caused by an infection of the upper limb. results in enlarged, tender and inflamed axillary lymph nodes. The humeral group is first to be involved.
Lymphedema:
caused by lymphatic drainage of the upper limb may be impeded after removal of axillary lymph nodes or swelling as a result of accumulated lymph in the subcutaneous tissue
. Biceps reflex: a positive response that confirms integrity of what nerve and what spinal cord levels?
Musculocutaneous nerve; C5, C6, C7
Why is the cubital fossa a common site for sampling and transfusion of blood?
The median cubital vein lies superior to the bicipital aponeurosis and is a good site for extraction of blood.
Compression of the axillary artery
necessary when profuse bleeding occurs; the distal segment can be palpated in the inferior lateral wall of the axilla. It may also be compressed at its origin, with pressure in the angle between sternocleidomastoid and the clavicle.
Wounds in the axilla
often involve the axillary vein due to its exposed position and are particularly dangerous because of profuse bleeding and the risk of air emboli (bubbles) entering the blood.
Upper/superior brachial plexus injury:
C5&6. Result from excessive angle between neck and shoulder.
● Erb Duchenne’s palsy- paralysis of deltoid, biceps, brachialis. Waiter’s tip position results: limb hangs by side in medial rotation, elbow extended, arm adducted.
22. Lower/inferior brachial plexus injury
Lower/inferior brachial plexus injury:
upper limb pulls superiorly, injuries C8 and T1.
● Claw hand results, also known as Klumpke Paralysis
Damage to coracoid process, what muscles will be affected?
Coracobrachialis
● Short head of biceps brachii
● Pectoralis minor
Crutches paralysis:
can injure the RADIAL nerve leading to wrist drop and other signs of typical radial nerve damage
Cubital Fossa/Forearm 1. Volkmann’s ischemic contracture:
permanent flexion of wrist (claw) caused by a supracondylar fracture that leads to the puncturing of the brachial artery, which causes ischemia (loss of blood flow) in the forearm muscles and their permanent contracture.
Colles fracture
complete fracture of radius 2 cm from wrist resulting from excessive extension/trying to break a fall
Dinner fork deformity:
distal end of broken radius in Colles fracture will project dorsally causing a curvature of the forearm just proximal to the wrist
Cubital fossa as common site of transfusion of blood:
median cubital vein is easy to access. Connects cephalic vein and basilic vein, sitting above the bicipital aponeurosis
Fracture of radius:
damage to radial artery, anterior/posterior interosseous nerve (due to the interosseous membrane damage); damage to radial nerve, musculocutaneous nerve (lateral cutaneous antebrachial n.)
Fracture of ulna:
damage to ulnar artery, anterior/posterior interosseous artery (due to the interosseous membrane damage); damage ulnar nerve, median nerve
Anatomical snuff box:
: contains the radial artery; lateral boundary formed by abductor pollicis longus and extensor pollicis brevis; medial boundary formed by extensor pollicis longus.
Fractured elbow:
fracture of olecranon
Clinical testing: Axillary n.:
resisted shoulder abduction (test deltoid) and lateral rotation of shoulder (test teres minor)
Clincially testing musculocutaneous n
.: weak flexion of the elbow and no cutaneous sensation on lateral forearm
Clinically testing radial nerve
inability to extend the wrist, resulting in wrist drop
Clinically testing median nerve
flexion of interphalangeal joints is lost (due to superficialis PIP flexion, and profundus DIP flexion only for lateral digits). When attempting to make a fist, fingers 2&3 remain extended (aka Hand of Benediction). Can’t make the “ok” sign, it looks like a “pinch” due to inability to flex IP joints in forefinger and thumb
Clinically testing ulnar n
most commonly damaged at funny bone (medial epicondyle). When attempting to flex wrist, wrist will be drawn to lateral side. When attempting to make a fist, fingers 4&5 remain extended, but also cannot extend due to lack of innervation to lumbricals. Results in claw hand.
Thumb testing radial
sensory to back of thumb
clinically testing thumMedian:
see if patient can oppose thumb
clinical testing ulnar thumb
hold an piece of paper between thumb and indicis, test grip
Upper Limb Joints 1. Shoulder separation:
disruption of the AC joint and coracoclavicular ligament. This results in the glenohumeral joint completely dropping from the shoulder
Shoulder dislocation:
most commonly anterior due to lack of anterior support. Posterior side reinforced by rotator cuff. Superiorly reinforced by coracoacromial ligament. Suprascapular artery and nerve are often injured
. What is the sternoclavicular (SC) joint and does it commonly dislocate?
● Clavicle, manubrium, and 1st costal cartilage
● Elevation of clavicle to 60° and anterior/posterior movement to 30°
● Anterior and posterior sternoclavicular ligaments
● Articular disc separates the joint into 2 compartments
● SC joint doesn’t commonly dislocate- the clavicle will usually break
Tennis elbow:
lateral epicondylitis (strained and inflamed)
Golfer’s elbow:
medial epicondylitis (strained and inflamed)
Little league elbow:
medial epicondyle apophysitis”): growth plate injury at the medial epicondyle due to overuse/throwing 7
Nursemaid’s elbow:
annular ligament slips off of radial head and becomes trapped between radial head and capitulum of humerus.
Knuckles:
formed from heads of metacarpals of digits 2-5
Compartment inflammation
Midpalmar space is continuous with the anterior forearm via the carpal tunnel; midpalmar spaces are potential spaces deep in the palm between the long flexor tendons and the fascia over the deep palmar muscles
. Fractured scaphoid:
most commonly fractured bone of the hand; occurs from fall on palm of the hand while hand is outstretched. Avascular necrosis (death of bone due to lack of blood supply) may occur to proximal fragment of bone resulting from lack of blood supply
Dupuytren contracture
shortening/thickening of palmar fascia resulting in flexion of digits 4 and 5
Carpal Tunnel:
compression of the median nerve resulting in excessive motion of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis. Often caused by a dislocation of lunate
Lunate dislocation
: lunate pushed out of floor in carpal tunnel, toward the palm. May compress median nerve, causing carpal tunnel; commonly occurs in auto accidents or a fall from a great height
Claw hand:
Ulnar nerve compression: damaged ulnar nerve results from inability to extend digits 4 and 5 due to lack of innervation to lumbricals, which also hyperextends MP joints
Mallet/baseball finger
rupture of extensor tendons in the DIP;Unopposed action of flexor digitorum profundus produces “mallet finger” in which the distal phalanx remains flexed
. Benediction hand
damage to median nerve, resulting in extended digits at 1-3 at MP joint (lumbricals affected) and IP joints (flexors affected)
Wrist drop
: caused by damage of radial nerve and lack of extensor muscles
Hamate fracture
ulnar nerve and ulnar artery affected
Abnormal Blastocysts:
Trophoblast is defective and could not produce sufficient hCG to maintain
corpus luteum.
Hydatidiform Moles:
Trophoblast develops and forms placental membranes with little or no
embryonic tissue. Moles secrete high levels of hCG and appear “grape-like.”
. Ectopic pregnancy
Implantation outside the uterus. 95% occur in the uterine tube. Symptoms:
signs/symptoms of pregnancy with abdominal pain and tenderness; treatment: laparoscopic operation to remove uterine tube containing the ectopic embryo
Endovaginal sonography:
technique used to confirm ectopic pregnancy diagnosis
Early Pregnancy factor
: immunosuppressive protein is detected by isolated maternal serum shortly after conception (36-48 hours after fertilization); this is the earliest available marker
Pregnancy test
detects hCG; day 8 can be detected in maternal blood; day 10 can be detected in
maternal urine
Placenta Previa
When the blastocyst implants close to the internal os (opening) of the cervix. Presents as painless vaginal bleeding in the later stages of pregnancy. Increased risk with IVF
Exocoelomic cysts
During formation of the definitive yolk sac, large portions of the primitive yolk sac (aka exocoelomic coelom) are pinched off in the chorionic cavity.
Conjoined twins:
result from partial splitting of the primitive node and streak
Sirenomelia
“mermaid syndrome”; insufficient mesoderm is formed in the caudal region of the
embryo, lower limbs are fused together. Kidney and bladder development are affected so that many babies that are born with this condition will generally die within a few days of birth
Sacrococcygeal Teratoma
: primitive streak doesn’t regress appropriately. remnants of the primitive streak in the sacrococcygeal area; commonly contain tissues derived from all 3 germ layers b/c primitive streak cells are pluripotent; most common tumor in newborns, 3-4x more likely in females than males
Chordoma:
tumor that arises from remnants of notochord. Intracranially or sacrally; more
common in adult men in their 50’s
Gastroschisis
: abdominal wall defect, characterized by an opening in the abdominal wall of the
fetus. Intestines and other abdominal organs herniate through a hole in the abdominal wall and spill out into the amniotic fluid around the fetus; if lateral folds don’t complete and form anterior abdominal wall in week 4
. Chorionic villus sampling
: Needle aspiration (transabdominal or transvaginal) of chorionic villus tissue for genetic testing; performed at 10-12 weeks. Will tell whether embryo has severe chromosomal abnormalities or not. (prior to month 4, therefore all 4 layers of chorionic villi are present: syncytiotrophoblast, cytotrophoblast, extraembryonic mesoderm, fetal circulation
. False knots
: When the umbilical vessels are longer than the umbilical cord so they commonly
twist around each other and sometimes bend to form loops
. Synctial knots
: In third trimester, large pieces of syncytiotrophoblast break off and enter
intervillous spaces; these enter maternal circulation and are broken down in the lungs
Amniocentesis
a hollow needle is inserted through the mother’s abdomen into the uterus and
amniotic fluid is drawn for analysis; performed at 16-20 weeks.
Amniotic bands/constriction ring syndrome:
amnion should be fused with chorion and pushed
against uterine wall. Bands can come loose or tears in the amnion may result in amniotic bands that encircle the fetal limbs or digits resulting in deformities or amputations.
Amniotic Fluid
30mL at 10 weeks and 1000mL at 37 weeks
. Polyhydramnios
excess amniotic fluids
○ correlated with maternal diabetes and disorders of central nervous system and gastrointestinal tract (various atresias)
○ Fetus is prevented from swallowing amniotic fluid OR fetus has increased urine production.
○ Twinning also increases risk of polyhydramnios
Oligohydramnios:
too little amniotic fluid
○ may result from failure of the fetal kidneys to form, poor fetal urine output or amniotic fluid leakage/rupture of membranes.
○ Severe oligohydramnios early in pregnancy is a risk factor for lung hypoplasia (lung underdevelopment)
○ Category X drugs:
absolute contraindication in pregnancy; thalidomide, Coumadin, alcohol, etc.
Category D drugs
definite evidence of risk to fetus; tetracycline, valium, etc
Potter’s syndrome
fetal kidneys are absent → lungs don’t develop
Single artery in umbilical cord:
1% of fetuses have this; increased risk for Down Syndrome
Substances that DO NOT cross the placental membrane:
○ Maternally derived cholesterol, triglycerides, phospholipids
○ Protein hormones like insulin
○ IgD, IgE, IgM
Erythroblastosis fetalis
severe fetal anemia. Baby “hydropic” or fluid-filled- like CHF
○ Results from Rh disease (Rh+ Dad and Rh- mom…second Rh+ baby is at risk)
○ maternal antibodies attacking Rh+ fetus
○ Prevention: Rhogam- dose of antibodies against the Rh protein
■ Given at 28 wks
■ After baby is born if it turns out to be Rh+
■ After any bleeding in pregnancy- works up to 72 hours after bleeding
Postpartum hemorrhage
can be caused by leaving maternal side segments of placenta
“cotyledons” behind after delivery; can exsanguinate in 10 minutes in brisk hemorrhage
. Preimplantation Genetic Diagnosis
Used to detect a single gene defect or chromosomal
anomalies or to identify sex of the embryo when a male embryo would be at risk of a serious X-linked disorder. This can be carried out after 3 days and NO LATER than 8-16 stage (early morula). Cells are still totipotent and it won’t injure the developing embryo.
Accessory lumbar ribs:
most common type of accessory rib, harmless
. Accessory cervical ribs
usually attached to C7, puts pressure on brachial plexus of nerves and
subclavian artery; produces paralysis and anesthesia of the upper limb; develop from the costal processes of the C7 vertebra and may fuse with first rib
Amelia
absence of limb
Meromelia:
absence of part of a limb
Phocomelia
hands and feet are attached to abbreviated arms and legs; seals flipper (results
from exposure to thalidomide)
Robert’s tetraphocomelia:
phocomelia that is genetic/inherited
Polydactyly
extra digit. Results if there is an abnormal formation of a digital ray
Syndactyly:
webbed digits. Results if apoptosis doesn’t fully occur between digital rays. Most
common limb anomaly
Upper limb buds rotate laterally 90
°, places thumb laterally. places flexor compartments
anteriorly and extensor compartments posteriorly
Lower limb buds rotate: medially 90°,
°, places great toe medially. places extensor compartments
anteriorly and flexor compartments posteriorly
AER (apical ectodermal ridge):
thickening of ectoderm on distal end of limb buds, signal growth
in proximal to distal direction. Cells differentiate into cartilage and muscle.
○ During week 6, distal ends of limb buds flatten into hand and foot plates
○ Cell death occurs in AER → fingers and toes form, dividing plate into 5 parts
○ Condensation of mesenchyme forms digital rays
○ apoptosis of cells occurs between digital rays
Multiple sclerosis
when your immune system attacks the myelin sheath in your CNS
Guillan-bare
degenerate the Schwann cells
Alzheimer’s disease:
one of the first signs of this disease is when there are disrupted
neurofilaments lead to neurofilament tangles
